Scoliosis Research Society
SRS: Scoliosis Research Society

Scoliosis Research Society

Dedicated to the optimal care of patients with spinal deformity

Quality & Safety Library

Welcome to the Safety Resource Library

This page serves as a central resource to find key information on important topics such as infection prevention, implant related complications, perioperative planning, and medical management. The content is split into pediatric and adult teams, and includes such tools as checklists, guidelines, key publications, videos, and webinars.



Indications and Classification

  • Adams AJ, Refakis CA, Flynn JM, Pahys JM, Betz RR, Bastrom TP, Samdani AF, Brusalis CM, Sponseller PD, Cahill PJ. Surgeon and Caregiver Agreement on the Goals and Indications for Scoliosis Surgery in Children With Cerebral Palsy.  Spine Deform. 2019 Mar;7(2):304-311. doi: 10.1016/j.jspd.2018.07.004.
    • 126 surgeon/caregiver pairs were surveyed to rank surgical indications in neuromuscular scoliosis. The greatest area of agreement was in improving sitting balance(69%) followed by to prevent pulmonary compromise and pain improvement.
  • Lenke LG, Betz RR, Harms J, Bridwell KH, Clements DH, Lowe TG, Blanke K. Adolescent idiopathic scoliosis: a new classification to determine extent of spinal arthrodesis.  J Bone Joint Surg Am. 2001 Aug;83(8):1169-81.
    • The lack of a reliable, universally acceptable system for classification of adolescent idiopathic scoliosis made comparisons between various types of operative treatment an impossible task.  This new two-dimensional classification of adolescent idiopathic scoliosis, as tested by two groups of surgeons, was shown to be much more reliable than the King system
  • Watanabe K, Lenke LG, Matsumoto M, Harimaya K, Kim YJ, Hensley M, Stobbs G, Toyama Y, Chiba K. A novel pedicle channel classification describing osseous anatomy: how many thoracic scoliotic pedicles have cancellous channels?  Spine (Phila Pa 1976). 2010 Sep 15;35(20):1836-42. doi: 10.1097/BRS.0b013e3181d3cfde.PMID: 20802397
    • This study aimed to quantify pedicles in 53 consecutive scoliosis patients according to the pedicle morphology.  Pedicles that had a large cancellous channel were labelled as Type A, those with small cancellous channels were Type B, the all “cortical channel” was labelled a Type C, and a Type D pedicle was when the pedicle probe could not locate a channel and hence this was described as a “slit/absent channel”.
  • Weinstein SL, Dolan LA, Spratt KF, Peterson KK, Spoonamore MJ, Ponseti IV. Health and function of patients with untreated idiopathic scoliosis: a 50-year natural history study. JAMA. 2003 Feb 5;289(5):559-67. doi: 10.1001/jama.289.5.559.PMID: 12578488
    • Prospective natural history study of 117 untreated patient at 50-year follow-up, Cwith 62 age- and sex-matched volunteers. An increased risk of shortness of breath was also associated with the combination of a Cobb angle greater than 80 degrees and a thoracic ape. S-six (61%) of 109 patients reported chronic back pain compared with 22 (35%) of 62 controls
  • Williams BA, Matsumoto H, McCalla DJ, Akbarnia BA, Blakemore LC, Betz RR, Flynn JM, Johnston CE, McCarthy RE, Roye DP Jr, Skaggs DL, Smith JT, Snyder BD, Sponseller PD, Sturm PF, Thompson GH, Yazici M, Vitale MG. Development and initial validation of the Classification of Early-Onset Scoliosis (C-EOS).  J Bone Joint Surg Am. 2014 Aug 20;96(16):1359-67. doi: 10.2106/JBJS.M.00253.

Preoperative Optimization and Risk Assessment

  • Boachie-Adjei O, Yagi M, Sacramento-Dominguez C, Akoto H, Cunningham ME, Gupta M, Hess WF, Lonner BS, Ayamga J, Papadopoulos EC, Sanchez-Perez-Grueso F, Pelise F, Paonessa KJ, Kim HJ; FOCOS Spine Research Group. Surgical Risk Stratification Based on Preoperative Risk Factors in Severe Pediatric Spinal Deformity Surgery.  Spine Deform. 2014 Sep;2(5):340-349. doi: 10.1016/j.jspd.2014.05.004. Epub 2014 Aug 27.PMID: 27927331
    • Retrospective review of consecutive pediatric spine deformity surgeries (n=145) to create a surgical risk classification.  Five levels of risk stratification were established based on curve magnitude, etiology, ASA grade, number of fusion levels, preoperative neurologic status, BMI, and type of osteotomies.  No single parameters predicted postoperative complications. However, a higher-level score in the classification trended toward increased intraoperative neuromonitoring change and postoperative neurologic risk.
  • Luhmann SJ, Smith JC.  Preoperative MRSA Screening in Pediatric Spine Surgery: A Helpful Tool or a Waste of Time and Money?  Spine Deform. 2016 Jul;4(4):272-276. doi: 10.1016/j.jspd.2015.12.006. Epub 2016 Jun 16.
    • Retrospective review from single surgeon spine database (n=339) to assess usefulness of preoperative nasal swab screening for Staphylococcus aureus in pediatric spine surgery patients.  MRSA was positive in 6% of patients and MSSA was positive in 16% of patients.  In 6.5% of patients, antibiotic resistance to cefazolin or clindamycin was identified.  Authors concluded that S. aureus preoperative nasal swab permitted adjustment of perioperative antibiotics in up to 6.5% of patients.
  • Luhmann SJ, Furdock R. Preoperative Variables Associated With Respiratory Complications After Pediatric Neuromuscular Spine Deformity Surgery. Spine Deform. 2019 Jan;7(1):107-111. doi: 10.1016/j.jspd.2018.05.005.
    • Retrospective review from a single surgeon database (n=111) to correlate preoperative variables with the risk of respiratory complications in neuromuscular spine deformity.  It showed that any history of pneumonia and presence of a gastrotomy tube correlated with an increased risk of postoperative respiratory complications with both univariate and multivariate analyses.  Univariate analysis of low serum transferrin and presence of a tracheostomy were suggestive of increased postoperative respiratory complications.
  • Matsumoto H, Campbell M, Minkara A, Roye DP, Garg S, Johnston C, Samdani A, Smith J, Sponseller P, Sturm PF, Vitale M; Children’s Spine Study Group; Growing Spine Study Group.
    Paper #45: Development of a Risk Severity Score (RSS) Predicting Surgical Site Infection in Early Onset Scoliosis: Identifying High-Risk Patients.  Spine Deform. 2017 Nov;5(6):464-465. doi: 10.1016/j.jspd.2017.09.048.PMID: 31997165
    • Multicenter retrospective cohort study of early onset scoliosis patients (n=1,168) undergoing spine deformity surgery.  A Risk Severity Score was developed to quantify the risk for surgical site infection.  The model predicted 3.3% probability of SSI in patients with no risk factors and 68.4% probably in patients with myelomeningocele, GI, endocrine, and pulmonary comorbidities, developmental delay, urinary incontinence, and VP shunt. 
  • Mistovich RJ, Jacobs LJ, Campbell RM, Spiegel DA, Flynn JM, Baldwin KD. Infection Control in Pediatric Spinal Deformity Surgery: A Systematic and Critical Analysis Review.  JBJS Rev. 2017 May;5(5):e3. doi: 10.2106/JBJS.RVW.16.00071.
    • Review article.  The authors reviewed 167 studies related to risk factors and interventions for reducing surgical site infections in pediatric spine deformity surgery.  Articles were stratified by diagnosis type (AIS, EOS, neuromuscular) and level of evidence.  Preventative strategy topics included use of intrawound antibiotics, preparation and irrigation, dressings, intravenous antibiotics, wound closure, implants, drains, bone graft, dual attending surgery, and pelvic fixation.  Modifiable risk factors reviewed consisted of obesity, hypothermia, duration of surgery, incontinence, and malnutrition.
  • Miyanji F, Slobogean GP, Samdani AF, Betz RR, Reilly CW, Slobogean BL, Newton PO. Is larger scoliosis curve magnitude associated with increased perioperative health-care resource utilization?: a multicenter analysis of 325 adolescent idiopathic scoliosis curves. J Bone Joint Surg Am. 2012 May 2;94(9):809-13. doi:10.2106/JBJS.J.01682.PMID: 22552670
    • 325 patients from a multicentre, surgical AIS database were analyzed and the authors found that larger curves were associated with increased utilization of perioperative health-care resources, namely OR time (significant increase), greater number of levels fused, and for every 10 degree increase in curve size, there was a 1.5 times higher odds of receiving a blood transfusion.
  • O'Brien MF, Lenke LG, Bridwell KH, Blanke K, Baldus C.  Preoperative spinal canal investigation in adolescent idiopathic scoliosis curves > or = 70 degrees.  Spine (Phila Pa 1976) 1994 Jul 15;19(14):1606-10.  doi: 10.1097/00007632-199407001-00009.
    • Prospective study of AIS patients (n=33) with curve > 70 degrees to assess for presence of spinal cord anomalies.  CT scan (n=3) or MRI (n=30) showed no neurologic abnormalities in any patients, and all patients were treated surgically without any neurologic sequelae.  Authors concluded preoperative investigation of the neural axis is not mandatory for large, typical AIS curves.
  • Sedra F, Shafafy R, Sadek AR, Aftab S, Montgomery A, Nadarajah R. Perioperative Optimization of Patients With Neuromuscular Disorders Undergoing Scoliosis Corrective Surgery: A Multidisciplinary Team Approach.  Global Spine J. 2021 Mar;11(2):240-248. doi: 10.1177/2192568220901692. Epub 2020 Feb 13.
    • Review article.  Describes a multidisciplinary approach to optimize patients with neuromuscular disease undergoing scoliosis surgery as it relates to pulmonary, gastrointestinal, nutritional, cardiac, genitourinary, and wound complications, blood loss during surgery, and neurologic injury. 
  • White KK, Bompadre V, Krengel WF, Redding GJ; Pediatric Spine Study Group. Low Preoperative Lung Functions in Children With Early Onset Scoliosis Predict Postoperative Length of Stay.  J Pediatr Orthop. 2021 Apr 1;41(4):e316-e320
    • Prospective data collection from a multicenter registry.  Evaluated preoperative lung function studies in Children with EOS (n=525) to correlate with length of hospital stay following growth friendly or definitive spine fusion surgeries.  Only preoperative FVC < 50% predicted was associated with increased risk of postoperative length of stay > 7 days.

Pre-operative Planning and Level Selection

  • Baghdadi S, Cahill P, Anari J, Flynn JM, Upasani V, Bachmann K, Jain A, Baldwin K; Harms Study Group. Evidence Behind Upper Instrumented Vertebra Selection in Adolescent Idiopathic Scoliosis: A Systematic and Critical Analysis Review. JBJS Rev. 2021 Sep 9;9(9). doi: 10.2106/JBJS.RVW.20.00255.
    • The authors conducted a systematic review to appraise various recommendations with regards to Upper Instrumented Vertebra (UIV) selection in Adolescent Idiopathic Scoliosis. Current guidelines for selection of UIV is still mostly inconclusive with mixed/ low-level evidence.
  • Beauchamp EC, Lenke LG, Cerpa M, Newton PO, Kelly MP, Blanke KM; Harms Study Group Investigators. Selecting the "Touched Vertebra" as the Lowest Instrumented Vertebra in Patients with Lenke Type-1 and 2 Curves: Radiographic Results After a Minimum 5-Year Follow-up.  J Bone Joint Surg Am. 2020 Nov 18;102(22):1966-1973.  doi: 10.2106/JBJS.19.01485.PMID: 32804885
    • The authors reviewed a multicenter database and analyzed the data of 299 Lenke 1 and 2 patients (minimum follow-up of 5 years. The authors recommended fusion to the ‘Touched Vertebra” (TV) for Lenke 1 and 2 curves. Patients with ‘A’ Lumbar Modifier who had fusion cephalad to the TV were at higher risk of Lower Instrumented Vertebra (LIV) translation with risk of poorer long term outcome.
  • Chan CM, Swindell HW, Matsumoto H, Park HY, Hyman JE, Vitale MG, Roye DP Jr, Roye BD. Effect of Preoperative Indications Conference on Procedural Planning for Treatment of Scoliosis.  Spine Deform. 2016 Jan;4(1):27-32. doi: 10.1016/j.jspd.2015.05.003. Epub 2015 Dec 23.
    • The authors evaluated the effect of preoperative indications conference on the surgical plan in 107 scoliosis surgeries. Change in surgical plan occurred in 28% of index surgeries and 8% of revision surgeries. Index surgeries for AIS/JIS patients were the most likely to be influenced by preoperative indications conference.
  • Marciano G, Ball J, Matsumoto H, Roye B, Lenke L, Newton P, Vitale M; Harms Study Group. Including the stable sagittal vertebra in the fusion for adolescent idiopathic scoliosis reduces the risk of distal junctional kyphosis in Lenke 1-3 B and C curves. Spine Deform. 2021 May;9(3):733-741. doi: 10.1007/s43390-020-00259-2. Epub 2021 Jan 5.
    • In this retrospective multicenter cohort study, the authors reviewed 856 AIS patients, 114 patients of which had discordant Coronal Last Touched Vertebra (c-LTV) and Sagittal Stable Vertebra (SSV). Among the 114 patients, patients with Lenke 1-3 with B/C Lumbar Modifier who were fused short of the SSV were 9 times more likely to develop distal junctional kyphosis.(DJK) However, those who were fused short of the SSV but did not develop DJ had better patient reported outcome measures.
  • Medrriman M, Hu C, Noyes K, Sanders J.Selection of the Lowest Level for Fusion in Adolescent Idiopathic Scoliosis-A Systematic Review and Meta-Analysis. Spine Deform. 2015 Mar;3(2):128-135. doi: 10.1016/j.jspd.2014.06.010. Epub 2015 Mar 4.
    • In this systematic review and meta-analysis to analyse the association between the lowest level of fusion to the occurrence of back pain following surgery. 8 retrospective studies were included in the analysis. Although there was a trend towards more back with fusion to L4 or L5 compared to L3 and cephalad, the association was not statistically significant. Therefore, the effect of distal level of fusion on post-oeprative low back pain is still not known.
  • Miyanji F, Newton PO, Perry A, Vanvalin S, Pawlek J.  Analysis of the Lenke 1A Curve Classification: Defining   2 Sub-Types Based on L4 Tilt.  Spine Nov 33(23):2545 – 51,2008.
    • 93 patients with Lenke 1A and 1B curves and 2 year f/u were analyzed. Lenke 1A curves were subdivide into 1A-L and 1A-R depending on the tilt of L4 (1A-L, L4 tilted to left and 1A-R, L4 tilted to right). Those that had L4 tilted to the left (1A-L) behaved like Lenke 1B curves with a similar location of the stable vertebrae and a median LIV of T12.  Lenke 1A-R had more distal stable vertebrae (L3 and L4) with significant more distal median LIV of L2.  The authors propose that the A and B lumbar modifier for Lenke 1 curves does not describe distinct curve types within Lenke 1curve types and propose a subdivision of Lenke 1A curves into 1A-R and 1A-L, depending on the tilt of L4.
  • Sardar ZM, Ames RJ, Lenke L. Scheuermann's Kyphosis: Diagnosis, Management, and Selecting Fusion Levels.  J Am Acad Orthop Surg. 2019 May 15;27(10):e462-e472. doi: 10.5435/JAAOS-D-17-00748.PMID: 30407981. Review article.
    • In this review article, the diagnosis, management and selection of fusion levels were discussed. Surgical indication included curved that has progressed beyond 70 degrees. There is a trend towards an all posterior approach for surgery. Upper instrumented vertebrae should include at least the upper end vertebrae but a more proximal UIV selection could reduce the risk of proximal junctional kyphosis. The authors recommended inclusion of the sagittal stable vertebrae in the fusion block to reduce the risk of distal junctional kyphosis.
  • Shao X, Sui W, Deng Y, Yang J, Chen J, Yang J. How to select the lowest instrumented vertebra in Lenke 5/6 adolescent idiopathic scoliosis patients with derotation technique.
    Eur Spine J. 2022 Apr;31(4):996-1005. doi: 10.1007/s00586-021-07040-7. Epub 2021 Nov 6.
    • The authors reported the outcome of 53 Lenke 5/6 patients in this retrospective study. The criteria for LIV selection were most cephalad vertebra touched by CSVL, Vertebra with grade 2 or less rotation, and vertebra with lowest instrumented vertebra disc angle that can be reversed on lateral bending. Utilising this selection criteria, at minimum 2 years follow up the incidence of adding on phenomenon and coronal decompensation was 3.8% respectively.
  • Toll BJ, Gandhi SV, Amanullah A, Samdani AF, Janjua MB, Kong Q, Pahys JM, Hwang SW. Risk Factors for Proximal Junctional Kyphosis Following Surgical Deformity Correction in Pediatric Neuromuscular Scoliosis.  Spine (Phila Pa 1976). 2021 Feb 1;46(3):169-174. doi: 10.1097/BRS.0000000000003755.
    • In this single center retrospective study, 60 pediatric neuromusuclar scoliosis patients were included in the analysis. The incidence of Proximal Junctional Kyphosis (PJK) was 27% and Proximal Junctional Failure (PJF) was 7%. Risk factors for PJK included pre-operative halo-gravity traction, greater C2 sagittal translation, loss of primary curve correction and smaller pre-operative proximal kyphosis.
  • Yang J, Andras LM, Broom AM, Gonsalves NR, Barrett KK, Georgiadis AG, Flynn JM, Tolo VT, Skaggs DL. Preventing Distal Junctional Kyphosis by Applying the Stable Sagittal Vertebra Concept to Selective Thoracic Fusion in Adolescent Idiopathic Scoliosis.
    Spine Deform. 2018 Jan;6(1):38-42. doi: 10.1016/j.jspd.2017.06.007.
    • The authors conducted a retrospective review of data obtained from two centers to analyze the importance of the Sagittal Stable Vertebra(SSV) in prevention of distal junctional  (DJK) in Adolescent Idiopathic Scoliosis (AIS) patients who underwent selective thoracic fusion (STF). Among the 113 patients, the rate of DJK was 17% (LIV cephalad to SSV) vs. 0% (LIV at SSV or distal to it). Selection of LIV at or distal to SSV would minimise risk of DJK.


  • Berry JG, Glaspy T, Eagan B, Singer S, Glader L, Emara N, Cox J, Glotzbecker M, Crofton C, Ward E, Leahy I, Salem J, Troy M, O'Neill M, Johnson C, Ferrari L. Pediatric complex care and surgery comanagement: Preparation for spinal fusion. J Child Health Care. 2020 Sep;24(3):402-410. doi: 10.1177/1367493519864741. Epub 2019 Jul 30.
    • Study looking at the impact of preoperative comanagement with complex care pediatricians (CCP) on patients with neuromuscular scoliosis undergoing spinal fusion.  The study found that those children who had involvement of the CCP team had fewer last minute coordination activities for surgical clearance, and fewer had last minute changes to preoperative plans.  Study was done at a large tertiary referral children’s hospital.
  • Flynn JM, Striano BM, Muhly WT, Kraus B, Sankar WN, Mehta V, Blum M, DeZayas B, Feldman J, Keren R.  A Dedicated Pediatric Spine Deformity Team Significantly Reduces Surgical Time and Cost. J Bone Joint Surg Am. 2018 Sep 19;100(18):1574-1580. doi: 10.2106/JBJS.17.01584.PMID: 3023462.
    • Retrospective analysis comparing dedicated OR teams made up a small group of anesthesiologists, CRNA’s, OR nurses and technicians (Dedicated Team) with PSF without dedicated teams in a large hospital setting.  Cases were categorized as I (<12 levels fused, no osteotomies, and a BMI < 25 kg/m2, or II (>= 12 levels fused and or >= 1 osteotomy and/or a BMI >= 25 kg/m2 .  Standardized protocols were developed and implemented.  Neuromuscular and more complex cases were excluded from analysis.  There was almost a 1-2 hour improvement in OR time, and a cost savings in cases where dedicated teams were used.
  • Miyanji F, Greer B, Desai S, Choi J, Mok J, Nitikman M, Morrison A.  Improving quality and safety in paediatric spinal surgery: the team approach. Bone Joint J. 2018 Apr 1;100-B(4):493-498. doi: 10.1302/0301-620X.100B4.BJJ-2017-1202.R1.
    • A retrospective consecutive case control study of spine surgeries lasting > 120 minutes of one surgeon before and after the implementation of a paediatric spinal surgical team (PSST) made up of a homogenous group of OR nurses, anesthitists, and IONM technician.  There were significant improvements in operating room time, length of stay, blood loss, and allogenic blood transfusion in the group with a PSST.   Complications were also higher in the pre PSST group compared to those patients with the PSST. There was a 2.4 times increased risk of surgical site infection in the pre PSST group. Of note surgeon experience (which was greater in the PSST group) may have had a confounding effect on the results.


Neurologic Injury Prevention

  • Halsey M, Myung K, Ghag A, Vitale M, Newton P, de Kleuver M. Neurophysiological monitoring of spinal cord function during spinal deformity surgery: 2020 SRS neuromonitoring information statement. Spine Deformity.2020; 8:591-596.
    • The Scoliosis Research Society developed an updated information statement on intraoperative neurophysiological monitoring of spinal cord function during spinal deformity surgery, expressing the opinion that its utilization in spinal deformity surgery is the standard of care when the spinal cord is at risk.
  • Iyer R, Vitale M, Fano A, Matsumoto H, Sucato D, Samdani A, Smith J, Gupta M, Kelly M, Kim H, Sciubba D, Cho S, Polly D, Boachie-Adjel O, Angevine P, Lewis S, Lenke L. Establishing consensus: determinants of high-risk and preventative strategies for neurological events in complex spinal deformity surgery. Spine Deformity. 2022; 10:733-744.
    • A resource highlighting several clinical factors found in complex, high-risk spinal deformity patients as well as strategies to prevent neurological events was created through expert consensus. 
  • Lenke L, Fano A, Iyer R, Matsumoto H, Sucato D, Samdani A, Smith J, Gupta M, Kelly M, Kim H, Sciubba D, Cho S, Polly D, Boachie-Adjei O, Lewis S, Angevine P, Vitale M. Development of consensus-based best practice guidelines for response to intraoperative neuromonitoring events in high-risk spinal deformity surgery. Spine Deformity. 2022; 10:745-761.
    • The authors provide consensus guidelines to help organize and direct surgical teams in exploring common diagnostic patterns of intraoperative neuromonitoring events and to serve as a source of potentially useful avenues for investigation and intervention.
  • Strike S, Hassanzadeh H, Jain A, Kebaish K, Njoku D, Becker D, Ain M, Sponseller P. Intraoperative Neuromonitoring in Pediatric and Adult Spine Deformity Surgery. Clin Spine Surg. 2017; 30:E1174-E1181.
    • This review of intraoperative neuromonitoring modalities provides a framework from which spine surgeons can select appropriate monitoring for their patients
  • Vitale MG, Skaggs DL, Pace GI, et al. Best practices in intraoperative neuromonitoring in spine deformity surgery: development of an intraoperative checklist to optimize response. Spine Deformity. 2014; 2(5):333-339.
    • The authors developed a checklist which includes the most important items to consider when responding to intraoperative neuromonitoring (IONM) changes in patients with a stable spine. 
  • Bjerke B, Zuchelli D, Nemani V, Emerson R, Kim H, Boachie-adjei O. Prognosis of significant intraoperative neurophysiologic monitoring events in severe spinal deformity surgery. Spine Deformity. 2017; 5:117-123.
    • In this study of 88 patients with severe deformities, intraoperative signal changes were most frequently from traction or positioning. The incidence of postoperative neurologic deficit is very low when the inciting cause is reversed; however, osteotomy-related events are irreversible, with a high incidence of associated lasting neurologic injury.
  • Dikmen P, Halsey M, Yucekul A, de Kleuver M, Hey L, Newton P, Havlucu I, Zulemyan T, Yilgor C, Alanay A. Intraoperative neuromonitoring practice patterns in spinal deformity surgery: a global survey of the Scoliosis Research Society. Spine Deformity. 2021; 9:315-325.
    • The responses of 205 experienced SRS members from different regions of the world showed that surgeons had different approaches in their routine IONM practices and in the handling of alerts, highlighting the need for consensus guidelines.
  • Sielatycki J, Cerpa M, Baum G, Pham M, Thuet E, Lehman R, Lenke L. A novel MRI-based classification of spinal cord shape and CSF presence at the curve apex to assess risk of intraoperative neuromonitoring data loss with thoracic spinal deformity correction. Spine Deformity. 2020; 8:655-661.
    • The authors present a new spinal cord risk classification scheme to identify patients with increased odds of losing spinal cord monitoring data during thoracic deformity correction. The odds of losing intraoperative MEPs/SSEPs are greater in type 3 spinal cords, where the cord is deformed against the concave pedicle in the axial plane.

Perioperative Blood Management

  • Bible JE, Mirza M, Knaub MA. Blood-loss Management in Spine Surgery. J Am Acad Orthop Surg. 2018;26(2):35–44. 6-00184.  PMID: 29303921                   
    • Advocate antifibrinolytic agents and anesthesia techniques over cell saver.
  • Dong Y, Tang N, Wang S, Zhang J, Zhao H.  Risk factors for blood transfusion in adolescent patients with scoliosis undergoing scoliosis surgery: a study of 722 cases in a single center.  BMC Musculoskeletal disorders 2021; 22:131-8.  PMID:  33402158.                                               
    • Diagnosis, osteotomies, number of segments fused, intra-operative blood loss were risk factors for allogenic blood transfusion.
  • Fletcher ND, Marks MC, Asghar JK, Hwang SW, Sponseller PD; Harms Study Group, Newton PO.  Development of Consensus Based Best Practice Guidelines for Perioperative Management of Blood Loss in Patients Undergoing Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.  Spine Deform. 2018 Jul-Aug;6(4):424-429. doi: 10.1016/j.jspd.2018.01.001.PMID: 29886914
  • Goobie SM, Zurakowski D, Glotzbecker MP, McCann ME, Hedequist D, Brustowicz RM, Sethna NF, Karlin LI, Emans JB, Hresko MT. Tranexamic acid is efficacious at decreasing the rate of blood loss in adolescent scoliosis surgery: a randomized placebo-controlled trial. J Bone Joint Surg Am. 2018; 100(23):2024 –32. PMID: 30516625
    • 50 mg/kg loading dose and 10 mg/kg/h infusion.  For AIS risk for clinically relevant blood loss of 20ml/kg was more than 2x higher in the placebo group compared to the TXA group and the TXA group had 27% less blood loss than the placebo group.  Duration of surgery, TXA, and number of levels fused were the main determinants of requiring a allogenic transfusion.
  • Liang J, Shen J, Chua S, Fan Y, Zhai J, Feng B, Cai S, Li Z, Xue X.  Does intraoperative cell salvage system effectively decrease the need for allogeneic transfusions in scoliotic patients undergoing posterior spinal fusion? A prospective randomized study.  Eur Spine J 2015 Feb;24(2):270-5.  PMID: 24682378                                                                                                                                     
    • Cell saver use significantly reduces the need for allogeneic blood in spine deformity surgery, particularly in patients with low preoperative hemoglobin or longer operation time. This study confirms the utility of routine cell saver use during PSF with segmental spinal instrumentation for scoliosis patients
  • Mange TR, Sucato DJ, Poppino KF, Jo CH, Ramo BR. The incidence and risk factors for perioperative allogeneic blood transfusion in primary idiopathic scoliosis surgery. Spine Deform. 2020. Case Series Published 09 March 2020.   PMID: 32152964                                                                                   
    • Knowing risk factors for allogeneic blood transfusion can help the surgeon avoid transfusion.
  • McVey MJ, Lau W, Nariaine N, Zaarour C, Zeller R.  Perioperative blood conservation strategies for pediatric scoliosis surgery.  Spine Deformity 2021 Sep:9(5):1289-1302.  PMID: 33900586        
    • Recommends interdisciplinary communication and multimodal blood conservation techniques.  This is an up-to-date review of many of the modalities available for effective PBC.  Autologous donation is no longer encouraged. Eventually evidence based individualized PBC interventions will become available.
  • Mihas A, Ramchandran S, Rivera S, Mansour A, Asghar J, Shufflebarger H, George S. Safe and effective performance of pediatric spinal deformity surgery in patients unwilling to accept blood transfusion: a clinical study and review of the literature.  BMC Musculoskeletal Disord 2021 Feb 19;22(1):204         PMID: 33607982           
    • Protocols developed for patients such as Jehovah witness can be applied to all patients to assure much less risk of needing an allogenic blood transfusion.  Technique included potentially staging a procedure, hypotensive (< 75 mm Hg) anesthesia, intraoperative blood salvage, tranexamic acid (50 mg/kg load, 5 mg/kg/hr), skin injection with 1% lidocaine and 1:100,000 epinephrine, bipolar tissue searler, topical TXA, surgifoam, bone scalpel.
  • Oetgen, ME, Litenta J. Perioperative blood management in pediatric spine surgery.  J Am Acad Orthop Surg 2017 July;25(7):480-488  PMID: 28644187
  • Stone N, Sardana V, Missiuna P. Indications and outcomes of cell saver in adolescent scoliosis correction surgery: a systematic review. Spine (Phila Pa 1976). 2017;42(6):E363–70.   PMID: 27398896.   
    • Cell saver reduces the demand for allogenic transfusion.  This review supports the use of cell saver if the associated monetary costs are expected to be less than the cost of transfusing one unit of allogenic blood.
  • Verma K, Errico T, Diefenbach C, Hoelscher C, Peters A, Dryer J, Huncke T, Boenigk K, Lonner BS.  The relative efficacy of antibibrinolytics in adolescent idiopathic scoliosis.  A prospective randomized trial.  J Bone Joint Surg Am 2014;96:e80 (1-10).                                                             
    • Double blind, placebo controlled.  Small study.  TXA loading dose was 10 mg/kg and maintained at 1 mg/kg/hr.  Tranexamic acid and epsilon-aminocaproic acid reduced operative blood loss but not transfusion rate. Tranexamic acid is more effective at reducing postoperative drainage and total blood losses compared with epsilonaminocaproic acid. Maintenance of the mean arterial pressure at < 75 m Hg during surgical exposure appears to be critical for maximizing antibibrinolytic benefit. 

Infection Prevention

  • Michael G Vitale, Matthew D Riedel, Michael P Glotzbecker, Hiroko Matsumoto, David P Roye, Behrooz A Akbarnia, Richard C E Anderson, Douglas L Brockmeyer, John B Emans, Mark Erickson, John M Flynn, Lawrence G Lenke, Stephen J Lewis, Scott J Luhmann, Lisa M McLeod, Peter O Newton, Ann-Christine Nyquist, B Stephens Richards 3rd, Suken A Shah, David L Skaggs, John T Smith, Paul D Sponseller, Daniel J Sucato, Reinhard D Zeller, Lisa Saiman. Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery. J Pediatr Orthop. 2013 Jul-Aug;33(5):471-8. doi: 10.1097/BPO.0b013e3182840de2.
    • A 14-statement consensus reached through a Delphi method regarding best practices for prevention of SSI in high-risk pediatric patients. It addresses pre-op, intraop and post-operative practices.
  • Michael P Glotzbecker, Tricia A St Hilaire, Jeff B Pawelek, George H Thompson , Michael G Vitale, Children’s Spine Study Group; Growing Spine Study Group. Best Practice Guidelines for Surgical Site Infection Prevention With Surgical Treatment of Early Onset Scoliosis. J Pediatr Orthop. 2019 Sep;39(8):e602-e607. doi: 10.1097/BPO.0000000000001079.
    • A 22-statement consensus reached through a Delphi method regarding best practices for prevention of SSI in EOS. It addresses pre-op, intraop and post-operative practices.
  • Matsumoto H, Campbell M, Minkara A, Roye DP, Garg S, Johnston C, Samdani A, Smith J, Sponseller P, Sturm PF, Vitale M; Children’s Spine Study Group; Growing Spine Study Group. Spine Deform. 2017 Nov;5(6):464-465. doi: 10.1016/j.jspd.2017.09.048. PMID: 31997165 Spine Deform. 2017 Nov;5(6):464-465. doi: 10.1016/j.jspd.2017.09.048.PMID: 31997165
    • Retrospective study assessing Risk Severity score that allows to predict SSI risk in patients with EOS. The presence of myelomeningocele, GI, endocrine, and pulmonary comorbidities, developmental delay, urinary incontinence, and ventriculoperitoneal shunt increase the risk of infection to 68.4% while the absence of these comorbidities lowers the risk to 3.3%.
  • Luhmann SJ, Smith JC. Preoperative MRSA Screening in Pediatric Spine Surgery: A Helpful Tool or a Waste of Time and Money? Spine Deform. 2016 Jul;4(4):272-276. doi: 10.1016/j.jspd.2015.12.006. Epub 2016 Jun 16.
    • In 6.5% of the cases, the use of nasal swab as a method for screening the presence of MRSA changed the preoperative antibyotic regime due to the presnece of resistance (4.7% MRSA and 1.8% MSSA).
  • Mistovich RJ, Jacobs LJ, Campbell RM, Spiegel DA, Flynn JM, Baldwin KD. Infection Control in Pediatric Spinal Deformity Surgery: A Systematic and Critical Analysis Review.
  • KD. JBJS Rev. 2017 May;5(5):e3. doi: 10.2106/JBJS.RVW.16.00071.
    • Systematic review on the risk of SSI in pediatric population: There is insufficient evidence to recommend either topical gentamycin or vancomycin, the use of irrigation (and other surgical preparation solutions), a specific type of dressing (including incisional vacuum and the participation of two attendings. There is grade B recommendation for any type of closure methods, in favor of titanium (instead of stainless steel), against the use of drains, the increased risk with the use of pelvic fixation (no difference with S2A1 screws), intraop hypothermia does not increase the risk of SSI and that length of surgery doesn’t impact SSI rates. There is grade C recommendation in favor of the use of iv atb, mixed evidence regarding allografts, mixed reviews regarding obesity, incontinence and malnutrition as modifiable factors.

Navigation and Enabling Technology

  • Safety in Spine Surgery site
  • Baky FJ, Milbrandt T, Echternacht S, et al. Intraoperative computed tomography-guided navigation for pediatric spine patients reduced return to operating room for screw malposition compared with freehand/fluoroscopic techniques. Spine Deform 2019; 7: 577-81.
    • Single center retrospective review of patients younger than 18 undergoing pedicle screw instrumentation were included. 112 patients had screws inserted using fluoroscopic guidance, whereas, 105 had screws inserted using intraoperative CT-guided navigation. Blood loss and number of levels fused were similar. There was a higher rate of screw malposition by >4mm in the fluoroscopic group (3.3% vs. 1%), higher rate of unplanned return to OR for screw malposition in the fluoroscopic group (3.6% vs. 0%). Use of intraop CT navigation eliminated unplanned return to OR for screw malposition
  • Baldwin KD, Kadiyala M, Talwar D, et al. Does intraoperative CT navigation increase the accuracy of pedicle screw placement in pediatric spinal deformity surgery? A systematic review and meta-analysis. Spine Deform 2022; 10: 19-29.
    • Systematic review of 13 articles comparing pedicle screws placed with freehand or 2D fluoroscopy assistance with screws placed using CT navigation. EBL was similar between groups but operative time was longer by about 30 minutes in the Navigation group. Intraop navigation resulted in more accurate screws and less unsafe screws. Effective radiation dose trended higher in navigated cases compared to non-navigated cases but did not reach statistical significance.
  • Chan A, Parent E, Narvacan K, et al. Intraoperative image guidance compared with free-hand methods in adolescent idiopathic scoliosis posterior spinal fusion surgery: a systematic review on screw-related complications and breach rates. Spine J 2017; 17: 1215-29.
    • Systematic review of 79 studies. CT guidance has lower breach rates than free-hand methods. Screw related complications were 0% in CT guidance and up to 1.7% in free-hand.
  • Chan A, Parent E, Wong J, et al. Does image guidance decrease pedicle screw-related complications in surgical treatment of adolescent idiopathic scoliosis: a systematic review update and meta-analysis. Eur Spine J 2020; 29: 694-71
    • Systematic review of 94 studies. Image/CT guidance had lower breach rate than free hand but with a surgical time longer by about 30 minutes.
  • Kaur J, Koltsov JCB, Kwong JW, et al. Does navigation make spinal fusion for adolescent idiopathic scoliosis safer? Insights from a national database. Spine 2021;46: E1049-57.
    • Retrospective review of 12,046 patients from a national database undergoing spinal fusion for AIS. 90 day complication rate was lower with navigation. Nav did not have an impact on neurologic complications or return to OR. Nav was associated with increased total reimbursement and a 0.32-day decrease in length of stay
  • Kudo H, Wada K, Kumagai G, et al. Accuracy of pedicle screw placement by fluoroscopy, a three-dimensional printed model, local electrical conductivity measurement device, and intra-operative computed tomography navigation in scoliosis patients. Eur J Orthop Surg Traumatolo 2021; 31: 563-9.
    • Retrospective, single center study that analyzed 553 pedicle screws in 31 patients. No significant difference in clinical results with different techniques except for longer operative time with Navigation. Accuracy of screw placement ranged from 91.3% to 93.7%
  • Moore HG, Samuel AM, Burroughs PJ, et al. Use of intraoperative navigation for posterior spinal fusion in adolescent idiopathic scoliosis surgfery is safe to consider. Spine Deform 2021; 9: 403-10.
    • Retrospective review of 12,739 non-navigated and 340 navigated patients from NSQIP-Pediatric database. Use of navigation increased from 0.5% of cases in 2012 to 5.2% of cases in 2018. No difference in demographics, comorbidities, and number of levels fused. Navigated cases were longer by about 41 minutes but had a 0.4-day decrease in length of stay. Perioperative adverse outcomes were not significantly different between groups
  • Tian W, Zeng C, An Y, et al. Accuracy and postoperative assessment of pedicle screw placement during scoliosis surgery with computer-assisted navigation: a meta-analysis. Int J Med Robot 2017; 13. Doi:10.1002/rcs.1732.
    • Meta-analysis. Pedicle screw accuracy was higher with navigation but operative time and curve correction was not different from non navigated cases.
  • Urbanski W, Jurasz W, Wolanczyk M, et al. Increased radiation but no benefits in pedicle screw accuracy with navigation versus a freehand technique in scoliosis surgery. Clin Orthop Relat Res 2018; 476: 1020-7.
    • Retrospective review of 49 patients undergoing posterior spinal fusion with all pedicle screw constructs for idiopathic scoliosis. 27 patients with navigation and 22 patients with freehand screw placement. Pedicle breach assessed on intraop O-Arm scan. There was no difference in screw accuracy, while navigated patients received a greater mean radiation dose.
  • Wong HK. CORR InsightsÒ: Increased radiation but no benefits in pedicle screw accuracy with navigation versus a freehand technique in scoliosis surgery. Clin Orthop Relat Res 2018; 476: 1028-30.
    • This article is a commentary on the previous article.


Optimizing Length of Stay in Adolescent Idiopathic Scoliosis Surgery

  • Fletcher ND, Glotzbecker MP, Marks M, Newton PO,Harms Study Group. Development of Consensus-Based Best Practice Guidelines for Postoperative Care Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.  Spine (Phila Pa 1976). 2017 May 1;42(9): E547-E554. doi: 10.1097/BRS.0000000000001865.PMID: 28441684 
    • An expert panel of 26 pediatric spine surgeons opined upon a detailed literature review and consensus was sought using the Delphi process. Consensus (agreement > 80%) was reached to support 19 best practice guideline (BPG) measures for postoperative care supporting non-ICU admission, perioperative pain control (supporting PCA pump, gabapentin, antispasmodics and ketorolac use; limiting epidural, early transition to oral narcotics), dietary management (supporting early clear liquids, chewing gum, bowel regimen and antiemetics), physical therapy (sitting, standing and twice daily PT POD#1), limiting postoperative radiographs, and indications for discharge (pain tolerated with oral analgesic, tolerating regular diet, bowel movement unnecessary, meeting PT goals).
  • Fletcher ND, Murphy JS, Austin TM, Bruce RW Jr, Harris H, Bush P, Yu A, Kusumoto H, Schmitz ML, Devito DP, Fabregas JA, Miyanji F. Short term outcomes of an enhanced recovery after surgery (ERAS) pathway versus a traditional discharge pathway after posterior spinal fusion for adolescent idiopathic scoliosis.  Spine Deform. 2021 Jul; 9(4): 1013-1019. doi: 10.1007/s43390-020-00282-3. Epub 2021 Jan 18.PMID: 33460022
    • A prospective dual-center study of patients treated using an ERAS pathway (203 patients) or a traditional discharge (TD) pathway (73 patients) was performed with focus on pain at discharge, quality of life at one month, and return to school/work. LOS was 55% less in the ERAS group (4.8 days TD vs. 2.2 days ERAS, p < 0.001). Regression analysis showed no difference in Visual Analog Score (VAS) score at discharge or quality of recovery using the QOR9 instrument between groups at follow up. There was no difference in return to school and parents' return to work between the groups.
  • Muhly WT, Sankar WN, Ryan K, Norton A, Maxwell LG, DiMaggio T, Farrell S, Hughes R, Gornitzky A, Keren R, McCloskey JJ, Flynn JM. Rapid Recovery Pathway After Spinal Fusion for Idiopathic Scoliosis.  Pediatrics. 2016 Apr; 137(4): e20151568. doi: 10.1542/peds.2015-1568. Epub 2016 Mar 23. PMID: 27009035
    • A quality improvement initiative was undertaken to assess a standardized rapid recovery pathway (RRP). Functional recovery was assessed using LOS and average daily pain scores. Process measures were medication adherence and order set utilization, balancing measure was 30-day readmission rate. Baseline average LOS was 5.7 days and decreased to 4 days after RRP implementation. Average daily pain scores remained stable with improvement on postoperative day 0 (3.8 vs 4.9 days) and 1 (3.8 vs 5 days) after RRP implementation. Gabapentin (91%) and ketorolac (95%) use became routine and order set utilization was 100%. Readmission rates did not increase as a result of the RRP.
  • Yang J, Skaggs DL, Chan P, Villamor GA, Choi PD, Tolo VT, Kissinger C, Lehman A, Andras LM.  High Satisfaction in Adolescent Idiopathic Scoliosis Patients on Enhanced Discharge Pathway.  J Pediatr Orthop. 2020 Mar;40(3): E166-170. doi: 10.1097/BPO.0000000000001436.PMID: 31403990
    • 46 prospectively enrolled patients were evaluated with a survey at their first postoperative clinic visit for satisfaction with an enhanced discharge pathway for PSF and whether they felt that their length of stay was appropriate. 80% of patients felt that they were discharged at an appropriate time (mean, 3.2 d) and had a trend toward shorter stays, whereas 20% felt they were discharged too early (mean, 3.7 d). Overall patient satisfaction of hospital stay was high with a mean of 9 on a 10-point scale (range, 1 to 10). There was no correlation between length of stay and patient satisfaction.

Optimizing Length of Stay in Neuromuscular Scoliosis Surgery

  • Spine Deform. 2019 Sep; 7(5): 804-811. doi: 10.1016/j.jspd.2019.02.002.PMID: 31495482
    • 74 patients with GMFCS class 4/5 CP undergoing PSF were reviewed. Thirty consecutive patients were cared for using a traditional discharge (TD) pathway, and 44 patients were subsequently treated using an accelerated discharge (AD) pathway. LOS was 19% shorter in patients managed with the AD pathway (AD 4.0 days vs. TD 4.9 days). There was no difference between groups with respect to age at surgery, GMFCS class, preoperative curve magnitude, pelvic obliquity, kyphosis, postoperative curve correction, fusion to the pelvis, or length of fusion between groups. LOS remained significantly shorter in the AD group by 0.9 days when controlling for EBL and length of surgery. There was no significant difference in wound complications, return to the operating room, or medical readmissions between groups.
  • Fletcher ND, Bellaire LL, Dilbone ES, Ward LA, Bruce RW Jr. Variability in length of stay following neuromuscular spinal fusion.  Spine Deform. 2020 Aug; 8(4): 725-732. doi: 10.1007/s43390-020-00081-w. Epub 2020 Feb 14.PMID: 32060807
    • 197 patients with NMS underwent PSF at a single hospital by two surgeons with a post-operative care pathway emphasizing early mobilization, rapid transition to enteral feeds, and discharge prior to first bowel movement. Severely involved cerebral palsy (CP) patients (GMFCS 4/5) were more likely to have extended stays than GMFCS 1-3 patients. Radiographic predictors included major coronal Cobb angle and pelvic obliquity. Intraoperative predictors included longer surgical times, greater numbers of levels fused and need for intraoperative or postoperative blood transfusion. The need for ICU admission and development of a pulmonary complication were significantly more likely to extend hospital stay.
  • Shaw KA, Heboyan V, Fletcher ND, Murphy JS. Comparative cost-utility analysis of postoperative discharge pathways following posterior spinal fusion for scoliosis in non-ambulatory cerebral palsy patients.  Spine Deform. 2021 Nov; 9(6): 1659-1667. doi: 10.1007/s43390-021-00362-y. Epub 2021 May 18.PMID: 34008146
    • An economic decision-analysis model was constructed using a hypothetical 15-year-old male with non-ambulatory CP undergoing PSF. Literature was reviewed to estimate costs, probabilities, and QALYs (age-matched US values, with a CP diagnosis corrective value applied) for identified complication profiles for discharge pathways, and probabilistic sensitivity analysis was performed. Accelerated discharge (AD) pathway resulted in an average cost and effectiveness of $67,069 and 15.4 QALYs compared with $81,312 and 15.4 QALYs for traditional discharge (TD). AD resulted in a 2.1% greater net monetary benefit with a cost-effectiveness ratio of $4361/QALY compared with $5290/QALY in the TD.
  • Simpson BE, Kara S, Wilson A, Wolf D, Bailey K, MacBriar J, Mayes T, Russell J, Chundi P, Sturm P. Reducing Patient Length of Stay After Surgical Correction for Neuromuscular Scoliosis.  Hosp Pediatr. 2022 Feb 17: e2021006196. doi: 10.1542/hpeds.2021-006196. Online ahead of print.PMID: 35174385
    • Quality improvement methodology was used to implement a standardized clinical care pathway for NMS patients during their primary spinal surgery. The outcome measure was LOS, and the process measure was percentage compliance with the pathway. Mean LOS decreased from 8.0 to 5.3 days; a statistically significant change based on statistical process control chart rules. Percentage compliance with the NMS pathway improved during the testing and sustain phases, compared with the pretesting phase. LOS variability decreased from pretesting to the combined testing and sustain phases.

Narcotic/pain management


Adding-on Phenomenon in Scoliosis Surgery

  • Cho RH, Yaszay B, Bartley CE, Bastrom TP, Newton PO. Which Lenke 1A curves are at the greatest risk for adding-on... and why?  Spine (Phila Pa 1976). 2012 Jul 15;37(16):1384-90. doi: 10.1097/BRS.0b013e31824bac7a.
    • 195 patients with Lenke 1A curves. Patients were grouped on the basis of the direction of the L4 verebral body tilt: 1A-L (left) and 1A-R (right).21% of patients met criteria for adding on. n the 1A-R curves, patients who added-on were fused at an average of 1.6 levels proximal to the neut ral vertebra for the patients who did not add-on
  • Fujii T, Daimon K, Fujita N, et al. Risk factors for postoperative distal adding-on in Lenke type 1B and 1C and its influence on residual lumbar curve. J Pediatr Orthop 2020; 40: E77-83.
    • This review of 46 patients with selective thoracic fusion examines lumbar curve behavior following adding on, specifically Lenke 1B and 1C patients. When comparing the 11 (24%) adding on patients to those without, there was better spontaneous correction of apical translataion of the lumbar curve, and a more horizontalized L4.
  • Fujii T, Kawabata S, Suzuki S, et al. Can postoperative distal adding-on be predicted in Lenke type 1B and 1C curves with intra-operative radiographs? Spine 2022; 47: E215-21.
    • This review explores risk factors for adding on in 69 AIS patients with either a Lenke 1B or 1C curve who underwent selective thoracic fusion and received intraoperative radiographs. In addition to selection of LIV as cranial to LTV being a risk factor, the authors identified that intraoperative wedging of the disc immediately below the LIV of greater than 3 degrees was a risk factor for adding on.
  • Liu CW, Lenke LG, Tan LA, et al. Selection of the lowest instrumented vertebra and relative odds ratio of distal adding-on for Lenke type 1A and 2A curves in adolescent idiopathic scoliosis: a systematic review and meta-analysis. Neurospine 2020; 17: 902-9.  Review Article
    • In a systematic review, the authors reported on 6 studies involving 732 patients treated with selective thoracic fusions. They identified five radiographic landmarks for LIV selection, as well as the pooled risk for adding on when LIV selection is cranial to that level: Stable Vertebra-1, End Vertebra+1, Neutral Vertebra, Touched Vertebra, and Substantially Touched Vertebra. They identified selection of the substantially touched vertebra as the absolute lowest risk of adding on. They also reported that LIV selection caudal to the 5 landmarks, did not reduce the risk of adding on.
  • Yang M, Zhao Y, Yin X, et al. Prevalence, risk factors, and characteristics of the ‘adding-on’ phenomenon in idiopathic scoliosis after correction surgery: a systematic review and meta-analysis. Spine 2018; 43: 780-90.
    • This systematic review identified 35 studies which were included in a meta-analysis examining the adding-on phenomenon. The overall prevalence of adding on was 14%, with slight variance between Lenke 1A (15%), 2 (12%), 5 (9%) and mixed curves (16%). Risk factors for adding on included smaller proximal thoracic and main thoracic curves, as well as smaller radiographic shoulder difference, and T1 tilt. Younger chronologic age and lower skeletal maturity were also identified as risk factors for adding on.

Distal Junctional Kyphosis

  • Marciano G, Ball J, Matsumoto H, Roye B, Lenke L, Newton P, Vitale M; Harms Study Group. Including the stable sagittal vertebra in the fusion for adolescent idiopathic scoliosis reduces the risk of distal junctional kyphosis in Lenke 1-3 B and C curves. Spine Deform. 2021 May;9(3):733-741. doi: 10.1007/s43390-020-00259-2. Epub 2021 Jan 5. PMID: 33400234.
    • Large cohort of 856 patients: Patients fused short of the SSV (stable sagittal vertebra) are at significant risk for the development of DJK at 2 years post-operatively. However, patients with shorter fusions were more likely to have an improvement in their pain as measured by patient-reported outcomes than patients with longer fusions.
  • Segal DN, Ball J, Fletcher ND, Yoon E, Bastrom T, Vitale MG; Harms Study Group. Risk factors for the development of DJK in AIS patients undergoing posterior spinal instrumentation and fusion. Spine Deform. 2022 Mar;10(2):377-385. doi: 10.1007/s43390-021-00413-4. Epub 2021 Sep 16. PMID: 34529249.
    • There was a low risk for progression of DJK when the SSV was proximal to the LTV, however, those with SSV distal to the LTV represent a high-risk group. The development of DJK occurred almost exclusively in patients with LIV at the thoracolumbar junction which demonstrates that surgeons need to be cautious when ending fusions at T11, T12, and L1 in patients at high risk for DJK.
  • Segal DN, Orland KJ, Yoon E, Bastrom T, Fletcher ND; Harms Study Group. Fusions ending above the sagittal stable vertebrae in adolescent idiopathic scoliosis: does it matter? Spine Deform. 2020 Oct;8(5):983-989. doi: 10.1007/s43390-020-00118-0. Epub 2020 May 13. PMID: 32405718.
    • Retrospective cohort study with 5 year follow up. There is an increased risk for development of DJK in patients with AIS treated with posterior fusion where the LIV was chosen proximal to the SSV.
  • Wang PY, Chen CW, Lee YF, Hu MH, Wang TM, Lai PL, Yang SH. Distal Junctional Kyphosis after Posterior Spinal Fusion in Lenke 1 and 2 Adolescent Idiopathic Scoliosis-Exploring Detailed Features of the Sagittal Stable Vertebra Concept. Global Spine J. 2021 Jun 7:21925682211019692. doi: 10.1177/21925682211019692. Epub ahead of print. PMID: 34096362.
    • Retrospective cohort study with minimum 2 year follow up, 122 patients. The primary outcome measure was the occurrence of postoperative DJK. When the SSV is intended to be spared from PSF to save more motion segments, TK and TLK should be carefully evaluated and attained in a lesser magnitude (TK < 25°, TLK < 10°) after surgery.

Proximal Junctional Kyphosis

  • Alzakri A, Vergari C, Van den Abbeele M, Gille O, Skalli W, Obeid I. Global Sagittal Alignment and Proximal Junctional Kyphosis in Adolescent Idiopathic Scoliosis. Spine Deform. 2019 Mar;7(2):236-244. doi: 10.1016/j.jspd.2018.06.014. PMID: 30660217.
    • Case control study 85 patients.  Evaluation of global sagittal alignment including the cranial center of mass (CCOM) and proximal junctional kyphosis (PJK) in adolescent idiopathic scoliosis (AIS) patients treated with posterior instrumentation.13% incidence of PJK- thought to be a compensatory mechanism, which allows for CCOM-HA( cranial center of mass  ) and, to a lesser extent, OD-HA ( dentiform apophysis of C2)to be invariant.
  • Erkilinc M, Baldwin KD, Pasha S, Mistovich RJ. Proximal junctional kyphosis in pediatric spinal deformity surgery: a systematic review and critical analysis. Spine Deform. 2022 Mar;10(2):257-266. doi: 10.1007/s43390-021-00429-w. Epub 2021 Oct 27. PMID: 34704232.
    • 635 papers:
    • There were 4 findings found to contribute to PJK with Grade B evidence in EOS: higher number of distractions, disruption of posterior elements, greater sagittal plane correction.  
    • Five findings with Grade B evidence were found to contribute to PJK in AIS populations: higher pre-operative thoracic kyphosis, higher pre-operative lumbar lordosis, longer fusion constructs, greater sagittal plane correction, and posterior versus anterior fusion constructs.  
  • Ferrero E, Bocahut N, Lefevre Y, Roussouly P, Pesenti S, Lakhal W, Odent T, Morin C, Clement JL, Compagnon R, de Gauzy JS, Jouve JL, Mazda K, Abelin-Genevois K, Ilharreborde B; Groupe d’Etude sur la Scoliose (GES). Proximal junctional kyphosis in thoracic adolescent idiopathic scoliosis: risk factors and compensatory mechanisms in a multicenter national cohort. Eur Spine J. 2018 Sep;27(9):2241-2250. doi: 10.1007/s00586-018-5640-y. Epub 2018 Jun 29. PMID: 29959554.
    • Cohort of 365 AIS patients – 2 year f/u: Conclusion PJK is a frequent complication in thoracic AIS, occurring 16%, but remains often asymptomatic (less than 3% of revisions in the entire cohort). An interesting finding is that patients with high pelvic incidence and consequently large LL and TK were more at risk of PJK.
  • Lonner BS, Ren Y, Newton PO, Shah SA, Samdani AF, Shufflebarger HL, Asghar J, Sponseller P, Betz RR, Yaszay B. Risk Factors of Proximal Junctional Kyphosis in Adolescent Idiopathic Scoliosis-The Pelvis and Other Considerations. Spine Deform. 2017 May;5(3):181-188. doi: 10.1016/j.jspd.2016.10.003. PMID: 28449961.
    • Muticenter study, 851 AIS patients:to assess the incidence of PJK. The incidence of PJK in patients after surgery for AIS is 7.05% and varies based on Lenke type. Loss of kyphosis, larger preoperative kyphosis, UIV caudal to the proximal UEV (Lenke 1), UIV at or cephalad to the UEV (Lenke 5), and decreased RCA were the major risk factors for PJK in AIS.  
  • Zhong J, Cao K, Wang B, Li H, Zhou X, Xu X, Lin N, Liu Q, Lu H. Incidence and Risk Factors for Proximal Junctional Kyphosis in Adolescent Idiopathic Scoliosis After Correction Surgery: A Meta-Analysis. World Neurosurg. 2019 May; 125: e326-e335. doi: 10.1016/j.wneu.2019.01.072. Epub 2019 Jan 26. PMID: 30690145.
    • Meta- Analysis, 7 studies : The incidence of PJK in patients with AIS was 14%. Proximal implants with screws and instrumentation types with all screws were significantly associated with increased occurrence of PJK. Larger preoperative TK, larger preoperative LL, larger postoperative LL, greater TK change, and greater LL change were also identified as risk factors for PJK in AIS after correction surgery.



Non-Operative versus Operative Treatment

  • Bridwell KH, Glassman S, Horton W, et al. Does treatment (nonoperative and operative improve the two-year quality of life in patients with adult symptomatic lumbar scoliosis: a prospective multicenter evidence-based medicine study. Spine (Phila Pa 1976). 2009;34(20):2171-2178. doi:10.1097/BRS.0b013e3181a8fdc8
  • Smith JS, Lafage V, Shaffrey CI, et al. Outcomes of Operative and Nonoperative Treatment for Adult Spinal Deformity: A Prospective, Multicenter, Propensity-Matched Cohort Assessment With Minimum 2-Year Follow-up. Neurosurgery. 2016;78(6):851-861. doi:10.1227/NEU.0000000000001116
    • Quality of life, determined by functional and pain scores, has been shown to improve in patients that undergo operative treatment for symptomatic adult spinal deformity at 2-years post-surgery compared to those that underwent non-operative treatment.
  • Scheer JK, Smith JS, Clark AJ, et al. Comprehensive study of back and leg pain improvements after adult spinal deformity surgery: analysis of 421 patients with 2-year follow-up and of the impact of the surgery on treatment satisfaction. J Neurosurg Spine. 2015;22(5):540-553. doi:10.3171/2014.10.SPINE14475
    • Decompression is shown to have greater improvement in leg pain
    • Osteotomies were associated with improvement in back pain, but worsened leg pain.
    • Reductions in back pain contributed to improvements in function and satisfaction more than reduction in leg pain
  • Smith JS, Shaffrey CI, Glassman SD, et al. Risk-benefit assessment of surgery for adult scoliosis: an analysis based on patient age. Spine (Phila Pa 1976). 2011;36(10):817-824. doi:10.1097/BRS.0b013e3181e21783
    • Older patients have been shown to have an increased risk of complication
    • Older patients stand to gain disappointingly greater improvement in function and pain after adult spinal deformity surgery

Radiographic Analysis and Classification of Deformity

  • Leveque JC, Segebarth B, Schroerlucke SR, et al. A multicenter radiographic evaluation of the rates of preoperative and postoperative malalignment in degenerative spinal fusions. Spine (Phila Pa 1976) 2018;43:E782–9.
    • In a large series of short-segment degenerative lumbar fusions, 30% of patients were misaligned both pre and post-operatively
    • alignment preservation/restoration considerations should be incorporated into the decision-making of even degenerative lumbar spinal fusions.
  • Smith JS, Klineberg E, Schwab F, et al. Change in classification grade by the SRS-Schwab Adult Spinal Deformity Classification predicts impact on health-related quality of life measures: prospective analysis of operative and nonoperative treatment. Spine (Phila Pa 1976) 2013;38:1663–71
    • The SRS-Schwab classification provides a validated system to evaluate ASD.
    • The classification modifiers are responsive to changes in disease state and reflect significant changes in patient-reported outcomes.

Team Based Approaches

  • Sethi R, Buchlak QD, Yanamadala V, et al. A systematic multidisciplinary initiative for reducing the risk of complications in adult scoliosis surgery. J Neurosurg Spine. 2017;26(6):744-750. doi:10.3171/2016.11.SPINE16537
    • Patients who underwent surgery after implementation of the Seattle Spine Team Protocol had a statistically significant reduction in all measured complications, including cardiovascular events, wound infections, other perioperative infections, and implant failures within 30 days after surgery.
  • Sethi RK, Pong RP, Leveque J-C, Dean TC, Olivar SJ, Rupp SM. The Seattle Spine Team Approach to Adult Deformity Surgery: A Systems-Based Approach to Perioperative Care and Subsequent Reduction in Perioperative Complication Rates. Spine Deform. 2014;2(2):95-103. doi:10.1016/j.jspd.2013.12.002
    • A team approach of a dual-attending surgeon approach in the operating room, a live preoperative screening conference, and an intraoperative protocol for managing coagulopathy will significantly reduce perioperative complication rates and enhance patient safety
  • Mannion R, Thompson C. Systematic biases in group decision-making: implications for patient safety. Int J Qual Heal care  J Int Soc Qual Heal Care. 2014;26(6):606-612. doi:10.1093/intqhc/mzu083
    • group decision-making can be imperfect and result in organizational and clinical errors which may harm patients
    • Four systematic biases arising from group decision-making: 'groupthink', 'social loafing', 'group polarization' and 'escalation of commitment’

Value (Econ)

  • Goodman RM, Powell CC, Park P. The Impact of Commercial Health Plan Prior Authorization Programs on the Utilization of Services for Low Back Pain. Spine (Phila Pa 1976). 2016;41(9):810-815. doi:10.1097/BRS.0000000000001329
    • Prior authorization via mandatory referral to a physiatrist before surgical evaluation has not been shown to result in a reduction of lumbar fusion surgery
    • Prior authorization programs were only associated with the unintended consequence of increased costs.

Pre-operative surgical optimization and modifiable risk factors


  • Buchlak QD, Yanamadala V, Leveque J-C, Sethi R. Complication avoidance with pre-operative screening: insights from the Seattle spine team. Curr Rev Musculoskelet Med. 2016;9(3):316-326. doi:10.1007/s12178-016-9351-x
    • Standardized preoperative evaluation protocols have been shown to significantly reduce the likelihood of a spectrum of negative outcomes associated with complex adult lumbar scoliosis surgery
    • To increase patient safety and reduce complication risk, an entire medical and surgical team should work together to care for adult lumbar scoliosis patients
    • An evidence-based comprehensive systematic preoperative surgical evaluation process is described


  • Schwab F, Dubey A, Gamez L, et al. Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine (Phila Pa 1976). 2005;30(9):1082-1085. doi:10.1097/
    • No association between nutrition and development of spinal deformity has been demonstrated
  • Adogwa O, Martin JR, Huang K, et al. Preoperative serum albumin level as a predictor of postoperative complication after spine fusion. Spine (Phila Pa 1976). 2014;39(18):1513-1519. doi:10.1097/BRS.0000000000000450
    • Preoperative hypoalbuminemia is an independent risk factor for postoperative complications, 30-day mortality, and increased length of hospital stay after spine surgery for degenerative and deformity causes
    • Should be used more frequently as a prognostic tool to detect malnutrition and risk of adverse surgical outcomes
  • Stoker GE, Buchowski JM, Bridwell KH, Lenke LG, Riew KD, Zebala LP. Preoperative vitamin D status of adults undergoing surgical spinal fusion. Spine (Phila Pa 1976). 2013;38(6):507-515. doi:10.1097/BRS.0b013e3182739ad1
    • Vitamin D plays a critical role in establishing optimal bone health, which, in turn, is vital to the success of spinal arthrodesis
    • There is a substantially high prevalence of vitamin D abnormality in the overall population.
    • Although advanced age is a well-established risk factor for hypovitaminosis, young adults undergoing fusion should not be overlooked with regard to vitamin D screening; this age bracket is less likely to have been previously supplemented


  • Di Capua J, Lugo-Fagundo N, Somani S, et al. Diabetes Mellitus as a Risk Factor for Acute Postoperative Complications Following Elective Adult Spinal Deformity Surgery. Glob spine J. 2018;8(6):615-621. doi:10.1177/2192568218761361
    • Patients with diabetes that undergo ASD surgery are significantly more likely to require longer hospital stays and develop 30-day post-operative complications, specifically UTI, cardiac, and surgical site infections


  • Soroceanu A, Burton DC, Diebo BG, et al. Impact of obesity on complications, infection, andpatient-reported outcomes in adult spinal deformity surgery. J Neurosurg Spine. 2015;23(5):656-664. doi:10.3171/2015.3.SPINE14743
    • Obesity is a large risk factor for the development of major post-operative complications prolonged ICU stay, but despite this, obese patients do benefit from surgical intervention.
  • Amin RM, Raad M, Jain A, Sandhu KP, Frank SM, Kebaish KM. Increasing Body Mass Index is Associated With Worse Perioperative Outcomes and Higher Costs in Adult Spinal Deformity Surgery. Spine (Phila Pa 1976). 2018;43(10):693-698. doi:10.1097/BRS.0000000000002407
    • Patients with obesity have improvement in health-related quality of life (HRQL), but less than that of nonobese patients


  • Soroceanu A, Burton DC, Oren JH, et al. Medical complications after adult spinal deformity surgery incidence, risk factors, and clinical impact. Spine (Phila Pa 1976). 2016;41(22):1718-1723. doi:10.1097/BRS.0000000000001636
    • smoking is associated with long term skeletal complications especially due to its effect on the reduction of bone density and healing compacity
    • highly recommended to incorporate a smoking cessation program prior to spine surgery to reduce likelihood of failure

High Risk Patients

  • Halpin RJ, Sugrue PA, Gould RW, et al. Standardizing care for high-risk patients in spine surgery: the Northwestern high-risk spine protocol. Spine (Phila Pa 1976). 2010;35(25):2232-2238. doi:10.1097/BRS.0b013e3181e8abb0
    • Standardizing preoperative risk assessment may lead to better outcomes after major spine operations
    • In the case of a high-risk patient, physicians should have protocol in place that facilitates improved care, grouped into 3 steps: Preoperative, Intraoperative, and Postoperative


Intraoperative Checklists

  • Vitale MG, Skaggs DL, Pace GI, et al. Best Practices in Intraoperative Neuromonitoring in Spine Deformity Surgery: Development of an Intraoperative Checklist to Optimize Response. Spine Deform. 2014;2(5):333-339. doi:10.1016/j.jspd.2014.05.003
    • Implementation of checklists has been associated with improved safety and management of operating room crises, neuromonitoring events, and significant decreases in rate of complication.

Team based approaches in the operating room

  • Scheer JK, Sethi RK, Hey LA, et al. Results of the 2015 Scoliosis Research Society Survey on Single Versus Dual Attending Surgeon Approach for Adult Spinal Deformity Surgery. Spine (Phila Pa 1976). 2017;42(12):932-942.
    • A survey of surgeons demonstrate that most believe the involvement of 2 attending surgeons in the operating room for a spinal deformity surgery overall improve patient care and have better outcomes: however, few attending surgeons current do cases with another one present, usually due to reimbursement purposes.
  • Mallory MA, Losk K, Camuso K, Caterson S, Nimbkar S, Golshan M. Does “Two is Better Than One” Apply to Surgeons? Comparing Single-Surgeon Versus Co-surgeon Bilateral Mastectomies. Ann Surg Oncol. 2016;23(4):1111-1116. doi:10.1245/s10434-015-4956
    • Several studies have demonstrated a dual attending approach to spine surgery improved outcomes, including operative time, blood loss, and length of stay, but there are some in contention with this.
  • Ames CP, Barry JJ, Keshavarzi S, Dede O, Weber MH, Deviren V. Perioperative Outcomes and Complications of Pedicle Subtraction Osteotomy in Cases With Single Versus Two Attending Surgeons. Spine Deform. 2013;1(1):51-58. doi:10.1016/j.jspd.2012.10.004
    • Dual Surgeon approach when performing a pedicle subtraction osteotomy (PSO) has shown to be decrease operative time, blood loss, and overall complications.

Intraoperative Neuromonitoring

  • Pelosi L, Lamb J, Grevitt M, Mehdian SMH, Webb JK, Blumhardt LD. Combined monitoring of motor and somatosensory evoked potentials in orthopaedic spinal surgery. Clin Neurophysiol. 2002;113(7):1082-1091. doi:10.1016/s1388-2457(02)00027-5
    • Combined SEPs and multi-pulse TES-MEPs is highly recommended because it provides a safe, reliable and sensitive method of monitoring spinal cord function in spine surgery and has been shown to be superior to single modality techniques.

Minimally Invasive versus Open Procedures

  • Uribe JS, Deukmedjian AR, Mummaneni P V, et al. Complications in adult spinal deformity surgery: an analysis of minimally invasive, hybrid, and open surgical techniques. Neurosurg Focus. 2014;36(5):E15. doi:10.3171/2014.3.FOCUS13534
    • Minimally invasive approaches to the spine have been shown to have significantly reduced intraoperative blood loss, intraoperative complications, and improved functional scores when compared to open procedures.
    • If the goals of ASD surgery can be achieved, consideration should be given to less invasive techniques.

Pedicle Subtraction Osteotomy (PSO)

  • Daubs MD, Brodke DS, Annis P, Lawrence BD. Perioperative Complications of Pedicle Subtraction Osteotomy. Glob spine J. 2016;6(7):630-635. doi:10.1055/s-0035-1570088
    • The overall rate of pseudarthrosis after a lumbar PSO spans 10-45%  
    • Optimizing patients to reduce the risk of pseudoarthrosis is highly suggested.
    • Other complications of PSO include: neurologic deficit, severe blood loss, infection, dural tears, and death.
  • Baldus CR, Bridwell KH, Lenke LG, Okubadejo GO. Can we safely reduce blood loss during lumbar pedicle subtraction osteotomy procedures using tranexamic acid or aprotinin? A comparative study with controls. Spine (Phila Pa 1976). 2010;35(2):235-239. doi:10.1097/BRS.0b013e3181c86cb9
    • Use of antifibrinolytics such as tranexamic acid can reduce likelihood of developing severe blood loss during PSO.

Intraoperative Complications

  • Rampersaud YR, Moro ERP, Neary MA, et al. Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols. Spine (Phila Pa 1976). 2006;31(13):1503-1510. doi:10.1097/01.brs.0000220652.39970.c2
    • Adverse events can frequently occur (14%) during spinal surgery, however, the majority (76.5%) are not associated with complications

Dural Tears

  • Iyer S, Klineberg EO, Zebala LP, et al. Dural Tears in Adult Deformity Surgery: Incidence, Risk Factors, and Outcomes. Glob spine J. 2018;8(1):25-31. doi:10.1177/2192568217717973
    • Adult spinal deformity surgery has a 3-10% rate of dural tears in with decompressive techniques being the largest risk factor.
    • Patients who suffer an intraoperative durotomy are more likely to have a post-operative complication, but 6-week and 2-year functional health scores are similar to those that don’t suffer an incidental dural tear.

Hemorrhagic Blood Loss

  • Yu X, Xiao H, Wang R, Huang Y. Prediction of massive blood loss in scoliosis surgery from preoperative variables. Spine (Phila Pa 1976). 2013;38(4):350-355. doi:10.1097/BRS.0b013e31826c63cb
    • Adult spinal deformity surgery is associated with severe intraoperative blood loss. Risk factors for massive blood loss include preoperative Cobb angle larger than 50º,  planned osteotomy, or fusion of more than 6 levels.
  • Elgafy H, Bransford RJ, McGuire RA, Dettori JR, Fischer D. Blood loss in major spine surgery: are there effective measures to decrease massive hemorrhage in major spine fusion surgery? Spine (Phila Pa 1976). 2010;35(9 Suppl):S47-56.
    • Based on the current literature, there is little support for routine use of CS during elective spinal surgery.
    • With respect to the antifibrinolytics of the lysine analog class (tranexamic acid and aminocaproic acid), based on the available efficacy and safety data, we recommend that they be considered as possible agents to help reduce major hemorrhage in adult spine surgery. Concerns related to the use of aprotinin were such that we recommended against its use in spine surgery on the basis of the reports of increased complications. 51,57


Rapid Recovery Protocol

  • Development of an Enhanced Recovery After Surgery (ERAS) approach for lumbar spinal fusion. J Neurosurg Spine. 2017;26(4):411-418. doi:10.3171/2016.9.SPINE16375
    • Development of a post-operative spine recovery protocol reduces postoperative recovery times, complications, and acute care cost
    • Protocol focuses on these major components: pre-operative education, multimodal pain management, surgical approach, blood loss, nutrition, and physiotherapy.

Pain control

  • Turan A, Karamanlioğlu B, Memiş D, et al. Analgesic effects of gabapentin after spinal surgery. Anesthesiology. 2004;100(4):935-938. doi:10.1097/00000542-200404000-00025
  • Nielsen R V, Siegel H, Fomsgaard JS, et al. Preoperative dexamethasone reduces acute but not sustained pain after lumbar disk surgery: a randomized, blinded, placebo-controlled trial. Pain. 2015;156(12):2538-2544. doi:10.1097/j.pain.0000000000000326
  • Khurana G, Jindal P, Sharma JP, Bansal KK. Postoperative pain and long-term functional outcome after administration of gabapentin and pregabalin in patients undergoing spinal surgery. Spine (Phila Pa 1976). 2014;39(6):E363-8. doi:10.1097/BRS.0000000000000185
    • Surgery as a whole has recently been shifting away from opioid pain monument due to the risk of addiction, nausea, and other side effects.
    • Preoperative oral gabapentin, pregabalin, dexamethazone have been shown to decrease pain scores in the early postoperative period and reduce post-operative morphine consumption after spine surgery.
    • they have been shown to improve patient function within the 90 day post operative period
  • De Oliveira GS, Castro-Alves LJ, McCarthy RJ. Single-dose systemic acetaminophen to prevent postoperative pain: a meta-analysis of randomized controlled trials. Clin J Pain. 2015;31(1):86-93. doi:10.1097/AJP.0000000000000081
    • Systemic acetaminophen, when used as a single-dose preventive regimen, is an effective intervention to reduce postoperative pain. It also reduces postoperative nausea and/or vomiting.
  • Loftus RW, Yeager MP, Clark JA, et al. Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery. Anesthesiology. 2010;113(3):639-646. doi:10.1097/ALN.0b013e3181e90914
    • Intraoperative ketamine has also been shown to reduce overall patient opioid consumption in the post-operative period.
  • Mathiesen O, Dahl B, Thomsen BA, et al. A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery. Eur Spine J. 2013;22(9):2089-2096. doi:10.1007/s00586-013-2826-1
    • A comprehensive and standardized multimodal pain and post-operative nausea and vomiting protocol can reduced opioid consumption, improved postoperative mobilization, and present with concomitant low levels of nausea, sedation and dizziness

Post-operative Complications

  • Glassman SD, Hamill CL, Bridwell KH, Schwab FJ, Dimar JR, Lowe TG. The impact of perioperative complications on clinical outcome in adult deformity surgery. Spine (Phila Pa 1976). 2007;32(24):2764-2770. doi:10.1097/BRS.0b013e31815a7644
    • Minor complications have a small effect on patient quality of life
    • Major complications, with a rate of 10%, have significant effects on a patients 1-year disposition.
  • Howe CR, Agel J, Lee MJ, et al. The morbidity and mortality of fusions from the thoracic spine to the pelvis in the adult population. Spine (Phila Pa 1976). 2011;36(17):1397-1401. doi:10.1097/BRS.0b013e3181f453e2
    • Major Medical complications after long fusion from thoracic spine to pelvis have been shown to be associated with ASA and CCI and estimated blood loss, but not age.
  • Lee MJ, Hacquebord J, Varshney A, et al. Risk factors for medical complication after lumbar spine surgery: a multivariate analysis of 767 patients. Spine (Phila Pa 1976). 2011;36(21):1801-1806. doi:10.1097/brs.0b013e318219d28d
    • The cumulative incidences of complication after lumbar spine surgery per organ system are as follows: cardiac - 13%, pulmonary – 7%, gastrointestinal – 6.7%, neurological – 8.2%, hematological – 17.5% and urologic complications – 10.3%.
    •  occurrence of cardiac or respiratory complication after lumbar spine surgery was significantly associated with death within 2 years (RR 6.09, 10.9 respectively).
    • Elevated surgical invasiveness is a significant risk factor for cardiac, pulmonary, neurological and hematological complication.
  • Schwab FJ, Hawkinson N, Lafage V, et al. Risk factors for major peri-operative complications in adult spinal deformity surgery: a multi-center review of 953 consecutive patients. Eur Spine J. 2012;21(12):2603-2610. doi:10.1007/s00586-012-2370-4
    • The major peri-operative complication rate was 8.4 % for 953 surgically treated ASD patients.
    • Higher rates of complications were associated with staged and combined anterior-posterior surgeries.
  • Sciubba DM, Yurter A, Smith JS, Kelly MP, et al. A Comprehensive Review of Complication Rates After Surgery for Adult Deformity: A Reference for Informed Consent. Spine Deform. 2015 Nov;3(6):575-594. doi: 10.1016/j.jspd.2015.04.005.
    • Review of the literature
    • Overall mean complication rate for adult spinal surgery was 55%
    • Major perioperative complications occurred at a mean rate of 18.5%
    • Minor perioperative complications occurred at a mean rate of 15.7%
    • Long-term complications occurred at a mean rate of 20.5%
  • Tormenti MJ, Maserati MB, Bonfield CM, et al. Perioperative surgical complications of transforaminal lumbar interbody fusion: a single-center experience. J Neurosurg Spine2012;16:44–50. 11
    • Complications with TLIF occurred more often in patients undergoing revision surgery or multilevel interbody fusion
    • Durotomy and infections were the most common complications
  • Street JT, Lenehan BJ, DiPaola CP, et al. Morbidity and mortality of major adult spinal surgery. A prospective cohort analysis of 942 consecutive patients. Spine J 2012;12:22–34. 12
    • The rate of intraoperative surgical complication was 10.5%
    • The incidence of postoperative complication was 73.5% (wound complications, 13.5%; delerium, 8%; pneumonia, 7%; neuropathic pain, 5%; dysphagia, 4.5%; and neurological deterioration, 3%).
  • Sansur CA, Smith JS, Coe JD, et al. Scoliosis research society morbidity and mortality of adult scoliosis surgery. Spine (Phila Pa 1976) 2011;36:E593–7. 15
    • The overall complication rate for ASD treatment is 13.4%
    • Complication rate is significantly higher when osteotomies, revision procedures, and combined anterior/posterior approaches are used.
  • Charosky S, Guigui P, Blamoutier A, et al. Complications and risk factors of primary adult scoliosis surgery: a multicenter study of 306 patients. Spine (Phila Pa 1976)2012;37:693–700. 16
    • Overall complication rate was 39% with a re-operative rate of 26% (mean follow-up 54-months)
    • Risk factors include number of instrumented vertebra, fusion to the sacrum, PSO, and preoperative pelvic tilt of 26° or more
    • There is a 44% risk of a new operation in the 6-year-period after the primary procedure.
  • Cho SK, Bridwell KH, Lenke LG, et al. Major complications in revision adult deformity surgery: risk factors and clinical outcomes with 2-to 7-year follow-up. Spine (Phila Pa 1976) 2012;37:489–500. 17
    • Overall, 34.4% of patients experienced major complications after long revision fusion surgery.
    • Performance of a 3-column osteotomy and postoperative radiographic changes that suggested progressive loss of sagittal correction were recognized as risk factors for follow-up complications

Neurologic Complications

  • Lenke LG, Fehlings MG, Shaffrey CI, et al. Neurologic Outcomes of Complex Adult Spinal Deformity Surgery: Results of the Prospective, Multicenter Scoli-RISK-1 Study. Spine (Phila Pa 1976). 2016;41(3):204-212. doi:10.1097/BRS.0000000000001338
    • Complex ASD surgery can restore neurologic function in patients with a preoperative neurologic deficit.
    • There is yet a significant portion of patients with ASD experienced postoperative decline in lower extremity motor function.
    • Many of those who had a neurologic deficit were found to have significant improvement at 6 months
  • Kim HJ, Iyer S, Zebala LP, Kelly MP, et al. Perioperative Neurologic Complications in Adult Spinal Deformity Surgery: Incidence and Risk Factors in 564 Patients. Spine (Phila Pa 1976). 2017 Mar 15;42(6):420-427. doi: 10.1097/BRS.0000000000001774
    • The overall incidence of neurologic complications in ASD surgery was 17.6%
    • Incidence of surgical neurologic complications was 13.7%
    • higher risk of neurologic complications in revision cases and in cases in which interbody fusion was required


  • Simchen E, Stein H, Sacks TG, Shapiro M, Michel J. Multivariate analysis of determinants of postoperative wound infection in orthopaedic patients. J Hosp Infect. 1984;5(2):137-146. doi:10.1016/0195-6701(84)90117-8
    • Diabetes, prolonged operative times (>3 hours), body mass index more than 35, posterior approach, smoking, and number of intervertebral levels (≥7) are associated with an increased risk of SSI after spinal surgery.
  • Anderson PA, Savage JW, Vaccaro AR, et al. Prevention of Surgical Site Infection in Spine Surgery. Neurosurgery. 2017;80(3S):S114-S123. doi:10.1093/neuros/nyw066
    • Screening for nasal carriage of methicillin-sensitive S. aureus (MSSA) and MRSA 5-days prior to surgery with subsequent eradication treatment has been shown to reduce rate of infection in several surgical procedures.

Mechanical failure and Pseudarthrosis

  • Berjano P, Bassani R, Casero G, Sinigaglia A, Cecchinato R, Lamartina C. Failures and revisions in surgery for sagittal imbalance: analysis of factors influencing failure. Eur Spine J. 2013;22 Suppl 6:S853-8. doi:10.1007/s00586-013-3024-x
    • Etiology of Mechanical failure and pseudoarthrosis include insufficient correction, junctional kyphosis, screw loosening and pseudoarthrosis with rod breakage.
  • Marques MF, Fiere V, Obeid I, et al. Pseudarthrosis in adult spine deformity surgery: risk factors and treatment options. Eur Spine J. 2021;30(11):3225-3232. doi:10.1007/s00586-021-06861-w
    • Risk factors for reoperation of pseudoarthrosis include age, long fusion constructs, osteotomies, and fusion to the sacrum.
    • Patients who are at high likelihood of developing pseudarthrosis following surgery should be closely monitored for their development to prevent catastrophic failure of the fusion construct.

Vision Loss

  • Baig MN, Lubow M, Immesoete P, Bergese SD, Hamdy E-A, Mendel E. Vision loss after spine surgery: review of the literature and recommendations. Neurosurg Focus. 2007;23(5):E15. doi:10.3171/FOC-07/11/15
    • Estimates for the incidence of post-operative vision loss after spinal surgery between 0.028 and 0.2%.
    • The most common diagnosis in patients in whom perioperative visual deficits develop after spine surgery is Ischemic Optic Neuropathy.
    • Perioperative factors that have been implicated in the development of ischemic optic neuropathy include intraoperative hypotension, duration of surgery, intraoperative blood loss, use of replacement fluids, and anemia.
    • Post-operative flat positioning should be avoided except in cases of hypotension.

Spinal Deformity Surgery Team Checklist

The Spinal Deformity Surgery Team Checklist is a suggested list of items for centers performing spinal deformity surgery to support ongoing efforts to improve safety. The material is intended to present a suggested approach that may be helpful to centers performing spinal deformity surgery. Download the checklist.


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SRS Statements and Practice Parameters

SRS statements and practice parameters assist healthcare professionals by providing information on clinical and scientific advances. These documents reflect the most current guidance available from the SRS on clinical topics related to spine deformity.

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