Selective versus hyperselective posterior fusions in Lenke 5 adolescent idiopathic scoliosis: comparison of radiological and clinical outcomes

Abstract

PURPOSE: Recent literature has reported that the ]progression risk of Lenke 5 adolescent idiopathic scoliosis (AIS) during adulthood had been underestimated. Surgery is, therefore, proposed more to young patients with progressive curves. However, choice of the approach and fusion levels remains controversial. The aim of this study was to analyze the influence of the length of posterior fusion on clinical and radiological outcomes in Lenke 5 AIS. METHODS: All Lenke 5 AIS operated between 2008 and 2012 were included with a minimum 2-year follow-up. Patients were divided into two groups according to the length of fusion. In the first group (selective), the upper instrumented level (UIV) was the upper end vertebra of the main structural curve and distally the fusion was extended to the stable and neutral vertebra, according to Lenke's classification. In the second group (hyperselective), shorter fusions were performed and the number of levels fused depended on the location of the apex of the curve (at maximum, 2 levels above and below, according to Hall's criteria). Apart from the fusion level selection, the surgical procedure was similar in both groups. Radiological outcomes and SRS-22 scores were reported. RESULTS: 78 patients were included (35 selective and 43 hyperselective). The number of levels fused was significantly higher in the first group (7.8 ± 3 vs 4.3 ± 0.6). None of the patients was fused to L4 in selective group. No correlation was found between length of fusion and complication rate. Eight patients had adding-on phenomenon among which 6 (75%) had initially undergone hyperselective fusions and had significantly higher postoperative lower instrumented vertebra (LIV) tilt. In the adding-on group, LIV was located above the last touching vertebra (LTV) in 62.5% of the cases and above the stable vertebra (SV) in 87.5%. Patients in the selective group reported a significantly lower score in the SRS function domain. CONCLUSION: Coronal alignment was restored in both groups. Hyperselective posterior fusions can be considered in Lenke 5 AIS, preserving one or two mobile segments, with similar clinical and radiological outcomes. However, selection of the LIV according to SV and LTV need to be accurately analyzed in order to avoid adding-on during follow-up.