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00007632-201104010-0001100007632_2011_36_564_master_complications_7miscellaneous-article< 102_0_9_6 >Spine© 2011 Lippincott Williams & Wilkins, Inc.Volume 36(7)01 April 2011p 564–571Risk Factors for Major Complications After Surgery for Neuromuscular Scoliosis[Deformity]Master, Daniel L. MD; Son-Hing, Jochen P. MD, FRCS (C); Poe-Kochert, Connie RN, CNP; Armstrong, Douglas G. MD, FRCS (C); Thompson, George H. MDFrom the Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH.Address correspondence and reprint requests to George H. Thompson, MD, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106; E-mail: ght@po.cwru.eduAcknowledgment date: November 17, 2009. Revision date: March 2, 2010. Acceptance date: March 12, 2010.The device(s)/drug(s) is/are FDA-approved by corresponding national agency for this indication.No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.AbstractStudy Design. Retrospective, case series.Objective. To determine the prevalence of major complications and to identify factors that increase the risk of complications in patients undergoing surgery for neuromuscular scoliosis.Summary of Background Data. Complications after surgery for neuromuscular scoliosis are more prevalent than in idiopathic scoliosis. However, the associated risk factors have not been statistically significant.Methods. Our computerized Pediatric Orthopedic Spine Database identified 131 consecutive patients with neuromuscular scoliosis, excluding those with myelodysplasia, who underwent surgery and had a minimum of 2 years of follow-up. Preoperative, intraoperative, and postoperative factors were analyzed for any association with major complications and length of stay using stepwise logistic and multiple regression analyses. Odds ratios were calculated for significant dichotomous variables, and receiver operator characteristic curves were created for significant continuous variables.Results. There were 81 male and 50 female patients with a mean age at surgery of 13.4 years (range, 6–21 years). The majority of patients (n = 75) had cerebral palsy. Eighty-eight patients (67%) underwent posterior spinal fusion and segmental spinal instrumentation (only), whereas 43 patients (33%) underwent an anterior spinal fusion followed by a posterior spinal fusion with segmental spinal instrumentation. Seventy-seven patients (59%) were fused to the pelvis using the Galveston technique. The mean follow-up was 3.9 years (range, 2–16.9 years). There were 46 major complications in 37 patients (28% prevalence), including 2 deaths.Nonambulatory status (P < 0.05) and preoperative curve magnitude (P < 0.01) were associated with an increased prevalence of major complications. Nonambulatory patients (n = 94) were almost 4 times more likely to have a major complication (odds ratio of 3.8, P < 0.05) in comparison with ambulatory patients. A preoperative major curve magnitude of ≥60° (P < 0.01) was the most accurate indicator for an increased risk for a major complication.Conclusion. Nonambulatory status and a preoperative curve magnitude (≥60°) are directly associated with an increased risk for major complications and indirectly associated with increased length of stay. As such, we recommend operative intervention in neuromuscular scoliosis before curve progression to ≥60°. Level of Evidence. Level III.Patients with neuromuscular scoliosis undergoing a posterior spinal fusion (PSF), with or without an anterior spinal fusion (ASF), and segmental spinal instrumentation (SSI) have higher complication rates than patients with idiopathic scoliosis.1,2 Furthermore, the complications encountered in these patients can be lifethreatening. The reported prevalence of complications associated with spinal surgery for neuromuscular scoliosis has ranged from 17% to 74%.2–9 However, many of these studies used small cohorts or heterogeneous patient populations, including patients with both neuromuscular and idiopathic scoliosis.2,4–6,8 Some of these studies included only minimum follow-up periods making an accurate assessment of the prevalence of late complications problematic.2,5,7 Finally, these studies did not identify preoperative and operative factors that affect the prevalence of complications in this unique patient population. The purpose of this study was to determine the prevalence of complications after surgery for neuromuscular scoliosis and to identify factors that increase this risk. We hypothesized that patients with smaller preoperative curve magnitudes and who were ambulatory would have lower complication rates.MATERIALS AND METHODSPatients who underwent surgical correction for neuromuscular scoliosis between January 1992 and January 2006 were identified from our institutional review board approved computerized Pediatric Orthopedic Spine Database. All patients were treated by 1 of 5 pediatric orthopedic fellowship trained surgeons. This specific study was also approved by our institutional review board. The inclusion criteria were (1) a diagnosis of neuromuscular scoliosis, (2) PSF ± ASF and SSI, and (3) a minimum of 2 years of postoperative follow-up. Our database identified 151 patients who met the inclusion criteria. Twenty patients (15%) were excluded because of a diagnosis of myelodysplasia and their history of previous spinal surgery. These patients were excluded because of their inherently higher risk for major complications associated with previous surgery on their spinal defect. The remaining 131 patients comprised the cohort for this study.Patient demographics, medical history, surgical data, imaging studies, and the prevalence of major and minor complications during the 2 years or more follow-up were recorded.The primary outcome measure was the presence of a major complication. This was defined as any unanticipated event requiring active medical or surgical intervention.10 Complications were classified into 1 of 9 categories: respiratory, gastrointestinal, cardiovascular, neurologic, wound infection, wound, genitourinary, instrumentation failure, and death. Each primary category was then divided into subcategories. The complications were classified as major or minor according to the criteria of Hod-Feins et al.11 These are presented in Table 1.TABLE 1. Classification of Major and Minor Complications*Statistical AnalysisStepwise logistic regression was used to analyze any association between preoperative and operative factors and the risk for any complication (minor, major, or both) and the risk for major complication. Preoperative factors included gender, diagnosis, age at surgery, preoperative curve magnitude, and ambulatory status. Operative factors included the type of surgery (PSF with SSI or combined ASF and PSF with SSI), total number of vertebrae fused, fusion to the pelvis, instrumentation system (hybrid with dual rods using lumbar pedicle screws and thoracic hooks or Luque rod instrumentation [LRI] with sublaminar wires), operative time, the use of Amicar, perioperative blood loss, and total transfusion requirements.After this initial analysis, preoperative factors, operative factors, the presence of at least 1 major complication, and the presence of at least 2 major complications were analyzed for any association with total length of hospitalization using a multiple regression model. For this analysis, patients undergoing combined ASF and PSF with SSI fusion on different days were not included because of an inherently increased length of total hospitalization.For logistic and multiple regression analyses, factors with P values <0.05 remained in the analysis and those with P values >0.06 were removed. Odds ratios were calculated for all significant dichotomous variables, and receiver operator characteristic (ROC) curves were created for all significant continuous variables. ROC analysis was used to evaluate the predictive value of the given factor by selecting all possible cut points for the measurement and then calculating the sensitivity and specificity for each cut point. An ROC curve is then drawn, plotting the true positive fraction versus the falsepositive fraction for each of the cut points. The area under the ROC curve is a measure of the diagnostic power for the given measurement. High (near 1.0) and low (near 0.0) values indicate a strong diagnostic tool, and values near 0.5 indicate that the measurement is no more predictive than random chance.10RESULTSThere were 81 male and 50 female patients. Ninety-four patients (72%) were nonambulatory, and 37 patients (28%) were ambulatory. The most common diagnoses included cerebral palsy (n = 75), muscular dystrophy (n = 15), Rett syndrome (n = 6), mental retardation (n = 5), genetic abnormalities (n = 5), spinal muscle atrophy (n = 4), encephalopathy (n = 3), Charcot Marie Tooth disease (n = 3), Syrinx (n = 3), and other diagnoses (n = 12). All diagnoses are listed in Table 2. The mean age at surgery was 13.4 years (range, 6–21 years). Eighty-eight patients (67%) underwent PSF and SSI alone, whereas 43 patients (33%) had a combined ASF and PSF with SSI (35 same day and 8 staged procedures). Fifty-three patients (40%) underwent PSF using hybrid instrumentation, whereas 78 (60%) patients underwent PSF using LRI with sublaminar wires. There were 77 patients (59%) who underwent fusion to the pelvis. All fusions to the pelvis used LRI and the Galveston technique of iliac fixation. This included 52 of the 88 patients (59%) undergoing PSF and SSI alone and 25 of the 43 patients (58%) who had a same-day or staged ASF and PSF with SSI. The mean length of follow-up was 3.9 years (range, 2–16.9 years).TABLE 2. DiagnosesThe mean preoperative curve was 70° (range, 44°–107°; 95% confidence interval [CI]: 66–75) with a mean correction of 54% (range, 2%–78%; 95% CI: 49–59) at a minimum of 2 years of follow-up (n = 77). The mean preoperative curve who underwent a PSF and SSI was 64° (range, 45°–105°; 95% CI: 59–69) with a mean correction of 53% (range, −3%–100%, 95% CI: 46–60) at a minimum of 2 years of follow-up. The mean preoperative curve in patients who underwent an ASF and PSF with SSI (same-day or staged procedures) was 85° (range, 41°–133°; 95% CI: 79–92) with a mean correction of 56% (range: 10%–78%; 95% CI: 50–62) at 2 years of follow-up.There were 46 major complications in 37 patients (28% prevalence) and 37 minor complications in 29 patients (22% prevalence). Twenty-three patients (18% prevalence) had 2 or more complications. Twenty multicomplicated patients had at least 1 major complication (15% prevalence), and 15 patients had at least 2 major complications. The most common major complications were respiratory (n = 23), instrumentation failure (n = 6), wound infection (n = 4), gastrointestinal (n = 4), neurologic (n = 3), cardiovascular (n = 2), death (n = 2), wound (n = 1), and curve progression (n = 1). One patient who underwent PSF and SSI died in the acute postoperative period due to coagulopathy, excessive blood loss, disseminated intravascular coagulation, and cardiac failure. Another patient undergoing same-day ASF and PSF with SSI died 2 days after discharge due to a history of chronic pulmonary obstruction from viscous secretions and subsequent respiratory arrest. The number of major and minor complications for each category and the analysis of complications by subcategory are presented in Tables 3 and 4.TABLE 3. Major Complications by CategoryTABLE 4. Minor Complications by CategoryFactors that were not associated with a statistically increased prevalence of major complication were gender (P = 0.57), age at surgery (P = 0.15), type (PSF and SSI versus ASF and PSF with SSI on the same or different days) of surgery (P = 0.78), the use of Amicar intraoperatively (P = 0.53), total number of levels fused (P = 0.86), fusion to the pelvis (P = 0.22), instrumentation system (P = 0.43), operative time (P = 0.30), perioperative blood loss (P = 0.61), and total transfusion requirement (P > 0.90).Factors associated with an increased prevalence of complications were the preoperative curve magnitude and ambulatory status. Stepwise logistic regression demonstrated significantly greater (P < 0.01) preoperative curve magnitude in those patients with any complication (minor, major, or both) and those patients with at least 1 major complication. For patients with any complication, a preoperative curve magnitude ≥58° (P < 0.01) was the most accurate indicator for an increased risk with a sensitivity of 83% (95% CI: 71–92) and a specificity of 48% (95% CI: 36–60). However, the area under the ROC curve was only 0.665 making this cut point only weakly predictive of increased risk. Nonambulatory status made patients 3.2 (95% CI: 1.4 –7.4) times more likely (P < 0.01) to have any complication in comparison with ambulatory patients. In addition, 66 of the 94 nonambulatory patients (70%) and 20 of the 37 ambulatory patients (54%) had major curve magnitudes ≥60°.For patients with at least 1 major complication, a preoperative major curve magnitude ≥60° (P < 0.01) was the most accurate indicator of increased risk with a 92% (95% CI: 79–98) sensitivity and a 49% (95% CI: 38– 60) specificity (Figure 1). The area under the ROC curve was 0.716 making this cut point predictive for an increased risk of at least 1 major complication. In addition, nonambulatory status made patients 3.8 (95% CI: 1.3– 10.5) times more likely (P < 0.05) to have at least 1 major complication in comparison with ambulatory patients.Figure 1. ROC curve for preoperative Cobb angle and the presence of 1 or more major complications. ROC curve demonstrating the false-positive fraction (x-axis) and true-positive fraction (y-axis) for the preoperative Cobb angle in determining the risk for 1 or more major complications among patients with neuromuscular scoliosis (blue line). The black lines represent the 95% CI. The area under the curve measures 0.716 (P < 0.01).For patients with 2 or more major complications, a preoperative curve ≥67° (P < 0.01) was the most accurate indicator of increased risk with a 100% (95% CI: 75–100) sensitivity and 55% (95% CI: 45–64) specificity (Figure 2). The area under the ROC curve was 0.779 making this cut point predictive of increased risk of 2 or more major complications.Figure 2. ROC curve for preoperative Cobb angle and the presence of 2 or more major complications. ROC curve demonstrating the false-positive fraction (x-axis) and true-positive fraction (y-axis) for the preoperative Cobb angle in determining the risk for 2 or more major complications among patients with neuromuscular scoliosis (blue line). The black lines represent the 95% CI. The area under the curve measures 0.7779 (P < 0.01).A stepwise multiple regression model (P < 0.01) for complication severity score confirmed all these results. Patients with higher preoperative curves (P < 0.01) and nonambulatory patients (P < 0.05) were more likely to have higher complication severity scores.Multiple regression analysis was also performed with total length of hospitalization as the primary outcome factor. Eight patients who underwent ASF and PSF with SSI on different days were excluded due to an inherently increased total length of hospitalization. Therefore, only patients undergoing PSF and SSI (n = 88) or same-day ASF and PSF with SSI (n = 35) were included in this analysis.The presence of 1 major (P < 0.05) and 2 major (P < 0.01) complications were both associated with an increased length of hospitalization independent of the type of surgery performed. Preoperative curve magnitude and ambulatory status did not correlate directly with increased length of stay (LOS).The mean LOS for patient with 1 or more major complications (15 days: 95% CI: 11–18) was significantly greater (P < 0.01) than the mean LOS for patients without major complications (7 days: 95% CI: 7–8). Similarly, mean LOS for patients with 2 or more major complications (22 days: 95% CI: 14–31) was significantly greater (P < 0.01) than the mean LOS for patients with less than 2 major complications (8 days: 95% CI: 7–9).DISCUSSIONThe reported prevalence of complications after surgical correction for neuromuscular scoliosis has been quite variable.2–9 However, many of these studies did not focus solely on patients with neuromuscular scoliosis or solely on complications. Benson et al3 reported the lowest prevalence of complications for patients with neuromuscular scoliosis undergoing corrective surgery. They reported complications in 3 of 24 patients (17%) in a retrospective review of patients who underwent surgery between 1990 and 1994. Larger studies have reported higher complication rates.2,4,5,7,8,12–14 In a study by Dias et al12 in 1996, complications occurred in 11 of 31 patients (32%) with excessive blood loss being the most common (10% prevalence; 3 of 31 patients). In a larger cohort of 175 patients with neuromuscular scoliosis in 2007, Mohamad et al5 reported complications in 58 of 175 patients (33%). In neuromuscular patients undergoing ASF, the overall complication rate was slightly higher. Sarwahi et al8 reported complications in 49 of 111 patients (49%) undergoing ASF. In another cohort of patients undergoing ASF, McDonnell et al2 reported complications in 140 of 447 patients (31%). Forty-seven patients (11%) had major complications, and 109 patients (24%) had minor complications. Comstock et al7 in 1998 reported complications in 54 of 79 patients (68%) in a cohort of primarily nonambulatory patients with total body involvement cerebral palsy treated with both ASF and/or PSF. Finally, a small retrospective series of 18 patients with myelodysplasia demonstrated complications in 13 patients (74%).4 This higher than expected prevalence is one of the reasons we decided to exclude patients with myelodysplasia from our study. In our cohort of 131 patients (which excluded patients with myelodysplasia), there were 46 major complications in 37 patients (28% prevalence). Of note, 94 of our 131 patients (72%) were nonambulatory indicating a significant level of neuromuscular involvement much similar to the patient population reviewed by Comstock et al.7Previous investigators have reported on the significance of the preoperative curve magnitude as a meaningful guide in determining the ideal time for operative intervention.8,15–18 Unlike idiopathic scoliosis, patients with neuromuscular scoliosis may progress even after skeletal maturity with larger curves progressing more rapidly than smaller curves. Neuromuscular curves less than 50° increase by 0.8° per year and curves greater than 50° increase by 1.4° per year.16 In addition, neuromuscular patients with preoperative curves greater than 50° have longer operative times and a smaller percentage of final correction.15 In agreement with these findings, Lipton et al17 in 1999 found that patients with cerebral palsy with curves greater than 70° have an increased risk for complications after PSF. In a mixed cohort of whom 138 of 599 patients had neuromuscular scoliosis (23%), undergoing ASF and SSI with preoperative curves greater than 100° had an increased risk for complications. However, the strength of the predictive value for preoperative curve magnitude was weak in this study.18 In another series of 111 patients with neuromuscular scoliosis undergoing ASF or staged ASF and PSF with SSI, a diagnosis of cerebral palsy and preoperative curve magnitudes greater than 100° were both associated with an increased rate of complication.8 However, Hod-Feins et al11 in 2007 found no correlation between the preoperative curve magnitude and postoperative outcomes.Our cohort of 131 patients demonstrates a clear association between preoperative curve magnitude and the risk for complication. Preoperative curves greater than 60° are associated with an increased risk for major complications and a higher complication severity score indicating a greater risk for multiple complications. In addition, the presence of 1 or 2 major complications in patients undergoing single stage surgeries is associated with a greater total length of hospitalization.Outcomes among patients undergoing same-day ASF and PSF with SSI versus staged procedures may be different. Ferguson et al19 found that patients with neuromuscular scoliosis undergoing staged procedures had higher complication rates, longer operative times, increased blood loss, and longer hospitalization than patients undergoing same-day ASF and PSF with SSI. Similarly, Viviani et al20 have found a greater incidence of major complication requiring reoperation, longer intensive care unit stays, and longer total hospitalization. Finally, some authors have reported better correction and decreased cost with same-day procedures.21,22 In contrast, others have shown increased intraoperative blood loss, prolonged operative time, a higher incidence of complications, and a higher incidence of perioperative death with same-day ASF and PSF with SSI.2,23 There may also be an increased incidence of pulmonary complications in particular with same-day procedures.24 Finally, O'Brien et al25 demonstrated no significant difference between complication rates for same-day and staged ASF and PSF with SSI. In our cohort, there was an increased incidence of major complications among patients undergoing staged procedures. There was a 42% prevalence of at least 1 major complication among patients undergoing same-day procedures (n = 35) versus a 63% prevalence of at least 1 major complication among patients undergoing staged procedures (n = 8). However, because of the small number of patients undergoing staged procedures in our series, we combined patients undergoing staged ASF and PSF with SSI with those patients undergoing same-day ASF and PSF with SSI for the purposes of our logistic regression model. As such, we cannot comment on the statistical significance of staged versus same-day PSF with SSI and ASF as a risk factor for major complications.Pulmonary complications were the most common complications among patients with neuromuscular scoliosis. Pulmonary function tests decline up to 60% after scoliosis surgery and only return to baseline 1 to 2 months after surgery.26 In a retrospective review of 38 patients with neuromuscular scoliosis, low preoperative vital capacity was associated with an increased risk for postoperative pulmonary complications and the need for prolonged postoperative ventilatory support.27 Similarly, Yuan et al28 found that a diagnosis of neuromuscular scoliosis and/or a preoperative FEV1 less than 40% of predicted correlated with the need for prolonged postoperative mechanical ventilation after corrective surgery. In contrast, a prospective analysis of 42 patients with nonidiopathic scoliosis by Almenrader and Patel,29 found no specific factors that predicted the need for postoperative ventilation. Furthermore, Gill et al30 found that the need for nocturnal ventilatory support at the time of surgery was not a contraindication for surgery in patients with neuromuscular scoliosis. In accordance with these reports, respiratory complications were the most common type of major complication in our cohort. There were 6 cases of major respiratory depression, 5 cases of pneumothorax and/or hemothorax, 5 cases of aspiration pneumonia, 4 cases of pneumonia, and 3 cases of pleural effusion.Preoperative nutritional status has also been shown to affect the risk of complication. A retrospective review of 44 patients with cerebral palsy and spastic quadriplegia revealed associations between the preoperative albumin and the total body lymphocyte count and the immediate postoperative course.31 A preoperative albumin less than 3.5 g/dL and a total body lymphocyte count less than 1.5 g/L were both associated with a higher rate of infection, longer intubation, and longer hospitalization.31 Unfortunately, we did not determine the preoperative albumin and total body lymphocyte counts for the patients in our series because of the retrospective nature of the study. However, gastrointestinal complications were the third most common type of major complication. Major gastrointestinal complications included 2 cases of superior mesenteric artery syndrome and 1 case of concomitant gallbladder hydrops and pancreatitis.The reported prevalence of wound infections among patients with neuromuscular scoliosis undergoing corrective surgery has ranged from 8.7% to 12%.32,33 In a review of 172 patients with neuromuscular scoliosis associated with cerebral palsy, Szöke et al32 reported wound infections in 15 of 172 patients (9%). Deep infections occurred in 7 patients (4%) and superficial infections in 8 patients (5%). Furthermore, severe neurologic involvement, nonambulatory status, and a history of seizure disorder were all associated with an increased risk for wound infection. Similarly, Sponseller et al33 retrospectively reviewed 210 patients with neuromuscular scoliosis after corrective surgery reported 25 patients (12%) with deep wound infections. The degree of cognitive impairment of the patient and the use of allograft were both associated with an increased rate of infection. Wound infection was the third most common major complication in our series. Four patients presented with major wound infection including 3 deep infections and 1 paraspinal infection (retroperitoneal abscess).Cardiovascular complications are also relatively common among patients with neuromuscular scoliosis. Neuromuscular patients have an almost 7 times higher risk of extensive blood loss (defined as greater than 50% of estimated total blood volume) during surgery in comparison with patients with idiopathic scoliosis.34 Cardiovascular complications were the sixth most common type of major complication in our series. There were 2 cases of hemodynamic instability because of acute blood loss anemia, which were effectively treated with fluid replacement and blood transfusion.CONCLUSIONComplications associated with corrective surgery for neuromuscular scoliosis are common and can be lifethreatening. However, specific preoperative factors are associated with an increased risk of complication. We have found that a preoperative curve magnitude of ≥60° is associated with an increased risk for major and multiple major complications. In addition, nonambulatory status is associated with an increased risk for complication. Finally, patients undergoing same-day procedures who develop 1 major or 2 major complications require greater lengths of hospitalization. On the basis of this data, we recommend strong consideration for operative intervention before curve progression past 60°. To increase our opportunity for early intervention, we must reemphasize the importance of close clinical monitoring in this patient population among both primary care physicians and caregivers alike.Key Points * Complications after surgery for neuromuscular scoliosis are high. We had 46 major complications in 37 patients (28% prevalence) in 131 patients with a minimum of 2 years of postoperative follow-up. * Using a complex statistical analysis, nonambulatory patients and those with preoperative curve magnitude of ≥60° are at increased risk for a major complication. * We recommend surgical intervention before scoliosis deformities reaching ≥60°.References1. Sarwark J, Sarwahi V. New strategies and decision making in the management of neuromuscular scoliosis. Orthop Clin North Am 2007;38:485–96. [CrossRef] [Full Text] [Medline Link] [Context Link]2. McDonnell MF, Glassman SD, Dimar JR II, et al.. Perioperative complications of anterior procedures on the spine. 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Link]11013497ovid.com:/bib/ovftdb/00007632-201104010-0001100045492_2003_13_818_edler_neuromuscular_|00007632-201104010-00011#xpointer(id(R34-11))|11065213||ovftdb|00042748-200311000-00011SL0004549220031381811065213P93[CrossRef]10.1046%2Fj.1460-9592.2003.01171.xovid.com:/bib/ovftdb/00007632-201104010-0001100045492_2003_13_818_edler_neuromuscular_|00007632-201104010-00011#xpointer(id(R34-11))|11065404||ovftdb|00042748-200311000-00011SL0004549220031381811065404P93[Full Text]00042748-200311000-00011ovid.com:/bib/ovftdb/00007632-201104010-0001100045492_2003_13_818_edler_neuromuscular_|00007632-201104010-00011#xpointer(id(R34-11))|11065405||ovftdb|00042748-200311000-00011SL0004549220031381811065405P93[Medline Link]14617124Major complications associated with surgery for neuromuscular scoliosis occurred in 37 of 131 patients (28% prevalence). Factors associated with major complications included nonambulatory status and major curve magnitude of [mtequ]60[deg]. We recommend surgery before the deformity reaching this magnitude.Risk Factors for Major Complications After Surgery for Neuromuscular ScoliosisMaster, Daniel L. MD; Son-Hing, Jochen P. MD, FRCS (C); Poe-Kochert, Connie RN, CNP; Armstrong, Douglas G. MD, FRCS (C); Thompson, George H. MDDeformity736