Sacral slanting—defined as the oblique tilt of the upper sacral endplate measurable on standing anteroposterior whole-spine radiographs—is a distinctive and clinically underappreciated finding in adolescent idiopathic scoliosis (AIS). Its etiology is multifactorial and incidence among AIS patients reaches 40%. The direction and degree of sacral slanting interact with the distal lumbar curve type (L4-left vs. L4-right) to influence the pattern of postoperative radiographic changes at the distal spine and shoulder. In patients with L4-left curves and left-sided slanting, stopping fusion at L3 generally prevents coronal decompensation. Furthermore, 5-year data show that the disc wedge angle below the lowermost instrumented vertebra (LIV) does not progress when LIV is L3, and patient-reported outcomes are preserved without revision surgery. When fusion extends to L4 in patients with high sacral slanting, coronal decompensation is more frequent, yet functional outcomes remain comparable and no revision has been required in published series to date, indicating that the decompensation observed is radiographically significant but clinically tolerable within the medium term. In Lenke 1A patients with right-sided sacral slanting (L4-right type), the slanting lowers the last touching vertebra and may facilitate distal adding-on. In Lenke 2A patients with right-sided slanting, distal adding-on serves as a natural shoulder-rebalancing mechanism and may be reasonably monitored conservatively rather than reflexively treated, pending further validation in independent cohorts, unless progressive or symptomatic. Across all scenarios, the optimal distal fusion level remains an unresolved dilemma requiring further long-term prospective study. This review synthesizes the available literature to characterize sacral slanting as a promising radiographic parameter that may serve as a potentially useful adjunct in distal fusion level planning, while highlighting the need for prospective multicenter validation before its routine incorporation into surgical decision-making in AIS.
Objective To investigate feasibility and effectiveness of minimally invasive scoliosis surgery (MISS) via posterior approach in patients with adolescent idiopathic scoliosis (AIS) presenting with very severe curve exceeding 80°.
Methods A total of 257 flexible AIS patients who underwent deformity correction using posterior MISS were retrospectively categorized into 3 groups based on the curve magnitude: moderate (M group, main Cobb angle <60°, n=142), severe (S group, 60°–80°, n=91), and very severe (VS group, ≥80°, n=24). Radiological parameters, perioperative outcomes, and complication rates were compared among the 3 groups.
Results The VS group required significantly longer operative times (p<0.001), more fused segments (p<0.001), and a greater number of rib resections during thoracoplasty (p=0.032) compared to the other groups. Despite these surgical demands, there were no statistical differences in the correction rate (p=0.954) and last follow-up thoracic kyphosis (p=0.830) among the 3 groups. Regarding complications, while the overall complication rate showed no statistical difference, the VS group required significantly more invasive management for pleural effusions (p=0.012).
Conclusion Posterior MISS demonstrated acceptable radiological and perioperative outcomes even in flexible AIS with Cobb angles ≥80°. These findings suggest the posterior MISS can be a feasible surgical option for selected very severe AIS patients with sufficient flexibility.
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Objective This study aimed to explore the correlation between balance function and core muscle activation in patients with adolescent idiopathic scoliosis (AIS), compared to healthy individuals.
Methods A total of 24 AIS patients and 25 healthy controls were recruited. The limits of stability (LOS) test were conducted to assess balance function, while surface electromyography was used to measure the activity of core muscles, including the internal oblique, external oblique, and multifidus. Diaphragm thickness was measured using ultrasound during different postural tasks. Center of pressure (COP) displacement and trunk inclination distance were also recorded during the LOS test.
Results AIS patients showed significantly greater activation of superficial core muscles, such as the internal and external oblique muscles, compared to the control group (p < 0.05). Diaphragm activation was lower in AIS patients during balance tasks (p < 0.01). Although no significant difference was observed in COP displacement between the groups, trunk inclination was significantly greater in the AIS group during certain tasks (p < 0.05).
Conclusion These findings suggest distinct postural control patterns in AIS patients, highlighting the importance of targeted interventions to improve balance and core muscle function in this population.
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Objective To explore the changes in coronal imbalance (CIB) in Lenke 5C adolescent idiopathic scoliosis (AIS) after posterior selective fusion surgery and determine their implications for surgical decision-making.
Methods One hundred twenty patients were categorized according to the preoperative coronal pattern (type A, coronal balance distance [CBD]<20 mm; type B, CBD≥20 mm and coronal C7 plumbline [C7PL] shifted to the concave side of the curve; type C, CBD≥20 mm and C7PL shifted to the convex side of the curve). CIB group (CIB+) was defined as having a CBD≥20 mm at the 2-year follow-up.
Results Compared to type A patients, the prevalence of postoperative CIB was higher in type C patients both immediately postoperative (22% vs. 38%, p<0.05) and at the final follow-up (5% vs. 29%, p<0.05), whereas type A patients showed a greater improvement in CBD (9 of 12 vs. 6 of 24, p<0.05) at the final follow-up. The majority of patients in all groups had recovered to type A at the final follow-up (96 of 120). The proximal Cobb-1 strategy reduced the incidence of postoperative CIB (1 of 38) at the 2-year follow-up, especially in preoperative type C patients. Multivariate logistic regression analysis revealed that type C and overcorrection of the thoracolumbar curve were risk factors for CIB at the 2-year follow-up (p=0.007 and p=0.026, respectively).
Conclusion Patients with type C CIB in AIS exhibited unsatisfactory restoration, with 29% of them exhibiting CIB at the final follow-up. The selective fusion strategy of proximal Cobb-1 may reduce the risk of postoperative CIB especially when the preoperative coronal pattern is type C.
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Objective Even minor sacral slanting can influence T1 tilt and shoulder balance. Yet, the relationship between sacral slanting and postoperative shoulder imbalance (PSI) has not been previously explored. To determine risk factors for PSI in Lenke 2A adolescent idiopathic scoliosis (AIS) patients, with an emphasis on sacral slanting.
Methods The study encompassed 96 consecutive patients who had undergone posterior correction and fusion surgery for Lenke type 2A AIS. Patients were grouped into PSI(+) and PSI(-) based on postoperative outcomes. Additionally, they were classified into left-sided slanting, no slanting, and right-sided slanting groups according to the degree of sacral slanting. Various radiological measures were compared.
Results Patients in the PSI(+) group exhibited a smaller preoperative proximal thoracic curve and a higher main thoracic curve correction rate than those in the PSI(-) group. The presence or absence of sacral slanting did not exhibit a significant variation in PSI occurrence. However, the right-sided sacral slanting group showed a larger delta radiologic shoulder height compared to the other 2 groups (7.1 mm vs. 1.5 & 3.3 mm).
Conclusion Sacral slanting was not directly linked to the development of PSI. Despite the common postoperative elevation of the left shoulder, the shoulder height differences decreased over the follow-up period. Especially in cases with a right-sided tilted sacrum, the PSI demonstrated progressive improvement, with an associated increase in the rightward distal wedging angle, leading to distal adding-on.
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Objective To compare the radiological outcomes in Lenke 5C type patients whose lowest instrumented vertebra (LIV) was L3 or L4 in a case-match study.
Methods We conducted a retrospective case-match study and included 82 patients in the study. Radiological results before surgery, after surgery, and at last follow-up were recorded and analyzed in the L3 and L4 groups.
Results After matching the age, Risser’s sign, sex, and main Cobb, 41 pairs of patients were enrolled in our study. The total fusion segments in the L3 group (median [interquartile range]: 5.0 [6.0–5.0]) were shorter than those in the L4 group (6.0 [6.5–6.0]). The main curve was significantly corrected after surgery in both groups, and was comparable at the last followup between groups. In addition, according to the results of Fisher precision probability test, there was no significant difference of coronal or sagittal imbalance between the 2 groups at the 2-year follow-up.
Conclusion The correction in coronal and sagittal planes in L3 group and L4 group remains similar. On account of more motion segments, L3 could be an ideal choice as LIV in moderate Lenke 5C type AIS. Long-term follow-up is needed to evaluate the effect of larger compensatory lumbar-sacral curve when stopping at L3.
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Adolescent idiopathic scoliosis (AIS) affects approximately 2% of adolescents across all ethnicities. The objectives of surgery for AIS are to halt curve progression, correct the deformity in 3 dimensions, and preserve as many mobile spinal segments as possible, avoiding junctional complications. Despite ongoing development in algorithms and classification systems for the surgical treatment of AIS, there is still considerable debate about selecting the appropriate fusion level. In this study, we review the literature on fusion selection and present current concepts regarding the lower instrumented vertebra in the selection of the fusion level for AIS surgery.
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Objective To determine whether the last touched vertebra (LTV) on supine radiographs is suitable for the lower instrumented vertebra (LIV) in adolescent idiopathic scoliosis (AIS) correction surgery.
Methods In total, 57 patients were included in the study following posterior instrumentation and fusion. The average follow-up period was 2.2 years. Patients were classified into 4 groups according to the relationship of the location of LIV, LTV, and the last substantially touched vertebra (LSTV) on upright radiographs and the LTV on supine radiographs. In group 1, the upright LTV and supine LTV were the same. Group 1 was subdivided into group 1A and group 1B according to whether the LTV and LSTV were different or the same, respectively. In group 2, the upright LTV was selected as the LIV, whereas in group 3, the supine LTV was selected as the LIV. The baseline characteristics and the preoperative and postoperative radiographic/clinical outcomes of the groups were analyzed.
Results No differences were found in the preoperative clinical and radiographic baseline characteristics of the 4 groups except the LIV-central sacral vertical line distance. The immediate, 6-month, 1-year, and 2-year postoperative outcomes were not significantly different among the 4 groups. One patient (4.3%) in group 1A experienced radiographic addingon without clinical symptoms. No patients underwent revision surgery.
Conclusion The group in whom the LIV was selected as the LTV on supine x-rays showed similar postoperative radiographic and clinical results to other groups. The LTV on preoperative supine radiographs is acceptable as the LIV in AIS surgery to maximize motion segments.
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Objective To evaluate the effect of Milwaukee brace treatment on adolescents with idiopathic scoliosis (AIS) with large curves (40° to 55°) who refuse to do surgery.
Methods In this retrospective cohort study, we gathered the clinical records of all adolescents with AIS with an initial curve of 40° to 55°. They had been referred to our center from December 1990 to January 2017. Although they had been advised to do surgery, they had all refused to do it. Their clinical data were recorded, such as sex, age, Risser sign, scoliosis, and kyphosis curve magnitude (at the beginning of brace treatment, weaning time, brace discontinuation, and minimum of 2 years after the treatment). Based on treatment success, the patients were divided into 2 groups: progressed and nonprogressed.
Results Sixty patients with an average initial Cobb angle of 44.93° ± 4.86° were included. The curve progressed in 57%, stabilized in 25%, and improved in 18% of the patients. In the progressed group (34 patients), 31 patients had undergone surgery. There was no significant association between the age of beginning the brace treatment and the final Cobb angle of nonprogressed group (p > 0.05). However, in-brace correction and initial Risser sign had a significant correlation with curve magnitude at the final follow-up (p < 0.05).
Conclusion Brace treatment seems to be effective in controlling the further curve progression in AIS with 40° and 55° curves. Our results can help physicians make sound decisions about the patients with larger curves who refuse to do surgery.
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Objective To compare and identify risk factors for distal adding-on (AO) or distal junctional kyphosis (DJK) in adolescent idiopathic scoliosis (AIS) treated by anterior- (ASF) and posterior spinal fusion (PSF) to L3.
Methods AIS patients undergoing ASF versus PSF to L3 from 2000–2010 were analyzed. Distal AO and DJK were deemed poor radiographic results. New stable (SV) and neutral vertebra (NV) scores were defined for this study. The total stability (TS) score was the sum of the SV and NV scores.
Results Twenty of 42 (ASF group: 47.6%) and 8 of 72 patients (PSF group: 11.1%) showed poor radiographic outcome. Fused vertebrae, correction rate of main curve, coronal reduction rate of L3 were significantly higher in PSF group. Multiple logistic regression results indicated that preoperative SV-3 at L3 in standing and side benders (odds ratio [OR], 2.7 and 3.7, respectively), TS score -5, -6 at L3 (OR, 4.9), rigid disc at L3–4 (OR, 3.7), lowest instrumented vertebra (LIV) rotation > 15° (OR, 3.3), LIV deviation > 2 cm from center sacral vertical line (OR, 3.1) and ASF (OR, 13.4; p < 0.001) were independent predictive factors. There was significant improvement of the Scoliosis Research Society (SRS)-22 average scores only in PSF group. Furthermore, the ultimate scores of PSF group were significantly superior to ASF group.
Conclusion The prevalence of AO or DJK at ultimate follow-up for AIS with LIV at L3 was significantly higher in ASF group. Ultimate SRS-22 scores were significantly better in PSF group.
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Objective To examine existing literature and pool the data to determine the relative odds ratio of “adding-on” (AO) based on various reported criteria for lower instrumented vertebra (LIV) selection in Lenke type 1A and 2A curves.
Methods Using electronic databases, studies reporting on AO and LIV selection in Lenke type 1A and 2A curves were identified. Studies were excluded if they failed to meet the following criteria: ≥ 30 patients, Lenke type 1A or 2A curves, thoracic-only fusions, and inclusion of outcome differences in AO and non-AO groups. Review articles, letters, and case reports were excluded.
Results Six studies were identified reporting on 732 patients with either Lenke type 1A or 2A curves treated with thoracic-only fusions. Five different landmarks were used for LIV selection in these studies including the stable vertebra (SV) -1, end vertebra (EV) +1, neutral vertebra (NV), touched vertebra (TV), and substantially touched vertebra (STV) versus nonsubstantially touched vertebra (nSTV) +1. The pooled odds ratios of AO for choosing LIV at levels above the afore landmarks (i.e. , ending the construct “short”) versus at the landmarks were 2.59 (SV-1), 2.43 (EV+1), 3.05 (NV), 3.40 (TV), and 4.52 (STV/nSTV+1), all at 95% confidence interval.
Conclusion Five landmarks shared a similar characteristic in that the incidence of AO was significantly higher if the LIV was proximal to the chosen landmark. In addition, choosing STV/(nSTV+1) as the LIV have the lowest absolute risk of AO and the greatest risk reduction. If additional levels were fused (i.e. , LIV distal to the landmark), there was no statistically significant benefit in further reducing the risk of AO. Selection of the optimal LIV is a complex issue and spine surgeons must balance the risk of AO with the need for motion preservation in young patients.
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Methods Two independent observers measured the Cobb angles for 123 curves on 83 consecutive long radiographs of patients with AIS using both Oxford Cobbmeter and digital computer software (Surgimap). The measurements were repeated a week. Curves were classified according to the severity into mild, moderate, and severe. The results were statistically analyzed for intraobserver and interobserver reliability
Results The mean Cobb angle was 48.12° ± 19.75° (range, 10.54°–110.76°). Globally the results of curve measurements were comparable between and within both observers using both methods, with small mean differences. According to intraclass correlation coefficient, there was high inter- and intraobserver high agreement for both methods. All readings were > 0.9. There was a good interobserver (κ = 0.745, 0.693) and a very good interobserver agreement (κ = 0.810, 0.804) for both methods for curve classification. However, poor agreement was observed as regards to the measurement time, being less with Oxford Cobbometer.
Conclusion The results of this study indicate that the Surgimap digital computer software measurement is an equivalent measuring tool to the Oxford Cobbmeter in Cobb angle measurement. Both have high intra and interobserver agreement for measurement and for curve classification, with small measurement differences. Oxford Cobbmeter is advantageous in being quicker, and therefore it is the method of choice for manual measurement, where PACS (patient archiving and communication system) or digital system is not available.
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Objective Magnetic resonance imaging (MRI)-verified neural axis abnormalities (NAAs) have been described in adolescent idiopathic scoliosis (AIS), and several risk factors have been associated with the presence of NAAs in AIS patients. However, the clinical significance of these findings is unclear. The purpose of the present study was to determine the prevalence of NAAs in a large consecutive cohort of AIS patients and to evaluate the clinical significance of previously proposed risk factors.
Methods We prospectively included AIS patients referred to a tertiary facility for evaluation. Full-spine MRI scans were performed on all included patients irrespective of curve magnitude or proposed treatment modality. MRI scans were prospectively analyzed by a neuroradiologist and the pathologic findings were confirmed by a second independent radiologist.
Results NAA was observed in 34 of the 381 patients (8.9%): 32 patients had a syrinx, 1 patient had an arachnoid cyst, and 1 patient had a Chiari malformation. Four patients were referred for a neurosurgical evaluation but none received any neurosurgical treatment. No statistically significant difference was observed between the NAA and non-NAA groups in terms of sex, major curve size, thoracic kyphosis, left thoracic curve, curve convexity, curve progression, or level of pain (p>0.05).
Conclusion In this prospective study examining the risk factors for NAA in AIS patients, we found that previously proposed risk factors could not predict the MRI outcomes. The finding of an NAA had no clinical implications and we do not support MRI scans as a routine diagnostic modality in all AIS patients.
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Following Dwyer introduction of anterior spinal instrumented fusion surgery, Zielke, Moss-Miami, and Kaneda had made a significant progression on anterior spinal instrumented fusion which allowed excellent correction without significant loss of correction or implant failure. King and Moe deveoped classification of thoracic major curve following Harrington rod intrumentation. King classification presented a stable vertebra concept and selective fusion concept. Surgical classification of Adolescent Idiopathic Scoliosis (AIS) developed by Harms study group provided a more sophisticated two dimensional understanding of curve nature. Surgical intervention of adult scoliosis and sagittal imbalance is still challenging and evolving.
Several evidences such as sacropelvic fixation and bone morphogenetic protein helped us to deal with adult deformity. The surgical decision making on spinal deformity surgery is still yet evolving.
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