title: The Deformity Angular Ratio: Does It Correlate With High-Risk Cases for Potential Spinal Cord Monitoring Alerts in Pediatric 3-Column Thoracic Spinal Deformity Corrective Surgery?
abstract: METHODS
  A retrospective analysis.
  
  
  OBJECTIVE
  The purpose of this study was to determine whether the deformity angular ratio (DAR) can reliably assess the neurological risks of patients undergoing deformity correction.
  
  
  BACKGROUND
  Identifying high-risk patients and procedures can help ensure that appropriate measures are taken to minimize neurological complications during spinal deformity corrections. Subjectively, surgeons look at radiographs and evaluate the riskiness of the procedure. However, 2 curves of similar magnitude and location can have significantly different risks of neurological deficit during surgery. Whether the curve spans many levels or just a few can significantly influence surgical strategies. Lenke et al have proposed the DAR, which is a measure of curve magnitude per level of deformity.
  
  
  METHODS
  The data from 35 pediatric spinal deformity correction procedures with thoracic 3-column osteotomies were reviewed. Measurements from preoperative radiographs were used to calculate the DAR. Binary logistic regression was used to model the relationship between DARs (independent variables) and presence or absence of an intraoperative alert (dependent variable).
  
  
  RESULTS
  In patients undergoing 3-column osteotomies, sagittal curve magnitude and total curve magnitude were associated with increased incidence of transcranial motor evoked potential changes. Total DAR greater than 45° per level and sagittal DAR greater than 22° per level were associated with a 75% incidence of a motor evoked potential alert, with the incidence increasing to 90% with sagittal DAR of 28° per level.
  
  
  CONCLUSIONS
  In patients undergoing 3-column osteotomies for severe spinal deformities, the DAR was predictive of patients developing intraoperative motor evoked potential alerts. Identifying accurate radiographical, patient, and procedural risk factors in the correction of severe deformities can help prepare the surgical team to improve safety and outcomes when carrying out complex spinal corrections.
  
  
  METHODS
  3.
authors.affiliation: *Toronto Western Hospital, The Hospital for Sick Children, Toronto, Ontario, Canada; †Washington University in St. Louis, St. Louis, MO; ‡Toronto Western Hospital, Toronto, Ontario, Canada; and §Children's Hospital Los Angeles, Los Angeles, CA.
authors.forename: Noah D H
authors.initials: ND
authors.lastname: Lewis
authors.forename: Sam G N
authors.initials: SG
authors.lastname: Keshen
authors.forename: Lawrence G
authors.initials: LG
authors.lastname: Lenke
authors.forename: Michael G
authors.initials: MG
authors.lastname: Zywiel
authors.forename: David L
authors.initials: DL
authors.lastname: Skaggs
authors.forename: Taylor E
authors.initials: TE
authors.lastname: Dear
authors.forename: Samuel
authors.initials: S
authors.lastname: Strantzas
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Lewis
mesh_terms: D004576:Electromyography; D019054:Evoked Potentials, Motor / Q000502:physiology*; D005073:Evoked Potentials, Somatosensory / Q000502:physiology*; D006801:Humans; D064795:Intraoperative Neurophysiological Monitoring; D007738:Kyphosis / Q000000981:diagnostic imaging; D010027:Osteotomy / Q000009:adverse effects; D011859:Radiography; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods; D013119:Spinal Cord Injuries / Q000209:etiology / Q000503:physiopathology*; D013121:Spinal Curvatures / Q000000981:diagnostic imaging* / Q000601:surgery*; D013131:Spine / Q000002:abnormalities / Q000000981:diagnostic imaging* / Q000601:surgery*