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Hu W, Wang H, Yang G, Ma H, Wu X, Gao Y. The Clinical and Imaging Outcome of the Tandem Growing Rod Technique in Early-Onset Scoliosis With the Proximal Upper Thoracic Curve Progression: A Modified Technique of Growing Rod. Global Spine J 2024:21925682231224774. [PMID: 38165079 DOI: 10.1177/21925682231224774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The orthopaedic ability of traditional GR for severe EOS is limited. The proximal upper thoracic curve may progress during the lengthening procedure, which may lead to coronal imbalance and inhibit the longitudinal growth of the spine. In this retrospective cohort study, we investigated the clinical outcome of tandem GR. METHODS We modified the traditional technique by using two groups of GR devices to control the major and the proximal upper thoracic curve, connected the two groups of GR in series, and named it tandem GR. The clinical and imaging outcomes of the new technique were evaluated and compared with traditional technique. RESULTS Twenty one patients were enrolled in the tandem GR group, and 30 patients were treated with traditional GR as the control. The baseline parameters were consistent between the two groups. In the tandem GR group, the secondary curve progressed from 24.9 ± 3.9° to 31.4 ± 3.2° (P = .006) in the procedure with the traditional GR and improved to 18.4 ± 4.5° (P = .001) after the switch. Meanwhile, the clavicular angle aggravated from 1.6 ± 1.0° to 2.6 ± .7° (P = .041), and improved to 1.7 ± .8° after changed to the tandem GR (P = .033). At the final of the follow-up, the secondary curve was higher in the control group (27.1 ± 8.3° vs 18.4 ± 4.5°, P = .034), the clavicle angle was 2.4 ± 1.1° in control and 1.7 ± .8° in the tandem GR group (P = .028), the T1-S1 height was 28.2 ± 4.8 cm in the control and 33.3 ± 3.0 cm in the tandem GR group (P = .027). The average growth rate was 1.0 ± .3 cm/year in the control and 1.2 ± .4 cm/year in the tandem GR group (P = .046). CONCLUSION Tandem GR can effectively improve the proximal upper thoracic curve progression during the treatment of EOS. Compared with the traditional GR, tandem GR can achieve better curve correction, better shoulder balance, and retains more capacity for longitudinal spine growth.
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Affiliation(s)
- Weiran Hu
- Department of Spinal Cord Surgery, Henan Provincial People's Hospital, Zhengzhou, China
- People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongqiang Wang
- Department of Spinal Cord Surgery, Henan Provincial People's Hospital, Zhengzhou, China
- People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Guang Yang
- Department of Spinal Cord Surgery, Henan Provincial People's Hospital, Zhengzhou, China
- People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Haohao Ma
- Department of Spinal Cord Surgery, Henan Provincial People's Hospital, Zhengzhou, China
- People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaonan Wu
- Department of Spinal Cord Surgery, Henan Provincial People's Hospital, Zhengzhou, China
- People's Hospital of Henan University, Zhengzhou, China
| | - Yanzheng Gao
- Department of Spinal Cord Surgery, Henan Provincial People's Hospital, Zhengzhou, China
- People's Hospital of Zhengzhou University, Zhengzhou, China
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Horiuchi Y, Yagi M, Suzuki S, Takahashi Y, Nori S, Tsuji O, Nagoshi N, Matsumoto M, Nakamura M, Watanabe K. Radiographical Results of Adolescent Idiopathic Scoliosis with Major Curve at Proximal Thoracic Spine. Spine Surg Relat Res 2023; 7:371-376. [PMID: 37636137 PMCID: PMC10447189 DOI: 10.22603/ssrr.2022-0088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 01/15/2023] [Indexed: 03/16/2023] Open
Abstract
Introduction Adolescent idiopathic scoliosis (AIS) with a major curve at the main thoracic (MT) area is classified as Lenke type 1, 2, or 3 depending on the flexibility of the proximal thoracic (PT) curve and lumbar curve. No definite classification has been established for a major curve at the PT spine. The purpose of this study is to investigate the radiographic characteristics before and after correction surgery for AIS with a major curve at the PT area. Methods This is a retrospective cohort study at a single academic institution. Twelve patients with a major curve at the PT spine participated in our study and followed for at least two years after surgery. We evaluated the pre- and postoperative Cobb angles of the curve, curve range, location of the apex, sagittal parameters, and shoulder balance-related parameters. All patients were treated by posterior correction and fusion surgery using pedicle screw constructs. Results The patients were classified as having a double-curve (DC) type, in which the MT curve was structural, or a single-curve (SC) type, in which the MT curve was corrected to less than 25° on supine side-bending films. The mean correction rates for the PT curve were favorable in both groups (DC, 65.7%±9.6%; SC, 39.2%±4.9%). The mean Cobb angle of the lumbar curve improved in the DC group (preoperative, 17.1°±4.0°; postoperative, 5.0°±4.2°) but deteriorated in the SC group (preoperative, 7.1°±1.2°; postoperative, 12.4°±4.4°) after surgery. Conclusions We illustrated the postoperative radiographical changes of 12 consecutive patients with the major curve at the PT curve. Although posterior correction and fusion surgery corrected the PT curve satisfactorily in both DC and SC patients, the Cobb angle of the lumbar curve deteriorated after surgery in all SC patients. Surgeons need to pay attention to the fusion area, especially LIV, when operating the SC curve type.
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Affiliation(s)
- Yosuke Horiuchi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
- Department of Orthopedic Surgery, JCHO Saitama Medical Center, Saitama, Japan
| | - Mitsuru Yagi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Suzuki
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Takahashi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Nori
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Osahiko Tsuji
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Narihito Nagoshi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
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Zhang W, Xu M, Zhang W, Li T, Lai Y, Chen F, Sun M, Wang H, Sun J, Cui X, Jiang Z. A Novel Method for Predicting Ideal Postoperative Upper Instrumented Vertebra Tilt to Prevent Lateral Shoulder Imbalance after Scoliosis Correction Surgery. J Pers Med 2023; 13:jpm13030393. [PMID: 36983575 PMCID: PMC10057819 DOI: 10.3390/jpm13030393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/18/2023] [Accepted: 02/20/2023] [Indexed: 02/26/2023] Open
Abstract
Lateral shoulder imbalance (LSI) is reflected radiologically by the clavicle angle (CA). How to achieve postoperative lateral shoulder balance (LSB) after scoliosis correction surgery remains unclear. In the current study, by using the preoperative upper instrumented vertebra (UIV) tilt, the CA, the flexibility between T1 and the UIV, and the ideal postoperative UIV tilt was predicted based on the following formula: ideal postoperative UIV tilt = preoperative UIV tilt—the flexibility between T1 and UIV—preoperative CA. The reliability of the formula was verified through a retrospective analysis, and 76 scoliosis patients were enrolled. The feasibility of this method was verified through a prospective analysis, and 13 scoliosis patients were enrolled. In the retrospective study, there was a significant correlation between the difference in the actual and ideal postoperative UIV tilt values and the postoperative CA, with correlation coefficients in the whole, LSI, and LSB groups of 0.981, 0.982, and 0.953, respectively (p < 0.001). In the prospective study, all patients achieved satisfactory LSB. Using the formula preoperatively to predict an ideal postoperative UIV tilt and controlling the intraoperative UIV tilt with the improved crossbar technique may be an effective digital method for achieving postoperative LSB and has important clinical significance.
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Affiliation(s)
- Wen Zhang
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Mengmeng Xu
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan 250012, China
| | - Weimin Zhang
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Tao Li
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Yudong Lai
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Fei Chen
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Mingtong Sun
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Haoyu Wang
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Jianmin Sun
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Xingang Cui
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Zhensong Jiang
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
- Correspondence: ; Tel.: +86-13853183743
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Banno T, Yamato Y, Hasegawa T, Yoshida G, Arima H, Oe S, Mihara Y, Ide K, Watanabe Y, Kurosu K, Nakai K, Matsuyama Y. Preoperative Less Right Shoulder Elevation Had a Higher Risk of Postoperative Shoulder Imbalance When Main Thoracic Curve Shows Higher Correction Regardless of the Upper Instrumented Vertebra Level for Patients with Adolescent Idiopathic Scoliosis Lenke Type 1. Asian Spine J 2023; 17:166-175. [PMID: 36138576 PMCID: PMC9977976 DOI: 10.31616/asj.2022.0020] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/10/2022] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN This is a retrospective study. PURPOSE This study aimed to investigate the incidence of and risk factors for postoperative shoulder imbalance (PSI) in patients with Lenke type 1. OVERVIEW OF LITERATURE PSI is a complication resulting in poor self-image and satisfaction in adolescent idiopathic scoliosis (AIS) patients. METHODS We examined the data of AIS patients with Lenke type 1 curves who underwent posterior fusion surgery in a retrospective manner. PSI was defined as a 2-year postoperative absolute radiographic shoulder height (RSH) of ≥2 cm. Patients were divided into two groups based on the presence of PSI and the level of their upper instrumented vertebra (UIV) (UIV at T2 or T3 [U-UIV] or UIV below T3 [L-UIV]). The radiographic parameters and clinical outcomes were compared, and the cutoff values of risk factors were identified by multivariate analysis. RESULTS Of 104 patients, 21 (20.2%) had left shoulder elevation PSI. The PSI group had a significantly greater preoperative RSH (-5.1 mm vs. -14.3 mm) and main thoracic (MT) curve correction rate (77.3% vs. 69.1%) than the non-PSI group. The PSI incidence did not differ between the U-UIV and L-UIV groups. Multivariate analysis identified preoperative RSH and the MT curve correction rate as independent risk factors for PSI. The receiver operating characteristic curve analysis identified the preoperative RSH cutoff value as -6.5 mm and MT curve correction rate cutoff value as 76.9%. CONCLUSIONS Even in AIS patients with Lenke type 1 curves, the incidence of PSI was relatively high (20.2%). Patients with preoperative lower right shoulder elevation (i.e., RSH >-6.5 mm) had a higher risk of PSI regardless of UIV level when the MT curve showed a higher correction rate (i.e., correction rate >76.9%).
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Affiliation(s)
- Tomohiro Banno
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yu Yamato
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomohiko Hasegawa
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Go Yoshida
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hideyuki Arima
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Shin Oe
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yuki Mihara
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Koichiro Ide
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yuh Watanabe
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kenta Kurosu
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Keiichi Nakai
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yukihiro Matsuyama
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Nikouei F, Ghandhari H, Ameri E, Mokarami F. Shoulder Imbalance in Adolescent Idiopathic Scoliosis: A Systematic Review of the Current State of the Art. THE ARCHIVES OF BONE AND JOINT SURGERY 2022; 10:992-1003. [PMID: 36721654 PMCID: PMC9846726 DOI: 10.22038/abjs.2022.64282.3086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 10/02/2022] [Indexed: 02/02/2023]
Abstract
Background Shoulder imbalance (SI) is among the most rated manifestations of adolescent idiopathic scoliosis (AIS) pointed to by patients and spine surgeons. It serves as a criterion to assess the outcome of scoliosis surgery and is also a cause of dissatisfaction for the patients postoperatively. Despite the availability of multiple studies on this issue, a comprehensive survey of the risk factors and preventive measures has yet to be elucidated. The present study aimed to highlight the most recent approach to the evaluation and management of SI, as well as medical counseling about the expectations and limitations of the surgery. Methods A systematic literature review using electric databases was conducted, including PubMed, Embase, the Cochrane Library, and Google Scholar, with a well-defined search strategy on SI definition, risk factors, and preventive and surgical recommendations. Results A total of 69 articles were identified; SI > 2 cm was the most used cut-off, and its risk factors included the main thoracic Cobb angle > 80˚, preoperative level shoulder, high left shoulder, and higher Risser grade. The most stated strategies to preclude SI were the sufficient correction of the proximal thoracic curve, and moderate correction of the main thoracic and lumbar curve (LC). Conclusion Shoulder imbalance should be prevented not only for appearance or satisfaction but also for possible complications such as distal adding-on, new LC progression, or trunk shift postoperatively in AIS patients.
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Affiliation(s)
- Farshad Nikouei
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Hasan Ghandhari
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Ebrahim Ameri
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Farzam Mokarami
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
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Shoulder Balance in Adult Spinal Deformity Patients Undergoing Selective Lumbar Fusion. Spine (Phila Pa 1976) 2022; 47:E385-E389. [PMID: 35533295 DOI: 10.1097/brs.0000000000004255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE To analyze if shoulder balance continues to change in the postoperative period in patients undergoing selective lumbar fusion for adult spinal deformity (ASD), and secondarily, analyze if shoulder balance correlates with health-related quality of life (HRQOL) outcomes. SUMMARY OF BACKGROUND DATA Shoulder balance in patients with ASD is poorly understood and has largely been extrapolated from adolescent scoliosis literature. MATERIALS AND METHODS Adult patients who underwent selective lumbar fusion (upper instrumented vertebra: Τ9-Τ12, lower instrumented vertebra: L4-Pelvis) for thoracolumbar or lumbar scoliosis (cobb angle > 30°) or sagittal plane deformity with thoracic compensatory curves (cobb angle > 10°) were identified. The clavicular angle (CA) was used to quantify shoulder balance. Shoulder balance was categorized into three groups postoperatively (balanced: CA <2°, mild imbalance: CA 2°-4°, severe imbalance: CA >4°). The average CA and proportion of patients in each shoulder balance group were compared at each postoperative period. Patients with 1-year postoperative HRQOL scores were identified. RESULTS Eighty-six patients were included. The preoperative CA was 2.7 ± 2.3° and did not significantly change at discharge (2.9 ± 2.4°), 6-weeks (2.5 ± 2.1°), 6-months (2.4 ± 2.2°), 1-year (2.4 ± 2.5°), or 2-years (2.3 ± 1.5°) postoperatively. The proportion of patients in each shoulder balance group did not significantly change from discharge to 6-weeks, 6-months, 1-year or 2-years postoperatively (P > 0.1). At 1-year follow-up, the CA demonstrated no significant correlation with Oswestry Disability Index, Scoliosis Research Society (SRS)-22 score, or SRS-22 subscores. There was no significant association between shoulder balance group and Oswestry Disability Index, SRS-22 score, or SRS-22 subscores. CONCLUSIONS In patients with ASD undergoing selective lumbar fusion, shoulder balance did not change over the postoperative period. From a functional standpoint, shoulder balance demonstrated no correlation with HRQOL scores. In patients undergoing selective lumbar fusion for ASD, shoulder balance may not spontaneously correct over the postoperative period, but this may not be of functional consequence.Level of Evidence: 4.
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Lee CS, Park S, Lee DH, Hwang CJ, Cho JH, Park JW, Park KB. Is the Combination of Convex Compression for the Proximal Thoracic Curve and Concave Distraction for the Main Thoracic Curve Using Separate-rod Derotation Effective for Correcting Shoulder Balance and Thoracic Kyphosis? Clin Orthop Relat Res 2021; 479:1347-1356. [PMID: 33471482 PMCID: PMC8133207 DOI: 10.1097/corr.0000000000001643] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 12/21/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Posterior correction of the proximal thoracic curve in patients with adolescent idiopathic scoliosis has been recommended to achieve shoulder balance. However, finding a good surgical method is challenging because of the small pedicle diameters on the concave side of the proximal thoracic curve. If the shoulder height can be corrected using screws on the convex side, this would appear to be a more feasible approach. QUESTIONS/PURPOSES In patients with adolescent idiopathic scoliosis, we asked: (1) Is convex compression with separate-rod derotation effective for correcting the proximal thoracic curve, shoulder balance, and thoracic kyphosis? (2) Which vertebrum is most appropriate to serve as the uppermost-instrumented vertebra? (3) Is correction of the proximal thoracic curve related to the postoperative shoulder balance? METHODS Between 2015 and 2017, we treated 672 patients with scoliosis. Of those, we considered patients with elevated left shoulder, Lenke Type 2 or 4, or King Type V idiopathic scoliosis as potentially eligible. Based on that, 17% (111 of 672) were eligible; 5% (6 of 111) were excluded because of other previous operations and left-side main thoracic curve, 22% (24 of 111) were excluded because they did not undergo surgery for the proximal thoracic curve with only pedicle screws, 21% (23 of 111) were excluded because the proximal thoracic curve was not corrected by convex compression and separate rod derotation, and another 3% (3 of 111) were lost before the minimum study follow-up of 2 years, leaving 50% (55 of 111) for analysis. During the study period, we generally chose T2 as the uppermost level instrumented when the apex was above T4, or T3 when the apex was T5. Apart from the uppermost-instrumented level, the groups did not differ in measurable ways such as age, sex, Cobb angles of proximal and main thoracic curves, and T1 tilt. However, shoulder balance was better in the T3 group preoperatively. The median (range) age at the time of surgery was 15 years (12 to 19 years). The median follow-up duration was 26 months (24 to 52 months). Whole-spine standing posteroanterior and lateral views were used to evaluate the improvement of radiologic parameters at the most recent follow-up and to compare the radiologic parameters between the uppermost-instrumented T2 (37 patients) and T3 (18 patients) vertebra groups. Finally, we analyzed radiologic factors related to shoulder balance, defined as the difference between the horizontal lines passing both superolateral tips of the clavicles (right-shoulder-up was positive), at the most recent follow-up. RESULTS Convex compression with separate-rod derotation effectively corrected the proximal thoracic curve (41° ± 11° versus 17° ± 10°, mean difference 25° [95% CI 22° to 27°]; p < 0.001), and the most recent shoulder balance changed to right-shoulder-down compared with preoperative right-shoulder-up (8 ± 11 mm versus -8 ± 10 mm, mean difference 16 mm [95% CI 12 to 19]; p < 0.001). Proximal thoracic kyphosis decreased (13° ± 7° versus 11° ± 6°, mean difference 2° [95% CI 0° to 3°]; p = 0.02), while mid-thoracic kyphosis increased (12° ± 8° versus 18° ± 6°, mean difference -7° [95% CI -9° to -4°]; p < 0.001). Preoperative radiographic parameters did not differ between the groups, except for shoulder balance, which tended to be more right-shoulder-up in the T2 group (11 ± 10 mm versus 1 ± 11 mm, mean difference 10 mm [95% CI 4 to 16]; p = 0.002). At the most recent follow-up, the correction proportion of the proximal thoracic curve was better in the T2 group than the T3 group (67% ± 10% versus 49% ± 22%, mean difference 19% [95% CI 8% to 30%]; p < 0.001). In the T2 group, T1 tilt (6° ± 4° versus 6° ± 4°, mean difference 1° [95% CI 0° to 2°]; p = 0.045) and shoulder balance (-14 ± 11 mm versus -7 ± 9 mm, mean difference -7 mm [95% CI -11 to -3]; p = 0.002) at the most recent follow-up improved compared with those at the first erect radiograph. The most recent shoulder balance was correlated with the correction proportion of the proximal thoracic curve (r = 0.29 [95% CI 0.02 to 0.34]; p = 0.03) and change in T1 tilt (r = 0.35 [95% CI 0.20 to 1.31]; p = 0.009). CONCLUSION Using the combination of convex compression and concave distraction with separate-rod derotation is an effective method to correct proximal and main thoracic curves, with reliable achievement of postoperative thoracic kyphosis and shoulder balance. T2 was a more appropriate uppermost-instrumented vertebra than T3, providing better correction of the proximal thoracic curve and T1 tilt. Additionally, spontaneous improvement in T1 tilt and shoulder balance is expected with upper-instrumented T2 vertebrae. Preoperatively, surgeons should evaluate shoulder balance because right-shoulder-down can occur after surgery in patients with a proximal thoracic curve. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Choon Sung Lee
- C. S. Lee, D.-H. Lee, C. J. Hwang, J. H. Cho, J. W. Park, Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- S. Park, Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Goyangsi, Gyeonggido, Korea
- K.-B. Park, Division of Pediatric Orthopedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sehan Park
- C. S. Lee, D.-H. Lee, C. J. Hwang, J. H. Cho, J. W. Park, Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- S. Park, Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Goyangsi, Gyeonggido, Korea
- K.-B. Park, Division of Pediatric Orthopedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong-Ho Lee
- C. S. Lee, D.-H. Lee, C. J. Hwang, J. H. Cho, J. W. Park, Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- S. Park, Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Goyangsi, Gyeonggido, Korea
- K.-B. Park, Division of Pediatric Orthopedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Ju Hwang
- C. S. Lee, D.-H. Lee, C. J. Hwang, J. H. Cho, J. W. Park, Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- S. Park, Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Goyangsi, Gyeonggido, Korea
- K.-B. Park, Division of Pediatric Orthopedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hwan Cho
- C. S. Lee, D.-H. Lee, C. J. Hwang, J. H. Cho, J. W. Park, Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- S. Park, Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Goyangsi, Gyeonggido, Korea
- K.-B. Park, Division of Pediatric Orthopedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Woo Park
- C. S. Lee, D.-H. Lee, C. J. Hwang, J. H. Cho, J. W. Park, Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- S. Park, Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Goyangsi, Gyeonggido, Korea
- K.-B. Park, Division of Pediatric Orthopedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kun-Bo Park
- C. S. Lee, D.-H. Lee, C. J. Hwang, J. H. Cho, J. W. Park, Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- S. Park, Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Goyangsi, Gyeonggido, Korea
- K.-B. Park, Division of Pediatric Orthopedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Korea
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Kim DH, Hyun SJ, Kim KJ. Selection of Fusion Level for Adolescent Idiopathic Scoliosis Surgery : Selective Fusion versus Postoperative Decompensation. J Korean Neurosurg Soc 2021; 64:473-485. [PMID: 34044493 PMCID: PMC8273784 DOI: 10.3340/jkns.2020.0258] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/09/2020] [Indexed: 11/27/2022] Open
Abstract
Adolescent idiopathic scoliosis (AIS), which is associated with an extensive range of clinical and radiological presentations, is the one of the most challenging spinal disorders. The goals of surgery are to correct the deformity in 3 dimensions and to preserve motion segments while avoiding complications. Despite the ongoing evolution of classification systems and algorithms for the surgical treatment of AIS, there has been considerable debate regarding the selection of an appropriate fusion level in AIS. In addition, there is no consensus regarding the exact description, relationship, and risk factors of coronal decompensation following selective fusion. In this review, we summarize the current concepts of selection of the fusion level for AIS and review the available information about postoperative coronal decompensation.
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Affiliation(s)
- Do-Hyoung Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Liu Z, Liu T, Hai Y, Wu L, Hai JJ, Gao K, Guo X, Yang H, Kang N, Zhao F. Evaluation of changes in shoulder balance and prediction of final shoulder imbalance during growing-rod treatment for early-onset scoliosis. BMC Musculoskelet Disord 2021; 22:354. [PMID: 33853576 PMCID: PMC8045187 DOI: 10.1186/s12891-021-04221-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/30/2021] [Indexed: 01/30/2023] Open
Abstract
Background Obtaining and maintaining final shoulder balance after the entire treatment course is essential for early-onset scoliosis (EOS) patients. The relatively small number of growing-rod (GR) graduates who complete final fusion has resulted in an overall paucity of research on the GR treatment of EOS and a lack of research on the shoulder balance of EOS patients during GR treatment. Methods Twenty-four consecutive patients who underwent GR treatment until final fusion were included. Radiographic shoulder balance parameters, including the radiographic shoulder height (RSH), clavicle angle (CA), and T1 tilt angle (T1T), before and after each step of the entire treatment were measured. Shoulder balance changes from GR implantation to the last follow-up after final fusion were depicted and analysed. Demographic data, surgical-related factors, and radiographic parameters were analysed to identify risk factors for final shoulder imbalance. The shoulder balance of patients at different time points was further analysed to explore the potential effect of the series of GR treatment steps on shoulder balance. Results The RSH showed substantial improvement after GR implantation (P = 0.036), during the follow-up period after final fusion (P = 0.021) and throughout the entire treatment (P = 0.011). The trend of change in the CA was similar to that of the RSH, and the T1T improved immediately after GR implantation (P = 0.037). Further analysis indicated that patients with shoulder imbalance before final fusion showed significantly improved shoulder balance after fusion (P = 0.045), and their RSH values at early postfusion and the final follow-up did not show statistically significant differences from those in the prefusion shoulder balance group (P > 0.05). Early postfusion shoulder imbalance (odds ratio (OR): 19.500; 95% confidence interval (CI) = 1.777–213.949; P = 0.015) was identified as an independent risk factor for final shoulder imbalance. Conclusions Shoulder balance could be improved by GR implantation but often changes during the multistep lengthening process, and the final result is relatively unpredictable. Final fusion could further adjust the prefusion shoulder imbalance. Focusing on the prefusion shoulder balance of GR graduates and providing patients with early shoulder balance after fusion might be necessary. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04221-9.
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Affiliation(s)
- Ziyang Liu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Gongti North Rd, No. 8, Beijing, 100020, China
| | - Tie Liu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Gongti North Rd, No. 8, Beijing, 100020, China
| | - Yong Hai
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Gongti North Rd, No. 8, Beijing, 100020, China.
| | - Lingyun Wu
- Karolinska Institutet, Stockholm, Sweden
| | | | - Kang Gao
- Capital Medical University, Beijing, China
| | - Xuanrong Guo
- University of Wisconsin Madison, Madison, WI, USA
| | - Honghao Yang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Gongti North Rd, No. 8, Beijing, 100020, China
| | - Nan Kang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Gongti North Rd, No. 8, Beijing, 100020, China
| | - Fan Zhao
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Gongti North Rd, No. 8, Beijing, 100020, China
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The Reliability of Intraoperative Crossbar Technique in Determining the Upper Instrumented Vertebra (UIV) Tilt Angle for Adolescent Idiopathic Scoliosis (AIS) Undergoing Posterior Spinal Fusion. Clin Spine Surg 2019; 32:256-262. [PMID: 30640749 DOI: 10.1097/bsd.0000000000000769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE This study looked into whether crossbar can reliably measure Upper Instrumend Vertebra (UIV) tilt angle intraoperatively and accurately predict the UIV tilt angle postoperatively and at final follow-up. SUMMARY OF BACKGROUND DATA Postoperative shoulder imbalance is a common cause of poor cosmetic appearance leading to patient dissatisfaction. There were no reports describing the technique or method in measuring the UIV tilt angle intraoperatively. Therefore, this study was designed to look into the reliability and accuracy of the usage of intraoperative crossbar in measuring the UIV tilt angle intraoperatively. METHODS Lenke 1 and 2 Adolescent Idiopathic Scoliosis patients who underwent instrumented Posterior Spinal Fusion using pedicle screw constructs with minimum follow-up of 24 months were recruited for this study. After surgical correction, intraoperative UIV tilt angle was measured using a crossbar. Immediate postoperative and final follow up UIV tilt angle was measured on the standing anteroposterior radiographs. RESULTS A total of 100 patients were included into this study. The reliability of the intraoperative crossbar to measure the optimal UIV tilt angle intraoperatively was determined by repeated measurements by assessors and measurement by different assessors. We found that the intra observer and inter observer reliability was very good with intraclass correlation coefficient values of >0.9. The accuracy of the intraoperative crossbar to measure the optimal UIV tilt angle intraoperatively was determined by comparing this measurement with the postoperative UIV tilt angle. We found that there was no significant difference (P>0.05) between intraoperative, immediate postoperative, and follow-up UIV tilt angle. CONCLUSIONS The crossbar can be used to measure the intraoperative UIV tilt angle consistently and was able to predict the postoperative UIV tilt angle. It was a cheap, simple, reliable, and accurate instrument to measure the intraoperative UIV tilt angle.
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How Common Is Medial and Lateral Shoulder Discordance in Lenke 1 and 2 Curves?: A Preoperative Analysis of Medial and Lateral Shoulder Balance Among 151 Lenke 1 and 2 Adolescent Idiopathic Scoliosis Patients. Spine (Phila Pa 1976) 2019; 44:E480-E486. [PMID: 30299417 DOI: 10.1097/brs.0000000000002890] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study of prospectively collected data. OBJECTIVE To analyze the incidence and the patterns of medial and lateral shoulder discordance among Lenke 1 and 2 patients. SUMMARY OF BACKGROUND DATA Postoperative shoulder imbalance (PSI) is still common in Lenke 1 and 2 adolescent idiopathic scoliosis (AIS). This could be due to presence of medial dan lateral shoulder discordance. METHODS One hundred fifty-one Lenke 1 and 2 AIS patients were recruited. Lenke 1 curves were subclassified into Lenke 1-ve (flexible) (proximal thoracic side bending [PTSB] Cobb angle <15°) and 1+ve curves (stiff) (PTSB Cobb angle between 15° and 24.9°). T1 tilt represented "medial shoulder balance" and radiological shoulder height (RSH) represented "lateral shoulder balance." We categorized patients into three concordant shoulder pattern types (medial balanced/lateral balanced [MBLB], medial imbalanced+ve/lateral imbalanced+ve (MI+ve/LI+ve), medial imbalanced-ve/lateral Imbalanced-ve (MI-ve/LI-ve), and six discordant shoulder pattern types. RESULTS The mean age was 16.2 ± 5.7 years. Eighty-one patients (53.6%) had concordant pattern and 70 patients (46.4%) had discordant pattern. Lateral shoulder imbalance was noted in 35.1% of patients and medial shoulder imbalance in 43.7% of patients. In Lenke 1-ve curves, 35 patients (68.6%) had concordant shoulder imbalance with medial imbalanced-ve/lateral imbalanced-ve (MI-ve/LI-ve) being the commonest pattern (68.6%). In Lenke 1+ve curves, 33 patients (55.0%) had concordant shoulder pattern with medial balanced/lateral balanced (MB/LB) being the commonest type (57.6%). In Lenke 2 AIS, 27 patients (67.5%) had discordant pattern with medial imbalanced+ve/lateral balanced (MI+ve/LB) being the commonest pattern (44.4%) (P value = 0.002). CONCLUSION 46.4% Lenke 1 and 2 AIS patients had shoulder discordant pattern. This was more prevalent in Lenke 2 curves (67.5%). In Lenke 1-ve (flexible) curves, MI-ve/LI-ve pattern was the commonest pattern. In Lenke 1+ve curves (stiff), there were almost equal number of concordant and discordant shoulder pattern. In Lenke 2 patients, the most common pattern was MI+ve/LB. LEVEL OF EVIDENCE 4.
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Upper Instrumented Vertebrae (UIV) Tilt Angle Is an Important Postoperative Radiological Parameter That Correlates With Postoperative Neck and Medial Shoulder Imbalance. Spine (Phila Pa 1976) 2018; 43:E1143-E1151. [PMID: 29557927 DOI: 10.1097/brs.0000000000002645] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To investigate the association between postoperative upper instrumented vertebrae (UIV) tilt angle with postoperative medial shoulder and neck imbalance. SUMMARY OF BACKGROUND DATA Studies had found that current recommendations for UIV selection were not predictive of good postoperative shoulder balance. METHODS A total of 98 patients with adolescent idiopathic scoliosis with Lenke 1/2 curves who underwent posterior spinal fusion between 2013 and 2014 with minimum follow-up of 2 years were recruited. Radiological parameters: UIV tilt angle, T1 tilt, cervical axis, and clavicle angle were measured preoperatively, postoperatively, and at final follow-up. RESULTS Mean age was 16.2 ± 6.2 years. Mean follow-up was 37.9 ± 6.5 months. There were 73.5% Lenke 1 and 26.5% Lenke 2 curves. Significant factors affecting postoperative T1 Tilt were postoperative UIV tilt angle, preoperative T1 tilt, and preoperative UIV tilt angle. Postoperative UIV tilt angle and preoperative cervical axis were significant factors affecting cervical axis at final follow-up. UIV level was not significant independent factor that affected postoperative T1 tilt and cervical axis. There was strong correlation between postoperative UIV tilt angle and T1 tilt for the whole cohort (P < 0.001), when UIV was at T2 (P < 0.001), T3 (P < 0.001), and T4 (P < 0.001). Postoperative UIV tilt angle also had significant correlation with cervical axis when UIV was at T2 (P = 0.021) and T3 (P = 0.009). CONCLUSION Postoperative UIV tilt angle was an independent factor, which had significant correlation with postoperative T1 tilt and cervical axis measurement. There was strong correlation between postoperative UIV tilt angle and T1 tilt for the whole cohort, when UIV was at T3 and T4. There was very strong correlation between postoperative UIV tilt angle and T1 tilt when UIV was at T2. There was also moderate and significant correlation between postoperative UIV tilt angle and cervical axis for the whole cohort. LEVEL OF EVIDENCE 2.
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Chiu CK, Bashir ES, Chan CYW, Kwan MK. Cervical Supine Side-Bending versus Cervical Supine Traction Radiographs: Which Is Better in Predicting Proximal Thoracic Flexibility for Lenke 1 and 2 Adolescent Idiopathic Scoliosis? Asian Spine J 2018; 12:669-677. [PMID: 30060375 PMCID: PMC6068410 DOI: 10.31616/asj.2018.12.4.669] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 12/17/2017] [Indexed: 11/23/2022] Open
Abstract
Study Design Prospective cohort study. Purpose This study compared cervical supine side-bending (CSSB) and cervical supine traction (CST) radiographs to assess the flexibility and predict the correctability of the proximal thoracic (PT) curve for patients with adolescent idiopathic scoliosis (AIS) classified as Lenke 1 and 2. Overview of Literature Knowledge of the flexibility of the PT curve is crucial in the management of patients with AIS. There are no reports comparing CSSB and CST radiographs to assess this parameter. Methods Thirty patients with Lenke 1 and 2 AIS scheduled for posterior spinal fusion surgery were recruited. A standing whole spine radiography and physician-supervised CSSB and CST radiographies were performed. Patient demographic and radiological parameters were recorded, including age, gender, weight, height, body mass index, PT angle, main thoracic angle, CSSB PT angle, CST PT angle, and postoperative PT angle. From the data collected, the curve flexibility and curve correction index were calculated and compared. Results CSSB had a significantly (p <0.05) smaller PT angle (16.6°±10.4°) in comparison to CST (23.7°±10.7°). CSSB had significantly (p <0.05) greater flexibility (44.2%±19.7%) in comparison to CST (19.5%±18.1%). The CSSB correction index (1.2±0.9) was significantly closer to 1 in comparison to the CST correction index (4.4±5.3). There was no difference (p =0.72) between the CSSB PT angle (16.6°±10.4°) and the postoperative PT angle (16.1°±7.5°). However, the CST PT angle (23.7°±10.7°) was significantly (p <0.05) larger than the postoperative PT angle (16.1°±7.5°). Conclusions CSSB radiographs were better for demonstrating PT flexibility and more accurately predicted correctability in comparison to the CST radiographs.
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Affiliation(s)
- Chee Kidd Chiu
- Department of Orthopaedic Surgery, National Orthopaedic Centre of Excellence for Research and Learning, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Chris Yin Wei Chan
- Department of Orthopaedic Surgery, National Orthopaedic Centre of Excellence for Research and Learning, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mun Keong Kwan
- Department of Orthopaedic Surgery, National Orthopaedic Centre of Excellence for Research and Learning, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Lin Y, Chen W, Chen A, Li F, Xiong W. Anterior versus Posterior Selective Fusion in Treating Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis of Radiologic Parameters. World Neurosurg 2018; 111:e830-e844. [DOI: 10.1016/j.wneu.2017.12.161] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 12/24/2017] [Accepted: 12/27/2017] [Indexed: 10/18/2022]
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Shoulder balance in Lenke type 2 adolescent idiopathic scoliosis: Should we fuse to the second thoracic vertebra? Clin Neurol Neurosurg 2017; 163:156-162. [DOI: 10.1016/j.clineuro.2017.10.036] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/13/2017] [Accepted: 10/29/2017] [Indexed: 11/18/2022]
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Zhang S, Zhang L, Feng X, Yang H. Incidence and risk factors for postoperative shoulder imbalance in scoliosis: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:358-369. [DOI: 10.1007/s00586-017-5289-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/20/2017] [Accepted: 08/27/2017] [Indexed: 01/11/2023]
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Predictors of shoulder level after spinal fusion in adolescent idiopathic scoliosis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:370-380. [DOI: 10.1007/s00586-017-5210-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 06/27/2017] [Indexed: 10/19/2022]
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Lee CS, Hwang CJ, Lee DH, Cho JH. Five major controversial issues about fusion level selection in corrective surgery for adolescent idiopathic scoliosis: a narrative review. Spine J 2017; 17:1033-1044. [PMID: 28373082 DOI: 10.1016/j.spinee.2017.03.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/12/2017] [Accepted: 03/29/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Shoulder imbalance, coronal decompensation, and adding-on phenomenon following corrective surgery in patients with adolescent idiopathic scoliosis are known to be related to the fusion level selected. Although many studies have assessed the appropriate selection of the proximal and distal fusion level, no definite conclusions have been drawn thus far. PURPOSE We aimed to assess the problems with fusion level selection for corrective surgery in patients with adolescent idiopathic scoliosis, and to enhance understanding about these problems. STUDY DESIGN This study is a narrative review. METHODS We conducted a literature search of fusion level selection in corrective surgery for adolescent idiopathic scoliosis. Accordingly, we selected and reviewed five debatable topics related to fusion level selection: (1) selective thoracic fusion; (2) selective thoracolumbar-lumbar (TL-L) fusion; (3) adding-on phenomenon; (4) distal fusion level selection for major TL-L curves; and (5) proximal fusion level selection and shoulder imbalance. RESULTS Selective fusion can be chosen in specific curve types, although there is a risk of coronal decompensation or adding-on phenomenon. Generally, wider indications for selective fusions are usually associated with more frequent complications. Despite the determination of several indications for selective fusion to avoid such complications, no clear guidelines have been established. Although authors have suggested various criteria to prevent the adding-on phenomenon, no consensus has been reached on the appropriate selection of lower instrumented vertebra. The fusion level selection for major TL-L curves primarily focuses on whether distal fusion can terminate at L3, a topic that remains unclear. Furthermore, because of the presence of several related factors and complications, proximal level selection and shoulder imbalance has been constantly debated and remains controversial from its etiology to its prevention. CONCLUSIONS Although several difficult problems in the diagnosis and treatment of adolescent idiopathic scoliosis have been resolved by understanding its mechanism and via technical advancement, no definite guideline for fusion level selection has been established. A review of five major controversial issues about fusion level selection could provide better understanding of adolescent idiopathic scoliosis. We believe that a thorough validation study of the abovementioned controversial issues can help address them.
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Affiliation(s)
- Choon Sung Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, PungNap-2-dong, SongPa-gu, Seoul 05505, Republic of Korea
| | - Chang Ju Hwang
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, PungNap-2-dong, SongPa-gu, Seoul 05505, Republic of Korea
| | - Dong-Ho Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, PungNap-2-dong, SongPa-gu, Seoul 05505, Republic of Korea
| | - Jae Hwan Cho
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, PungNap-2-dong, SongPa-gu, Seoul 05505, Republic of Korea.
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Gotfryd AO, Silber Caffaro MF, Meves R, Avanzi O. Predictors for Postoperative Shoulder Balance in Lenke 1 Adolescent Idiopathic Scoliosis: A Prospective Cohort Study. Spine Deform 2017; 5:66-71. [PMID: 28038696 DOI: 10.1016/j.jspd.2016.09.046] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 09/14/2016] [Accepted: 09/27/2016] [Indexed: 10/20/2022]
Abstract
STUDY DESIGN Prospective cohort. OBJECTIVES To determine the predictors of the shoulder balance after main thoracic (MT) fusion in patients with Lenke 1 adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA Imbalanced shoulders are a major cause of dissatisfaction in AIS patients. In Lenke 1 curves, MT curve fusion is supposed to lead to spontaneous correction of the proximal thoracic (PT) curve and thereby promote shoulder balance. However, this is not always observed. METHODS Fifty-two Lenke 1 AIS patients who underwent MT fusion by a posterior approach were prospectively evaluated preoperatively, immediately postoperatively and two years after the surgical procedure. The shoulder balance was determined using the biacromial angle. The clinical results were examined for their correlation with several radiographic measurements. RESULTS Spontaneous correction of the PT Cobb angle after MT fusion was noted in 52% of cases, similar to that observed on preoperative bending films. A total of 51% of patients had unbalanced shoulders before surgery (right side higher). Two years after surgery, 30.77% showed unbalanced shoulders (p < .001). However, 17.1% of patients presented with a higher left shoulder, a reversion of the initial deformity. This phenomenon was more common among the patients with mild or no shoulder asymmetry (biacromial angle inferior to 1°) before surgery (p < .001). It was also determined that for each degree measured for the clavicle angle, there was an elevation of 0.14° for the ipsilateral shoulder. CONCLUSIONS In Lenke 1 cases with higher right shoulder and absence of abnormalities in the sagittal plane view, the correction of the main right thoracic curve could be enough to balance the shoulders. No correlation was found between shoulder balance and the amount of correction of the PT and MT curves.
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Affiliation(s)
- Alberto O Gotfryd
- Department of Orthopedics and Traumatology, Santa Casa de Misericórdia de São Paulo, Rua Dr. Cesário Mota Júnior, 112 Vila Buarque, São Paulo, SP CEP: 01221-020, Brazil.
| | - Maria Fernanda Silber Caffaro
- Department of Orthopedics and Traumatology, Santa Casa de Misericórdia de São Paulo, Rua Dr. Cesário Mota Júnior, 112 Vila Buarque, São Paulo, SP CEP: 01221-020, Brazil
| | - Robert Meves
- Department of Orthopedics and Traumatology, Santa Casa de Misericórdia de São Paulo, Rua Dr. Cesário Mota Júnior, 112 Vila Buarque, São Paulo, SP CEP: 01221-020, Brazil
| | - Osmar Avanzi
- Department of Orthopedics and Traumatology, Santa Casa de Misericórdia de São Paulo, Rua Dr. Cesário Mota Júnior, 112 Vila Buarque, São Paulo, SP CEP: 01221-020, Brazil
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Assessing the Flexibility of the Proximal Thoracic Segments Above the "Potential Upper Instrumented Vertebra" Using the Cervical Supine Side Bending Radiographs in Lenke 1 and 2 Curves for Adolescent Idiopathic Scoliosis Patients. Spine (Phila Pa 1976) 2016; 41:E973-E980. [PMID: 26909833 DOI: 10.1097/brs.0000000000001516] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective study. OBJECTIVE The aim of this study was to analyze the proximal thoracic (PT) flexibility and its compensatory ability above the "potential UIV." SUMMARY OF BACKGROUND DATA Shoulder and neck imbalance can be caused by overcorrection of the main thoracic (MT) curve due to inability of PT segment to compensate. METHODS Cervical supine side bending (CSB) radiographs of 100 Lenke 1 and 2 patients were studied. We further stratified Lenke 1 curves into Lenke 1-ve: PT side bending (PTSB) < 15° (n = 33) and Lenke 1+ve: PTSB 15° to 24.9° (n = 37). The right side bending (RSB) and left side bending (LSB) angles were measured (T1-T6). Compensatory ability of the PT segment was analyzed with assumption of a "horizontal UIV" position. RESULTS From T1 to T6 vertebrae, the RSB angle values showed increasing positive values. The LSB angle, comparing Lenke 1-ve versus 2 and Lenke 1+ve versus 2, showed significant difference at T2 to T6. The LSB angle comparing Lenke 1-ve versus 1+ve achieved significant difference at T5 and T6. In Lenke 2 curves, >80.0% of cases of the PT segment were unable to compensate at T3-T6. In Lenke 1+ve curves, 78.4% were unable to compensate at T6, followed by T5 (75.7%), T4 (73.0%), T3 (59.5%), T2 (27.0%), and T1 (21.6%). In Lenke 1-ve curves, 36.4% of cases were unable to compensate at T6, followed by T5 (45.5%), T4 (45.5%), T3 (30.3%), T2 (21.2%), and T1 (15.2%). A significant difference between Lenke 1-ve and Lenke 1+ve was observed from T3 to T6. The difference between Lenke 1+ve and Lenke 2 curves was significant only at T2. CONCLUSION The compensation ability and the flexibility of the PT segments of Lenke 1-ve and Lenke 1+ve curves were different. Lenke 1+ve curves demonstrated similar characteristics to Lenke 2 curves. LEVEL OF EVIDENCE 3.
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Samartzis D, Bow C, Cheung JPY, Sham P, Mak KC, Cheung WY, Wong YW, Luk KDK, Cheung KMC, Lawmin JC. Efficacy of Postoperative Pain Management Using Continuous Local Anesthetic Infusion at the Iliac Crest Bone Graft Site in Patients with Adolescent Idiopathic Scoliosis: A Parallel, Double-Blinded, Randomized Controlled Pilot Trial. Global Spine J 2016; 6:220-8. [PMID: 27099812 PMCID: PMC4836927 DOI: 10.1055/s-0035-1558656] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 06/09/2015] [Indexed: 11/21/2022] Open
Abstract
Study Design Randomized controlled trial. Objective Adolescent idiopathic scoliosis (AIS) is a common spinal deformity that affects every population. In severe deformity, surgical intervention is performed. Autogenous iliac crest bone graft (ICBG) harvesting remains a common procedure worldwide for scoliosis surgery. Postoperative pain at the ICBG donor site is a major concern in patients undergoing spine surgery that affects postoperative functional outcome and consumes health care resources. Previous studies have noted a decrease in pain and postoperative analgesic use with the application of continuous infusion of anesthetic at the ICBG site in comparison with placebo. However, there is lack of evidence addressing the efficacy of continuous anesthetic infusion at the ICBG site in young patients and in particular those with spinal deformity, such as AIS. As such, this parallel, double-blinded, randomized controlled trial addressed the pain management efficacy of continuous anesthetic infusion versus saline at the ICBG site in patients with AIS during the immediate postoperative period. Methods Participants were randomized into two groups. Group A (control subjects) received 3 mL per hour of saline locally at the ICBG site, and group B (treatment subjects) received a constant rate of infusion of 3 mL per hour of 0.25% levobupivacaine. Both groups received their postoperative intervention for 47 hours. All subjects and outcome assessors were blinded to the type of intervention. Utilizing the visual analog pain scale, pain was assessed at the primary spine surgical site, ICBG site, and contralateral ICBG site. Overall physical pain was assessed by the McGill Pain Questionnaire. The degree of analgesic use and complications were also evaluated. All outcomes were assessed up until the fourth day of the patients' hospitalization following surgery. Results Twelve subjects were recruited (five in group A; seven in group B). No difference was noted at baseline regarding age, weight, height, arm span, sex, curve type, instrumented and fused levels, length of hospitalization, and pain scores between groups. Postoperatively, no difference was noted in surgical site pain between groups (p > 0.05). However, decreased ICBG and contralateral ICBG pain decreased twofold in group B patients in comparison with group A. Similarly, group B subjects had notably decreased postoperative overall pain scores (group A, mean 15.3; group B, mean 3.8). No significant differences were noted for the pain scores due to the small sample size. Conclusions This study is the first with a robust level I study design to assess the efficacy of continuous infusion of analgesia into the ICBG site in young patients with AIS. This pilot study noted a trend that continuous anesthetic infusion reduces pain at the ICBG site and may further decrease overall physical bodily pain. This study further established a sample size calculation to facilitate large-scale studies addressing these parameters. This study provides further support of postoperative pain management options for children with spinal deformities.
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Affiliation(s)
- Dino Samartzis
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China,Address for correspondence Dino Samartzis, DSc Department of Orthopaedics and Traumatology, The University of Hong Kong, Professorial Block5th Floor, 102 Pokfulam Road, Pokfulam, Hong Kong, SARChina
| | - Cora Bow
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China
| | - Jason Pui Yin Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China
| | - Phoebe Sham
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China
| | - Kin-Cheung Mak
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China
| | - Wai-Yuen Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China
| | - Yat-Wa Wong
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China
| | - Keith D. K. Luk
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China
| | - Kenneth M. C. Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China
| | - Jean-Claude Lawmin
- Department of Anesthesiology, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China
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Kwan MK, Chan CYW. Is there an optimal upper instrumented vertebra (UIV) tilt angle to prevent post-operative shoulder imbalance and neck tilt in Lenke 1 and 2 adolescent idiopathic scoliosis (AIS) patients? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:3065-3074. [DOI: 10.1007/s00586-016-4529-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 03/10/2016] [Accepted: 03/13/2016] [Indexed: 10/22/2022]
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Kwan MK, Wong KA, Lee CK, Chan CYW. Is neck tilt and shoulder imbalance the same phenomenon? A prospective analysis of 89 adolescent idiopathic scoliosis patients (Lenke type 1 and 2). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:401-8. [DOI: 10.1007/s00586-015-4016-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 05/06/2015] [Accepted: 05/06/2015] [Indexed: 11/28/2022]
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Koller H, Meier O, McClung A, Hitzl W, Mayer M, Sucato D. Parameters leading to a successful radiographic outcome following surgical treatment for Lenke 2 curves. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24:1490-501. [DOI: 10.1007/s00586-015-3772-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 12/07/2014] [Accepted: 01/18/2015] [Indexed: 11/24/2022]
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Skipped versus consecutive pedicle screw constructs for correction of Lenke 1 curves. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24:1473-80. [PMID: 25599851 DOI: 10.1007/s00586-015-3769-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 01/12/2015] [Accepted: 01/12/2015] [Indexed: 10/24/2022]
Abstract
PURPOSE Thoracic pedicle screws provide superior curve correction to hook and wire constructs in adolescent idiopathic scoliosis, while increasing cost. The number of implants required for best correction and outcome has not yet been determined. METHODS We retrospectively reviewed pre- and post-operative radiographs and self-reported outcome measures in an age- and curve-matched cohort of 40 patients with Lenke I AIS who underwent selective fusions between T3/4 and L1. Twenty patients were treated with thoracic pedicle screws at every level bilaterally (CON) and 20 patients with screws at every level on the concave side and skipped levels on the convex side of the curve (SKP). All patients had a minimum 2-year follow-up. Radiographs were assessed for coronal and sagittal curvatures, as well as thoracic torsion and vertebral rotation. Health-related quality of life was assessed using the SRS-22 instrument. Instrumentation cost data were collected for each case. RESULTS Postoperative follow-up averaged 28 months for the CON group and 29 months for the SKP group. No statistically significant differences were found between groups with respect to age and pre- and post-operative radiographic parameters. Both constructs provided acceptable correction of the main thoracic curves (66.9 vs. 66.6 %, CON group and SKP group, respectively; p = 0.92), and spontaneous correction of the proximal thoracic (41.5 vs. 41.1 %; p = 0.92) and thoracolumbar/lumbar curves (54.8 vs. 54.3 %; p = 0.92). No significant difference was found in postoperative SRS-22 scores (96 vs. 94.3; p = 0.34). The CON group cost for instrumentation was significantly higher than the SKP group ($19,500 vs. $13,300; p = 0.002). There was no statistically significant difference in operating room times between groups. CONCLUSION Both construct types provide excellent coronal correction and sagittal balance, with no significant differences in radiographic findings or clinical outcomes. A significant decrease in cost was found with use of skipped screw constructs.
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