CHAPTER
Brett Freedman
85
Selective Thoracic Fusion
INTRODUCTION
Selection of fusion levels for adolescent idiopathic scoliosis
(AIS) has and continues to be one of the greatest challenges to
the scoliosis surgeon. The proper selection of fusion levels
requires a balance between two competing goals: improved
deformity correction and preservation of spinal mobility. The
ultimate goal is a balanced spine in both the coronal and sagit-
tal planes, while fusing as few motion segments as possible.
Nowhere is the tension between these two competing goals
more evident than in the treatment of patients with double
curves.
HISTORICAL BACKGROUND
In the preinstrumentation era, the typical surgical strategy was
arthrodesis of both curves from the upper T-spine (i.e., T4) to
L3-4. Curve progression, nonunion, and adjacent segment
degeneration were common occurrences and resulted in a
dampened enthusiasm for this approach.
Experience with Harrington instrumentation since the
1950s led Dr. Moe and others to identify specific curve types
that could be successfully treated with fusion of the thoracic
curve alone. Culminating this experience, King et al introduced
a five-part operative classification system in 1983.12 The system
identified scoliotic curves that could be successfully treated
with arthrodesis of the thoracic major curve alone, without
including the compensatory lumbar curve (King II and King III
curves).
Selective thoracic fusion refers to cases of AIS in which only
the vertebrae of the major thoracic curve are fused, typically
from upper end to lower end or the stable vertebra, leaving the
compensatory lumbar curve to partially correct spontaneously.
Strictly speaking, the term selective thoracic fusion refers to
cases of AIS in which the compensatory lumbar curve deviates
from the midline (King II curves). In contrast, King III curves
have a compensatory lumbar curve, which does not cross the
midline and the fusion of the main thoracic curve alone is the
accepted standard.12,17,21,25 Adding confusion to matters, some
published studies on selective thoracic fusion have included
King III curves in conjunction with King II curves.20 A final
operational convention is that selective thoracic fusion should
end at L1 or above.5,6,25
Classification systems that aim to identify patients who are
amenable to selective thoracic fusion have evolved to keep pace
with ever-improving spinal fixation devices. The three-column
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Charles Edwards II
Keith H. Bridwell
fixation afforded through pedicle screws along with direct api-
cal vertebral derotation techniques allow for greater degrees of
correction in all planes. Likewise, improvements in anterior
instrumentation and surgical techniques have yielded improved
three-dimensional correction over fewer segments. The sum-
mation of these advances is that a subset of patients with tho-
racic major curves are best served with selective thoracic fusion
techniques, which minimize fusion levels, while still affording
balanced spinal deformity correction, that reliably yields excel-
lent long-term subjective and cosmetic outcomes.
THE KING CLASSIFICATION EXPERIENCE
King et al recommended that patients with type II (major tho-
racic/compensatory lumbar; in which the lumbar was more
flexible than the main thoracic curve) and type III (overhang
main thoracic/apical lumbar vertebra still in contact with the
center sacral vertical line (CSVL)) curves be treated with fusion
of only the main thoracic curve from the upper end vertebra to
the stable vertebra, whereas patients with type I (double major;
lumbar is larger and main thoracic is more flexible) curves
should undergo fusion spanning both the thoracic and lumbar
curves, typically down to the L4 level.12 The results of the 405
cases reviewed to construct this classification system demon-
strated that the lowest instrumented level needs to be stable
(bisected by a vertical line drawn from the center of the sacrum
in the coronal plane). Stopping short or going beyond the sta-
ble vertebra in cases of selective thoracic fusion led to a 62%
chance of adding on. This phenomena refers to a condition
in which unfused vertebrae caudal to the preoperative main
thoracic curve spontaneously tilt into the thoracic curve and
now become a measured level of the main thoracic curve.12
Similarly, when the fusion stopped at the stable vertebra, which
also happened to be the neutral vertebra two third of the time,
there were no cases of adding on, the postoperative lumbar
curve remained smaller than the main thoracic curve, and no
reoperations to add the previously unfused lumbar curve were
necessary.12 No direct comment regarding coronal balance was
included in the results section of this sentinel paper. The indi-
cation for reoperation in the 1% that required surgery was pro-
gression of the unfused lumbar curve.12
CORONAL DECOMPENSATION
The selective thoracic fusion principles expressed in the King
paper soon gained widespread acceptance. With the introduc-
tion of segmental spinal instrumentation (Cotrel-Dubousset
889
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 890 Section VII Idiopathic Scoliosis
Causes of Coronal
TABLE 85.1 Decompensation After
Selective Thoracic Fusion
Immediate:
1. Overcorrection of the thoracic curve
2. Underappreciation of the corrective power of segmental
implants
3. Overestimation of the spontaneous lumbar curve correction
4. Misdiagnosis of curve type (double major curve)
Late:
1. Progression of the unfused lumbar curve in the skeletally
immature
2. Adding on phenomena due to improper selection of fusion
levels
(CD) hooks), however, challenges in establishing balanced
spinal alignment emerged.2 Global coronal decompensation to
the left of midline (in the direction of the lumbar apex)
occurred in a subset of patients with King type II and III curves
managed with and selective thoracic fusion.2,20 Coronal
decompensation was found to occur at one of two time points,
either acutely due to overcorrection of the thoracic curve or in
the long term from progression of the unfused lumbar curve
(Table 85.1).
In cases that avoided immediate postoperative decompensa-
tion, the thoracic correction with both CD and Harrington
instrumentation typically was a modest 40% to 45%, and about
0% to 5% less than that on preoperative supine side bending
films.12,20 Likewise, spontaneous compensatory lumbar curve
correction tended to be 40% to 60% less than that seen on pre-
operative side bending films, and about 5 to 10 less than the
main thoracic curve correction. Relatively matched incomplete
correction reliably yielded a balanced thoracolumbar spine.
Subsequent progression of the unfused lumbar curve can
also produce global coronal imbalance. For cases with greater
than 4 to 5 cm of coronal decompensation, distal extension of
the fusion to include the entire lumbar curve may be necessary
to restore global balance. The clinical impact of coronal imbal-
ance, however, is variable, with many surgeons reporting that
mild to moderate imbalance in the coronal plane has no sig-
nificant impact on long-term postoperative patient-reported
outcomes.68
Although there is no consensus on the clinical impact of
coronal imbalance, it is certainly agreed that coronal imbal-
ance is an unintended occurrence that followed certain cases of
selective thoracic fusion. Retrospective reviews have identified
inappropriate curve classification (failing to appreciate that the
lumbar curve was structural) and/or excessive thoracic correc-
tion as the most common etiologies for coronal decompensa-
tion following selective thoracic fusion.20 This unintended out-
come caused investigators to question whether a classification
system based on the Harrington distraction rod technique was
still applicable in the era of improved segmental fixation and
deformity correction. An additional weakness in the King clas-
sification was its limited criteria for determining the difference
between a true double major curve, in which both curves
needed to be included, and a false double major curve (King II
with a nonstructural lumbar curve or King III), in which only
the main thoracic curve needed to be fused.
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As experience with the concept of selective thoracic fusion
using segmental fixation techniques grew, it became clear that
lumbar curves with structural characteristics that resemble or
exceed those of the main thoracic curve were prone to coronal
decompensation and/or curve progression after selective tho-
racic fusion. Radiographic traits that suggest the lumbar curve
to be structural and not merely compensatory are limited flex-
ibility, large curve magnitude (45 to 60), high-grade apical
vertebral rotation (AVR) (2 to 2.5), and apical vertebral trans-
lation (AVT) (30 to 40 mm).
Lenke et al sought to refine the King classification, by segre-
gating true double major curves from false double major curves
based on the ratio between thoracic and lumbar curve magni-
tude, as well as, rotation and translation of the apical vertebra.20
When any of these ratios were less than or equal to 1.0, the
curve was considered a true double major curve and both the
thoracic and lumbar curves (typically down to L3 or L4) needed
to be included in the fusion. When the curve magnitude and
AVT ratio (thoracic:lumbar) were greater than 1.2, or greater
than 1.0 for AVR ratio, based on standing coronal scoliosis
films, the curve pattern was regarded as false double major.
For such false double major curves, the compensatory lumbar
curve could be excluded from the fusion.20 Applying this stan-
dard appeared to limit most or all cases of postoperative dec-
ompensation, so long as careful attention was paid not to over-
correcting the main thoracic curve.
Although these criteria proved clinically useful, the King
classification system still had inherent limitations. Specifically,
the King system did not fully define the structural nature of
regional curves, nor did it include consideration of sagittal cur-
vature. In addition, this classification system demonstrated fair-
poor inter- and intraobserver reliability.
THE LENKE CLASSIFICATION SYSTEM
In 1997, Lenke et al, appreciating the strengths and weaknesses
of the King classification system, proposed a new comprehen-
sive operative classification system for AIS, which accounted for
both structural and sagittal characteristics of the regional
curves.18 Multiple studies demonstrated good to excellent
observer reliability for this system. Under this system, the struc-
tural nature of minor curves was assessed according to defined
criteria (Table 85.2). The most important aspect of the classifi-
cation system was that it dictated levels to be included in the
final construct. According to this system, all major curves and
structural minor curves should be fused from end to end verte-
brae. Lenke type 1 curves, which includes all King III and some
King II curves with flexible lumbar curves, are regarded as sin-
gle main thoracic curves. They account for 40% to 50% of
operative AIS cases.18 This most common curve type can be
treated successfully, regardless of the lumbar or sagittal modi-
fier, with selective anterior or posterior thoracic fusion 90% of
the time.6,11,16,25
As with all operative classification systems that attempt to
categorize all possible pathology into a limited number of cat-
egories, a gray zone persists.17,18,21 A retrospective review of the
Lenke classification system shows that at least 10% of operative
AIS cases fall in this gray zone.16,18,25 Thus, the Lenke classifica-
tion system was a leap forward and remains the current accepted
platform for classifying AIS cases and determining fusion levels;
however, certain cases still require additional consideration
when determining final fusion levels.
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 Chapter 85 Selective Thoracic Fusion 891

TABLE 85.2 Criteria for Selective Thoracic Fusion

Curve type Lenke 1 and 2(all), 3(some), 4(some); King III(all) and
II(some)
Absolute lumbar curve magnitude 4560
Flexibility on supine side benders Lumbar thoracic; flexibility index*
Curve magnitude ratio Thoracic:lumbar 1.2
AVT ratio Thoracic:lumbar 1.2 (preferably 2)
Absolute: lumbar AVT 40 mm
AVR ratio (NashMoe rotation grade) Thoracic:lumbar 1.01.2
Absolute: lumbar AVR 2.5
Horizontalization of LIV on SB 05
Clinical (scoliometer) Thoracic apical trunk rotation lumbar apical trunk
rotation
Cosmetic More concern over thoracic truncal shift and rotation, than
lumbar hump or waistline crease

AVR, apical vertebral rotation; AVT, apical vertebral translation; LIV, lowest instrumented vertebra.
*Flexibility index % correction of lumbar curve on side-benders (SB) % correction of Main Thoracic
Curve on (SB). A value, indicates the lumbar curve is more flexible.

Lenke et al report that at least two of these three criteria should be met when using selective thoracic
fusion.

THE DECISION-MAKING PROCESS FOR
SELECTIVE THORACIC FUSION
The remaining sections of this chapter will focus on the factors
and outcomes that direct the decision-making process regard-
ing the use of selective thoracic fusion for AIS (Table 85.2).
Case 1 (Figs. 85.1A to O) illustrates the key findings measured
from a complete set of preoperative films that indicate selective
thoracic fusion has a high likelihood of success. As you can see,
immediate and long-term postoperative films demonstrated
partial spontaneous correction of the nonstructural lumbar
compensatory curve and maintenance of global coronal bal-
ance. Note that most of the lumbar curve correction occurred
through the inflection point and upper portions of the lumbar
curve, likewise, there was very little correction of the rotational
component of the lumbar curve. The patients Scoliosis
Research Society (SRS)-22 score reveals a high degree of satis-
faction with the final outcome.
The first step in deciding on whether a case is appropriate
for selective thoracic fusion is to identify the curve type, using
the Lenke classification system. Selective thoracic fusion is only
appropriate in those cases in which the thoracic curve is the
major curve. Although some have advocated selective thoracic
fusion in cases in which either the lumbar or proximal thoracic
minor curves are structural (Lenke 3 and 2, respectively), the
bulk of the literature and our collective clinical experience sup-
port the use of selective thoracic fusion specifically for Lenke 1
curves.18,21 In Lenke 2 curves, the proximal and main thoracic
curves should be included and exclusion of the lumbar curve
should be based on the same criteria used for type 1 curves,
thus 90% to 100% of the time, the lumbar curve should be
excluded.21 Since most Lenke 3 curves have C lumbar modifi-
ers, selective thoracic fusion should be used conservatively,
applying the criteria described in this chapter for Lenke 1C
curves.
The major curve is simply the curve with the highest magni-
tude. The only caveat is that in cases in which the thoracic and
lumbar curves are within 5 of each other, the thoracic curve is
recorded as the major curve. Supine maximal effort side bend-
ing and standard 36 anteroposterior (AP) and lateral upright
films, need to be reviewed to detect the structural nature of the
compensatory lumbar and proximal thoracic curves. Next the
lumbar modifier needs to be scrutinized. Originally only AIS
cases with lumbar A and B modifiers were indicated for selec-
tive thoracic fusion. However, Edwards and others have shown
that even Lenke 1C cases can be successfully treated with selec-
tive thoracic fusion, as long as Lenkes previously mentioned
ratio criteria are abided.3,6,20,25,29 The incidence of coronal
imbalance of greater than 2 cm is higher in these cases; how-
ever, this did not impact SRS-24 scores and 81% of patients are
satisfied.6
Unlike the lumbar modifier, the sagittal modifier has little
influence on the role of selective thoracic fusion for AIS, aside
from the choice of anterior versus posterior fusion. Patients
with hypokyphotic thoracic spines ( sagittal modifier) may be
better candidates for anterior thoracic fusion, as anterior radi-
cal discectomies not only improve coronal and rotational cor-
rection, but increase kyphosis, by closing down the disc space.1,19
Likewise, hyperkyphosis ( sagittal modifier) is a relative indi-
cation for posterior spinal fusion.
The sagittal parameter that demands the most scrutiny in the
context of selective thoracic fusion is thoracolumbar segmental
kyphosis (T10-L2). Given the known potential for problems
related to junctional kyphosis (i.e., progressive kyphosis, accel-
erated disc degeneration, and progressive sagittal imbalance)
caution should be exercised in performing a selective thoracic
fusion in the presence of thoracolumbar kyphosis. The Lenke
classification recognizes this concern by defining the thora-
columbar/lumbar curve as structural if the thoracolumbar
kyphosis is greater than 20. For such scoliotic curves, inclusion
of both the thoracic and lumbar curve is recommended. For
patients with thoracolumbar junction kyphosis between 0 and
20, the role of selective thoracic fusion remains controversial.
Lenke et al have suggested that 10 is an appropriate threshold;
however, this was based on a case series in which hooks and
wires were the primary mode of instrumentation.21,25

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 892 Section VII Idiopathic Scoliosis

A B C

D E

Figure 85.1. Case example: An 11-year-old premenopausal otherwise healthy girl with a newly diagnosed
AIS deformity. (A and B) Standing anteroposterior and lateral 36 radiographs demonstrating 65 thoracic
curve and a 53 lumbar curve. She is Risser 0. Thoracic apical vertebral translation (AVT) 60 and lumbar
AVT 24. Thoracic apical vertebral rotation (AVR) II and lumbar AVR II. She has mild thoracic
hyperkyphosis (40). (C) Push-prone radiograph demonstrates correction of the thoracic curve from 65 to
61, and lumbar correction from 53 to 44. (D and E) Supine maximal effort side bending radiographs
demonstrating thoracic curve correction from 65 to 56, and lumbar correction from 53 to 35. The
lumbar curve is more flexible with a flexibility ratio of 34% (thoracic 14%). (continued)

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 Chapter 85 Selective Thoracic Fusion 893

Figure 85.1. (Continued) (F through I) Clinical

preoperative photographs demonstrating the thoracic
curve to be more clinically apparent with a prominent
right scapula, elevated right shoulder, and marked
translation of the midthoracic region to the right. The
lumbar curve is less visible with a more subtle left
thoracolumbar prominence. (J) Preoperative Scoliosis
Research Society (SRS)-22 scores. (K and L) The
patient underwent a posterior segmental instrumented
fusion from T3 to T12. Care was taken to not overcor-
rect the thoracic curve and to leave residual tilt at the
lower instrumented vertebra (T12 tilt 12 relative
to the horizontal). Two-week postoperative standing
radiographs demonstrating excellent maintenance of
coronal balance (C7 plumb shifted 4.9 cm to the left).
The thoracic curve from T5 to T11 measures 30 and
the lumbar curve measures 29. The thoracic kyphosis G I
now measures 23 (T2 to T12). (continued)

Preop SRS-22 Broken into Domains

Score Potential Scores
30
30
25 25 25 25
25 22 23
20
20

15
10
10
6
5

0
J Pain Function Self-Image Mental Health Satisfaction K L

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 894 Section VII Idiopathic Scoliosis

Figure 85.1. (Continued) (M) Preoperative and 1-year follow-up standing radiographs reveal maintenance
of global coronal and sagittal balance. Despite the skeletal immaturity, the lumbar curve (30) has retained
its spontaneous correction since the early postoperative time period. (N) Clinical preoperative and 1-year
follow-up photographs demonstrate marked cosmetic improvement with correction of the truncal asymmetry,
leveling of the shoulders, and improvement in the right scapular prominence. (continued)

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 Chapter 85 Selective Thoracic Fusion 895

Postop SRS-22 Broken into Domains

Standard Preoperative
Score Potential Scores TABLE 85.3 Radiographic Analysis for
30 Selective Thoracic Fusion
30
25 25 26 25 Radiographs and measures needed:
25 23 22 Standard 36 AP and lateral scoliosis films
For MT and L curves:
20 18 Absolute magnitude
AVT
15 AVR
10 10 Thoracolumbar kyphosis (T10-L2)
10 Risser sign
Neutral and stable vertebra
5 Right and left maximal effort supine side bending films
Flexibility/correctability of MT and L curves
0 Pushprone films
O Pain Function Self-Image Mental Health Satisfaction Corrected LIV tilt
Figure 85.1. (Continued) (O) Postoperative SRS-22 scores demon- Flexibility/correctability of MT and L curves
strate improvement in pain, self-image, and satisfaction.
AP, anteroposterior; AVR, apical vertebral rotation; AVT, apical
Lower Cobb vertebral translation; LIV, lowest instrumented vertebra; MT, main
thoracic; L, lumbar.
Interval Upper Cobb T5-T11 T11-L5
Preoperative 65 53
7 wk postoperative 30 29
AVTs in which the apical vertebra is to the left of midline are
1 yr 33 30
negative, and those to the right are positive. Thus, most main
thoracic AVTs are positive, and most lumbar AVTs are negative.
The AVT ratio for determining selective thoracic fusion is cal-
culated by dividing the main thoracic AVT by the lumbar AVT.
If this ratio is greater than 1.2, and preferably greater than or
ADDITIONAL FACTORS THAT DETERMINE
equal to 2, which demonstrates that thoracic apex is more than
APPROPRIATENESS OF SELECTIVE
20% further translated from the midline than the lumbar apex,
THORACIC FUSION
then the curve meets this selective fusion criteria.
While the fine points of applying the Lenke classification sys- Similarly, the AVR for the main thoracic and lumbar curves
tem to AIS cases have been covered thoroughly in another is graded using the NashMoe five-point system (grade 0 (neu-
chapter, we will pay now special attention to Lenkes ratio crite- tral) to grade V (pedicle rotated beyond midline)). Some
ria for assessing the feasibility of selective thoracic fusion. In authors also use -point increments.20 The quotient from divid-
addition to applying the Lenke classification to the curve, the ing the thoracic AVR grade by the lumbar AVR grade should be
ratio between thoracic and lumbar curve magnitude, AVT, and greater than 1.0 to 1.2.20,21 Lastly, the ratio between the abso-
AVR should be measured. As with the King classification sys- lute thoracic and lumbar curve magnitude, using the Cobb
tem, these ratios are important for accurate identification of method, should be greater than 1.2. The AVT is more reliably
cases that are appropriate for selective thoracic fusion. measured and has come to be the most commonly used of the
First, it is important to note that these three measures should ratios for determining the appropriateness of selective thoracic
be made on high-quality upright, standing 36 scoliosis films. fusion.
The arms should be at the patients side and the patient should Ideally, all three, but at least two of the three ratio criteria
stand erect, with knees in the fully extend position. In cases should be met in order to perform selective thoracic fusion.20
with pelvic obliquity (5), lifts should be placed under the Failing to meet these criteria alerts the surgeon to the struc-
foot ipsilateral to the lower hemipelvis, to level the pelvis.16 In tural characteristic of the lumbar curve and the likelihood (as
films in which the pelvis is level, all vertical lines are made par- much as 50%) that failing to incorporate the lumbar curve
allel to the long edge of the radiograph and horizontal lines will result in its postoperative progression, coronal decompen-
should be made perpendicular to the long edge of the film. For sation, and potentially unacceptable clinical and cosmetic out-
supine bending films, the patient should be instructed to maxi- comes, necessitating revision surgery.20,21 Lastly, Lenke et al
mally bend to the left and right. An objective measure of bend- have added additional absolute radiographic selection
ing effort is the distance between the lowest rib and the iliac criterion.20,21 If the lumbar curve is substantial, which is identi-
crest, the closer these two structures are the better the effort fied as a magnitude greater than 60, AVR greater than 2.5,
(Table 85.3). and/or AVT greater than 40 mm, it is recommended that the
The AVT is measured on the standing coronal films as the lumbar curve be included in the fusion regardless of the ratio
horizontal distance between the center of the apical vertebra or criteria.20,21,25 Likewise, the lumbar curve absolute flexibility
disc (determined as the point of intersection between two diag- (percentage correction on supine side bending films) needs to
onal lines connecting opposite corners of the vertebra or disc be greater than the main thoracic curve.
space, also referred to as the centroid) and the C7-plumb line Margulies et al have developed a simplified algorithm for
in main and proximal thoracic curves and the CSVL in lumbar selecting fusion levels in AIS, which focuses explicitly on curve
curves. This distance is recorded in millimeters. By convention flexibility.23 The first step in the algorithm is to identify the

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 896 Section VII Idiopathic Scoliosis
major curve and its flexibility (or correctability) on supine side
bending. Next measure the flexibility of the compensatory
curves. If the compensatory curves correct more than the major
curve, then fuse only the major curve. If the major curve cor-
rects more, then either include the compensatory curve in the
fusion or intentionally undercorrect the major curve to achieve
a balanced spine. Curves selected by this criteria were fused
from superior end vertebra to inferior end vertebra as long as
the end vertebra was neutral, horizontal, and corrected to lie
within the stable zone of Harrington (between vertical lines
extending from each lumbosacral facet) on side bending films
or intraoperatively after surgical instrumentation. In a retro-
spective review, Margulies et al found that all 176 patients whose
actual fusion levels matched with those recommended by the
algorithm had stable, balanced spines at intermediate follow-up
(12 months). While 16 of 16 patients who were fused over
different levels than those predicted by the algorithm had spi-
nal imbalance, typically due to the lack of inclusion of the lum-
bar curve. While this algorithm may be too simplistic, it does
stress the importance of relative curve flexibility in the decision-
making process for selective thoracic fusion.
In addition to considering preoperative flexibility, it is gen-
erally recommended that the lowest instrumented vertebra
(LIV) should horizontalize or correct to within 5 to 10 of lumbar curve have evolved to objectively guide the surgeon
horizontal on reverse side bending to prevent decompensation
and excessive disc wedging.1 Correction of the planned LIV on
preoperative reverse side bending to less than 5 correlates with
improved and maintained postoperative correction of the com-
pensatory lumbar curve and horizontalization of the LIV. The
push-prone view has been shown to predict the postoperative
alignment, compensatory lumbar curve correction, and posi-
tion of the LIV better than supine side bending views.5 Although
it is strongly recommended that the LIV be horizontalized to
less than 5 to 10 for lumbar modifier A and B curves, the tilt
of the LIV should be undercorrected in C curves to allow har-
monious transition between the fused main thoracic and
unfused lumbar curve6 (Figs. 85.2A to E).
One additional criteria that cannot be overlooked is cosme-
sis. Improved cosmesis is a primary goal of scoliosis surgery and
therefore it should influence the decision to perform selective
thoracic fusion. While lumbar coronal magnitude and to a
lesser extent AVT tend to reduce spontaneously following selec-
tive thoracic fusion, AVR typically does not change, especially
following posterior spinal fusion.21 As such, the patients preop-
erative cosmetic concerns should be focused on the thorax.
Right thoracic rib hump and trunk shift as well as an elevated
right shoulder should overshadow the patients concern for
waistline asymmetry, a right (concave) flank crease, and left
(convex) lumbar hump on forward bending. Scoliometer mea-
surements can add some objectivity to this assessment. The tho-
racic scoliometer measures should be 20% (1.2) greater than
that in the lumbar region.21 Pre- and postoperative high-quality
clinical photographs (upright and forward bending) should be
obtained for comparison and to demonstrate improvement in
balance, curvatures, and rotation. These images should be
reviewed and shared with the patient at successive follow-up vis-
its to reinforce the correction made at surgery and as a clinical
indicator of progression. Cosmetic factors, while difficult to
objectify and compare between clinical studies, are neverthe-
less important cofactors in the decision-making process.
The preceding criteria establish a framework for determin-
ing the appropriateness of each case of AIS for selective thoracic
LWBK836_Ch85_p889-904.indd 896
fusion. Without exception Lenke 1A and King III curves should
be selectively fused. Although all Lenke 1B curves should be
strongly considered for selective thoracic fusion, up to 10% of
these cases may at the fail one or more of the criteria reported
above and be treated with fusion of both the thoracic and lum-
bar curves.16,25 Recommendations for the selective fusion of
Lenke 1C/true double major King II curves vary the greatest
among scoliosis surgeons, but application of the preceding cri-
teria can identify 80% or more of these patients that will reli-
ably have good to excellent clinical outcomes following selec-
tive thoracic fusion.6
PREDICTING THE POSTOPERATIVE
LUMBAR CURVE
Once it has been decided that selective thoracic fusion is appro-
priate, the next step is to determine the optimal degree of main
thoracic curve correction that will reliably yield a stable, bal-
anced spine. The lumbar curve has a limited capacity for spon-
taneous correction. Overcorrection occurs when the main
thoracic curve correction surpasses the lumbar curves ability to
spontaneously correct.2
Methods for predicting the response of the compensatory
regarding the ideal degree of main thoracic correction. Dobbs
et al have identified the push-prone view as the standard preop-
erative radiograph that most reliably predicts postoperative
lumbar curve correction.5 Using a multivariant analysis, Dobbs
et al developed a formula, which accurately predicted sponta-
neous postoperative lumbar correction based on measure-
ments from push-prone and coronal scoliosis films. The final
lumbar Cobb curvature 14.4 3.06 (lumbar modifier; B
0, C 1) 0.30 (preoperative standing lumbar Cobb)
0.18 (preoperative supine lumbar Cobb) 0.81 (preoper-
ative push-prone lumbar Cobb) 0.15 (preoperative stand-
ing thoracic Cobb) 0.16 (% thoracic Cobb change from
preoperative to immediate postoperative). Although this com-
plicated formula is not conducive to routine use, this study did
point out that thoracic curve correction obtained at the time of
surgery that was on average 1 to 2 less than that measured on
the push-prone film resulted in final lumbar curve spontaneous
correction that was within 1 to 2 of that on the preoperative
push-prone films. More importantly, 5% of patients who devel-
oped coronal decompensation (2 cm), were overcorrected
(instrumented correction push-prone correction) by an aver-
age of 7. Interestingly, all five patients had preoperative coro-
nal imbalance greater than 2 cm, which was concluded to be a
risk factor for postoperative coronal imbalance, along with
overcorrection of the thoracic curve. This was the first study to
quantify the role of thoracic overcorrection in cases of coronal
decompensation following selective thoracic fusion. No revi-
sion surgeries were required in the five patients with coronal
decompensation.
Large et al performed a similar study in which they attempted
to calculate a formula for the lumbar curve spontaneous cor-
rection following selective fusion to a stable zone vertebra
using Harrington distraction for 50% of the cases and distrac-
tion compression techniques for all but five remaining cases,
which received a Dwyer anterior spinal fusion (ASF).13 Their
multivariate analysis examined the predictive value of the pre-
operative magnitude of the lumbar curve, patient age, AVR,
and correction of the lumbar curve on side bending. The only
8/25/11 10:11:17 PM
 Chapter 85 Selective Thoracic Fusion 897

Figure 85.2. Case example of a 15-year-old

skeletally mature girl who is actively involved in
competitive martial arts. (A) Preoperative
standing anteroposterior (AP) and lateral
radiographs demonstrate a Lenke 1CN curve
type with a 58 thoracic and 48 lumbar curves
and normal sagittal alignment. Her coronal
balance is shifted to the left by 2 cm. (B) Supine
neutral and bending radiographs reveal the
lumbar curve to be more flexible than the
A thoracic curve. (continued)

LWBK836_Ch85_p889-904.indd 897 8/25/11 10:11:17 PM

 898 Section VII Idiopathic Scoliosis

Figure 85.2. (Continued) (C) Standing AP and lateral

radiographs a few days after a partial instrumented correction
and selective thoracic fusion from T4-L1. Incomplete
thoracic curve correction and residual tilt of the L1 vertebra
were intentionally performed so as to avoid coronal
decompensation to the left. (D) At 5 years postoperative, a
partially corrected thoracic curve (58 35) is matched by
spontaneous correction of the unfused lumbar curve (48
35). Despite ongoing high performance martial arts
competition, the lumbar spine remains without radiographic
D signs of disc degeneration. (continued)

LWBK836_Ch85_p889-904.indd 898 8/25/11 10:11:18 PM


Figure 85.2. (Continued) (E) The patient
continues to enjoy and utilize the flexibility of
her lumbar spine, which would have been largely
sacrificed had arthrodesis of the lumbar curve
been initially carried out. E
variable that correlated to postoperative lumbar curve magni-
tude was the preoperative magnitude. Final Cobb .66 pre-
operative Cobb 0.8. This study included minimum 10-year
follow-up, which showed that the incidence of low back pain
following scoliosis surgery was directly correlated to the num-
ber of lumbar levels fused. The combination of these findings
led the authors to conclude that selective thoracic fusion should
be performed in cases in which the lumbar curve has sufficient
flexibility and modest preoperative magnitude (50 in this
study).13 Thus from the earliest days of instrumented thoracic
fusion, spine surgeons have repeatedly confirmed that with
proper patient selection, selective thoracic fusion is the ideal
treatment of AIS in which the main thoracic curve is the major
curve.
UPPER INSTRUMENTED VERTEBRA AND LOWEST
INSTRUMENTED VERTEBRA SELECTION
The final step in planning the selective correction of the main
thoracic curve is establishing the end points for the fusion. The
upper instrumented vertebra (UIV) should be the upper end
vertebra of the main thoracic curve. The only caveat is that this
level needs to be checked in the sagittal plane, as well. If there
is a proximal thoracic kyphosis, the UIV should be moved
cephalad to the apex of this kyphosis.14 The LIV is the level that
is significantly more controversial.
In the case of selective ASF, the UIV and LIV are well
accepted to be the end vertebrae of the main thoracic curve.
For posterior selective thoracic fusion, which is the most com-
mon method for treating AIS, the LIV typically is one to two
levels caudal to the lower end vertebrae of the main thoracic
curve. It is this discrepancy in LIV selection, which forms the
LWBK836_Ch85_p889-904.indd 899
Chapter 85 Selective Thoracic Fusion 899
primary advantage of ASF over PSF: ASF saves one to two levels
on average. According to the King classification system from
1983, the LIV should be the stable vertebra when selectively fus-
ing the thoracic spine. Today, the stable vertebra remains the
most commonly recommended LIV, at least for lumbar modi-
fier B and C curves. Interestingly more is not better when it
comes to selecting fusion levels, as fusing caudal to the stable
vertebra is consistently associated with coronal decompensa-
tion.24 With lumbar modifier A, a level can often be saved. In
this situation, the LIV should be the most cephalad neutral ver-
tebra (NashMoe grade 0 to 1) equal or distal to the main tho-
racic (MT) end vertebra, as long it is as least intersected (not
necessarily bisected stable vertebra) by the CSVL. In addi-
tion, Betz et al have added the provision that disc immediately
below the LIV should correct at least five degrees on reverse
side bending.1 This is usually one level caudal to the MT lower
end vertebra (often L1) for Lenke type 1 and 3 curves.
ANTERIOR VERSUS POSTERIOR APPROACH
In 1999, Betz et al reported a prospective cohort study that
compared ASF with PSF for thoracic fusion and found that
there was no significant difference in outcomes between the
techniques. Subsequent comparative studies, mostly retrospec-
tive, have similarly found that while ASF does typically save 1 to
2.5 fusion levels, it does not clinically outperform PSF in selec-
tive thoracic fusion.1,4,10,15,26,28 The consensus conclusion from
these studies has been that selecting ASF or PSF is left to sur-
geon preference (Table 85.4). Advocates of the anterior
approach point to its advantages of saving 1 to 2.5 distal levels
of arthrodesis and improved derotation. Champions of the pos-
terior approach argue that the anterior approach unnecessarily
8/25/11 10:11:19 PM
 900 Section VII Idiopathic Scoliosis
Comparison of Anterior Versus Posterior Surgical
TABLE 85.4
Approaches for Selective Thoracic Fusion
Approach Advantages
Anterior spinal fusion Saves 12.5 fusion levels
Superior rotational correction
Improves hypokyphosis
Reduced posterior coronal
decompensation
Posterior spinal fusion Most common and familiar
approach
Improves hyperkyphosis
Less impact on PFTs
Fewer complications
PFT, pulmonary function testing
introduces the potential for severe iatrogenic morbidity due to
unintended injuries to thoracic structures. Anterior approaches
also lead to diminished pulmonary function relative to that
experienced with posterior approaches. Although such changes
in pulmonary function are measurable, they are rarely of any
clinical consequence. Both sides agree, however, that for the
severely hypokyphotic patient ASF affords a superior restora-
tion of physiologic kyphosis.31 The converse is also true. Hyper-
kyphotic patients receive superior sagittal correction with PSF
compared with ASFespecially when the ASF is performed etally immature (Risser 4 or less, open proximal humerus, or
with nonstructural grafts.1 Lastly, PSF has been associated with
increased incidence of asymptomatic coronal decompensation
on the order of 2 to 3 cm.5,21
IMPACT OF AGE/SKELETAL MATURITY
The impact of age in the decision to proceed or not with selec-
tive thoracic fusion is controversial. While no study has specifi-
cally investigated this topic, more investigators have noted that
skeletal immaturity does increase the risk for progression of the
uninstrumented lumbar curve and decompensation in the
direction of the lumbar apex.9,10,20,21 On the contrary, King et al
found that curve progression was not related to age or skeletal
maturity, as patients with lumbar curve progression in their
series were actually older than those who showed no postopera-
tive curve progression.12 Edwards et al showed that while greater
than 10 loss of immediate postoperative lumbar curve correc-
tion occurred more frequently in patients who were Risser 0.1
(27%) versus Risser greater than or equal to 2 (7%), in no case
did the uninstrumented lumbar curve progress greater than its
preoperative magnitude and no revision surgery for adding on,
decompensation, or curve progression was required.6 This was
a study looking at patients with Lenke 1C AIS, and the authors
did not postoperatively brace their patients.6 SRS-24 scores
were statistically equivalent between mature and skeletally
immature patients at long-term follow-up (average 5-year
follow-up).
In light of these findings and our clinical experience, we do
not consider relative skeletal maturity to have a significant
impact on whether we perform a selective thoracic fusion.
Skeletal immaturity may, however, influence the surgeons
LWBK836_Ch85_p889-904.indd 900
Disadvantages
Challenging/morbid exposure
Altered PFTs
Less derotation of both curves
May require thoracoplasty
Cannot correct hypokyphosis
postoperative management. According to the Heuter-Volkmann
epiphyseal growth principals, skeletal immaturity and residual
lumbar curve magnitude are the two factors that most directly
affect curve progression.9,30 Accordingly, the argument can be
made that certain skeletally immature patients undergoing
selective thoracic fusion should undergo postoperative bracing
of their lumbar curves to minimize the potential for lumbar
curve progression (Table 85.5). Patients considered to be at
increased risk for lumbar curve progression are the more skel-
rib epiphyses, 2 years from menarche), those in whom the
lumbar curve demonstrates limited spontaneous correction
(25 residual curvature), and those for whom postoperative
coronal decompensation (typically to the left) are noted. In
these circumstances, bracing is typically utilized until the end
of spinal growth (Risser 5, closure of the proximal humerus or
rib epiphyses, lack of increase in seated height over a 6- to
8-month period).9,10,20,30
COMPLICATIONSPREVENTING CORONAL
DECOMPENSATION AND LUMBAR PROGRESSION
Patients undergoing selective thoracic fusion are exposed to
many of the same risks as those who undergo longer fusions.
Selectively limiting fusion levels may, in fact, reduce the risk of
infection in the short term and adjacent segment degeneration
Considerations for
Postoperative Bracing (Until
TABLE 85.5 Skeletal Maturity) Following
Selective Thoracic Fusion
1. All Risser 0.1, prepubescent patients and those with an open
triradiate cartilage
2. Skeletally immature patients (Risser 25) with:
a. Uninstrumented lumbar curve 2530
b. Postoperative coronal imbalance
8/25/11 10:11:20 PM

and low back pain in the long term. Since anterior approaches
to scoliosis are only indicated for selective fusion strategies, the
risk specific to an anterior approach (atelectasis/pneumonia,
lung injury, diaphragmatic hernia, great vessel injury, ischemic
myelopathy, etc.) should be discussed with the patient. These
complications are more thoroughly reviewed in another chap-
ter. Preoperative pulmonary function testing (PFT) may be war-
ranted, as open thoracotomy for ASF of main thoracic curves
results in a significant reduction in forced vital capacity (FVC)
that persists more than 2 years after surgery, while thoracoscop-
ically assisted anterior fusions have less impact on final FVC.11
It should be noted that this reduction in PFTs is not singly
attributable to the anterior approach as patients with modest
(55) Lenke 1 AIS who have not undergone surgery and to a
greater degree those who have undergone fusion of the thorax,
regardless of approach (anterior or posterior) have PFTs, which
are less than predicted for their age.22
The complication that is more uniquely attributable to selec-
tive thoracic fusion versus longer fusions is postoperative defor-
mity progression, most commonly in the form of left side coro-
nal decompensation, increased lumbar curve magnitude,
adding on to the preoperative thoracic curve, or thoracolum-
bar junctional kyphosis. By far, coronal decompensation is the
most common of these complications (Table 85.6). Preoperative
decompensation of greater than 20 mm and a lumbar type C
modifier are the two factors most strongly correlated with an
increased chance of postoperative coronal decompensation.5,6
Patients with these findings should be warned about the poten-
tial for postoperative coronal decompensation, which is often
asymptomatic. Only in rare cases of extreme coronal decom-
pensation is revision surgery with distal extension of the arthro-
desis necessary.5 While innocuous in the young adult, negative
coronal imbalance may predispose to the development of a
lumbosacral fractional curve (L4-S1 obliquity). Obliquity of the
distal lumbar levels has been described by some authors as a
potential risk factor for the development of symptomatic cen-
tral or foraminal stenosis later in life.27,29 Fortunately, despite its
abundant discussion in the literature, deformity progression
following selective thoracic fusion is relatively rare in well-
selected patients (10%; 1% to 3% when strict selection cri-
teria are applied).6,23
FOLLOW-UP
As with all cases of AIS, routine clinical and radiographic
follow-up is mandatory for the short and long term. In the
short-term, immediate postoperative radiographic parameters
needed to be measured from standing AP and lateral scoliosis
films, to establish a baseline for detecting progression. Curve
magnitude of the instrumented and noninstrumented curves,
coronal and sagittal balance, and LIV horizontalization should
all be assessed immediately and regularly until solid fusion has
been documented (Figs. 85.3A to D). Most cases of selective
thoracic fusion for AIS demonstrate some loss of immediate
curve correction over the first 2 postoperative years, which is
typically on the order of 5 to 10. Follow-up should be contin-
ued at least 10 years past skeletal maturity, marked as the cessa-
tion of growth in seated height, Risser 5, or closure of the
proximal humeral or rib epiphyses.9,30 Since adult curve pro-
gression can be of the order of 1 or less per year and the
LWBK836_Ch85_p889-904.indd 901
Chapter 85 Selective Thoracic Fusion 901
Complications Specifically
TABLE 85.6 Associated with Selective
Thoracic Fusion
Coronal decompensation
Adding on to the main thoracic curve
Lumbar curve progression
Lumbosacral fractional curve development
Thoracolumbar junctional kyphosis
Unacceptable correctionpersistent deformity
measurement error for repeat measures of coronal curve mag-
nitude is 5, 10-year follow-up ensures that films that are at least
5 years apart will be collected and measured to confirm the
absence of progression.32 Following this, extended postopera-
tive evaluation period, patients without demonstrable progres-
sion do not require further follow-up, with the caveat, that as
patients age, adjacent segment degeneration and osteoporosis
may lead to degenerative spinal deformity.
In those patients who demonstrate postoperative progres-
sion of a radiographic parameter, the surgeon should first try to
identify the etiology and the clinical impact. Radiographic
changes without clinical impact, for example, asymptomatic
coronal decompensation, should be simply followed.5,21
Likewise, progression of an uninstrumented lumbar or proxi-
mal thoracic compensatory curve should be followed until it
results in marked deformity or clinical symptoms. In cases in
which postoperative deformity progression is symptomatic (i.e.,
truncal shift, shoulder elevation, progression rib or lumbar
hump, pain, mechanical symptoms, etc.), the etiology of the
progression should first be sought. The most common etiology
will be related to fusion level selection and technique. If a ret-
rospective review of the preoperative imaging studies suggests
that the lumbar curve did not meet criteria for exclusion, it
should then be included in a revision procedure.
CONCLUSION
The past 25 years have seen a dramatic development in our
understanding the role for selective thoracic fusion in the treat-
ment of AIS. The King classification raised the awareness of
specific curve types that may be amenable to fusion of the tho-
racic curve alone. With the introduction of segmental instru-
mentation, the potential for coronal decompensation after
selective thoracic fusion became more widely recognized. Spe-
cific quantitative criteria have been developed by Lenke and
others to determine preoperatively whether a case of AIS may
be amenable to selective thoracic fusion or whether arthrodesis
of both the thoracic and lumbar curves is necessary. Careful
attention to curve identification, selection of the appropriate
fusion levels, and the amount of instrumented correction pro-
duced predictably result in satisfactory clinical and radiographic
results. Recent studies highlight the potential of selective tho-
racic fusion to be an appropriate treatment even the more
challenging thoracic major deformities with Lenke C modi-
fier compensatory lumbar curves and the skeletally immature
adolescent.
8/25/11 10:11:20 PM
 902 Section VII Idiopathic Scoliosis

B
Figure 85.3. Case example of a 15-year-old skeletally mature girl with a Lenke 1BN curve. (A) Standing
anteroposterior (AP) and lateral preoperative radiographs demonstrating the thoracic curve to have a larger
curve magnitude, apical vertebral translation (AVT), and apical vertebral rotation (AVR) than the lumbar
curve. (B) Supine maximal effort side bending and push-prone radiographs demonstrating the
thoracic curve to be less flexible than the lumbar curve. (continued)

LWBK836_Ch85_p889-904.indd 902 8/25/11 10:11:20 PM

 Chapter 85 Selective Thoracic Fusion 903

D
Figure 85.3. (Continued) (C) Standing AP and lateral radiographs 19 years after selective thoracic partial
correction and posterior T3-T12 arthrodesis using a Harrington distraction rod and segmental sublaminar
wires. Coronal and sagittal balance has been well maintained. Spontaneous correction of the lumbar curve
has been preserved over long-term follow-up. (D) 19-year follow-up clinical photographs demonstrating
minimal truncal deformity and preserved flexibility of the lumbar spine.

LWBK836_Ch85_p889-904.indd 903 8/25/11 10:11:21 PM

 904 Section VII Idiopathic Scoliosis

16. Lenke LG, Betz RR, Clements D, et al. Curve prevalence of a new classification of operative
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