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Baghdadi S, Baldwin K. Selection of Fusion Levels in Adolescent Idiopathic Scoliosis. Curr Rev Musculoskelet Med 2024; 17:23-36. [PMID: 38095837 PMCID: PMC10767118 DOI: 10.1007/s12178-023-09876-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 01/06/2024]
Abstract
PURPOSE OF REVIEW: Posterior spinal fusion (PSF) is the preferred treatment for adolescent idiopathic scoliosis (AIS) patients with surgical range curves. Selection of the proper upper and lower instrumented vertebrae (UIV and LIV) is essential in curve correction and achieving a successful outcome, while preventing short and long-term complications. RECENT FINDINGS: The literature lacks high-level evidence, especially on outcomes of modern surgical techniques. However, evidence seems to show that a great majority of AIS patients have excellent clinical and functional long-term outcomes after PSF. We have reviewed the evidence and provided our level selection recommendations, which should be weighed against the body of evidence on the topic when selecting fusion levels in AIS.
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Affiliation(s)
- Soroush Baghdadi
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Keith Baldwin
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Hou X, Sun Z, Li W, Wang H, Zhuo L, Yuan L, Zeng Y, Ding L, Chen Z. Upper instrumented vertebrae selection criteria for degenerative lumbar scoliosis based on the hounsfield unit asymmetry of the first coronal reverse vertebrae: an observational study. J Orthop Surg Res 2023; 18:819. [PMID: 37907995 PMCID: PMC10619298 DOI: 10.1186/s13018-023-04325-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/26/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Selection of the upper instrumented vertebra (UIV) is crucial for surgical treatment of degenerative lumbar scoliosis (DLS), given the relevance of UIV in postoperative proximal adjacent segment degeneration (pASD). Our previous research found that selection of UIV not lower than (≤) the first coronal reverse vertebra (FCRV), which marks the turning point of Hounsfield unit (HU) asymmetry, could significantly reduce pASD. However, the degree of HU asymmetry can vary among patients, suggesting a demand for more individualized UIV selection criteria, which we aimed to develop using quantitative HU measurement in the current study. METHODS We included 153 consecutive patients with DLS. Quantitative measurement of HU of both sides of the vertebrae of these patients was performed on three planes of CT reconstruction for average values and determination of FCRV. Pre- and postoperative X-ray plain films were examined for radiological measurements and determination of pASD. Further, 35 patients with lumbar disc herniation and without significant scoliosis were also included as the reference group, and their bilateral HU was measured. RESULTS In all 153 patients, those with UIV ≤ FCRV had a significantly lower rate of pASD (9.4% vs. 24.6%, P = 0.011). The difference between HU of the left and right sides of the FCRV (dF) could range from close to 0-59.4. The difference between HU of the left and right sides of the vertebrae in the reference group had an average value of 5.21. In 101 dF ≥ 5 DLS patients, those with UIV ≤ FCRV had a significantly lower rate of pASD (7.6% vs. 28.6%, P = 0.005), while this rate was insignificant in the other 52 dF < 5 patients (13.3% vs. 18.2%, P = 0.708). No other general, radiological, or operative parameter was found to have significant influence on the occurrence of pASD. CONCLUSIONS Selection of UIV ≤ FCRV can significantly reduce the risk of pASD for patients with DLS with dF ≥ 5. Trial Registration Not applicable, since this is an observational study.
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Affiliation(s)
- Xiangyu Hou
- Department of Orthopaedics, Peking University Third Hospital, Haidian District, No 49. North Garden Road, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Zhuoran Sun
- Department of Orthopaedics, Peking University Third Hospital, Haidian District, No 49. North Garden Road, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Weishi Li
- Department of Orthopaedics, Peking University Third Hospital, Haidian District, No 49. North Garden Road, Beijing, 100191, China.
- Engineering Research Center of Bone and Joint Precision Medicine, Beijing, China.
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China.
| | - Hui Wang
- Department of Orthopaedics, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lin Zhuo
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Lei Yuan
- Department of Orthopaedics, Peking University Third Hospital, Haidian District, No 49. North Garden Road, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Yan Zeng
- Department of Orthopaedics, Peking University Third Hospital, Haidian District, No 49. North Garden Road, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Linyao Ding
- Department of Orthopaedics, Peking University Third Hospital, Haidian District, No 49. North Garden Road, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Ze Chen
- Department of Orthopaedics, Peking University Third Hospital, Haidian District, No 49. North Garden Road, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
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Dalton J, Mohamed A, Akioyamen N, Schwab FJ, Lafage V. PreOperative Planning for Adult Spinal Deformity Goals: Level Selection and Alignment Goals. Neurosurg Clin N Am 2023; 34:527-536. [PMID: 37718099 DOI: 10.1016/j.nec.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Adult Spinal Deformity (ASD) is a complex pathologic condition with significant impact on quality of life, including pain, loss of function, and fatigue. Achieving realignment goals is crucial for long-term results. Reliable preoperative planning strategies, including nomograms, measurement tools, and level selection, are key to maximizing the likelihood of achieving a good outcome following ASD corrective surgery. This review covers recent literature on such strategies, including review of the different targets for realignment and their association with outcomes (both patients-reported outcomes and complications), selection of upper and lower instrumented vertebrae, and the latest innovation in preoperative planning for deformity surgery.
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Affiliation(s)
- Jay Dalton
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Ayman Mohamed
- Department of Orthopaedic Surgery, Lenox Hill Hospital, 130 East 77th Street, 11th Floor, New York, NY 10075, USA
| | - Noel Akioyamen
- Department of Orthopaedic Surgery, Monteriore Medical Center, 1250 Waters Place, Tower 1, 11th Floor, Bronx, NY 10461, USA
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Lenox Hill Hospital, 130 East 77th Street, 11th Floor, New York, NY 10075, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, 130 East 77th Street, 11th Floor, New York, NY 10075, USA.
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Li Y, Yang D, Bergman R, Jha S, Casden M, Smith JT, Vitale M, Heffernan M. Preoperative left shoulder elevation > 1 cm is predictive of severe postoperative shoulder imbalance in early onset idiopathic scoliosis patients treated with growth-friendly instrumentation. Spine Deform 2023; 11:1157-1167. [PMID: 37155134 DOI: 10.1007/s43390-023-00696-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/22/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE Prior research has demonstrated the influence of preoperative shoulder elevation (SE), proximal thoracic curve magnitude, and upper instrumented vertebra (UIV) on shoulder balance after PSF for AIS. Our purpose was to evaluate the impact of these factors on shoulder balance in early onset idiopathic scoliosis (EOIS) patients treated with growth-friendly instrumentation. METHODS This was a multicenter retrospective review. Children with EOIS treated with dual TGR, MCGR, or VEPTR and minimum 2-year follow-up were identified. Demographics and radiographic/surgical data were collected. RESULTS 145 patients met inclusion criteria: 74 had right SE (RSE), 49 left SE (LSE), and 22 even shoulders (EVEN) preoperatively. Mean follow-up was 5.3 years (range, 2.0-13.1 years). The LSE group had a larger pre-index mean main thoracic curve (p = 0.021) but no difference was observed between groups at the post-index or most recent timepoints. RSE patients with UIV of T2 were more likely to have balanced shoulders post-index than patients with UIV of T3 or T4 (p = 0.011). Pre-index radiographic shoulder height (RSH) was predictive of post-index shoulder imbalance ≥ 2 cm in the LSE group (p = 0.007). A ROC curve showed a cut-off of 1.0 cm for RSH. 0/16 LSE patients with pre-index RSH < 1.0 cm had post-index shoulder imbalance ≥ 2 cm compared to 8/28 (29%) patients with pre-index RSH > 1.0 cm (p = 0.006). CONCLUSION Preoperative LSE > 1.0 cm is predictive of shoulder imbalance ≥ 2 cm after insertion of TGR, MCGR, or VEPTR in children with EOIS. In patients with preoperative RSE, UIV of T2 resulted in a higher likelihood of balanced shoulders postoperatively.
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Affiliation(s)
- Ying Li
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, Michigan Medicine, 1540 E. Hospital Dr., SPC 4241, Ann Arbor, MI, 48109-4241, USA.
| | - Daniel Yang
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Rachel Bergman
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Sahil Jha
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, Michigan Medicine, 1540 E. Hospital Dr., SPC 4241, Ann Arbor, MI, 48109-4241, USA
| | - Michael Casden
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - John T Smith
- Department of Orthopaedic Surgery, Intermountain Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Michael Vitale
- Department of Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University, New York, NY, USA
| | - Michael Heffernan
- Department of Orthopaedic Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
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Yamada T, Hasegawa T, Yamato Y, Yoshida G, Banno T, Arima H, Oe S, Mihara Y, Ushirozako H, Ide K, Watanabe Y, Nakai K, Kurosu K, Matsuyama Y. Characteristics of pedicle screw misplacement using freehand technique in degenerative scoliosis surgery. Arch Orthop Trauma Surg 2023; 143:1861-1867. [PMID: 35194658 DOI: 10.1007/s00402-022-04380-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 02/05/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE This study aimed to estimate the accuracy of pedicle screw (PS) placement in degenerative scoliosis surgery, characterize a patient population with PS misplacement, and analyze the association between misplaced PS vector and lumbar coronal curve. METHODS In this study, 122 patients (average age 68.6 years), who underwent corrective and decompression surgery, were selected retrospectively. PS accuracy was evaluated in the thoracic to lumbar spine. We identified characteristics of misplacement in each patient. Screw positions were categorized into grade A, entirely in the pedicle; grade B, < 2 mm breach; grade C, 2-4 mm breach; and grade D, > 4 mm breach using postoperative computed tomography. RESULTS The mean preoperative lumbar coronal curve was 32.3 ± 18.4°, and the number of fused vertebrae was 8.9 ± 2.8. A total of 2032 PS were categorized as follows: grade A, 1897 PS (93.3%); grade B, 67 (3.3%); grade C, 26 (1.3%); and grade D, 43 (2.1%). One PS (grade D), inserted at T5, needed surgery for removal due to neurological deficit. The misplacement group (grades C and D) had a significantly stronger lumbar coronal curve and apical vertebral rotation than the accuracy group (grades A and B). Misplaced PS vector (direction and degree) was significantly correlated with inserted vertebral rotation. Grade D misplacement was distributed mainly around the transitional vertebra of the lumbar curve. CONCLUSIONS The accuracy of PS insertion in the thoracic to lumbar spine was high in DS surgery, but the need for care was highlighted in the transitional vertebra.
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Affiliation(s)
- Tomohiro Yamada
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan.
| | - Tomohiko Hasegawa
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Yu Yamato
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
- Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, Hamamatsu City, Shizuoka, Japan
| | - Go Yoshida
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Tomohiro Banno
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Hideyuki Arima
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Shin Oe
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
- Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, Hamamatsu City, Shizuoka, Japan
| | - Yuki Mihara
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Hiroki Ushirozako
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Koichiro Ide
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Yuh Watanabe
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Keiichi Nakai
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Kenta Kurosu
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
| | - Yukihiro Matsuyama
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu City, Shizuoka, 431-3192, Japan
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Oku N, Demura S, Tawara D, Kato S, Shinmura K, Yokogawa N, Yonezawa N, Shimizu T, Kitagawa R, Handa M, Ryohei A, Tsuchiya H. Biomechanical investigation of long spinal fusion models using three-dimensional finite element analysis. BMC Musculoskelet Disord 2023; 24:175. [PMID: 36890531 DOI: 10.1186/s12891-023-06290-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/03/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND This study represents the first finite element (FE) analysis of long-instrumented spinal fusion from the thoracic vertebrae to the pelvis in the context of adult spinal deformity (ASD) with osteoporosis. We aimed to evaluate the von Mises stress in long spinal instrumentation for models that differ in terms of spinal balance, fusion length, and implant type. METHODS In this three-dimensional FE analysis, FE models were developed based on computed tomography images from a patient with osteoporosis. The von Mises stress was compared for three different sagittal vertical axes (SVAs) (0, 50, and 100 mm), two different fusion lengths (from the pelvis to the second [T2-S2AI] or 10th thoracic vertebra [T10-S2AI]), and two different types of implants (pedicle screw or transverse hook) in the upper instrumented vertebra (UIV). We created 12 models based on combinations of these conditions. RESULTS The overall von Mises stress was 3.1 times higher on the vertebrae and 3.9 times higher on implants for the 50-mm SVA models than that for the 0-mm SVA models. Similarly, the values were 5.0 times higher on the vertebrae and 6.9 times higher on implants for the 100-mm SVA models than that for the 0-mm SVA models. Higher SVA was associated with greater stress below the fourth lumbar vertebrae and implants. In the T2-S2AI models, the peaks of vertebral stress were observed at the UIV, at the apex of kyphosis, and below the lower lumbar spine. In the T10-S2AI models, the peaks of stress were observed at the UIV and below the lower lumbar region. The von Mises stress in the UIV was also higher for the screw models than for the hook models. CONCLUSION Higher SVA is associated with greater von Mises stress on the vertebrae and implants. The stress on the UIV is greater for the T10-S2AI models than for the T2-S2AI models. Using transverse hooks instead of screws at the UIV may reduce stress in patients with osteoporosis.
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Banno T, Yamato Y, Oba H, Ohba T, Hasegawa T, Yoshida G, Arima H, Oe S, Mihara Y, Ide K, Takahashi J, Haro H, Matsuyama Y. Should the upper end vertebra be selected as the upper instrumented vertebra in patients with Lenke type 5C adolescent idiopathic scoliosis? Spine Deform 2022; 10:1139-1148. [PMID: 35322389 DOI: 10.1007/s43390-022-00496-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/05/2022] [Indexed: 11/28/2022]
Abstract
STUDY DESIGN Retrospective study. PURPOSE The upper end vertebra (UEV) is often selected as the upper instrumented vertebra (UIV) in patients with adolescent idiopathic scoliosis (AIS) with Lenke type 5C curves; however, the effect of adjusting UIV selection one level toward the cranial side (UEV + 1) is unknown. Therefore, this study aimed to assess the effect of UIV extension on scoliosis correction and global alignment in patients with the UIV as the UEV and UEV + 1. METHODS Data of 52 patients with AIS with Lenke type 5C curves who underwent selective thoracolumbar/lumbar (TL/L) fusion with a minimum follow-up period of 2 years were retrospectively analyzed. The patients were divided according to the UIV in relation to the UEV: the UEV and UEV + 1 groups. Radiographic parameters and clinical outcomes were compared between the two groups. RESULTS Among the 52 patients, 24 and 28 were included in the UEV and UEV + 1 group. Baseline data showed no intergroup differences except for the UIV level. While the UEV + 1 group showed a significantly greater TL/L curve correction (72.9% vs. 62.8%, p < 0.05) and a lower UIV tilt, it showed a significantly greater absolute value of radiographic shoulder height (RSH) (- 7.9 vs. - 0.9 mm, p < 0.05) and coronal balance (- 11.0 mm vs - 4.8 mm, p < 0.05) at 2 years postoperatively. The rate of post-operative shoulder imbalance (RSH ≥ 2 cm) was significantly higher in the UEV + 1 than in the UEV group. No intergroup differences were observed in the sagittal alignment and patient outcomes between the two groups. CONCLUSION When the UIV was selected as the UEV + 1, correction of the TL/L curve improved; however, it increased the risk of shoulder and coronal imbalance. There is no clinical benefit observed in terms of extending the UIV to the UEV + 1; therefore, the UIV should be selected as the UEV to maintain harmonious global alignment. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Tomohiro Banno
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan.
| | - Yu Yamato
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Hiroki Oba
- Department of Orthopedic Surgery, Shinshu University, Matsumoto, Nagano, Japan
| | - Tetsuro Ohba
- Department of Orthopedic Surgery, Yamanashi University, Chuo, Yamanashi, Japan
| | - Tomohiko Hasegawa
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Go Yoshida
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Hideyuki Arima
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Shin Oe
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Yuki Mihara
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Koichiro Ide
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Jun Takahashi
- Department of Orthopedic Surgery, Shinshu University, Matsumoto, Nagano, Japan
| | - Hirotaka Haro
- Department of Orthopedic Surgery, Yamanashi University, Chuo, Yamanashi, Japan
| | - Yukihiro Matsuyama
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
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Yang B, Xu L, Zhou Q, Qian Z, Wang B, Zhu Z, Qiu Y, Sun X. Relook into the Risk Factors of Proximal Junctional Kyphosis in Early Onset Scoliosis Patients: Does the Location of Upper Instrumented Vertebra in Relation to the Sagittal Apex Matter? Orthop Surg 2022; 14:1695-1702. [PMID: 35766793 PMCID: PMC9363734 DOI: 10.1111/os.13380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/29/2022] [Accepted: 05/29/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Growing rods surgery is the mainstay of treatment for early-onset scoliosis (EOS) while proximal junctional kyphosis (PJK) is one of the most commonly reported postoperative complications. We sought to investigate the impact of the location of upper instrumented vertebra (UIV) in relation to the sagittal apex on proximal junctional kyphosis in EOS after traditional growing rods (GRs) treatment. METHODS A total of 102 EOS patients who received traditional growing rods treatment with a follow-up of at least 2 years between 2009 and 2020 were retrospectively reviewed. Radiographic measurements were performed before and after the index surgery and at the latest follow-up. We investigated the coronal Cobb angle and spinopelvic parameters of the whole spine. The location of the UIV, apex, lower instrumented vertebra (LIV), inflection vertebra (IV), the number and distance of UIV-apex, LIV-apex and IV-apex were also recorded. Risk factors for PJK were analyzed by logistic regression analysis. RESULTS PJK was observed in 21 patients (20.6%) during the follow-up period. The PJK group showed a younger age at the index surgery (5.9 vs. 7.1 years, P = 0.042), more lengthening procedure times (5.0 vs. 4.0, P = 0.032), larger preoperative coronal Cobb angle (82.0 vs. 75.6°, P = 0.038), higher correction rate (51.2% vs. 44.4%, P = 0.047) and larger postoperative proximal junctional angle (PJA) (13.9 vs. 5.5°, P < 0.001) than the non-PJK group. The ratio of the number and distance from UIV-apex to IV-apex also differed significantly between the two groups. The logistic regression revealed that age at the index surgery ≤ 7 years, the ratio of the number from UIV- apex to IV- apex ≤ 0.6 and the ratio of the distance from UIV- apex to IV- apex ≤ 0.6 were independent risk factors for postoperative PJK. CONCLUSION Besides younger age, a closer location of UIV relative to the sagittal apex is identified to be an independent risk factor of postoperative PJK. Selection of UIV at a relatively farther location away from the sagittal apex might help prevent occurrence of PJK.
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Affiliation(s)
- Bo Yang
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Liang Xu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Qingshuang Zhou
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zhuang Qian
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Bin Wang
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zezhang Zhu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yong Qiu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xu Sun
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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Mao S, Li S, Ma Y, Shi BL, Liu Z, Zhu ZZ, Qiao J, Qiu Y. How to rectify the convex coronal imbalance in patients with unstable dystrophic scoliosis secondary to type I neurofibromatosis: experience from a case series. BMC Musculoskelet Disord 2022; 23:368. [PMID: 35443648 PMCID: PMC9020035 DOI: 10.1186/s12891-022-05321-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 04/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There was a paucity of valid information on how to rectify the convex coronal imbalance effectively in dystrophic scoliosis secondary to Type I neurofibromatosis (DS-NF1), while postoperative inadvertent aggravation of CCI occurred regularly resulting in poor patient satisfaction. We aimed to identify the risk factors for persistent postoperative CCI in DS-NF1, and to optimize the coronal rebalancing strategies based on the lessons learned from this rare case series. METHODS NF1-related scoliosis database was reviewed and those with significant CCI (> 3 cm) were identified, sorted and the outcomes of surgical coronal rebalance were analyzed to identify the factors being responsible for failure of CCI correction. RESULTS CCI with dystrophic thoracolumbar/lumbar apex was prone to remain uncorrected (7 failure cases in 11) when compared to those with thoracic apex (0 failure cases in 4) (63.6% vs. 0.0%, p = 0.077). Further comparison between those with and without post-op CCI showed a higher correction of main curve Cobb angle (65.9 ± 9.1% vs. 51.5 ± 37.3%, p = 0.040), more tilted instrumentation (10.3 ± 3.6° vs. 3.2 ± 3.1°, p = 0.001) and reverse tilt and translation of upper instrumented vertebra (UIV) to convex side (8.0 ± 2.3° vs. -3.4 ± 5.9°, p < 0.001; 35.4 ± 6.9 mm vs. 12.3 ± 13.1 mm, p = 0.001) in the uncorrected imbalanced group. Multiple linear regression analysis revealed that △UIV translation (pre- to post-operation) (β = 0.832; p = 0.030) was significantly correlated with the correction of CBD. CONCLUSION Thoracolumbar/lumbar CCI in dystrophic scoliosis was prone to suffer high risk of persistent post-op CCI. Satisfying coronal rebalance should avoid UIV tilt and translation to the convex side, tilted morphology of instrumentation and over correction maneuvers for main curve, the upper hemi-curve region in particular.
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Affiliation(s)
- Saihu Mao
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China.
| | - Song Li
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Yanyu Ma
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Ben-Long Shi
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Zhen Liu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Ze-Zhang Zhu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Jun Qiao
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Yong Qiu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
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Harris AB, Kebaish FN, Puvanesarajah V, Raad M, Wilkening MW, Jain A, Cohen DB, Neuman BJ, Kebaish KM. Caudally directed upper-instrumented vertebra pedicle screws associated with minimized risk of proximal junctional failure in patients with long posterior spinal fusion for adult spinal deformity. Spine J 2021; 21:1072-1079. [PMID: 33722729 DOI: 10.1016/j.spinee.2021.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 02/06/2021] [Accepted: 03/08/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT It is unknown whether upper instrumented vertebra (UIV) pedicle screw trajectory and UIV screw-rod angle are associated with development of proximal junctional kyphosis (PJK) and/or proximal junctional failure (PJF). PURPOSE To determine whether (1) the cranial-caudal trajectory of UIV pedicle screws and (2) UIV screw-vertebra angle are associated with PJK and/or PJF after long posterior spinal fusion in patients with adult spinal deformity (ASD). STUDY DESIGN/SETTING Retrospective review. PATIENT SAMPLE We included 96 patients with ASD who underwent fusion from T9-T12 to the pelvis (>5 vertebrae fused) between 2008 and 2015. OUTCOME MEASURES Pedicle screw trajectory was measured as the UIV pedicle screw-vertebra angle (UIV-PVA), which is the mean of the two angles between the UIV superior endplate and both UIV pedicle screws. (Positive values indicate screws angled cranially; negative values indicate screws angled caudally.) We measured UIV rod-vertebra angle (UIV-RVA) between the rod at the point of screw attachment and the UIV superior endplate. METHODS During ≥2-year follow-up, 38 patients developed PJK, and 28 developed PJF. Mean (± standard deviation) UIV-PVA was -0.9° ± 6.0°. Mean UIV-RVA was 87° ± 5.2°. We examined the development of PJK and PJF using a UIV-PVA/UIV-RVA cutoff of 3° identified by a receiver operating characteristic curve, while controlling for osteoporosis, age, sex, and preoperative thoracic kyphosis. RESULTS Patients with UIV-PVA ≥3° had significantly greater odds of developing PJK (odds ratio 2.7; 95% confidence interval: 1.0-7.1) and PJF (odds ratio 3.6; 95% confidence interval: 1.3-10) compared with patients with UIV-PVA <3°. UIV-RVA was not significantly associated with development of PJK or PJF. CONCLUSIONS In long thoracic fusion to the pelvis for ASD, UIV-PVA ≥3° was associated with 2.7-fold greater odds of PJK and 3.6-fold greater odds of PJF compared with UIV-PVA <3°. UIV-RVA was not associated with PJK or PJF. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Andrew B Harris
- Department of Orthopedic Surgery, The Johns Hopkins University, 601 N. Caroline St, JHOC 5223, Baltimore, MD, USA
| | - Floreana N Kebaish
- Department of Orthopedic Surgery, The Johns Hopkins University, 601 N. Caroline St, JHOC 5223, Baltimore, MD, USA
| | - Varun Puvanesarajah
- Department of Orthopedic Surgery, The Johns Hopkins University, 601 N. Caroline St, JHOC 5223, Baltimore, MD, USA
| | - Micheal Raad
- Department of Orthopedic Surgery, The Johns Hopkins University, 601 N. Caroline St, JHOC 5223, Baltimore, MD, USA
| | - Matthew W Wilkening
- Department of Orthopedic Surgery, The Johns Hopkins University, 601 N. Caroline St, JHOC 5223, Baltimore, MD, USA
| | - Amit Jain
- Department of Orthopedic Surgery, The Johns Hopkins University, 601 N. Caroline St, JHOC 5223, Baltimore, MD, USA
| | - David B Cohen
- Department of Orthopedic Surgery, The Johns Hopkins University, 601 N. Caroline St, JHOC 5223, Baltimore, MD, USA
| | - Brian J Neuman
- Department of Orthopedic Surgery, The Johns Hopkins University, 601 N. Caroline St, JHOC 5223, Baltimore, MD, USA
| | - Khaled M Kebaish
- Department of Orthopedic Surgery, The Johns Hopkins University, 601 N. Caroline St, JHOC 5223, Baltimore, MD, USA.
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Zhang T, Shu S, Jing W, Gu Q, Zhu Z, Liu Z, Qiu Y, Sun X, Wang B, Bao H. Optimizing the fusion level for lenke 5C adolescent idiopathic scoliosis: is the S-line a validated and reproducible tool to predict coronal decompensation? Eur Spine J 2021; 30:1935-42. [PMID: 33661397 DOI: 10.1007/s00586-021-06781-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 01/06/2021] [Accepted: 02/18/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE To validate the predictability of S-line in Lenke 5C patients. METHODS Lenke 5C patients with a minimum 2-year follow-up and with the lowest instrumented vertebra (LIV) at lower end vertebra were included. The S-line was defined as a line connecting the centers of concave-side pedicles of upper instrumented vertebra (UIV) and LIV on baseline films. The S-line tilt to right was defined as positive S-line status (S-line +) and tilt to left as S-line - status. Statistical analysis was performed between different subgroups. RESULTS Among the 92 patients, 69 patients had a left lumbar curve and 23 patients had a right lumbar curve. For left curves, the S-line + status had a significantly higher incidence of both proximal and distal decompensation. However, for right curves, the S-line - status was the risk factor. Thus, we modified the definition of S-line: The value of S-line tilt for right curves was opposite to that for left curves. Patients with modified S-line + showed a significantly higher incidence of both proximal and distal decompensation in Lenke 5C patients with both left and right curves (p < 0.001 and p = 0.010). In UEV group, patients with modified S-line + showed significantly higher incidence of proximal decompensation (P = 0.001). However, in UEV-1 group, the incidence of proximal decompensation was not statistically affected by modified S-line + (P = 0.281). CONCLUSION Modified S-line + is a validated risk factor that predisposed to post-operative coronal decompensation in Lenke 5C AIS patients. Selecting UIV at one level caudal to UEV could be a possible solution if the modified S-line was positive.
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12
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Virk S, Platz U, Bess S, Burton D, Passias P, Gupta M, Protopsaltis T, Kim HJ, Smith JS, Eastlack R, Kebaish K, Mundis GM, Nunley P, Shaffrey C, Gum J, Lafage V, Schwab F. Factors influencing upper-most instrumented vertebrae selection in adult spinal deformity patients: qualitative case-based survey of deformity surgeons. J Spine Surg 2021; 7:37-47. [PMID: 33834126 DOI: 10.21037/jss-20-598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background The decision upper-most instrumented vertebrae (UIV) in a multi-level fusion procedure can dramatically influence outcomes of corrective spine surgery. We aimed to create an algorithm for selection of UIV based on surgeon selection/reasoning of sample cases. Methods The clinical/imaging data for 11 adult spinal deformity (ASD) patients were presented to 14 spine deformity surgeons who selected the UIV and provided reasons for avoidance of adjacent levels. The UIV chosen was grouped into either upper thoracic (UT, T1-T6), lower thoracic (LT, T7-T12), lumbar or cervical. Disagreement between surgeons was defined as ≥3 not agreeing. We performed a descriptive analysis of responses and created an algorithm for choosing UIV then applied this to a large database of ASD patients. Results Surgeons agreed in 8/11 cases on regional choice of UIV. T10 was the most common UIV in the LT region (58%) and T3 was the most common UIV in the UT region (44%). The most common determinant of UIV in the UT region was proximal thoracic kyphosis and presence of coronal deformity. The most common determinant of UIV in the LT region was small proximal thoracic kyphosis. Within the ASD database (236 patients), when the algorithm called for UT fusion, patients fused to TL region were more likely to develop proximal junctional kyphosis (PJK) at 1 year post-operatively (76.9% vs. 38.9%, P=0.025). Conclusions Our algorithm for selection of UIV emphasizes the role of proximal and regional thoracic kyphosis. Failure to follow this consensus for UT fusion was associated with twice the rate of PJK.
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Affiliation(s)
- Sohrab Virk
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Uwe Platz
- Department of spine surgery, Schön Kllink Neustadt, Neustadt, Germany
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Douglas Burton
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Peter Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University, St Louis, MO, USA
| | | | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Robert Eastlack
- Scripps Clinic Medical Group Division of Orthopaedic Surgery, La Jolla, CA, USA
| | - Khaled Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gregory M Mundis
- Scripps Clinic Medical Group Division of Orthopaedic Surgery, La Jolla, CA, USA
| | | | | | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville, KY, USA
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
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Daniels AH, Reid DBC, Durand WM, Line B, Passias P, Kim HJ, Protopsaltis T, LaFage V, Smith JS, Shaffrey C, Gupta M, Klineberg E, Schwab F, Burton D, Bess S, Ames C, Hart RA. Assessment of Patient Outcomes and Proximal Junctional Failure Rate of Patients with Adult Spinal Deformity Undergoing Caudal Extension of Previous Spinal Fusion. World Neurosurg 2020; 139:e449-e454. [PMID: 32305603 DOI: 10.1016/j.wneu.2020.04.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/03/2020] [Accepted: 04/04/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This case series examined patients undergoing caudal extension of prior fusion without alteration of the prior upper instrumented vertebra (UIV) to assess patient outcomes and rates of proximal junctional kyphosis (PJK)/proximal junctional failure (PJF). METHODS Patients eligible for 2-year minimum follow-up undergoing caudal extension of prior fusion with unchanged UIVs were identified. These patients were evaluated for PJK/PJF, and patient reported outcomes were recorded. RESULTS In total, 40 patients were included. Mean follow-up duration was 2.2 ± 0.3 years. Patients in this cohort had poor preoperative sagittal alignment (pelvic incidence minus lumbar lordosis [PI-LL] 26.7°, T1 pelvic angle [TPA] 29.0°, sagittal vertical axis [SVA] 93.4 mm) and achieved substantial sagittal correction (ΔSVA -62.2 mm, ΔPI-LL -19.8°, ΔTPA -11.1°) after caudal extension surgery. At final follow-up, there was a 0% rate of PJF among patients undergoing caudal extension of previous fusion without creation of a new UIV, but 27.5% of patients experienced PJK. Patients experienced significant improvement in both the Oswestry Disability Index and Scoliosis Research Society-22r total score at 2 years postoperatively (P < 0.05). In total, 7.5% (n = 3) of patients underwent further revision, at an average of 1.1 ± 0.54 years after the surgery with unaltered UIV. All 3 of these patients underwent revision for rod fracture with no revisions for PJK/PJF. CONCLUSIONS Patients undergoing caudal extension of previous fusions for sagittal alignment correction have high rates of clinical success, low revision surgery rates, and very low rates of PJF. Minimizing repetitive tissue trauma at the UIV may result in decreased PJF risk because the PJF rate in this cohort of patients with unaltered UIV is below historical PJF rates of patients undergoing sagittal balance correction.
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Affiliation(s)
- Alan H Daniels
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
| | - Daniel B C Reid
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Wesley M Durand
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Breton Line
- Department of Orthopedics, Denver International Spine Center, Presbyterian/St. Luke's, Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Peter Passias
- Department of Orthopaedics, NYU Langone Medical Center, New York, New York, USA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA
| | | | - Virginie LaFage
- Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | | | - Munish Gupta
- Department of Orthopedics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Eric Klineberg
- Department of Orthopedics, University of California, Davis, California, USA
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA
| | - Doug Burton
- Department of Orthopedics, University of Kansas Hospital, Kansas City, Kansas, USA
| | - Shay Bess
- Department of Orthopedics, Denver International Spine Center, Presbyterian/St. Luke's, Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Christopher Ames
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Robert A Hart
- Department of Orthopedics, Swedish Medical Center, Seattle, Washington, USA
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Simon AL, Ferrero E, Mazda K, Ilharreborde B. Bivertebral autostable claws for the proximal fixation in thoracic adolescent idiopathic scoliosis surgery. Spine Deform 2020; 8:77-84. [PMID: 31950478 DOI: 10.1007/s43390-020-00040-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 05/19/2019] [Indexed: 10/25/2022]
Abstract
STUDY DESIGN Retrospective monocentric study. OBJECTIVES To report radiologic outcomes of a consecutive series of AIS patients, operated with a bivertebral autostable claw for the upper instrumentation over a 5-year period. The upper fixation represents the weakest part of long constructs because of local anatomy and the high pull-out forces. Various implants have been proposed, but proximal junctional failures (PJF) and shoulder imbalance still occur with variable incidence. The autostable claw is a new implant, safe, and low profile, combining the mechanical strength of hooks with the initial stability of pedicle screws. METHODS All AIS patients operated between January 2010 and July 2015 for a Lenke 1 or 2 curve with the bivertebral autostable claw were included. A minimum 2-year follow-up was required. Full-spine biplanar stereoradiographs were performed preoperatively, within 8 weeks postoperative and at latest examination. Local and global sagittal and coronal parameters were analyzed and complications were reported. RESULTS 237 patients (191 Lenke 1 and 46 Lenke 2) were included, with a mean follow-up of 4.1 ± 0.6 years. PJF occurred in 2 patients (0.8%), and radiologic PJKs were observed in 8.4% of the series. Shoulder balance was efficiently restored or maintained in 88.2%. CONCLUSIONS The bivertebral autostable claw is a safe and robust alternative to pedicle screws for proximal fixation in AIS long constructs. Compression and/or distraction can be applied to level shoulders, and mechanical failures remain rare at 4-year follow-up. LEVEL OF EVIDENCE IV.
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15
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Jung JM, Hyun SJ, Kim KJ, Jahng TA, Kim HJ, Choi Y. Anatomic Trajectory Screw Fixation at Upper Instrumented Vertebra Is a Substantial Risk Factor for Proximal Junctional Kyphosis. World Neurosurg 2019; 129:e522-e529. [PMID: 31152888 DOI: 10.1016/j.wneu.2019.05.198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/23/2019] [Accepted: 05/23/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND This study aimed to investigate the risk of proximal junction kyphosis (PJK) and proximal junction failure (PJF) associated with screw trajectory (straightforward vs. mixed vs. anatomic) at upper instrumented vertebra (UIV). METHODS A single-center, single-surgeon consecutive series of adult patients who underwent lumbar fusion for ≥4 levels (the UIV of the thoracolumbar spine, T9-L2, and the lower instrumented vertebra at the sacrum or pelvis) was retrospectively reviewed. Patients were divided into 3 groups according to UIV screw trajectory: group S, 2 straightforward screws; group M, 1 straightforward screw and 1 anatomic trajectory screw; and group A, 2 anatomic trajectory screws. RESULTS A total of 83 patients were included in this study, including 51 in group S, 16 in group M, and 16 in group A. The incidence of PJK in group S (12 patients, 23.5%), group M (7 patients, 43.8%), and group A (9 patients, 56.3%) significantly increased in sequence by group (P = 0.044). Anatomic trajectory screw fixation increased the risk for PJF requiring revision surgery compared with straightforward screw fixation (3 patients [18.8%] vs. 1 patient [2.0%]; P = 0.040). Multivariable analysis identified that anatomic trajectory screw fixation was a significant risk factor for PJK (P = 0.008; adjusted odds ratio = 7.591; 95% confidence interval, 1.69-34.093). CONCLUSION Anatomic trajectory screw fixation at the UIV is a substantial risk factor for PJK and PJF. To reduce PJK and PJF, straightforward screw fixation at the UIV is recommended in adult spinal deformity correction surgery.
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Affiliation(s)
- Jong-Myung Jung
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea.
| | - Ki-Jeong Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Tae-Ahn Jahng
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Hyun-Jib Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
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Brooks JT, Bastrom TP, Bartley CE, Lonner BS, Shah SA, Miyanji F, Asghar J, Newton PO, Yaszay B. In Search of the Ever-Elusive Postoperative Shoulder Balance: Is the T2 UIV the Key? Spine Deform 2019; 6:707-711. [PMID: 30348348 DOI: 10.1016/j.jspd.2018.03.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/11/2018] [Accepted: 03/12/2018] [Indexed: 10/28/2022]
Abstract
STUDY DESIGN Multicenter review of prospectively collected data. OBJECTIVE The purpose of this study was to evaluate whether a UIV of T2 reliably results in level shoulders postoperatively. SUMMARY OF BACKGROUND DATA Adolescent idiopathic scoliosis (AIS) patients with a risk of a high left shoulder postoperatively are generally recommended to have instrumentation to T2, those with neutral shoulders a T3 UIV, and those with an elevated right shoulder are recommended a UIV of T4 or below in order to achieve postoperative shoulder balance. METHODS A prospective, multicenter AIS database was queried for subjects with minimum two-year follow-up who underwent posterior spinal fusion to correct their main thoracic deformity. Subjects were grouped based on their proximal fusion level. A high shoulder was defined as >1 cm difference on radiographs. RESULTS A total of 626 subjects met inclusion criteria and were divided by UIVs of T2 189, T3 205, and T4 232. Preoperatively, the groups had similar rates of balanced shoulders (T2 47%, T3 49%, T4 45%) and high left shoulders (T2 8.5%, T3 8.8%, and T4 7.3%). Postoperatively, there was a greater percentage of postoperative shoulder imbalance for T2 (45%) and T3 (48%) UIV groups as compared to T4 (34%, p = .008). As expected, the T2 (46%) and T3 (49%) groups had significantly better upper thoracic curve correction as compared to the T4 group (42%, p < .001). CONCLUSIONS The selection of a T4 UIV results in more shoulder balance postoperatively than T2 or T3, regardless of which shoulder was elevated preoperatively. The selection of a T2 UIV does not guarantee postoperative shoulder balance following posterior treatment of main thoracic curves; however, when compared to the more caudal UIV of T4, an improved upper thoracic curve correction can be anticipated. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Jaysson T Brooks
- Children's of Mississippi, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216, USA
| | - Tracey P Bastrom
- Rady Children's Hospital, 7910 Frost Street, San Diego, CA 92123, USA
| | - Carrie E Bartley
- Rady Children's Hospital, 7910 Frost Street, San Diego, CA 92123, USA
| | - Baron S Lonner
- Scoliosis and Spine Associates, 820 2nd Ave, New York, NY 10017, USA
| | - Suken A Shah
- Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803, USA
| | - Firoz Miyanji
- British Columbia Children's Hospital, 4480 Oak St, Vancouver, BC V6H 3N1, Canada
| | - Jahangir Asghar
- Nicklaus Children's Hospital, 3100 SW 62nd Ave, Miami, FL 33155, USA
| | - Peter O Newton
- Rady Children's Hospital, 7910 Frost Street, San Diego, CA 92123, USA
| | - Burt Yaszay
- Rady Children's Hospital, 7910 Frost Street, San Diego, CA 92123, USA.
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Uei H, Tokuhashi Y, Maseda M, Nakahashi M, Sawada H, Matsumoto K, Miyakata H. Exploratory analysis of predictors of revision surgery for proximal junctional kyphosis or additional postoperative vertebral fracture following adult spinal deformity surgery in elderly patients: a retrospective cohort study. J Orthop Surg Res 2018; 13:252. [PMID: 30314520 DOI: 10.1186/s13018-018-0960-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 09/28/2018] [Indexed: 12/02/2022] Open
Abstract
Background Proximal junctional kyphosis (PJK) following adult spinal deformity (ASD) surgery in elderly patients is markedly influenced by osteoporosis causing additional vertebral fracture and loosening of pedicle screws (PS). This study aimed to investigate the association between mean bone density represented in Hounsfield units (HU) on spinal computed tomography (CT) and revision surgery for PJK or postoperative additional vertebral fracture following ASD surgery in elderly patients. Methods The subjects were 54 ASD patients aged 65 years or older who were treated with correction and fusion surgery of four or more levels and could be followed for 2 years or longer. Bone density was measured before surgery using lumbar dual-energy X-ray absorptiometry (DXA) and spinal CT in all patients. The patients were divided into group A (n = 14) in which revision surgery was required for PJK or additional vertebral fracture and group B (n = 40) in which revision surgery was not required. We retrospectively investigated incidences of PJK, additional vertebral fracture, and PS loosening, perioperative parameters, radiographic parameters before and after surgery, and osteoporosis treatment administration rate. Results No significant difference was noted in young adult mean (YAM) on DXA between groups A and B, respectively (P = 0.62), but the mean bone densities represented in HU of the T8 (P = 0.002) and T9 (P = 0.01) vertebral bodies on spinal CT were significantly lower in group A, whereas those of the L4 (P = 0.002) and L5 (P = 0.01) vertebral bodies were significantly higher in group A. The incidence of PJK was not significantly different (P = 0.07), but the incidence of additional vertebral fracture was significantly higher in group A (P < 0.001). The incidences of uppermost PS loosening within 3 months after surgery were 71% and 40% in groups A and B, respectively (P = 0.04). Conclusions In elderly patients who required revision surgery, the mean bone densities of vertebral bodies at T8 and T9 were significantly lower. The mean bone density represented in HU on spinal CT may be useful for risk assessment of and countermeasures against revision surgery after ASD surgery in elderly patients.
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Ketenci IE, Yanik HS, Erdem S. The effect of upper instrumented vertebra level on cervical sagittal alignment in Lenke 1 adolescent idiopathic scoliosis. Orthop Traumatol Surg Res 2018; 104:623-629. [PMID: 29933123 DOI: 10.1016/j.otsr.2018.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 06/01/2018] [Accepted: 06/12/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND This study aimed to evaluate the relationship between upper instrumented vertebra (UIV) level and cervical sagittal alignment (CSA) in Lenke 1 adolescent idiopathic scoliosis (AIS) patients, treated with posterior instrumentation. The hypothesis was that higher level of UIV would cause decreased cervical lordosis. METHODS Sixty-three Lenke 1AIS patients that underwent posterior fusion with pedicle screw instrumentation were retrospectively evaluated. Patients were divided into three groups according to UIV level (T2, T3, T4). Twenty patients without spinal deformity made up the control group. Patients were compared at two years follow-up according to radiographic changes in coronal and sagittal planes. Main sagittal parameters were C2-C7 cervical lordosis (CL), T1 slope, T1-T5 and T5-T12 kyphosis. Clinical outcomes were assessed using scoliosis research society (SRS)-22, short form (SF)-36 and neck disability index (NDI) questionnaires. RESULTS Preoperative sagittal plane values of AIS patients were similar to the control group. C2-C7 CL, T1-T5 kyphosis and T1 slope significantly decreased postoperatively in T2 and T3 groups (p<0.05). These parameters were not changed significantly in T4 group after the surgery. T5-T12 kyphosis did not change significantly in all groups. SRS-22 and SF-36 scores significantly improved (p<0.05), while NDI scores were not changed significantly after the surgery. CONCLUSIONS In Lenke 1 AIS, treated with segmental all pedicle screw instrumentation using precontoured rods and rod rotation maneuver, postoperative decreased CL is more likely to occur if the UIV is selected as T2 or T3. Decreased CL seems to be caused by reduced T1-T5 kyphosis and T1 slope. However the decrease in CL did not effect clinical outcome scores, including NDI, adversely. Hence, extending the fusion to appropriate level for shoulder balance seems reasonable. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Ismail Emre Ketenci
- Haydarpasa Numune Education and Research Hospital, Department of Orthopaedics and Traumatology, Tibbiye Cad. No.23, 34668 Uskudar Istanbul, Turkey.
| | - Hakan Serhat Yanik
- Haydarpasa Numune Education and Research Hospital, Department of Orthopaedics and Traumatology, Tibbiye Cad. No.23, 34668 Uskudar Istanbul, Turkey
| | - Sevki Erdem
- Haydarpasa Numune Education and Research Hospital, Department of Orthopaedics and Traumatology, Tibbiye Cad. No.23, 34668 Uskudar Istanbul, Turkey
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Hey HWD, Tan KA, Neo CSE, Lau ETC, Choong DAW, Lau LL, Liu GKP, Wong HK. T9 versus T10 as the upper instrumented vertebra for correction of adult deformity-rationale and recommendations. Spine J 2017; 17:615-621. [PMID: 27856380 DOI: 10.1016/j.spinee.2016.11.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/18/2016] [Accepted: 11/09/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Adult spinal deformity correction sometimes involves long posterior pedicle screw constructs extending from the lumbosacral spine to the thoracic vertebra. As fusion obliterates motion and places supraphysiological stress on adjacent spinal segments, it is crucial to ascertain the ideal upper instrumented vertebra (UIV) to minimize risk of proximal junctional failure (PJF). The T10 vertebra is often chosen to allow bridging of the thoracolumbar junction into the immobile thoracic vertebrae on the basis that it is the lowest immobile thoracic vertebra strut by the rib cage. PURPOSE This study aimed to characterize the range of motion (ROM) of each vertebral segment from T7 to S1 to determine if T10 is truly the lowest immobile thoracic vertebra. STUDY DESIGN/SETTING This is a prospective, comparative study. PATIENT SAMPLE Seventy-nine adults (mean age of 45.4 years) presenting with low back pain or lower limb radiculopathy or both, without previous spinal intervention, metastases, fractures, infection, or congenital deformities of the spine, were included in the study. OUTCOME MEASURES A ROM >5° across two vertebral segments as determined by the Cobb method from radiographs. METHODS Lumbar flexion-extension and neutral erect radiographs were obtained in randomized order using a slot scanner. Segmental ROM was measured from T7-T8 to L5-S1 and analyzed for significant differences using t tests. Age, gender, radiographical indices such as standard spinopelvic parameters, sagittal vertical axis (SVA), C7-T12 SVA, T1 slope, thoracic kyphosis (TK), and lumbar lordosis (LL) were studied via multivariate analysis to identify predictive factors for >5° change in ROM at the various segmental levels. There were no sources of funding and no conflicts of interest associated with this study. RESULTS In the thoracolumbar spine, significant decreases in ROM when compared with the adjacent caudad segment occurs up to T9-T10, with mean total ROM of 1.98±1.47° (p<.001) seen in T9-T10, 2.19±1.67° (p<.001) in T10-T11, and 3.92±3.21°(p<.001) in T11-T12. The total ROM of T8-T9 (2.53±1.79°) was not significantly different from that of T9-T10 (p=.261). At the thoracolumbar junction, absence of scoliosis (OR 11.37, p=.020), high pelvic incidence (OR 1.14, p=.046), and low T1 slope (OR 1.45, p=.030) were predictive of ROM >5°. CONCLUSIONS Lumbar spine flexion-extension ROM decreases as it approaches the thoracolumbar junction. T10 is indeed the lowest immobile thoracic vertebra strut by the rib cage, and the last significant decrease in ROM is observed at T9-T10, in relation to T10-T11. However, because this also implies that a UIV of T10 would mean there is only one level of fixation above the relatively mobile segment, while respecting other factors that influence UIV selection, we propose the T9 vertebra as a more ideal UIV to fulfill the biomechanical concept of bridge fixation. However, this decision should still be taken on a case-by-case basis.
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Affiliation(s)
| | - Kimberly-Anne Tan
- Department of Orthopedic Surgery, National University Health System, Singapore
| | | | - Eugene Tze-Chun Lau
- Department of Orthopedic Surgery, National University Health System, Singapore
| | | | - Leok-Lim Lau
- Department of Orthopedic Surgery, National University Health System, Singapore
| | - Gabriel Ka-Po Liu
- Department of Orthopedic Surgery, National University Health System, Singapore
| | - Hee-Kit Wong
- Department of Orthopedic Surgery, National University Health System, Singapore
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Sudo H, Kaneda K, Shono Y, Iwasaki N. Selection of the upper vertebra to be instrumented in the treatment of thoracolumbar and lumbar adolescent idiopathic scoliosis by anterior correction and fusion surgery using dual-rod instrumentation: a minimum 12-year follow-up study. Spine J 2016; 16:281-7. [PMID: 26291399 DOI: 10.1016/j.spinee.2015.08.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 08/11/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Consensus regarding the optimal upper vertebra to be instrumented during surgical treatment of Lenke 5C thoracolumbar and lumbar adolescent idiopathic scoliosis (AIS) remains limited. PURPOSE This study aimed to assess whether a short fusion strategy is appropriate for correction of a Lenke 5C AIS curve by anterior correction and fusion surgery using dual-rod instrumentation. STUDY DESIGN This study design used retrospective comparative analysis of a prospectively collected, consecutive, non-randomized series of patients at a single institution. PATIENT SAMPLE Thirty consecutive patients with Lenke 5C AIS treated with anterior correction and fusion surgery using dual-rod instrumentation were included. OUTCOME MEASURES Patient demographics, radiographic measurements, and Scoliosis Research Society-22 questionnaire (SRS-22) scores were the outcome measures for this study. METHODS Thirty patients were treated surgically for AIS with a Lenke 5C curve (mean age, 14.4 years [11-19 years)]) and followed up for a mean period of 17.2 years (12-23 years). Radiographical parameters and clinical outcomes were compared between patients treatment with the end vertebra (EV) instrumented (n=14) and those treated by short fusion (S group) with instrumentation starting at the vertebra one level caudal to the EV (n=16 patients). There were no study-specific biases related to conflicts of interest. RESULTS In the EV group, a mean preoperative Cobb angle of 56° was corrected to 5° after surgery and to 8° at the final follow-up. In the S group, a mean preoperative Cobb angle of 55° was corrected to 10° after surgery and 14° at the final follow-up. The mean correction rate at the final follow-up was significantly lower in the S group (74%) than in the EV group (86%; p=.020). The coronal and sagittal balance, thoracic kyphosis, lumbar lordosis, and clinical outcomes evaluated using SRS-22 did not differ between the two groups. CONCLUSIONS The short fusion strategy, which involves instrumentation of the vertebra one level caudal to the upper EV, can be considered as an alternative to the conventional strategy, which includes instrumentation of the upper EV, for treating Lenke 5C curves via anterior spinal fusion.
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Affiliation(s)
- Hideki Sudo
- Department of Orthopaedic Surgery, Hokkaido University Hospital, North-15, West-7, Sapporo, Hokkaido 060-8638, Japan.
| | - Kiyoshi Kaneda
- Department of Orthopaedic Surgery, Orthopaedic Hokushin Hospital, Kikusuimotomachi 3-3, Sapporo, Hokkaido 003-0823, Japan
| | - Yasuhiro Shono
- Department of Orthopaedic Surgery, Japan Community Health Care Organization Hokkaido Hospital, Nakanoshima 1-8 Sapporo, Hokkaido 062-8618, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Hokkaido University Hospital, North-15, West-7, Sapporo, Hokkaido 060-8638, Japan
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