Predictors of Prolonged Pediatric Intensive Care Unit Length of Stay Following Posterior Spinal Fusion for Neuromuscular Scoliosis

Background Pediatric patients with neuromuscular scoliosis (NMS) undergoing posterior spinal fusion (PSF) frequently experience prolonged postoperative recovery, including extended pediatric intensive care unit (PICU) stays. Identifying perioperative predictors of prolonged critical care utilization may inform strategies to optimize perioperative management and improve outcomes. Methods A retrospective cohort study was conducted of NMS patients who underwent PSF by a single surgeon (2017–2022). Patients were stratified based on PICU length of stay (LOS) into short (0–2 days) and prolonged (≥3 days) groups. Preoperative, intraoperative, and postoperative variables were compared between groups using two-sample t -tests/ANOVA and Fisher's exact/Chi-square tests. Generalized linear modeling utilizing a Gamma distribution and log-link function was performed to evaluate predictors of continuous PICU duration. Results Fifty-two patients were included, of whom 33 (63%) had short PICU stays and 19 (37%) had prolonged stays. Prolonged PICU stay was significantly associated with higher preoperative hemoglobin (p=0.004), gastrostomy tube dependence (p=0.048), and lower intraoperative transfusion volumes (p=0.007). Intraoperatively, patients with prolonged stays experienced a significantly greater intraoperative hemoglobin drop (5.5 vs. 4.2 g/dL, p=0.008). Postoperatively, patients with prolonged PICU stays also demonstrated significantly lower first postoperative hemoglobin levels (p=0.004), increased postoperative transfusion volumes (p<0.001), and increased complication rates (p=0.005). Regression modeling demonstrated that higher intraoperative hemoglobin nadir was independently associated with shorter PICU stay, with each 1 g/dL increase corresponding to an estimated 25% reduction in ICU duration (p=0.032). Conclusions Prolonged PICU stay following PSF for neuromuscular scoliosis is associated with markers of medical complexity, perioperative anemia, and increased transfusion burden. These findings suggest that perioperative hemoglobin optimization in medically fragile patients may represent an opportunity to improve postoperative recovery and resource utilization. Prospective studies are warranted to define optimal transfusion and hemoglobin management strategies in this high-risk population. Key Concepts 1. Prolonged PICU stay is significantly associated with higher preoperative hemoglobin (p=0.004), gastrostomy tube dependence (p=0.048), and lower intraoperative transfusion volumes (p=0.007). 2. Postoperatively, patients with prolonged PICU stays demonstrate significantly lower first postoperative hemoglobin levels (p=0.004), increased postoperative transfusion volumes (p<0.001), and increased complication rates (p=0.005). 3. Higher intraoperative hemoglobin nadir is independently associated with shorter PICU stay, with each 1 g/dL increase corresponding to an estimated 25% reduction in ICU duration (p=0.032). Level of Evidence III; This was a retrospective cohort study.