title: Surgical Risk Stratification Based on Preoperative Risk Factors in Severe Pediatric Spinal Deformity Surgery.
abstract: Retrospective review.
  
  
  
  The purpose of this study is to review the postoperative complications in pediatric patients undergoing spine surgery and to establish a preoperative classification that stratifies surgical risk and case difficulty.
  
  
  
  Pediatric spinal deformity (PSD) surgery can be challenging technically as well as economically. Often, a multidisciplinary approach to managing these patients is necessary. In an environment where resources are limited, such as in global outreach efforts, a method for stratifying PSD surgical cases can be useful for allocating appropriate resources and assigning appropriate skill sets in order to optimize patient outcomes and to streamline efforts.
  
  
  
  A total of 145 consecutive PSD patients who underwent instrumented spinal fusion were reviewed. Radiographic measurements and demographic data were reviewed. A classification was established based on the curve magnitude, etiology, ASA grade, number of levels fused, the preoperative neurologic status, body mass index and type of osteotomies. Multiple regression analysis (MRA) and logistic regression analysis (LRA) were applied to indicate risk factors for complications.
  
  
  
  The average age was 14.3 years (10-20 years). The etiology was idiopathic scoliosis (n = 71), congenital scoliosis (n = 38), infectious (n = 11), and others. 23 patients had neurologic deficits preoperatively. Twenty-three patients had a posterior vertebral column resection. Patients were classified as Level 1 (n = 5), Level 2 (n = 19), Level 3 (n = 24), Level 4 (n = 58), and Level 5 (n = 39). Intraoperative neuro-monitoring changes were observed in 46 cases. Major complications were seen in 45 cases. A major complication consisted of implant related (n = 13), deep wound infection (n = 8), neurologic deficit (n = 7), death (n = 2), and others (n = 9). MRA demonstrated a significant correlation between classified level and %EBL/TBV, operative time, and complication rate. The risk level predicted the occurrence of general (odds ratio [OR] = 1.54; 95% confidence interval [CI] = 1.08-2.21; p = .019) and neurologic (OR = 3.34; 95% CI = 1.06-17.70; p = .036) complications. Osteotomy and resection procedures were independent predictors for postoperative neurologic complications (OR = 1.7, 95% CI = 1.11-2.85; p = .015).
  
  
  
  Corrective spine surgery for complex pediatric deformity is challenging and carries a substantial risk. No single parameter appears to independently predict postoperative complications. However, when all risk factors are considered, there is a trend toward increased intraoperative electromonitoring change and postoperative neurologic risk with the higher level score in our classification. The newly established surgical risk stratification based on patient-specific clinical and radiographic factors can guide surgeons in their preoperative planning and surgical management of severe spine deformity in order to achieve optimal outcomes.
authors.affiliation: Adult and Pediatric Spine and Scoliosis Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA. Electronic address: oboachie@gmail.com.
authors.forename: Oheneba
authors.initials: O
authors.lastname: Boachie-Adjei
authors.affiliation: Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan.
authors.forename: Mitsuru
authors.initials: M
authors.lastname: Yagi
authors.affiliation: Department of Orthopedic Surgery, Hospital Ruber Internacional, Calle de la Masó, 38, 28034, Madrid, Spain.
authors.forename: Cristina
authors.initials: C
authors.lastname: Sacramento-Dominguez
authors.affiliation: Department of Neurosurgery, Korle Bu Teaching Hospital, P.O. Box KB77, Korle Bu, Accra, Ghana.
authors.forename: Harry
authors.initials: H
authors.lastname: Akoto
authors.affiliation: Adult and Pediatric Spine and Scoliosis Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
authors.forename: Matthew E
authors.initials: ME
authors.lastname: Cunningham
authors.affiliation: Department of Orthopaedic Surgery, University of California, Davis Medical Center, 2315 Stockton Boulevard, Sacramento, CA 95817-2282, USA.
authors.forename: Munish
authors.initials: M
authors.lastname: Gupta
authors.affiliation: Department of Orthopaedics, Geisinger Medical Center, 100 North Academy Avenue, Danville, PA 17822, USA.
authors.forename: William F
authors.initials: WF
authors.lastname: Hess
authors.affiliation: Department of Orthopedic Surgery, New York University-Hospital for Joint Diseases, 301 East 17th Street, 1402, New York, NY 10003, USA.
authors.forename: Baron S
authors.initials: BS
authors.lastname: Lonner
authors.affiliation: Research Department, FOCOS Hospital, P.O. Box KD 779, Kanda, No. 8 Teshie Street, Accra, Ghana.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Ayamga
authors.affiliation: 2 Orthopaedic Clinic, University of Athens, Greece.
authors.forename: Elias C
authors.initials: EC
authors.lastname: Papadopoulos
authors.affiliation: Spine Unit, Department of Orthopedic Surgery, Hospital La Paz, P° de la Castellana, 261 28046, Madrid, Spain.
authors.forename: Federico
authors.initials: F
authors.lastname: Sanchez-Perez-Grueso
authors.affiliation: Spine Unit, Servicio de COT, Hospital Vall d'Hebron, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain.
authors.forename: Feran
authors.initials: F
authors.lastname: Pelise
authors.affiliation: Norwich Orthopedic Group, 82 New Park Ave, North Franklin, Norwich, CT 06254, USA.
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Paonessa
authors.affiliation: Adult and Pediatric Spine and Scoliosis Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
authors.forename: Han Jo
authors.initials: HJ
authors.lastname: Kim
authors.affiliation: Research Department, FOCOS Hospital, P.O. Box KD 779, Kanda, No. 8 Teshie Street, Accra, Ghana.
keywords: Complication; Congenital scoliosis; Deformity; Idiopathic scoliosis; Scoliosis