1. Complication Classification for Growing Spine Surgery has Strong Observer Agreement
Nicole Michael, BA
John Smith, MD
Tricia St. Hilaire, MPH
Claire Palmer, MS
Micaela Cyr, BA
Jessica Morgan, BS
Victoria Heagy, MS
Nikki Bloch, BA
Mark Erickson, MD, MMM
Children’s Spine Study Group
Sumeet Garg, MD

2. Complication Severity Score for Growth Friendly Surgery
Background
Complication Severity Score for Growth Friendly Surgery
Grade
Device Related
Disease Related I
Does not require unplanned surgery
Outpatient medical management only II
Inpatient medical management
IIA
Requires 1 unplanned surgery
IIB
Requires multiple unplanned surgeries
III
Requires abandoning growth-friendly strategy IV
Death
Smith JT, Johnston C, Skaggs D, Flynn J, Vitale M. A New Classification System to Report Complications in Growing
Spine Surgery: A Multicenter Consensus Study. Journal of Pediatric Orthopaedics Dec;35(8):

3. Research Question Purpose Hypothesis
To show the inter-rater and intra-rater reliability for use of the Complication Severity Score for Growing Spine Surgery
Hypothesis
The Complication Severity Score will show high levels of both inter- and intra-rater reliability

4. Methods
Two pediatric hospitals queried an Early Onset Scoliosis database for complications of patients undergoing growth friendly treatment
Block randomization was used to select complication cases and build survey
63-question survey sent to pediatric spine faculty and research coordinators
Reviewers determined the complication severity score
Surveys sent twice to test intra-rater reliability
20 total participants completed the survey twice
12 faculty, and 8 research coordinators

5. Methods Cohen’s Kappa used to asses intra-rater reliability
Kappa value
Degree of agreement
<=0
Poor
0-0.2
Slight
Fair
Moderate
Substantial
Almost perfect
Cohen’s Kappa used to asses intra-rater reliability
Fleiss Kappa used to asses inter-rater reliability

6. Results
Overall Cohen’s Kappa for intra-rater reliability: almost perfect
All raters, 0.86 (95% CI: )
Faculty, 0.87 (95% CI: )
Coordinators, 0.85 (95% CI: )

7. Results
Overall Fleiss Kappa for inter-rater reliability: almost perfect
All raters, 0.86 (95%Cl: )
Faculty, 0.86 (95% CI: )
Coordinators, 0.87 (95% CI: )

8. Device related complications: inter-rater reliability with 95% CI
*Fellows not included because there were only 2 responses
Almost perfect for Device I and IIB
Did not measure reliability for Device Related IV category
because no applicable complications from either institution.

9. Disease related complications: inter-rater reliability with 95% CI
*Fellows not included because there were only 2 responses
Almost perfect for Disease I, II, and IV
Did not measure reliability for Disease III category
because no applicable complications from either institution.

10. Conclusions
Complication Severity Score for Growth Friendly Surgery shows very strong levels of inter-rater and intra-rater reliability
Both overall and among individual severity score
Device IIA and III are more difficult to classify
This is a reliable tool for standardizing inconsistencies in reporting complications
*Fellows not included because there were only 2 responses

11. References
1. Lenke, L.G., et al., Adolescent idiopathic scoliosis a new classification to determine extent of spinal arthrodesis. The Journal of Bone & Joint Surgery, (8): p
2. Clavien, P.A., et al., The Clavien-Dindo classification of surgical complications: five-year experience. Annals of surgery, (2): p
3. Sink, E.L., et al., Reliability of a complication classification system for orthopaedic surgery. Clinical Orthopaedics and Related Research®, (8): p
4. Williams, B.A., et al., Development and Initial Validation of the Classification of Early-Onset Scoliosis (C- EOS). The Journal of Bone & Joint Surgery, (16): p
5. Park, H.Y. The Classification for Early Onset Scoliosis (C-EOS) Predicts Timing of VEPTR Anchor Failure. in AAP National Conference and Exhibition American Academy of Pediatrics.
6. Cummings, R.J., et al., Interobserver Reliability and Intraobserver Reproducibility of the System of King et al. for the Classification of Adolescent Idiopathic Scoliosis*. The Journal of Bone & Joint Surgery, (8): p
7. Fleiss, J.L., B. Levin, and M.C. Paik, Statistical methods for rates and proportions. 2013: John Wiley & Sons.
8. Cohen, J. A coefficient of agreement for nominal scales. Educational and Psychological Measurement, (1): p
9. Landis, J.R. and G.G. Koch, The measurement of observer agreement for categorical data. biometrics, 1977: p
10. Smith JT, Johnston C, Skaggs D, Flynn J, Vitale M. A New Classification System to Report Complications in Growing Spine Surgery: A Multicenter Consensus Study. Journal of Pediatric Orthopaedics Dec;35(8):