|SYMPOSIUM: ADOLESCENT IDIOPATHIC SCOLIOSIS
|Year : 2020 | Volume
| Issue : 2 | Page : 185-195
Posterior techniques for correcting deformity in adolescent idiopathic scoliosis––How much correction is optimal?
Sean M Rider, Daniel R Rubio, Munish C Gupta
Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
|Date of Submission||01-Oct-2019|
|Date of Decision||02-Dec-2019|
|Date of Acceptance||10-Feb-2020|
|Date of Web Publication||13-Jul-2020|
Dr. Sean M Rider
Department of Orthopedic Surgery, Washington University School of Medicine, 425 S. Euclid Avenue, Suite, St. Louis, MO.
Source of Support: None, Conflict of Interest: None
The optimal surgical treatment of adolescent idiopathic scoliosis is heavily debated in the literature. This study aimed to review posterior surgical techniques in the treatment of adolescent idiopathic scoliosis. Literature review was performed. In treating adolescent idiopathic scoliosis with posterior spine fusion, there are many factors to consider when determining where to start and end the fusion construct: skeletal maturity, stress/bending radiographs, and assessment of vertebral rotation and translation. When considering selective thoracic fusion, the relative magnitudes of the main thoracic (MT) and thoracolumbar/lumbar (TL/L) curves and the overall sagittal profile of the thoracolumbar junction are assessed. Selective thoracic fusion can be appropriate if two of the three are found to be true: the MT-to-TL/L Cobb angle ratio is >1.2, the MT-to-TL/L apical vertebral translation (AVT) ratio is >1.2, and/or the MT-to-TL/L apical vertebral rotation (AVR) ratio is >1.2. Moreover, selective thoracic fusion can be an option in the presence of a nonstructural lumbar curve (bending Cobb angle <25°) with thoracolumbar (T10-L2) kyphosis <20°. When choosing the uppermost and lowest instrumented vertebra, one must consider standing coronal balance and regional kyphosis to lessen risk of postoperative complication. The uppermost instrumented vertebra should be a stable, neutral vertebra with <5° of junctional kyphosis; and the lowest instrument vertebra should be touched by the central sacral vertical line and within two vertebrae proximal to the neutral vertebra. To aid in correction, the addition of posterior surgical releases improves the mobility of spine, especially in more rigid curves, but may increase intraoperative blood loss and operative time. Rod derotation and vertebral translation appear to have similar results in correcting coronal and sagittal deformities. The addition of direct vertebral rotation and segmental rotation plays a role in surgical correction as well.
Keywords: Adolescent idiopathic scoliosis, fusion levels, lowest instrumented vertebra, posterior instrumentation techniques, posterior release, selective thoracic fusion, uppermost instrumented vertebra
Key Messages: Review article discussing posterior surgical techniques in treating adolescent idiopathic scoliosis.
|How to cite this article:|
Rider SM, Rubio DR, Gupta MC. Posterior techniques for correcting deformity in adolescent idiopathic scoliosis––How much correction is optimal?. Indian Spine J 2020;3:185-95
|How to cite this URL:|
Rider SM, Rubio DR, Gupta MC. Posterior techniques for correcting deformity in adolescent idiopathic scoliosis––How much correction is optimal?. Indian Spine J [serial online] 2020 [cited 2020 Aug 10];3:185-95. Available from: http://www.isjonline.com/text.asp?2020/3/2/185/289658
| Introduction|| |
Adolescent idiopathic scoliosis (AIS) is the most common spinal deformity in the pediatric population with a reported prevalence of 1.8%., It is characterized as a three-dimensional (coronal, sagittal, and rotational) deformity of the spine in children between the ages of 10 and 18.,, Radiographic and clinical measures are essential in the management of AIS. These parameters include skeletal maturity, risk of progression, timing and type of intervention, curve location and flexibility, and degree of rotation and curvature.,,,,,
Surgical treatment of AIS was revolutionized in the 1960s when the Harrington rod system was introduced. This instrumentation provided internal fixation for coronal plane correction at times at the expense of sagittal alignment. In early 1980s, Luque rods and sublaminar wires were introduced providing segmental correction with a more rigid construction that reduced the need for external support and immobilization. Boucher was one of the first to publish the report on pedicle screw fixation which later was popularized by Roy-Camille et al. [16,17] In 1984, the Cotrel–Dubousset system was introduced to the United States, which allowed multiple forces to be applied on the same rod through its hook attachments for spinal deformity correction., In 1985, the Isola system (DePuy AcroMed, Raynham, Massachusetts) was introduced using hybrid construct of hooks, sublaminar wire, and pedicles screws. This approach used proximal and distal anchor sites and emphasized segmental apical vertebral translation via fixation of the intervening vertebra to a pre-contoured rod by sublaminar wires. In 1986, Luque was one of the first to publish the report on transpedicular screw instrumentation increasing the stiffness and strength of constructs compared to hooks., Suk et al. popularized the use of pedicle screws to provide better coronal, sagittal, and rotation correction for spinal deformities with shorter fusion lengthens and less loss of correction.
With these advances in instrumentation and use of pedicle screws, many surgical techniques developed including rod de-rotation,, vertebral translation,,, compression–distraction, differential rod contouring, direct vertebral rotation, apical wiring,, and cantilever bending.
After the introduction of the Lenke classification in 2001, surgical treatment of AIS has become more consistent in regard to choosing fusion levels with improved postoperative outcomes.,, However, the optimal level of correction remained heavily debated and depends largely on surgeon training and experience. The goal of posterior spinal fusion for AIS is to achieve a balanced spine in both the sagittal and coronal plane in addition to preserving motion by limiting the length of the fusion.,,
| Choosing Fusion Levels|| |
In the 1960–1970s, Goldstein, discussed the role of the neutral vertebra. Prior to advancements in instrumentation, end-to-end vertebra with neutral rotation was recommended as the ideal upper and lower instrumented vertebra. During the Harrington rod era, King et al. defined that the stable vertebra by central sacral vertebral line was ideal for the lowest instrumented vertebra (LIV).
Selective thoracic fusion with spontaneous coronal correction of the lumbar cure was first described by Moe. In Lenke 1C and 2C curves, choosing between selective thoracic fusion versus nonselective thoracic fusion remains controversial. King et al. recommended selective thoracic fusion for King II (Lenke 1C and 3C) curves with main thoracic curves <80°. More recently, several authors have endorsed selective thoracic fusion for Lenke 3C and 4C curves., Some of the benefits of selective thoracic fusion include lowering perioperative morbidity with shorter operative times, decrease blood loss, and preserved lumbar motion., But selective thoracic fusion in Lenke 1C, 2C, 3C, and 4C curves may be linked with postoperative coronal decompensation, lumbar decompensation, adding-on phenomenon, and thoracolumbar kyphosis., These complications maybe why only approximately 50% of surgeons chose selective thoracic fusion for Lenke 1C curves.
Selecting the correct patient for selective thoracic fusion can be difficult, but there are some published criteria that can help. The goal of selective thoracic fusion for Lenke 1-4C curves is to allow for as many mobile vertebral segments as possible while allowing minor curves to spontaneous correct. As aforementioned, Moe recommended selective thoracic fusion King II/Lenke 1C and 3C when the lumbar curve is more flexible and smaller, but Lenke and Bridwell reported that the King II definition was not sufficient to recommend selective thoracic fusion. Lenke and Bridwell recommend more strict guidelines that include apical vertebral translation, apical vertebral rotation, Cobb angle, and flexibility of the two curves in addition to the sagittal assessment of the thoracolumbar junction. Other important factors when deciding to perform selective thoracic fusion include lifestyle, activity level, age, and sports preference. Specifically, high-performance athletes and dancers require more flexibility of the lumbar spine; thus, selective thoracic fusion should be considered., On the contrary, in patients with connective tissue disorders or similar flexibility selective thoracic fusion should be avoided.
Lenke’s proposed radiographic criteria include critical assessment of the apical vertebrae. The thoracic apical vertebral translation is the distance between the C-7 plumb line and center of the apical vertebral body or interspace of the thoracic curve, and the thoracolumbar/lumbar apical vertebral translation is the distance between the apical vertebral body or interspace of the respective curve and center sacral vertebral line. A ratio of thoracic apical vertebral translation to thoracolumbar apical vertebral translation >1.2 (20%+) indicates more vertebral translation of the thoracic curve and may be considered for treatment with selective thoracic fusion.,, Another factor to consider is the apical vertebral rotation. On the basis of the Nash–Moe grading for vertebral rotation, a ratio of main thoracic to thoracolumbar/lumbar and the apical vertebral rotation >1.2 (20% or greater) suggests that the surgeon may consider selective thoracic fusion.,, The third factor to critically access is the magnitude of the Cobb measurements. When the thoracic Cobb angle is larger (20% or greater) than the thoracolumbar/lumbar Cobb, these curve characteristics make considering selective thoracic fusion more advantageous.,, In addition, when a patient’s lumbar curve is nonstructural with side bending to <25° and the T10-L2 kyphosis is <20°, these two measurements make a better candidate for selective thoracic fusion., However, non-flexible thoracolumbar/lumbar curves with bending of more than 25° have been shown to spontaneously correct.
When two of the three above ratios (Cobb angle, apical vertebral translation, apical vertebral rotation of the main thoracic, and thoracolumbar/lumbar curves) are >1.2, the literature has shown good postoperative coronal balance and outcomes. Of note, this excluded lumbar Cobb angles >60° as these curves are less likely to spontaneously correct. As aforementioned, the sagittal balance is also important to consider. Ideally, the thoracolumbar junctional angle between T10 and L2 should be <10°, and the sagittal disc angle caudal to the LIVs should be lordotic., These parameters have been shown to help prevent distal junctional kyphosis [Table 1] and [Table 2].,
|Table 2: Criteria for optimizing selective thoracolumbar and lumbar fusions|
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Skeletal maturity is another important factor to consider when choosing levels for fusion. With closure of the triradiate cartilage, patients are less likely to have postoperative progression of the lumbar spine and junctional decompensation requiring adding-on levels.
With regard to preoperative planning, the lateral-bending and push-prone radiographs both have been shown to helpful, but keeping in mind, they typically under predict the amount of surgical correction of the Cobb angle and the angle of the LIV to the horizontal. In addition, the push-prone radiographs may help in determining the effects of the correction of the primary curve on the curves above and below the level of the planned fusion. The push-prone radiographs also better predict the rotation and translational correction of LIV from the central sacral line. More recently, traction radiographs under general anesthesia were found to be more predictive of curve correction compared to fulcrum bend radiographs when using pedicle screw constructs.
| Uppermost Instrumented Vertebra|| |
Choosing the correct uppermost instrumented vertebra has been shown to improve the longevity of the fusion constructs.,,, With the focus on the selection of the uppermost instrumented vertebra, it is important to consider shoulder balance in addition to the preservation of thoracic kyphosis to help prevent proximal junctional kyphosis., When selecting the uppermost instrumented vertebra, choosing one vertebra above the proposed vertebra of >5° of junctional kyphosis has been shown to decrease the rates of proximal junctional kyphosis. In addition to selecting the stable, neutral vertebra with <5° of junctional kyphosis, type of instrumentation may have an effect on postoperative outcomes and complications. Although pedicle screws have shown a significant improvement in coronal curve correction and vertebral rotation,,,,, pedicle screws may have a negative effect on postoperative sagittal alignment by decreasing kyphosis and increasing the risk for proximal junctional kyphosis.,,, In addition, apical wiring has been shown to have similar coronal correction with a potential improvement in hypokyphosis compared to all-screw constructs., Also, distraction of the concave side of the curve rather than compression of the convex side at the upper instrumented vertebra has been shown to decrease proximal junctional kyphosis. With regard to shoulder balance, Clements et al. found that pedicle screw constructs had higher percentage of shoulder asymmetry compared to hybrid constructs with hooks. Although not proven, historical thought of more cephalad uppermost instrumented vertebra decreasing the risk of shoulder imbalance may be the possible explanation. But more recently, significant correction of the main thoracic curve with under correction of upper curve resulted in increased shoulder imbalance independent of the uppermost instrumented vertebra. This suggests that the proximal curve should be critically assessed to optimize shoulder balance when a larger correction of the main thoracic curve is planned.
| Lowest Instrumented Vertebra|| |
Choosing the correct LIV is also an important factor for good outcomes. The decision for choosing the more proximal, LIV to preserve motion but without increasing the risk of distal junctional kyphosis or adding on phenomenon is debated in the literature. Majority of studies have shown acceptable outcomes when the LIV is at the stable and neutral vertebra.,,,,,, Lumbar decompensation is reported up to 22% when the fusion does not end at the stable and neutral vertebra. A more recent study helped determine parameters for LIV ending proximal to the stable vertebra in relation to the neutral vertebra. As aforementioned, the neutral vertebra is classified by the rotational stability based on pedicle symmetry. Factors for poor radiographic outcomes include when the central sacral vertical line does not touch the LIV, LIV is 3 or more proximal to the neutral vertebra, open triradiate cartilage, lumbar C modifier, and Risser 0. Parameters to prevent adding-on and distal junctional kyphosis include selection of the LIV to be touched by the central sacral vertical line and within two vertebrae cephalad to the neutral vertebra after triradiate cartilage closure or above Risser 0.
| Posterior Release|| |
Smith-Petersen et al. introduced the posterior column osteotomy to correct fused spine deformities. Later, Ponte et al., described similar technique involving the facet joints, ligamentum flavum, and posterior ligamentous complex in non-fused spines. For AIS, Schufflebarger and Clark described wide posterior release with removal of the interspinous ligament, ligamentum flavum, and part of the facet joint allowing increase motion of curves that helped avoiding more invasive anterior releases. There have been several studies since describing the benefits of Ponte osteotomies for AIS with decreased torque needed for correction, reported coronal correction of 60%–80% with statistically significant greater correction compared to without wide posterior release, and improved thoracic kyphosis and lumbar lordosis.,,,,, However, Halanski and Cassidy found no difference in coronal and sagittal correction comparing Ponte to inferior facetectomies. In addition, they found higher blood loss and increased operative time. Feng et al. reported comparable corrections of rigid AIS curves with Ponte osteotomies and pedicle screws compared to flexible curves without wide posterior releases but with increased operative times and higher blood loss.
| Posterior Instrumentation Techniques|| |
As aforementioned, in the 1980s after in the introduction of the Cotrel–Dubousset instrumentation, the correction techniques changed from the stable zone Harrington principles of the concave distraction to segmental realignment. Harrington instrumentation was used to distract the concavity and to compress the convexity of the scoliosis curve, but lacked the ability of rotational correction and sagittal balance., Distraction forces applied to the posterior spine allow for correction in the coronal plane only.
The advancement in instrumentation and use of pedicle screws lead to many other surgical techniques including rod derotation,, vertebral translation,,, differential rod contouring, direct vertebral rotation,, direct vertebral body derotation,,,,, derotation vertebral coplanar alignment,,, apical wiring,, and cantilever bending.,,,,,,,
With regard to rod derotation, the Cotrel–Dubousset segmental instrumentation through derotation allowed for correction in the coronal and sagittal plane.,,,,, This derotation technique refers to the 90° rod rotation in connection to vertebra used to force correction of the curve. This technique allows for two forces to be applied to the curve. The first is directed posteriorly and medially correcting the coronal and sagittal deformities. Second, the rod is rotated 90°, which may affect the vertebral rotation. This technique has pitfalls with curves having sagittal and coronal plane apical mismatches. It can also exacerbate the rotation on the convexity of the curve and required under contouring of the convex rod to correct the kyphosis.,
Vertebral translation is another posterior technique to place a contoured rod in the desired sagittal plane and to bring the spine to the rod.,, Delorme et al. showed comparable results using the rod rotation and vertebral translation techniques. However, Muschik et al. showed greater correction of the thoracic curve with rod rotation but translation was more beneficial on overall spinal balance. Also, vertebral translation technique with two differently shaped rods, also known as differential rod bending, helps in reducing the rib hump deformity.
A third frequently described posterior technique is direct vertebral rotation. This technique is the correction of the vertebral rotation by application of a force directed posteriorly in the direction opposite to the deformity. The rotational force is transmitted to vertebra through a pedicle screw unlike hooks and wires, which cannot deliver sufficient torque anteriorly to enable vertebral rotation. Mattila et al. showed an improved postoperative rotation in the presence of similar coronal correction with direct vertebral derotation compared to rod rotation technique. But in a 2014 meta-analysis, there appears to be little evidence to recommend widespread direct vertebral body derotation with only weak evidence for better clinical outcomes following direct derotation techniques. Although direct derotation techniques have shown to decrease rib hump by upto 59%, thoracoplasty, which can subject the patient to reduced pulmonary function tests, may still be required in addition to direct vertebral rotation for significant rib hump corrections upto 72%.,,,,,,,,,,,, More recently, thoracoplasty was shown to not significantly decrease pulmonary function tests, but did have an increased incidence of pleural effusions of 72% with one patient requiring drainage.
| Amount of Correction|| |
The balance of too little versus too much correction can be difficult to determine. Over correction has been related to progression of the lumbar curve below selective thoracic fusion due to lack of compensatory lumbar curve correction.,,,,,, This lack of compensation of the lumbar curve results in global coronal decompensation.,, It has been shown that the magnitude and stiffness of the lumbar curve correlates to the amount of compensation., The preoperative push prone and supine lumbar radiographs have been used to help predict the ideal amount of thoracic curve correction and expected amount spontaneous lumbar curve correction. One study found up to 83% correction of the thoracic spine and 81% spontaneous correction of the lumbar spine when the preoperative flexibility imaging showed a spontaneous lumbar correction of 66%. Other studies have shown similar results of spontaneous correction of lumbar curve between 60% and 81%, which corresponded to the 61%–83% surgical correction of the thoracic curve.,, Another study reported that the use of pedicle screws may enhance the ability to control spontaneous correction of the lumbar curve exceeding the preoperative flexibility radiographic correction amount. Suk et al. showed 81% spontaneous correction of the lumbar spine with 83% correction of the thoracic spine. Preoperative flexibility radiographs only showed 66% correction of the lumbar spine.
Preoperative traction is another factor to consider. In the 1960s, Dr. John Moe from Minneapolis described a treatment plan of several weeks of halo-femoral traction followed by posterior spine fusion. Several studies have shown preoperative traction to improve curves by 34%–39% with an additional 14% improvement after surgery,, but with pure pedicle screw constructs without traction it has been shown to improve curves by about 65%. It is difficult to subject most patients to skeletal traction,, but may have role in patients with poor pulmonary function and large deformities to gain safe surgical correction. Also, in general when considering preoperative planning, coronal plane deformities are known to improve with supine positioning versus standing radiographs.
| Case Examples|| |
Case example of nonselective thoracolumbar fusion: An 18-year-old female patient with progressive adolescent idiopathic scoliosis. She underwent posterior spine fusion T3–L4 with posterior column osteotomy T4–L4. [Figure 1]A shows her preoperative radiographs and parameters. [Figure 1]B shows her 1-year postoperative radiographs.
|Figure 1: Case 1. Case example of nonselective thoracolumbar fusion (A) 18-year-old female patient with progressive adolescent idiopathic scoliosis. (B) Following posterior spine fusion T3–L4 and posterior column osteotomies T4–L4|
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Case example of selective thoracic fusion: A 10-year-old female patient with progressive adolescent idiopathic scoliosis. She underwent posterior spine fusion T4–T12 with posterior column osteotomy T4–T12. [Figure 2]A shows her preoperative radiographs and parameters. [Figure 2]B shows her 1-year postoperative radiographs.
|Figure 2: Case 2. Case example of selective thoracic fusion (A) 10-year-old female patient with progressive idiopathic scoliosis (B) Following posterior spine fusion T2–T12 and posterior column osteotomies T5–T12|
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Case example of selective thoracolumbar fusion: A 16-year-old female patient with progressive adolescent idiopathic scoliosis. She underwent posterior spine fusion T10–L3 with posterior column osteotomy T10–L3. [Figure 3]A shows her preoperative radiographs and parameters. [Figure 3]B shows her 1 year postoperative radiographs.
|Figure 3: Case 3. Case example of selective thoracolumbar fusion (A) 16-year-old female patient with progressive idiopathic scoliosis. (B) Following posterior spine fusion T2–T12 and posterior column osteotomies T5–T12|
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| Summary|| |
In treating AIS with posterior spine fusion, there are many elements to contemplate when determining where to start and end the fusion construct. In addition to skeletal maturity, preoperative radiographs should be systematically viewed with the knowledge of supine radiographs that may show the flexibility of the coronal deformity. Also, push-prone radiographs may help in determining the effects of the planned correction of the primary curve on the minor curves and may also help in predicting the rotation and translation of correction of LIVs.
When determining if selective thoracic fusion is appropriate, having two of the three ratios: Cobb angle, apical vertebral translation, apical vertebral rotation of the main thoracic and thoracolumbar/lumbar >1.2 have been shown to improve postoperative coronal balance. It is also important to consider if patient’s lumbar curve is nonstructural with side bending to <25° and if the T10–L2 kyphosis is <20°. With regard to the uppermost instrumented vertebra, selecting the stable, neutral vertebra with <5° of junctional kyphosis may help in preventing postoperative complications. Also, although pedicle screws may help improvement in coronal curve correction and vertebral rotation, be aware that they may lead to hypokyphosis. With regard to the lowest instrumented vertebra, the vertebra should be touched by the central sacral vertical line and within two vertebrae proximal to the neutral vertebra [Table 3]. Also, if possible waiting to skeletal maturity after triradiate cartilage closure or above Risser 0 may help decrease postoperative decompensation in cases of selective thoracic fusion.
|Table 3: Selection guidelines for upper instrumented vertebra (UIV) and lower instrumented vertebra (LIV).|
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With respect to posterior surgical releases, Ponte osteotomies improve the mobility of spine, especially in more rigid curves, but increase intraoperative blood loss and may increase operative time. With regard to surgical technique, surgeon training and experience should be weighed with patient’s curve characteristics. Rod derotation and vertebral translation appear to have similar results in correcting coronal and sagittal deformities. Surgeon experience is likely the major factor for success using these two techniques. Direct vertebral rotation can have a role in rotational correction [Table 4]. And finally, preoperative traction may be useful in some patients, especially those who are at risk of significant intraoperative pulmonary complication due to the severity of their curves.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]