Skip to main content

The pediatric “Spine at Risk” program: 9-year review of a novel safety screening tool



We implemented an EMR-based “Spine at Risk” (SAR) alert program in 2011 to identify pediatric patients at risk for intraoperative spinal cord injury (SCI) and prompt an evaluation for peri-operative recommendations prior to anesthetic. SAR alerts were activated upon documentation of a qualifying ICD-9/10 diagnosis or manually entered by providers. We aimed to determine the frequency of recommended precautions for those auto-flagged by diagnosis versus by provider, the frequency of precautions, and whether the program prevented SCIs during non-spinal surgery.


We performed a retrospective chart review of patients from 2011 to 19 with an SAR alert. We recorded how the chart was flagged, recommended precautions, and reviewed data for SCIs at our institution during non-spinal operations.


Of the 3453 patients with an SAR alert over the 9-year study period, 1963 were auto-flagged by diagnosis and 1490 by manual entry. Only 38.7% and 24.3% of the patients in these respective groups were assigned precaution recommendations, making the auto-flag 62.8% better than providers at identifying patients needing precautions. Cervical spine positioning precautions were needed most frequently (86.7% of diagnosis-flagged; 30.0% of provider-flagged), followed by intraoperative neuromonitoring (IONM) (25.2%; 6.1%), thoracolumbar positioning restrictions (16.1%; 7.9%), and fiberoptic intubation (13.9%; 5.7%). There were no SCIs in non-spinal procedures during the study.


EMR-based alerts requiring evaluation by a Neurosurgeon or Orthopaedic surgeon prior to anesthesia can prevent SCIs during non-spinal procedures. The majority of identified patients are not found to be at risk, and will not require special precautions.

Level of evidence


This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2

Data availability

Data are available without HPI.


  1. 1.

    Bodensteiner JB (2019) Neurological manifestations of achondroplasia. Curr Neurol Neurosci Rep 19(12):105

    CAS  Article  Google Scholar 

  2. 2.

    Solanki GA, Sun PP, Martin KW et al (2016) Cervical cord compression in mucopolysaccharidosis VI (MPS VI): Findings from the MPS VI Clinical Surveillance Program (CSP). Mol Genet Metab 118(4):310–318

    CAS  Article  Google Scholar 

  3. 3.

    Savarirayan R, Rimoin DL (2004) Skeletal dysplasias. Adv Pediatr 51:209–229

    PubMed  Google Scholar 

  4. 4.

    Pruszczynski B, Mackenzie WG, Rogers K et al (2015) Spinal cord injury after extremity surgery in children with thoracic kyphosis. Clin Orthop Relat Res 473(10):3315–3320

    Article  Google Scholar 

  5. 5.

    Drummond JC, Krane EJ, Tomatsu S et al (2015) Paraplegia after epidural-general anesthesia in a Morquio patient with moderate thoracic spinal stenosis. Can J Anaesth 62(1):45–49

    Article  Google Scholar 

  6. 6.

    White KK, Bompadre V, Goldberg MJ et al (2017) Best practices in peri-operative management of patients with skeletal dysplasias. Am J Med Genet A 173(10):2584–2595

    Article  Google Scholar 

  7. 7.

    Kandil AI, Pettit CS, Berry LN et al (2020) Tertiary pediatric academic institution’s experience with intraoperative neuromonitoring for nonspinal surgery in children with mucopolysaccharidosis, based on a novel evidence-based care algorithm. Anesth Analg 130(6):1678–1684

    Article  Google Scholar 

Download references


No funding was received for this work.

Author information




Galambas, Krengel, Parker, Kolenko, Browd, White, and Bauer: data collection, writing—original draft preparation, writing—approval final version, agree to be accountable.

Corresponding author

Correspondence to Jennifer M. Bauer.

Ethics declarations

Conflict of interest

None pertinent to this study; see declaration form.

Ethical approval

This study is covered under approved IRB permission; exemption for consent.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Galambas, A.K., Krengel, W.F., Parker, C.E. et al. The pediatric “Spine at Risk” program: 9-year review of a novel safety screening tool. Spine Deform (2021).

Download citation


  • Cervical spine
  • Pediatric spine
  • Cervical instability
  • Cervical stenosis
  • Neuromonitoring
  • Spine at risk