Becker Spine Review One Level Fusion at Apex of Scoliosis

Eur Spine J. 2011 Jul; twenty(7): 1048–1057.

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

Charla R. Fischer

622 Westward 168th Street, PH11-1130, New York, NY 10032 USA

Yongjung Kim

622 West 168th Street, PH11-1130, New York, NY 10032 Us

Received 2009 Dec 6; Revised 2011 Jan 18; Accepted 2011 Feb eleven.

Abstruse

Selective fusion of thoracic and thoracolumbar/lumbar curves in boyish 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 handling 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 report volition review the literature on various aspects of selective fusion.

Keywords: Selective fusion, Adolescent idiopathic scoliosis, Spinal fusion, Selective thoracic fusion, Selective thoracolumbar/lumbar fusion, Spinal deformity

Introduction

The surgical treatment of adolescent idiopathic scoliosis (AIS) has made remarkable progress since the development of the Harrington rod in the tardily 1950s [1]. Equally new instrumentation was introduced over the side by side few decades, the ability to correct patients' curves improved significantly. The engineering has changed, but the goals of surgery for AIS remain the same: (1) halt curve progression and correct deformity, (2) maintain a balanced spine in the coronal and sagittal planes, (3) preserve as many mobile spinal segments as possible, and, (4) foreclose surgical complications such as junctional kyphosis, adding-on, and revision surgery [2–11]. Since the publication of the landmark commodity past King et al. [12], some double major curves accept been identified equally containing a structural and a compensatory component. The King Type 2 bend is known equally the "faux double major" pattern, considering the lumbar curve shows less magnitude and more flexibility on side-bending films which suggests that it is a compensatory curve present only to maintain coronal residue in the setting of a stock-still thoracic curve. The King Type Two curve was later reclassified by Lenke et al. [13–xv] as Lenke 1C, 2C, 3C, and 4C curves. Controversy exists over the handling of the compensatory lumbar bend in King Type Ii curves [xv, 16]. Moe recommended selective fusion of the thoracic curve because the lumbar curve in a King Type II curve would undergo spontaneous correction post-obit selective thoracic fusion [4, 12, 17–21]. Recent studies have shown that more flexible compensatory curves are able to correct spontaneously later fusion of the structural curve [3–5, 7, 10, 17, eighteen, 22–27]. Equally pedicle screws began to be used in the thoracic spine, studies showed superior curve correction with all pedicle screw constructs due to the 3 cavalcade fixation of pedicle screws and greater ability to translate and derotate the spine [v, 28]. Dobbs et al. [3] in 2006 found that pedicle screws allowed for better curve correction than hooks for selective thoracic fusion. The majority of spinal deformity surgeons believe that a balanced and mobile lumbar spine without progression of the lumbar curve is meliorate than a straight and stiff lumbar spine. They feel comfortable with selective fusions for a more mobile and less corrected spine considering it is also possible to extend the selective thoracic fusion to the lumbar spine in instances when the lumbar curve is progressing, although the rate of progression requiring fusion is very low in the current published literature. However, some advocated for long fusions including the major thoracic bend and compensatory lumbar curve from the upper thoracic spine to either L3 or L4 for better correction of both curves and too to diminish the take chances of postoperative coronal decompensation, progression of lumbar bend, adding-on, junctional kyphosis, and eventual revision surgery. Selective fusion is a concept that has developed over this controversy and is defined in this review as isolated thoracic fusion with Lenke 1C, 2C, some 3C, and some 4C curves also as isolated thoracolumbar/lumbar curves in Lenke 5C and some 6C curves.

One of the cardinal features of the Lenke nomenclature system is the ability for the classification to guide surgeons in handling. Each Lenke curve blazon indicates which role of the spine should undergo fusions. In patients with Lenke Blazon 1C curves, but the thoracic curve should undergo fusion by classification. Yet many surgeons prefer to fuse both curves. One study showed that selective thoracic fusion was performed in 62% of patients with Lenke 1C curves [14]. This written report found that both the thoracic and lumbar curves are fused in 38% of the Lenke 1C curves. This outcome is contradictory to the recommendations provided past the Lenke nomenclature and thus the Lenke lumbar C modifier was termed a "dominion breaker". Some other study by Newton et al. [29] showed that five AIS centers in the The states varied between 6 and 67% for selective thoracic fusions for Lenke 1C curves.

The difficulty now lies in determining which patients should undergo selective fusion and which vertebrae should be included in the fusion. There are many parameters that must exist considered when evaluating a patient for selective fusion of either the main thoracic or thoracolumbar/lumbar curves including patient lifestyle and expectation besides as guidelines for selective fusion, fusion levels, amount of curve correction, and potential complications. The purpose of this written report is to review the literature to make up one's mind the guidelines for selective fusion in boyish idiopathic scoliosis.

Criteria of selective thoracic fusion

The goal of selective thoracic fusions in Lenke 1C, 2C, 3C, and 4C curves is to allow for as many mobile vertebral segments as possible while still achieving spontaneous correction of minor curves [10]. The Male monarch–Moe Blazon Two curve is an s-shaped double curve pattern that comprised right thoracic and left lumbar curves which cross the midline (the apical vertebrae of each curve are past the midline) and the thoracic curve is equal to or larger and more rigid than the lumbar curve [12]. Moe recommended selective thoracic fusion if the lumbar curve is more than flexible and smaller. Lenke and Bridwell [30] reported that the Rex–Moe definition of a Blazon II curve was not sufficient to recommend selective thoracic fusion and delineated more strict radiographic guidelines for selective thoracic fusion. Their criteria included relative upmost vertebral translation, apical vertebral rotation, Cobb angle, and flexibility of the 2 curves as well as sagittal plane assessment of the thoracolumbar junction.

The most important factors to decide whether or not to perform selective thoracic fusion consist of patient lifestyle and clinical patient status including activity level, age, and preference to sports. Some patients such every bit professional dancers or athletes require more than lumbar flexibility for their action and thus require selective thoracic fusion if indicated [17, 22]. The patient and family unit demand to understand the potential for lumbar bend progression, junctional problems, and revision surgery to extend the fusion. Concrete examination such as Adams frontward angle test is very important. Thoracic rotational prominence should exist larger than the lumbar prominence with a scoliometer. Flexibility on thumb abduction testing is besides important. If a patient is very flexible, a selective fusion may non be a good pick.

Radiographic criteria proposed by Lenke et al. are to be considered more when evaluating a patient for possible selective thoracic fusion. The thoracic apical vertebral translation (AVT) is the distance between the C-seven plumb line and the center of the apical vertebral body of the thoracic curve (Fig.ane). The thoracolumbar/lumbar AVT is the altitude between the center of the upmost vertebral body of the thoracolumbar/lumbar curve and the middle sacral vertebral line. A ratio of thoracic AVT to thoracolumbar/lumbar AVT larger than ane.2 indicates a more translated (xx% or more than) thoracic curve that may be treated with selective thoracic fusion [10, 22, 31, 32]. The second factor that helps to determine if selective thoracic fusion is viable is apical vertebral rotation (AVR). This is based on the Nash–Moe grading for vertebral rotation based on the radiographic pedicle appearance of the thoracic or thoracolumbar/lumbar upmost vertebrae [33]. A ratio of thoracic AVR to thoracolumbar/lumbar AVR greater than ane.ii suggests that the thoracic curve is more than rotated (20% or more than) than the thoracolumbar/lumbar curve, and thus may undergo selective thoracic fusion [10, 22, 31, 32]. This radiographic rotation may be replaced by a scoliometric measurement mentioned to a higher place. The third gene is the magnitude of the curves on Cobb measurements. The thoracic Cobb angle must be larger (20% or more) than the thoracolumbar/lumbar Cobb angle past a suggested ratio of ane.ii [ten, 22, 31, 32]. The lumbar curve which is non-structural with side angle to less than 25° and a sagittal kyphosis T10–L2 of less than 20° is a ameliorate candidate [13, sixteen]. A more flexible thoracolumbar/lumbar curve is one that volition spontaneously correct upon selective fusion of the thoracic spine [22, 31]. Still, Behensky et al. [34] showed relatively non-flexible thoracolumbar/lumbar curves with side bending to more than 25°, Lenke 3C curves, spontaneously correct. They constitute that of 21 patients in Lenke 3C curves who met 2 or 3 out of 3 of the above criteria had skilful postoperative coronal remainder and outcomes. They did non perform selective fusion in patients with lumbar Cobb angles greater than lx°. Relative ratio of AVT is known to be the most of import factor for good outcomes among the three radiographic parameters. Selective fusion of the thoracic spine is possible in Lenke 3C curves if AVT, AVR or Cobb ratio is larger [34]. A 4th variable to consider is the sagittal plane remainder. The thoracolumbar junctional angle betwixt T10 and L2 should be less than ten°. The sagittal disc angle beneath the instrumented vertebrae should exist lordotic [15, xxx]. Skeletal maturity is also important. Closure of the triradiate cartilage is very of import in preventing postoperative progression of the lumbar spine and junctional decompensation [31].

The thoracic apical vertebral translation (A) is the distance between the center of the thoracic apical vertebra (A) and the C7 plumb line (solid line). The lumbar apical vertebral translation (B) is the altitude between the eye of the lumbar apical vertebra and central sacral vertical line (dashed line)

These various factors for selective fusion of thoracic curves are summarized in Tabular arrayi. The level of evidence for these recommendations are based on mostly level IV evidence instance series studies that report outcomes after treatment as sited above. There are no studies that compare outcomes to controls nor are there randomized command trials.

Table 1

Factors for selective fusion of thoracic curves

AVT apical vertebral translation, AVR upmost vertebral rotation, LIV lowest instrumented vertebra, TL/Fifty thoracolumbar/lumbar, LEV lower end vertebrae

Determination of fusion levels for selective thoracic fusion

Once a patient is determined for selective fusion, the next pace is to determine which levels need to be fused. Selection of the ideal everyman instrumented vertebrae (LIV) is crucial in preventing distal junctional problems such as adding-on or distal junctional kyphosis. However it is however important to retain equally many mobile vertebral segments every bit possible. Goldstein [35] noted that the fusion should oftentimes be extended to the neutral vertebra to preclude future adding-on of the curve. Male monarch et al. [25] identified the stable and neutral vertebra as the advisable area to end a fusion for faux double major curve. The majority of studies have shown satisfactory outcomes when the LIV is at the stable and neutral vertebra [3, 5, 7, 17, 20, 36, 37]. Ane study showed a significantly increased risk of lumbar decompensation when the fusion did not end at the stable and neutral vertebra, and decompensation occurred at a rate of 22% [four].

In that location are some patients with Lenke 1C curves that accept a meaning pre-operative trunk shift toward the left side. This ways that the stable vertebra by the eye sacral line is located around the thoracic apex and ending the fusion construct around the thoracic apex would lead to poor outcomes. In this situation, Goldstein's recommendation of ending the fusion at neutral or ane vertebra distal to the neutral vertebra may be an option for selective thoracic fusion, not to extend the fusion to the lower lumbar spine and retain a mobile lumbar spine.

Other factors that contribute to LIV choice include the sagittal balance and patient skeletal maturity. A sagittal kyphosis at the thoracolumbar junction (T10–L2) of less than 20° and a lordotic disc angle below the LIV is important to forbid distal junctional kyphosis [x, 38]. Additionally, closure of the triradiate cartilage is important to prevent calculation-on and distal junctional bug [36].

Selection of the uppermost instrumented vertebra (UIV) is also important for shoulder residuum and proximal junctional kyphosis. The important pre-operative factors are standing shoulder balance (left high, level, and right loftier), structurality of the proximal thoracic bend, sagittal thoracic kyphosis at T2–T5, and instrumentation technique. If the left shoulder is high, so the UIV should be T2 in Lenke 2C curves or 2 vertebra proximal to the upper terminate vertebra in Lenke 1C curves [39]. Preservation of the thoracic kyphosis or an intra-operative increase of thoracic kyphosis is of import to prevent proximal junctional kyphosis [40]. Surgical technique is as well an important component to forbid junctional kyphosis. Distraction of the concave side of the curve rather than compression of convex side at the UIV is better to forestall proximal junctional kyphosis [41].

The corporeality of correction for selective thoracic fusion

Bend correction is another aspect of selective thoracic fusion that is frequently debated. Although spontaneous lumbar curve correction occurs consistently post-obit 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 beneath a selective thoracic fusion [42, 43] due to lack of compensatory lumbar bend correction [30, 44–49]. Information technology has been hypothesized that the unfused lumbar compensatory bend cannot compensate for excessive correction of the master thoracic bend and this therefore results in coronal decompensation [eight, fifty, 51]. Richards et al. [8] reported less postoperative spontaneous correction of the lumbar curves than shown on pre-operative flexibility radiographs (27 compared to 70%, respectively) in King Blazon Ii curves with Cotrel–Dubousset instrumentation. The thoracic curve was corrected to 48% of pre-operative bend in this study, which may explain why the lumbar bend was unable to spontaneously correct more 27%. Roye et al. [51] also reported significantly less correction of the lumbar curves than of the thoracic curves (38 compared to 50%, respectively). Lumbar curve magnitude or stiffness also correlates to decreased correction of the lumbar bend and lumbar curve decompensation [30, 52]. As a upshot of these and other studies, the pre-operative push-prone and supine lumbar radiographs were recommended as the best cess of pre-operative flexibility imaging to predict the ideal amount of thoracic bend correction and expected spontaneous lumbar curve correction [53].

In dissimilarity, several studies have shown spontaneous correction of the lumbar curve between 60 to 81%, which corresponded to the 61–83% correction of the thoracic curve [37, 54, 55]. They did not notice a correlation between over correction of the thoracic curve and decreased spontaneous correction of the lumbar bend. 1 report states that newer intra-operative techniques using pedicle screws may accept an enhanced capacity to control spontaneous correction of the lumbar spine which exceeds the pre-operative flexibility radiographic correction amount [37]. They accept constitute up to 83% correction of the thoracic spine and 81% spontaneous correction of the lumbar spine when pre-operative flexibility imaging showed a spontaneous lumbar correction of 66%.

Thompson et al. [44] studied the influence of rod rotation for correction of the major curve on the secondary bend in computed tomography scans. They concluded that patients who underwent rod derotation techniques for selective fusion of the primary thoracic curve demonstrated decreased spontaneous correction of the secondary lumbar curve. This and so led to a larger size of the secondary lumbar bend and later progression of this curve beneath their selective thoracic fusion. The rod derotation maneuver led to their reported 75% decompensation in King Type Ii curves. This is more mutual in those patients with larger and more deviated lumbar curves. However, Suk et al. [37] showed that the rod derotation maneuver did not lead decompensation.

Postoperative complications

Preservation of global coronal and sagittal balance is key to ensure good patient outcomes for all spinal deformity surgery, and coronal residual is at greater hazard than sagittal residue in selective thoracic fusion. When the C7 plumb line is left of the curve pre-operatively, the coronal residual will increase to the left postoperatively since the spontaneous lumbar correction comes generally from the proximal lumbar spine and not the distal lumbar spine [8].

Several studies examined the trouble of postoperative coronal decompensation and found a prevalence of four to 41% [46, 51]. 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 [thirty, 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 subsequently selective thoracic fusion, the overall revision rate to accommodate worsening deformity was 6% (ii/32 patients) [sixty]. In this study, 12 patients were considered marginal radiographic outcomes due to: xvi% (v/32) with LIV more than three cm translation from the CSVL, 12.5% (4/32) with worsening lumbar AVT compared to pre-op, iii% (1/32) with worsening lumbar AVT compared to pre-op, 16% (v/32) with distal junctional kyphosis more than than 10° increased from pre-op, and six% (2/32) with lumbar Cobb angle more than 5° from pre-op. These results are consistent with previous reports in the literature [17, 36, 61].

Selective thoracolumbar/lumbar fusion

While the studies examining the selective fusion of thoracolumbar/lumbar curves are much fewer in number, it is no less feasible. The lack of literature on this topic may be due to the fact that extending a fusion from the lumbar spine to the thoracic spine does non lead to the same amount of motion loss as extending a fusion from the thoracic to the lumbar spine. Regardless, many of the aforementioned considerations as for selective thoracic fusion apply to selective thoracolumbar/lumbar fusions such as conscientious choice of fusion levels, correction corporeality, and potential complications. Lenke Type 5 and six curves are thoracolumbar/lumbar major curves with small thoracic curves [13, 15, 16]. If the thoracic bend side bends to less than 25° and the T10–L2 kyphosis is less than 20°, it is classified as Lenke Blazon 5 curve and selective thoracolumbar/lumbar fusion is possible. However, even if the thoracic curve side bends to more than 25° and the T10–L2 kyphosis is more than 20° (Lenke Type 6), selective thoracolumbar/lumbar fusion is even so possible if they encounter the criteria.

In 2003, Sanders et al. [62] examined the criteria necessary for successful selective anterior fusion of thoracolumbar/lumbar curves. They followed 49 patients for 2 years after selective anterior thoracolumbar/lumbar fusion and adamant that a thoracic curve of less than 40° was necessary for a satisfactory consequence. The best predictor of successful outcome was skeletal maturity as adamant by the triradiate cartilage. Also predictive of a satisfactory consequence was thoracolumbar/lumbar to thoracic Cobb ratio of greater than ane.25, thoracolumbar/lumbar bend 55° or less, and/or a thoracic curve side-bending Cobb measurement of 20° or less. These factors for good outcomes after selective fusion of thoracolumbar/lumbar curves are shown in Table2. Similar to the recommendations listed in Tableane, the studies for Table2 are level four show based on case series reports.

Table two

Factors for selective fusion of thoracolumbar/lumbar curves

AVT apical vertebral translation, AVR apical vertebral rotation, UIV uppermost instrumented vertebra, TL/L thoracolumbar/lumbar

Schulte et al. [27] in 2006 studied the spontaneous vertebral derotation of secondary curves. They found a significant spontaneous derotation of lumbar curves afterwards selective anterior thoracic fusion. Yet for selective anterior thoracolumbar/lumbar fusion, in that location was an increase in the rotation of the compensatory thoracic curve. A spontaneous thoracic correction of 36% was shown in this study. Li et al. [63] followed patients after selective lumbar fusion in Lenke 5C curves. They found an average of 57% lumbar bend correction and 26% thoracic curve correction with a minimum 2 twelvemonth follow-upwards.

Conclusion

Selective fusion of thoracic or thoracolumbar/lumbar curves in C lumbar modifiers is a way to provide balanced curve correction while leaving the maximum number of mobile vertebral segments. The majority of studies demonstrated satisfactory outcomes based upon patient activity level, curve grapheme such as curve magnitude, flexibility, rotation, translation and sagittal profile, and skeletal maturity. Poor patient selection, option of the incorrect fusion levels, and inadequate correction can lead to progressive deformity, calculation-on, shoulder imbalance, and worsening trunk rotation. Virtually of the literature on this subject field comes from level iv studies that are example serial and higher level comparison studies would be beneficial to decision making. Further research is needed to evaluate the long-term outcomes of selective anterior or posterior instrumentation methods.

Conflict of interest

None.

Appendix: Case presentation

Example i

North.P. is a 17-year-old female with idiopathic scoliosis. Pre-operative standing AP radiograph showed a right thoracic curve of 56° and a left thoracolumbar curve of 52° that bent downwardly to 4° on side-angle films. The thoracic apical vertebral rotation was two and the lumbar apical vertebral rotation was 2. The thoracic upmost vertebral translation was 37 mm and the lumbar apical vertebral translation was 32 mm. Pre-operative continuing lateral radiograph showed thoracic kyphosis at T5–T12 7° and lumbar lordosis T12–S1 at 80°. Scoliometer measurement showed a thoracic bending of 14° and lumbar angle of 5°. She also has an L5/S1 grade two spondylolisthesis. She underwent selective thoracic fusion from T4–T11 and postoperative thoracic curve of 35° and lumbar curve of 29° (Fig.2).

Selective thoracic fusion for Lenke 1CN curve

Case ii

T.F. is a 13-year-old boy with an idiopathic scoliosis. Pre-operative standing AP radiograph showed a right thoracic curve of 47° and a left thoracolumbar curve of eighty°. The lumbar upmost vertebral rotation at T13 was 40° and thoracic apical vertebral rotation at T7 was 5°, according to Perdriolle. The thoracic apical vertebral translation was 18 mm and the lumbar upmost vertebral translation was 77 mm. The C7 plumb line was 44 mm toward the left side. Pre-operative standing lateral radiograph showed thoracic kyphosis at T5–T12 of 3°, thoracolumbar kyphosis at T10–L2 of 23°, and lumbar lordosis at T12–S1 of 42°. The left side bender of the thoracolumbar bend was 58° and the right side bender was 22°. He also had a left-side merely synostosis of L5–S1. His curve is a 6C according to the Lenke classification system. He underwent posterior osteotomy at L5–S1 and selective posterior thoracolumbar instrumentation and fusion at T10–L3 and presented at 12 months follow-up with satisfactory frontal and sagittal spinal alignment (Fig.3).

Selective thoracolumbar fusion for Lenke 6C curve

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3176697/

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