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Unplanned return to OR (UPROR) for children with early onset scoliosis (EOS): a comprehensive evaluation of all diagnoses and instrumentation strategies

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Study design

Retrospective analysis of a prospectively collected multicenter database.


Our goal was to study unplanned return to the OR (UPROR, a postoperative complication that could not be treated without an additional anesthetic) as a function of C-EOS diagnosis and implant type.

Summary of background data

Growing concerns over the impact of multiple anesthetic events on the young brain have focused attention on limiting UPROR in early onset scoliosis (EOS).


We studied all patients with a diagnosis of EOS who had surgical implantation of growing instrumentation from October 4, 2010, to September 27, 2015, with a minimum 2-year follow-up. Among the complications requiring surgical treatment (revision for implant or anchor failure, infection, or implant removal), we analyzed all UPROR events—those that required a separate anesthetic (could not be treated as part of a planned surgical lengthening) within the first 2 years after initial implantation. UPROR was analyzed by diagnosis, deformity type, and implant strategy using the C-EOS classification.


A total of 369 patients met inclusion criteria. Eighty-five of the 369 (23%) required unplanned trips to the operating room for various reasons. The C-EOS group at highest risk of an unplanned trip to the operating room is the hyperkyphotic neuromuscular (M3+, 14/85) cohort, followed closely by the congenital (C3N, 9/85) and neuromuscular (M3N, 8/85) groups with normal sagittal profiles and Cobb angles between 50° and 90°. Implant strategy was significantly related to risk of UPROR (p = .009; Table 1), with traditional implants (vertically expandable prosthetic titanium rib/traditional growing rod) being less likely to have an UPROR event.


Growing instrumentation to treat EOS, when considered comprehensively, results in a true unplanned reoperation rate within 2 years of implantation of 23% (85/369). UPROR events are more common with certain C-EOS groups (hyperkyphotic neuromuscular deformities) and implant strategies. Families should be counseled that unplanned anesthetics are common with any implant strategy available today.

Level of evidence

Level III, therapeutic.

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Correspondence to Jason B. Anari.

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Conflict of interest

JBA (none), JMF (other from Biomet, other from LWW, outside the submitted work), PJC [personal fees from Biogen, Inc., NuVasive, Inc., outside the submitted work; and board or committee member in AAOS, Pediatric Orthopaedic Society of North America (POSNA), and Scoliosis Research Society (SRS); member of editorial or governing board of Journal of Bone and Joint SurgeryAmerican and Spine Deformity], MGV (grants from Pediatric Orthopaedic Society of North America, during the conduct of the study; other from POSNA and Biomet, personal fees from Stryker, personal fees from Biomet and Medtronic; other from Wellinks, outside the submitted work), JTS (none), JAG (none), SG (other from Decision Support in Medicine; personal fees from Medtronic and Mighty Oak Medical; other from POSNA, SRS, and US News & World Report Best Children’s Hospitals Orthopedics Working Group, outside the submitted work), KDB (none), Children’s Spine Study Group (none).

IRB approval

John Flynn, MD; Surgery/Orthopedics, Wood Building; 2nd Floor. Effective: 8/23/2006, RE: Expedited Approval of Report of New Protocol, IRB No: 2006-8-4935, Title: The Chest Wall and Spine Deformity Registry, Sponsor: Unsponsored.

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Anari, J.B., Flynn, J.M., Cahill, P.J. et al. Unplanned return to OR (UPROR) for children with early onset scoliosis (EOS): a comprehensive evaluation of all diagnoses and instrumentation strategies. Spine Deform 8, 295–302 (2020).

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