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Study Design: A retrospective cohort study., Objective: To evaluate long-term rotational changes in the vertebrae of patients with adolescent idiopathic scoliosis (AIS) who underwent direct vertebral rotation (DVR)., Summary of Background Data: DVR using thoracic pedicle screws, a rotational corrective maneuver used in the surgical treatment of AIS, was introduced in 2004. Although DVR is considered to be the main axial corrective maneuver, the long-term rotational changes of vertebrae following this treatment are not well understood., Materials and Methods: A total of 135 vertebrae that underwent DVR using thoracic pedicle screws with a minimum five-year follow-up were retrospectively assessed for the vertebral rotation angle. The vertebral rotation of the apical vertebra (AV) and distal end vertebra (EV) was evaluated using the Nash-Moe scale, the rotational angle to the sacrum (RAsac), and the Aaro and Dahlborn method. The Student t test (paired means) was used for continuous variables, and the χ 2 test was used for categorical variables, as appropriate. A comparison of two and three groups used a one-way repeated measures analysis of variance, and the post hoc analysis used the Bonferroni test., Results: The mean Nash-Moe scale of distal EV showed statistically significant differences between preoperative and postoperative values ( P =0.034) and no statistically significant difference between postoperative and last follow-up values ( P =1.000). The last follow-up RAsac of AV did not differ significantly from the preoperative RAsac of AV ( P =0.515). The last follow-up RAsac of distal EV was significantly lower than the preoperative RAsac of distal EV ( P =0.001). The Pearson correlation analysis showed that the last follow-up RAsac of distal EV was correlated with the Cobb angle of the main curve ( r =0.459, P =0.004), loss of correction ( r =0.541, P =0.001), and lowest instrumented vertebra tilt angle ( r =0.504, P =0.001)., Conclusions: The rotation regression phenomenon in AV and rotation maintenance in distal EV were observed after DVR over an average 10-year follow-up. These findings suggest that the DVR in the surgical treatment of AIS has a positive long-term effect on the stabilization of distal EV from the point of view of axial rotation., Level of Evidence: 4., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: This was a retrospective comparative study., Objective: To evaluate long-term outcomes of selective thoracic fusion (STF) using both rod derotation (RD) and direct vertebral rotation (DVR) with pedicle screw instrumentation (PSI) in the treatment of thoracic adolescent idiopathic scoliosis (AIS) with a minimum 10-year follow-up., Summary of Background Data: Postoperative compensation and maintenance of the unfused lumbar curve after STF is very important factor for the satisfactory results in the treatment of thoracic AIS., Patients and Methods: Sixty-five patients with thoracic AIS treated with STF from the neutral vertebra (NV) to NV or NV-1 with RD and DVR were retrospectively analyzed with a minimum 10-year follow-up. Patients were divided into 2 groups: satisfactory (n=52) and unsatisfactory groups (n=13). Unsatisfactory results were defined as an adding-on, a lowest instrumented vertebra (LIV) tilt of >10 degrees, or coronal balance >15 mm., Results: No significant differences were observed in the main thoracic curve between the satisfactory and unsatisfactory groups postoperatively (P=0.218) and at the last follow-up (P=0.636). Significant improvements of LIV tilt and disk angle were observed in both groups, but these improvements deteriorated during the follow-up period in the unsatisfactory group. Significant differences of apical vertebra (AV) and end vertebra (EV) were observed postoperatively (AV: P=0.001, EV: P=0.001) and at the last follow-up (AV: P<0.000, EV: P<0.000) between the 2 groups., Conclusions: STF using RD and DVR can achieve satisfactory deformity correction for thoracic AIS with satisfactory compensatory lumbar curve that was maintained over long-term follow-up. Progression of unfused lumbar curve closely related with LIV tilt and disk angle showing insufficient DVR. Therefore, STF with sufficient DVR required to achieve satisfactory deformity correction and prevent a distal adding-on phenomenon in the treatment of thoracic AIS.

Objective: To analyze the effects of direct vertebral rotation (DVR) on radiologic outcomes in the treatment of thoracic adolescent idiopathic scoliosis after selective thoracic fusion with pedicle screw instrumentation., Methods: Adolescent idiopathic scoliosis patients with single thoracic curves (n = 110) treated by selective thoracic fusion with a minimum of 2 years of follow-up were retrospectively analyzed. The patients were separated into 2 groups: non-DVR (n = 63) and DVR (n = 47)., Results: There was a significant difference in fused segments between the non-DVR and DVR groups (P < 0.001). There was also a significant difference in main thoracic curve postoperatively (P = 0.001) and at the last follow-up (P = 0.006) between the non-DVR and DVR groups. However, there was no significant difference in proximal thoracic and lumbar curves postoperatively (proximal thoracic curve: P = 0.186; lumbar curve: P = 0.155) and at the last follow-up (proximal thoracic curve: P = 0.250; lumbar curve: P = 0.060) between the 2 groups. Significant improvements in the lowest instrumented vertebra tilt and disc angle were noted but then slight deteriorations in such were observed during the follow-up period in the non-DVR group. The prevalence of unsatisfactory results was 20.6% (13 of 63) in the non-DVR group and 19.1% (9 of 47) in the DVR group, with no significant difference (P = 0.522)., Conclusions: For correcting single thoracic adolescent idiopathic scoliosis by selective thoracic fusion with pedicle screw instrumentation, the addition of DVR to the surgical procedure showed comparable radiologic outcomes compared with non-DVR procedures., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Rationale: The management of congenital scoliosis concentrates on early diagnosis and proper surgical treatment before the development of severe deformities. Decision making regarding the appropriate fusion levels, proper surgical treatment, and reduction amount of kyphoscoliosis is very important but difficult in the treatment of congenital scoliosis, especially in young children., Patient Concerns: We report an 11-year follow-up of revision surgery for fractional curve progression after combined anterior and posterior fusion without hemivertebra resection using pedicle screw fixation (PSF) in congenital kyphoscoliosis at age 4 years (a total 18-year follow-up). A T12 hemivertebra was documented in a 4-year-old girl and was treated by combined anterior and posterior fusion in two stages with PSF. The fusion mass was maintained but the distal compensatory curve progressed during the follow-up period. The patient underwent a posterior vertebral column resection (PVCR) with extended posterior fusion at the age of 11, 7 years after initial surgery., Outcomes: Eleven years after the revision surgery with PVCR, the patient showed satisfactory results and her spine was well balanced., Lessons: The cause of revision surgery for the curve progression may include inappropriate fusion level, incomplete hemivertebra resection, or failure of anterior and posterior fusion. Especially, inappropriate fusion level may result in deterioration of the compensatory curve even without progression of the fusion mass., Conclusion: Appropriate selection of fusion levels, complete resection of hemivertebra, and satisfactory reduction of scoliosis and kyphosis are important factors for deformity correction and prevention of progression of both main and compensatory curves (adding-on of structural curve or progression of compensatory curve) as well as reducing the influence of adjacent vertebral growth using as short a fusion as possible.

Study Design: A retrospective comparative study., Objective: The aim of this study was to analyze the exact distal fusion level in the treatment of major thoracolumbar and lumbar (TL/L) adolescent idiopathic scoliosis (AIS) using rod derotation (RD) and direct vertebral rotation (DVR) following pedicle screw instrumentation (PSI)., Summary of Background Data: Proper determination of distal fusion level is a very important factor in deformity correction and preservation of motion segments in the treatment of major TL/L AIS., Methods: AIS patients with major TL/L curves (n = 64) treated by PSI with RD and DVR methods with a minimum 2-year follow-up were divided into AL3 (flexible) and BL3 (rigid) according to the flexibility and rotation by preoperative bending radiographs., Results: There was no significant difference in TL/L (major) curve between the AL3 and BL3 groups postoperatively (P = 0.933) and at the last follow-up (P = 0.144). In addition, there was no significant difference in thoracic (minor) and compensatory (caudal) curve postoperatively (thoracic curve: P = 0.828, compensatory curve: P = 0.976); however, there was a significant difference in compensatory (caudal) curve at the last follow-up (P = 0.041). The overall prevalence of unsatisfactory results was 28.1% (18/64 patients), and the prevalence was 15.2% (7/46) in the AL3 group and 61.1% (11/18) in the BL3 group, which was significantly different (P < 0.05)., Conclusion: Lowest instrumented vertebra (LIV) would be selected at L3 (EV) when the curve is flexible; L3 crosses CSVL with a rotation of less than grade II in preoperative bending radiographs. However, if the curve is rigid, LIV should be extended to L4 (EV + 1) in order to prevent the adding-on phenomenon in the treatment of major TL/L AIS using RD and DVR following PSI., Level of Evidence: 4.

The etiology of congenital scoliosis and its development remains unclear and has not yet been fully identified, even there are theories that congenital scoliosis could be derived from the failure of formation or failure of segmentation, which are etiologically heterogeneous with genetic, epigenetic, and environmental factors contributing to their occurrence. We reported a case of long-term follow-up after posterior vertebral column resection (PVCR) in both identical twins with similar congenital kyphoscoliosis at thoracolumbar levels. Twin I had been noticed by his parents to have asymmetry of his back at age 5 years, but no treatment was given. Twin II was first noticed to have a spinal problem at 11 years of age by his parents. Overtime, spine of both twins became further deviated to the left with kyphosis and was referred to our hospital. Both monozygotic twins were treated by PVCR and satisfactory results were demonstrated at 10-year follow-up.This case is the first report on the surgical treatment with PVCR, almost simultaneously, in both identical twins who had similar congenital vertebral anomalies causing kyphoscoliosis. Both identical twins with congenital kyphoscoliosis had undergone surgical correction by PVCR, anterior support with a mesh cage and posterior fusion using pedicle screws at the age of 14 years and achieved a satisfactory correction and a stable spine without curve progression with 10-year follow-up., Competing Interests: The authors have no funding and conflicts of interest to disclose. Institutional Review Board approval of Inje University Sanggye Paik Hospital (IRB No. 2015-02-019) was obtained before data collection and analysis.

Study Design: A retrospective study., Objective: To evaluate the surgical outcomes of posterior hemivertebra resection and short segment fusion with segmental pedicle screw fixation in congenital scoliosis in children younger than 10 years., Summary of Background Data: This is the first long-term follow-up on surgical outcomes of posterior hemivertebra resection and short segment fusion using segmental pedicle screw fixation in children younger than 10 years with congenital scoliosis., Methods: Patients with congenital scoliosis (n = 18) younger than 10 years at the time of the surgery were treated by posterior hemivertebra resection and bilateral pedicle screw fixation. The mean age at the time of surgery was 6.6 years (range, 2.6-9.8 yr). They were retrospectively studied with a mean follow-up of 11.4 years (range, 7.1-17.3 yr)., Results: The mean Cobb angle of the main curve was 34.4° before surgery, 8.6° after surgery, and 12.9° at last follow-up. In the compensatory cranial curve, the preoperative Cobb angle of 14.5° was corrected to 5.9° postoperatively and was 8.4° at last follow-up. In the compensatory caudal curve, the preoperative Cobb angle of 17.4° improved to 4° postoperatively and 6.6° at last follow-up. There were no crankshaft phenomena and no clinical and radiographical features suggestive of spinal stenosis during follow-up. There were no major vascular or neurological complications related to the pedicle screws., Conclusion: Posterior hemivertebra resection after pedicle screw fixation in congenital scoliosis is a safe and effective procedure that can achieve rigid fixation and deformity correction and restore spinal balance. This study showed that early posterior hemivertebra resection of congenital scoliosis before structural changes occur above or below can reduce fusion length, prevent curve progression, and effectively achieve a more satisfactory correction without hazardous iatrogenic spinal stenosis, crankshaft phenomena, or neurological complications., Level of Evidence: 3.

Study Design: A retrospective comparative study., Objective: To evaluate the shoulder balance resulting from the correction of double thoracic adolescent idiopathic scoliosis (AIS) comparing rod derotation (RD) with direct vertebral rotation (DVR) and RD only after pedicle screw instrumentations., Summary of Background Data: This is the first report on the effect of DVR on the shoulder balance using segmental pedicle screw instrumentation in the treatment of double thoracic AIS with minimum 5-year follow-up., Methods: Patients with double thoracic AIS (n = 57) were treated by fusing both thoracic curves with RD and DVR (n=35), or RD (n=22) methods and retrospectively studied with a minimum 5 years of follow-up., Results: In the RD with DVR group, the preoperative proximal thoracic curve of 40.2° improved to 17.9° postoperatively and 19.9° at the last follow-up. In the RD group, the preoperative proximal thoracic curve of 37.5° improved to 22.4° postoperatively and 23.2° at the last follow-up. In the RD with DVR group, the preoperative distal thoracic curve of 56.6° improved to 16.1° postoperatively and 16.7° at the last follow-up. In the RD group, the preoperative distal thoracic curve of 50.6° improved to 17.8° postoperatively and 18.2° at the last follow-up. In the RD with DVR group, the average preoperative shoulder height difference of 16.3 mm had improved to 7.2 mm postoperatively and was 7.0 mm at the last follow-up. In the RD group, the average preoperative shoulder height difference of 15.1 mm had changed to 7.5 mm postoperatively and was 7.3 mm at the last follow-up., Conclusion: Shoulder balance had not significantly improved even with additional correction method of DVR using segmental pedicle screw instrumentation in double thoracic AIS. The proximal thoracic curve was rigid and corrected less in both groups. Therefore, less correction of the distal thoracic curve effectively achieves better shoulder balance., Level of Evidence: 3.

Study Design: A retrospective study of clinical results of operative treatment for degenerative lumbar scoliosis., Objective: To determine the risk factors of sagittal decompensation after long instrumentation and fusion to L5 or S1., Summary of Background Data: Little is known about the risk factors for sagittal decompensation, which was defined in this study as sagittal C7 plumb falling anterior >8 cm from the posterosuperior corner of the sacrum., Methods: Forty-five patients (mean age: 64.4 year) with adult degenerative lumbar scoliosis were reviewed retrospectively with a minimum 2 years. The mean number of levels fused was 6.1 +/- 1.6 segments. The upper instrumented vertebra ranged from T9 to L2. The lower instrumented vertebra was L5 and S1 in 24 and 21 patients, respectively., Results: Sagittal decompensation (SD) developed in 19 patients. The most significant risk factors of SD were preoperative sagittal imbalance and high pelvic incidence. The preoperative sagittal C7 plumb was more positive (67.9 mm) in the decompensation group than in the balance group (37.0 mm) (P = 0.002). There was a significant difference in pelvic incidence between 61.7 degrees in the decompensation and 54.9 degrees in the balance group (P = 0.01). The preoperative lumbar lordosis was hypolordotic in the decompensation group, however, it was not found to be a risk factor. Pseudarthrosis was identified at the lumbosacral junction in 5 patients, and 4 of them (80%) had SD. SD developed in 55% of patients who had loosening of the distal screws and 50% of patients with hypolordotic lumbar fusion. Distal adjacent segment disease was more likely to cause SD than proximal adjacent segment disease., Conclusion: Sagittal decompensation is common after long posterior instrumentation and fusion for degenerative lumbar scoliosis. It is mostly associated with complications at the distal segments, including pseudarthrosis and implant failure at the lumbosacral junction. Restoration of optimal lumbar lordosis and secure lumbosacral fixation is necessary especially in patients with preoperative sagittal imbalance and high pelvic incidence in order to prevent sagittal decompensation after surgery.

Study Design: Retrospective study., Objective: To evaluate the effect and outcome of thoracoplasty in conjunction with pedicle screw instrumentation in the treatment of thoracic adolescent idiopathic scoliosis (AIS)., Summary of Background Data: Some spine surgeons recently think more correction of hump deformity using pedicle screws without thoracoplasty. Although thoracoplasty has been conventional treatment of rib hump, there are few papers about the results of pedicle screw instrumentation and concomitant thoracoplasty., Methods: Eighty-seven patients with thoracic AIS (mean age, 14.4 years) treated by pedicle screw instrumentation were retrospectively analyzed after a minimum follow-up of 2 years. Patients were divided into 3 groups; N-T group (no thoracoplasty with iliac bone graft, n = 37), T+N-DVR [thoracoplasty without direct vertebral rotation (DVR), n = 20] and T+DVR group (thoracoplasty with DVR, n = 30). In the T (T+N-DVR and T+DVR) group, 4 to 8 ribs were resected and used for bone graft. Patients were evaluated for deformity correction, balance, pulmonary function, height and angle of rib hump, clinical outcomes (SRS-30), and complications., Results: In the N-T group, the thoracic curve was corrected from 53 degrees to 16 degrees (69% correction), in the T+N-DVR group from 55 degrees to 18 degrees (69%) and in the T+DVR group from 54 degrees to 10 degrees (81%). There was no difference in postoperative spinal balance and pulmonary function among the 3 groups. The correction rates of hump height and angle were 35% and 38% in the N-T group, respectively, 57% and 58% in the T+N-DVR, and 70% and 72% in the T+DVR. The T group showed significantly better correction of rib hump and self-image score in the SRS-30 questionnaire than the N-T group. There were 8 iliac donor site problems in the N-T group and 3 hemothorax in the T group, which had no adverse effect in the final result., Conclusion: Thoracoplasty showed significantly better rib hump correction, satisfactory clinical outcomes without pulmonary function compromise, or iliac bone graft site morbidity in the treatment of thoracic AIS with pedicle screw instrumentation.

Study Design: Retrospective study., Objectives: To report the results and the technique of posterior vertebral column resection (PVCR) in fixed lumbosacral deformity., Summary of Background Data: Fixed lumbosacral deformity has gross imbalance as well as progressive compensatory thoracolumbar deformity because of the absence of a mobile spine caudally. There is no consensus of the surgical treatment of fixed lumbosacral deformity. Fixed lumbosacral deformity can be managed by PVCR, which not only corrects the deformity but also restores the trunk balance by translation of spinal column., Methods: Twenty-five consecutive fixed lumbosacral deformity patients subjected to PVCR were reviewed after a minimum follow-up of 2 years. The apical vertebra and the ultimately resected vertebra were below L4 in most cases. Etiologic diagnoses were congenital scoliosis in 6, congenital kyphoscoliosis in 3, post-traumatic kyphosis in 2, and postinfectious kyphosis in 14. The average age at the operation was 38 years (range, 2.5-61 years) with a male:female ratio of 7:18. The indication for PVCR was fixed lumbosacral deformities that could not be brought to a reasonable balance on traction or forced side bending. Before surgery, 12 patients (48%) presented with neurologic compromise and 20 patients (80%) presented with intractable back pain. The surgical technique consisted of segmental pedicle screw fixation, decompression of neural structures, and resection of the vertebral column at the apex of the deformity via the posterior route, followed by deformity correction and global fusion. During the resection, all the nerve roots were preserved., Results: Two and one tenth (2.1) vertebrae removed on average (range, 1-5 vertebrae), and 52 in all. The average fusion extent was 4.5 vertebrae (range, 2-8 vertebrae). The anterior column reconstruction was carried out with autogenous bone graft in all patients and additional insertion of titanium mesh in 12. The distal anchor went down to L5 in 4 patients, S1 in 12, and S2 in 9. Preoperative scoliosis of 38 degrees +/- 12 degrees was corrected to 15 degrees +/- 8 degrees (60% correction) at most recent follow-up, and preoperative kyphosis of 35 degrees +/- 25 degrees was corrected to -5 degrees +/- 11 degrees (40 degrees correction). The compensatory coronal curve of 26 degrees was spontaneously corrected to 12 degrees at most recent follow-up. The preoperative thoracic lordosis of -16 degrees was corrected to 4 degrees at most recent follow-up, and the preoperative lumbar kyphosis of 20 degrees was corrected to -17 degrees . Preoperative coronal imbalance of 2.0 cm was improved to 0.9 cm at most recent follow-up, and preoperative sagittal imbalance of 9.3 cm was improved to 4.6 cm. Mean operation time was 280 minutes with a blood loss of 2,810 mL. The preoperative neurologic compromise was improved in all patients, and pain was reduced to less than half of preoperative visual analog analog scale in 17 patients. The following complications were encountered in 5 patients: 2 with transient neurology that spontaneously improved without a sequel within 6 months, 2 with compression fractures at proximal adjacent vertebra, and 1 with pseudarthrosis., Conclusions: PVCR is an effective procedure for the management of fixed lumbosacral deformity. It provides satisfactory correction and improved functional outcomes. However, it is a technically demanding and exhausting procedure with possible risks for complications.

Study Design: Retrospective study., Objectives: To evaluate outcomes of selective thoracic fusion with segmental pedicle screw fixation in thoracic idiopathic scoliosis with a minimum 5-year follow-up., Summary of Background Data: Segmental pedicle screw fixation has been proven to enable true segmental control and greater correction both in coronal and sagittal planes of scoliosis. However, there is no long-term study of selective thoracic fusion with segmental pedicle screw fixation in thoracic idiopathic scoliosis., Methods: Two hundred and three thoracic idiopathic scoliosis patients with 236 thoracic curves subject to selective thoracic fusion with segmental pedicle screw fixation were analyzed. Mean patient age at the time of operation was 13.8 years (range: 8.9-18)., Results: The preoperative thoracic curve of 51 +/- 12 degrees was corrected to 16 +/- 7 degrees (69% correction, 3% loss of correction) at the most recent follow-up. The noninstrumented lumbar curve of 30 +/- 10 degrees was corrected to 10 +/- 8 degrees (66% correction, 5% loss of correction) at the most recent follow-up. The preoperative thoracic kyphosis of 18 +/- 11 degrees and the lumbar lordosis of 43 +/- 10 degrees were improved to 23 +/- 8 degrees and 46 +/- 9 degrees , respectively, at the most recent follow-up. There was no junctional kyphosis at the most recent follow-up. Coronal decompensation at the most recent follow-up occurred in 10 patients. Postoperative adding-on occurred in 17 patients, who were fused two levels short of the neutral vertebra. Of the 2,867 thoracic pedicle screws inserted in the thoracic level, 43 screws were found to be malpositioned (1.5%), but they did not cause neurologic complications or adversely affect the long-term results., Conclusions: Selective thoracic fusion with segmental pedicle screw fixation in thoracic idiopathic scoliosis had satisfactory radiographic and clinical outcomes after surgery and has been well-maintained for minimum 5-year follow-up. It is a safe and effective method for preservation of lumbar motion segments as well as for restoration and maintenance of both coronal and sagittal alignment.

Study Design: Retrospective study., Objective: To report on the technique and results of posterior vertebral column resection (PVCR) for severe rigid scoliosis., Summary of Background Data: The treatment of severe rigid scoliosis is a demanding surgical challenge. Conventional procedures such as combined anteroposterior instrumentation enable limited correction. In rigid scoliosis, vertebral column resection is a better option for accomplishing translation of spinal column. PVCR is performed through a single posterior approach., Methods: A total of 16 patients with scoliosis (average age 29 years) subjected to PVCR were retrospectively reviewed after a minimum follow-up of 2 years (range 2-6.8). The indication for PVCR was scoliosis more than 80 degrees , with flexibility less than 25%. The radiographic parameters were evaluated, and clinical records were reviewed., Results: The number of vertebrae removed averaged 1.3, and 21 total (15 thoracic and 6 lumbar). Average fusion extent was 10.6 vertebrae. The mean preoperative scoliosis of 109.0 degrees was corrected to 45.6 degrees (59% correction) at the most recent follow-up, and the minor curve of 59.3 degrees was corrected to 29.2 degrees (51% correction). The mean preoperative coronal imbalance of 4.0 cm was improved to 1.0 cm at the most recent follow-up, and sagittal imbalance of 4.2 cm was improved to 1.6 cm. Complications were encountered in 4 patients, including 1 complete paralysis, 1 hematoma, 1 hemopneumothorax, and 1 proximal junctional kyphosis., Conclusions: PVCR is an effective alternative for severe rigid scoliosis. It is a highly technical procedure and should only be performed by an experienced surgical team.

Study Design: Retrospective study., Objectives: To compare the surgical results between combined anterior-posterior procedures and posterior closing wedge osteotomy procedures in patients with posttraumatic kyphosis and neurologic compromise secondary to osteoporotic fractures., Summary of Background Data: Combined anterior-posterior procedures are usually recommended in cases of kyphotic deformities with neurologic deficit secondary to osteoporosis. However, combined anterior-posterior surgery is associated with significant morbidity in elderly patients., Materials and Methods: Twenty-six patients with posttraumatic kyphosis and neurologic compromise secondary to osteoporotic fracture were indicated for operative intervention using either a combined anterior-posterior surgery (n = 11) or a posterior closing wedge osteotomy procedure (n = 15). The results of the two procedures were analyzed. The average patient age at the operation was 62.6 years (range: 50-82) with a 12:14 male-to-female ratio. Mean follow-up was 3.5 years (range: 2.1-5.4). Preoperative interval from injury to operation was 15.4 months (range: 1-36). There were 20 thoracolumbar (T12-L1) fractures and six lumbar fractures indicated for operative intervention., Results: In the combined anterior-posterior group, the mean operative time was 351 minutes with a mean blood loss of 2,892 mL. In the posterior closing wedge osteotomy group, the mean operative time was 215 minutes with blood loss of 1,930 mL. Eighteen patients showed a postoperative improvement in Frankel grading, 64% (7/11) in the combined anterior-posterior group, and 73% (11/15) in posterior closing wedge osteotomy group. There were no neurologic or vascular complications in either group. In the combined anterior-posterior group, there were five complications: two postoperative pneumonias, one superficial infection, and two distal screw loosening. There were only two complications in the posterior closing wedge osteotomy group: two distal screw loosening. One of the four cases of distal screw loosening required surgical revision. The other three cases were treated by bracing for more than 6 months., Conclusions: Although technically demanding, the posterior closing wedge osteotomy procedure demonstrated a better surgical result with significant less mean operative time and mean blood loss (P < 0.05). It may be a better alternative than a combined anterior-posterior procedure in patients with posttraumatic kyphosis and neurologic compromise secondary to osteoporotic fracture.

Study Design: A retrospective study was conducted., Objective: To determine the exact distal fusion level in the treatment of single thoracic idiopathic scoliosis (King Types 3 and 4) with segmental pedicle screw fixation., Summary of Background Data: Pedicle screw fixation effectively shortens the distal fusion extent by improved three-dimensional deformity correction. However, the selection of distal fusion extent remains controversial in single thoracic idiopathic scoliosis., Methods: This study analyzed 42 patients with single thoracic adolescent idiopathic scoliosis (32 King 3 patients and 10 King 4 patients) who underwent segmental pedicle screw fixation and had a minimum follow-up period of 2 years (range, 2-6 years). The patients were grouped according to the distal fusion level with reference to the standing neutral rotated vertebra (NV) for comparison of deformity correction and spinal balance using standing radiographs. Failure to restore an adequate trunk balance and progression or extension of the primary curve (adding on) was considered unsatisfactory., Results: Preoperative 50 degrees +/- 11 degrees of thoracic deformity was corrected to 13 degrees +/- 5 degrees, for a curve correction of 74%. Preoperative 23 degrees +/- 7 degrees of lumbar deformity was corrected to 2 degrees +/- 8 degrees, for a curve correction of 93%. Curve correction was not significantly affected by King type or distal fusion level (P > 0.05). Postoperative unsatisfactory results were obtained in 14 patients. When the preoperative NV was the same or one level distal to end vertebra (EV), fusion down to NV was satisfactory (14/14). When the preoperative NV was more than two levels distal to EV, fusion down to one level shorter than NV (NV-1) also was satisfactory (9/9). However, when fusion down to NV-2 or shorter was performed, the chances of adding on were higher (14/19; P < 0.01). Preoperative 17 degrees +/- 8 degrees of thoracic kyphosis was improved to 24 degrees +/- 7 degrees., Conclusions: In single thoracic idiopathic scoliosis, NV is an important factor for the determination of fusion level. When preoperative NV and EV show no more than two-level gap differences, the curve should be fused down to NV. When the gap is more than two levels, fusion down to NV-1 is satisfactory, saving one or two motion segments, as compared with fusion extending to the stable vertebra.

Introduction: Pedicle screw instrumentation in AIS has advantages of rigid fixation, improved deformity correction and a shorter fusion, but needs an exacting technique. Materials and methods: The author has been using the K-wire method with intraoperative single PA and lateral radiographs, because it is safe, accurate and fast. Pedicle screws are inserted in every segment on the correction side (thoracic concave) and every 2-3 on the supportive side (thoracic convex). After an over-bent rod is inserted on the corrective side, the rod is rotated 90° counterclockwise. This maneuver corrects the coronal and sagittal curves. Then the vertebra is derotated by direct vertebral rotation (DVR) correcting the rotational deformity. The direction of DVR should be opposite to that of the vertebral rotation. A rigid rod has to be used to prevent the rod from straightening out during the rod derotation and DVR. The ideal classification of AIS should address all curve patterns, predicts accurate fusion extent and have good inter/intraobserver reliability. The Suk classification matches the ideal classification is simple and memorable, and has only four structural curve patterns; single thoracic, double thoracic, double major and thoracolumbar/lumbar. Each curve has two types, A and B. When using pedicle screws in thoracic AIS, curves are usually fused from upper neutral to lower neutral vertebra. Identification of the end vertebra and the neutral vertebra is important in deciding the fusion levels and the direction of DVR. In lumbar AIS, fusion is performed from upper neutral vertebra to L3 or L4 depending on its curve types. Conclusions: Rod derotation and DVR using pedicle screw instrumentation give true three dimensional deformity correction in the treatment of AIS. Suk classification with these methods predicts exact fusion extent and is easy to understand and remember. [ABSTRACT FROM AUTHOR]

Study Design: A retrospective comparative study.Objective: The aim of this study was to analyze the exact distal fusion level in the treatment of major thoracolumbar and lumbar (TL/L) adolescent idiopathic scoliosis (AIS) using rod derotation (RD) and direct vertebral rotation (DVR) following pedicle screw instrumentation (PSI).Summary Of Background Data: Proper determination of distal fusion level is a very important factor in deformity correction and preservation of motion segments in the treatment of major TL/L AIS.Methods: AIS patients with major TL/L curves (n = 64) treated by PSI with RD and DVR methods with a minimum 2-year follow-up were divided into AL3 (flexible) and BL3 (rigid) according to the flexibility and rotation by preoperative bending radiographs.Results: There was no significant difference in TL/L (major) curve between the AL3 and BL3 groups postoperatively (P = 0.933) and at the last follow-up (P = 0.144). In addition, there was no significant difference in thoracic (minor) and compensatory (caudal) curve postoperatively (thoracic curve: P = 0.828, compensatory curve: P = 0.976); however, there was a significant difference in compensatory (caudal) curve at the last follow-up (P = 0.041). The overall prevalence of unsatisfactory results was 28.1% (18/64 patients), and the prevalence was 15.2% (7/46) in the AL3 group and 61.1% (11/18) in the BL3 group, which was significantly different (P < 0.05).Conclusion: Lowest instrumented vertebra (LIV) would be selected at L3 (EV) when the curve is flexible; L3 crosses CSVL with a rotation of less than grade II in preoperative bending radiographs. However, if the curve is rigid, LIV should be extended to L4 (EV + 1) in order to prevent the adding-on phenomenon in the treatment of major TL/L AIS using RD and DVR following PSI.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]