Choosing Fusion Levels in Progressive Thoracic Idiopathic Scoliosis

Knapp, D. Raymond; Price, Charles T.; Jones, Eric T.; Coonrad, Ralph W.; Flynn, Joseph C.

doi:10.1097/00007632-199210000-00006

Cited by 44 publications

(23 citation statements)

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“…In other words, surgeons do not agree on which curves are structural and therefore need to be included in the fusion. This is reflected by current controversies in the literature regarding the definition of a structural upper thoracic [20,21,42,44] or lumbar curve [19,21,34,36]. We suspect that part of the disagreement can also be explained by the well documented inter-observer variability of current surgical classification systems [8,22,24,35].…”

Section: Discussionmentioning

confidence: 99%

“…Despite numerous clinical publications [4,5,18,19,23,30,31,33,37,43], there is no clear consensus on the preferred instrumentation system to use and even less consensus on the optimal operative plan for each curve type with modern multi-segmental instrumentation systems. Selection of the appropriate fusion levels remains one of the most challenging decisions in scoliosis surgery, and many guidelines have been proposed.…”

Section: Introductionmentioning

confidence: 99%

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Variability of spinal instrumentation configurations in adolescent idiopathic scoliosis

2006

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Surgical instrumentation for the correction of adolescent idiopathic scoliosis (AIS) is a complex procedure involving many difficult decisions (i.e. spinal segment to instrument, type/location/number of hooks or screws, rod diameter/ length/shape, implant attachment order, amount of rod rotation, etc.). Recent advances in instrumentation technology have brought a large increase in the number of options. Despite numerous clinical publications, there is still no consensus on the optimal surgical plan for each curve type. The objective of this study was to document and analyse instrumentation configuration and strategy variability. Five females (12-19 years) with AIS and an indication for posterior surgical instrumentation and fusion were selected. Curve patterns were as follows: two right thoracic (Cobb: 34°, 52°), two right thoracic and left lumbar (Cobb T/L: 57°/45°, 72°/70°) and 1 left thoraco-lumbar (Cobb: 64°). The pre-operative standing posteroanterior and lateral radiographs, supine side bending radiographs, a three-dimensional (3D) reconstruction of the spine, pertinent 3D measurements as well as clinical information such as age and gender of each patient were submitted to six experienced independent spinal deformity surgeons, who were asked to provide their preferred surgical planning using a posterior spinal approach. The following data were recorded using the graphical user interface of a spine surgery simulator (6·5 cases): implant types, vertebral level, position and 3D orientation of implants, anterior release levels, rod diameter and shape, attachment sequence, rod rotation (angle, direction), adjustments (screw rotation, contraction/distraction), etc. Overall, the number of implants used ranged from 11 to 26 per patient (average 16; SD ±4). Of these, 45% were mono-axial screws, 31% multi-axial screws and 24% hooks. At one extremity of the spectrum, one surgeon used only mono-axial screws, while at the other, another surgeon used 81% hooks. The selected superior-and inferior-instrumented vertebrae varied up to six and five levels, respectively (STD 1.2 and 1.5). A top-tobottom attachment sequence was selected in 61% of the cases, a bottom-up in 29% and an alternate order in 11%. The rod rotation maneuver of the first rod varied from 0°(no rotation) to 140°, with a median at 90°. In conclusion, a large variability of instrumentation strategy in AIS was documented within a small experienced group of spinal deformity surgeons. The exact cause of this large variability is unclear but warrants further investigation with multicenter outcome studies as well as experimental and computer simulation studies. We hypothesize that Eur Spine J (2007) 16: 57-64

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Variability of spinal instrumentation configurations in adolescent idiopathic scoliosis

2006

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“…Poor outcomes are related with progression of the unfused lumbar curve below a selective fusion [42,43], overcorrection of the thoracic curve [30,44,45], poor choice of fusion levels [42,47,56,57], incorrect identification of curve patterns [30,58], lumbar curve magnitude or stiffness [30,52], and relative position and rotation of the apical vertebrae [30,59]. In a study following patient outcomes with a minimum 5 years follow-up after selective thoracic fusion, the overall revision rate to accommodate worsening deformity was 6% (2/32 patients) [60].…”

Section: Postoperative Complicationsmentioning

confidence: 99%

Selective fusion for adolescent idiopathic scoliosis: a review of current operative strategy

Fischer

Kim

2011

Eur Spine J

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Selective fusion of thoracic and thoracolumbar/ lumbar curves in adolescent idiopathic scoliosis is a concept critically debated in the literature. While some surgeons strongly believe that a more rigid and straighter spine provides predictably excellent outcomes, some surgeons recommend a mobile and less straight spine. This topic is a crucial part of surgical treatment of idiopathic scoliosis, particularly in young patients who will deal with the stress of the fusion mass at the proximal and distal junctions over many years. This study will review the literature on various aspects of selective fusion.

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“…Such studies discuss stable and neutral vertebrae, coronal tilt of end vertebrae, selective thoracic fusion, and a variety of additional parameters that can be measured on straight and side bending radiographs [13][14][15][16]. There is a paucity of studies which analyze how to restore appropriate lumbar lordosis.…”

Section: Introductionmentioning

confidence: 99%

Analysis of risk factors for loss of lumbar lordosis in patients who had surgical treatment with segmental instrumentation for adolescent idiopathic scoliosis

et al. 2013

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Purpose Iatrogenic flattening of lumbar lordosis in patients with adolescent idiopathic scoliosis (AIS) was a major downside of first generation instrumentation. Current instrumentation systems allow a three-dimensional scoliosis correction, but flattening of lumbar lordosis remains a significant problem which is associated with decreased healthrelated quality of life. This study sought to identify risk factors for loss of lumbar lordosis in patients who had surgical correction of AIS with the use of segmental instrumentation. Methods Patients were included if they had surgical correction for AIS with segmental pedicle screw instrumentation Lenke type 1 or 2 and if they had a minimum follow-up of 24 months. Two groups were created, based on the average loss of lumbar lordosis. The two groups were then compared and multivariate analysis was performed to identify parameters that correlated to loss of lumbar lordosis. Results Four hundred and seventeen patients were analyzed for this study. The average loss of lumbar lordosis at 24 months follow-up was an increase of 10°lordosis for group 1 and a decrease of 15°for group 2. Risk factors for loss of lumbar lordosis included a high preoperative lumbar lordosis, surgical decrease of thoracic kyphosis, and the particular operating surgeon. The lowest instrumented vertebra or spinopelvic parameters were two of many parameters that did not seem to influence loss of lumbar lordosis. Conclusion This study identified important risk factors for decrease of lumbar lordosis in patients who had surgical treatment for AIS with segmental pedicle screw instrumentation, including a high preoperative lumbar lordosis, surgical decrease of thoracic kyphosis, and factors attributable to a particular operating surgeon that were not quantified in this study.

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Choosing Fusion Levels in Progressive Thoracic Idiopathic Scoliosis

Cited by 44 publications

References 0 publications

Variability of spinal instrumentation configurations in adolescent idiopathic scoliosis

Variability of spinal instrumentation configurations in adolescent idiopathic scoliosis

Selective fusion for adolescent idiopathic scoliosis: a review of current operative strategy

Analysis of risk factors for loss of lumbar lordosis in patients who had surgical treatment with segmental instrumentation for adolescent idiopathic scoliosis

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