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Journal of Peking University (Health Sciences) ›› 2025, Vol. 57 ›› Issue (5): 941-946. doi: 10.19723/j.issn.1671-167X.2025.05.019

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Establishment and validation of a risk prediction model for scoliosis after Nuss procedure in children and young adults with pectus excavatum

Bowen LI, Qiang ZHANG*(), Yixin SUN   

  1. Department of Thoracic Surgery, Beijing Jishuitan Hospital Affiliated to Capital Medical University, National Center for Orthopedics, Beijing 100035, China
  • Received:2024-06-16 Online:2025-10-18 Published:2025-09-04
  • Contact: Qiang ZHANG

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Abstract: Objective: To identify the risk factors associated with the development of post-Nuss procedure scoliosis in pectus excavatum patients and to establish a relevant predictive model. Methods: A retro-spective review was conducted on pectus excavatum patients who underwent Nuss procedure in Department of Thoracic Surgery at Beijing Jishuitan Hospital between January 2018 and February 2023. We gathered the patient demographic information (including age, sex, height, weight, and body mass index) and diagnostic imaging results (echocardiogram, chest CT scan, full-spine radiography, and PA/lateral chest X-rays), and measurements of Haller index, asymmetry index, sternal torsion angle (STA) index, and Cobb angle changes. The risk of post-Nuss procedure scoliosis was assessed. Cox regression analysis was performed to identify independent risk factors for scoliosis development in the pectus excavatum patients. Based on the results of the Cox regression analysis, a risk prediction model was established, and its specific predictive performance was assessed through internal cross-validation. Results: A total of 59 pectus excavatum patients who underwent Nuss procedure were included after applying inclusion and exclusion criteria. The median follow-up duration was 6.84 months, and the follow-up results showed significant improvements in Haller index, STA index, and asymmetry index postoperatively. Twelve patients developed scoliosis 3 months after Nuss procedure, while 47 patients did not, the incidence of scoliosis was 20.3%. Cox regression analysis identified preoperative pulmonary artery hypertension and preoperative asymmetry index as independent risk factors for post-Nuss procedure scoliosis. A predictive model was constructed based on single-factor Cox regression analysis results, incorporating age, height, weight, body mass index, preoperative pulmonary artery hypertension, preoperative Haller index, STA index, asymmetry index, and Cobb angle. The receiver operating characteristic (ROC) curve was plotted, and the area under the curve (AUC) for the overall predictive model was calculated to be 0.995. A calibration curve demonstrated good alignment between predicted values and actual values. Conclusion: Nuss procedure achieved favorable clinical outcomes. However, postoperative scoliosis emerged as a significant complication with a high incidence rate. Pulmonary artery hypertension and asymmetry index were independent predictors of post-Nuss procedure scoliosis. The predictive model developed in this study demonstrated robust performance in estimating the risk of postoperative scoliosis.

Key words: Pectus excavatum, Nuss surgery, Scoliosis, Risk factors, Nomograms

CLC Number: 

  • R655

Table 1

Baseline characteristics of pectus excavatum patients before Nuss procedure (n=59)"

Characteristics Values
Age/years, ${\bar x}$±s 16.0±3.99
Gender, n(%)
  Male 52 (88.1)
  Female 7 (11.9)
Height/cm, ${\bar x}$±s 134±8.71
Weight/kg, ${\bar x}$±s 38.3±8.15
Body mass index/(kg/m2), ${\bar x}$±s 20.0±2.36
Mitral valve prolapse, n(%) 3 (5.08)
Mitral regurgitation, n(%) 6 (10.2)
Tricuspid regurgitation, n(%) 1 (1.69)
Pulmonary artery hypertension, n(%) 4 (6.78)

Table 2

Radiographic parameter changes before and 3 months after Nuss procedure in pectus excavatum patients"

Radiographic parameters Before Nuss 3 months after Nuss P
Haller index, median (P25, P75) 3.20 (0.47, 5.35) 1.32 (0.18, 2.53) < 0.000 1
Sternal torsion angle index, median (P25, P75) 16.0 (5.75, 29.8) 11.8 (1.78, 21.6) < 0.000 1
Asymmetry index, median (P25, P75) 0.59 (0.33, 0.89) 0.32 (0.12, 0.48) < 0.000 1
Cobb angel, ${\bar x}$±s 7.16±2.45 8.86±3.20 0.001 6

Table 3

Univariate Cox regression analysis of factors associated with scoliosis in pectus excavatum patients after the Nuss procedure"

Variable HR (95%CI) β SE P
Age 1.19 (1.05-1.36) 0.18 0.07 0.010
Gender 0.00 (0.00-Infinity) -18.20 6 900.00 1.000
Height 1.07 (1.01-1.14) 0.07 0.03 0.040
Weight 1.10 (1.02-1.19) 0.10 0.04 0.020
BMI 0.67 (0.49-0.90) -0.40 0.15 0.010
Mitral valve prolapse 4.75 (0.54-41.64) 1.56 1.11 0.160
Mitral regurgitation 1.54 (0.34-7.04) 0.43 0.78 0.580
Pulmonary artery hypertension 17.08 (4.66-62.62) 2.84 0.66 < 0.001
Haller index 0.25 (0.14-0.43) -1.40 0.29 < 0.001
STA index 0.68 (0.58-0.80) -0.39 0.08 < 0.001
Asymmetry index 0.00 (0.00-0.00) -19.70 4.30 < 0.001
Cobb angle 0.41 (0.28-0.61) -0.89 0.20 < 0.001

Table 4

Multivariate Cox regression analysis of factors associated with scoliosis in pectus excavatum patients after the Nuss procedure"

Variable HR (95%CI) β SE P
Age 1.19 (0.96-1.48) 0.176 0.110 0.111
Height 1.09 (0.94-1.25) 0.083 0.073 0.259
Weight 1.04 (0.87-1.25) 0.040 0.092 0.664
BMI 1.13 (0.61-2.08) 0.119 0.313 0.704
Pulmonary artery hypertension 20.80 (1.37-314.00) 3.030 1.390 0.029
Haller index 39.9 (0.19-8 380) 3.690 2.730 0.177
STA index 0.47 (0.06-3.55) -0.749 1.030 0.466
Asymmetry index 1.8×10-54 (3.6×10-96-9.1×10-13) -124.000 49.000 0.011
Cobb angle 54.4 (0.31-9 650) 4.000 2.640 0.131

Figure 1

Establishment of a risk prediction model for scoliosis in pectus excavatum patients after the Nuss procedure A, B, forest plots showing the results of the multivariate Cox regression analysis, indicating that AI and PAH are key risk factors influencing postoperative scoliosis in patients; C, nomogram displaying the prediction model. BMI, body mass index; PAH, pulmonary arterial hypertension; STA, sternal torsion angle; AI, asymmetry index; Pr, prediction."

Figure 2

Validation of the risk prediction model for scoliosis in pectus excavatum patients after the Nuss procedure A, time-dependent receiver operating characteristic (ROC) curve at 3, 6, and 12 months evaluating the predictive performance of the overall prediction model on patient prognosis; B-D, calibration curves at 3, 6, and 12 months assessing the consistency between predicted and actual values respectively. AUC, area under the curve."

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