I posted this is September 2012. The first bullet is the conclusion from one of the talks BY A SURGEON. It is actually better NOT to fuse the lumbar on these false doubles. Now Neustadt clearly has plenty of experience so I am at a loss about why he did what he did given the material quoted below. The only potential saving grace is that as of 2010, not fusing the lumbar on a false double is apparently still considered controversial but that may be due to the inability of surgeons to balance the fusion. I am simply saying with what I (a lay person) can find in the literature (not to be confused with "truth"), I cannot even begin to imagine allowing a surgeon to fuse my child's lumbar in these situations.
- if you only want the T curve fused in a false double, you better get someone who has mucho experience - they tend to do selective T fusions much more than less experienced surgeons who fuse well into the lumbar. (I am extremely relieved that our surgeon did a selective fusion on my one kid with a false double. He is non SRS but we were referred to him by an SRS surgeon.)
It is important to point out that selective thoracic fusion is considered the optimal treatment. So apparently, only the experienced guys are comfortable doing the optimal treatment. This situation sounds completely unacceptable because apparently it is better to NOT fuse into the lumbar on these false doubles and indeed there is a study showing the lumbars under selectively fused T curves in false doubles are stable for at least a few decades (the length of study) in all patients in the study (I don't remember how they were selected). Wait a minute... here it is:
http://journals.lww.com/spinejournal...ive_Thoracic.5. aspx
Lumbar Curve Is Stable After Selective Thoracic Fusion for Adolescent Idiopathic Scoliosis: A 20-Year Follow-up
Larson, A. Noelle MD*; Fletcher, Nicholas D. MD†; Daniel, Cindy‡; Richards, B. Stephens MD‡
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Abstract
Study Design. A retrospective cohort study comparing long-term clinical and radiographical outcomes using selective thoracic instrumented fusion versus long instrumented fusion for the treatment of adolescent idiopathic scoliosis (AIS).
Objective. To evaluate long-term behavior of the lumbar curve in patients with AIS treated with selective thoracic fusion and to assess clinical outcome measures in this patient population compared with those patients treated with fusion in the lumbar spine.
Summary of Background Data. Selective thoracic fusion for the treatment of AIS preserves motion segments, but leaves residual lumbar deformity. Long-term results of selective fusion using segmental fixation are limited.
Methods. Nineteen patients with AIS treated with selective thoracic fusion and 9 patients treated with a long fusion returned at a mean 20 years (range, 14–24 years) postoperatively for radiographs, clinical evaluation, and outcome surveys (Short Form-12, Scoliosis Research Society-24, Spinal Appearance Questionnaire, Oswestry Disability Index, and visual analogue scale for pain and stiffness). Curve types were Lenke 1B, 1C, or 3C. All patients underwent posterior fusion with Texas Scottish Rite Hospital or Cotrel-Dubousset hook-rod instrumentation.
Results. The selective thoracic fusion group had no significant progression in the lumbar curve magnitude and no worsening of L4 obliquity to the pelvis between initial postoperative and 20-year follow-up. Mean preoperative lumbar curve magnitude (mean, 44°; range, 32–64) corrected 43% on initial postoperative films versus 38% at latest follow-up. Mean L4 obliquity to the pelvis, trunk shift, sagittal balance, and coronal balance were stable over time. Outcome scores between the 2 groups were similar. Scores in long fusion group, when compared with the selective group, were higher for 2 Scoliosis Research Society domains: self-image after surgery (P = 0.005) and function after surgery (P = 0.0006).
Conclusion. Spinal balance and correction of the lumbar curve remain stable over time in selective thoracic fusion. Those with selective fusions have outcome measures comparable with those with long fusions.
And another...
http://www.ncbi.nlm.nih.gov/pubmed/21030900
Spine (Phila Pa 1976). 2010 Nov 15;35(24):2128-33.
Predicting the outcome of selective thoracic fusion in false double major lumbar "C" cases with five- to twenty-four-year follow-up.
Chang MS, Bridwell KH, Lenke LG, Cho W, Baldus C, Auerbach JD, Crawford CH 3rd, O'Shaughnessy BA.
Source
Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA.
Abstract
STUDY DESIGN:
Retrospective radiographic and clinical study.
OBJECTIVE:
To examine the long-term outcome of selective thoracic fusion (STF) performed for lumbar "C" modifier curves in adolescent idiopathic scoliosis.
SUMMARY OF BACKGROUND DATA:
The efficacy of STF in lumbar "C" false double major curves is controversial. We examined the 5- to 24-year outcomes of patients with "C" lumbar curves who underwent STF at a single institution to determine which factors help predict successful outcome.
METHODS:
Thirty-two patients (age, 14.8 ± 2.0 years) with a lumbar "C" modifier underwent primary STF and had minimum 5-year follow-up (mean, 6.8 years). All patients were fused distally to either T12 or L1. At latest follow-up, 18 were considered successful (group S), 2 required reoperation to accommodate worsening deformity (group R), and 12 were considered marginal outcomes (group M), as defined by >3 cm coronal imbalance (n = 5), >5 mm worsening of lumbar apical vertebra translation compared with preoperative (n = 4), >1 Nash-Moe grade worsening of lumbar apical vertebra rotation (n = 1), >10° thoracolumbar junction kyphosis which was at least 5° worse than preoperative (n = 5), and lumbar Cobb angle >5° worse than preoperative (n = 2). Clinical outcomes were determined by Scoliosis Research Society (SRS)-30 at final follow-up.
RESULTS:
Of the multiple factors considered, 2-month postoperative standing lumbar sagittal alignment was most predictive for long-term outcome (P < 0.019 by Kruskal-Wallis ANOVA). Satisfactory outcomes had statistically significantly greater T12-S1 lordosis than those that were marginal (64.8° (group S) vs. 52.0° (group M); P = 0.014) or required reoperation (64.8° [group S] vs. 38.0° [group R]; P < 0.001). Traditionally considered variables such as apical vertebra rotation, apical vertebra translation, Cobb angle magnitudes, coronal and sagittal balance, and their respective thoracic-to-lumbar ratios were not independently significant.
CONCLUSION:
Selective thoracic fusions performed for lumbar "C" modifier scoliotic deformities generally have excellent long-term radiographic and SRS-30 outcomes at 5- to 24-year follow-up. Care should be taken to ensure that overcorrection of the thoracic curve is not performed beyond the ability of the lumbar curve to compensate. Furthermore, consideration of selective thoracic fusion should not be ruled out simply because the patient may have a somewhat stiff lumbar curve based on side-bending radiographs.
It is important to point out that selective thoracic fusion is considered the optimal treatment. So apparently, only the experienced guys are comfortable doing the optimal treatment. This situation sounds completely unacceptable because apparently it is better to NOT fuse into the lumbar on these false doubles and indeed there is a study showing the lumbars under selectively fused T curves in false doubles are stable for at least a few decades (the length of study) in all patients in the study (I don't remember how they were selected). Wait a minute... here it is:
http://journals.lww.com/spinejournal...ive_Thoracic.5. aspx
Lumbar Curve Is Stable After Selective Thoracic Fusion for Adolescent Idiopathic Scoliosis: A 20-Year Follow-up
Larson, A. Noelle MD*; Fletcher, Nicholas D. MD†; Daniel, Cindy‡; Richards, B. Stephens MD‡
Collapse Box
Abstract
Study Design. A retrospective cohort study comparing long-term clinical and radiographical outcomes using selective thoracic instrumented fusion versus long instrumented fusion for the treatment of adolescent idiopathic scoliosis (AIS).
Objective. To evaluate long-term behavior of the lumbar curve in patients with AIS treated with selective thoracic fusion and to assess clinical outcome measures in this patient population compared with those patients treated with fusion in the lumbar spine.
Summary of Background Data. Selective thoracic fusion for the treatment of AIS preserves motion segments, but leaves residual lumbar deformity. Long-term results of selective fusion using segmental fixation are limited.
Methods. Nineteen patients with AIS treated with selective thoracic fusion and 9 patients treated with a long fusion returned at a mean 20 years (range, 14–24 years) postoperatively for radiographs, clinical evaluation, and outcome surveys (Short Form-12, Scoliosis Research Society-24, Spinal Appearance Questionnaire, Oswestry Disability Index, and visual analogue scale for pain and stiffness). Curve types were Lenke 1B, 1C, or 3C. All patients underwent posterior fusion with Texas Scottish Rite Hospital or Cotrel-Dubousset hook-rod instrumentation.
Results. The selective thoracic fusion group had no significant progression in the lumbar curve magnitude and no worsening of L4 obliquity to the pelvis between initial postoperative and 20-year follow-up. Mean preoperative lumbar curve magnitude (mean, 44°; range, 32–64) corrected 43% on initial postoperative films versus 38% at latest follow-up. Mean L4 obliquity to the pelvis, trunk shift, sagittal balance, and coronal balance were stable over time. Outcome scores between the 2 groups were similar. Scores in long fusion group, when compared with the selective group, were higher for 2 Scoliosis Research Society domains: self-image after surgery (P = 0.005) and function after surgery (P = 0.0006).
Conclusion. Spinal balance and correction of the lumbar curve remain stable over time in selective thoracic fusion. Those with selective fusions have outcome measures comparable with those with long fusions.
And another...
http://www.ncbi.nlm.nih.gov/pubmed/21030900
Spine (Phila Pa 1976). 2010 Nov 15;35(24):2128-33.
Predicting the outcome of selective thoracic fusion in false double major lumbar "C" cases with five- to twenty-four-year follow-up.
Chang MS, Bridwell KH, Lenke LG, Cho W, Baldus C, Auerbach JD, Crawford CH 3rd, O'Shaughnessy BA.
Source
Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA.
Abstract
STUDY DESIGN:
Retrospective radiographic and clinical study.
OBJECTIVE:
To examine the long-term outcome of selective thoracic fusion (STF) performed for lumbar "C" modifier curves in adolescent idiopathic scoliosis.
SUMMARY OF BACKGROUND DATA:
The efficacy of STF in lumbar "C" false double major curves is controversial. We examined the 5- to 24-year outcomes of patients with "C" lumbar curves who underwent STF at a single institution to determine which factors help predict successful outcome.
METHODS:
Thirty-two patients (age, 14.8 ± 2.0 years) with a lumbar "C" modifier underwent primary STF and had minimum 5-year follow-up (mean, 6.8 years). All patients were fused distally to either T12 or L1. At latest follow-up, 18 were considered successful (group S), 2 required reoperation to accommodate worsening deformity (group R), and 12 were considered marginal outcomes (group M), as defined by >3 cm coronal imbalance (n = 5), >5 mm worsening of lumbar apical vertebra translation compared with preoperative (n = 4), >1 Nash-Moe grade worsening of lumbar apical vertebra rotation (n = 1), >10° thoracolumbar junction kyphosis which was at least 5° worse than preoperative (n = 5), and lumbar Cobb angle >5° worse than preoperative (n = 2). Clinical outcomes were determined by Scoliosis Research Society (SRS)-30 at final follow-up.
RESULTS:
Of the multiple factors considered, 2-month postoperative standing lumbar sagittal alignment was most predictive for long-term outcome (P < 0.019 by Kruskal-Wallis ANOVA). Satisfactory outcomes had statistically significantly greater T12-S1 lordosis than those that were marginal (64.8° (group S) vs. 52.0° (group M); P = 0.014) or required reoperation (64.8° [group S] vs. 38.0° [group R]; P < 0.001). Traditionally considered variables such as apical vertebra rotation, apical vertebra translation, Cobb angle magnitudes, coronal and sagittal balance, and their respective thoracic-to-lumbar ratios were not independently significant.
CONCLUSION:
Selective thoracic fusions performed for lumbar "C" modifier scoliotic deformities generally have excellent long-term radiographic and SRS-30 outcomes at 5- to 24-year follow-up. Care should be taken to ensure that overcorrection of the thoracic curve is not performed beyond the ability of the lumbar curve to compensate. Furthermore, consideration of selective thoracic fusion should not be ruled out simply because the patient may have a somewhat stiff lumbar curve based on side-bending radiographs.
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