What We Mean by "Complex"
In paediatric spinal deformity, "complex" is not a euphemism — it describes a specific set of clinical characteristics that change the risk, the surgical plan, and the outcome expectations. A complex case in our practice typically involves one or more of the following:
- Congenital deformity with segmentation failure, hemivertebra, or rib fusions
- Neuromuscular scoliosis requiring sacropelvic fixation in a medically fragile child
- Revision surgery after failed prior instrumentation (broken rods, pseudarthrosis, infection, hardware prominence)
- Severe rigid curves requiring pre-operative traction or anterior release before posterior fusion
- Scoliosis associated with intraspinal pathology (syrinx, tethered cord, diastematomyelia) requiring coordinated neurosurgical management
- Deformity in the context of skeletal dysplasia, Marfan syndrome, or neurofibromatosis
The common thread is that these cases require planning that goes well beyond selecting an implant size and a fusion level. They require preoperative imaging protocols, multidisciplinary team input, patient-specific risk stratification, and often, a staged surgical approach.
Complexity in paediatric spine is not a barrier to care — it is a mandate for a different kind of preparation. Every added variable demands a wider team, not a shorter operation.
How We Plan
For every complex case accepted to our service, the pre-operative workup follows a structured protocol:
- Full-spine standing imaging (EOS): We use EOS biplanar low-dose X-ray as the baseline. This provides true coronal and sagittal Cobb measurements, pelvic parameters, and sagittal balance data in a single low-radiation exposure. For cases with pelvic involvement, we include a standing pelvis view.
- MRI of the full neuraxis: Mandatory for all congenital and syndrome-associated cases; strongly recommended for EOS and cases with any neurological signs or symptoms. We look specifically for intraspinal anomalies that could change the surgical approach or require neurosurgical input.
- CT with 3D reconstruction: Used selectively for congenital cases, revision surgery, and any case where pedicle anatomy requires pre-operative planning. We generate patient-specific 3D models for cases with complex congenital fusions where screw trajectories are non-standard.
- Pulmonary function testing: Mandatory for neuromuscular cases and for any child with thoracic-level deformity where respiratory compromise is suspected. We establish a baseline FVC and work with paediatric pulmonology for cases below 50%.
- Multidisciplinary team meeting: Complex cases are presented at our weekly MDT, which includes spinal deformity surgery, paediatric anaesthesia, paediatric neurology, and where relevant, paediatric cardiology and pulmonology. The plan documented from this meeting drives the surgical approach.
Intraoperative Standards
Complex paediatric spine deformity surgery at our centre is performed with the following standards as non-negotiable:
- Intraoperative neurophysiological monitoring (IONM): Continuous multimodal monitoring including transcranial motor evoked potentials (TcMEP) and somatosensory evoked potentials (SSEP). A dedicated neurophysiology technician is present throughout the case.
- Cell salvage: For cases with anticipated blood loss above 500 ml (all neuromuscular and revision cases), intraoperative blood salvage (cell saver) is used to reduce allogeneic transfusion. We also use tranexamic acid routinely.
- Intraoperative CT navigation (O-arm): Used for all revision cases, cases with distorted anatomy, and sacropelvic fixation. Navigation-guided pedicle screw placement significantly reduces the rate of malpositioned hardware in complex anatomy.
- Wake-up test: Standard in cases where IONM changes are noted intraoperatively; supplementary to IONM, not a replacement.
Post-Operative Care and ICU
All complex deformity cases are admitted to our paediatric high-dependency unit post-operatively. Neuromuscular patients and those with pre-operative pulmonary compromise are planned for a minimum 24-hour ventilated period.
Our anaesthetic team — experienced specifically in paediatric spinal deformity — uses a standardised extubation protocol that avoids premature extubation in patients with borderline respiratory reserve. Average hospital stay for complex cases is 7–10 days. We do not discharge until the child is eating, independently mobile to a functional level, and pain is managed on oral analgesia alone.
What We Do Not Offer
Transparency about limitations is as important as describing capability. There are situations that fall outside what we can safely provide:
- Paediatric cardiac surgery required concurrently with spinal deformity correction in children with Marfan-related aortic pathology — these cases require a cardiac surgical team and hybrid unit that we coordinate with specialist centres.
- Halo-gravity traction for severe rigid curves — we use this technique selectively, but cases requiring prolonged inpatient traction (4–6 weeks) are resource-intensive and we plan these in advance as a dedicated admission.
- Spinal cord stimulation or intrathecal drug delivery as part of pain management — we refer to our neurosurgical colleagues for these components.
Referrals From Other Centres
We accept direct referrals from orthopaedic surgeons, paediatricians, and paediatric neurologists across Europe, the Gulf, and the Balkans. For complex cases, our preference is to review imaging and have a telephone or video discussion with the referring clinician before the family travels.
This avoids diagnostic surprises and allows us to prepare appropriately. We aim to respond to all complex referrals within 72 hours of receiving the clinical summary and imaging.