Clinical study| Volume 62, P105-111, April 2019

Impact of presenting patient characteristics on surgical complications and morbidity in early onset scoliosis

Published:January 09, 2019DOI:


      • EOS patients with musculoskeletal conditions more likely to have renal anomalies.
      • Epilepsy and pulmonary failure were risks for patients with pulmonary disease.
      • Clustered neurologic and pulmonary anomalies increased mortality risk.
      • Clustered musculoskeletal and cardiovascular anomalies increased length of stay.


      This study sought to assess comorbidity profiles unique to early-onset-scoliosis (EOS) patients by employing cluster analytics and to determine the influence of isolated comorbidity clusters on perioperative complications, morbidity and mortality using a high powered administrative database. The KID database was queried for ICD-9 codes pertaining to congenital and idiopathic scoliosis from 2003, 2006, 2009, 2012. Patients <10 y/o (EOS group) were included. Demographics, incidence and comorbidity profiles were assessed. Comorbidity profiles were stratified by body systems (neurological, musculoskeletal, pulmonary, cardiovascular, renal). K-means cluster and descriptive analyses elucidated incidence and comorbidity relationships between frequently co-occurring comorbidities. Binary logistic regression models determined predictors of perioperative complication development, mortality, and extended length-of-stay (≥75th percentile). 25,747 patients were included (Age: 4.34, Female: 52.1%, CCI: 0.64). Incidence was 8.9 per 100,000 annual discharges. 55.2% presented with pulmonary comorbidities, 48.7% musculoskeletal, 43.8% neurological, 18.6% cardiovascular, and 11.9% renal; 38% had concurrent neurological and pulmonary. Top inter-bodysystem clusters: Pulmonary disease (17.2%) with epilepsy (17.8%), pulmonary failure (12.2%), restrictive lung disease (10.5%), or microcephaly and quadriplegia (2.1%). Musculoskeletal comorbidities (48.7%) with renal and cardiovascular comorbidities (8.2%, OR: 7.9 [6.6–9.4], p < 0.001). Top intra-bodysystem clusters: Epilepsy (11.7%) with quadriplegia (25.8%) or microcephaly (20.5%). Regression analysis determined neurological and pulmonary clusters to have a higher odds of perioperative complication development (OR: 1.28 [1.19–1.37], p < 0.001) and mortality (OR: 2.05 [1.65–2.54], p < 0.001). Musculoskeletal with cardiovascular and renal anomalies had higher odds of mortality (OR: 1.72 [1.28–2.29], p < 0.001) and extLOS (OR: 2.83 [2.48–3.22], p < 0.001). EOS patients with musculoskeletal conditions were 7.9x more likely to have concurrent cardiovascular and renal anomalies. Clustered neurologic and pulmonary anomalies increased mortality risk by as much as 105%. These relationships may benefit pre-operative risk assessment for concurrent anomalies and adverse outcomes.
      Level of Evidence: III – Retrospective Prognostic Study.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Clinical Neuroscience
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Dickson R.
        Early-onset idiopathic scoliosis.
        in: Weinstein S. The Pediatric Spine: Practice and Principles. Raven Press, New York, NY1994: 421-430
        • Ventura N.
        • Huguet R.
        • Ey A.
        • Montaner A.
        • Lizarraga I.
        • Vives E.
        Infantile idiopathic scoliosis in the newborn.
        Int Orthop. 1998; 22: 82-86
        • Thompson S.K.
        • Bentley G.
        Prognosis in infantile idiopathic scoliosis.
        J Bone Joint Surg Br. 1980; 62-B: 151-154
        • Scott J.C.
        • Morgan T.H.
        The natural history and prognosis of infantile idiopathic scoliosis.
        J Bone Joint Surg Br. 1955; 37-B: 400-413
        • Mehta M.H.
        Growth as a corrective force in the early treatment of progressive infantile scoliosis.
        J Bone Joint Surg Br. 2005; 87: 1237-1247
        • Koumbourlis A.C.
        Scoliosis and the respiratory system.
        Paediatr Respir Rev. 2006; 7: 152-160
        • Campbell R.M.
        • et al.
        The characteristics of thoracic insufficiency syndrome associated with fused ribs and congenital scoliosis.
        J Bone Joint Surg Am. 2003; 85-A: 399-408
        • Ferguson R.L.
        Medical and congenital comorbidities associated with spinal deformities in the immature spine.
        J Bone Joint Surg Am. 2007; 89: 34-41
        • Phillips J.H.
        • Knapp D.R.
        • Herrera-Soto J.
        Mortality and morbidity in early-onset scoliosis surgery.
        Spine (Phila Pa 1976). 2013; 38: 324-327
        • Pehrsson K.
        • Larsson S.
        • Oden A.
        • Nachemson A.
        Long-term follow-up of patients with untreated scoliosis. A study of mortality, causes of death, and symptoms.
        Spine (Phila Pa 1976). 1992; 17: 1091-1096
        • Goldberg C.J.
        • et al.
        Respiratory function and cosmesis at maturity in infantile-onset scoliosis.
        Spine (Phila Pa 1976). 2003; 28: 2397-2406
        • Karol L.A.
        • Johnston C.
        • Mladenov K.
        • Schochet P.
        • Walters P.
        • Browne R.H.
        Pulmonary function following early thoracic fusion in non-neuromuscular scoliosis.
        J Bone Joint Surg Am. 2008; 90: 1272-1281
        • Yang S.
        • Andras L.M.
        • Redding G.J.
        • Skaggs D.L.
        Early-onset scoliosis: a review of history, current treatment, and future directions.
        Pediatrics. 2016; 137
        • Fletcher N.D.
        • Bruce R.W.
        Early onset scoliosis: current concepts and controversies.
        Curr Rev Musculoskelet Med. 2012; 5: 102-110
        • Baulesh D.M.
        • Huh J.
        • Judkins T.
        • Garg S.
        • Miller N.H.
        • Erickson M.A.
        The role of serial casting in early-onset scoliosis (EOS).
        J Pediatr Orthop. 2012; 32: 658-663
        • Fletcher N.D.
        • McClung A.
        • Rathjen K.E.
        • Denning J.R.
        • Browne R.
        • Johnston C.E.
        Serial casting as a delay tactic in the treatment of moderate-to-severe early-onset scoliosis.
        J Pediatr Orthop. 2012; 32: 664-671
        • Akbarnia B.A.
        • Emans J.B.
        Complications of growth-sparing surgery in early onset scoliosis.
        Spine (Phila Pa 1976). 2010; 35: 2193-2204
        • Mineiro J.
        • Weinstein S.L.
        Subcutaneous rodding for progressive spinal curvatures: early results.
        J Pediatr Orthop. 2002; 22: 290-295
        • Klemme W.R.
        • Denis F.
        • Winter R.B.
        • Lonstein J.W.
        • Koop S.E.
        Spinal instrumentation without fusion for progressive scoliosis in young children.
        J Pediatr Orthop. 1997; 17: 734-742
        • Harrington P.R.
        Treatment of scoliosis. Correction and internal fixation by spine instrumentation.
        J Bone Joint Surg Am. 1962; 44-A: 591-610
        • Bess S.
        • et al.
        Complications of growing-rod treatment for early-onset scoliosis: analysis of one hundred and forty patients.
        J Bone Joint Surg Am. 2010; 92: 2533-2543
        • Greggi T.
        • et al.
        Complications incidence in the treatment of early onset scoliosis with growing spinal implants.
        Stud Health Technol Inform. 2012; 176: 334-337
        • Watanabe K.
        • et al.
        Risk factors for proximal junctional kyphosis associated with dual-rod growing-rod surgery for early-onset scoliosis.
        Clin Spine Surg. 2016; 29: E428-E433
        • Watanabe K.
        • et al.
        Risk factors for complications associated with growing-rod surgery for early-onset scoliosis.
        Spine (Phila Pa 1976). 2013; 38: E464-E468
        • Liang J.
        • et al.
        Risk factors for predicting complications associated with growing rod surgery for early-onset scoliosis.
        Clin Neurol Neurosurg. 2015; 136: 15-19
        • Deyo R.A.
        • Cherkin D.C.
        • Ciol M.A.
        Adapting a clinical comorbidity index for use with ICD-9 administrative databases.
        J Clin Epidemiol. 1992; 45: 613-619
        • Passias P.G.
        • et al.
        Predictors of hospital length of stay and 30-day readmission in cervical spondylotic myelopathy patients: an analysis of 3057 patients using the ACS-NSQIP database.
        World Neurosurg. 2018; 110: e450-e458
        • Upasani V.V.
        • et al.
        Age at initiation and deformity magnitude influence complication rates of surgical treatment with traditional growing rods in early-onset scoliosis.
        Spine Deform. 2016; 4: 344-350
        • McPhail G.L.
        • et al.
        Obstructive lung disease is common in children with syndromic and congenital scoliosis: a preliminary study.
        J Pediatr Orthop. 2013; 33: 781-785
        • Wick J.M.
        • Konze J.
        • Alexander K.
        • Sweeney C.
        Infantile and juvenile scoliosis: the crooked path to diagnosis and treatment.
        AORN J. 2009; 90: 347-376
        • Toder D.S.
        Respiratory problems in the adolescent with developmental delay.
        Adolesc Med. 2000; 11: 617-631
        • Böhmer C.J.
        • Niezen-de Boer M.C.
        • Klinkenberg-Knol E.C.
        • Devillé W.L.
        • Nadorp J.H.
        • Meuwissen S.G.
        The prevalence of gastroesophageal reflux disease in institutionalized intellectually disabled individuals.
        Am J Gastroenterol. 1999; 94: 804-810
        • Pugely A.J.
        • Martin C.T.
        • Gao Y.
        • Ilgenfritz R.
        • Weinstein S.L.
        The incidence and risk factors for short-term morbidity and mortality in pediatric deformity spinal surgery: an analysis of the NSQIP pediatric database.
        Spine (Phila Pa 1976). 2014; 39: 1225-1234
        • Taniguchi Y.
        • et al.
        In-hospital mortality and morbidity of pediatric scoliosis surgery in Japan.
        Medicine (Baltimore). 2018; 97e0277
        • Bohl D.D.
        • et al.
        Incidence and risk factors for pneumonia after posterior lumbar fusion procedures: an ACS-NSQIP study.
        Spine (Phila Pa 1976). 2016; 41: 1058-1063
        • Baydur A.
        • Adkins R.H.
        • Milic-Emili J.
        Lung mechanics in individuals with spinal cord injury: effects of injury level and posture.
        J Appl Physiol. 2001; 90: 405-411
        • Shen J.
        • Wang Z.
        • Liu J.
        • Xue X.
        • Qiu G.
        Abnormalities associated with congenital scoliosis: a retrospective study of 226 Chinese surgical cases.
        Spine (Phila Pa 1976). 2013; 38: 814-818
        • Rai A.S.
        • Taylor T.K.F.
        • Smith G.H.H.
        • Cumming R.G.
        • Plunkett-Cole M.
        Congenital abnormalities of the urogenital tract in association with congenital vertebral malformations.
        J Bone Joint Surg Br. 2002; 84: 891-895
        • Bozcali E.
        • Ucpunar H.
        • Sevencan A.
        • Balioglu M.B.
        • Albayrak A.
        • Polat V.
        A retrospective study of congenital cardiac abnormality associated with scoliosis.
        Asian Spine J. 2016; 10: 226-230
        • Smith J.S.
        • et al.
        Rates and causes of mortality associated with spine surgery based on 108,419 procedures: a review of the scoliosis research society morbidity and mortality database.
        Spine (Phila Pa 1976). 2012; 37: 1975-1982
        • Shaffrey E.
        • et al.
        Defining rates and causes of mortality associated with spine surgery.
        Spine (Phila Pa 1976). 2014; 39: 579-586
        • Pumberger M.
        • Chiu Y.L.
        • Ma Y.
        • Girardi F.P.
        • Vougioukas V.
        • Memtsoudis S.G.
        Perioperative mortality after lumbar spinal fusion surgery: an analysis of epidemiology and risk factors.
        Eur Spine J. 2012; 21: 1633-1639
        • Johnson E.K.
        • Nelson C.P.
        Values and pitfalls of the use of administrative databases for outcomes assessment.
        J Urol. 2013; 190: 17-18
        • Tanpowpong P.
        • et al.
        Multicenter study on the value of ICD-9-CM codes for case identification of celiac disease.
        Ann Epidemiol. 2013; 23: 136-142