J Korean Neurosurg Soc.  2016 Jul;59(4):327-333. 10.3340/jkns.2016.59.4.327.

Decision Making Algorithm for Adult Spinal Deformity Surgery

• Kim YJ
• Hyun SJ
• Cheh G
• Cho SK
• Rhim SC

• KMID: 2315965
• DOI: http://doi.org/10.3340/jkns.2016.59.4.327

Abstract

Adult spinal deformity (ASD) is one of the most challenging spinal disorders associated with broad range of clinical and radiological presentation. Correct selection of fusion levels in surgical planning for the management of adult spinal deformity is a complex task. Several classification systems and algorithms exist to assist surgeons in determining the appropriate levels to be instrumented. In this study, we describe our new simple decision making algorithm and selection of fusion level for ASD surgery in terms of adult idiopathic idiopathic scoliosis vs. degenerative scoliosis.

Keyword

Adult spinal deformity; Idiopathic scoliosis; Classification; Spinal fusion; Selective fusion; Algorithm

MeSH Terms

Adult*
Classification
Congenital Abnormalities*
Decision Making*
Humans
Scoliosis
Spinal Fusion
Surgeons

Figure

• 

  Fig. 1 Re-grouping of Lenke classification.

• 

  Fig. 2 A : Group 1. All lumbar AB modifier. B : Group 2. All lumbar C modifier with thoracic major curve. C : Group 3. All lumbar C modifier with lumbar major curve.

• 

  Fig. 3 New stable vertebra at TL junction and lower lumbar spine.

Reference

1. Bridwell KH. Decision making regarding Smith-Petersen vs. pedicle subtraction osteotomy vs. vertebral column resection for spinal deformity. Spine (Phila Pa 1976). 2006; 31(19 Suppl):S171–S178. PMID: 16946635.

2. Bridwell KH, Lewis SJ, Lenke LG, Baldus C, Blanke K. Pedicle subtraction osteotomy for the treatment of fixed sagittal imbalance. J Bone Joint Surg Am. 85-A:2003; 454–463. PMID: 12637431.

3. Cho SK, Shin JI, Kim YJ. Proximal junctional kyphosis following adult spinal deformity surgery. Eur Spine J. 2014; 23:2726–2736. PMID: 25186826.

4. Clements DH, Marks M, Newton PO, Betz RR, Lenke L, Shufflebarger H. Harms Study Group. Did the Lenke classification change scoliosis treatment? Spine (Phila Pa 1976). 2011; 36:1142–1145. PMID: 21358471.

5. Edwards CC 2nd, Bridwell KH, Patel A, Rinella AS, Jung Kim Y, Berra AB, et al. Thoracolumbar deformity arthrodesis to L5 in adults : the fate of the L5-S1 disc. Spine (Phila Pa 1976). 2003; 28:2122–2231. PMID: 14501924.

6. Fischer CR, Kim Y. Selective fusion for adolescent idiopathic scoliosis : a review of current operative strategy. Eur Spine J. 2011; 20:1048–1057. PMID: 21387194.

7. Ha Y, Maruo K, Racine L, Schairer WW, Hu SS, Deviren V, et al. Proximal junctional kyphosis and clinical outcomes in adult spinal deformity surgery with fusion from the thoracic spine to the sacrum : a comparison of proximal and distal upper instrumented vertebrae. J Neurosurg Spine. 2013; 19:360–369. PMID: 23848349.

8. Harrington PR. Treatment of scoliosis. Correction and internal fixation by spine instrumentation. J Bone Joint Surg Am. 44-A:1962; 44-A:591–610. PMID: 14036052.

9. Hibbs RA. A report of fifty-nine cases of scoliosis treated by the fusion operation. By Russell A. Hibbs, 1924. Clin Orthop Relat Res. 1988; (229):4–19. PMID: 3280202.

10. Hyun SJ, Kim YJ, Rhim SC. Spinal pedicle subtraction osteotomy for fixed sagittal imbalance patients. World J Clin Cases. 2013; 1:242–248. PMID: 24340276.

11. Hyun SJ, Lenke LG, Kim YC, Koester LA, Blanke KM. Comparison of standard 2-rod constructs to multiple-rod constructs for fixation across 3-column spinal osteotomies. Spine (Phila Pa 1976). 2014; 39:1899–1904. PMID: 25299168.

12. Hyun SJ, Rhim SC. Clinical outcomes and complications after pedicle subtraction osteotomy for fixed sagittal imbalance patients : a long-term follow-up data. J Korean Neurosurg Soc. 2010; 47:95–101. PMID: 20224706.

13. Hyun SJ, Rhim SC, Kim YJ, Kim YB. A mid-term follow-up result of spinopelvic fixation using iliac screws for lumbosacral fusion. J Korean Neurosurg Soc. 2010; 48:347–353. PMID: 21113363.

14. Kim YJ, Bridwell KH, Lenke LG, Glattes CR, Rhim S, Cheh G. Proximal junctional kyphosis in adult spinal deformity after segmental posterior spinal instrumentation and fusion : minimum five-year follow-up. Spine (Phila Pa 1976). 2008; 33:2179–2184. PMID: 18794759.

15. Kim YJ, Bridwell KH, Lenke LG, Rhim S, Cheh G. An analysis of sagittal spinal alignment following long adult lumbar instrumentation and fusion to L5 or S1 : can we predict ideal lumbar lordosis? Spine (Phila Pa 1976). 2006; 31:2343–2352. PMID: 16985463.

16. Kim YJ, Bridwell KH, Lenke LG, Rhim S, Kim YW. Is the T9, T11, or L1 the more reliable proximal level after adult lumbar or lumbosacral instrumented fusion to L5 or S1? Spine (Phila Pa 1976). 2007; 32:2653–2661. PMID: 18007240.

17. Kim YJ, Fischer CR, Lenke LG, Bridwell KH, Boachie-Adjei O, Clement J, et al. Optimal lower instrumented vertebra to avoid adding-on or distal junctional kyphosis for thoracic adolescent idiopathic scoliosis. Podium presentation no. 88. In : Proceeding of the Scoliosis Research Society Annual Meeting; 2011 Sep 14-17; Louisville, USA. Milwaukee, WI: SRS;2011.

18. King HA, Moe JH, Bradford DS, Winter RB. The selection of fusion levels in thoracic idiopathic scoliosis. J Bone Joint Surg Am. 1983; 65:1302–1313. PMID: 6654943.

19. Lenke LG, Betz RR, Bridwell KH, Clements DH, Harms J, Lowe TG, et al. Intraobserver and interobserver reliability of the classification of thoracic adolescent idiopathic scoliosis. J Bone Joint Surg Am. 1998; 80:1097–1106. PMID: 9730118.

20. Lenke LG, Betz RR, Harms J, Bridwell KH, Clements DH, Lowe TG, et al. Adolescent idiopathic scoliosis : a new classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am. 83-A:2001; 1169–1181. PMID: 11507125.

21. Lenke LG, Bridwell KH, Baldus C, Blanke K. Preventing decompensation in King type II curves treated with Cotrel-Dubousset instrumentation. Strict guidelines for selective thoracic fusion. Spine (Phila Pa 1976). 1992; 17(8 Suppl):S274–S281. PMID: 1523512.

22. Lowe T, Berven SH, Schwab FJ, Bridwell KH. The SRS classification for adult spinal deformity : building on the King/Moe and Lenke classification systems. Spine (Phila Pa 1976). 2006; 31(19 Suppl):S119–S125. PMID: 16946628.

23. Rose PS, Bridwell KH, Lenke LG, Cronen GA, Mulconrey DS, Buchowski JM, et al. Role of pelvic incidence, thoracic kyphosis, and patient factors on sagittal plane correction following pedicle subtraction osteotomy. Spine (Phila Pa 1976). 2009; 34:785–791. PMID: 19365245.

24. Smith JS, Klineberg E, Schwab F, Shaffrey CI, Moal B, Ames CP, et al. Change in classification grade by the SRS-Schwab Adult Spinal Deformity Classification predicts impact on health-related quality of life measures : prospective analysis of operative and nonoperative treatment. Spine (Phila Pa 1976). 2013; 38:1663–1671. PMID: 23759814.

25. Sudo H, Kaneda K, Shono Y, Iwasaki N. Selection of the upper vertebra to be instrumented in the treatment of thoracolumbar and lumbar adolescent idiopathic scoliosis by anterior correction and fusion surgery using dual-rod instrumentation : a minimum 12-year follow-up study. Spine J. 2016; 16:281–287. PMID: 26291399.

26. Suk SI, Lee SM, Chung ER, Kim JH, Kim SS. Selective thoracic fusion with segmental pedicle screw fixation in the treatment of thoracic idiopathic scoliosis : more than 5-year follow-up. Spine (Phila Pa 1976). 2005; 30:1602–1609. PMID: 16025028.

27. Sun Z, Qiu G, Zhao Y, Wang Y, Zhang J, Shen J. Lowest instrumented vertebrae selection for selective posterior fusion of moderate thoracolumbar/lumbar idiopathic scoliosis : lower-end vertebra or lower-end vertebra+1? Eur Spine J. 2014; 23:1251–1257. PMID: 24664427.

28. Terran J, Schwab F, Shaffrey CI, Smith JS, Devos P, Ames CP, et al. The SRS-Schwab adult spinal deformity classification : assessment and clinical correlations based on a prospective operative and nonoperative cohort. Neurosurgery. 2013; 73:559–568. PMID: 23756751.

29. Weinstein SL, Ponseti IV. Curve progression in idiopathic scoliosis. J Bone Joint Surg Am. 1983; 65:447–455. PMID: 6833318.

30. Youssef JA, Orndorff DO, Patty CA, Scott MA, Price HL, Hamlin LF, et al. Current status of adult spinal deformity. Global Spine J. 2013; 3:51–62. PMID: 24436852.