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Including the stable sagittal vertebra in the fusion for adolescent idiopathic scoliosis reduces the risk of distal junctional kyphosis in Lenke 1–3 B and C curves

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Abstract

Purpose

The selection of lowest instrumented vertebra (LIV) in adolescent idiopathic scoliosis (AIS) is determined by coronal and sagittal plane indicators. Failure to properly select the LIV can lead to suboptimal outcomes and the need for revision surgery. A subset of patients have discordant coronal last touched vertebra (cLTV) and stable sagittal vertebra (SSV) which complicates the choice of LIV. The purpose of this study is to report the incidence of discordant cLTV and SSV when choosing LIV and investigate the association between length of fusion and patient-reported outcomes (PROs) and distal junctional kyphosis (DJK).

Methods

This retrospective multicenter cohort study included AIS patients with discordant pre-operative cLTV and SSV. Patients fused only to include the proximal cLTV were compared to patients fused to include the distal SSV. Primary outcomes included DJK and PROs measured by SRS-22.

Results

Eight hundred and fifty-six patients were identified of which 114 (13.3%) had discordant SSV and cLTV. The DJK incidence was 7.7% and 45.5% in patients fused to include the SSV versus short of the SSV, respectively. Lenke Modifier type B and C patients with fusions short of the SSV had a 9.2 times increased risk of developing DJK at 2 years compared to patients with fusions including the SSV (95% CI 2.8, 29.7; p < 0.001). However, patients with fusions short of the SSV and no evidence of DJK were 9.2 times more likely to have improvement in the SRS-22 pain domain compared to patients with fusions including the distal SSV (95% CI 1.1, 77.4; p = 0.042)

Conclusion

Patients fused short of the SSV are at significant risk for the development of DJK at 2 years post-operatively. However, patients with shorter fusions were more likely to have an improvement in their pain as measured by patient-reported outcomes than patients with longer fusions.

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Acknowledgements

This work was conducted with the support of additional funding.

This study was supported in part by grants to the Setting Scoliosis Straight Foundation in support of Harms Study Group research from DePuy Synthes Spine, EOS imaging, K2M, Medtronic, NuVasive and Zimmer Biomet.

See Harms Study Group Investigators: Aaron Buckland, MD; New York University, Amer Samdani, MD; Shriners Hospitals for Children—Philadelphia, Amit Jain, MD; Johns Hopkins Hospital, Baron Lonner, MD; Mount Sinai Hospital, Benjamin Roye, MD; Columbia University, Burt Yaszay, MD; Rady Children’s Hospital, Chris Reilly, MD; BC Children’s Hospital, Daniel Hedequist, MD; Boston Children’s Hospital, Daniel Sucato, MD; Texas Scottish Rite Hospital, David Clements, MD; Cooper Bone & Joint Institute New Jersey, Firoz Miyanji, MD; BC Children’s Hospital, Harry Shufflebarger, MD; Nicklaus Children's Hospital, Jack Flynn, MD; Children’s Hospital of Philadelphia, Jahangir Asghar, MD; Cantor Spine Institute, Jean Marc Mac Thiong, MD; CHU Sainte-Justine, Joshua Pahys, MD; Shriners Hospitals for Children—Philadelphia, Juergen Harms, MD; Klinikum Karlsbad-Langensteinbach, Karlsbad, Keith Bachmann, MD; University of Virginia, Larry Lenke, MD; Columbia University, Mark Abel, MD; University of Virginia, Michael Glotzbecker, MD; Boston Children’s Hospital, Michael Kelly, MD; Washington University, Michael Vitale, MD; Columbia University, Michelle Marks, PT, MA; Setting Scoliosis Straight Foundation, Munish Gupta, MD; Washington University, Nicholas Fletcher, MD; Emory University, Patrick Cahill, MD; Children’s Hospital of Philadelphia, Paul Sponseller, MD; Johns Hopkins Hospital, Peter Gabos, MD: Nemours/Alfred I. duPont Hospital for Children, Peter Newton, MD; Rady Children’s Hospital, Peter Sturm, MD; Cincinnati Children’s Hospital, Randal Betz, MD; Institute for Spine & Scoliosis, Ron Lehman, MD; Columbia University, Stefan Parent, MD: CHU Sainte-Justine, Stephen George, MD; Nicklaus Children’s Hospital, Steven Hwang, MD; Shriners Hospitals for Children—Philadelphia, Suken Shah, MD; Nemours/Alfred I. duPont Hospital for Children, Tom Errico, MD; Nicklaus Children’s Hospital, Vidyadhar Upasani, MD; Rady Children’s Hospital.

Funding

This study was supported in part by grants to the Setting Scoliosis Straight Foundation in support of Harms Study Group research from DePuy Synthes Spine, EOS imaging, K2M, Medtronic, NuVasive and Zimmer Biomet.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Morgan Stanley Children’s Hospital of New York Presbyterian, Columbia University Medical Center, ATTN: Hiroko Matsumoto, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA

    Gerard Marciano, Jacob Ball, Hiroko Matsumoto, Benjamin Roye, Lawrence Lenke & Michael Vitale

  2. Department of Orthopaedic Surgery, Rady Children’s Hospital, San Diego, CA, USA

    Peter Newton

Authors
  1. Gerard Marciano
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  2. Jacob Ball
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  3. Hiroko Matsumoto
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  4. Benjamin Roye
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  5. Lawrence Lenke
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  6. Peter Newton
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  7. Michael Vitale
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Consortia

Harms Study Group

  • Aaron Buckland
  • , Amer Samdani
  • , Amit Jain
  • , Baron Lonner
  • , Benjamin Roye
  • , Burt Yaszay
  • , Chris Reilly
  • , Daniel Hedequist
  • , Daniel Sucato
  • , David Clements
  • , Firoz Miyanji
  • , Harry Shufflebarger
  • , Jack Flynn
  • , Jahangir Asghar
  • , Jean Marc Mac Thiong
  • , Joshua Pahys
  • , Juergen Harms
  • , Keith Bachmann
  • , Larry Lenke
  • , Mark Abel
  • , Michael Glotzbecker
  • , Michael Kelly
  • , Michael Vitale
  • , Michelle Marks
  • , Munish Gupta
  • , Nicholas Fletcher
  • , Patrick Cahill
  • , Paul Sponseller
  • , Peter Gabos
  • , Peter Newton
  • , Peter Sturm
  • , Randal Betz
  • , Ron Lehman
  • , Stefan Parent
  • , Stephen George
  • , Steven Hwang
  • , Suken Shah
  • , Tom Errico
  •  & Vidyadhar Upasani

Contributions

GM: Conception and design, data collection, data analysis, data interpretation, drafting manuscript, revising manuscript, and final approval. JB: Conception and design, data analysis, data interpretation, drafting manuscript, revising manuscript, and final approval. HM: Conception and design, data analysis, data interpretation, and final approval. BR: Resources, conception and design, data interpretation, revision, and final approval. LL: Resources, conception and design, revision, and final approval. PN: Resources, conception and design, revision, and final approval. MGV: Resources, conception and design, supervision, revision, and final approval. HARMS Study Group: Resources, conception and design, supervision, revision, and final approval.

Corresponding author

Correspondence to Hiroko Matsumoto.

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This work is approved by the Institutional Review Boards at all sites, including Columbia University (Protocol AAAS0702).

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The members of Harms Study Group are listed in Acknowledgements.

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Marciano, G., Ball, J., Matsumoto, H. et al. Including the stable sagittal vertebra in the fusion for adolescent idiopathic scoliosis reduces the risk of distal junctional kyphosis in Lenke 1–3 B and C curves. Spine Deform 9, 733–741 (2021). https://doi.org/10.1007/s43390-020-00259-2

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