Influence of correction objectives on the optimal scoliosis instrumentation strategy: a preliminary study

In three recent studies we have shown how different correction objectives from a group of experienced spine surgeons add to the variability in AIS instrumentation strategies. This study examined the effect of correction objectives of three surgeons on the optimal instrumentation strategy. An optimization method using six instrumentation design parameters (e.g. limits of the instrumented segment, number, type and location of implants and rod shape) that were manipulated in a uniform experimental design framework was linked to a patient-specific biomechanical model to analyze the effects of a specific instrumentation configuration. The optimization cost function was formulated to maximize correction in the three anatomic planes and with minimal number of instrumented levels. Three surgeons from the Spinal Deformity Study Group provided their respective correction objectives for a single patient (56 degrees thoracic and 38 degrees lumbar Cobb angle). For each surgeon, 702 surgical configurations were iteratively simulated using a biomechanical model. The influence of the three different correction objectives on the optimal surgical strategy was evaluated. The resulting optimal fusion levels were T2-L4, T4-L2, and T4-L1. A Wilcoxon non parametric test analysis showed that fusion levels and the location of implants significantly were influenced by the correction objectives strategies (p<0.05). The optimal number of implants although different (12 vs.11 vs.10) was not statistically significant (p>0.1). Thus different surgeon-specified correction objectives produced different optimal instrumentation strategies for the same patient.