The Behavior of the Unfused Lumbar Curve Following Selective Thoracic Fusion for Idiopathic Scoliosis

Kalen, Vicki; Conklin, Matthew M.

doi:10.1097/00007632-199004000-00004

Cited by 53 publications

(24 citation statements)

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“…When comparing postoperative radiographic parameters between STF and NSTF, the overall correction is similar with respect to MT Cobb angles and MT:TL/L ratios. Given the trend seen in the literature, 17,20 it is expected that the STF group has a correction of the TL/L curve that mirrors that of the MT curve. Unfortunately, due to the limited sample data available, additional radiographic parameters were not analyzed.…”

Section: Discussionmentioning

confidence: 96%

“…Despite the initially promising experiences with STF, postoperative spinal imbalance and progression of the unfused lumbar curve is nevertheless reported. 3,20,38,43 With the evolution of spinal instrumentation and surgical techniques, STF has been shown to provide successful correction of the thoracic curve with spontaneous correction of the uninstrumented lumbar curve to allow for a well-balanced postoperative spinal column; 5,6,23,32,34,36,40,42 however, the risk for coronal decompensation remains a concern. 1,13,14,24,28,29,31,32,43 The decision to include the lumbar compensatory curve by performing a nonselective thoracic fusion (NSTF) may provide a "safer" option in the context of preventing revision surgery for coronal decompensation.…”

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confidence: 99%

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Selective versus nonselective thoracic fusion in Lenke 1C curves: a meta-analysis of baseline characteristics and postoperative outcomes

Boniello¹,

Hasan²,

Sun³

et al. 2015

SPI

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OBJECT Lenke 1C curves are challenging to manage surgically due to the structural thoracic deformity and nonstructural lumbar curve. Selective thoracic fusion (STF) is considered the standard of care because it preserves motion of the lumbar segment, yet nonselective STF (NSTF) remains prevalent. This study aims to identify baseline patient characteristics that drive treatment and to compare postoperative outcomes for both procedures. METHODS Studies that compared baseline and postoperative demographic data, health-related quality of life (HRQL) questionnaires, and radiographic parameters of patients with Lenke 1C curves undergoing STF or NSTF were identified for meta-analysis. The effect measure is expressed as a mean difference (MD) with 95% CI. A positive MD signifies a greater STF value, or a mean increase within the group. RESULTS One prospective and 6 retrospective case-control studies with sample size of 488 patients (344 STF and 144 NSTF) were identified. Baseline age, sex, and HRQLs were equivalent, except for better scores in the STF group for the Scoliosis Appearance Questionnaire (SAQ): Unrelated to Deformity item (3.47 vs 3.88, p = 0.01) and the Spine Research Society questionnaire, Item 22: Pain (4.13 vs 3.92, p = 0.04). Radiographic findings were significantly worse in NSTF, as measured by the thoracolumbar/lumbar (TL/L) Cobb angle (MD: −4.29°, p < 0.01) and TL/L apical vertebral translation (AVT) (MD: −6.08, p < 0.01). Radiographic findings significantly improved in STF, as measured in the main thoracic (MT) Cobb angle (MD: −27.78°, p < 0.01), TL/L Cobb angle (MD: −16.24°, p < 0.01), MT:TL/L Cobb ratio (MD: −0.21, p < 0.01), coronal balance (MD: 0.47, p = 0.02), and thoracic kyphosis (MD: 7.87°, p < 0.01); and in NSTF in proximal thoracic (PT) Cobb angle (24° vs 14.1°, p < 0.01), MT Cobb angle (53.5° vs 20.5°, p < 0.01), and TL/L Cobb angle (41.6° vs 16.6°, p < 0.01). Postoperative TL/L Cobb angle (23.1° vs 16.6°, p < 0.01) was significantly higher in STF; but PT Cobb angle, MT Cobb angle, and MT:TL/L Cobb ratio are equivalent. CONCLUSIONS Patients with larger lumbar compensatory curves displaying a larger degree of coronal translation, as measured by the TL/L AVT, are more likely to undergo an NSTF. Contrary to established guidelines, larger MT curve magnitudes and MT:TL/L Cobb angle ratios have not been found to influence the decision to pursue a selective thoracic fusion. Although overall both STF and NSTF groups are found to have effective postoperative coronal balance, the STF group has only modest improvements in the lumbar curve position as determined by a relatively unchanged TL/L AVT. Furthermore, surgeons may prefer NSTF in patients who may have a worse overall perception of their spinal deformity as measured by HRQL measures of pain and desire for appearance change.

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Section: Discussionmentioning

confidence: 96%

mentioning

confidence: 99%

Selective versus nonselective thoracic fusion in Lenke 1C curves: a meta-analysis of baseline characteristics and postoperative outcomes

Boniello¹,

Hasan²,

Sun³

et al. 2015

SPI

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“…Although spontaneous lumbar curve correction occurs consistently following a selective thoracic spinal fusion, the degree of correction is somewhat unpredictable. Previous studies have shown that over correction of the thoracic curve is related to progression of the lumbar curve below a selective thoracic fusion [42,43] due to lack of compensatory lumbar curve correction [30,[44][45][46][47][48][49]. It has been hypothesized that the unfused lumbar compensatory curve cannot compensate for excessive correction of the main thoracic curve and this therefore results in coronal decompensation [8,50,51].…”

Section: The Amount Of Correction For Selective Thoracic Fusionmentioning

confidence: 99%

“…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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“…There were many reports on the selective thoracic fusion for idiopathic scoliosis with King II type II [3,7,9,11,14,20]. However, there were few reports on the selective TL/L fusion for double curves with a minor thoracic curve (Lenke type 5) [21,25].…”

Section: Discussionmentioning

confidence: 99%

Radiographic evaluation of selective anterior thoracolumbar or lumbar fusion for adolescent idiopathic scoliosis

Wang

Zeng

et al. 2008

Eur Spine J

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According to Lenke classification of adolescent idiopathic scoliosis (AIS), patients with type 5 curve in which the structural major curve is thoracolumbar or lumbar curve with nonstructural proximal thoracic and main thoracic curves, could be surgically treated with selective anterior thoracolumbar or lumbar (TL/L) fusion. This study retrospectively analyzed the radiographies of selective anterior TL/L fusion in 35 cases of AIS with Lenke type 5 curve. Segmental fixation with a single rigid rod through anterior thoracoabdominal approach was applied in all patients. Measurements of scoliosis curve in preoperative, immediate postoperative and follow-up radiographies were analyzed. The average follow up time was 36 months (24-42 months). The average preoperative Cobb angle of the TL/L curve was 45.6°and improved into 9.7°immediate postoperatively, with 79.7% curve correction. In addition, the minor thoracic curve decreased from 29.7°preopera-tively to 17.6°postoperatively, with a spontaneous correction of 41.5%. During the follow-up, a loss of 4.6°c orrection was found and the average Cobb angle of TL/L increased to 14.4°. Also, the minor thoracic curve increased to average 20.1°with a loss of 2.4°correction. Trunk shift deteriorated slightly immediate postoperatively and improved at the follow-up. The lowest instrumented vertebra (LIV) tilt was improved significantly and maintained its results at the follow-up. During the follow-up, the coronal disc angle immediately above the upper instrumented vertebra (UIVDA) and below the LIV (LIVDA) aggravated, while the sagittal contours of T5-T12 and T10-L2 were well maintained. The lumbar lordosis of L1-S1 and the sagittal Cobb angle of the instrumented segments were reduced slightly postoperatively and at the follow-up. There were no major complications or pseudarthrosis. The outcomes of this study show that selective anterior thoracolumbar or lumbar fusion with solid rod instrumentation is effective for surgical correction of AIS with Lenke type 5 curve. The TL/L curve, minor thoracic curve, and LIV title can be improved significantly, with good maintenance of sagittal contour. However, the UIVDA and LIVDA aggravate postoperatively when the trunk rebalances itself during follow-up. The degeneration of LIV disc warrants longer-term follow-up.

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The Behavior of the Unfused Lumbar Curve Following Selective Thoracic Fusion for Idiopathic Scoliosis

Cited by 53 publications

References 0 publications

Selective versus nonselective thoracic fusion in Lenke 1C curves: a meta-analysis of baseline characteristics and postoperative outcomes

Selective versus nonselective thoracic fusion in Lenke 1C curves: a meta-analysis of baseline characteristics and postoperative outcomes

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

Radiographic evaluation of selective anterior thoracolumbar or lumbar fusion for adolescent idiopathic scoliosis

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