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Modified Clavien–Dindo–sink classification system for adolescent idiopathic scoliosis

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Abstract

Purpose

The Clavien–Dindosink (CDS) classification system provides more treatment-focused granularity than subjective methods of describing surgical complications; however, it has not been validated in posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). The purpose of this study was to modify the CDS system for application in patients with AIS undergoing PSF to assess its inter- and intra-rater reliability for describing complications faced by this population.

Methods

A review of all complications specific to patients with AIS captured in a large multicenter international database was performed. All complications were classified according to CDS, modified by addition of “prolonged initial hospital stay” as a criterion for Grade II. A survey of this complication list and an additional 20 clinical vignettes (sent out on two occasions) was sent to nine spinal deformity surgeons. Weighted kappa values were used to determine inter- and intra-rater reliability.

Results

The Fleiss κ value for interrater reliability among 5 respondents grading all AIS complications was 0.8 (very good). For each grade, interrater reliability was very good, with an overall range of 0.8–1. The overall kappa value for intrarater reliability among eight respondents grading 20 vignettes was between 0.6 (good) and 0.9 (very good).

Conclusion

The modified CDS classification system has very good interrater and intrarater reliability in describing complications following PSF in patients with AIS. This system may be of greater utility for reporting outcomes than a “major” versus “minor” complication system and can serve as a valuable tool for improving surgical practices and patient outcomes in this population.

Level of evidence

IV case series.

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Acknowledgements

Harms Study Group Investigators: Aaron Buckland, MD; Royal Children’s Hospital—Melbourne Australia. Amer Samdani, MD; Shriners Hospitals for Children—Philadelphia. Amit Jain, MD; Johns Hopkins Hospital. Baron Lonner, MD; Mount Sinai Hospital. Benjamin Roye, MD; Columbia University. Burt Yaszay, MD; Rady Children’s Hospital. Chris Reilly, MD; BC Children’s Hospital. Daniel Hedequist, MD; Boston Children’s Hospital. Daniel Sucato, MD; Texas Scottish Rite Hospital. David Clements, MD; Cooper Bone & Joint Institute New Jersey. Firoz Miyanji, MD; BC Children’s Hospital. Harry Shufflebarger, MD; Paley Orthopedic & Spine Institute. Jack Flynn, MD; Children’s Hospital of Philadelphia. John Asghar, MD; Paley Orthopedic & Spine Institute. Jean Marc Mac Thiong, MD; CHU Sainte-Justine. Joshua Pahys, MD; Shriners Hospitals for Children—Philadelphia. Juergen Harms, MD; Klinikum Karlsbad-Langensteinbach, Karlsbad. Keith Bachmann, MD; University of Virginia. Lawrence Lenke, MD; Columbia University. Lori Karol, MD; Children’s Hospital, Denver Colorado. Mark Abel, MD; University of Virginia. Mark Erickson, MD; Children’s Hospital, Denver Colorado. Michael Glotzbecker, MD; Rainbow Children’s Hospital, Cleveland. Michael Kelly, MD; Washington University. Michael Vitale, MD; Columbia University. Michelle Marks, PT, MA; Setting Scoliosis Straight Foundation. Munish Gupta, MD; Washington University. Nicholas Fletcher, MD; Emory University. Noelle Larson, MD; Mayo Clinic Rochester Minnesota. Patrick Cahill, MD; Children’s Hospital of Philadelphia. Paul Sponseller, MD; Johns Hopkins Hospital. Peter Gabos, MD: Nemours/Alfred I. duPont Hospital for Children. Peter Newton, MD; Rady Children’s Hospital. Peter Sturm, MD; Cincinnati Children’s Hospital. Randal Betz, MD; Institute for Spine & Scoliosis. Stefan Parent, MD: CHU Sainte-Justine. Stephen George, MD; Nicklaus Children's Hospital. Steven Hwang, MD; Shriners Hospitals for Children—Philadelphia. Suken Shah, MD; Nemours/Alfred I. duPont Hospital for Children. Sumeet Garg, MD; Children’s Hospital, Denver Colorado. Tom Errico, MD; Nicklaus Children's Hospital. Vidyadhar Upasani, MD; Rady Children’s Hospital.

Funding

This study was supported in part by grants to the Setting Scoliosis Straight Foundation in support of Harms Study Group research from DePuy Synthes Spine, EOS imaging, Stryker Spine, Medtronic, NuVasive, Zimmer Biomet and the Food and Drug Administration.

Author information

Authors and Affiliations

  1. Department of Orthopaedics, Washington University, St. Louis, MO, USA

    Ndéye F. Guissé

  2. Department of Orthopaedic Surgery, University of North Carolina, Chapel Hill, NC, USA

    Joseph D. Stone & Lukas G. Keil

  3. Department of Orthopaedic Surgery, Children’ Healthcare of Atlanta, 1400 Tullie Road, Atlanta, GA, 30329, USA

    Tracey P. Bastrom & Nicholas D. Fletcher

  4. Department of Orthopaedic Surgery, University of Colorado, Boulder, CO, USA

    Mark A. Erickson

  5. Department of Orthopaedic Surgery, University of California, San Diego, CA, USA

    Burt Yaszay

  6. Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA

    Patrick J. Cahill

  7. Department of Orthopaedic Surgery, University of Montreal, Montreal, Canada

    Stefan Parent

  8. Department of Orthopaedic Surgery, Afred I. DuPont Institute, Wilmington, DE, USA

    Peter G. Gabos

  9. Department of Orthopedics Surgery, UC San Diego School of Medicine, San Diego, CA, USA

    Peter O. Newton

  10. Department of Orthopaedic Surgery, University Hospitals Rainbow Babies Hospital, Cleveland, OH, USA

    Michael P. Glotzbecker

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

    Michael P. Kelly

  12. Department of Orthopaedic Surgery, Shriners Hospital for Children, Philadelphia, PA, USA

    Joshua M. Pahys

Authors
  1. Ndéye F. Guissé
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  2. Joseph D. Stone
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  14. Nicholas D. Fletcher
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Contributions

NFG: study design, aided in editing Harms Study Group comprehensive list of Adolescent Idiopathic Scoliosis complications and creating the modified version of the Clavien–Dindo-Sink complication classification system. Data collection, writing original draft preparation, approval of final version of manuscript, agree to be accountable for the work. JDS: study design, complications revisions and modification of the Clavien–Dindo-Sink complication classification system. Writing original draft preparation, approval of final version of manuscript, agree to be accountable for the work. LGK: contributed to Harms Study Group list of complications revisions. Writing original draft preparation, approval of final version of manuscript, agree to be accountable for the work. TPB: conducted statistical analyses on both the initial complications survey and the vignettes survey. Wrote “Data Analysis” section of the manuscript and provided revisions to the manuscript, agree to be accountable for the work. MAE, BY, PJC, SP, PGG, PON, MPG, MPK, JMP: all authors are members of the Harms Study Group who contributed to the research design, provided feedback for both surveys, approval of final version of manuscript, agree to be accountable for the work. MDF: research design, harms study group complications revisions and modification of the Clavien–Dindo-sink complication classification system. Writing original draft preparation, approval of final version of manuscript, agree to be accountable for the work.

Corresponding author

Correspondence to Nicholas D. Fletcher.

Ethics declarations

Conflict of interest

Not applicable.

Ethical approval

IRB approval was not necessary as this study as it included no patient subjects or patient information.

Supplementary Information

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Supplementary file1 (DOCX 33 KB)

Appendix

Appendix

CDS clinical vignettes

  1. 1.

    13 year-old AIS s/p PSF T3-L3 13 year-old AIS s/p PSF T3-L3 experiences no bowel movement after one week post-operatively. Patient calls nurse and is recommended increasing stool softener, laxatives, fluids, and fiber which results in resolution of symptoms.

    1. a.

      CDS I

  2. 2.

    16 year-old AIS T2-T12 follows up for routine One year follow-up with careful review of imaging revealing hook dislodgement at T2 on the right side. Reports no change in symptoms other than occasional activity-related back pain for which family defers PT stating “It really doesn’t stop him from doing anything”

    1. a.

      CDS I

  3. 3.

    15 year-old AIS with neglected 85 degree thoracolumbar scoliosis undergoes uncomplicated PSF and experiences nausea, vomiting, and pain post-operatively requiring prolongation of initial hospitalization for resolution of GI symptoms.

    1. a.

      CDS II

  4. 4.

    17 year-old 4 months s/p T4-L3 PSF comes to clinic unscheduled complaining of paraspinal thoracolumbar back pain that has caused him to miss three days over the past two weeks after initially returning to school 4 weeks postop. After management options discussed with family, they opt to initiate PT and planned f/u in 2 months. Despite PT the family returns in 5 weeks requesting new XRAYS after they and their PT feel they are not making enough progress. XRAYS unchanged with physical exam inconsistent with surgical pathology and decision made to continue PT/nonop management.

    1. a.

      CDS II

  5. 5.

    15 year-old presumed AIS 6 months s/p T3-L3 who comes to clinic regularly scheduled complaining of right-sided thoracic lump with pain whenever it contacts his chair at school. Physical exam reveals lump that is tender to palpation adjacent to well-healed incision. Close examination of radiographs reveals retained cap on screw at T7. Initial plans were to watch but family calls 3 weeks later requesting to have it removed as it is affecting has ability to function at home and school. Cap is removed uneventfully later that week.

    1. a.

      CDS III

  6. 6.

    14 year-old female with 78 degree right main thoracic curve who undergoes PSF from T3-L1 with 3-level apical PCOs. During completion of first PCO increased suction of clear fluid with subsequent diagnosis of small durotomy is observed which is repaired at that time. Patient is discharged home POD #2 but returns to the ED complaining of headache with benign appearing incision that responds to 2-day admission for bedrest and repeat clinical evaluations. No additional deviation in expected; postoperative course is noted through 2 years postop.

    1. a.

      CDS III

  7. 7.

    16 year-old muscular male undergoes T4-L1 PSF with PCOs in hospital without routine cellsaver use with 1500 cc of EBL and is noted to have difficulty with progression of ambulation POD#1 and 2 with Hb on respective days trending from 8.1 to 7.0 and resultant hypotension/tachycardia that responds favorably to transfusion of 1U PRBCs.

    1. a.

      CDS I

  8. 8.

    13 year-old female undergoes selective thoracic fusion experiences decreased blood pressure post-operatively at first two PT visits requiring no treatment.

    1. a.

      CDS I

  9. 9.

    14 year-old female undergoes selective thoracic fusion experiences an uncomplicated UTI (no history) within 30 days post-operatively requiring PO antibiotics and outpatient treatment by her PCP

    1. a.

      CDS I

  10. 10.

    16 year-old male with no urological PMH undergoes uncomplicated STF without IONM and experiences inability to empty his bladder completely POD #2 and 3. Urology consultation obtained with recommendation for urethral stent placement which is done during the initial hospitalization.

    1. a.

      CDS III

  11. 11.

    15 year-old female with history of ulcerative colitis undergoes T3-L3 PSF and experiences fever, tachycardia, hypotension on POD #2. She also has three episodes of bloody stools, and diffuse vague abdominal pain and distension. Abdominal radiograph and CT shows 6 cm dilation colon distal to the hepatic flexure. She undergoes uncomplicated subtotal colectomy and end ileostomy for toxic megacolon.

    1. a.

      CDS IVb

  12. 12.

    17 year-old female undergoes PSF and experiences blood loss requiring transfusion with 2 units of packed RBCs postoperatively. During the transfusion, she experiences hypotension, difficulty breathing, flushing and swelling in her face, and wheals over her chest and upper extremities. She stabilizes after administration of oxygen, IV epinephrine, antihistamines, and fluids.

    1. a.

      CDS IVa

  13. 13.

    13 year-old male who underwent selective thoracic fusion returns to office with a productive cough and fever of 102.1 for the past 2 days. His O2 sat is 93% on RA and he has decreased breath sounds in the RLL. CXR confirms findings of pneumonia and he is admitted to the floor and treated with antibiotics, fluids, and supportive care. His fever and oxygenation improve and he is discharged on day 3 with instructions to complete oral antibiotics at home

    1. a.

      CDS III

  14. 14.

    14 year-old female undergoes PSF and develops pain, minimal drainage, warmth and erythema at the incision site on POD#2. She is given topical and oral antibiotics and monitored closely in the office 2 days after discharge and again a week later. The incision improves and goes on to heal without further incident.

    1. a.

      CDS II

  15. 15.

    15 year-old male undergoes T11-L3 PSF experiences excruciating back pain 1 year post-operatively after a fall during a basketball game. X-ray reveals a broken rod requiring hardware removal and replacement.

    1. a.

      CDS III

  16. 16.

    16 year-old male undergoes PSF and complains of pain in his left lower leg during his 1-month check-up. His left lower leg is noted to be swollen, tender to palpation, and erythematous but not warm. He also has calf pain on dorsiflexion of the left toes. Compression venous ultrasonography with doppler reveals a noncompressible popliteal vein and decreased flow consistent with a DVT. He is treated with anticoagulation and his symptoms resolve.

    1. a.

      CDS II

  17. 17.

    13 year-old female undergoes T5-L4 PSF and develops shooting pain down the back of her left leg 1 month postoperatively. She has been tripping over herself and has difficulty with balance along with weakness on dorsiflexion. She undergoes decompression of the L5 nerve root but still has some residual weakness and instability requiring an ankle brace.

    1. a.

      CDS IVb

  18. 18.

    16 year-old female develops moderate chest pain at her first post-operative visit that is worse with movement and palpation of the sternum. She is given analgesics and anti-inflammatories which resolve her symptoms.

    1. a.

      CDS I

  19. 19.

    14 year-ols male who underwent T3-L1 PSF develops sudden shortness of breath, tachycardia, and low blood pressure while in the PACU. His O2 sat is 88% on RA, breath sounds are absent on the R lung fields, and neck veins are distended. ABG reveals respiratory acidosis and CXR reveals tracheal deviation to the left with a tension pneumothorax. A chest tube is immediately placed and he is admitted to the ICU.

    1. a.

      CDS IVa

  20. 20.

    17 year-old male undergoes PSF and is noted to have a pseudoarthrosis at his 1-year follow-up visit. He is asymptomatic and otherwise healthy. He is monitored closely for the following year with no additional derivation in his post-op course.

    1. a.

      CDS II

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Guissé, N.F., Stone, J.D., Keil, L.G. et al. Modified Clavien–Dindo–sink classification system for adolescent idiopathic scoliosis. Spine Deform 10, 87–95 (2022). https://doi.org/10.1007/s43390-021-00394-4

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