Surgical treatment of Lenke 5 adolescent idiopathic scoliosis: Comparison of anterior vs posterior approach

Is the anterior approach still superior to posterior correction in AIS regarding correction, fusion levels and kyphosis when modern posterior systems are used?

PURPOSE

The aim of our study is to compare anterior and posterior corrections of thoracic (Lenke I) and lumbar (Lenke V) curves when modern posterior pedicle screw systems with vertebral derotation techniques are used. Curves that could not be corrected with both systems were excluded.

METHODS

A thoracic group (N = 56) of Lenke I AIS patients (18 anterior and 38 posterior) and a lumbar group (N = 42) of Lenke V patients (14 anterior and 28 posterior) with similar curves < 65° were identified.

RESULTS

Thoracic group The mean postoperative correction (POC) was 68 ± 13.4% in the anterior and 72 ± 10.5% in the posterior group. The postoperative change in thoracic kyphosis was +4° and +5° respectively. The median length of fusion was eight segments in the posterior and seven segments in the anterior groups. In 89% the LIV was EV or shorter in the anterior, and in 71% of the posterior corrections. Lumbar group The mean POC was 75 ± 18.3% (anterior) and 72 ± 8.5% (posterior). The postoperative gain in lumbar lordosis was 0.8° (anterior) and 4° (posterior). The median length of fusion was five segments in both groups and there was no difference in relation of the LIV to the EV.

CONCLUSION

With modern implants and derotation techniques, the posterior approach can achieve similar coronal correction, apical derotation and thoracic kyphosis with similar length of fusion and better lumbar lordosis restoration.

Development of Notch-Free, Pre-Bent Rod Applicable for Posterior Corrective Surgery of Thoracolumbar/Lumbar Adolescent Idiopathic Scoliosis

Adolescent idiopathic scoliosis (AIS), the most common pediatric musculoskeletal disorder, causes a three-dimensional spine deformity. Lenke type 5 AIS is defined as a structural thoracolumbar/lumbar curve with nonstructural thoracic curves. Although a rod curvature will affect clinical outcomes, intraoperative contouring of the straight rod depends on the surgeon's knowledge and experience. This study aimed to determine the optimum rod geometries to provide a pre-bent rod system for posterior spinal surgery in patients with Lenke type 5 AIS. These pre-bent rods will be beneficial for achieving proper postoperative outcomes without rod contouring based on surgeon experience. We investigated 20 rod geometries traced in posterior spinal reconstruction in patients with Lenke type 5 AIS. The differences between the center point clouds in each cluster were evaluated using the iterative closest point (ICP) method with modification. Before the evaluation using the ICP method, the point clouds were divided into four clusters based on the rod length using a hierarchical cluster analysis. Because the differences in the values derived from the ICP method were <5 mm for each length-based cluster, four representative rod shapes were generated from the length-based clusters. We identified four optimized rod shapes that will reduce operation time, leading to a decreased patient and surgeon burden.

Association Between Lenke Classification, The Extent of Lumbar Spinal Fusion, and Health-Related Quality of Life After Instrumented Spinal Fusion for Adolescent Idiopathic Scoliosis

STUDY DESIGN

Prospective cohort study.

SUMMARY OF BACKGROUND DATA

Lenke classification is used to define the curve type in adolescent idiopathic scoliosis (AIS). The association of Lenke classification and long-term postoperative health-related quality of life (HRQoL) remains unclear.

OBJECTIVE

The purpose of this study was to assess the association between Lenke classification and HRQoL in patients who underwent spinal fusion for AIS.

MATERIALS AND METHODS

In all, 146 consecutive patients (mean age 15.1 yr) operated for AIS between 2007 and 2019 with a minimum 2-year follow-up were included. Fifty-three (36%) patients reached the 10-year follow-up. Their HRQoL was assessed with the SRS-24 questionnaire preoperatively, at six months, two years, and 10 years after surgery.

RESULTS

The preoperative major curve was the largest in Lenke 3 (mean 63 ° ) and 4 (mean 62 ° ) groups and the lowest in Lenke 5 groups (mean 48 ° , P <0.05). These curves were corrected to a mean of 15 ° with no differences between groups. We found no evidence of differences between the preoperative HRQoL scores between the Lenke groups. The self-image domain of SRS-24 was lower in patients with isolated major thoracolumbar scoliosis (Lenke 5) when compared with double-thoracic (Lenke 2) group at the two-year follow-up (mean [95% CI] 3.6 [3.3-3.9] vs. 4.3 [4.1-4.6]). The postoperative satisfaction domain was lower in Lenke 5 group when compared with main thoracic (Lenke 1) group (mean [95% CI] 3.8 [3.5-4.0] vs. 4.3 [4.2-4.5]) and Lenke 2 group (mean 4.4, 95% CI 4.2-4.6) at the two-year follow-up. The mean total score of SRS-24 at the 10-year follow-up was highest in Lenke 1 group (mean 4.06, 95% CI 3.79-4.33) and lowest in Lenke 6 group (mean 2.92, 95% CI 2.22-3.61).

CONCLUSIONS

Lenke classification and especially its curve type (major thoracic vs. major thoracolumbar scoliosis) was associated with long-term health-related quality of life after instrumented spinal fusion for AIS.

How to make a more optimal surgical plan for Lenke 5 adolescent idiopathic scoliosis patients: a comparative study based on the changes of the sagittal alignment and selection of the lowest instrumented vertebra

BACKGROUND

The treatment of patients with Lenke 5 adolescent idiopathic scoliosis (AIS) is closely related to the pelvic because the spine-pelvis is an interacting whole. Besides, the choice of fusion segment is a significant issue; with the optimal choice, there will be fewer complications and restoring the pelvic morphology to some extent. This study aims to analyze the impact of changes in sagittal parameters and selection of the lowest instrumented vertebra (LIV) on spine and pelvic morphology for better surgical strategy.

METHOD

Ninety-four patients with Lenke 5 AIS who underwent selective posterior thoracolumbar/lumbar (TL/L) curve fusion were included in the study and grouped according to pelvic morphology and position of LIV. Spinopelvic parameters were measured preoperatively, postoperatively, and at the latest follow-up. The patient's preoperative and last follow-up quality of life was assessed with the MOS item short-form health survey (SF-36) and scoliosis research society 22-item (SRS-22).

RESULT

Patients being posterior pelvic tilt had the oldest mean age (P = 0.010), the smallest lumbar lordosis (LL) (P = 0.036), the smallest thoracic kyphosis (TK) (P = 0.399) as well as the smallest proximal junctional angle (PJA) while those being anterior pelvic tilt had the largest PJA. The follow-up TK significantly increased in both groups of anterior and normal pelvic tilt (P < 0.039, P < 0.006) while no significant changes were observed in the posterior pelvic tilt group. When LIV is above L4, the follow-up PJA was larger than other groups (P = 0.049, P = 0.006). When LIV is below L4, the follow-up TK and PT were larger and LL was smaller than other groups(P < 0.05). The SF-36 and SRS-22 scores were better in the LIV = L4 group than in other groups at the last follow-up (P < 0.05).

CONCLUSION

The correction of TK and LL after surgery can improve pelvic morphology. Besides, LIV is best set at L4, which will facilitate the recovery of TK, the improvement of symptoms, and the prevention of complications and pelvic deformities. Level of evidence Level III.

Ten-year follow-up of Lenke 5 curves treated with spinal fusion

INTRODUCTION

Patients with surgically treated Lenke 5 curves require at least partial fusion of the lumbar spine. The implications of lumbar fusion remain unknown as long-term follow-up is sparse.

METHODS

A retrospective review of a prospectively collected registry of patients with Lenke 5 curves treated with spinal fusion was performed. Clinical and radiographic outcomes as well as SRS-22 scores were collected at 2- and 10-year follow-up.

RESULTS

54 of 247 available patients met all inclusion criteria [26 treated with posterior spinal fusion (PSF) and 28 with anterior spinal fusion (ASF)]. Preoperative lumbar curve magnitude was 45.1 ± 8.4° and corrected to 14.0 ± 7.2° (p < 0.001). A 3.3 ± 7.3° increase in curve size was noted at final follow-up (p < 0.008) with 20.3% of patients having a loss of correction (LOC)of 10° or more. Thoracic curve correction and kyphosis were stable at 10-year follow-up. End vertebrae angulation improved from 11.2 ± 23.2° to 0.96 ± 6.4° (p = 0.004) and translation improved from 2.5 ± 2.9 to 0.92 ± 1.5 cm (p = 0.008) with no LOC. Disc wedging below the lower instrumented vertebrae increased from 0.3 ± 4.9° to 2.8 ± 4.4° (p < 0.001) with no change at 10 years. SRS-22 self-image and satisfaction improved from post-operative to final follow-up. No patient required a second operation.

CONCLUSIONS

Both ASF and PSF showed durable results at 10-year follow-up with no obvious difference between approaches. 20% of patients had a LOC > 10°; this did not correlate with pain or need for revision surgery. Disc wedging was stable. Selection of LIV did not correlate with pain scores.

LEVEL OF EVIDENCE

Level III.

Long-Term Follow-up of Posterior Selective Thoracolumbar/Lumbar Fusion in Patients With Lenke 5C Adolescent Idiopathic Scoliosis: An Analysis of 10-Year Outcomes

STUDY DESIGN

Retrospective study.

OBJECTIVE

The aim of this study was to assess long-term radiographic and clinical outcomes in Lenke 5C adolescent idiopathic scoliosis (AIS) patients after posterior selective fusion.

METHODS

Lenke 5C AIS patients who underwent posterior selective thoracolumbar/lumbar (TL/L) fusion in our hospital from January 2007 to January 2010 were recruited. Radiographic parameters were measured preoperatively and at the 3-month, 1-year, 2-year, 5-year, and 10-year follow-ups. The SRS-22 (Scoliosis Research Society) questionnaire was used to assess the clinical outcomes.

RESULTS

We included 37 patients who underwent posterior selective TL/L fusion surgery in our study, and the mean follow-up time was 11.26 ± 0.85 years. The average preoperative Cobb angles of the thoracic and TL/L curves were 24.0 ± 9.0° and 45.4 ± 6.3°, respectively, which were corrected to 12.2° and 12.4° at the 3-month follow-up postoperatively, with correction losses of 2.2° and 1.5° at the 10-year follow-up. In the sagittal plane, the degree of thoracic kyphosis (TK) gradually increased over the follow-up period. The proximal junctional angle (PJA) also gradually increased from 6.7 ± 4.6 to 13.7 ± 5.6 during the follow-up period. For the clinical outcomes, correction surgery improved the SRS-22 scores in each domain, especially in the self-image domain.

CONCLUSIONS

Posterior selective TL/L fusion can effectively correct spinal deformities, leading to stable outcomes for 10 years postoperatively. During the follow-up period, the degree of TK presented an increasing trend that remained almost constant after the 1-year follow-up. Moreover, the variation in the PJA was highly significant in the postoperative period, and it showed an increasing trend until the 2-year follow-up.

Scoliosis: Causes and Treatments

Scoliosis is an abnormal curvature of the spine, which generally develops during childhood or adolescence. It affects 2–4 percent of the global population and is more prevalent among girls. Scoliosis is classified by its etiology: idiopathic, congenital, or neuromuscular. Among these, the former is the most common. Treatment options for scoliosis vary depending on the severity of the curve. Most scoliosis diagnoses tend to be mild and only require monitoring. However, curves between 20 and 40 degrees require bracing, while 40 degrees and above require surgery. There are various bracings available, such as Boston, Charleston, and Milwaukee. In severe cases of scoliosis, either fusion or fusionless surgery may be required. This review aims to discuss etiologies and different treatment interventions for scoliosis.

Anterior versus posterior spinal fusion for Lenke type 5 adolescent idiopathic scoliosis: a systematic review and meta-analysis of comparative studies

PURPOSE

To review and compare clinical and radiologic outcomes between anterior spinal fusion (ASF) and posterior spinal fusion (PSF) for the treatment of Lenke type 5 adolescent idiopathic scoliosis (AIS).

METHODS

A systematic review was performed according to Preferred reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. All level I-III evidence studies investigating the clinical and radiologic outcomes of ASF and PSF for the treatment of Lenke type 5 AIS were included.

RESULTS

Nine studies (285 ASF patients, 298 PSF patients) were included. ASF was associated with a significantly lower number of levels fused compared with PSF (p < 0.01) with similar immediate and long-term coronal deformity correction (p = 0.16; p = 0.12, respectively). PSF achieved a better correction of thoracic hypokyphosis in one study and lumbar hypolordosis in three studies. PSF was associated with a significant shorter length of stay (LOS) compared with ASF (p < 0.01). One long-term study demonstrated a significantly higher rate of proximal junctional kyphosis (PJK) with PSF compared with ASF. There were no significant differences in major complication or re-operation rates.

CONCLUSION

For the treatment of Lenke type 5 AIS, there is moderate evidence to suggest that ASF requires a lower number of instrumented levels to achieve similar immediate and long-term coronal deformity correction compared with PSF. There is some evidence to suggest that PSF may achieve better thoracic and lumbar sagittal deformity correction compared with ASF. There is some evidence to suggest a higher incidence of PJK at long-term follow-up with PSF compared with ASF. ASF is associated with a longer post-operative LOS compared with PSF.

C-Arm-Free Anterior Correction for Adolescent Idiopathic Scoliosis (Lenke Type 5C): Analysis of Early Outcomes and Complications

BACKGROUND

Computer-assisted spinal surgery as a technique for reducing radiation exposure to the operating staff and the complications of spinal deformity are receiving considerable attention. However, no technical reports have described the technique for navigating anterior correction of adolescent idiopathic scoliosis without C-arm fluoroscopy. The purpose of this study was to evaluate the efficacy and safety of this new C-arm-free anterior correction for scoliosis.

METHODS

This study investigated 38 consecutive patients with Lenke type 5C curves who underwent selective lumbar or thoracolumbar fusion, comprising 26 patients with conventional anterior correction surgery, and 12 patients with C-arm-free navigation surgery. The 2 groups were evaluated immediately postoperatively and at the 2-year follow-up.

RESULTS

No vascular injuries, screw malpositioning, or major complications were associated with the surgical procedure in either group. Correction rates of the lumbar curve were satisfactory with no significant difference between groups (mean, 82.6% ± 5.7% vs. 80.7% ± 10.2%, respectively). However, mean time for fluoroscopy in group C was 133 ± 9.5 seconds (P < 0.0001). No significant differences in intraoperative blood loss (642 ± 123 mL vs. 731 ± 222 mL, respectively) or surgical time (251 ± 13 min vs. 301 ± 38 min, respectively) were seen between groups. Mean final follow-up Scoliosis Research Society Outcomes Questionnaire (SRS-22) was also excellent for both group C (4.2 ± 0.19) and group N (4.3 ± 0.20).

CONCLUSIONS

C-arm-free anterior correction offers safe, effective surgery for adolescent idiopathic scoliosis. The advantage of this new technique is no radiation exposure for medical staff at centers performing large numbers of spinal procedures.

Current concepts in the diagnosis and management of adolescent idiopathic scoliosis

BACKGROUND

Adolescent Idiopathic Scoliosis (AIS) is a complex 3D structural disorder of the spine that has a significant impact on a person's physical and emotionalstatus. Thus, efforts have been made to identify the cause of the curvature and improve management outcomes.

AIM

This comprehensive review looks at the relevant literature surrounding the possible aetio-pathogenesis of AIS, its clinical features, investigations, surgicalmanagement options, and reported surgical outcomes in anterior spinal fusion, posterior spinal fusion or combined approach in the treatment of AIS.

Thoraco-abdominal neuroblastoma resection: the thoracophrenolaparotomic (TPL) approach

OBJECTIVE

The aim of the present study is to describe, for the first time in paediatric age, the technique and the outcomes of the thoracophrenolaparotomic (TPL) approach for surgical resection of thoraco-abdominal neuroblastomas (NBs) in children.

METHODS

A retrospective study was performed analysing clinical features and surgical outcomes of all children undergoing surgical resection of thoraco-abdominal NBs via the TPL approach in our third referral children's hospital, from January 2010 to November 2018. The details of the surgical technique were also reported.

RESULTS

5 children suffering from thoraco-abdominal NBs (n = 4 stage L2, n = 1 stage M-according to the International Neuroblastoma Risk Group Staging System, INRGSS-and n = 4 stage 3, n = 1 stage 4-according to International Neuroblastoma Staging System, INSS) underwent the TPL approach at a mean age of 72 months (range 27-180 months). The surgical procedure was performed in a mean operative time of 5 h 57 min (range 2 h 56 min-9 h) without any major intraoperative or postoperative complications. Following 24 h in intensive care unit, all patients were safely discharged in a mean time of 12 days (range 4-21 days). All patients were alive, without any tumour relapse, at the last follow-up visit (mean 3.2 years, range 1-7 years).

CONCLUSION

This is the first study reporting the excellent surgical results we gained applying the TPL approach for surgical excision of multi-compartment tumours in children, allowing a gross total resection without intra- or post-operative complications.

Surgical Treatment of Lenke Type 5 Adolescent Idiopathic Scoliosis: A Systematic Review

STUDY DESIGN

A systematic review.

OBJECTIVE

To systemically review the previous literature regarding surgical treatment of Lenke type 5 adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

The Lenke classification was published in 2001 as the classification of AIS. Since then, numerous articles have been published reporting the outcomes of surgical treatment of Lenke type 5 AIS.

METHODS

The electronic databases PubMed, EMBASE, and Web of Science were queried up to Aug 2018 for articles regarding surgical treatment of Lenke type 5 AIS. Surgical variables, radiographic assessments, and clinical outcomes of surgical treatment of Lenke type 5 AIS were summarized.

RESULTS

Fifty studies met the inclusion criteria. The average fused levels, % correction of thoracolumbar/lumbar curve at final follow-up, and % correction of thoracic curve at final follow-up for anterior and posterior procedures were reported to be 3.6-5.3 and 4.3-7.8 levels, 53-86 and 55-94% and 17-52 and 19-67%, respectively. Average coronal balance was imbalanced (≥20 mm) at preoperation in 22/43 reporting study groups and balanced (<20 mm) at final follow-up in all 37 reporting study groups. Scoliosis Research Society Version 22 scores showed no difference between anterior and posterior procedures in most of the reporting studies (5/6).

CONCLUSION

Overall, the outcomes of surgical treatment of Lenke type 5 AIS are excellent. The thoracic curve was spontaneously corrected after surgery and coronal balance after surgery was better than before surgery. Both anterior and posterior procedures demonstrated satisfactory outcomes.

LEVEL OF EVIDENCE

4.

The Ecuador Pediatric Spine Deformity Surgery Program: An SRS-GOP Site, 2008-2016

STUDY DESIGN

Retrospective case series.

OBJECTIVES

The purpose of this study is to (1) describe the development of our Spinal Deformity Program; (2) assess the surgical outcomes, including health-related quality of life (HRQOL), radiographic measures, and complications; and (3) explore predictors for HRQOL outcomes.

SUMMARY OF BACKGROUND DATA

The Scoliosis Research Society (SRS) is very interested in international program site development to provide safe surgical care for children in low- and middle-income countries (LMICs). There is a need for reporting program development and outcomes from these sites. After several years of building local relations and infrastructure, our program started performing spine surgery in 2008.

METHODS

All operations were performed at Roberto Gilbert Elizalde Children's Hospital in Guayaquil, Ecuador. At a minimum of two years and average of four years postoperatively, patients received a clinical evaluation, radiographs, and the Spanish SRS-22r questionnaire.

RESULTS

Twenty-eight (74%) of the 38 children who received spine surgery between May 2008 and 2015 are included in this study. Twenty-three (82%) were female with an average age of 14 years at the time of surgery and 18 years at follow-up. The mean total SRS-22r score was 4.3 and mean percentage major curve correction was 57%. Curve location was found to be a significant predictor of postoperative SRS-22r scores with double curves having poorer scores (p = .004). Two complications were pseudarthrosis and postoperative delayed paraplegia, both of which resolved after revision surgery. No infections or other long-term complications have occurred.

CONCLUSIONS

The development of equitable surgical care for all children is a primary goal of the SRS. Undertaking the task to perform surgery in LMIC comes with the responsibility to monitor and maintain the highest quality. Our program was safely developed to address the surgical needs of children with good midterm HRQOL outcomes, adequate radiographic curve correction, and no permanent complications.

LEVEL OF EVIDENCE

Level IV.

Current concepts in the surgical management of adolescent idiopathic scoliosis

Adolescent idiopathic scoliosis (AIS) is a complex 3D deformity of the spine. Its prevalence is between 2% and 3% in the general population, with almost 10% of patients requiring some form of treatment and up to 0.1% undergoing surgery. The cosmetic aspect of the deformity is the biggest concern to the patient and is often accompanied by psychosocial distress. In addition, severe curves can cause cardiopulmonary distress. With proven benefits from surgery, the aims of treatment are to improve the cosmetic and functional outcomes. Obtaining correction in the coronal plane is not the only important endpoint anymore. With better understanding of spinal biomechanics and the long-term effects of multiplanar imbalance, we now know that sagittal balance is equally, if not more, important. Better correction of deformities has also been facilitated by an improvement in the design of implants and a better understanding of metallurgy. Understanding the unique character of each deformity is important. In addition, using the most appropriate implant and applying all the principles of correction in a bespoke manner is important to achieve optimum correction.

In this article, we review the current concepts in AIS surgery.

Cite this article: Bone Joint J 2018;100-B:415–24.

Five major controversial issues about fusion level selection in corrective surgery for adolescent idiopathic scoliosis: a narrative review

BACKGROUND CONTEXT

Shoulder imbalance, coronal decompensation, and adding-on phenomenon following corrective surgery in patients with adolescent idiopathic scoliosis are known to be related to the fusion level selected. Although many studies have assessed the appropriate selection of the proximal and distal fusion level, no definite conclusions have been drawn thus far.

PURPOSE

We aimed to assess the problems with fusion level selection for corrective surgery in patients with adolescent idiopathic scoliosis, and to enhance understanding about these problems.

STUDY DESIGN

This study is a narrative review.

METHODS

We conducted a literature search of fusion level selection in corrective surgery for adolescent idiopathic scoliosis. Accordingly, we selected and reviewed five debatable topics related to fusion level selection: (1) selective thoracic fusion; (2) selective thoracolumbar-lumbar (TL-L) fusion; (3) adding-on phenomenon; (4) distal fusion level selection for major TL-L curves; and (5) proximal fusion level selection and shoulder imbalance.

RESULTS

Selective fusion can be chosen in specific curve types, although there is a risk of coronal decompensation or adding-on phenomenon. Generally, wider indications for selective fusions are usually associated with more frequent complications. Despite the determination of several indications for selective fusion to avoid such complications, no clear guidelines have been established. Although authors have suggested various criteria to prevent the adding-on phenomenon, no consensus has been reached on the appropriate selection of lower instrumented vertebra. The fusion level selection for major TL-L curves primarily focuses on whether distal fusion can terminate at L3, a topic that remains unclear. Furthermore, because of the presence of several related factors and complications, proximal level selection and shoulder imbalance has been constantly debated and remains controversial from its etiology to its prevention.

CONCLUSIONS

Although several difficult problems in the diagnosis and treatment of adolescent idiopathic scoliosis have been resolved by understanding its mechanism and via technical advancement, no definite guideline for fusion level selection has been established. A review of five major controversial issues about fusion level selection could provide better understanding of adolescent idiopathic scoliosis. We believe that a thorough validation study of the abovementioned controversial issues can help address them.