Should L3 be selected as the lowest instrumented vertebra in patients with Lenke type 5C adolescent idiopathic scoliosis whose lowest end vertebra is L4?

Tomohiro Banno MD, PhD1, Yu Yamato MD, PhD1, Hiroki Oba MD, PhD2, Tetsuro Ohba MD, PhD3, Tomohiko Hasegawa MD, PhD1, Go Yoshida MD, PhD1, Hideyuki Arima MD, PhD1, Shin Oe MD, PhD1, Yuki Mihara MD, PhD1, Hiroki Ushirozako MD, PhD1, Jun Takahashi MD, PhD2, Hirotaka Haro MD, PhD3, and Yukihiro Matsuyama MD, PhD1
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  • 1 Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka;
  • | 2 Department of Orthopaedic Surgery, Shinshu University, Matsumoto, Nagano; and
  • | 3 Department of Orthopaedic Surgery, Yamanashi University, Chuo, Yamanashi, Japan
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OBJECTIVE

L3 is most often selected as the lowest instrumented vertebra (LIV) to conserve mobile segments in fusion surgery; however, in cases with the lowest end vertebra (LEV) at L4, LIV selection as L3 could have a potential risk of correction loss and coronal decompensation. This study aimed to compare the clinical and radiographic outcomes depending on the LEV in adolescent idiopathic scoliosis (AIS) patients with Lenke type 5C curves.

METHODS

Data from 49 AIS patients with Lenke type 5C curves who underwent selective thoracolumbar/lumbar (TL/L) fusion to L3 as the LIV were retrospectively analyzed. The patients were classified according to their LEVs into L3 and L4 groups. In the L4 group, subanalysis was performed according to the upper instrumented vertebra (UIV) level toward the upper end vertebra (UEV and 1 level above the UEV [UEV+1] subgroups). Radiographic parameters and clinical outcomes were compared between these groups.

RESULTS

Among 49 patients, 32 and 17 were in the L3 and L4 groups, respectively. The L4 group showed a lower TL/L curve correction rate and a higher subjacent disc angle postoperatively than the L3 group. Although no intergroup difference was observed in coronal balance (CB), the L4 group showed a significantly higher main thoracic (MT) and TL/L curve progression during the postoperative follow-up period than the L3 group. In the L4 group, the UEV+1 subgroup showed a higher absolute value of CB at 2 years than the UEV subgroup.

CONCLUSIONS

In Lenke type 5C AIS patients with posterior selective TL/L fusion to L3 as the LIV, patients with their LEVs at L4 showed postoperative MT and TL/L curve progression; however, no significant differences were observed in global alignment and clinical outcome.

ABBREVIATIONS

AIS = adolescent idiopathic scoliosis; AVT = apical vertebral translation; CB = coronal balance; CSVL = central sacral vertical line; LEV = lowest end vertebra; LIV = lowest instrumented vertebra; LL = lumbar lordosis; LSTOA = lumbosacral takeoff angle; MT = main thoracic; RSH = radiographic shoulder height; SDA = subjacent disc angle; SRS-22r = 22-item Scoliosis Research Society questionnaire (revised); TK = thoracic kyphosis; TLK = thoracolumbar kyphosis; TL/L = thoracolumbar or lumbar; UEV = upper end vertebra; UEV+1 = 1 level above the UEV; UIV = upper instrumented vertebra.

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Contributor Notes

Correspondence Tomohiro Banno: Hamamatsu University School of Medicine, Shizuoka, Japan. tomohiro.banno0311@gmail.com.

INCLUDE WHEN CITING Published online July 9, 2021; DOI: 10.3171/2020.11.SPINE201807.

Disclosures Drs. Yamoto and Oe work in a laboratory in the Division of Geriatric Musculoskeletal Health at Hamamatsu University School of Medicine that is funded by: Meitoku Medical Institute Jyuzen Memorial Hospital, Shizuoka, Japan; Japan Medical Dynamic Marketing Inc., Tokyo, Japan; and Medtronic Sofamor Danek USA, Inc., Memphis, TN.

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