Distal Adding-On Phenomenon in Lenke IA and Lenke IIA: Risk Analysis and Selection of the Lowest Instrumented Vertebra

Li, Yaobin; Bai, Hao; Liu, Chenxin; Zhao, Yan; Yan, Feng; Li, Tianqing; Wang, Xingli; Zhang, Yang; Lei, Wei; Xiong, Zhi‐Gang; Wu, Zixiang

doi:10.1016/j.wneu.2019.12.087

Cited by 11 publications

(8 citation statements)

References 23 publications

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“…Regarding the adverse surgical outcomes, the rate of AO was 9.7% (seven of the 72 patients) in this study, which was lower than the AO rates (13.8%–51.1%) following STF reported in previous studies [ 2 , 5 – 7 , 31 , 32 ]. Reports have shown high rates of AO because most studies only examined Lenke type 1A curves, in which distal AO most frequently occurs, and included hybrid constructs (pedicle screw and hooks) with inferior correction powers than all-pedicle screw constructs.…”

Section: Discussioncontrasting

confidence: 86%

“…Possible adverse outcomes following STF include the progression of unfused lumbar curves, the occurrence of distal adding-on (AO), and decompensation [2,3]. In some studies, the level of the lowest instrumented vertebra (LIV), along with its axial rotation, has been widely discussed as an important factor associated with the aforementioned adverse outcomes [4][5][6][7][8].…”

Section: Introductionmentioning

confidence: 99%

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The Use of High-Density Pedicle Screw Construct with Direct Vertebral Derotation of the Lowest Instrumented Vertebra in Selective Thoracic Fusion for Adolescent Idiopathic Scoliosis: Comparison of Two Surgical Strategies

et al. 2023

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This study was a retrospective case series. Purpose: This study was designed to determine whether direct vertebral rotation (DVR) of the lowest instrumented vertebra (LIV) using a high-density (HD) construct can reduce fusion segments without increasing adverse outcomes in selective thoracic fusion (STF) for adolescent idiopathic scoliosis (AIS). Overview of Literature: LIV DVR is used to maximize spontaneous lumbar curve correction and reduce adverse outcomes during STF for AIS. However, evidence is limited on whether LIV DVR can allow a proximally located LIV and reduce fusion segments without increasing adverse outcomes. Methods: We reviewed consecutive patients with Lenke 1 AIS who underwent STF from 2000 to 2017. The patients were divided into two groups based on the surgical strategy used: low-density (LD) construct without DVR of the LIV (LD group) versus HD construct with DVR of the LIV (HD group). We collected data on the patient's demographic characteristics, skeletal maturity, operative data, and measured radiological parameters in the preoperative and final follow-up radiographs. The occurrence of adding-on (AO) and coronal decompensation was also determined. Results: In this study, 72 patients (five males and 67 females) with a mean age of 14.1±2.3 years were included. No significant differences in the demographics, skeletal maturity, and Lenke type distribution were observed between the two groups; however, the follow-up duration was significantly longer in the LD group (64.3±25.7 months vs. 40.7±22.2 months, p<0.001). The HD group had significantly shorter fusion segments (7.1±1.3 vs. 8.5±1.2, p<0.001) and a more proximal LIV level (12.1±0.9 vs. 12.7±1.0, p=0.009). In the radiological measurements, the improvement of LIV+1 rotation (Nash-Moe scale) was significantly larger in the HD group (0.53±0.51 vs. 0.21±0.41, p=0.008). AO and decompensation occurred in 7 (9.7%) and 4 (5.6%) patients in the HD and LD groups, respectively, without any significant difference between the two groups. Conclusions: In this study, the HD group had a significantly shorter fusion level and a more proximal LIV than the LD group; however, the two groups had similar curve correction and adverse radiological outcome rates.

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Section: Discussioncontrasting

confidence: 86%

Section: Introductionmentioning

confidence: 99%

The Use of High-Density Pedicle Screw Construct with Direct Vertebral Derotation of the Lowest Instrumented Vertebra in Selective Thoracic Fusion for Adolescent Idiopathic Scoliosis: Comparison of Two Surgical Strategies

et al. 2023

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“…In previous studies, it has been shown that inappropriate LIV selection, larger LIV translation, and skeletal immaturity were common risk factors for postoperative distal adding-on in patients diagnosed as Lenke 1A and 2A AIS [ 15 , 20 , 21 ]. Therefore, during the surgical procedures, it may be critical to horizontalize the LIV and minimize the LIV translation to prevent postoperative distal adding-on [ 21 ].…”

Section: Discussionmentioning

confidence: 99%

Distal adding-on after surgery in Lenke 5C adolescent idiopathic scoliosis: clinical and radiological outcomes

Hua

Liao

et al. 2022

BMC Musculoskelet Disord

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Background To evaluate the incidence and risk factors of postoperative distal adding-on in patients with Lenke 5C adolescent idiopathic scoliosis (AIS). More accurate selection criteria for the lower instrumented vertebra (LIV) should be confirmed to prevent distal adding-on. Methods Forty-six patients with Lenke 5C AIS who underwent posterior fusion were enrolled in the study. Patients were allocated into adding-on and no adding-on groups. Demographic data, clinical data, and radiographic parameters were recorded and compared. Results Postoperative distal adding-on occurred in eight patients (17.4%) during follow-up. Demographic data, clinical data, and baseline radiographic parameters of the two groups were not significantly different. The postoperative thoracolumbar (TL) or lumbar (L) Cobb angle, LIV translation, and LIV + 1 translation were higher in the adding-on group than those in the no adding-on group, while the postoperative coronal imbalance of the adding-on group was lower than that of the no adding-on group. The level difference of last barely touched vertebra (LBTV) and last substantial touched vertebra (LSTV) with LIV were higher in the adding-on group than in the no adding-on group. Conclusion Postoperative TL/L curve, postoperative LIV translation, postoperative LIV + 1 translation, and postoperative coronal imbalance were determined as risk factors for postoperative distal adding-on in patients with Lenke 5C AIS. Moreover, LIV selection of LBTV-1 or LSTV-1 may cause a higher risk of postoperative distal adding-on.

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“…As shown in previous study, inappropriate selection of LIV, larger LIV translation, and skeletal immaturity rise the risk for postoperational distal adding-on effect, especially in Lenke 1A and 2A AIS. 25,26 Moreover, it has been reported 23 that there is higher risk of unsatisfactory clinical outcomes in the L3 group than in the L4 group. In addition, Hyun et al 27 reported that adding-on phenomenon and DJK is more likely prevalent after anterior spinal fusion than after posterior spinal fusion, even if the LIV in both groups were L3.…”

Section: Discussionmentioning

confidence: 99%

Lowest Instrumented Vertebra at L3 Versus L4 in Posterior Fusion for Moderate Lenke 5C Type Adolescent Idiopathic Scoliosis: A Case-Match Radiological Study

Li,

Du,

Zhao

et al. 2023

Neurospine

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Objective: To compare the radiological outcomes in Lenke 5C type patients whose lowest instrumented vertebra (LIV) was L3 or L4 in a case-match study.Methods: We conducted a retrospective case-match study and included 82 patients in the study. Radiological results before surgery, after surgery, and at last follow-up were recorded and analyzed in the L3 and L4 groups.Results: After matching the age, Risser’s sign, sex, and main Cobb, 41 pairs of patients were enrolled in our study. The total fusion segments in the L3 group (median [interquartile range]: 5.0 [6.0–5.0]) were shorter than those in the L4 group (6.0 [6.5–6.0]). The main curve was significantly corrected after surgery in both groups, and was comparable at the last followup between groups. In addition, according to the results of Fisher precision probability test, there was no significant difference of coronal or sagittal imbalance between the 2 groups at the 2-year follow-up.Conclusion: The correction in coronal and sagittal planes in L3 group and L4 group remains similar. On account of more motion segments, L3 could be an ideal choice as LIV in moderate Lenke 5C type AIS. Long-term follow-up is needed to evaluate the effect of larger compensatory lumbar-sacral curve when stopping at L3.

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Distal Adding-On Phenomenon in Lenke IA and Lenke IIA: Risk Analysis and Selection of the Lowest Instrumented Vertebra

Cited by 11 publications

References 23 publications

The Use of High-Density Pedicle Screw Construct with Direct Vertebral Derotation of the Lowest Instrumented Vertebra in Selective Thoracic Fusion for Adolescent Idiopathic Scoliosis: Comparison of Two Surgical Strategies

The Use of High-Density Pedicle Screw Construct with Direct Vertebral Derotation of the Lowest Instrumented Vertebra in Selective Thoracic Fusion for Adolescent Idiopathic Scoliosis: Comparison of Two Surgical Strategies

Distal adding-on after surgery in Lenke 5C adolescent idiopathic scoliosis: clinical and radiological outcomes

Lowest Instrumented Vertebra at L3 Versus L4 in Posterior Fusion for Moderate Lenke 5C Type Adolescent Idiopathic Scoliosis: A Case-Match Radiological Study

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