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L3 translation predicts when L3 is not distal enough for an “ideal” result in Lenke 5 curves

  • Lee Phillips
  • Burt YaszayEmail author
  • Tracey P. Bastrom
  • Suken A. Shah
  • Baron S. Lonner
  • Firoz Miyanji
  • Amer F. Samdani
  • Stefan Parent
  • Jahangir Asghar
  • Patrick J. Cahill
  • Peter O. Newton
Original Article

Abstract

Purpose

Determining whether to fuse a Lenke 5 curve to L3 or to L4 is often a difficult decision. The purpose of this study was to determine preoperative variables predictive of an “ideal” or “less than ideal” outcome for Lenke 5 curves instrumented to L3.

Methods

A multicentre registry of adolescent idiopathic scoliosis patients was queried for surgically treated Lenke 5 curves with a lowest instrumented vertebra (LIV) of L3 and minimum 2 years of follow-up. Five seasoned surgeons qualitatively rated the 2-year postoperative images as “ideal” or “less than ideal” with respect to correction and alignment. Preoperative and postoperative radiographic variables were compared between the two groups. Multivariate regression analysis was performed to determine variables most predictive of a “less than ideal” outcome.

Results

One hundred and thirty-nine patients met criteria. Twenty-three were considered “less than ideal” by ≥ 3 surgeons; 81 were unanimously “ideal”. Preoperatively, the “less than ideal” group had significantly stiffer curves, greater apical translation, and greater LIV angulation and translation. Multivariate regression found that preoperative L3 translation (p = 0.009) was the single most important predictor of a “less than ideal” outcome: < 3.5 cm consistently resulted in an “ideal” outcome, while > 3.5 cm risked a “less than ideal” result.

Conclusion

While multiple variables are important in achieving an “ideal” outcome in Lenke 5 curves, this study found preoperative L3 translation was the most important predictor of success with an L3 translation < 3.5 cm being a potential threshold for selecting L3 as the LIV.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.

Keywords

Adolescent idiopathic scoliosis Thoracolumbar/lumbar curve Lenke 5 Lowest instrumented vertebra Fusion 

Notes

Acknowledgements

A research Grant to Setting Scoliosis Straight Foundation from DePuy Synthes Spine was received for Harms Study Group research.

Compliance with ethical standards

Conflict of interest

Dr. Phillips has nothing to disclose. Dr. Yaszay reports grants from Setting Scoliosis Straight Foundation, during the conduct of the study; grants and personal fees from K2M, grants and personal fees from DePuy Synthes Spine, personal fees from Nuvasive, personal fees from Medtronic, personal fees from Orthopediatrics, personal fees from Stryker, personal fees from Globus, grants from Setting Scoliosis Straight Foundation, outside the submitted work; In addition, Dr. Yaszay has a patent K2M with royalties paid. Ms. Bastrom reports grants from Setting Scoliosis Straight Foundation to her institution, during the conduct of the study. Dr. Shah reports grants from Setting Scoliosis Straight Foundation, during the conduct of the study; personal fees from DePuy Synthes Spine, grants from Setting Scoliosis Straight Foundation, personal fees from Nuvasive, outside the submitted work. Dr. Lonner reports grants from Setting Scoliosis Straight Foundation, during the conduct of the study; grants from Setting Scoliosis Straight Foundation, personal fees from DePuy Synthes Spine, personal fees from K2M, personal fees from Paradigm Spine , personal fees from Spine Search , personal fees from Ethicon, non-financial support from Spine Deformity Journal, grants from John and Marcella Fox Fund Grant , grants from OREF , personal fees from Zimmer Biomet, personal fees from Apifix, outside the submitted work. Dr. Miyanji reports grants from Setting Scoliosis Straight Foundation, during the conduct of the study. Dr. Samdani reports grants from Setting Scoliosis Straight Foundation, during the conduct of the study; personal fees from DePuy Synthes Spine, personal fees from Ethicon, personal fees from Globus Medical, personal fees from Misonix, personal fees from Stryker, personal fees from Zimmer Biomet, other from Setting Scoliosis Straight Foundation, other from Scoliosis Research Society, other from Children's Spine Study Group, outside the submitted work. Dr. Parent reports grants and personal fees from EOS Imaging, grants and personal fees from Spinologics, grants, personal fees and other from DePuy Synthes Spine, grants, personal fees and other from Metronic, personal fees from K2M, other from Scoliosis Research Society, other from Canadian Spine Society, grants from Canadian Institutes of Health Research, grants from Canadian Foundation for Innovation, grants from Natural Sciences and Engineering Council of Canada, grants from Fonds de Recherche Quebec - Sante, grants from Orthopedic Research and Education Foundation, grants from Setting Scoliosis Straight Foundation, outside the submitted work. Dr. Asghar reports grants from Setting Scoliosis Straight Foundation, during the conduct of the study; personal fees and non-financial support from Omega innovative Technologies, personal fees from Life Spine, personal fees from Globus Medical, outside the submitted work. Dr. Cahill reports personal fees from Biogen, Inc., personal fees from NuVasive, Inc. , outside the submitted work; and AAOS: Board or committee memberÐournal of Bone and Joint Surgery - American: Editorial or governing boardÐediatric Orthopaedic Society of North America: Board or committee memberÐcoliosis Research Society: Board or committee memberÐpine Deformity: Editorial or governing board. Dr. Newton reports grants from Setting Scoliosis Straight Foundation, during the conduct of the study; grants and other from Setting Scoliosis Straight Foundation, other from Rady Children's Specialists, grants, personal fees and non-financial support from DePuy Synthes Spine, grants and other from SRS, grants from EOS imaging, personal fees from Thieme Publishing, grants from NuVasive, other from Electrocore, personal fees from Cubist, other from International Pediatric Orthopedic Think Tank, grants, non-financial support and other from Orthopediatrics, grants, personal fees and non-financial support from K2M, grants and non-financial support from Alphatech, outside the submitted work; In addition, Dr. Newton has a patent Anchoring systems and methods for correcting spinal deformities (8540754) with royalties paid to DePuy Synthes Spine, a patent Low profile spinal tethering systems (8123749) licensed to DePuy Spine, Inc., a patent Screw placement guide (7981117) licensed to DePuy Spine, Inc., a patent Compressor for use in minimally invasive surgery (7189244) licensed to DePuy Spine, Inc., and a patent Posterior spinal fixation pending to K2M.

Ethical approval

IRB approval was received for this study.

Supplementary material

586_2019_5960_MOESM1_ESM.pptx (8.7 mb)
Supplementary material 1 (PPTX 8898 kb)

References

  1. 1.
    Lenke LG, Betz RR, Harms J, Bridwell KH, Clements DH, Lowe TG, Blanke K (2001) Adolescent idiopathic scoliosis: a new classification to determine extent of spinal arthrodesis. J Bone Jt Surg Am 83-A:1169–1181CrossRefGoogle Scholar
  2. 2.
    Suk SI, Lee SM, Chung ER, Kim JH, Kim WJ, Sohn HM (2003) Determination of distal fusion level with segmental pedicle screw fixation in single thoracic idiopathic scoliosis. Spine (Phila Pa 1976) 28:484–491.  https://doi.org/10.1097/01.brs.0000048653.75549.40 Google Scholar
  3. 3.
    Ilharreborde B, Ferrero E, Angelliaume A, Lefevre Y, Accadbled F, Simon AL, de Gauzy JS, Mazda K (2017) Selective versus hyperselective posterior fusions in Lenke 5 adolescent idiopathic scoliosis: comparison of radiological and clinical outcomes. Eur Spine J 26:1739–1747.  https://doi.org/10.1007/s00586-017-5070-2 CrossRefGoogle Scholar
  4. 4.
    Li J, Hwang SW, Shi Z, Yan N, Yang C, Wang C, Zhu X, Hou T, Li M (2011) Analysis of radiographic parameters relevant to the lowest instrumented vertebrae and postoperative coronal balance in Lenke 5C patients. Spine (Phila Pa 1976) 36:1673–1678.  https://doi.org/10.1097/brs.0b013e3182091fba CrossRefGoogle Scholar
  5. 5.
    Rose PS, Lenke LG (2007) Classification of operative adolescent idiopathic scoliosis: treatment guidelines. Orthop Clin North Am 38(521–529):vi.  https://doi.org/10.1016/j.ocl.2007.06.001 Google Scholar
  6. 6.
    Akazawa T, Kotani T, Sakuma T, Minami S, Orita S, Inage K, Fujimoto K, Shiga Y, Torii Y, Umehara T, Iinuma M, Kuroya S, Niki H, Ohtori S, Takahashi K (2017) Modic changes and disc degeneration of non-fused segments 27 to 45 years after harrington instrumentation for adolescent idiopathic scoliosis: comparison to healthy controls. Spine.  https://doi.org/10.1097/brs.0000000000002362 Google Scholar
  7. 7.
    Rinella A, Bridwell K, Kim Y, Rudzki J, Edwards C, Roh M, Lenke L, Berra A (2004) Late complications of adult idiopathic scoliosis primary fusions to L4 and above: the effect of age and distal fusion level. Spine 29:318–325CrossRefGoogle Scholar
  8. 8.
    Kim SS, Lim DJ, Kim JH, Kim JW, Um KS, Ahn SH, Suk SI (2014) Determination of the distal fusion level in the management of thoracolumbar and lumbar adolescent idiopathic scoliosis using pedicle screw instrumentation. Asian Spine J 8:804–812.  https://doi.org/10.4184/asj.2014.8.6.804 CrossRefGoogle Scholar
  9. 9.
    Wang Y, Bunger CE, Zhang Y, Wu C, Li H, Dahl B, Hansen ES (2013) Lowest instrumented vertebra selection for Lenke 5C scoliosis: a minimum 2-year radiographical follow-up. Spine (Phila Pa 1976) 38:E894–E900.  https://doi.org/10.1097/brs.0b013e31829537be CrossRefGoogle Scholar
  10. 10.
    Barsi J, Caprio B, Garg S, Baulesh D, Erickson M (2015) Do intraoperative LIV-tilt and disk angle remain stable at 2-year follow-up compared with upright radiographs in patients with idiopathic scoliosis?: A retrospective cohort study. J Spinal Disord Tech 28:264–269.  https://doi.org/10.1097/BSD.0b013e3182aa4c4b CrossRefGoogle Scholar
  11. 11.
    Koller H, Meier O, Hitzl W (2014) Criteria for successful correction of thoracolumbar/lumbar curves in AIS patients: results of risk model calculations using target outcomes and failure analysis. Eur Spine J 23:2658–2671.  https://doi.org/10.1007/s00586-014-3405-9 CrossRefGoogle Scholar
  12. 12.
    Sun Z, Qiu G, Zhao Y, Wang Y, Zhang J, Shen J (2014) Lowest instrumented vertebrae selection for selective posterior fusion of moderate thoracolumbar/lumbar idiopathic scoliosis: lower-end vertebra or lower-end vertebra + 1? Eur Spine J 23:1251–1257.  https://doi.org/10.1007/s00586-014-3276-0 CrossRefGoogle Scholar
  13. 13.
    Hu B, Yang X, Yang H, Liu L, Chen P, Wang L, Zhu C, Zhou C, Song Y (2018) Coronal imbalance in Lenke 5C adolescent idiopathic scoliosis regarding selecting the lowest instrumented vertebra: lower end vertebra versus lower end vertebra +1 in posterior fusion. World Neurosurg 117:e522–e529.  https://doi.org/10.1016/j.wneu.2018.06.070 CrossRefGoogle Scholar
  14. 14.
    Morrissy RT, Goldsmith GS, Hall EC, Kehl D, Cowie GH (1990) Measurement of the Cobb angle on radiographs of patients who have scoliosis. Evaluation of intrinsic error. J Bone Jt Surg Am 72:320–327CrossRefGoogle Scholar
  15. 15.
    Schulz J, Asghar J, Bastrom T, Shufflebarger H, Newton PO, Sturm P, Betz RR, Samdani AF, Yaszay B (2014) Optimal radiographical criteria after selective thoracic fusion for patients with adolescent idiopathic scoliosis with a C lumbar modifier: does adherence to current guidelines predict success? Spine (Phila Pa 1976) 39:E1368–E1373.  https://doi.org/10.1097/brs.0000000000000580 CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Lee Phillips
    • 1
    • 2
  • Burt Yaszay
    • 3
    Email author
  • Tracey P. Bastrom
    • 3
  • Suken A. Shah
    • 4
  • Baron S. Lonner
    • 5
  • Firoz Miyanji
    • 6
  • Amer F. Samdani
    • 7
  • Stefan Parent
    • 8
  • Jahangir Asghar
    • 9
  • Patrick J. Cahill
    • 10
  • Peter O. Newton
    • 3
  1. 1.Children’s Orthopaedics and Scoliosis Surgery AssociatesSaint PetersburgUSA
  2. 2.University of South Florida OrthopaedicsTampaUSA
  3. 3.Rady Children’s HospitalSan DiegoUSA
  4. 4.Alfred I. duPont Hospital for ChildrenWilmingtonUSA
  5. 5.Scoliosis and Spine AssociatesNew YorkUSA
  6. 6.British Columbia Children’s HospitalVancouverCanada
  7. 7.Shriner’s Hospital for ChildrenPhiladelphiaUSA
  8. 8.Sainte-Justine University Hospital CenterMontrealCanada
  9. 9.Nicklaus Children’s HospitalMiamiUSA
  10. 10.Children’s Hospital of PhiladelphiaPhiladelphiaUSA

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