Neurosurgical Review

, Volume 42, Issue 2, pp 319–336 | Cite as

Pseudarthrosis in adult and pediatric spinal deformity surgery: a systematic review of the literature and meta-analysis of incidence, characteristics, and risk factors

  • Nathan E. How
  • John T. Street
  • Marcel F. Dvorak
  • Charles G. Fisher
  • Brian K. Kwon
  • Scott Paquette
  • Justin S. Smith
  • Christopher I. Shaffrey
  • Tamir Ailon


We conducted a systematic review with meta-analysis and qualitative synthesis. This study aims to characterize pseudarthrosis after long-segment fusion in spinal deformity by identifying incidence rates by etiology, risk factors for its development, and common features. Pseudarthrosis can be a painful and debilitating complication of spinal fusion that may require reoperation. It is poorly characterized in the setting of spinal deformity. The MEDLINE, EMBASE, and Cochrane databases were searched for clinical research including spinal deformity patients treated with long-segment fusions reporting pseudarthrosis as a complication. Meta-analysis was performed on etiologic subsets of the studies to calculate incidence rates for pseudarthrosis. Qualitative synthesis was performed to identify characteristics of and risk factors for pseudarthrosis. The review found 162 articles reporting outcomes for 16,938 patients which met inclusion criteria. In general, the included studies were of medium to low quality according to recommended reporting standards and study design. Meta-analysis calculated an incidence of 1.4% (95% CI 0.9–1.8%) for pseudarthrosis in adolescent idiopathic scoliosis, 2.2% (95% CI 1.3–3.2%) in neuromuscular scoliosis, and 6.3% (95% CI 4.3–8.2%) in adult spinal deformity. Risk factors for pseudarthrosis include age over 55, construct length greater than 12 segments, smoking, thoracolumbar kyphosis greater than 20°, and fusion to the sacrum. Choice of graft material, pre-operative coronal alignment, post-operative analgesics, and sex have no significant impact on fusion rates. Older patients with greater deformity requiring more extensive instrumentation are at higher risk for pseudarthrosis. Overall incidence of pseudarthrosis requiring reoperation is low in adult populations and very low in adolescent populations.


Pseudarthrosis Spine curvature Scoliosis Surgical complication Spinal Fusion 



This research would not have been possible without the generous support of the J.D. Hatcher Award from the Department of Biomedical and Molecular Sciences at Queen’s University.


The research was funded in part by the J.D. Hatcher Award awarded to Nathan How by the Department of Biomedical and Molecular Sciences in the School of Medicine at Queen’s University. The award provided monies to be used as salary.

Compliance with ethical standards

Conflict of interest

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Ethical approval and informed consent

The great majority of included studies were observational in nature, and of those the most were retrospective. Hence, they did not require formal consent, but did abide by institutional ethical standards. All procedures performed in non-observational studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Previous use of material

Portions of this work were presented in poster format at the 5th annual Medical Student Research Showcase at Queen’s University in Kingston, Ontario, Canada on September 21st 2016.

Supplementary material

10143_2018_951_MOESM1_ESM.pdf (641 kb)
ESM 1 (PDF 641 kb).
10143_2018_951_MOESM2_ESM.pdf (152 kb)
ESM 2 (PDF 152 kb).


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Nathan E. How
    • 1
  • John T. Street
    • 2
  • Marcel F. Dvorak
    • 2
  • Charles G. Fisher
    • 2
  • Brian K. Kwon
    • 2
  • Scott Paquette
    • 2
  • Justin S. Smith
    • 3
  • Christopher I. Shaffrey
    • 3
  • Tamir Ailon
    • 2
  1. 1.School of MedicineQueen’s UniversityKingstonCanada
  2. 2.Department of OrthopaedicsUniversity of British ColumbiaVancouverCanada
  3. 3.Department of NeurosurgeryUniversity of Virginia Health SystemCharlottesvilleUSA

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