Do Current Recommendations for Upper Instrumented Vertebra Predict Shoulder Imbalance? An Attempted Validation of Level Selection for Adolescent Idiopathic Scoliosis

Abstract

Background

Shoulder balance for adolescent idiopathic scoliosis (AIS) patients is associated with patient satisfaction and self-image. However, few validated systems exist for selecting the upper instrumented vertebra (UIV) post-surgical shoulder balance.

Questions/Purposes

The purpose is to examine the existing UIV selection criteria and correlate with post-surgical shoulder balance in AIS patients.

Methods

Patients who underwent spinal fusion at age 10–18 years for AIS over a 6-year period were reviewed. All patients with a minimum of 1-year radiographic follow-up were included. Imbalance was determined to be radiographic shoulder height |RSH| ≥ 15 mm at latest follow-up. Three UIV selection methods were considered: Lenke, Ilharreborde, and Trobisch. A recommended UIV was determined using each method from pre-surgical radiographs. The recommended UIV for each method was compared to the actual UIV instrumented for all three methods; concordance between these levels was defined as “Correct” UIV selection, and discordance was defined as “Incorrect” selection.

Results

One hundred seventy-one patients were included with 2.3 ± 1.1 year follow-up. For all methods, “Correct” UIV selection resulted in more shoulder imbalance than “Incorrect” UIV selection. Overall shoulder imbalance incidence was improved from 31.0% (53/171) to 15.2% (26/171). New shoulder imbalance incidence for patients with previously level shoulders was 8.8%.

Conclusions

We could not identify a set of UIV selection criteria that accurately predicted post-surgical shoulder balance. Further validated measures are needed in this area. The complexity of proximal thoracic curve correction is underscored in a case example, where shoulder imbalance occurred despite “Correct” UIV selection by all methods.

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

Graph 1
Fig. 1

References

  1. 1.

    Asher MA, Lai SM, Glattes RC, et al. Refinement of the SRS-22 health-related quality of life questionnaire function domain. Spine (Phila Pa 1976). 2006; 31(5): 593-597.

    Article  Google Scholar 

  2. 2.

    Asher M, Min Lai S, Burton D, et al. The reliability and concurrent validity of the scoliosis research society-22 patient questionnaire for idiopathic scoliosis. Spine (Phila Pa 1976). 2003; 28(1): 63-69.

    Article  Google Scholar 

  3. 3.

    Bago J, Carrera L, March B, et al. Four radiological measures to estimate shoulder balance in scoliosis. J Pediatr Orthop B. 1996; 5(1): 31-34.

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Cammarata M, Aubin CE, Wang X, Mac-Thiong JM. Biomechanical risk factors for proximal junctional kyphosis: a detailed numerical analysis of surgical instrumentation variables. Spine (Phila Pa 1976). 2014.

  5. 5.

    Delorme S, Labelle H, Poitras B, et al. Pre-, intra-, and postoperative three-dimensional evaluation of adolescent idiopathic scoliosis. J Spinal Disord. 2000; 13(2): 93-101.

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Duong L, Mac-Thiong JM, Labelle H. Real time noninvasive assessment of external trunk geometry during surgical correction of adolescent idiopathic scoliosis. Scoliosis. 2009; 4: 5.

    PubMed Central  Article  PubMed  Google Scholar 

  7. 7.

    Haher TR, Merola A, Zipnick RI, et al. Meta-analysis of surgical outcome in adolescent idiopathic scoliosis. A 35-year English literature review of 11,000 patients. Spine (Phila Pa 1976). 1995; 20(14): 1575-1584.

    CAS  Article  Google Scholar 

  8. 8.

    Hoashi JS, Cahill PJ, Bennett JT, et al. Adolescent scoliosis classification and treatment. Neurosurg Clin N Am. 2013; 24(2): 173-183.

    Article  PubMed  Google Scholar 

  9. 9.

    Hong JY, Suh SW, Modi HN, et al. Centroid method: reliable method to determine the coronal curvature of scoliosis: a case control study comparing with the Cobb method. Spine (Phila Pa 1976). 2011; 36(13): E855-E861.

    Article  Google Scholar 

  10. 10.

    Hong JY, Suh SW, Yang JH, et al. Reliability analysis of shoulder balance measures: comparison of the 4 available methods. Spine (Phila Pa 1976). 2013; 38(26): E1684-E1690.

    Article  Google Scholar 

  11. 11.

    Ilharreborde B, Even J, Lefevre Y, et al. How to determine the upper level of instrumentation in Lenke types 1 and 2 adolescent idiopathic scoliosis: a prospective study of 132 patients. J Pediatr Orthop. 2008; 28(7): 733-739.

    Article  PubMed  Google Scholar 

  12. 12.

    Kim YJ, Lenke LG, Bridwell KH, et al. Proximal junctional kyphosis in adolescent idiopathic scoliosis after 3 different types of posterior segmental spinal instrumentation and fusions: incidence and risk factor analysis of 410 cases. Spine (Phila Pa 1976). 2007; 32(24): 2731-2738.

    Article  Google Scholar 

  13. 13.

    King HA, Moe JH, Bradford DS, et al. The selection of fusion levels in thoracic idiopathic scoliosis. J Bone Joint Surg Am. 1983; 65(9): 1302-1313.

    CAS  PubMed  Google Scholar 

  14. 14.

    Kuklo TR, Lenke LG, Graham EJ, et al. Correlation of radiographic, clinical, and patient assessment of shoulder balance following fusion versus nonfusion of the proximal thoracic curve in adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2002; 27(18): 2013-2020.

    Article  Google Scholar 

  15. 15.

    Kuklo TR, Lenke LG, Won DS, et al. Spontaneous proximal thoracic curve correction after isolated fusion of the main thoracic curve in adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2001; 26(18): 1966-1975.

    CAS  Article  Google Scholar 

  16. 16.

    Lee CK, Denis F, Winter RB, et al. Analysis of the upper thoracic curve in surgically treated idiopathic scoliosis. A new concept of the double thoracic curve pattern. Spine (Phila Pa 1976). 1993; 18(12): 1599-1608.

    CAS  Article  Google Scholar 

  17. 17.

    Lenke LG, Betz RR, Haher TR, et al. Multisurgeon assessment of surgical decision-making in adolescent idiopathic scoliosis: curve classification, operative approach, and fusion levels. Spine (Phila Pa 1976). 2001; 26(21): 2347-2353.

    CAS  Article  Google Scholar 

  18. 18.

    Lenke LG, Bridwell KH, O’Brien MF, et al. Recognition and treatment of the proximal thoracic curve in adolescent idiopathic scoliosis treated with Cotrel-Dubousset instrumentation. Spine (Phila Pa 1976). 1994; 19(14): 1589-1597.

    CAS  Article  Google Scholar 

  19. 19.

    Li M, Gu S, Ni J, et al. Shoulder balance after surgery in patients with Lenke Type 2 scoliosis corrected with the segmental pedicle screw technique. J Neurosurg Spine. 2009; 10(3): 214-219.

    Article  PubMed  Google Scholar 

  20. 20.

    Luk KD, Don AS, Chong CS, et al. Selection of fusion levels in adolescent idiopathic scoliosis using fulcrum bending prediction: a prospective study. Spine (Phila Pa 1976). 2008; 33(20): 2192-2198.

    Article  Google Scholar 

  21. 21.

    Nash CL Jr, Moe JH. A study of vertebral rotation. J Bone Joint Surg Am. 1969; 51(2): 223-229.

    PubMed  Google Scholar 

  22. 22.

    Ono T, Bastrom TP, Newton PO. Defining 2 components of shoulder imbalance: clavicle tilt and trapezial prominence. Spine (Phila Pa 1976). 2012; 37(24): E1511-E1516.

    Article  Google Scholar 

  23. 23.

    Pahys JM, Samdani AF, Betz RR, Trobisch PD, Garg H, Newton PO, Marks MC, Bastrom T, Harms Study Group, Cahill PJ. Assessment of proximal junctional kyphosis and shoulder balance with proximal screws vs. hooks in posterior spinal fusion for adolescent idiopathic scoliosis. Spine: Affiliated Society Meeting Abstracts 2011;Podium Presentation Abstracts:58.

  24. 24.

    Poncet P, Delorme S, Ronsky JL, et al. Reconstruction of laser-scanned 3D torso topography and stereoradiographical spine and rib-cage geometry in scoliosis. Comput Methods Biomech Biomed Eng. 2000; 4(1): 59-75.

    CAS  Article  Google Scholar 

  25. 25.

    Qiu XS, Ma WW, Li WG, et al. Discrepancy between radiographic shoulder balance and cosmetic shoulder balance in adolescent idiopathic scoliosis patients with double thoracic curve. Eur Spine J. 2009; 18(1): 45-51.

    PubMed Central  Article  PubMed  Google Scholar 

  26. 26.

    Smith PL, Donaldson S, Hedden D, et al. Parents’ and patients’ perceptions of postoperative appearance in adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2006; 31(20): 2367-2374.

    Article  Google Scholar 

  27. 27.

    Smyrnis PN, Sekouris N, Papadopoulos G. Surgical assessment of the proximal thoracic curve in adolescent idiopathic scoliosis. Eur Spine J. 2009; 18(4): 522-530.

    PubMed Central  Article  PubMed  Google Scholar 

  28. 28.

    Sponseller PD, Betz R, Newton PO, et al. Differences in curve behavior after fusion in adolescent idiopathic scoliosis patients with open triradiate cartilages. Spine (Phila Pa 1976). 2009; 34(8): 827-831.

    Article  Google Scholar 

  29. 29.

    Trobisch PD, Ducoffe AR, Lonner BS, et al. Choosing fusion levels in adolescent idiopathic scoliosis. J Am Acad Orthop Surg. 2013; 21(9): 519-528.

    Article  PubMed  Google Scholar 

  30. 30.

    Yagi M, Takemitsu M, Machida M. Clavicle chest cage angle difference (CCAD): a novel predictor of postoperative shoulder imbalance in patient with adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2013.

  31. 31.

    Yang S, Feuchtbaum E, Werner BC, et al. Does anterior shoulder balance in adolescent idiopathic scoliosis correlate with posterior shoulder balance clinically and radiographically? Eur Spine J. 2012; 21(10): 1978-1983.

    PubMed Central  Article  PubMed  Google Scholar 

Download references

Disclosures

Conflict of Interest

Benjamin T. Bjerke, MD, MS, Zoe B. Cheung, MS, Grant D. Shifflett, MD, Sravisht Iyer, MD, Peter B. Derman, MD, MBA, and Matthew E. Cunningham, MD, PhD have declared that they have no conflict of interest.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5).

Informed Consent

Informed consent was obtained from all patients for being included in the study.

Required Author Forms

Disclosure forms provided by the authors are available with the online version of this article.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Benjamin T. Bjerke MD, MS.

Additional information

Level of Evidence: IV

Electronic supplementary material

Below is the link to the electronic supplementary material.

ESM 1

(PDF 1224 kb)

ESM 2

(PDF 1224 kb)

ESM 3

(PDF 1224 kb)

ESM 4

(PDF 1224 kb)

ESM 5

(PDF 1224 kb)

ESM 6

(PDF 1224 kb)

ESM 7

(PDF 1224 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Bjerke, B.T., Cheung, Z.B., Shifflett, G.D. et al. Do Current Recommendations for Upper Instrumented Vertebra Predict Shoulder Imbalance? An Attempted Validation of Level Selection for Adolescent Idiopathic Scoliosis. HSS Jrnl 11, 216–222 (2015). https://doi.org/10.1007/s11420-015-9451-y

Download citation

Keywords

  • shoulder balance
  • validation of expert opinion
  • adolescent idiopathic scoliosis
  • deformity correction
  • radiographic shoulder height
  • T1 tilt
  • upper instrumented vertebra
  • level selection
  • proximal thoracic curve correction