Selection of upper instrumented vertebra for long-segment fixation in adult degenerative scoliosis_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

DONG Junfeng ^1,2,3 ,  LI Weishi ^1,2 , JIANG Yu ¹ , SUN Zhuoran ^1,2

1. Department of Orthopedics, Peking University Third Hospital, Beijing, 100191, P. R. China;
2. Beijing Key Laboratory of Spine Disease Research, Beijing, 100191, P. R. China;
3. Department of Orthopedics, the First Dongguan Affiliated Hospital of Guangdong Medical University, Dongguan Guangdong, 523710, P. R. China;

Corresponding author：

LI Weishi, Email: wslee72@163.com

Keywords：

Adult degenerative scoliosis; long-segment fixation; upper instrumented vertebra; minimally invasive surgery

DOI：

10.7507/1002-1892.202205081

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Objective To review the research progress of upper instrumented vertebra (UIV) selection strategy for long-segment fixation (LSF) in adult degenerative scoliosis (ADS). Methods The relevant domestic and foreign literature in recent years was reviewed, and the selection strategy of sagittal and coronal UIV for LSF in ADS patients, the relationship between UIV selection and proximal junctional kyphosis (PJK) and proximal junctional failure (PJF), the impact of minimally invasive spine surgery on the selection strategy of UIV were summarized. Results LSF can restore the biomechanical balance of the spine and reconstruct the physiological curve of the spine for ADS patients. LSF should be selected for ADS patients with severe scoliosis, vertebral rotation, and severe sagittal imbalance. For patients with poor general condition, UIV can choose the thoracic and lumbar vertebrae to reduce the operation time and intraoperative bleeding, which is conducive to early mobilization and reduce complications; for patients with good general condition, the upper thoracic vertebrae can be considered if necessary, in order to achieve satisfactory long-term effectiveness. However, the lower thoracic vertebra (T_9、10) should be selected as much as possible to reduce postoperative complications such as PJK and PJF. In recent years, a new reference marker, the first coronal reverse vertebra was proposed, to guide the selection of UIV. But a large-sample multicenter randomized controlled study is needed to further verify its reliability. Studies have shown that different races and different living habits would lead to different parameters of the spine and pelvis, which would affect the selection of UIV. Minimally invasive surgeries have achieved satisfactory results in the treatment of ADS, but the UIV selection strategy in specific applications needs to be further studied. Conclusion The selection strategy of UIV in LSF has not yet been unified. The selection of UIV in the sagittal plane of the upper thoracic spine, the lower thoracic spine, or the thoracolumbar spine should comprehensively consider the biomechanical balance of the spine and the general condition of the patient, as well as the relationship between the upper horizontal vertebra, the upper neutral vertebra, and the upper end vertebra on the coronal plane.

Citation： DONG Junfeng, LI Weishi, JIANG Yu, SUN Zhuoran. Selection of upper instrumented vertebra for long-segment fixation in adult degenerative scoliosis. Chinese Journal of Reparative and Reconstructive Surgery, 2022, 36(10): 1305-1311. doi: 10.7507/1002-1892.202205081 Copy

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2.	孙健, 方超, 高飞, 等. 长节段与短节段内固定治疗退变性脊柱侧弯疗效与并发症的Meta分析. 中国组织工程研究, 2020, 24(3): 438-445.
3.	Wang G, Hu J, Liu X, et al. Surgical treatments for degenerative lumbar scoliosis: a meta analysis. Eur Spine J, 2015, 24(8): 1792-1799.
4.	Lafage R, Line BG, Gupta S, et al. Orientation of the upper-most instrumented segment influences proximal junctional disease following adult spinal deformity surgery. Spine (Phila Pa 1976), 2017, 42(20): 1570-1577.
5.	Lee KY, Kim MW, Im CS, et al. Radiologic and clinical courses of degenerative lumbar scoliosis (10°-25°) after a short-segment fusion. Asian Spine J, 2017, 11(4): 570-579.
6.	Dangelmajer S, Zadnik PL, Rodriguez ST, et al. Minimally invasive spine surgery for adult degenerative lumbar scoliosis. Neurosurg Focus, 2014, 36(5): E7. doi: 10.3171/2014.3.FOCUS144.
7.	Masuda K, Higashi T, Yamada K, et al. The surgical outcome of decompression alone versus decompression with limited fusion for degenerative lumbar scoliosis. J Neurosurg Spine, 2018, 29(3): 259-264.
8.	Faldini C, Di Martino A, Borghi R, et al. Long vs. short fusions for adult lumbar degenerative scoliosis: does balance matters? Eur Spine J, 2015, 24 Suppl 7: 887-892.
9.	Wang N, Wang D, Wang F, et al. Evaluation of degenerative lumbar scoliosis after short segment decompression and fusion. Medicine (Baltimore), 2015, 94(47): e1824. doi: 10.1097/MD.0000000000001824.
10.	Phan K, Xu J, Maharaj MM, et al. Outcomes of short fusion versus long fusion for adult degenerative scoliosis: A systematic review and meta-analysis. Orthop Surg, 2017, 9(4): 342-349.
11.	Transfeldt EE, Topp R, Mehbod AA, et al. Surgical outcomes of decompression, decompression with limited fusion, and decompression with full curve fusion for degenerative scoliosis with radiculopathy. Spine (Phila Pa 1976), 2010, 35(20): 1872-1875.
12.	Cho KJ, Suk SI, Park SR, et al. Short fusion versus long fusion for degenerative lumbar scoliosis. Eur Spine J, 2008, 17(5): 650-656.
13.	何守玉, 朱锋, 邱勇, 等. 长、短节段融合内固定治疗成人退变性脊柱侧凸并发症分析. 中国骨与关节杂志, 2015, (3): 176-181.
14.	Shu S, Jing W, Zhu Z, et al. Risk factors for postoperative coronal decompensation in adult lumbar scoliosis after posterior correction with osteotomy. Arch Orthop Trauma Surg, 2022, 142(2): 211-217.
15.	Zhang J, Wang Z, Chi P. Risk factors for immediate postoperative coronal imbalance in degenerative lumbar scoliosis patients fused to pelvis. Global Spine J, 2021, 11(5): 649-655.
16.	Virk S, Platz U, Bess S, et al. Factors influencing upper-most instrumented vertebrae selection in adult spinal deformity patients: qualitative case-based survey of deformity surgeons. J Spine Surg, 2021, 7(1): 37-47.
17.	Kim HJ, Boachie-Adjei O, Shaffrey CI, et al. Upper thoracic versus lower thoracic upper instrumented vertebrae endpoints have similar outcomes and complications in adult scoliosis. Spine (Phila Pa 1976), 2014, 39(13): E795-E799.
18.	O’Shaughnessy BA, Bridwell KH, Lenke LG, et al. Does a long-fusion “T3-sacrum” portend a worse outcome than a short-fusion “T10-sacrum” in primary surgery for adult scoliosis? Spine (Phila Pa 1976), 2012, 37(10): 884-890.
19.	Hey HWD, Tan KA, Neo CS, et al. T₉ versus T₁₀ as the upper instrumented vertebra for correction of adult deformity-rationale and recommendations. Spine J, 2017, 17(5): 615-621.
20.	Zhu Y, Wang K, Wang B, et al. Selection of proximal fusion level for degenerative scoliosis and the entailing proximal-related late complications. Int J Clin Exp Med, 2015, 8(4): 5731-5738.
21.	Du J, Tang X, Li N, et al. Limited long-segment fusion for degenerative lower lumbar scoliosis: a special kind of scoliosis. Int Orthop, 2016, 40(6): 1227-1231.
22.	钱邦平, 邱勇. 退变性脊柱侧凸近端融合椎的选择: 原则及相关问题. 中国脊柱脊髓杂志, 2016, 26(8): 673-675.
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24.	Dickson DD, Lenke LG, Bridwell KH, et al. Risk factors for and assessment of symptomatic pseudarthrosis after lumbar pedicle subtraction osteotomy in adult spinal deformity. Spine (Phila Pa 1976), 2014, 39(15): 1190-1195.
25.	Kuklo TR. Principles for selecting fusion levels in adult spinal deformity with particular attention to lumbar curves and double major curves. Spine (Phila Pa 1976), 2006, 31(19 Suppl): S132-S138.
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29.	Ha KY, Kim YH, Ahn JH. Is it real adjacent segment pathology by stress concentration after limited fusion in degenerative lumbar scoliosis? Spine (Phila Pa 1976), 2014, 39(13): 1059-1066.
30.	徐用亿, 田纪伟, 赵庆华, 等. 长节段近端融合固定椎的选择对治疗退变性腰椎侧凸疗效的影响. 中华医学杂志, 2016, 96(45): 3674-3679.
31.	费晗, 李危石, 孙卓然, 等. 退变性腰椎侧凸脊柱-骨盆矢状位影像学特点. 中国脊柱脊髓杂志, 2015, 25(6): 528-532.
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34.	Koike Y, Kotani Y, Terao H, et al. Risk factor analysis of proximal junctional kyphosis after surgical treatment of adult spinal deformity with oblique lateral interbody fusion. Asian Spine J, 2021, 15(1): 107-116.
35.	Iyer S, Lovecchio F, Elysée JC, et al. Posterior ligamentous reinforcement of the upper instrumented vertebrae+1 does not decrease proximal junctional kyphosis in adult spinal deformity. Global Spine J, 2020, 10(6): 692-699.
36.	Hyun SJ, Lee BH, Park JH, et al. Proximal junctional kyphosis and proximal junctional failure following adult spinal deformity surgery. Korean J Spine, 2017, 14(4): 126-132.
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39.	Decker S, Lafage R, Krettek C, et al. Is sacral extension a risk factor for early proximal junctional kyphosis in adult spinal deformity surgery? Asian Spine J, 2020, 14(2): 212-219.
40.	Liu FY, Wang T, Yang SD, et al. Incidence and risk factors for proximal junctional kyphosis: a meta-analysis. Eur Spine J, 2016, 25(8): 2376-2383.
41.	袁磊, 陈萧霖, 曾岩, 等. 退变性腰椎侧凸患者椎旁肌退变与术后近端交界性后凸的相关性研究. 中国脊柱脊髓杂志, 2018, 28(5): 425-433.
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1. Kim W, Porrino JA, Hood KA, et al. Clinical evaluation, imaging, and management of adolescent idiopathic and adult degenerative scoliosis. Curr Probl Diagn Radiol, 2019, 48(4): 402-414.
2. 孙健, 方超, 高飞, 等. 长节段与短节段内固定治疗退变性脊柱侧弯疗效与并发症的Meta分析. 中国组织工程研究, 2020, 24(3): 438-445.
3. Wang G, Hu J, Liu X, et al. Surgical treatments for degenerative lumbar scoliosis: a meta analysis. Eur Spine J, 2015, 24(8): 1792-1799.
4. Lafage R, Line BG, Gupta S, et al. Orientation of the upper-most instrumented segment influences proximal junctional disease following adult spinal deformity surgery. Spine (Phila Pa 1976), 2017, 42(20): 1570-1577.
5. Lee KY, Kim MW, Im CS, et al. Radiologic and clinical courses of degenerative lumbar scoliosis (10°-25°) after a short-segment fusion. Asian Spine J, 2017, 11(4): 570-579.
6. Dangelmajer S, Zadnik PL, Rodriguez ST, et al. Minimally invasive spine surgery for adult degenerative lumbar scoliosis. Neurosurg Focus, 2014, 36(5): E7. doi: 10.3171/2014.3.FOCUS144.
7. Masuda K, Higashi T, Yamada K, et al. The surgical outcome of decompression alone versus decompression with limited fusion for degenerative lumbar scoliosis. J Neurosurg Spine, 2018, 29(3): 259-264.
8. Faldini C, Di Martino A, Borghi R, et al. Long vs. short fusions for adult lumbar degenerative scoliosis: does balance matters? Eur Spine J, 2015, 24 Suppl 7: 887-892.
9. Wang N, Wang D, Wang F, et al. Evaluation of degenerative lumbar scoliosis after short segment decompression and fusion. Medicine (Baltimore), 2015, 94(47): e1824. doi: 10.1097/MD.0000000000001824.
10. Phan K, Xu J, Maharaj MM, et al. Outcomes of short fusion versus long fusion for adult degenerative scoliosis: A systematic review and meta-analysis. Orthop Surg, 2017, 9(4): 342-349.
11. Transfeldt EE, Topp R, Mehbod AA, et al. Surgical outcomes of decompression, decompression with limited fusion, and decompression with full curve fusion for degenerative scoliosis with radiculopathy. Spine (Phila Pa 1976), 2010, 35(20): 1872-1875.
12. Cho KJ, Suk SI, Park SR, et al. Short fusion versus long fusion for degenerative lumbar scoliosis. Eur Spine J, 2008, 17(5): 650-656.
13. 何守玉, 朱锋, 邱勇, 等. 长、短节段融合内固定治疗成人退变性脊柱侧凸并发症分析. 中国骨与关节杂志, 2015, (3): 176-181.
14. Shu S, Jing W, Zhu Z, et al. Risk factors for postoperative coronal decompensation in adult lumbar scoliosis after posterior correction with osteotomy. Arch Orthop Trauma Surg, 2022, 142(2): 211-217.
15. Zhang J, Wang Z, Chi P. Risk factors for immediate postoperative coronal imbalance in degenerative lumbar scoliosis patients fused to pelvis. Global Spine J, 2021, 11(5): 649-655.
16. Virk S, Platz U, Bess S, et al. Factors influencing upper-most instrumented vertebrae selection in adult spinal deformity patients: qualitative case-based survey of deformity surgeons. J Spine Surg, 2021, 7(1): 37-47.
17. Kim HJ, Boachie-Adjei O, Shaffrey CI, et al. Upper thoracic versus lower thoracic upper instrumented vertebrae endpoints have similar outcomes and complications in adult scoliosis. Spine (Phila Pa 1976), 2014, 39(13): E795-E799.
18. O’Shaughnessy BA, Bridwell KH, Lenke LG, et al. Does a long-fusion “T3-sacrum” portend a worse outcome than a short-fusion “T10-sacrum” in primary surgery for adult scoliosis? Spine (Phila Pa 1976), 2012, 37(10): 884-890.
19. Hey HWD, Tan KA, Neo CS, et al. T₉ versus T₁₀ as the upper instrumented vertebra for correction of adult deformity-rationale and recommendations. Spine J, 2017, 17(5): 615-621.
20. Zhu Y, Wang K, Wang B, et al. Selection of proximal fusion level for degenerative scoliosis and the entailing proximal-related late complications. Int J Clin Exp Med, 2015, 8(4): 5731-5738.
21. Du J, Tang X, Li N, et al. Limited long-segment fusion for degenerative lower lumbar scoliosis: a special kind of scoliosis. Int Orthop, 2016, 40(6): 1227-1231.
22. 钱邦平, 邱勇. 退变性脊柱侧凸近端融合椎的选择: 原则及相关问题. 中国脊柱脊髓杂志, 2016, 26(8): 673-675.
23. 马超, 侯树勋. 成人退变性脊柱侧凸手术治疗的研究进展. 中国骨与关节杂志, 2015, 4(5): 426-429.
24. Dickson DD, Lenke LG, Bridwell KH, et al. Risk factors for and assessment of symptomatic pseudarthrosis after lumbar pedicle subtraction osteotomy in adult spinal deformity. Spine (Phila Pa 1976), 2014, 39(15): 1190-1195.
25. Kuklo TR. Principles for selecting fusion levels in adult spinal deformity with particular attention to lumbar curves and double major curves. Spine (Phila Pa 1976), 2006, 31(19 Suppl): S132-S138.
26. 侯东坡, 海涌, 康南. 退变性脊柱侧凸长节段固定融合端椎选择的研究进展. 中国脊柱脊髓杂志, 2017, 27(6): 557-560.
27. Kim HJ, Yang JH, Chang DG, et al. Adult spinal deformity: Current concepts and decision-making strategies for management. Asian Spine J, 2020, 14(6): 886-897.
28. Kim YJ, Bridwell KH, Lenke LG, et al. 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(24): 2653-2661.
29. Ha KY, Kim YH, Ahn JH. Is it real adjacent segment pathology by stress concentration after limited fusion in degenerative lumbar scoliosis? Spine (Phila Pa 1976), 2014, 39(13): 1059-1066.
30. 徐用亿, 田纪伟, 赵庆华, 等. 长节段近端融合固定椎的选择对治疗退变性腰椎侧凸疗效的影响. 中华医学杂志, 2016, 96(45): 3674-3679.
31. 费晗, 李危石, 孙卓然, 等. 退变性腰椎侧凸脊柱-骨盆矢状位影像学特点. 中国脊柱脊髓杂志, 2015, 25(6): 528-532.
32. Wang H, Sun Z, Wang L, et al. Proximal fusion level above first coronal reverse vertebrae: An essential factor decreasing the risk of adjacent segment degeneration in degenerative lumbar scoliosis. Global Spine J, 2021. doi: 10.1177/2192568221994082.
33. Cho SK, Shin JI, Kim YJ. Proximal junctional kyphosis following adult spinal deformity surgery. Eur Spine J, 2014, 23(12): 2726-2736.
34. Koike Y, Kotani Y, Terao H, et al. Risk factor analysis of proximal junctional kyphosis after surgical treatment of adult spinal deformity with oblique lateral interbody fusion. Asian Spine J, 2021, 15(1): 107-116.
35. Iyer S, Lovecchio F, Elysée JC, et al. Posterior ligamentous reinforcement of the upper instrumented vertebrae+1 does not decrease proximal junctional kyphosis in adult spinal deformity. Global Spine J, 2020, 10(6): 692-699.
36. Hyun SJ, Lee BH, Park JH, et al. Proximal junctional kyphosis and proximal junctional failure following adult spinal deformity surgery. Korean J Spine, 2017, 14(4): 126-132.
37. Lau D, Clark AJ, Scheer JK, et al. Proximal junctional kyphosis and failure after spinal deformity surgery: a systematic review of the literature as a background to classification development. Spine (Phila Pa 1976), 2014, 39(25): 2093-2102.
38. Yagi M, King AB, Boachie-Adjei O. Incidence, risk factors, and natural course of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Minimum 5 years of follow-up. Spine (Phila Pa 1976), 2012, 37(17): 1479-1489.
39. Decker S, Lafage R, Krettek C, et al. Is sacral extension a risk factor for early proximal junctional kyphosis in adult spinal deformity surgery? Asian Spine J, 2020, 14(2): 212-219.
40. Liu FY, Wang T, Yang SD, et al. Incidence and risk factors for proximal junctional kyphosis: a meta-analysis. Eur Spine J, 2016, 25(8): 2376-2383.
41. 袁磊, 陈萧霖, 曾岩, 等. 退变性腰椎侧凸患者椎旁肌退变与术后近端交界性后凸的相关性研究. 中国脊柱脊髓杂志, 2018, 28(5): 425-433.
42. 袁磊, 张心灵, 曾岩, 等. 退变性腰椎侧凸长节段融合术后远端交界性问题分析. 中国脊柱脊髓杂志, 2019, 29(6): 505-513.
43. 李危石, 费晗, 陈仲强, 等. 退变性腰椎侧凸患者腰椎前凸矫正程度与疗效的关系. 中国脊柱脊髓杂志, 2016, 26(10): 912-918.
44. Lafage R, Beyer G, Schwab F, et al. Risk factor analysis for proximal junctional kyphosis after adult spinal deformity surgery: A new simple scoring system to identify high-risk patients. Global Spine J, 2020, 10(7): 863-870.
45. Kwon BK, Elgafy H, Keynan O, et al. Progressive junctional kyphosis at the caudal end of lumbar instrumented fusion: etiology, predictors, and treatment. Spine (Phila Pa 1976), 2006, 31(17): 1943-1951.
46. Fujimori T, Inoue S, Le H, et al. Long fusion from sacrum to thoracic spine for adult spinal deformity with sagittal imbalance: upper versus lower thoracic spine as site of upper instrumented vertebra. Neurosurg Focus, 2014, 36(5): E9. doi: 10.3171/2014.3.FOCUS13541.
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