Skip to main content
SpringerLink
Log in

Fusions ending above the sagittal stable vertebrae in adolescent idiopathic scoliosis: does it matter?

  • Case Series
  • Published:
Spine Deformity Aims and scope Submit manuscript

Abstract

Study design

Retrospective cohort study.

Objective

To validate whether fusions that end proximal to the sagittal stable vertebrae are at risk for developing distal junctional kyphosis in adolescent idiopathic scoliosis.

Background

Posterior spinal fusion is routinely used for the treatment of patients with adolescent idiopathic scoliosis. Fusions that end in either the lower thoracic or upper lumbar spine have the advantage of preserving motion segments. However, fusions ending proximal to the sagittal stable vertebrae has been shown to be at higher risk for developing distal junctional kyphosis.

Methods

A multi-center database of prospectively enrolled subjects was queried for patients with adolescent idiopathic scoliosis that had Lenke type 1, 2 and 3 curves treated with posterior pedicle screw instrumentation. PA (posterior-anterior) and lateral full-length scoliosis films were obtained on each patient. PA radiographs were viewed to determine the coronal deformity and lateral radiographs to determine the sagittal deformity. Distal junctional kyphosis was defined as a greater than 10° increase in segmental kyphosis between the LIV and the LIV + 1 vertebra.

Results

346 patients were included with 85% being female and mean age of cohort 14.2 \(\pm\) 2.08 years. At 5 years postoperatively, there was significant difference occurrence of distal junctional kyphosis dependent on whether the LIV relative to SSV with only 2.2% of fusions below the SSV developing DJK compared to 6.5% for fusions ending at the SSV and 15% for fusions with LIV above the SSV (p < 0.001). There was no statistical difference in revision rates based on the relationship of LIV to SSV.

Conclusion

There is an increased risk for development of DJK in patients with AIS treated with posterior fusion where the LIV was chosen proximal to the SSV.

Level evidence

Level III.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Qin X, Sun W, Xu L, Liu Z, Qiu Y, Zhu Z (2016) Selecting the last "substantially" touching vertebra as lowest instrumented vertebra in lenke type 1a curve: radiographic outcomes with a minimum of 2-year follow-up. Spine (Phila Pa 1976) 41(12):E742–E750

    Article  Google Scholar 

  2. Kim YJ, Lenke LG, Cho SK, Bridwell KH, Sides B, Blanke K (2004) Comparative analysis of pedicle screw versus hook instrumentation in posterior spinal fusion of adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 29(18):2040–2048

    Article  Google Scholar 

  3. Fan H, Wang Q, Huang Z, Sui W, Yang J, Deng Y et al (2016) Comparison of functional outcome and quality of life in patients with idiopathic scoliosis treated by spinal fusion. Med (Baltim) 95(19):e3289

    Article  Google Scholar 

  4. Wilk B, Karol LA, Johnston CE, Colby S, Haideri N (2006) The effect of scoliosis fusion on spinal motion: a comparison of fused and nonfused patients with idiopathic scoliosis. Spine (Phila Pa 1976) 31(3):309–314

    Article  Google Scholar 

  5. Takahashi J, Newton PO, Ugrinow VL, Bastrom TP (2011) Selective thoracic fusion in adolescent idiopathic scoliosis: factors influencing the selection of the optimal lowest instrumented vertebra. Spine (Phila Pa 1976) 36(14):1131–1141

    Article  Google Scholar 

  6. Cho W, Faloon MJ, Essig D, Sokunbi G, Ross T, Cunningham M et al (2018) Additional risk factors for adding-on after selective thoracic fusion in adolescent idiopathic scoliosis: implication of lowest instrumented vertebra angle and lumbosacral takeoff. Spine Deform 6(2):164–169

    Article  Google Scholar 

  7. Yang J, Andras LM, Broom AM, Gonsalves NR, Barrett KK, Georgiadis AG et al (2018) Preventing distal junctional kyphosis by applying the stable sagittal vertebra concept to selective thoracic fusion in adolescent idiopathic scoliosis. Spine Deform 6(1):38–42

    Article  Google Scholar 

  8. Cho KJ, Lenke LG, Bridwell KH, Kamiya M, Sides B (2009) Selection of the optimal distal fusion level in posterior instrumentation and fusion for thoracic hyperkyphosis: the sagittal stable vertebra concept. Spine (Phila Pa 1976) 34(8):765–770

    Article  Google Scholar 

  9. King HA, Moe JH, Bradford DS, Winter RB (1983) The selection of fusion levels in thoracic idiopathic scoliosis. J Bone Jt Surg Am 65(9):1302–1313

    Article  CAS  Google Scholar 

  10. Erickson MA, Baulesh DM (2011) Lowest instrumented vertebra selection in AIS. J Pediatr Orthop 31(1 Suppl):S69–76

    Article  Google Scholar 

Download references

Acknowledgements

Harms Study Group: Grants were received from DePuy Synthes Spine to the Setting Scoliosis Straight Foundation in support of Harms Study Group research Nicholas D. Fletcher: reports grants from Harrison Foundation, personal fees from Orthopaediatrics, personal fees from Medtronic Spine, personal fees from Nuvasive, personal fees from Zimmer Biomet, outside the submitted work. 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.

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

Grants were received from DePuy Synthes Spine to the Setting Scoliosis Straight Foundation in support of Harms Study Group research.

Author information

Authors and Affiliations

  1. Department of Orthopedics, Emory University, 59 Executive Park Dr. S, Atlanta, GA, 30329, USA

    Dale N. Segal, Keith J. Orland, Eric Yoon, Tracey Bastrom, Nicholas D. Fletcher, 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

Authors
  1. Dale N. Segal
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Keith J. Orland
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Eric Yoon
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Tracey Bastrom
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Nicholas D. Fletcher
    View author publications

    You can also search for this author in PubMed Google Scholar

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

All authors contributed substantially. DNS: synthesis of idea, data analysis, manuscript writing, editing work, approving work. KJO: data analysis, manuscript writing approving work. EY: data analysis, editing manuscript approving work. TB: statistical analysis, editing manuscript approving work. NDF: synthesis of idea, data analysis, manuscript writing approving work. Harms Study Group reviewing and editing manuscript.

Corresponding author

Correspondence to Nicholas D. Fletcher.

Ethics declarations

Conflicts of interest

Dale N. Segal, Keith J. Orland, Eric Yoon, Tracy Bastrom have no conflicts of interest to declare. Harms Study Group: Grants were received from DePuy Synthes Spine to the Setting Scoliosis Straight Foundation in support of Harms Study Group research. Nicholas D. Fletcher: reports grants from Harrison Foundation, personal fees from Orthopaediatrics, personal fees from Medtronic Spine, personal fees from Nuvasive, personal fees from Zimmer Biomet, outside the submitted work.

Statement of Human rights/ethical approval

IRB approval for the multicenter study was obtained locally from each contributing institution’s review board, and consent was obtained from each patient prior to data collection.

Informed consent

Consent was obtained from each patient prior to data collection.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The members of the investigators of the Harms Study Group Investigators are listed in acknowledgements.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Segal, D.N., Orland, K.J., Yoon, E. et al. Fusions ending above the sagittal stable vertebrae in adolescent idiopathic scoliosis: does it matter?. Spine Deform 8, 983–989 (2020). https://doi.org/10.1007/s43390-020-00118-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s43390-020-00118-0

Keywords

Search

Navigation