SRS 57th ANNUAL MEETING 2022/09/16

Simultaneous Hypercorrection of Lowest Instrumented Vertebral Tilt

and Main Thoracic Curve is Related to Progression of Unfused Residual
Lumbar Curve after Posterior Fusion in Adolescent Idiopathic Scoliosis

I-Hsin Chen1 Chih-Wei Chen1 Ming-Hsiao Hu1 Po-Yao Wang1 Yu-Cheng Yeh2
Yuan-Fuu Lee1 Po-Liang Lai2 Shu-Hua Yang1
1
Department of Orthopedics, National Taiwan University College of Medicine and National
Taiwan University Hospital
2
Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
2
Disclosures
 The authors have NO financial relationship(s) with an
ineligible company producing healthcare goods or
services.
3
Introduction
 Selective thoracic fusion (STF) as a treatment option for correction of main thoracic
AIS since 1958[1]

 Simultaneous correction of the uninstrumented lumbar curve durable for at least 10

years[2]

 Accurate prediction of simultaneous lumbar curve correction remains difficult

 Factors related to potential progression of unfused lumbar curves (LCs) aren't clear
4
Purpose and Hypothesis
 In AIS patients who underwent thoracic curve fusion (TCF):

 Purpose

• To establish an optimized model for predicting the postoperative magnitude of residual LCs

• To disclose specific radiographic variables related to postoperative progression of residual LCs

 Hypothesis

• LIV tilt affects the postoperative magnitude and progression of residual LCs.

• Hyper-correction may lead to rebound phenomenon of residual LCs.

5
Patients Selection
 Inclusion criteria:
• Lenke type 1,2,3, or 4 with lumbar modifier A,B or C
(Except for type 1/2 A-R)
• Posterior spinal fusion (PSF) with LIV at or above L1
• Age at surgery ≥ 10 years
• Minimum follow-up for 2 years
6
Radiographic Parameters
 Cobb angle: thoracic, TL/L curves
 LC-bending: LC at bending films
 LSTOA: lumbosacral takeoff angle[3]
 LIV-tilt: tilt of lowest instrumented vertebra on coronal plane
 Progression:
• > 5 degrees change over lumbar Cobb angle at final follow up
• Adding-on phenomenon
7
Statistical Analysis
Multivariate linear regression analysis to establish the prediction
model

Mann-Whitney U test and Chi-square test for comparison between

progressive and non-progressive group

Sensitivity analysis for best cut-off point predicting curve progression

8

 Immediate postoperative thoracolumbar/lumbar Cobb =−3.54+0.102 preoperative thoracolumbar/lumbar Cobb+

0.0703 preoperative LC-bending+0.598 preoperative lumbosacral takeoff angle+0.828 immediate postoperative LIV tilt.
Overall formula R2= 0.86 (R = 0.93), P < 0.0001.

 Final thoracolumbar/lumbar Cobb =−2.49+0.283 preoperative thoracolumbar/lumbar Cobb+

0.360 preoperative lumbosacral takeoff angle+0.543 immediate postoperative LIV tilt.
Overall model R2= 0.58 (R =0.77), P < 0.0001.
9
10
11
12
 13

OR=16.3, 95% CI= 5.3 - 50.1; OR=17.5, 95% CI=6.6 - 46.2;

Sensitivity=89%, Specificity=67%, PPV=51%, NPV=94% Sensitivity=81%, Specificity=81%, PPV=62%, NPV=92%
14
Discussion
Best-fit equations, binary models, and decision tree have been formulated;
however, only with modest accuracy[4-7]

The variables used in previous studies have never been examined together or
analyzed systemically.

Although hypercorrection of MTCs has been considered to lead to coronal

imbalance, the definition of hypercorrection has yet to be established.
15
Discussion
Preoperative TL/L Cobb angle: pre-operative status

Preoperative LC-bending angle: flexibility of LCs

Preoperative LSTA: rigidity of the lumbar spine

Immediate postoperative LIV tilt: intraoperative bending force

15

Cases Demonstrations

 Patient #1: 13F, Lenke 1BN

Postoperative-LIV-tilt = 11°
* (-) for criterion < 10°
MTC-correction-ratio = 60%
* (+) for criterion > 53%

* Progression (-)
16

Cases Demonstrations

 Patient #2: 13F, Lenke 1BN

Postoperative-LIV-tilt = 3°
* (+) for criterion < 10°
MTC-correction-ratio = 45%
* (-) for criterion > 53%

* Progression (-)
17

Cases Demonstrations

 Patient #3: 11F, Lenke 2BN

Postoperative-LIV-tilt = 5°
* (+) for criterion < 10°
MTC-correction-ratio = 67%
* (+) for criterion > 53%

* Progression (+)
18

Cases Demonstrations

 Patient #4: 12F, Lenke 1AL

Postoperative-LIV-tilt = 6°
* (+) for criterion < 10°
MTC-correction-ratio = 68%
* (+) for criterion > 53%

* Adding-on (+)
20
Conclusion
In AIS patients who underwent PSF with LIV at or above L1 (TCF):

LIV tilt, as an operable factor during AIS surgery, is not only a determinant in
prediction models showing high correlation with the magnitude of postoperative LCs
but also a predictor for progression of residual LCs.

“Immediate postoperative LIV-tilt angle <10 0 and correction rate of MTC Cobb angle
>53%” as a united criterion, serves as a predictor with moderate discrimination for
progression of residual LCs.
21
References
1. Moe JH. J Bone Joint Surg Am. 1958
2.Craig LJ. J Bone Joint Surg Am. 2019
3.Keith RB. J Bone Joint Surg Am. 2019
4.Mason DE. J Pediatr Orthop. 1998
5.Koller H. Eur Spine J. 2019
6.Bachmann KR. J Bone Joint Surg Am. 2020
7.Pasha S. Eur J Orthop Surg Traumatol. 2020