Spine Deformity 5 (2017) 369e373

www.spine-deformity.org

Case Series

Prevalence of Vitamin D Deficiency in Pediatric Patients With Scoliosis

Preparing for Spinal Surgery
Theresa Mayes, RD, CSP, CCRCa,*, Jennifer M. Anadio, MAb, Peter F. Sturm, MD, MBAb
a
Division of Nutrition Therapy, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
b
Division of Orthopaedic Surgery, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
Received 4 November 2016; revised 11 March 2017; accepted 19 March 2017

Abstract
Background: Establishing prevalence of vitamin D deficiency in elective scoliosis surgery may impact clinical outcomes. The objectives
of this study were to document vitamin D status of patients with scoliosis preparing for surgical intervention in order to establish frequency
of deficiency and determine characteristics influencing levels.
Methods: Records were queried for patients with scoliosis diagnosis who underwent posterior spinal fusion or initial growing rod
placement and had serum vitamin 25 hydroxyvitamin D (D25) recorded in the preoperative period. Demographic data (gender, age, body
mass index [BMI], race, scoliosis type, spine surgery procedure, and season of the year) were extracted. Chi-square analysis and
multivariate modeling were used to evaluate deficiency status among various demographic categories and determine the demographic
factors impacting D25.
Results: A total of 217 patients with a mean age of 13.6
3.6 years had vitamin D levels drawn a mean of 38.7
20.6 days prior to
surgery. The majority of the sample presented with a diagnosis of idiopathic scoliosis (n 5 126), and most patients were scheduled for
spinal fusion surgery (n 5 192). Nearly 75% of the study population (n 5 162) demonstrated D25 values below normal. African Americans
presented with greater risk of deficiency (p ! .0002) compared to Caucasians, as did patients preparing for spinal fusion versus growing rod
placement (p ! .03). Severe hypovitaminosis D was more common in winter than any other season (p ! .005). Patients with
neuromuscular scoliosis demonstrated significantly higher D25 levels over the idiopathic diagnosis type (p ! .0002). Gender, BMI, and age
did not impact D25.
Conclusion: Low D25 levels are reported in pediatric patients with scoliosis preparing for corrective spinal surgery. Population subsets
most at risk for deficiency in this limited study include African American children, those presenting for spinal fusion surgery, and patients
admitted in winter season.
Ó 2017 Scoliosis Research Society. All rights reserved.
Keywords: Growing rod construct; Pediatrics; Scoliosis; Spinal fusion; Vitamin D

Introduction characterized as a prehormone that promotes calcium

Multiple physiological roles for vitamin D have been
established [1-9]; however, its function in bone metabolism
is most commonly reported [10-14]. Vitamin D is
The statistical component of this project was supported by the National
Center for Advancing Translational Sciences of the National Institutes of
Health, under Award Number UL1TR000077. The content is solely the
responsibility of the authors and does not necessarily represent the official
views of the NIH.
Author disclosures: none.
*Corresponding author. Division of Nutrition Therapy, Cincinnati Chil-
dren’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH
45229, USA. Tel.: (513) 803-7007; fax: (513) 636-5877.
E-mail address: theresa.mayes@cchmc.org (T. Mayes).
2212-134X/$ - see front matter Ó 2017 Scoliosis Research Society. All rights reserved.
http://dx.doi.org/10.1016/j.jspd.2017.03.008
absorption, assisting with hemodynamic concentration of
calcium and phosphate, enabling bone mineralization, bone
growth, and remodeling [15]. Low levels of vitamin D
potentiate increased parathyroid hormone and hence
reduction in skeletal accretion. Although not investigated in
children, optimal intestinal calcium absorption occurs in
adults at a serum 25 hydroxyvitamin D (D25) level
approximating 32 ng/mL [16].
Scoliosis is the most common spinal disorder in children
and adolescents aged 10e16 years [17]. Determination of
vitamin D status is not standard practice in the pediatric
scoliosis population preparing for corrective surgery.
Hypovitaminosis D may impact postoperative bone healing,
and determining prevalence of deficiency has the potential
370 T. Mayes et al. / Spine Deformity 5 (2017) 369e373

to influence future care and outcomes of this surgical
population. The objectives of this study were to document
the vitamin D status of pediatric patients with scoliosis
preparing for spinal repair and to evaluate demographic
factors that influence vitamin D levels in this population.
Materials and Methods
Following institutional review board approval, a
retrospective chart review over a 25-month period (August
1, 2012 to August 31, 2014) was conducted to record serum
25 hydroxyvitamin D (D25) levels in all patients admitted
for surgical posterior spinal fusion or initial growing rod
construct (eg, Growing Rods, VEPTR, or MAGEC Rod)
placement. Values for D25 were included if available
within 90 days preceding the operation. Children with renal
disease or phenobarbital use in the 3 months preceding the
lab draw were excluded from the analysis. Demographic
data including gender, age, body mass index (BMI), race,
scoliosis type, spine surgery type, and season of the year at
the time of testing were recorded. These parameters were
examined to determine association between any noted
demographic and D25. Approval has been given for this
study by the Cincinnati Children’s Hospital Institutional
Review Board.
Distribution of D25 levels were stratified into 4 groups
characterized as normal (>32 ng/mL), insufficient (20 to
!32 ng/mL), deficient (12 to !20 ng/mL), and severely
Table 1
Overall 25-hydroxyvitamin D levels in scoliosis patients prior to surgery.
Deficiency category 25-hydroxyvitamin Number (%) of patients
D (ng/mL) in total sample
Severe !12 17 (7.8)
Deficient 12 to !20 37 (17.1)
Insufficient 20 to 32 108 (49.7)
Normal >32 55 (25.4)
deficient (!12 ng/mL) (Table 1). Scoliosis type was cate-
gorized as idiopathic, neuromuscular, syndromic, or other.
Seasons were divided into the 4 standard sections of time
within a year (Autumn: September 23eDecember 22;
Winter: December 23eMarch 22; Spring: March 23eJune
22; Summer: June 23eSeptember 22). Chi-square analysis
and multivariate modeling were used to determine
the association between D25 levels and recorded
demographics. An a priori level of !.05 was used to
determine statistical significance.
Results
A total of 217 patients met study criteria. Approximately
67% were female; nearly 90% were Caucasian, 8% African
American, and 2% combined from other races (Table 2).
Table 2 categorizes the number of patients with a diagnosis
of idiopathic scoliosis (n 5 126) versus the numbers of the
patients with nonidiopathic curves (n 5 91) and further-
more stratifies vitamin D levels based on sample de-
mographics. Additionally, the number of patients preparing
for spinal fusion (n 5 192) versus growing rod placement
(n 5 25) surgery, as well as a summary of D25 levels
characterized by season, were identified. Vitamin D levels
were drawn a mean of 38.7
20.6 days prior to surgery.
The average BMI of the sample was 20.7
5.1 and mean
age was 13.8
3.6 years.
Categorization of D25 for the entire sample is recorded
in Table 1. Nearly 75% of the entire study population
demonstrated a vitamin D level below normal; almost half
(49.7%) of the study patients fell within the insufficient
serum range; 17% were in the deficient range; and
approximately 8% of the sample exhibited D25 levels
indicative of severe deficiency. Analysis of vitamin D levels
stratified for age, gender, and BMI revealed no significant
differences in these variables among deficiency categories.
Bivariate analysis revealed that patients of African

Table 2
Overall demographics and vitamin D characterization of pediatric scoliosis patients.
Demographic variable Specific Overall n (%) Number (%) of patients by serum vitamin D category p value
comparative of sample Severe Deficient Insufficient Normal
Gender Male 72 (33.2) 9 (12.5) 33 (45.8) 10 (13.9) 20 (27.8) .074
Female 145 (66.8) 28 (19.3) 75 (51.7) 7 (4.8) 35 (24.1)
Race Caucasian 195 (89.9) 10 (5.1) 32 (16.4) 101 (51.8) 52 (26.7) .005
African American 17 (7.8) 7 (41.2) 4 (23.5) 5 (29.4) 1 (5.9)
Other 5 (2.3) 0 (0.0) 1 (20.0) 2 (40.0) 2 (40.0)
Scoliosis diagnosis Idiopathic 126 (58.1) 13 (10.3) 23 (18.3) 65 (51.6) 25 (19.8) .153
Neuromuscular 43 (19.8) 1 (2.3) 5 (11.6) 18 (41.9) 19 (44.2)
Syndromic 26 (12.0) 1 (3.9) 4 (15.4) 15 (57.7) 6 (23.1)
Other 22 (10.1) 2 (9.1) 5 (22.7) 10 (45.5) 5 (22.7)
Surgery type Fusion 192 (88.5) 17 (8.9) 37 (19.3) 93 (48.4) 45 (23.4) .002
Rod 25 (11.5) 0 (0.0) 0 (0.0) 15 (60.0) 10 (40.0)
Season Fall 39 (18.0) 5 (1.8) 24 (61.5) 1 (2.6) 9 (23.1) .005
Spring 94 (43.3) 15 (16.0) 45 (47.9) 4 (4.3) 30 (31.9)
Summer 26 (12.0) 1 (3.9) 17 (65.4) 2 (7.7) 6 (23.1)
Winter 58 (26.7) 16 (27.6) 22 (37.9) 10 (17.2) 10 (17.2)
 T. Mayes et al. / Spine Deformity 5 (2017) 369e373
Table 3
Multivariate predictors of serum D25 concentration.
Demographic Serum level difference to
(comparative group), ng/mL
African American 9.4 (Caucasians)
Surgery type, fusion 5.0 (growing rods)
Neuromuscular scoliosis þ6.6 (idiopathic)
diagnosis
American descent were significantly more likely to
demonstrate decreased D25 (p ! .005). Additionally, pa-
tients planning for fusion surgery had a significantly greater
possibility for lower D25 levels than those scheduled for
growing rod insertion (p ! .002). Chi-square analysis
revealed that season of the year significantly impacted D25
levels (p ! .005), with the most severe categorization of
D25 deficiency identified in winter (Table 2).
African American children presenting for spine fusion
surgery were the most at risk population for severe D25
deficiency. Multivariate analysis revealed that serum D25
levels of African American patients were reported at a
value of 9.4 ng/mL below that of their Caucasian coun-
terparts (p ! .0002). In addition, spinal fusion patients
experienced a serum level that was 5 ng/mL lower than
patients preparing for growing rod placement (p ! .0271).
On the contrary, patients with a neuromuscular scoliosis
diagnosis were noted as having higher amounts of D25 than
the other scoliosis types with an average serum level of 6.6
ng/mL above patients with an idiopathic scoliosis diagnosis
(p ! .0002) (Table 3).
Discussion
A multitude of factors predispose children to vitamin D
deficiency. Primary reasons include poor intake of vitamin
Decontaining foods and low exposure to sunlight [18],
especially during the winter months [18-20]. In the general
population, a greater propensity toward D25 deficiency has
been documented among the obese [19,21-23] and those of
African American descent [24]. As this study was a
retrospective chart review, the sources of vitamin D intake
of our study sample was not available. Therefore, the
impact of diet on D25 is unknown. Although BMI did not
correlate with D25 levels in this study, our data support the
literature given that more severe D25 deficiency was noted
in African American patients and those tested during the
winter season.
Fifty-eight percent of the study population was made
up of patients devoid of chronic health problems pre-
senting with an idiopathic scoliosis diagnosis. Interest-
ingly, approximately 80% of these otherwise healthy
patients were noted to have D25 levels below normal
(Table 1). Our report of incidence of D25 deficiency in the
idiopathic scoliosis population supports studies that have
noted generalized deficiency in the healthy pediatric
population [25-31].
371
This study brings awareness to the risk of D25 defi-
ciency in patients presenting for spine surgery. Given the
p value widespread tendency toward depressed D25 levels, routine
monitoring of vitamin D in scoliosis patients preparing for
.0002 surgical correction appears warranted. Patients in this study
.0271 had D25 levels available greater than 5 weeks prior to their
.0002
orthopaedic procedure. The scheduling of the lab draw
permits ample time to improve levels via supplementation
during the preoperative period. The dose of vitamin D
necessary to improve levels to normal in this interval is
unknown. Guidelines for treatment of hypovitaminosis D
exist in general pediatrics [30] and are suggested until
further research in this distinct population is available.
Patients with neuromuscular scoliosis had higher levels
of D25 in comparison to those with idiopathic diagnosis
(Table 3). The neuromuscular group commonly has their
nutrition status monitored in the outpatient setting at our
institution on an annual or semiannual basis. This includes
review of vitamin D status and treatment as indicated.
Furthermore, this group often has long-term nutrition re-
quirements met with gastric enteral feedings that would
routinely supply enteral vitamin D alimentation. This
attention to nutrition detail may be responsible for the
higher D25 levels documented in this group in the preop-
erative period.
Age and gender have been shown to influence D25; but
these factors did not statistically influence vitamin D levels
in our study sample. Patients preparing for a growing rod
placement had significantly higher levels of D25 (p ! .02).
This surgical intervention is characteristically completed at
a preadolescent age, considerably lower than the permanent
spinal fusion operation that is typically performed in the
teen years. The hormonal milieu of the pubescent years has
been shown to negatively impact vitamin D levels [32,33]
and may account for the differences noted in these surgi-
cal populations. Our study did not differentiate various
levels of tanner stage development. Perhaps the various
stages of puberty may have influenced prevalence of defi-
ciency in the older spinal fusion patients.
This study supports a previous study conducted by Parry
et al. that documented risk factors for low vitamin D levels
in pediatric patients with an array of orthopedic diagnoses
preparing for an elective corrective procedure [34]. Our
study is unique because it focused on the pediatric scoliosis
population only. Similar to Parry and colleagues, our
investigation reveals no relationship between BMI and
vitamin D levels. Likewise, our study documents a signif-
icantly lower D25 level in the African American subset of
patients (p ! .001), and furthermore, supports that season
of lab draw affected levels, with the most severe vitamin D
deficiency noted in winter (p ! .005).
As the physiological role of vitamin D emerges beyond
its impact on bone metabolism, the implications of this
study assume a wider range of potential clinical influence.
Vitamin D’s role in muscle strength [2,35-38] as well as
immune [1,3,39-43], inflammatory [4,8,44,45], and
372 T. Mayes et al. / Spine Deformity 5 (2017) 369e373
scarring processes [9,46-48] may have a significant clinical
impact. Turan et al. associated low levels of vitamin D with
in-hospital deaths, serious infections, and serious cardio-
vascular events in patients recovering from noncardiac
surgery [49]. The authors suggested a large prospective,
randomized trial evaluating the effect of preoperative
vitamin D supplementation on postoperative outcomes.
Indeed, a review of nonskeletal concerns is applicable in
the postsurgical spine population whereby physical per-
formance, risk of infection, inflammation, and surgical
scarring are key outcomes of interest. Furthermore,
Balioglu and colleagues recently compared the vitamin D
levels of scoliosis patients to age-matched controls and
found the individuals with scoliosis had lower vitamin D
levels [50]. Although their study corroborates our findings,
the authors raise an intriguing question as to whether or not
the high incidence of vitamin D deficiency in the idio-
pathic population potentiates predisposition to the scoliosis
defect. This concept is certainly worthy of further
investigation.
Our findings must be interpreted in light of acknowl-
edged limitations. We did not analyze weight by BMI
percentile. Given no differences in BMI were noted across
deficiency categories, no further analysis was indicated.
Also, given the retrospective study design we were unable
to evaluate the vitamin D intake of our sample or review for
use of vitamin supplements. However, it has been the
clinical observation of the authors that the majority of pa-
tients preparing for this surgery do not take single or multi-
vitamin/mineral supplements on a regular basis. As noted
previously in the Discussion, because of lack of clinical
documentation in this retrospective study, we were unable
to differentiate tanner stages of development and therefore
impact on D25. Finally, our regional spine center attracts
patients locally as well as from surrounding Midwestern
states. Given the general commonness of states of origin,
we did not evaluate patients by geographic latitude of
residence, which may have influenced sun exposure.
Conclusion
Low D25 levels are reported in pediatric patients with
scoliosis preparing for corrective spinal surgery. Population
subsets most at risk for deficiency in this limited study
include African American children, those presenting for
spinal fusion surgery, and patients admitted in winter sea-
son. Research is required to determine vitamin D supple-
mentation requirements and the longitudinal impact of such
on recovery from scoliosis surgery.
Acknowledgment
The authors would like to thank Julie Ballweg, BSN, RN
II, CPN, Tisha Danzinger, BSN, RN II, CPN and Maureen
Grady, RN II, for their organizational contributions to
this project.
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