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Disc Degeneration in Unfused Caudal Motion Segments Ten Years Following Surgery for Adolescent Idiopathic Scoliosis

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Abstract

Hypothesis

The frequency of disc degeneration (DD) in the distal mobile segments will increase over time following surgery for adolescent idiopathic scoliosis (AIS).

Design

Retrospective review of a prospective AIS registry.

Introduction

Durability of surgical outcomes is essential for maintenance of quality of life as well as for family decision making and for assessment of the value of a healthcare intervention. We assessed DD, its risk factors, and association with health-related quality of life 10 years after AIS surgery.

Methods

Five radiographic indicators of DD, previously validated, were evaluated preoperatively and 1 month, 2, 5, and 10 years postoperatively by a radiologist in operative AIS patients. A composite radiographic score (CRS; range 0-10) was calculated using the sum of each of the DD indicators. The severity of CRS in relation to the time point after surgery and various risk factors were assessed using linear regression or Pearson χ2 test. CRS ≥3 was chosen to indicate significant DD. Association of CRS with SRS-22 outcome was evaluated by linear regression.

Results

193 consecutive patients (mean age at surgery 14.4 years; 86% female) were assessed. Surgical approach included 102 posterior and 91 anterior fusions. Contributors to maximum CRS at 10 years were Schmorl’s nodes (7.3% of patients), osteophytes (40.4%), sclerosis (29%), and irregular endplate (8.3%). CRS ≥3 occurred in 1.6%, 0.54%, 3.7%, 6.8%, and 7.3% of patients at the various time points (r 2=0.83, p=.0313), respectively. More than 50% of DD occurred at the second (35.5%) and third (20%) disc caudal to the LIV. LIV of L4 compared with more cephalad LIV had the highest risk of developing significant DD (27.3%; p=.0267). It was found that disc wedging subjacent to the LIV (≥5°) and LIV translation (≥2 cm) lead to a sixfold increase in significant DD (odds ratio=6.71 and 6.13, respectively). Severity of DD was not associated with the number of levels fused (p=.2131), the surgical approach (p=.8245), or the construct type (p=.2922). No significant association was established between 10-year CRS and SRS-22 scores.

Conclusion

In the first study of its kind, we found that only 7.3% of patients had significant DD 10 years after surgical correction of AIS. Rates of DD increased over time. Our data provide evidence to support recommendations to save as many caudal motion segments as possible, to avoid fusing to L4, and maintain the LIV tilt angle below 5° and LIV translation less than 2 cm.

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Authors and Affiliations

  1. Mount Sinai Hospital, 820 Second Avenue, Suite 7A, 10017, New York, NY, USA

    Baron S. Lonner MD, Yuan Ren PhD, Colin T. Dabrowski BS & Randal R. Betz MD

  2. Rady Children’s Hospital San Diego, 3020 Children’s Way, 92123, San Diego, CA, USA

    Vidyadhar V. Upasani MD, Michelle M. Marks MA & Peter O. Newton MD

  3. Shriners Hospital for Children, 3551 N Broad St, 19140, Philadelphia, PA, USA

    Amer F. Samdani MD

  4. Mount Sinai West, 1000 10th Ave, 10019, New York, NY, USA

    Karen Chen MD, Daniel R. Lefton MD & Hussein Nasser MD

  5. Miami Children’s Hospital, 3100 S.W. 62 Ave, Miami, FL 33155, USA, Miami, 33155, FL, USA

    Harry L. Shufflebarger MD

  6. Alfred I. duPont Hospital for Children, 1600 Rockland Rd, 19803, Wilmington, DE, USA

    Suken A. Shah MD

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  1. Baron S. Lonner MD
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  2. Yuan Ren PhD
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  3. Vidyadhar V. Upasani MD
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  4. Michelle M. Marks MA
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  13. Randal R. Betz MD
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Corresponding author

Correspondence to Baron S. Lonner MD.

Additional information

Author disclosures: BSL (grants from Setting Scoliosis Straight Foundation, during the conduct of the study; grants from Setting Scoliosis Straight Foundation; personal fees from DePuy Synthes Spine, K2M, Paradigm Spine, Spine Search, Ethicon, Zimmer Biomet, and Apifix; nonfinancial support from Spine Deformity Journal; grants from John and Marcella Fox Fund Grant, and Orthopaedic Research and Education Foundation [OREF], outside the submitted work), YR (grants from Setting Scoliosis Straight Foundation, during the conduct of the study), MMM (grants from DePuy Synthes Spine, during the conduct of the study; grants from K2M, Inc, EOS Imaging, Zimmer Biomet, Ellipse, SpineGuard, Stryker, Globus, Medtronic, NuVasive, Mazor Robotics, and Orthopediatrics, outside the submitted work), PON (grants from Setting Scoliosis Straight Foundation, during the conduct of the study; grants and other from Setting Scoliosis Straight Foundation; other from Rady Children’s Specialists; grants and personal fees from DePuy Synthes Spine; personal fees from Law firm of Carroll, Kelly, Trotter, Franzen & McKenna, Law Firm of Smith, Haughey, Rice & Roegge, and Thieme Publishing, Ethicon Endosurgery, Cubist, and K2M; grants from NIH, OREF, and EOS imaging; grants and other from the Scoliosis Research Society; other from NuVasive, Electrocore, International Orthopedic Think Tank, and Orthopediatrics Institutional Support, outside the submitted work; in addition, PON has a patent “Anchoring Systems and Methods for Correcting Spinal Deformities” (8540754) with royalties paid to DePuy Synthes Spine, a patent “Low Profile Spinal Tethering Systems” (8123749) issued to DePuy Spine, Inc, a patent “Screw Placement Guide” (7981117) issued to DePuy Spine, Inc, and a patent “Compressor for Use in Minimally Invasive Surgery” (7189244) issued to DePuy Spine, Inc), AFS (grants from DePuy Synthes Spine, during the conduct of the study; personal fees from DePuy Synthes Spine, Ethicon, Globus Medical, Misonix, Stryker, and Zimmer Biomet, outside the submitted work), KC (none), HLS (grants and personal fees from DePuy Synthes, during the conduct of the study; personal fees from K2M, outside the submitted work), SAS (grants from Setting Scoliosis Straight Foundation, during the conduct of the study; personal fees from DePuy Synthes Spine, outside the submitted work), DRL (none), HN (none), CTD (none), Randal R. Betz (grants from DePuy Synthes Spine, during the conduct of the study; personal fees and other from Abyrx, ApiFix, and SpineGuard; other from Advanced Vertebral Solutions, Electrocore, Medovex, MiMedx, and Orthobond; grants and personal fees from DePuy Synthes Spine; personal fees from Globus Medical, Medtronic, and MacKeith Publishers, outside the submitted work; his son Randal Betz Jr. is an employee of DePuy Synthes Spine).

Funding: Research Grant funding was received by Setting Scoliosis Straight Foundation to support Harms Study Group’s research.

IRB Approval: Institutional Review Board approval was obtained for this study from all participating sites.

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Lonner, B.S., Ren, Y., Upasani, V.V. et al. Disc Degeneration in Unfused Caudal Motion Segments Ten Years Following Surgery for Adolescent Idiopathic Scoliosis. Spine Deform 6, 684–690 (2018). https://doi.org/10.1016/j.jspd.2018.03.013

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