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. 2026 Jan;16(1):349-363.
doi: 10.1177/21925682251344928. Epub 2025 May 26.

Towards a Definition of Physiologic Vulnerability in Pediatric Spine Surgery: Identification of Key Risk Factors in a Cohort Study of Children With Neuromuscular Disease Undergoing Spinal Fusion

Muhammad S Ghauri  1 , Sujay Rajkumar  2 , Lauren E Stone  3 , Michael P Kelly  4 , Rajiv R Iyer  5   6 , Jennifer Bauer  7 , Christopher P Ames  8 , Peter O Newton  4 , David D Gonda  9 , Michael L Levy  3 , Vijay M Ravindra  3   5   9   6
Affiliations

Towards a Definition of Physiologic Vulnerability in Pediatric Spine Surgery: Identification of Key Risk Factors in a Cohort Study of Children With Neuromuscular Disease Undergoing Spinal Fusion

Muhammad S Ghauri et al. Global Spine J. 2026 Jan.

Abstract

Study DesignRetrospective cohort study.ObjectivesPreoperative risk stratification using frailty is common for adults but difficult to apply to pediatric populations. We aimed to identify risk factors indicating physiologic vulnerability and predict perioperative complications in children with neuromuscular scoliosis (NMS) and to create a prediction model for physiological vulnerability (PV-5).MethodsPatients with NMS were identified from the American College of Surgeons National Surgical Quality Improvement Program Pediatric database. The 9442 patients identified were randomly divided into training and testing cohorts. Univariate and multivariable logistic regression were performed; variables significantly associated with complications were evaluated using the Akaike information criterion and area under the curve. Significant variables received weighted scores, and a patient-specific prediction model was generated and evaluated using the Brier score.ResultsPatients with central nervous system abnormality (OR 1.32 [95%CI 1.13-1.53]), hematologic disorder (OR 1.40 [1.06-1.85]), congenital malformation (OR 1.30 [1.1-1.54]), nutritional support (OR 2.21 [1.91-2.57]), and preoperative wound infection (OR 2.3 [1.4-3.76]) were more likely to develop complications after spinal fusion surgery. PV-5 scores were calculated from these risk factors to generate a prediction model. PV-5 scores of 1 (OR: 2.0 [1.27-3.43], P < 0.004), 2 (OR: 2.75 [1.63-4.64], P < 0.001), 3 (OR: 3.67 [2.18-6.19], P < 0.001), 4 (OR: 4.09 [2.39-6.99], P < 0.001), and 5+ (OR: 3.58 [1.35-9.47], P = 0.01) predicted greater complication risk than PV-5 of zero (accuracy = 89.65%, Brier score = 0.09).ConclusionsUsing factors associated with complications in children with NMS undergoing spinal fusion surgery, we created a prediction model to illustrate physiologic vulnerability and morbidity. Our model serves as a foundation for further body system-specific investigation.

Keywords: deformity correction; frailty; neuromuscular scoliosis; pediatric; physiologic vulnerability; risk stratification; screening tool; spinal deformity; spine surgery.

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Conflict of interest statement

Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Jennifer Bauer is a consultant for Orthopaediatrics, Depuy Synthes, and Proprio; serves on the Board of Directors of the Pediatric Orthopaedic Society of North America; and her institution has received a quality improvement grant from POSNA. Christopher P. Ames is a consultant for DePuySynthes, Medtronic, Medicrea, K2M, Agada Medical, and Carlsmed; receives royalties from Stryker, Biomet Zimmer Spine, DePuy Synthes, Nuvasive, Next Orthosurgical, Medicrea, and K2M; has research support from Titan Spine, DePuy Synthes, and ISSG; and has a grant from the Scoliosis Research Society. Peter O. Newton is a consultant for DePuy Synthes Spine, Stryker/K2M, MiRus, Globus Medical, and Pacira; has received honoraria from DePuy Synthes Spine and Medtronic; receives royalties from DePuy Synthes Spine, Thieme Publishing, and Stryker/K2M; has patents with DePuy Synthes Spine (anchoring systems and methods for correcting spinal deformities [8540754], low-profile spinal tethering systems [8123749], screw placement guide [79811117], compressor for use in minimally invasive surgery [7189244]) and Stryker/K2M (posterior spinal fixation); is on the leadership of the Scoliosis Research Society, the Setting Scoliosis Straight Foundation, the Rady Children’s Specialists of San Diego, and the International Pediatric Orthopedic Think Tank; has equity interest in Accelus and Spinology; and his institution receives grant funding from DePuy Synthes Spine, the Scoliosis Research Society, EOS Imaging, Nuvasive, Orthopediatrics, Stryker/K2M, Alphatech, Mazor Robotics, and the Setting Scoliosis Straight Foundation. The other authors report no conflicts of interest.

Figures

Figure 1.
Figure 1.
Diagram of analysis workflow. Note. CPT, Common Procedural Terminology; ICD, International Classification of Diseases; ACS-NSQIP-P, American College of Surgeons National Surgical Quality Improvement Program–Pediatric; UVA, univariate analysis, AUC, area under the curve; AIC, Akaike information criterion; PV-5, 5-factor physiological vulnerability score; OR, odds ratio.
Figure 2.
Figure 2.
Distribution of 5-factor physiological vulnerability (PV-5) scores within validation cohort.
See this image and copyright information in PMC

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