15 Years and 2530 Patients The Evolution of Instrumentation PDF

Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2018. Elsevier Inc.
Todos los derechos reservados.

Descargado para Anonymous User (n/a) en Universidad Peruana Cayetano Heredia de ClinicalKey.es por Elsevier en agosto 13, 2018.
Accepted Manuscript
15 years and 2530 patients: The evolution of instrumentation, surgical strategies, and
outcomes in adolescent idiopathic scoliosis in a single institution
Hongda Bao, Shibin Shu, Peng Yan, Shunan Liu, Zhen Liu, Zezhang Zhu, Bangping
Qian, Yong Qiu
PII: S1878-8750(18)31532-8
DOI: 10.1016/j.wneu.2018.07.054
Reference: WNEU 8619
To appear in: World Neurosurgery
Received Date: 9 March 2018

Revised Date: 3 July 2018
Accepted Date: 5 July 2018
Please cite this article as: Bao H, Shu S, Yan P, Liu S, Liu Z, Zhu Z, Qian B, Qiu Y, 15 years and 2530
patients: The evolution of instrumentation, surgical strategies, and outcomes in adolescent idiopathic
scoliosis in a single institution, World Neurosurgery (2018), doi: 10.1016/j.wneu.2018.07.054.
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
our customers we are providing this early version of the manuscript. The manuscript will undergo
copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please
note that during the production process errors may be discovered which could affect the content, and all
legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
15 years and 2530 patients: The evolution of instrumentation, surgical strategies,

and outcomes in adolescent idiopathic scoliosis in a single institution
Hongda Bao1, Shibin Shu1, Peng Yan1, Shunan Liu1, Zhen Liu1, Zezhang Zhu1, Bangping Qian1,
Yong Qiu1
PT
RI
1: Spine Surgery, Nanjing Drum Town Hospital, Nanjing University Medical School, Nanjing,
China
SC
The first 2 authors (Dr. Bao and Dr. Shu) contribute equally to this article.
Correspondence should be addressed to: Yong Qiu, MD, Spine Surgery,
Drum Town Hospital, Nanjing University Medical School,

U
AN
Nanjing 210008, China;
E-mail: scoliosis2002@sina.com
M
Tel +86-025-83106666;
Disclosure. This work is supported by Jiangsu Provincial Key Medical Center

D
TE
C EP
AC
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2018. Elsevier Inc. Todos los derechos reservados.
ACCEPTED MANUSCRIPT
1 Abstract
3 Over the past decade, the surgical treatment of AIS has established new techniques to reduce
4 curve severity and shifted to include the regular use of pedicle screws. Few studies have focused
5 on this evolving trend in AIS correction surgery. The current study aimed to investigate how the
PT
6 operative approach, instrumentation, and surgical techniques have changed over the past 15
7 years and to quantify the related improvements in AIS surgical treatment.
8 This is a retrospective review of a prospective AIS registry in a single center. Patient data were
RI
9 reviewed from January 2001 to December 2015. The age and surgical case distribution was
10 recorded for each year. Trends in classification utilizations, instrumentation types, levels of
11 fusion, and surgical approaches were analyzed by year. The major Cobb angles and correction
SC
12 rates were compared between different instrumentations and surgical approaches.
13 A total of 2530 AIS patients (83.0% female) were included with a mean age of 15.14 years. The
14 largest portion of patients underwent surgery at 14 years of age (473 cases, 18.7%), followed by
U
15 15 years of age (468 cases, 18.5%). In our center, the classification of AIS patients shifted from
16 the King classification to the Lenke classification in 2005. The major baseline Cobb angle of the
AN
17 entire cohort averaged 50.99° and this mean Cobb angle decreased to 14.41° after surgery. The
18 correction rates for the first 3 years (2001-2003) were less than 70%, while the correction rates
19 for the rest of the years were all greater than 70%. In addition, significantly higher correction
M
20 rates were observed in patients with Cobb angles < 90° (72.93% versus. 55.61%, p<0.001). A
21 total of 218 anterior-only surgeries and 109 combined antero-posterior surgeries were
D
22 performed; the remaining 2205 surgeries were performed with a posterior-only approach. The
23 use of anterior only and antero-posterior approached trended to decrease after 2005. The
TE
24 correction rate of anterior-only approaches was significantly greater than posterior-only and
25 antero-posterior approaches (77.86%, 72.51% and 59.37%, respectively). In patients corrected
26 with a posterior-only approach, the screw-hook hybrid construct was used in 342 patients while
27 the all-pedicle-screw construct was used in 1835 patients. The shift from hybrid to all-screw
EP
28 construct occurred in 2006. In thoracic AIS patients, the correction rate was significantly higher
29 in all-screw group (73.26% versus 67.76%, p<0.001).
30 The consistent improvement of major curve correction is an achievement made by the spine
C
31 community over a period of 15 years. After stabilized coronal correction and less fusion levels,
32 the next steps in this evolution are the restoration of sagittal profiles, especially the
AC
33 hypokyphosis seen in Lenke 1 patients, the posterior minimally invasive approach and “fast
34 track” return to activity.
35
36 Key Words: Adolescent idiopathic scoliosis, Evolution, Surgery strategy, Outcome
37
38 Introduction
ACCEPTED MANUSCRIPT
2 Adolescent idiopathic scoliosis (AIS) reaches back over a century ago, and its surgical treatment
3 has emerged ever since. The natural course of its progressive, crippling, and sometimes even
4 life-threatening deformity can overwhelm conservatively modes of therapy, often requiring
5 effective but invasive procedures. The ultimate goal of surgery has never changed: halting curve
6 progression, correcting the curve, fusion the affected bony segments, and preserving function1.
PT
7 Early in 1911, Hibbs was the first to publish on a series of patients who underwent long,
8 uninstrumented, in situ fusions followed by extended cast immobilizations2. Fusions may halt
9 curve progression but offer little or no curve correction. 50 years later, Paul Harrington was
RI
10 credited as the first to introduce implants into the world of scoliosis correction3. However, the
11 resulting pseudoarthrosis, implant breakage, and flatback syndrome from unidirectional
12 distraction called for further evolution of implant and surgical techniques4. The introduction of
SC
13 the Cotrel-Dubousset instrumentation, which aims at 3-dimensional correction for the first time,
14 ushered in the era of modern spine surgery5,6.
15 Operative strategies for treating AIS has grown over the past decade. It now combines the
U
16 regular use of pedicle screws, bone substitutes, and spinal cord monitoring with new curve
17 reduction and blood conservation tools. Instrumentations and other peri-operative devices are
AN
18 not the only areas of improvement. Surgical approaches, techniques, and surgical concepts are
19 also improving over time. Anterior correction was once popular for both Lenke Type 1 and Type
20 5 AIS patients, but the loss of correction and the limited restoration of the sagittal profile
reduced the enthusiasm for the anterior-only approach7. Various surgical techniques, including
M
21
22 cantilever, de-rotation, and coplanar alignment also populate the arsenal available to spine
23 surgeons8,9. Advances in the field have also modified surgical strategy to be better tailored for
D
24 each subtype of AIS. For example, the criteria for fusing the upper thoracic curve changed after
25 the publication of the Lenke classification10. Another example is the forward shifting of the
lower instrumented vertebra (LIV) selection with increasing evidence from the literature11.
TE
26
27 Surgical techniques and instrumentations in AIS surgery have advanced considerably over the
28 past 15 years. Pedicle screws gradually replaced hooks, and the polyaxial screws, uniaxial screws
EP
29 are also invented for easier rod installation and correction. Based on the pedicle screws, many
30 correction systems and techniques (Coplanar system, derotation system, etc) are introduced by
31 different implant companies. However, to the best of our knowledge, few studies have focused
32 on the evolving trends in AIS correction surgery. Looking back 15 years later may aid in
C
33 understanding how the correction of AIS developed and what the next steps should be for
34 better treatment. The current study aimed to investigate how the operative approach,
AC
35 instrumentation, and surgical techniques have changed over the past 15 years and to quantify
36 the related improvements in AIS surgical treatment.
37
38 Methods
39
40 Subjects
ACCEPTED MANUSCRIPT
1 This is a retrospective review of a prospective AIS registry in single center. Patient data were
2 reviewed from January 2001 to October 2015. The study was approved by the Clinical Research
3 Ethics Committee of the Hospital. Inclusion criteria in the current study were as follow: (1)
4 Diagnosed as AIS; (2) Age between 8 and 20 years; (3) underwent surgical correction; (4)
5 primary surgery; (5) with baseline and 2-week post-operative radiographs; (6) with at least 1-
6 year follow-up. Patients were excluded in the following scenario: with spondylolisthesis, with
7 previous hip or lower limbs surgery or with spinal tumors.
PT
8
9 Evaluation of instrumentations and surgical strategies
RI
10 The following information on instrumentations were recorded: (1) Types of instrumentation: all-
11 pedicle-screw system or hybrid hook-screw instrumentation; (2) Type of screws: Polyaxial,
SC
12 monoaxial, or uniplanar screws. Surgical approaches (posterior-only approach (including
13 minimally invasive posterior approach), anterior-only approach (including minimally invasive
14 anterior approach) and combined antero-posterior approach) were also recorded. The evolution
U
15 of instrumentations and surgical approaches was shown with both numbers and percentages of
16 cases per year.
AN
17 The selection of upper instrumented vertebra (UIV) and lower instrumented vertebra (LIV) was
18 also evaluated, the change over time was then recorded. The selection of levels of fusion was
19 based on the surgeons’ experience and the latest international consensus at that time.
M
20
21 Outcome evaluation
D
22 Surgical outcome in the current study was evaluated by radiographic parameters. Regular DX
23 radiographs were utilized during the first a few years and long-cassette radiographs took place
TE
24 after 2005. The Cobb angles of main curve at baseline and post-op were recorded. The
25 correction rates of the main Cobb angles were then calculated.
26
EP
27 To quantify the improvement of radiographic outcomes with the change in instrumentation and
28 surgical strategy, 30 pairs of Lenke 1A patients with either anterior or posterior-only approaches
C
29 were analyzed in detail, as well as 30 pairs of Lenke 5 patients with either uniplanar or
30 traditional screws. The subjects for comparison were selected from the registry after matching
AC
31 demographic data, follow-up time, and baseline radiographic parameters. Radiographic

32 parameters included the main coronal Cobb angle, sagittal thoracic kyphosis (TK), and lumbar
33 lordosis (LL). The vertebral rotation after surgery was evaluated by Upasani grade21, Grade 0:
34 both screws tips are central to the two rods (rotation 0-8 degrees); Grade 1: right screw tip
35 hidden by right-sided rod (rotation 9-12 degrees); Grade 2: right dcrew tip lateral to the right-
36 sided rod (rotation >13 degrees).
37
38 Statistical analysis
3
ACCEPTED MANUSCRIPT
1 Data were statistically analyzed using IBM SPSS Statistics v.20.0.0 (SPSS Inc., 2009, Chicago, IL). A
2 descriptive analysis (mean, range and standard deviations) was reported for the radiographic
3 parameters and demographic data. An ANOVA analysis was performed to compare parameters
4 between different surgical strategies/instrumentations. Statistically significant differences were
5 defined by a p<0.05.
PT
7 Results
RI
9 Demographics
10 A total of 2530 AIS patients were included in this study with an average age of 15.14±2.27 years.
SC
11 The largest proportion of patients underwent surgery at the age of 14 years (472 cases, 18.7%,
12 Figure 1), followed by the ages of 15 years (465 cases, 18.4%), 13 years (341 cases, 13.5%), 16
13 years (339 cases, 13.4%), and 17 years (223 cases, 8.8%). The percentage of females in this
U
14 population was 83.0% (2100 cases). The first period was from 2001-2003 (73-90 cases per year).
15 Afterwards a sharp increase was observed at 2004 and the number was stable for another 4
AN
16 years (2004-2007, 129-168 cases per year). After 2008, the number of surgical cases per year
17 was over 200 (206-234 cases per year, Figure 2).
18
M
19 Classification of AIS patients
20 In our center, the classification of AIS patients shifted from the King classification to the Lenke
D
21 classification in 2005. The Lenke classification was applied in 1974 patients (78%), King
22 classification in 247 patients (9.7%), and the rest 309 patients (12.3%) were lumbar AIS before
TE
23 2005. In the 1974 patients with the Lenke classification, 500 patients (25.3%) were Lenke 1A,
24 240 (12.2%) were Lenke 1B, 242 (12.3%) were Lenke 1C and 545 patients (27.6%) were Lenke 5C
25 (Figure 3). The distribution of Lenke types was also similar between each year (p>0.05). For the
EP
26 King classification, the most common type was King III (38.9%), followed by King II (32.0%, Figure
27 4).
28
C
29 Radiographic evaluation of the cohort

AC
30 The Cobb angle of main curve in the entire cohort averaged 53.37±15.94 (Range: 40°-165°).
31 After surgical correction, this mean Cobb angle decreased to 14.24±10.31° (Range: 0-93°) with
32 an average correction rate of 74.09%. As shown in Figure 5, statistically significant differences in
33 terms in baseline and post-op Cobb angles was demonstrated over the 15 years (p<0.001)
34 despite less than 5° of differences between mean Cobb angles in each year. The correction rate
35 for the first three years (2001-2003) was less than 70%, while correction rates for the remaining
36 years were all greater than 70% (Figure 5). In addition, when classifying patients based on Cobb
ACCEPTED MANUSCRIPT
1 severity, significantly greater correction rates were observed in patients with Cobb angles < 90°
2 compared to those with Cobb angles 90° (74.69% versus. 57.08%, p<0.001). At the same time,
3 significantly greater corrections were observed in severe AIS patients (37.68° versus 60.69°,
4 p<0.001).
5 Surgical strategy
PT
6 A total of 221 (8.7%) anterior-only surgeries and 107 (4.2%) combined antero-posterior
7 surgeries were performed over the past 15 years; the remaining 2202 (87.1%) surgeries were
RI
8 accessed by posterior-only approaches. The decreasing frequency of anterior-only and antero-
9 posterior approaches was observed after 2005, while the utilization of posterior-only
10 approaches (Table 1) correspondingly increased. In addition, 18 posterior cases were performed
SC
11 with minimally invasive posterior approaches with the help of an intra-operative cone-beam CT
12 and navigation system. On the large scale, the baseline major Cobb angles in anterior-only and
13 posterior-only groups were significantly smaller than that of the antero-posterior approach
U
14 group (91.22°). The correction rate of anterior-only approaches was significantly larger than the
15 correction rate of posterior-only or antero-posterior approach (79.63%, 70.21% and 61.53%,
AN
16 respectively). In patients with Cobb angle over 90, similar correction was achieved from
17 posterior only and combined approach (Table 2).
18 A detailed analysis was performed in 30 pairs of matched Lenke 1A patients with anterior-only
M
19 and posterior-only approaches. Baseline parameters were similar between anterior and
20 posterior groups (all p>0.05). After surgical correction, significantly larger post-op major Cobb
21 angle was found in the posterior group (20.4° versus 13.5°, p= 0.001). However, after 2 years
D
22 follow-up, no significant differences was found in terms of a loss of correction (21.5° versus
TE
23 19.7°, p=0.493). In the sagittal plane, TK restoration in the anterior group was also significantly
24 better than in the posterior group (24.8° versus 16.7°, p=0.002), while changes in LL after
25 surgery were similar.
EP
26 A total of 1682 patients (66.5%) had records of levels fused. The mean number of levels fused
27 was 9.25±2.69 (Range 3-15). Fusing more than 12 levels was found to decrease after 2011
C
28 (Table 3). The UIV/LIV location and levels fused were further analyzed by segmenting by Lenke
29 classification. Regarding the location of UIV in Lenke 1 patients, more UIVs at T3-T4 was found
AC
30 between 2008 and 2010, while UIVs at T4 and T5 were more common in 2012-2015. In Lenke 2
31 patients, UIV gradually transfer from T1 and T2 (86.7% T2 before 2010) to T1-T3 (13.7% T1,
32 56.8% T2, 29.5% T3). In Lenke 5C patients, more T12 was selected as UIV after 2010 (Appendix
33 1). For LIVs, fewer L4’s and more L3’s were identified as the LIV after 2013 in Lenke 1C and
34 Lenke 5C patients. The change of LIVs in Lenke 1A and Lenke 2A patients showed no significant
35 difference (p=0.354).
36
37 Instrumentations
5
ACCEPTED MANUSCRIPT
1 In patients with a posterior-only approach, screw-hook hybrid constructs were used in 342
2 patients (15.5%) and all-pedicle-screw constructs were used in 1835 patients (84.5%). The shift
3 from a hybrid to all-screw construct occurred in 2006 (73 cases with hybrid constructs and 23
4 with all-screw constructs in 2006). In thoracic AIS patients, the correction rate was significantly
5 higher in the all-screw group (73.26% versus 67.76%, p<0.001). In lumbar patients, however, the
6 correction rate was similar (74.74% versus 74.51%, p=0.951).
PT
7
8 Further detailed comparisons were made between uniplanar screws and traditional screws in 60
9 matched Lenke 5 patients. The correction rate of the major lumbar Cobb angle was found to be
RI
10 similar (77.6% in uniplanar group and 76.1% in traditional group, p=0.40), along with similar
11 restoration of lumbar lordosis (51.1° versus 48.7°, p=0.52). Regarding axial correction, more
SC
12 patients were corrected to a Upasani grade 0 or I in the uniplanar group.
13
U
14 Complication
15 This database recorded the major complications, including severe neurological deficit and
AN
16 radiographic complication. In the Lenke 1 and Lenke 2 patients, the adding-on phenomenon (a
17 radiographic complication) was recorded in 28 patients (2.3%) and 1 patient had revision
18 surgery. 5 patients experienced severe neurological deficit after surgery and 3 improved to
M
19 normal at the discharge. In total, 7 patients underwent revision surgery: 2 patients due to
20 screw/hook dislodgment, 1 due to adding-on and 4 due to delayed infection.
21
D
22 Discussion
TE
23
24 AIS, a life-long fight once established, is a typical chronic disease that requires treatment
25 improvement. From in situ fusions to 3-dimentional corrections with various instrumentations,
EP
26 the surgical correction of AIS has seen tremendous advances by a century’s worth of effort by
27 the spine community. The current study, therefore, reviewed a large prospective AIS registry
28 from a single center and aimed to demonstrate the trending improvement of surgical correction
C
29 during the past 15 years. The results revealed the overtake of the hybrid hook-screw system the
30 by all-pedicle-screw system and the consequent switch from a posterior to anterior and back to
AC
31 posterior approach with the development of instrumentations. Increasing correction rates and
32 less complications were also revealed by the results of the current study.
33
34 Similar studies were performed previously. In 2009, Canadian surgeons reviewed the evolution
35 of AIS surgery from 1982 to 2008 with the conclusion that an increased 3-D correction was
36 achieved as spinal instrumentation evolved towards derotation maneuvers when comparing
37 Harrington, CDI and DVD techniques12. Another 20-year evolution of AIS surgery was recently
38 recorded by a multicenter study with 1819 patients, presenting on an academic conference13.
6
ACCEPTED MANUSCRIPT
1 Lonner and his colleagues summarized that evolution of surgical technique has resulted in a
2 cessation of anterior only surgery for single curves, increasing use of all pedicle screw constructs,
3 less blood loss, greater use of antifibrinolytics, shorter operative times and LOS, lower major
4 complication rates and greater improvements in SRS outcome scores13. The current study
5 achieved similar results in another country, with more patients, and in a single institution. The
6 similar results also imply that the evolution is international and help to quantify the
7 improvement of AIS correction in the recent decade. The correction rate of Cobb angle didn’t
PT
8 change significantly because the correction rate was already satisfactory. In addition, the
9 evolution did result in increase in more solid instrumentation, more sagittal realignment and
10 shorter OR time.
RI
11
12 The debate on using thoracic pedicle screws and hooks has persisted since the mid-1990s,
SC
13 focusing on deformity correction and complications.14 Although there is still not a consensus, we
14 do observe a shift from the hybrid system to a screw system in 2006 in our center, which is in
15 line with the international trend observed in the literature. A few articles between 2002 and
U
16 2007 compared the surgical outcomes between hybrid systems and screw systems; only a few
17 studies reported on it thereafter15-17. The results of the current study were in accordance with
AN
18 previous conclusions that a significantly greater coronal correction could be achieved with the
19 screw system. According to a biomechanical study, pedicle screws provide a superior vertebral
20 grip with a 3-column purchase and advantageous moment arm from the anatomic location of
pedicle screws compared with the hook placement on the lamina18. A recent high level evidence,
M
21
22 prospective, randomized study ends the controversy with a conclusion that screw constructs
23 outperformed hybrid constructs, especially over time19. In addition to a greater correction rate,
D
24 malpositioning in screw constructs are not as risky as previously hypothesized. With the help of
25 intra-operative cone-beam CT and navigation systems, screw insertion is even safer than laminar
hooks considering the average 2-3mm canal intrusion20. The design of instrumentations also saw
TE
26
27 huge improvements. Uniplanar screws were used in our center since 2012 in Lenke 5 patients.
28 Compared with traditional polyaxial or monoaxial screws, no benefits in coronal correction were
29 observed using uniplanar screws in the current study; however, significantly more apical
EP
30 vertebral derotation was achieved. This result is echoed by Dalal et al, speculating that more
31 derotation may be attributed to the increase in rotational leverage afforded by uniplanar
32 screws21.
C
33
AC
34 The surgical approach, another foundation for surgical correction, also saw revolution and
35 restoration during the past 15 years. The anterior approach is not as classic when compared to
36 the posterior approach. However, it attracted attention from its minimally invasive and fewer
37 levels of fusion requirement2223. A total of 221 anterior surgeries were performed in our center.
38 After the switch to an all-pedicle-screw construct in 2006, the number of anterior-only surgeries
39 gradually decreased and vanished after 2008. The reason that we tend to replace anterior by
40 posterior approach is the evolution of instrumentation and the recognition of importance of
41 sagittal plane. Maybe the anterior approach does have its advantages, but the posterior
42 approach outperformed the anterior approach by better restoring lumbar lordosis. Despite the
7
ACCEPTED MANUSCRIPT
1 increasing number of posterior surgeries, the controversy between anterior and posterior
2 approaches continues even today. Abel et al. favored the anterior approach from fewer fusion
3 levels required and greater correction when controlling the distal level of fixation24. A meta-
4 analysis by Chen et al. demonstrated that the posterior approach had smaller complication rate,
5 blood loss, operative time, length of hospital stay, and better percent-predicted FVC compared
6 to anterior-posterior approach25. This mean-analysis was then challenged by Gardner stating
7 that the heterogeneity of the included studies may diminish the reliability of the conclusion26. A
PT
8 definite conclusion can only be made based on a prospective randomized controlled trial study
9 to compared outcomes in anterior versus posterior approaches. In addition, more posterior-only
RI
10 approaches were performed in patients with over 90° Cobb angle after 2010 (Table 3),
11 indicating that posterior approaches could achieve similar correction rates compared to antero-
12 posterior approaches with a smaller chance of anterior-approach related complications.
SC
13
14 Kyphosis restoration in AIS has been an issue since the beginning. Our results revealed that the
15 anterior approach can even provide better kyphosis restoration in Lenke 1A patients, which is in
U
16 accordance with previous data by the Harms Study Group27. For hybrid constructs, a meta-
analysis found it more powerful in restoring kyphosis compared with an all-screw construct28.
AN
17
18 Lonner et al. also found that a greater percentage of hooks in the construct were associated
19 with increased kyphosis while more screws were associated with hypokyphosis29. Correcting
20 hypokyphosis is definitely one of the ultimate and most difficult goals in AIS treatment. Failure
M
21 to restore kyphosis may also lead to reciprocal flat lumbar and kyphotic cervical alignments.
22 Therefore, restoration of the sagittal profile, especially hypokyphosis in Lenke 1 patients, should
23 be the next key point in advancing modern spine surgery.
D
24
TE
25 Surgical strategy also changed during the last 15 years, along with the popularity of the Lenke
26 classification. Compared with the previous King classification, the Lenke classification provides a
27 template for the selection of fusion levels by curve type. Therefore, the most important content
EP
28 in surgical decision-making is where to stop the LIV. The current study revealed trends of shorter
29 fusion levels, lower UIV locations in Lenke 1 patients, and higher LIV location Lenke 1C and
30 Lenke 5C patients. With increasing experience and the utilization of advancing technology,
31 shorter fusion levels were chosen because solid clinical evidence supports that spontaneous
C
32 correction of the lumbar curve could be achieved and maintained. Recent reports on the last
33 touching vertebra concept may also help avoid unnecessary extension of constructs30.
AC
34
35 The current study reviewed a prospective AIS registry from a single institution with a large
36 sample size. This single center database provided more in-depth surgical details compared to
37 the national-wide database. In addition, another advantage lies on the stable team of surgeons
38 in our center who are always connected to the frontier of clinical spine research and thus reflect
39 the trend of the spine community in their surgeries. However, one of the limitations is still
40 linked to the learning curve of the team, which was not analyzed in the current study. The lack
ACCEPTED MANUSCRIPT
1 of length of stay, operation time, EBL data, health related quality of life records was also a
2 limitation in this study.
4 Conclusion
PT
6 Modern spine surgery, with posterior approaches and all-pedicle-screw constructs, was
7 internationally present starting in 2005-2006. The consistent improvement of major curve
8 correction is an achievement made by the spine community over a period of 15 years. After
RI
9 stabilized coronal correction and less fusion levels, the next steps in this evolution are the
10 restoration of sagittal profiles, especially the hypokyphosis seen in Lenke 1 patients, the
SC
11 posterior minimally invasive approach and “fast track” return to activity.
12
13
14
U
AN
15
16
M
17
18
D
19
TE
20
21
22 References
EP
23
24 1. Hasler C C. A brief overview of 100 years of history of surgical treatment for adolescent
C
25 idiopathic scoliosis. Journal of Childrens Orthopaedics. 2013, 7(1):57-62.
26 2.
AC
Hibbs R A. An operation for progressive spinal deformities: a preliminary report of three

27 cases from the service of the orthopaedic hospital. 1911. Clin Orthop Relat Res. 2007,
28 460(35):17.
29 3. Harrington P R. Treatment of scoliosis: correction and internal fixation by spine

30 instrumentation. June 1962. Journal of Bone & Joint Surgery American Volume. 1962, 44-
31 A(44-A):591.
32 4. Aaro S, Dahlborn M. The effect of Harrington instrumentation on the longitudinal axis

33 rotation of the apical vertebra and on the spinal and rib-cage deformity in idiopathic
34 scoliosis studied by computer tomography. Spine. 1982, 7(5):456-462.
ACCEPTED MANUSCRIPT
1 5. Cotrel Y, Dubousset J. A new technic for segmental spinal osteosynthesis using the
2 posterior approach ☆. Orthopaedics & Traumatology Surgery & Research Otsr. 2014,
3 100(1):37-41.
4 6. Cotrel Y, Dubousset J, Guillaumat M. New universal instrumentation in spinal surgery.

5 Clinical Orthopaedics & Related Research. 1988, 227(227):10.
6 7. Geck M J, Rinella A, Hawthorne D, et al. Anterior Dual Rod Versus Posterior Pedicle
PT
7 Fixation Surgery for the Surgical Treatment in Lenke 5C Adolescent Idiopathic Scoliosis: A
8 Multicenter, Matched Case Analysis of 42 Patients. Spine Deform. 2013, 1(3):217-222.
9 8. He S, Bao H, Zhu Z, et al. Vertebral coplanar alignment technique: a surgical option for
RI
10 correction of adult thoracic idiopathic scoliosis. European Spine Journal. 2016, 25(2):417-
11 423.
12 9. Rushton P R, Grevitt M P. Do vertebral derotation techniques offer better outcomes
SC
13 compared to traditional methods in the surgical treatment of adolescent idiopathic
14 scoliosis? European Spine Journal. 2014, 23(6):1166-1176.
15 10. Lenke L G. Lenke classification system of adolescent idiopathic scoliosis: treatment

16 recommendations. Instructional Course Lectures. 2005, 54:537.
17 11.
U
Sun Z, Qiu G, Zhao Y, et al. Lowest instrumented vertebrae selection for selective
AN
18 posterior fusion of moderate thoracolumbar/lumbar idiopathic scoliosis: lower-end vertebra
19 or lower-end vertebra+1? European Spine Journal. 2014, 23(6):1251-1257.
20 12. Kadoury S, Cheriet F, Beauséjour M, et al. A three-dimensional retrospective analysis of

21 the evolution of spinal instrumentation for the correction of adolescent idiopathic scoliosis.
M
22 European Spine Journal. 2009, 18(1):23-37.
23 13. Lonner B S, Ren Y, Yaszay B, et al. Evolution of Surgery for Adolescent Idiopathic
24
D
Scoliosis over 20 Years: Have Outcomes Improved? Spine. 2017, 16(10):S242-S242.
25 14. Boucher H H. A method of spinal fusion. Journal of Bone & Joint Surgery British Volume.
TE
26 1959, 41-B(2):248.
27 15. Dobbs M B, Lenke L G, Kim Y J, et al. Selective posterior thoracic fusions for adolescent
28 idiopathic scoliosis: comparison of hooks versus pedicle screws. Spine. 2006,
29 31(20):2400-2404.
EP
30 16. Lowenstein J E, Matsumoto H, Vitale M G, et al. Coronal and sagittal plane correction in
31 adolescent idiopathic scoliosis: a comparison between all pedicle screw versus hybrid
32 thoracic hook lumbar screw constructs. Spine. 2007, 32(4):448-452.
C
33 17. Storer S K, Vitale M G, Hyman J E, et al. Correction of adolescent idiopathic scoliosis

34 using thoracic pedicle screw fixation versus hook constructs. Journal of Pediatric
AC
35 Orthopaedics. 2005, 25(4):415.
36 18. Yilmaz G, Borkhuu B, Dhawale A A, et al. Comparative analysis of hook, hybrid, and
37 pedicle screw instrumentation in the posterior treatment of adolescent idiopathic scoliosis.
38 Journal of Pediatric Orthopedics. 2012, 32(5):490-499.
39 19. Newton P O, Marks M C, Bastrom T P, et al. Surgical treatment of Lenke 1 main thoracic
40 idiopathic scoliosis: results of a prospective, multicenter study. Spine. 2013, 38(4):328-38.
41 20. Jin M, Zhen L, Liu X, et al. Does intraoperative navigation improve the accuracy of pedicle
42 screw placement in the apical region of dystrophic scoliosis secondary to
10
ACCEPTED MANUSCRIPT
1 neurofibromatosis type I: comparison between O-arm navigation and free-hand technique.

2 European Spine Journal. 2016, 25(6):1729-1737.
3 21. Dalal A, Upasani V V, Bastrom T P, et al. Apical vertebral rotation in adolescent idiopathic
4 scoliosis: comparison of uniplanar and polyaxial pedicle screws. Clinical Spine Surgery.
5 2011, 24(24):251-257.
6 22. Dwyer A F, Newton N C, Sherwood A A. An anterior approach to scoliosis. A preliminary
PT
7 report. Clin Orthop. 1969, 62:192.
8 23. Mack M J, Regan J J, Mcafee P C, et al. Video-assisted thoracic surgery for the anterior
9 approach to the thoracic spine. China Journal of Endoscopy. 1995, 59(5):1100-6.
RI
10 24. Abel M F, Anuj S, Feger M A, et al. Surgical treatment of Lenke 5 adolescent idiopathic
11 scoliosis: Comparison of anteriorvsposterior approach. World Journal of Orthopedics.
12 2016, 7(9):553-560.
SC
13 25. Chen Z, Rong L. Comparison of combined anterior-posterior approach versus posterior-
14 only approach in treating adolescent idiopathic scoliosis: a meta-analysis. European Spine
15 Journal. 2016, 25(2):363-371.
U
16 26. Chen Z, Rong L. Comparison of combined anterior-posterior approach versus posterior-
17 only approach in treating adolescent idiopathic scoliosis: a meta-analysis. European Spine
AN
18 Journal. 2016, 25(2):363-371.
19 27. Khakinahad M, Ameri E, Ghandhari H, et al. Preservation of thoracic kyphosis is critical to

20 maintain lumbar lordosis in the surgical treatment of adolescent idiopathic scoliosis. Acta
21 Medica Iranica. 2012, 50(7):477.
M
22 28. Cao Y, Xiong W, Li F. Pedicle screw versus hybrid construct instrumentation in adolescent
23 idiopathic scoliosis: meta-analysis of thoracic kyphosis. Spine. 2014, 39(13):800-10.
D
24 29. Lonner B S, Lazar-Antman M A, Sponseller P D, et al. Multivariate analysis of factors

25 associated with kyphosis maintenance in adolescent idiopathic scoliosis. Spine. 2012,
26 37(15):1297-302.
TE
27 30. Qin X, Sun W, Xu L, et al. Selecting the Last "Substantially" Touching Vertebra as Lowest
28 Instrumented Vertebra in Lenke Type 1A Curve: Radiographic Outcomes With A Minimum
29 Of 2-Year Follow-Up. Spine. 2015, 41(12):E742.
EP
30
31
C
32
AC
33
34
35
36
37
38
11
ACCEPTED MANUSCRIPT
PT
5
RI
7
SC
9
10
11
12
U
AN
M
D
TE
C EP
AC
12
ACCEPTED MANUSCRIPT
1 Figure legend
2 Fig 1: Age distribution among the included AIS patients
3 Fig 2: Surgical cases each year during the last 15 years.
4 Fig 3: Distribution of Lenke classification subtypes
PT
5 Fig 4: Distribution of King classification subtypes
6 Fig 5: Comparison of baseline, post-op Cobb angle between each year
RI
7
U SC
AN
M
D
TE
C EP
AC
13
ACCEPTED MANUSCRIPT
1 Table 1: Information on surgical approach evolution
Year of surgery Anterior Posterior only Combined AP Total No.

only approach approach
approach
2001 17 46 10 73
2002 19 54 17 90
PT
2003 18 48 12 78
2004 47 75 12 134
2005 42 69 18 129
RI
2006 26 101 7 134
2007 26 127 15 168
2008 20 180 6 206
SC
2009 4 208 6 218
2010 0 212 0 212
2011 1 189 1 191
2012 1 233 0 234
U
2013 0 220 3 223
2014 0 232 0 232
AN
2015 0 208 0 208
Total No. 221 2202 107 2530
Baseline Cobb angle 48.18° 52.05° 91.22°
M
Post-op Cobb angle 12.22° 16.17° 36.43°

Correction rate 79.63% 70.21% 61.53%
2
D
3 Table 2: Change in surgical approach in patients when Cobb angle over 90°
TE
Posterior Combined Total No.

AP
2003 0 2 2
EP
2004 0 6 6
2005 1 8 9
2006 1 1 2
C
2007 0 10 10
2008 3 3 6
AC
2009 4 4 8
2010 4 0 4
2011 3 0 3
2012 8 0 8
2013 5 3 8
2014 5 0 5
2015 3 0 3
Total No. 37 37 74
p
14
ACCEPTED MANUSCRIPT
Baseline Cobb angle 107.38° 107.76° 0.921

Post-op Cobb angle 47.89° 45.86° 0.618
Correction rate 56.17% 58.00% 0.545
1
2 Table 3: Number of levels fused by year
PT
Fusion Levels Total
3 4 5 6 7 8 9 10 11 12 13 14 15
2008 1 11 10 0 1 14 28 44 32 27 14 8 0 191
RI
2009 0 10 18 7 5 6 23 47 41 30 14 5 2 208
2010 1 3 15 8 5 4 15 43 58 32 14 6 1 205
2011 7 12 18 10 3 6 19 37 36 29 10 0 1 189
SC
2012 7 31 20 11 3 7 42 37 45 18 7 0 1 229
2013 3 22 10 4 0 20 45 43 48 16 9 0 0 222
2014 5 26 12 9 0 8 50 51 45 17 4 1 0 229
U
2015 2 21 9 3 5 13 48 47 44 10 3 0 0 205
Total 26 136 112 52 22 78 27 349 349 179 75 20 5 1673
AN
0
3
4
M
5 Appendix 1: UIV/LIV location by year

UIV Total
D
T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2

2002 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1
TE
2006 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1
2007 0 1 0 0 0 0 0 0 0 1 0 0 0 0 2
2008 12 22 35 52 39 4 4 1 0 5 14 2 1 0 191
2009 12 30 45 50 19 7 6 2 6 11 21 0 0 0 209
EP
2010 9 28 49 56 21 7 5 2 3 14 6 6 0 0 206
2011 2 14 34 59 16 10 1 5 5 11 20 10 1 1 189
2012 5 25 24 66 30 4 1 4 5 14 29 19 3 0 229
C
2013 2 19 12 78 67 2 0 0 4 10 17 10 1 0 222
2014 0 26 14 74 60 1 3 2 1 8 27 13 1 0 230
AC
2015 2 17 10 69 59 3 3 6 2 6 19 9 0 0 205
44 182 223 505 311 38 23 22 26 80 154 69 7 1 1685
6
LIV Total
T12 L1 L2 L3 L4 L5
2002 0 0 0 1 0 0 1
2006 0 0 0 1 0 0 1
2007 0 0 0 0 2 0 2
15
ACCEPTED MANUSCRIPT
2008 7 48 30 81 23 2 191
2009 3 58 25 76 45 2 209
2010 2 44 34 70 51 4 205
2011 1 35 22 76 53 2 189
2012 13 51 29 77 55 4 229
2013 15 48 30 91 37 1 222
PT
2014 2 65 32 89 39 2 229
2015 1 63 25 84 33 0 206
44 412 227 646 338 17 1684
1
RI
2
SC
3
6
U
AN
7
8
M
9
D
TE
C EP
AC
16
ACCEPTED MANUSCRIPT
PT
RI
U SC
AN
M
D
TE
C EP
AC
ACCEPTED MANUSCRIPT
PT
RI
U SC
AN
M
D
TE
C EP
AC
ACCEPTED MANUSCRIPT
PT
RI
U SC
AN
M
D
TE
C EP
AC
ACCEPTED MANUSCRIPT
PT
RI
U SC
AN
M
D
TE
C EP
AC
ACCEPTED MANUSCRIPT
PT
RI
U SC
AN
M
D
TE
C EP
AC
ACCEPTED MANUSCRIPT
1. The consistent improvement of major curve correction is an achievement made by the
spine community over a period of 15 years, possibly due to the involvement of pedicle
screws.
2. Anterior approaches or combined antero-posterior approaches have been less
PT
performed in the treatment of Adolescent idiopathic scoliosis.
3. The next steps are the restoration of sagittal profiles, especially the hypokyphosis
RI
seen in Lenke 1 patients, the posterior minimally invasive approach and fast track
SC
return to activity.
U
AN
M
D
TE
C EP
AC
ACCEPTED MANUSCRIPT
AIS (adolescent idiopathic scoliosis)
LIV (lower instrumented vertebra)
UIV (upper instrumented vertebra)
PT
TK (thoracic kyphosis)
LL (lumbar lordosis)
RI
U SC
AN
M
D
TE
C EP
AC

15 Years and 2530 Patients The Evolution of Instrumentation PDF

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

15 Years and 2530 Patients The Evolution of Instrumentation PDF

Hochgeladen von

Copyright:

Verfügbare Formate

Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2018. Elsevier Inc.

Todos los derechos reservados.

To appear in: World Neurosurgery

Received Date: 9 March 2018

15 years and 2530 patients: The evolution of instrumentation, surgical strategies,

Correspondence should be addressed to: Yong Qiu, MD, Spine Surgery,

Drum Town Hospital, Nanjing University Medical School,

Disclosure. This work is supported by Jiangsu Provincial Key Medical Center

36 Key Words: Adolescent idiopathic scoliosis, Evolution, Surgery strategy, Outcome

9 Evaluation of instrumentations and surgical strategies

31 demographic data, follow-up time, and baseline radiographic parameters. Radiographic

19 Classification of AIS patients

29 Radiographic evaluation of the cohort

25 idiopathic scoliosis. Journal of Childrens Orthopaedics. 2013, 7(1):57-62.

Hibbs R A. An operation for progressive spinal deformities: a preliminary report of three

29 3. Harrington P R. Treatment of scoliosis: correction and internal fixation by spine

32 4. Aaro S, Dahlborn M. The effect of Harrington instrumentation on the longitudinal axis

4 6. Cotrel Y, Dubousset J, Guillaumat M. New universal instrumentation in spinal surgery.

12 9. Rushton P R, Grevitt M P. Do vertebral derotation techniques offer better outcomes

15 10. Lenke L G. Lenke classification system of adolescent idiopathic scoliosis: treatment

20 12. Kadoury S, Cheriet F, Beauséjour M, et al. A three-dimensional retrospective analysis of

22 European Spine Journal. 2009, 18(1):23-37.

Scoliosis over 20 Years: Have Outcomes Improved? Spine. 2017, 16(10):S242-S242.

33 17. Storer S K, Vitale M G, Hyman J E, et al. Correction of adolescent idiopathic scoliosis

35 Orthopaedics. 2005, 25(4):415.

1 neurofibromatosis type I: comparison between O-arm navigation and free-hand technique.

6 22. Dwyer A F, Newton N C, Sherwood A A. An anterior approach to scoliosis. A preliminary

19 27. Khakinahad M, Ameri E, Ghandhari H, et al. Preservation of thoracic kyphosis is critical to

24 29. Lonner B S, Lazar-Antman M A, Sponseller P D, et al. Multivariate analysis of factors

2 Fig 1: Age distribution among the included AIS patients

3 Fig 2: Surgical cases each year during the last 15 years.

4 Fig 3: Distribution of Lenke classification subtypes

6 Fig 5: Comparison of baseline, post-op Cobb angle between each year

1 Table 1: Information on surgical approach evolution

Year of surgery Anterior Posterior only Combined AP Total No.

Post-op Cobb angle 12.22° 16.17° 36.43°

Posterior Combined Total No.

Baseline Cobb angle 107.38° 107.76° 0.921

2 Table 3: Number of levels fused by year

5 Appendix 1: UIV/LIV location by year

T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2

1. The consistent improvement of major curve correction is an achievement made by the

2. Anterior approaches or combined antero-posterior approaches have been less

AIS (adolescent idiopathic scoliosis)

LIV (lower instrumented vertebra)

UIV (upper instrumented vertebra)

Das könnte Ihnen auch gefallen