Case Report Proximal Adding On WAN

Revision Surgery for Proximal Curve
Decompensation on a Patient with Lenke 5C

Adolescence Idiopathic Scoliosis Post Correction
Deformity Surgery – A Case Report
By: dr. Wan Adi Surya Perdana

Supervised by: dr. Rieva Ermawan, Sp.OT(K)
Program Studi Pendidikan Dokter Spesialis Ilmu Orthopaedi dan Traumatologi

Fakultas Kedokteran Universitas Sebelas Maret
Introduction
 Scoliosis is a three-dimensional deformity of the spine with lateral, antero-posterior and
rotational components. In most cases, the disease is idiopathic.
 The primary goals in the surgical treatment of adolescent idiopathic scoliosis (AIS) are to
achieve a well-balanced spine, arrest deformity progression, and maintain correction by
achieving a solid arthrodesis.
 However, progression of the scoliotic deformity after posterior spinal fusion has been
described
 Various etiologies for loss of correction have been proposed, including pseudarthrosis, implant
failure, incorrect selection of fusion levels, ‘‘adding-on’’, biologic plasticity of the fusion
mass, and the crankshaft phenomenon (continued anterior growth of the spine)
 Revision rates reported in the literature vary considerably, ranging from 3.9% to 22%
Case presentation
• Patient complaints of uncommon posture and sometimes complaining about back pain.
• The uncommon posture had been noticed since patient was a girl, and getting worse as patient grown up.
Aug
ust • Menarche at 13 years old of age
2019
• Diagnosed with AIS Lenke 5C Risser IV

Sept • Underwent correction surgery (Coronal and sagittal balance, Posterior stabilization and Fusion, with UIV T8
emb and LIV L5)
er
2019
• Patient came for routine control, complaining about her aback become “crooked” again
• She felt her right shoulder higher than the left side, and sometimes feels discomfort at her back
June • Diagnosed with Proximal Curve Decompensation post AIS correction Surgery
2020
• Underwent revision surgery

• Extending the UIV proximally to T4, without rotational correction
July
2020
Clinical Appearance (July 2020)
Clinical Appearance (July 2020)
Pre Operative Xray (Sept 2019)
PT T1-T5: 8o
MT T6-T10: 28o
8o
TL T11-L3: 34o
28o
34o
Pre Operative Xray (Sept 2019)
0o
8o
15o
Pre Operative Xray (July 2020)
1o
18o
3o
Durante Operation
Post Operative Xray
0o
32o
2o
4o
Discussion
 The literature regarding revision surgery in AIS is not extensive and the
rates of repeated surgery differ widely.
 In a study conducted by Luhmann, et al., they identified and
categorized reason for reoperation for AIS into:
 Infection (early vs. late),
 Re-instrumentation or re-osteotomy (due to implant failure, fixation failure,
pseudarthrosis, curve progression, crankshaft, or fracture),
 Implant removal due to pain (partial vs. complete),
 Early implant fixation failure (i.e., loosening),
 Thoracoplasties,
 Implant malposition (anterior vs. posterior),
 Minor procedures (i.e., repeated wound closure, scar revisions, etc.)
Disccussion
 There is a high prevalence of wrong-level surgery performed by spine surgeons.
 Unusual patient anatomy and a failure to verify the operative site on radiography
have been commonly reported.
 Therefore, it is necessary to count thoracic–lumbar vertebrae preoperatively to
avoid wrong-level surgery in the course of scoliosis correction due to the variation
in vertebral number
 Recently, Ibrahim et al reported for the first time that variations in the numbers of
thoracic or lumbar vertebrae were found in 10% of patients with AIS.
Discussion
Another possible causes that had been proposed the determination of UIV relative to UEV
and the skeletal maturity of the patient.
Upasani et.al. reported the importance of chronologic age, as the patients in the deformity
progression group tended to be younger (mean 13.7 vs. 14.7 years old).
According to Ding Q et al., 8.5% (11/130) patients following anterior selective fusion in
Lenke 5 AIS developed proximal adding on with lower Risser grade, upper instrumented
vertebra (UIV) lower than upper end vertebra (UEV) and C7 plumbline (PL) away from UIV
were the associated risk factors.
In their study, they found that the incidence of adding-on in Risser sign grade 0 to 1 (3/8)
was higher than that of grade 2 to 3 (12.1%) and grade 4 to 5 (4.5%). In addition, the
incidence of adding-on in UIV lower than UEV group (20.6%) was obviously higher than that of
UIV higher than or equal to UEV group (4.2%).
Discussion
 Selection of the UIV may not be as controversial as selecting the LIV,
 Improper UIV selection in selective fusion could lead to progressive thoracic compensatory
curve, shoulder imbalance, and even coronal imbalance
 In recent study by Shu et.al., proposed that UIV could be selected as the vertebra one level
caudal to the UEV (UEV-1) in Lenke 5C patients
 The criteria for UEV-1 group patients were:
 Patients with Risser more than grade 2
 Thoracic compensatory curve over 15 o
 The Risser grade 2 indicated less growth potential and thus less chance of curve progression,
especially the unfused thoracic curve.
Summary
0o
1o
8o
2o
28o 18o
4o
34o 3o
September 2019 June 2020 July 2020

Conclusion
 Proximal curve decompensation can occur in patient who has undergone posterior spinal
fusion for idiopathic scoliosis, and this could be an indication for revision surgery to improve
the patient's quality of life.
 There are several factors that can lead to proximal curve decompensation, such as the
severity of the scoliosis curve, determination of the UIV level, and the patient's bone
maturity.
 Proximal curve progression can be corrected by extend the UIV proximally to the upper of the
UEV.
Thank You
Reference
1. Federico Canavese, Marie Rousset, Benoit Le Gledic, Antoine Samba, Alain Dimeglio. Surgical advances in the treatment of neuromuscular scoliosis, World J
Orthop 2014 April 18; 5(2): 124-133
2. Upasani VV, et al., Spinal deformity progression after posterior segmental instrumentation and fusion for idiopathic scoliosis, J Child Orthop (2015) 9:29–37.
3. Cho RH, Yaszay B, Bartley CE, Bastrom TP, Newton PO (2012) Which Lenke 1A curves are at the greatest risk for adding-on …and why? Spine (Phila Pa 1976)
37(16):1384–1390
4. RichardsBS,HasleyBP,CaseyVF.Repeat surgical interventions following “defi nitive” instrumentation and fusion for idiopathic scoliosis.Spine2006;31:3018–26.
5. Campos M, Dolan L, Weinstein S, Unanticipated Revision Surgery in Adolescent Idiopathic Scoliosis, Spine2012;37:1048–1053
6. Luhmann SJ, Lawrence G, Bridwell KH, Scootman M, Revision Surgery After Primary Spine Fusion for Idiopathic Scoliosis, SPINE Volume 34, Number 20, pp
2191–2197
7. Zongshan Hu, Zhen Zhang, Zhihui Zhao, Zezhang Zhu, Zhen Liu, Yong Qiu, A Neglected Point in Surgical Treatment of Adolescence Idiopathic Scoliosis.
Medicine (2016) 95:34
8. Mody MG, Nou rbakhsh A, Stahl DL, et al. The preval ence of wrong level surgery among spine surgeons. Spine 2008;33: 194– 8.
9. Ibrahim DA, Myung KS, Skaggs DL. Ten percent of patients with adolescent idio p athic scoliosi s h ave variations in the number of thoracic or lumbar
vertebrae. J B one Joint Surg A m 2013;95: 828– 33.
10. Sarlak AY, Atmaca H, Kim W J, et al. Radio graphic features of the Lenke 1A curves to help to determine the optimu m distal fusion level selection. Spine 2
011;36: 1 592– 9 .
11. Takahashi J, Newton PO, Ugrinow VL, et al. Selective thor acic fusi on in adolesce nt idio pathic scoliosis: factors infl uencing the selecti on of the optimal
lowest instrumented vertebra. Spine 2 011;36:1131– 4 1.
12. Louer, C.J., et al., Ten-Year Outcomes of Selective Fusions for Adolescent Idiopathic Scoliosis. JBJS, 2019. 101(9): p. 761 -770.
13. Ding, Q., et al., Risk factors of thoracic curve decompensation after anterior selective fusion in adolescent idiopathic scoliosis with major thoracolumbar or
lumbar curve. Chinese journal of surgery, 2012. 50(6): p. 518-523.
14. Trobisch PD, Ducoffe AR, Lonner BS, et al. Choosing fusion levels in adolescent idiopathic scoliosis. J Am Acad Orthop Surg 2013;21:519–28.
15. Shu S, et al., Hyper-Selective Posterior Fusion in Lenke 5C Adolescent Idiopathic Scoliosis: When Can We St op Below th e Upper End Vertebra?, SPINE
Volume 45, Number 18, pp 1269–1276

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Revision Surgery for Proximal Curve

Decompensation on a Patient with Lenke 5C

By: dr. Wan Adi Surya Perdana

Program Studi Pendidikan Dokter Spesialis Ilmu Orthopaedi dan Traumatologi

• Diagnosed with AIS Lenke 5C Risser IV

• Underwent revision surgery

September 2019 June 2020 July 2020

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