Early Revision Surgery for Distal Adding-On Correction in Lenke 1 and 2 Adolescent Idiopathic Scoliosis

Objective To evaluate the outcome of an early revision strategy for postoperative distal adding-on (DAO) after Lenke 1 and 2 adolescent idiopathic scoliosis (AIS) surgery. Summary of background data Improper choice of the lowest instrumented vertebra (LIV) is a major cause of postoperative imbalance and unsatisfactory results in AIS surgery. The long-term consequences of such imbalance remain unclear. Early corrective surgery has not been described. Methods We retrieved the records of operated AIS patients at the former institution of the senior author. There were 18 cases of early revision by one-level distal extension of instrumentation and fusion. Patients were reoperated based on progressive distal local imbalance and clinical lumbar asymmetry. Several local and global balance parameters were compared on serial long-standing radiographs before and after the index surgery, before and after the revision surgery, and at the last follow-up. The Kruskal-Wallis test was used for the comparison of the results. A value of p<0.05 was considered significant. Results All patients were female with a mean age of 13.9 years. The mean delay between the two surgeries was 8.4 months and the last follow-up was at 32.5 months after the revision surgery. Unsatisfactory results after the index surgery were reflected by a progressive increase in disc angulation below the lowest instrumented vertebra (LIV) and an increased tilt and rotation of the LIV+1. The clinical lumbar shift was also accentuated from 19 mm to 25 mm. Revision surgery significantly reduced local and global balance parameters. There was a decrease in the LIV translation (from 26 mm to 19 mm) and of the wedging below it (from 7.9° to 1.3°) and a better positioning of the LIV+1 with less tilt (from 14.6° to 3.6°), translation (from 22.2 mm to 13.8 mm) and rotation (from 20° to 15°). The clinical lumbar shift was reduced from 25 mm to 3.6 mm. Global coronal and sagittal balance were also ameliorated. All results were maintained at a mean follow-up of 32.5 months from the revision surgery. No complications were noted and there was no need for a blood transfusion. Conclusion The revision surgery proposed in this paper is simple with low morbidity and may be considered as a fine-tuning of the failed index surgery. Further studies are needed to evaluate the long-term consequences of treated and untreated postoperative distal adding-on in AIS surgery.