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Severe persistent coronal imbalance following instrumented posterior spinal fusion for adolescent idiopathic scoliosis

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Abstract

Study design

Retrospective case–control study.

Objective

The aim of this study was to identify the risk factors and health-related quality of life (HRQoL) impact of severe (> 4 cm) post-operative coronal imbalance at 2 years following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

Summary of background data

Coronal imbalance is an unfavorable outcome following PSF for AIS, though the degree of imbalance in such patients is typically mild. We hypothesize that a small number of patients become and remain severely imbalanced post-operatively, though this phenomenon has not been well studied.

Methods

Prospectively collected data from a large multicenter registry were reviewed. Patients with severe coronal imbalance (SCIB; > 4 cm) 2 years after PSF were included. Matched controls without SCIB at 2 years were included at a 3:1 ratio. Comparisons were made between demographics, pre-operative radiographic measures, surgical factors, residual post-operative radiographic measures, and 2-year SRS-22 scores.

Results

Nine of 954 (0.9%) patients (88.9% females; mean age 14.8 ± 2.3 years) were found to be severely imbalanced at 2 years. These patients had significantly greater pre-operative bending thoracic curve magnitude (45° vs. 33°; p = 0.013), curve flexibility (22.9% vs. 63.3%; p = 0.004), and kyphosis (41° vs. 26.5°; p = 0.034) compared to matched controls. Pre-operative curve flexibility of < 20% was associated with a 23.8 times greater odds of SCIB (95% CI 2.1—250; p = 0.008). With respect to HRQoL, median SRS-22 pain (4.1 vs. 4.8; p = 0.041), self-image (3.9 vs. 4.6; p = 0.013), general function (4.5 vs. 5; p = 0.022), and total (4.1 vs. 4.7; p = 0.012) scores at 2 years were significantly lower in cases compared to controls.

Conclusions

In the present study, thoracic curve stiffness was a strong risk factor for severe post-operative coronal imbalance, which was associated with poor HRQoL measures. Increased pre-operative thoracic curve stiffness (< 20% flexibility) should raise surgeon awareness for altering surgical approach to minimize the risk of severe post-operative coronal imbalance.

Level of evidence

Level III.

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Funding

The main institution receives funding from the Setting Scoliosis Straight Foundation in support of Harms Study Group research. IRB approval: This study was approved by the Institutional Review Board.

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Authors and Affiliations

  1. Children’s Hospital of Philadelphia, Philadelphia, PA, USA

    Jason B. Anari, Scott M. LaValva, John M. Flynn & Aaron M. Tatad

  2. Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA

    Scott M. LaValva

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  1. Jason B. Anari
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the Harms Study Group

Contributions

Conception or design of work: JBA and JMF. Acquisition, analysis, or interpretation of data for the work: JBA, SML, AMT, and JMF. Drafting of work or revising it critically for important intellectual content: JBA, SML, JMF, and HSG. Final approval of version to be published: JBA, SML, AMT, JMF, and HSG.

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Correspondence to John M. Flynn.

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Anari, J.B., LaValva, S.M., Flynn, J.M. et al. Severe persistent coronal imbalance following instrumented posterior spinal fusion for adolescent idiopathic scoliosis. Spine Deform 8, 1295–1304 (2020). https://doi.org/10.1007/s43390-020-00153-x

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