Reducing the kyphosis effect of anterior short thoracolumbar/lumbar scoliosis correction with an autograft fulcrum effect

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Abstract

Background

Anterior scoliosis correction is a powerful technique with the disadvantage of a kyphotic effect on lumbar and thoracolumbar curves. We aimed to investigate whether a cognizant interposition of a rib graft anteriorly and at the concave side of the scoliotic curve causes significant fulcrum effect to enforce scoliosis correction and to reduce interfusional kyphosis in anterior scoliosis corrections.

Methods

Twenty otherwise comparable patients with lumbar and thoracolumbar adolescent idiopathic scoliosis (AIS) curves undergoing anterior short scoliosis correction with ( n = 10) or without ( n = 10, matched for age, gender and degree of deformity) fulcrum effect were retrospectively compared by means of radiographic measurements (sagittal and coronal profile, Cobb angles and intersegmental deformity correction angles) to evaluate the effect of this modified surgical technique.

Results

The overall amount of scoliosis correction was similar with 74 and 60% of initial curves of 57° and 53° in the case and control group respectively with a mean of 3 fused segments (4 screws).

Statistically relevant differences were found for intersegmental coronal cobb angles at the apex of 20° to 3° and 17° to 9° with and without fulcrum, respectively ( p < 0.05). Creation of kyphosis in the fused segments was reduced with an interfusional kyphotic sagittal cobb angle of 15° pre-operatively vs. 3° post-operatively compared to the control group (13° pre-operatively vs. 18° post-operatively), ( p < 0.05).

Conclusions

Interfusional hyperkyphosis associated with anterior scoliosis correction for thoracolumbar/lumbar curves can be reduced with cognizant positioning of the bone autograft at the antero-lateral (concave) site in the intervertebral region to create a fulcrum effect.

Trial registration

Registered at swissethics: BASEC No.: 2018–00180.

Related collections

Most cited references 26

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Radiographic analysis of sagittal plane alignment and balance in standing volunteers and patients with low back pain matched for age, sex, and size. A prospective controlled clinical study.

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A global and segmental study on standing lateral radiographs of 100 volunteers and 100 patients who had low back pain was undertaken to further define sagittal plane alignment and balance. The volunteer control group and the patient group were matched for age, sex, and size. Measurements and determinations made on the standing radiographs included the following: segmental and total lordosis L1-S1 (Cobb method); thoracic kyphosis; thoracic apex; plumbline dropped from the center of C7; and sacral inclination measured between the plumbline and a line drawn along the back of the proximal sacrum. Segmental lordoses were significantly different between each motion segment in both groups. Approximately two-thirds of total lordosis occurred at the bottom two discs, i.e., L4-5 and L5-S1. Total lordosis was significantly less in the patients and was not age- or sex-related in either group. Patients tended to stand with less distal segmental lordosis, but more proximal lumbar lordosis, a more vertical sacrum and, therefore, more hip extension. This may be related to compensation as C7 sagittal plumb lines were comparable in both groups. Both groups had similar thoracic kyphosis. A much higher percentage of smokers was found in the low back pain patient population studied. Because of the significant amount of angulation in the lower lumbar spine, measurement of lordosis should include the L5-S1 motion segment and be done standing to better assess balance. Sacral inclination is a determinate of both standing pelvic rotation and hip extension. It is strongly correlated with segmental and total lordosis in both volunteers and patients. Definitions of sagittal balance are provided as well as additional sagittal plane data by which to compare corrections and fusions for different spinal disorders.

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Comparison of anterior and posterior instrumentation for correction of adolescent thoracic idiopathic scoliosis.

Jürgen Harms, H L Shufflebarger, Rohan Lowe … (1999)

This was a prospective study of two cohort groups of patients (one group receiving anterior instrumentation and the other posterior instrumentation) receiving treatment for thoracic idiopathic scoliosis. To present the 2-year postoperative results of a prospective multicenter study comparing the use of anterior instrumentation with that of posterior multisegmented hook instrumentation for the correction of adolescent thoracic idiopathic scoliosis. Despite reports of satisfactory results, problems have been reported with posterior systems, including worsening of the lumbar curve after surgery and failure to correct hypokyphosis. Theoretically, the advantages of anterior instrumentation include prevention of lumbar curve decompensation by shortening the convexity of the thoracic curve. In addition, by removing the disc, better correction of thoracic hypokyphosis could be obtained. Seventy-eight patients who underwent an anterior spinal fusion using flexible threaded rods and nuts (Harms-MOSS instrumentation, De Puy-Motech-Acromed, Cleveland, OH) were analyzed and compared with 100 patients who underwent posterior spinal fusion with multisegmented hook systems. Parameters of comparison included coronal and sagittal correction, balance, distal lumbar fusion levels, and complication. All patients had idiopathic thoracic curves of King Types II to V. The average age at surgery was 14 years in each group, the average preoperative curve 57 degrees, and the minimum duration of follow-up for all patients 24 months. All data were collected prospectively and analyzed via Epl into statistical analysis (Centers of Disease Control, Atlanta, GA). Average coronal correction of the main thoracic curve was 58% in the anterior group and 59% in the posterior group (P = 0.92). Analysis of sagittal contour showed that the posterior systems failed to correct a preoperative hypokyphosis (sagittal T5 to T12 less than 20 degrees) in 60% of cases, whereas 81% were normal postoperatively in the anterior group. However, hyperkyphosis (sagittal T5 to T12 greater than 40 degrees) occurred after surgery in 40% of the anterior group when the preoperative kyphosis was greater than 20 degrees. Postoperative coronal balance was equal in both groups. An average of 2.5 (range, 0-6) distal fusion levels were saved using the anterior spinal instrumentation according to the criteria used for determining posterior fusion levels in this study. Selective fusion of the thoracic curve (distal fusion level T11, T12, L1) was performed in 76 of 78 patients (97%) in the anterior group as compared with only 18 of 100 (18%) in the posterior group. Surgically confirmed pseudarthrosis occurred in 4 of 78 patients (5%) in the anterior group and in 1 of 100 patients (1%) in the posterior group (P = 0.10). Loss of correction greater than 10 degrees occurred in 18 of 78 patients (23%) in the anterior group and in 12 of 100 patients (12%) in the posterior group (P = 0.01). Implant breakage occurred in 24 patients (31%) of the anterior group and in only 1 patient (1%) of the posterior group. 1) Coronal correction and balance were equal in both the anterior and posterior groups, even though the anterior group had the majority of curves (97%) fused short or to L1, whereas only 18% were fused short or to L1 in the posterior group. 2) In the anterior group there was a better correction of sagittal profile in those with a preoperative hypokyphosis less than 20 degrees. However, hyperkyphosis (with a mean of 54 degrees) occurred in 40% of those in the anterior group with a preoperative kyphosis of more than 20 degrees. 3) An average of 2.5 lumbar levels can be saved with anterior fusion and instrumentation according to the criteria used for choosing posterior fusion levels in this study. 4) Using the 3.2-mm flexible rod in this study, loss of correction, pseudarthrosis, and rod breakage were unacceptably highe

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All references

Author and article information

Contributors

José Miguel Spirig: jose.spirig@balgrist.ch

Journal

Journal ID (nlm-ta): BMC Musculoskelet Disord

Journal ID (iso-abbrev): BMC Musculoskelet Disord

Title: BMC Musculoskeletal Disorders

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2474

Publication date (Electronic): 23 February 2021

Publication date PMC-release: 23 February 2021

Publication date Collection: 2021

Volume: 22

Electronic Location Identifier: 216

Affiliations

[1 ]GRID grid.7400.3, ISNI 0000 0004 1937 0650, Spine Division, Balgrist University Hospital, , University of Zurich, ; Forchstrasse 340, 8008 Zurich, Switzerland

[2 ]GRID grid.412373.0, ISNI 0000 0004 0518 9682, Laboratory for Orthopaedic Biomechanics, , Balgrist University Hospital, ; Zürich, Switzerland

[3 ]GRID grid.5801.c, ISNI 0000 0001 2156 2780, Institute of Biomechanics, , ETH Zurich, ; Zurich, Switzerland

Article

Publisher ID: 4083

DOI: 10.1186/s12891-021-04083-1

PMC ID: 7903709

PubMed ID: 33622298

SO-VID: 86480b8d-a2c6-4220-a225-c6ec05393f76

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 18 October 2020

Date accepted : 9 February 2021

Custom metadata

ScienceOpen disciplines: Orthopedics

Keywords: scoliosis,kyphosis correction,anterior scoliosis correction,lumbar scoliosis,thoracolumbar scoliosis,kyphosis prevention

Data availability: