European Spine Journal

, Volume 22, Issue 6, pp 1312–1316 | Cite as

Analysis of risk factors for loss of lumbar lordosis in patients who had surgical treatment with segmental instrumentation for adolescent idiopathic scoliosis

  • Per D. TrobischEmail author
  • Amer F. Samdani
  • Randal R. Betz
  • Tracey Bastrom
  • Joshua M. Pahys
  • Patrick J. Cahill
Original Article



Iatrogenic flattening of lumbar lordosis in patients with adolescent idiopathic scoliosis (AIS) was a major downside of first generation instrumentation. Current instrumentation systems allow a three-dimensional scoliosis correction, but flattening of lumbar lordosis remains a significant problem which is associated with decreased health-related quality of life. This study sought to identify risk factors for loss of lumbar lordosis in patients who had surgical correction of AIS with the use of segmental instrumentation.


Patients were included if they had surgical correction for AIS with segmental pedicle screw instrumentation Lenke type 1 or 2 and if they had a minimum follow-up of 24 months. Two groups were created, based on the average loss of lumbar lordosis. The two groups were then compared and multivariate analysis was performed to identify parameters that correlated to loss of lumbar lordosis.


Four hundred and seventeen patients were analyzed for this study. The average loss of lumbar lordosis at 24 months follow-up was an increase of 10° lordosis for group 1 and a decrease of 15° for group 2. Risk factors for loss of lumbar lordosis included a high preoperative lumbar lordosis, surgical decrease of thoracic kyphosis, and the particular operating surgeon. The lowest instrumented vertebra or spinopelvic parameters were two of many parameters that did not seem to influence loss of lumbar lordosis.


This study identified important risk factors for decrease of lumbar lordosis in patients who had surgical treatment for AIS with segmental pedicle screw instrumentation, including a high preoperative lumbar lordosis, surgical decrease of thoracic kyphosis, and factors attributable to a particular operating surgeon that were not quantified in this study.


AIS Sagittal balance Segmental instrumentation Pelvic tilt Lumbar lordosis 



IRB approval for the study was obtained locally from each contributing institution’s review board, and consent was obtained from each patient prior to data collection. This study was supported by a research grant from DePuy Synthes Spine to the Setting Scoliosis Straight Foundation for the Harms Study Group.

Conflict of interest



  1. 1.
    Cotrel Y, Dubousset JF (1984) A new technique for segmental spinal osteosynthesis using the posterior approach. Rev Chir Orthop Reparatrice Appar Mot 70:489–494PubMedGoogle Scholar
  2. 2.
    De Jonge T, Dubousset JF, Illes T (2002) Sagittal plane correction in idiopathic scoliosis. Spine (Phila Pa 1976) 27:754–760CrossRefGoogle Scholar
  3. 3.
    Cochran T, Irstam L, Nachemson A (1983) Long-term anatomic and functional changes in patients with adolescent idiopathic scoliosis treated by Harrington rod fusion. Spine (Phila Pa 1976) 8:576–584CrossRefGoogle Scholar
  4. 4.
    Schwab F, Patel A, Ungar B, Farcy JP, Lafage V (2010) Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery. Spine (Phila Pa 1976) 35:2224–2231CrossRefGoogle Scholar
  5. 5.
    Lafage V, Schwab F, Patel A, Hawkinson N, Farcy JP (2009) Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity. Spine (Phila Pa 1976) 34:E599–E606CrossRefGoogle Scholar
  6. 6.
    Barrey C, Roussouly P, Perrin G, Le Huec JC (2011) Sagittal balance disorders in severe degenerative spine. Can we identify the compensatory mechanism? Eur Spine J Suppl 5:626–633CrossRefGoogle Scholar
  7. 7.
    Skalli W, Zeller RD, Miladi L et al (2006) Importance of pelvic compensation in posture and motion after posterior spinal fusion using CD instrumentation for idiopathic scoliosis. Spine (Phila Pa 1976) 31:E359–E366CrossRefGoogle Scholar
  8. 8.
    Boulay C, Tardieu C, Hecquet J et al (2006) Sagittal alignment of the spine and pelvis regulated by pelvic incidence: standard values and prediction of lordosis. Eur Spine J 15:414–422CrossRefGoogle Scholar
  9. 9.
    Mac-Thiong JM, Labelle H, Charlebois M, Huot MP, de Guise JA (2003) Sagittal plane analysis of the spine and pelvis in adolescent idiopathic scoliosis according to the coronal curve type. Spine (Phila Pa 1976) 28:1404–1409Google Scholar
  10. 10.
    Tanguay F, Mac-Thiong JM, de Guise JA et al (2007) Relation between the sagittal pelvic and lumbar spine geometries following surgical correction of adolescent idiopathic scoliosis. Eur Spine J 16:531–536PubMedCrossRefGoogle Scholar
  11. 11.
    Potter BK, Lenke LG, Kuklo TR (2004) Prevention and management of iatrogenic flatback deformity. J Bone Joint Surg Am 86:1793–1808PubMedGoogle Scholar
  12. 12.
    Swank SM, Mauri TM, Brown JC (1990) The lumbar lordosis below Harrington instrumentation for scoliosis. Spine (Phila Pa 1976) 3:181–186CrossRefGoogle Scholar
  13. 13.
    Knapp DR Jr, Price CT, Jones ET, Coonrad RW, Flynn JC (1992) Choosing fusion levels in progressive thoracic idiopathic scoliosis. Spine (Phila Pa 1976) 17:1159–1165CrossRefGoogle Scholar
  14. 14.
    Kuklo TR, O’Brien MF, Lenke LG, Polly DW, Sucato DS, Richards BS, Lubicky J, Ibrahim K, Kawakami N, King A (2006) Comparison of the lowest instrumented, stable, and lower end vertebrae in “single overhang” thoracic adolescent idiopathic scoliosis: anterior versus posterior spinal fusion. Spine (Phila Pa 1976) 31:2232–2236CrossRefGoogle Scholar
  15. 15.
    Suk S-I, Lee S-M, Chung E-R, Kim J-H, Kim W-J, Sohn HM (2003) Determination of distal fusion level with segmental pedicle screw fixation in single thoracic idiopathic scoliosis. Spine (Phila Pa 1976) 28:484–491Google Scholar
  16. 16.
    Newton PO, Faro FD, Lenke LG, Betz RR, Clements DH, Lowe TG, Haher TR, Merola AA, D’Andrea LP, Marks M, Wenger DR (2003) Factors involved in the decision to perform a selective versus nonselective fusion of Lenke 1B and 1C (King-Moe II) curves in adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 28:S217–S223CrossRefGoogle Scholar
  17. 17.
    Newton PO, Yaszay B, Upasani VV, Pawelek JB, Bastrom TP, Lenke LG, Lowe T, Crawford A, Betz R, Lonner B (2010) Preservation of thoracic kyphosis is critical to maintain lumbar lordosis in the surgical treatment of adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 35:1365–1370Google Scholar
  18. 18.
    Lee SM, Suk SI, Chung ER (2004) Direct vertebral rotation: a new technique of three-dimensional deformity correction with segmental pedicle screw fixation in adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 29:343–349CrossRefGoogle Scholar
  19. 19.
    Mladenov KV, Vaeterlein C, Stuecker R (2011) Selective posterior thoracic fusion by means of direct vertebral derotation in adolescent idiopathic scoliosis: effects on the sagittal alignment. Eur Spine J 20:1114–1117PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Per D. Trobisch
    • 1
    Email author
  • Amer F. Samdani
    • 2
  • Randal R. Betz
    • 2
  • Tracey Bastrom
    • 3
  • Joshua M. Pahys
    • 2
  • Patrick J. Cahill
    • 2
  1. 1.Orthopädische Universitätsklinik MagdeburgMagdeburgGermany
  2. 2.Shriners Hospitals for ChildrenPhiladelphiaUSA
  3. 3.Rady Children’s HospitalSan DiegoUSA

Personalised recommendations