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Grading of Complications After Cervical Deformity-corrective Surgery

Are Existing Classification Systems Applicable?

Bortz, Cole A. BA*; Passias, Peter G. MD*; Segreto, Frank A. BS*; Horn, Samantha R. BA*; Lafage, Renaud MS; Smith, Justin S. MD, PhD; Line, Breton G. BS§; Mundis, Gregory M. Jr MD; Kelly, Michael P. MD; Park, Paul MD#; Sciubba, Daniel M. MD**; Hamilton, D. Kojo MD††; Gum, Jeffrey L. MD‡‡; Burton, Douglas C. MD§§; Hart, Robert A. MD∥∥; Schwab, Frank J. MD; Bess, Shay MD¶¶; Shaffrey, Christopher MD; Klineberg, Eric O. MD## International Spine Study Group

doi: 10.1097/BSD.0000000000000748

Study Design: This is a retrospective review of prospective multicenter cervical deformity (CD) database.

Objective: Assess the impact of complication type and Clavien complication (Cc) grade on clinical outcomes of surgical CD patients

Background: Validated for general surgery, the Clavien-Dindo complication classification system allows for broad comparison of postoperative complications; however, the applicability of this system is unclear in CD-specific populations.

Methods: Surgical CD patients above 18 years with baseline and postoperative clinical data were included. Primary outcomes were complication type (renal, infection, cardiac, pulmonary, gastrointestinal, neurological, musculoskeletal, implant-related, radiographic, operative, wound) and Cc grade (I, II, III, IV, V). Secondary outcomes were estimated blood loss (EBL), length of stay (LOS), reoperation, and health-related quality of life (HRQL) score. The univariate analysis assessed the impact of complication type and Cc grade on improvement markers and 1-year postoperative HRQL outcomes.

Results: In total, 153 patients (61±10 y, 61% female) underwent surgery for CD (8.1±4.6 levels fused; surgical approach included 48% posterior, 18% anterior, 34% combined). Overall, 63% of patients suffered at least 1 complication. Complication breakdown by type: renal (2.0%), infection (5.2%), cardiac (7.2%), pulmonary (3.9%), gastrointestinal (2.0%), neurological (26.1%), musculoskeletal (0.0%), implant-related (3.9%), radiographic (16.3%), operative (7.8%), and wound (5.2%). Of complication types, only operative complications were associated with increased EBL (P=0.004), whereas renal, cardiac, pulmonary, gastrointestinal, neurological, radiographic, and wound infections were associated with increased LOS (P<0.050). Patients were also assessed by Cc grade: I (28%), II (14.3%), III (16.3%), IV (6.5%), and V (0.7%). Grades I and V were associated with increased EBL (both P<0.050); Cc grade V was the only complication not associated with increased LOS (P=0.610). Increasing complication severity was correlated with increased risk of reoperation (r=0.512; P<0.001), but not inferior 1-year HRQL outcomes (all P>0.05).

Conclusions: Increasing complication severity, assessed by the Clavien-Dindo classification system, was not associated with increased EBL, inpatient LOS, or inferior 1-year postoperative HRQL outcomes. Only operative complications were associated with increased EBL. These results suggest a need for modification of the Clavien system to increase applicability and utility in CD-specific populations.

*Department of Orthopedics, NYU Langone Orthopedic Hospital

Department of Orthopedics, Hospital for Special Surgery, New York, NY

Department of Neurosurgery, University of Virginia, Charlottesville, VA

§Denver, CO

San Diego Center for Spinal Disorders, La Jolla, CA

Department of Orthopaedic Surgery, Washington University, St. Louis, MO

#Department of Neurologic Surgery, University of Michigan, Ann Arbor, MI

**Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD

††Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA

‡‡Norton Leatherman Spine Center, Louisville, KY

§§Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS

∥∥Department of Orthopedic Surgery, Swedish Neuroscience Institute, Seattle, WA

¶¶Rocky Mountain Scoliosis and Spine, Denver, CO

##Department of Orthopaedic Surgery, University of California, Davis, Davis, CA

Supported by Grant from DePuy Synthes.

P.G.P.: personal consulting fees—Spinewave and Medicrea; teaching arrangements—Zimmer-Biomet and Globus; membership to the scientific advisory board of Allosource, research study funding—Aesculap; grant to the institution—CSRS; all outside the submitted work. R.L.: reports grants—Depuy Synthes Spine, outside the submitted work. J.S.S.: consulting fees—reports Depuy Synthes, Medtronic, Stryker; royalties—Zimmer-Biomet, all outside the submitted work. D.M.S.: consulting fees outside the work—Medtronic. J.L.G.: royalties—acuity; consulting—Medtronic, DePuy, Alphatec, Stryker, Acuity, K2M, Nuvasive; speaking and/or teaching arrangements—Pacira Pharmaceuticals; honorarium and research support (investigator salary, staff/materials)—Integra, Intellirod Spine Inc., Pfizer, International Spine Study Group Foundation, Norton Healthcare; grants—Fischer Owen Funds, all outside the submitted work. D.C.B.: royalties—DePuy Spine; consulting—DePuy Spine; Board of Directors—International Spine Study Group, Scoliosis Research Society, University of Kansas Physicians; research support—DePuy Spine, Bioventus, Pfizer, all outside the submitted work. R.A.H.: consulting—DePuy; research support—DJO, Seeger, K2M, DePuy, NuVasive, all outside the submitted work. F.J.S: speaking/teaching, consulting, royalties/patents—Zimmer Biomet, NuVasive, K2M, MSD; speaking/teaching, consulting—Medicrea; Board of Directors, shareholder—Nemaris, all outside the submitted work. S.B.: royalties—K2 Medical, Pioneer; consulting—Allosource, K2 Medical; Scientific Advisory Board—Allosource; grants—DePuy Synthes, Medtronic, K2 Medical, NuVasive, all outside the submitted work. C.S.: royalties, patents, consultant—Medtronic, Nuvasive, stock holder Zimmer Biomet; consultant—K2M, Stryker, In Vivo; grants—NIH, Department of Defense, ISSG, DePuy Synthes, AOSpine, all outside the submitted work. E.O.K.: consulting—DePuy Synthes, Stryker, Springer, Trevana; honoraria, fellowship support—AOSpine; honoraria—K2M, all outside the submitted work. The remaining authors declare no conflict of interest.

Reprints: Peter G. Passias, MD, Departments of Orthopaedic and Neurological Surgery, New York Spine Institute, NYU Langone Medical Center, Orthopaedic Hospital, 301 East 17th Street, New York, NY 10003 (e-mail:

Received May 8, 2018

Accepted October 1, 2018

© 2019 by Lippincott Williams & Wilkins, Inc.