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7.7% Prevalence of neural axis abnormalities on routine magnetic resonance imaging in patients with presumed adolescent idiopathic scoliosis scheduled for spine surgery: a consecutive single surgeon retrospective cohort of 182 patients

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Abstract

Purpose

The purpose of this study was to use a Delphi analysis to identify a clinically relevant threshold for the prevalence of neural axis abnormalities (NAAs) that would warrant routine preoperative screening.

Methods

A panel of experienced physicians specializing in pediatric spine surgery, pediatric neurosurgery, and pediatric neuroradiology was formed to establish consensus using a Delphi process to identify a minimum prevalence of NAAs that would initiate the implementation of preoperative MRIs as standard of care. Following the Delphi analysis, patients scheduled for PSF (Posterior Spinal Fusion) from 2010 to 2018 were retrospectively identified. Patients were included based on the following criteria: (1) 10–18 years old at time of MRI (inclusive), (2) AIS diagnosis prior to preoperative MRI (no concerning curve pattern, rate of progression, or neurologic signs/symptoms to suggest alternative diagnosis to AIS), and (3) standard preoperative MRI of the cervical, thoracic, and lumbar spine undergone. The prevalence of NAAs on preoperative MRI was recorded for all patients.

Results

There were 182 eligible patients. 14 had NAAs on MRI. The prevalence of NAAs was 7.7% [95% CI 4.27–12.57%]. This prevalence was significantly [p < 0.0001] higher than the clinically relevant threshold of 1.3% established by the Delphi panel. Of the 14 patients with NAAs noted on preoperative MRI, neurosurgical intervention was recommended for 4 patients, 2.2% [95% CI 0.6–5.5%] of the total cohort.

Conclusions

Delphi panelists reported a low tolerance for NAAs among patients undergoing PSF for presumed AIS. Group consensus recommended routine screening should be implemented if the prevalence of NAAs is greater than 1.3%. The prevalence of NAAs in our cohort as well as related studies was significantly higher than this threshold.

Level of evidence

Diagnostic—level III.

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Funding

No funding was received for conducting this study.

Author information

Authors and Affiliations

  1. Children’s Hospital Colorado, 13123 East 16th Avenue, Box 060, Aurora, CO, 80045, USA

    Sumeet Garg, Hannah Darland, Eun Kim, Brenda Sanchez & Patrick Carry

Authors
  1. Sumeet Garg
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  2. Hannah Darland
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  3. Eun Kim
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  4. Brenda Sanchez
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  5. Patrick Carry
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Contributions

SG: conception/design of work. SG, HD, EBK, BS, PC: drafted or critically revised the work. SG, HD, EBK, BS, PC: approved version to be published. SG, HD, EBK, BS, PC: agreed to be accountable for all aspects of work. HD, EBK, BS: substantial contribution to acquisition and maintenance of data. PC: statistical analysis/interpretation of data.

Corresponding author

Correspondence to Sumeet Garg.

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Conflict of interest

The authors declare no financial interests. Author SG is on the board of directors for the Pediatric Orthopedic Society of North America.

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IRB or Research Ethics Committee approval was not necessary for the production of this manuscript.

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Appendices

Appendix 1

Overview

The Delphi methodology employs a series of adaptive surveys intended to establish consensus among experts to identify pragmatic solutions to questions or problems that cannot be addressed empirically. The Delphi analysis structure was designed based on the study by Jackson et al. [16] Consensus was established when a given measure was either accepted or rejected. A measure was accepted if > 55% (5/9) of the participants agreed with the statement. A measure was rejected if ≤ 22% (2/9) agreed the statement. All 9 panelists completed 3 rounds of online questionnaires.

Round 1

In the first round of questionnaires, panelists were asked two open-ended questions. Q1: “What types of spinal cord abnormalities do you consider a potential danger to the patient during spine fusion surgery? Please be as specific as possible.” Q2: “What is the MINIMUM prevalence of spinal cord abnormalities that would prompt you to recommend the use of preoperative MRIs as standard of care for adolescent idiopathic scoliosis (AIS) patients?”.

Literature review

Following panelist responses to the first round, a literature review was conducted investigating the rates of panelist-reported anomalies and their potential danger in the context of PSF for presumed AIS. The literature review process is described in the section describing the meta-analysis. The results of the literature review were summarized and sent to panelists with the second questionnaire.

Round 2

Each panelist’s response from the first round was reworded into a statement. Panelists reviewed the results of the literature review and then rated the statements using a five-point Likert scale (strongly agree, agree, unsure, disagree, strongly disagree). The median of the answers to Q2 was used to create a statement. In round 2, the experts were asked whether they Strongly Agree, Agree, Unsure, Disagree, Strongly Disagree with the following statements: (1) a prevalence of spinal cord anomalies of 1.3% is high enough that I would recommend the use of preoperative MRIs in the presumed AIS population as a standard of care practice. (2) Low-lying conus medullaris (below L2-3) present a real and potential danger to spine fusion patients. (3) Disc herniations present a real and potential danger to spine fusion patients. (4) Fibrolipomas of the filum terminale (if particularly thick) present a real and potential danger to spine fusion patients. (5) Arachnoid cysts present a real and potential danger to spine fusion patients. (6) Dermoid cysts present a real and potential danger to spine fusion patients. (7) Segmentation abnormalities present a real and potential danger to spine fusion patients.

A response of agree/disagree or strongly agree/disagree was considered an acceptance or rejection of the statement, respectively. Any statement that did not reach consensus as defined above was asked again in the third questionnaire.

Round 3

Statements were sent back to panelists along with a summary of the average responses from round 2. With this new information, panelists were once again asked to rate the statements using a Likert scale. The Delphi analysis ended after responses from the 3rd questionnaire was collected.

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Garg, S., Darland, H., Kim, E. et al. 7.7% Prevalence of neural axis abnormalities on routine magnetic resonance imaging in patients with presumed adolescent idiopathic scoliosis scheduled for spine surgery: a consecutive single surgeon retrospective cohort of 182 patients. Spine Deform 11, 95–104 (2023). https://doi.org/10.1007/s43390-022-00568-8

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