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Preventing Distal Junctional Kyphosis by Applying the Stable Sagittal Vertebra Concept to Selective Thoracic Fusion in Adolescent Idiopathic Scoliosis

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Abstract

Study Design

Multicenter retrospective review.

Objective

To assess the effectiveness of using the stable sagittal vertebra (SSV) for selecting the lowest instrumented vertebrae (LIV) to prevent distal junctional kyphosis (DJK) in selective thoracic fusions.

Summary of Background Data

Cho et al. reported that including the SSV in a fusion decreased the rate of DJK in thoracic hyperkyphosis.

Methods

A retrospective review was performed of patients from two pediatric hospitals with adolescent idiopathic scoliosis who underwent selective posterior thoracic fusion with the LIV at L2 or above from 2000 to 2012. Patients with less than 2 years’ follow-up were excluded. The primary outcome measure was DJK, defined radiographically as ≥10° between the superior end plate of the LIV and the inferior end plate of the vertebra below on a standing lateral radiograph. We investigated the SSV, which was defined as the vertebral level at which 50% of the vertebral body was in front of the posterior sacral vertical line (PSVL) on a standing lateral radiograph. This particular definition was referred to as SSV.

Results

A total of 113 patients met the inclusion criteria. Mean age was 14.4 years. Mean Cobb angle was 58°. The overall rate of DJK was 7% (8/113). When the LIV was superior to SSV, the rate of DJK was 17% (8/46) versus 0% (0/67) when the LIV was at or inferior to SSV (p=.01). The rates of DJK for patients with the LIV one, two, and three levels above SSV were 17% (4/24), 7% (1/14), and 43% (3/7), respectively. There was no significant association between preoperative or postoperative maximum kyphosis, thoracic kyphosis, thoracolumbar kyphosis, pelvic incidence, sagittal balance or coronal balance, and development of DJK.

Conclusion

Although LIV selection is complex, choosing the LIV at or below the SSV is a simple rule that minimizes the risk of DJK.

Level of Evidence

Level IV.

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Authors and Affiliations

  1. Children’s Orthopaedic Center, Children’s Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA

    Joshua Yang BA, Lindsay M. Andras MD, Alexander M. Broom MD, Nicholas R. Gonsalves MD, Kody K. Barrett MD, Vernon T. Tolo MD & David L. Skaggs MD, MMM

  2. Children’s Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA, 19104, USA

    Andrew G. Georgiadis MD & John M. Flynn MD

Authors
  1. Joshua Yang BA
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  2. Lindsay M. Andras MD
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  3. Alexander M. Broom MD
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  4. Nicholas R. Gonsalves MD
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  5. Kody K. Barrett MD
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  6. Andrew G. Georgiadis MD
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  7. John M. Flynn MD
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  8. Vernon T. Tolo MD
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  9. David L. Skaggs MD, MMM
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Corresponding author

Correspondence to David L. Skaggs MD, MMM.

Additional information

Author disclosures

JY (none), LMA (personal fees from Biomet; Medtronic, other from Eli Lilly, personal fees from Orthobullets, nonfinancial support from Pediatric Orthopaedic Society of North America, nonfinancial support from Scoliosis Research Society, other from Journal of Pediatric Orthopaedics, outside the submitted work), AMB (none), NRG (none), KKB (none), AGG (nonfinancial support from Journal of Orthopaedic Trauma, outside the submitted work), JMF (personal fees from Biomet, outside the submitted work), VTT (other from Journal of Bone and Joint Surgery—American, other from Wolters Kluwer Health—Lippincott Williams & Wilkins, outside the submitted work), DLS (grants from Pediatric Orthopaedic Society of North America & Scoliosis Research Society, Paid to Columbia University; Ellipse [Co-PI, Paid to GSF], personal fees from ZimmerBiomet; Medtronic; Zipline Medical, Inc; Orthobullets; Grand Rounds [a healthcare navigation company], Green Sun Medical, other from Zipline Medical, Inc, Green Sun Medical, other from Orthobullets, nonfinancial support from Growing Spine Study Group, Scoliosis Research Society, Growing Spine Foundation, personal fees from ZimmerBiomet; Medtronic; Johnson & Johnson, from Medtronic & ZimmerBiomet, other from Wolters Kluwer Health—Lippincott Williams & Wilkins; Biomet Spine, other from Orthobullets, Co-Editor in Chief, outside the submitted work).

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Yang, J., Andras, L.M., Broom, A.M. et al. Preventing Distal Junctional Kyphosis by Applying the Stable Sagittal Vertebra Concept to Selective Thoracic Fusion in Adolescent Idiopathic Scoliosis. Spine Deform 6, 38–42 (2018). https://doi.org/10.1016/j.jspd.2017.06.007

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  • DOI: https://doi.org/10.1016/j.jspd.2017.06.007

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