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Predictors of Distal Adding-On in Thoracic Major Curves with AR Lumbar Modifiers.
Spine 2016 July 8
STUDY DESIGN: Retrospective review of prospectively collected dataObjective: To determine whether the last substantially touched vertebra (LSTV) is a valid lowest instrumented vertebra (LIV) for both Lenke 1 and 2 curve patterns with AR lumbar modifiers,and to identify pre-operative risk factors of distal adding-on.
SUMMARY OF BACKGROUND: Previous studies have recommended selecting the LSTV as the LIV for Lenke 1AR curves (main thoracic curve with 'A' lumbar modifier and L4 tilt to the right (thoracic overhang / King type IV curve).
METHODS: One hundred sixty patients with a Lenke 1 or 2 curve pattern and AR lumbar modifier who underwent posterior spinal fusion between 2008 and 2012 were reviewed. All patients had minimum 2-year follow-up. Patients were identified with distal adding-onbetween first erect radiographs and 2-year follow-up based on previously defined parameters.Factors predictive of the adding-on phenomenon were identified in a multivariate binary logistic regression model.
RESULTS: Twenty seven patients (17%) were identified as having distal adding-on of their primary thoracic curve; however only 8 of 89 patients (9%) fused to the LSTV developed adding-on (p = 0.005). Three variables were found to be significant predictors of adding-on: LIV proximal to LSTV (O.R. 3.63; p = 0.01), Risser zero (O.R. 4.93; p = 0.02), and C7-CSVL distance <2 cm (O.R. 3.97; p = 0.01). The risk of adding-on increased as the number of predictors increased from 16% with 1 risk factor to 80% when all 3 pre-operative risk factors were present (p < 0.001).
CONCLUSION: Choosing the LSTV as the LIV in Lenke 1 and 2 curve patterns with an AR lumbar modifier significantly decreases the risk of distal adding-on. Skeletally immature patients, those fused short of LSTV, and those with relative coronal balance pre-operatively are at increased risk of distal adding-on between the initial post-operative visit and two year follow-up.
LEVEL OF EVIDENCE: 4.
SUMMARY OF BACKGROUND: Previous studies have recommended selecting the LSTV as the LIV for Lenke 1AR curves (main thoracic curve with 'A' lumbar modifier and L4 tilt to the right (thoracic overhang / King type IV curve).
METHODS: One hundred sixty patients with a Lenke 1 or 2 curve pattern and AR lumbar modifier who underwent posterior spinal fusion between 2008 and 2012 were reviewed. All patients had minimum 2-year follow-up. Patients were identified with distal adding-onbetween first erect radiographs and 2-year follow-up based on previously defined parameters.Factors predictive of the adding-on phenomenon were identified in a multivariate binary logistic regression model.
RESULTS: Twenty seven patients (17%) were identified as having distal adding-on of their primary thoracic curve; however only 8 of 89 patients (9%) fused to the LSTV developed adding-on (p = 0.005). Three variables were found to be significant predictors of adding-on: LIV proximal to LSTV (O.R. 3.63; p = 0.01), Risser zero (O.R. 4.93; p = 0.02), and C7-CSVL distance <2 cm (O.R. 3.97; p = 0.01). The risk of adding-on increased as the number of predictors increased from 16% with 1 risk factor to 80% when all 3 pre-operative risk factors were present (p < 0.001).
CONCLUSION: Choosing the LSTV as the LIV in Lenke 1 and 2 curve patterns with an AR lumbar modifier significantly decreases the risk of distal adding-on. Skeletally immature patients, those fused short of LSTV, and those with relative coronal balance pre-operatively are at increased risk of distal adding-on between the initial post-operative visit and two year follow-up.
LEVEL OF EVIDENCE: 4.
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