구조적 흉요부/요부 만곡 청소년기 특발성 측만증에서 원위부 유합 범위를 결정하는데 있어서 동적 혹은 정적 기준의 신뢰도 비교 = Which Criterion Is More Reliable for Selecting the Distal Fusion Level in Cases of Adolescent Idiopathic Scoliosis with Structural Thoracolumbar/Lumbar Curves: Static or Dynamic?

다국어 초록 (Multilingual Abstract)

Study Design: Retrospective comparative study.
Objectives: To compare the reliability of 2 criteria to predict the radiological outcomes of corrective surgery in cases of adolescent idiopathic scoliosis (AIS) with structural thoracolumbar/lumbar (TL/L) curves.
Summary of Literature Review: Distal fusion level selection in AIS with structural TL/L curves is debatable.
Materials and Methods: This study included 131 AIS patients with structural TL/L curves who underwent corrective surgery in which distal fusion was stopped at L3. Whole-spine standing radiographs and bending radiographs were obtained preoperatively. The patients were divided into 2 groups according to their findings on bending radiographs (dynamic criterion) and by the last touching vertebra and the lower end vertebra (static criterion). Radiological outcomes were assessed by reviewing postoperative radiographs. Reliability tests were conducted to compare the predictability of radiological outcomes using these 2 methods. In addition, radiological parameters were compared between both criteria.
Results: Among 131 patients, 25 showed radiologically poor outcomes (19.1%). The sensitivity of the dynamic and static criteria was 0.69 and 0.50, respectively. The specificity of each criterion was 0.49 and 0.64, respectively. Overall, the dynamic criterion showed superior reliability (p=0.03). However, no significant difference in radiological parameters could be found in a comparison of both criteria.
Conclusions: Although the dynamic criterion was more sensitive for predicting poor radiological outcomes when stopping fusion at L3 in patients with structural TL/L curves, its specificity was lower than that of the static criterion. Thus, both dynamic and static criteria should be considered when selecting the distal fusion level in cases of AIS with structural TL/L curves.
Key words: Adolescent idiopathic scoliosis, Double major curve, Distal fusion level, Lower instrumented vertebra

국문 초록 (Abstract)

연구 계획: 후향적 비교 연구목적: 구조적 흉요부/요부 만곡 청소년기 특발성 측만증 환자 수술 후 방사선학적 결과를 예측하는 2가지 기준의 신뢰도를 비교하기 위함선행 연구문헌의 요약: 구조적 흉요부/요부 만곡 청소년기 특발성 측만증의 원위부 유합 부위 결정은 이견이 많음.
대상 및 방법: 원위 유합을 L3까지 수술한 구조적 흉요부/요부 만곡 청소년기 특발성 측만증 환자 131명을 대상으로 하였다. 수술전 전신 척추 기립 자세와 측부 굽힘 방사선 사진을 촬영하였다. 환자들은 측부 굽힘 사진 상의 기준(동적)과, Last touching vertebra와 lower end vertebra에 따른 기준(정적)에따라 분류하였고, 술후 방사선학적 결과에 따라 분석하였다. 두 기준에 따른 방사선학적 결과 예측의 신뢰도를 분석하였고, 여러 방사선학적 인자들의 차이를 분석하였다.
결과: 131명의 환자중 25명이 불량한 결과를 보였다(19.1%). 동적 기준과 정적 기준의 민감도는 각각 0.69와 0.50이었고, 특이도는 0.49와 0.64였다. 전반적으로는 동적 기준이 우월한 신뢰도를 보여주었다(p=0.03). 하지만, 두 기준에 따른 방사선학적 인자들의 차이는 없었다.
결론: L3에서 유합을 멈췄을 때 동적 기준이 더 불량한 예후를 예측하는데 민감했지만, 특이도는 정적 기준보다 낮았다. 구조적 흉요부/요부 만곡 청소년기 특발성 측만증 환자에서 원위 유합 범위 결정에 두 기준 모두를 고려하는 것이 좋을 것으로 생각된다.
약칭 제목: 구조적 흉요부/요부 만곡 청소년기 특발성 측만성 환자의 원위 유합 범위 결정

참고문헌 (Reference)

1 Xiaodong Qin, "Where to stop distally in Lenke modifier C AIS with lumbar curve more than 60°: L3 or L4?" Elsevier BV 178 : 77-81, 2019

2 Hamzaoglu A, "Traction X-ray under general anesthesia helps to save motion segment in treatment of Lenke type 3C and 6C curves" 13 (13): 845-852, 2013

3 Lenke LG, "The Lenke classification of adolescent idiopathic scoliosis: how it organizes curve patterns as a template to perform selective fusions of the spine" 28 : S199-S207, 2003

4 Choon Sung Lee, "The Clinical Importance of Lumbosacral Transitional Vertebra in Patients With Adolescent Idiopathic Scoliosis" Ovid Technologies (Wolters Kluwer Health) 40 (40): E964-E970, 2015

5 Tsutomu Akazawa, "Spinal fusion on adolescent idiopathic scoliosis patients with the level of L4 or lower can increase lumbar disc degeneration with sagittal imbalance 35 years after surgery" Japanese Society for Spine Surgery and Related Research 1 (1): 72-77, 2017

6 Charla R. Fischer, "Optimal Lowest Instrumented Vertebra for Thoracic Adolescent Idiopathic Scoliosis" Springer Science and Business Media LLC 6 (6): 250-256, 2018

7 Bartie BJ, "Long-term follow-up of adolescent idiopathic scoliosis patients who had Harrington instrumentation and fusion to the lower lumbar vertebrae:is low back pain a problem" 178 : 77-81, 2019

8 Lee CS, "Is it enough to stop distal fusion at L3 in adolescent idiopathic scoliosis with major thoracolumbar/lumbar curves?" 25 (25): 3256-3264, 2016

9 Dong-Gune Chang, "Importance of Distal Fusion Level in Major Thoracolumbar and Lumbar Adolescent Idiopathic Scoliosis Treated by Rod Derotation and Direct Vertebral Rotation Following Pedicle Screw Instrumentation" Ovid Technologies (Wolters Kluwer Health) 42 (42): E890-E898, 2017

10 Dong-Gune Chang, "How to Avoid Distal Adding-on Phenomenon for Rigid Curves in Major Thoracolumbar and Lumbar Adolescent Idiopathic Scoliosis? Identifying the Incidence of Distal Adding-on by Selection of Lowest Instrumented Vertebra" Elsevier BV 132 : e472-e478, 2019

11 Choon Sung Lee, "Five major controversial issues about fusion level selection in corrective surgery for adolescent idiopathic scoliosis: a narrative review" Elsevier BV 17 (17): 1033-1044, 2017

12 Ran Ding, "Evaluation of Quality of Life in Adolescent Idiopathic Scoliosis With Different Distal Fusion Level" Ovid Technologies (Wolters Kluwer Health) 27 (27): E155-E161, 2014

13 Meric Enercan, "Does It Make a Difference to Stop Fusion at L3 Versus L4 in Terms of Disc and Facet Joint Degeneration: An MRI Study With Minimum 5 Years Follow-up" Springer Science and Business Media LLC 4 (4): 237-244, 2016

14 Jae Hwan Cho, "Disc Wedge and Vertebral Body Tilt Angle Below Lower Instrumented Vertebra After Posterior Correction and Fusion in Patients With a Structural Thoracolumbar/Lumbar Curve" Ovid Technologies (Wolters Kluwer Health) 44 (44): E1436-E1442, 2019

15 김성수, "Determination of the Distal Fusion Level in the Management of Thoracolumbar and Lumbar Adolescent Idiopathic Scoliosis Using Pedicle Screw Instrumentation" 대한척추외과학회 8 (8): 804-812, 2014

16 Suk SI, "Determination of distal fusion level with segmental pedicle screw fixation in single thoracic idiopathic scoliosis" 28 (28): 484-491, 2003

17 Mehmet N Erdem, "Criteria for Ending the Distal Fusion at the L3 Vertebra vs. L4 in Surgical Treatment of Adolescent Idiopathic Scoliosis Patients with Lenke Type 3C, 5C, and 6C Curves: Results After Ten Years of Follow-up" Cureus, Inc 10 (10): e2564-, 2018

18 Lenke LG, "Ability of Cotrel-Dubousset instrumentation to preserve distal lumbar motion segments in adolescent idiopathic scoliosis" 6 (6): 339-350, 1993