Original Article
Does Scoliosis Affect Sleep Breathing?
Xingye Li1,2, Haiwei Guo1,3, Chong Chen1, Haining Tan1, Youxi Lin1, Zheng Li1, Jianxiong Shen1
- OBJECTIVE: Scoliosis, especially thoracic curves, cau-
ses poor pulmonary function. As a result, scoliosis may
impair sleep breathing. The literature regarding the rela-
tionship between scoliosis and sleep breathing is sparse.
- METHODS: Fifty-seven patients with adolescent idio-
pathic scoliosis or congenital scoliosis and 25 healthy
control subjects were included. The wrist sleep monitors
was used. Sleep breathing was evaluated with the
following parameters: 1) Respiratory Disorders Index
(pRDI), indicating mean respiratory events per hour of sleep
including apnea, hypoxia, and respiratory efforterelated
arousal; 2) Apnea and Hypopnea Index (pAHI), expressing
the number of apnea and hypopnea events per hour of
sleep; and 3) mean and minimal oxygen saturation (SaO2)
during sleep.
- RESULTS: No differences in age, sex distribution, and
body mass index were found between the two groups.
Patients with scoliosis had statistically significant higher
pRDI (median, 10.10 vs. 8.65; P [ 0.039) and pAHI (median,
1.60 vs. 0.72; P [ 0.029) scores than the control group. The
minimal SaO2 value in patients with scoliosis was lower
(median, 93% vs. 94%, respectively; P [ 0.005), whereas no
difference was found in the mean SaO2 value during sleep.
In patients with scoliosis, pAHI scores were higher when
lying on the convex side of the thoracic curve compared
with the concave side (2.34 vs. 2.28, respectively; P [
0.044), whereas no such difference was observed in the
control group.
Key words
- Hypopnea
- Scoliosis
- Sleep apnea
- Sleep-disordered breathing
- Thoracic cage deformity
Abbreviations and Acronyms
AASM: American Academy of Sleep Medicine
BMI: Body mass index
PAT: Peripheral arterial tone
pAHI: Apnea and Hypopnea Index
pRDI: Respiratory Disorders Index
PSG: Polysomnography
SaO2: Oxygen saturation
SDB: Sleep-disordered breathing
WORLD NEUROSURGERY -: e1-e5, - 2018
- CONCLUSIONS: Patients with scoliosis have more res-
piratory events of apnea and hypopnea during sleep than
the control group. The minimal SaO2 value in patients with
scoliosis is lower than the normal population. Sleeping on
the convex side of the thoracic curve results in higher pAHI
scores than on the concave side.
INTRODUCTION
S
leep-disordered breathing (SDB) consists of a series of
disorders featuring abnormal respiratory patterns (e.g.,
apnea, hypopneas) or insufficient ventilation during sleep.1
If untreated, patients with SDB can have dysfunction in
neurocognitive, endocrine, cardiovascular, and metabolic
systems and increased mortality.2-5 Partial airway obstruction
and chest deformity are considered etiologic factors.6,7
Scoliosis is the most common 3-dimensional deformation
abnormality of the spine with direct effects on the thoracic
cage. Previous studies have shown that scoliosis impairs res-
piratory function by limiting chest wall movement and pre-
venting normal inflation of the lungs.8,9 Airway obstruction has
also been observed in patients with scoliosis,10 which is
thought to be the result of locational shift of intrathoracic
organs.11 The nature of scoliosis may increase the risk of SDB
in patients.
To date, the literature regarding the relationship between
scoliosis and SDB is sparse. The aim of this study is to describe
the sleep architecture and abnormalities of breathing during sleep
among patients with scoliosis.
From the 1Department of Orthopaedics, Peking Union Medical College Hospital, Chinese
Academy of Medical Sciences, Peking Union Medical College, Beijing; 2Department of
Orthopaedics, Peking University Fourth Clinical Medical College, Beijing Jishuitan Hospital,
Beijing; and 3Department of Thyroid Breast Surgery, Zhejiang Province People’ Hospital,
Hangzhou, China
To whom correspondence should be addressed: Jianxiong Shen, M.D.
[E-mail: sjxpumch@163.com]
Citation: World Neurosurg. (2018).
https://doi.org/10.1016/j.wneu.2018.07.106
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org e1

XINGYE LI ET AL.
METHODS
Subjects
For the patient group, 57 patients with scoliosis were enrolled.
They were scheduled for elective posterior spine instrumentation
and fusion from October 2015 to October 2016 in 1 medical center.
The patient was included if 1) he/she was aged between 12 and 22
years old, 2) he/she was diagnosed with adolescent/adult idio-
pathic scoliosis and congenital scoliosis with a thoracic curve
more than 40
, 3) he/she had no history of chest or spine surgery,
4) he/she had no history of lung diseases or neuromuscular dis-
eases, and 5) he/she had normal pulmonary function test results.
In the reference group, 25 healthy adolescent control subjects
were recruited. They had no history of spine deformity, orthopedic
surgeries, or lung and neuromuscular diseases.
Careful history taking and physical examination on both the
patients and the control group, including inspection on the
pharynx and tone, was performed to exclude obvious upper airway
obstruction. Anesthesia records of the patients were reviewed later
after their surgeries to exclude difficult airways.
Informed consent was obtained from all subjects and their legal
guardians. The demographic background, height, and body
weight of all subjects were collected. The coronal Cobb angle and
the direction of thoracic curves in patients with scoliosis were
measured. The researchers could access information to identify
individual participants during data collection; however, after this,
each patient was assigned with a study number and individual
information was unidentifiable in further analysis.
Sleep Breathing Monitoring
Traditionally, sleep efficiency and breathing are measured by poly-
somnography (PSG); however, it is costly and requires overnight
hospitalization. Sleep breathing of all subjects was monitored using
Watch-PAT 200 (Itamar Medical Ltd., Caesarea, Israel), a watch-like
compatible device. The Watch-PAT 200 has been proven to have
very strong correlations with PSG and other level III portable devices in
detecting sleep apnea12,13 and has been widely adopted as a useful tool
in diagnostic and screening studies.14-17 It has been categorized as a
level 3 device by the American Academy of Sleep Medicine (AASM) for
diagnostic methods of sleep apnea.18 The Watch PAT 200 device has 4
channels: 1) peripheral arterial tone (PAT), 2) pulse oximetry, 3) heart
rate, and 4) sleeping body position and snoring decibel.
PAT is a physiologic signal that reflects the vascular tone of
fingertips. Respiratory difficulties such as apnea and hypopnea
(indicated by the decrease of oxygen saturation [SaO2] by 3% from
baseline) are accompanied by an increased heart rate, blood
pressure, and sympathetic activation. This sympathetic activity
increment triggers peripheral vasoconstriction and is measured as
an attenuation in the PAT signal amplitude.3 Therefore, a
respiratory event and its associated arousal can be identified.
Sleep breathing of patients with scoliosis was monitored in the
hospital overnight. The night before the operation was avoided to
rule out the interference of anxiety before the operation. Moni-
toring for the reference group was conducted at home.
Outcome Measures
The data recorded by the Watch PAT 200 device was uploaded to
its analytic software zzzPAT (Itamar Medical Ltd.) for further
e2 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.07.106
ORIGINAL ARTICLE
DOES SCOLIOSIS AFFECT SLEEP BREATHING?
calculation. Completeness of all channels was checked before
further analyses. The decrease in SaO2 or the pause of respiration
accompanied by increased heart rate was marked as a hypopnea or
apnea event. Sleep breathing quality was described with the
following parameters: 1) Respiratory Disorders Index (pRDI),
indicating mean respiratory events per hour of sleep including
apnea and hypopnea events and respiratory efforterelated arousal;
2) Apnea and Hypopnea Index (pAHI) expressing the number of
apnea and hypopnea events per hour of sleep; and 3) mean and
lowest SaO2 during sleep.
Statistical Analysis
All analyses were performed using IBM SPSS Statistics 22 (IBM,
Armonk, New York, USA). Descriptive data were presented as
mean  SD. The Mann-Whitney U test was used to analyze
comparisons between groups. Paired t test was used to compare
parameters between different sleeping positions. P < 0.05 was
considered to indicate statistical significance.
RESULTS
Subjects
The average age of the 57 (14 men and 43 women) patients was
15.32 years (range, 12e22 years); 14 of them were diagnosed with
congenital scoliosis and 43 of them were diagnosed with idio-
pathic scoliosis (adult or adolescent). The average Cobb angle of
the thoracic curves of the involved patients was 58.79
. The
average age of the reference group was 15.52 years (range, 13e20
years). Body mass index (BMI) values of the patient and reference
groups were 18.97 and 19.12 kg/m2, respectively. No statistically
significant differences in age, sex distribution, and BMI were
found between the 2 groups (Table 1).
Sleep Breathing Parameters
Patients with scoliosis had significantly higher pRDI (median,
10.80 vs. 8.65; P ¼ 0.018) and pAHI scores (median, 1.60 vs. 0.72;
P ¼ 0.044) than the reference group, respectively. The lowest SaO2
value of patients with scoliosis was lower (median, 93% vs. 94%,
respectively; P ¼ 0.011). However, no difference was found in the
mean SaO2 value during sleep (Figure 1 and Table 2).
Sleep Breathing and Body Position
Sleeping parameters in different body positions were separately
recorded. pAHI and pRDI of the right and left lateral positioned
Table 1. Characteristics of Involved Subjects
Patients Control Subjects
Characteristic (n [ 57) (n [25) P Value
Female 75% 76% 0.914
Age (years) 15.32  3.48 15.52  2.31 0.276
BMI (kg/m )2
18.87  3.93 19.12  2.41 0.245
Thoracic Cobb angle 58.79
 24.09

Values are mean  SD or as otherwise indicated.
BMI, body mass index.
 ORIGINAL ARTICLE
XINGYE LI ET AL. DOES SCOLIOSIS AFFECT SLEEP BREATHING?

Table 2. Comparison of Sleep Breathing Parameters Between

the 2 Groups
Median

Parameter Patients Control Subjects Mann-Whitney U P Value

pRDI 10.80 8.65 477.00 0.018*

pAHI 1.60 0.72 512.50 0.044*
Lowest SaO2 93% 94% 963.00 0.011*
Mean SaO2 97% 97% 708.00 0.960

pRDI, Respiratory Disorders Index (indicating mean respiratory events per hour of sleep
including apnea and hypopnea events and respiratory efforterelated arousal); pAHI,
Apnea and Hypopnea Index (expressing the number of apnea and hypopnea events per
hour of sleep); SaO2, oxygen saturation.
*P < 0.05.

(Figure 2). PAT sleep breathing monitoring reported that her pRDI
score was 13.0 and pAHI score was 1.7, meaning that she had on
average 13 apnea and hypopnea events and 1.7 respiratory events
(including apnea and hypopnea events and respiratory efforte
related arousals) per hour of sleep.

Case 2. Case 2 was a 13-year-old girl diagnosed with adolescent

idiopathic scoliosis of 4 years, with an 81
right thoracic curve
(Figure 3). She denied symptoms of SDB. However, PAT sleep
breathing monitoring reported that her pRDI score was 14.7 and
pAHI score was 12.6, meaning that she had 12.6 respiratory
events (including apnea and hypopnea events and respiratory

Figure 1. Comparison of Respiratory Disorders Index and Apnea and

Hypopnea Index between the 2 groups: (A) Respiratory Disorders Index
and (B) Apnea and Hypopnea Index. Each triangle indicates a subject
involved in the study. pRDI, Respiratory Disorders Index; pAHI, Apnea
and Hypopnea Index.

sleeping were compared if both were available (parameters were

invalid if time duration of a certain position of sleeping was not
long enough for calculation). In patients with scoliosis, 38 paired
parameters were recorded. The pAHI scores were higher when
lying on the convex side of the thoracic curve than when lying on
the concave side (2.34 vs. 2.28, respectively; P ¼ 0.044), whereas
the difference for the pRDI was not significant (11.27 vs. 12.54,
respectively; P ¼ 0.987). In the reference group, pAHI and pRDI
were compared between the left and right lateral lying, and no
statistical significance was seen (pAHI: 0.77 vs. 0.95, P ¼ 0.55;
pRDI: 7.67 vs. 10.72, P ¼ 0.59, respectively) in 19 valid pairs of
parameters.

Case Examples
Figure 2. Anterior-posterior and lateral radiographs of a 12-year-old girl
Case 1. The first case is a 12-year-old girl diagnosed with adoles- with adolescent idiopathic scoliosis.
cent idiopathic scoliosis of 4 years, with an 81
right thoracic curve

WORLD NEUROSURGERY -: e1-e5, - 2018 www.WORLDNEUROSURGERY.org e3


XINGYE LI ET AL.
Figure 3. Anterior-posterior and lateral radiographs of a 13-year-old girl
with adolescent idiopathic scoliosis.
efforterelated arousals) per hour of sleep. This indicates that she
had mild obstructive sleep apnea according to the AASM
guidelines.18
DISCUSSION
This study revealed that compared with the normal population,
patients with scoliosis had slightly but significantly higher pAHI
and pRDI scores, indicating an increased frequency of hypoxia
and apnea events and its related arousals. Patients with scoliosis
also had lower lowest SaO2 values but similar mean SaO2 values.
There was no difference in background characteristics between
patients with scoliosis and the reference group, especially in age
and BMI, which are proven risk factors for SDB.19
Previous studies have revealed SDB in different groups of
patients that may relate to scoliosis. Striegl et al.7 reviewed charts
of 51 pediatric patients with thoracic insufficiency syndrome; of
these, 11 underwent PSG and 10 were found to have SDB.
Gonzalez et al.20 found frequent nocturnal oxygen desaturation
events in patients with severe kyphoscoliosis. SDB was also
found in patients with neurofibromatosis type 1,21,22 Chiari mal-
formation,23,24 and Duchenne muscular dystrophy.25-27 However,
different from the current study, these studies did not focus on
adolescent or young adult patients with idiopathic or congenital
scoliosis, and lacked either a relatively larger study population or a
control group.
The etiology of SDB commonly involves obstruction of the
airway.6,19 Obstructive pulmonary dysfunction has been observed
e4 www.SCIENCEDIRECT.com
ORIGINAL ARTICLE
DOES SCOLIOSIS AFFECT SLEEP BREATHING?
in patients with scoliosis.28 In these patients, compression and
rotation to the airways may result in displacement and rotation
of the intrathoracic and/or main stem of the bronchi. The
compression to the main stem of the bronchus against vertebra
and mediastinal structures, resulting in mechanical airway
obstruction, reduces expiratory flows and increases airway
resistance, therefore causing impaired sleep breathing. Patients
in this study showed higher pAHI scores when lying on the
convex side of the thoracic curve. Lying on the convex side
reduces the thoracic curve and therefore may partially relieve
obstruction of the airway. Besides obstruction, respiratory
muscle weakness and abnormal chest wall mechanics also cause
SDB.29 Evidence has shown that patients with scoliosis
frequently have complications with restrictive pulmonary
dysfunction.8,30,31
Although there were higher indices regarding sleep respiratory
events, no subject in this study can be clinically diagnosed with
obstructive sleep apnea according to the AASM 2009 guideline.32
However, we need to be cautious about complaints of related
symptoms because SDB is not rare among patients with
scoliosis. Under certain circumstances, we should consider
performing a PSG if SDB is suspected. If confirmed, previous
studies have proven that patients with scoliosis complicated
with impaired sleep respiration can be well managed with
intermittent positive pressure ventilation.20,33
This study has 4 main limitations. First, both idiopathic and
congenital scoliosis were involved, causing heterogeneity in
diagnosis. Second, laboratory workups including arterial blood
gas were not examined because such invasive examination was
inappropriate to perform on healthy adolescents of the reference
group. Third, kyphosis and flexibility of the curve was not
considered. Finally, the actigraphy used for sleep monitoring was
not the golden standard; however, it was accurate.
Despite these limitations, this study revealed that respiratory
events are more common among at least some portion of patients
with scoliosis, implying the complexity in the mechanism of
respiratory complications in scoliosis. PSG should be performed
as a part of respiratory evaluation for patients with scoliosis
showing sleep/breathing-related symptoms, including headaches,
daytime drowsiness, learning difficulties, or even psychologic
changes and nocturia. Early detection and treatment of sleep
respiratory events in patients with scoliosis may improve their
somatic and cognitive development. Findings in this study prompt
future studies with a larger cohort of patients. More importantly,
large-number prospective studies comparing pre- and post-
operative sleep breathing are needed.
CONCLUSIONS
Patients with scoliosis have more respiratory events of apnea
and hypopnea during sleep than the control group. The mini-
mal SaO2 value in patients with scoliosis is lower than the
normal population, whereas no difference was found in the
mean SaO2 value. Sleeping on the convex side of the thoracic
curve results in higher apnea and hypoxia index than the
concave side.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.07.106

XINGYE LI ET AL.
REFERENCES
1. Myers KA, Mrkobrada M, Simel DL. Does this
patient have obstructive sleep apnea?: The
Rational Clinical Examination systematic review.
JAMA. 2013;310:731-741.
2. Partinen M, Jamieson A, Guilleminault C. Long-
term outcome for obstructive sleep apnea syn-
drome patients. Mortality. Chest. 1988;94:
1200-1204.
3. Marin JM, Carrizo SJ, Vicente EF, Agusti A. Long-
term cardiovascular outcomes in men with
obstructive sleep apnoea-hypopnoea with or
without treatment with continuous positive airway
pressure: an observational study. Lancet. 2005;365:
1046-1053.
4. Gruber A, Horwood F, Sithole J, Ali NJ, Idris I.
Obstructive sleep apnoea is independently associ-
ated with the metabolic syndrome but not insulin
resistance state. Cardiovasc Diabetol. 2006;5:22.
5. Jun JC, Polotsky VY. Metabolic consequences of
sleep-disordered breathing. ILAR J. 2009;50:
289-306.
6. Strollo PJ, Rogers RM. Obstructive sleep apnea.
N Engl J Med. 2009;334:99-104.
7. Striegl AM, Chen M, Kifle Y, Song K, Redding GJ.
Sleep-disordered breathing in children with
thoracic insufficiency syndrome. Pediatr Pulmonol.
2010;45:469-474.
8. Koumbourlis AC. Scoliosis and the respiratory
system. Paediatr Respir Rev. 2006;7:152-160.
9. Tsiligiannis T, Grivas T. Pulmonary function in
children with idiopathic scoliosis. Scoliosis. 2012;7:
7.
10. Boyer J, Amin N, Taddonio RF, Dozor AJ. Evi-
dence of airway obstruction in children with
idiopathic scoliosis. Chest. 1996;109:1532-1535.
11. Huh S, Eun LY, Kim NK, Jung JW, Choi JY,
Kim HS. Cardiopulmonary function and scoliosis
severity in idiopathic scoliosis children. Korean J
Pediatr. 2015;58:218-223.
12. Korkuyu E, Duzlu M, Karamert R, Tutar H,
Yilmaz M, Ciftci B, et al. The efficacy of Watch
PAT in obstructive sleep apnea syndrome diag-
nosis. Eur Arch Otorhinolaryngol. 2015;272:111-116.
13. Ting J, Tan LL, Balakrishnan ID, Chan SP, Yeo TC,
Lee CH. Watch-PAT versus Level III device in
diagnosing sleep disordered breathing in first
WORLD NEUROSURGERY -: e1-e5, - 2018
DOES SCOLIOSIS AFFECT SLEEP BREATHING?
myocardial infarction [e-pub ahead of print] Clin
Respirat J. 2018. https://doi.org/10.1111/crj.12909.
14. Wee JH, Lim JH, Gelera JE, Rhee CS, Kim JW.
Comparison of success criteria based on long-
term symptoms and new-onset hypertension in
mandibular advancement device treatment for
obstructive sleep apnoea: observational cohort
study. BMJ Open. 2018;8. e021644.
15. Serra A, Cocuzza S, Maiolino L, Abramo A,
Spinato G, Tonoli G, et al. The watch-pat in pe-
diatrics sleep disordered breathing: pilot study on
children with negative nocturnal pulse oximetry.
Int J Pediatr Otorhinolaryngol. 2017;97:245-250.
16. Correa CM, Gismondi RA, Cunha AR, Neves MF,
Oigman W. Twenty-four hour blood pressure in
obese patients with moderate-to-severe obstruc-
tive sleep apnea. Arq Bras Cardiol. 2017;109:313-320.
17. Boyd SB, Upender R, Walters AS, Goodpaster RL,
Stanley JJ, Wang L, et al. Effective Apnea-
Hypopnea Index (“Effective AHI”): a new mea-
sure of effectiveness for positive airway pressure
therapy. Sleep. 2016;39:1961-1972.
18. Hedner J, Pillar G, Pittman SD, Zou D, Grote L,
White DP. A novel adaptive wrist actigraphy al-
gorithm for sleep-wake assessment in sleep apnea
patients. Sleep. 2004;27:1560-1566.
19. Ayas NT, Hirsch AA, Laher I, Bradley TD,
Malhotra A, Polotsky VY, et al. New frontiers in
obstructive sleep apnoea. Clin Sci (Lond). 2014;127:
209-216.
20. Gonzalez C, Ferris G, Diaz J, Fontana I, Nuñez J,
Marín J. Kyphoscoliotic ventilatory insufficiency:
effects of long-term intermittent positive-pressure
ventilation. Chest. 2003;124:857-862.
21. Johnson H, Wiggs L, Stores G, Huson SM. Psy-
chological disturbance and sleep disorders in
children with neurofibromatosis type 1. Dev Med
Child Neurol. 2005;47:237-242.
22. Licis A, Vallorani A, Gao F, Chen C, Lenox J,
Yamada KA, et al. Prevalence of sleep distur-
bances in children with neurofibromatosis type 1.
J Child Neurol. 2013;28:1400-1405.
23. Maso AF, Poca M, La Calzada MD, Solana E,
Tomas OR, Sahuquillo J. Sleep disturbance: a
forgotten syndrome in patients with Chiari I
malformation. Neurologia. 2014;29:294-304.
24. Dauvilliers Y, Stal VO, Abril BC, Coubes PA,
Bobin S, Touchon J, et al. Chiari malformation
and sleep related breathing disorders. J Neurol
Neurosurg Psychiatry. 2007;78:1344-1348.
ORIGINAL ARTICLE
25. Bloetzer C, Jeannet P, Lynch B, Newman CJ. Sleep
disorders in boys with Duchenne muscular
dystrophy. Acta Paediatr. 2012;101:1265-1269.
26. Bhat S, Gupta D, Chokroverty S. Sleep disorders
in neuromuscular diseases. Neurol Clin. 2012;30:
1359-1387.
27. Polat M, Sakinci O, Ersoy B, Sezer RG, Yilmaz H.
Assessment of sleep-related breathing disorders
in patients with duchenne muscular dystrophy.
J Clin Med Res. 2012;4:332-337.
28. Ito K, Kawakami N, Miyasaka K, Tsuji T, Ohara T,
Nohara A. Scoliosis associated with airflow
obstruction due to endothoracic vertebral hump.
Spine. 2012;37:2094-2098.
29. Dhand UK, Goyal M, Sahota P. Sleep-related
hypoventilation and hypoxemia due to neuro-
muscular and chest wall disorders. In:
Kushida CA, ed. Encyclopedia of Sleep. Waltham:
Academic Press; 2013:325-331.
30. Yu W, Song K, Zhang Y, Zheng GQ, Dong T.
Relationship between lung volume and pulmonary
function in patients with adolescent idiopathic
scoliosis: computed tomographic-based three-
dimensional volumetric reconstruction of lung
parenchyma. Clin Spine Surg. 2016;29:E396-E400.
31. Liu JM, Shen JX, Zhang JG, Zhao H, Li SG, Zhao Y,
et al. Roles of preoperative arterial blood gas tests
in the surgical treatment of scoliosis with mod-
erate or severe pulmonary dysfunction. Chin Med J.
2012;125:249-252.
32. Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N,
Malhotra A, Patil SP, et al. Clinical guideline for
the evaluation, management and long-term care
of obstructive sleep apnea in adults. J Clin Sleep
Med. 2009;5:263-276.
33. Bach JR, Robert D, Leger P, Langevin B. Sleep
fragmentation in kyphoscoliotic individuals with
alveolar hypoventilation treated by NIPPV. Chest.
1995;107:1552-1558.
Conflict of interest statement: This work was supported by
the Beijing Natural Science Foundation (15G10025).
Received 22 March 2018; accepted 12 July 2018
Citation: World Neurosurg. (2018).
https://doi.org/10.1016/j.wneu.2018.07.106
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2018 Elsevier Inc. All
rights reserved.
www.WORLDNEUROSURGERY.org e5