Outcomes of the modified Woodward procedure with and without concomitant clavicular osteotomy and intraoperative neurophysiological monitoring for Sprengel deformity: a retrospective cohort study with a minimum 2-year follow-up

Surgical treatment of Sprengel deformity aims to improve shoulder symmetry and active shoulder motion while avoiding neurovascular injury. Whether clavicular osteotomy should be added to the modified Woodward procedure remains controversial, particularly because intraoperative neurophysiological monitoring (IONM) may independently influence neurological safety. This study compared clinical, radiographic, and safety outcomes after the modified Woodward procedure performed without adjuncts versus with a combined protocol of prophylactic clavicular osteotomy and IONM. We retrospectively reviewed 26 consecutive children with moderate-to-severe Sprengel deformity treated between January 2015 and July 2023. Group A included 16 patients who underwent the modified Woodward procedure without clavicular osteotomy or IONM. Group B included 10 patients who underwent prophylactic clavicular osteotomy and IONM before scapular descent. Outcomes included Cavendish cosmetic grade, Rigault radiographic grade, active shoulder abduction, perioperative variables, and complications over a minimum follow-up of 2 years. Ordinal outcomes were analyzed with Wilcoxon signed-rank and Mann–Whitney U tests. One transient postoperative brachial plexus palsy occurred in Group A (1/16, 6.3%; exact 95% CI 0.2–30.2%), whereas no neurovascular complication occurred in Group B (0/10, 0%; exact 95% CI 0.0–30.8%; Fisher exact P = 1.000). All clavicular osteotomy sites healed without non-union. Both groups demonstrated significant improvements in Cavendish grade, Rigault grade, and shoulder abduction at final follow-up (all within-group P ≤ 0.002). Shoulder abduction improved by 52.5° (95% CI 44.4°–60.6°) in Group A and 51.5° (95% CI 46.4°–56.6°) in Group B; the between-group difference in improvement was not statistically significant ( P = 0.768). Operative time was longer in Group B (201.0 ± 74.9 min vs 150.0 ± 52.5 min; P = 0.031), while hospitalization was shorter (10.6 ± 1.9 days vs 13.8 ± 4.3 days; P = 0.034). The modified Woodward procedure achieved clinically meaningful cosmetic, radiographic, and functional improvement in both cohorts. The absence of neurovascular complications in the clavicular osteotomy plus IONM group is noteworthy, but this preliminary safety signal cannot be attributed to clavicular osteotomy alone because of the sequential retrospective design, small sample size, and concomitant use of IONM. Adjunctive clavicular osteotomy with IONM may be considered when substantial scapular descent is planned, but larger prospective multicenter studies are needed to define its independent indications.