1. POSTOPERATIVE LEFT SHOULDER ELEVATION (LSE) IN PATENTS WITH NON-STRUCTURAL PROXIMAL THORACIC CURVES (PT): CAN IT BE PREVENTED IN PATIENTS WITH PREOPERATIVE RIGHT SHOULDER ELEVATION (RSE)? Ahmet ALANAY, MD Cagatay OZTURK, MD Meric ENERCAN, MD Ibrahim ORNEK, MD Mehmet TEZER, MD Azmi HAMZAOGLU, MD Istanbul Spine Center Florence Nightingale Hospital Istanbul-TURKEY

2. The criteria for the fusion of proximal thoracic curves when there is negative T1 tilt and right shoulder elevation SHOULDER IMBALANCE Proximal thoracic curve of more than 25 0 Level or higher shoulders on the side of the proximal thoracic curve Nonstructural unfused proximal thoracic curves undergo spontaneous correction during the postoperative period. Structural criteria of side bending to <25 degrees is insufficient for defining upper thoracic curves that require instrumentation (39% shoulder imbalance rate) Lenke LG, et al, Spine, 1994 Suk SI, et al, Spine, 2000 Kuklo TR, et al, Spine, 2002 Cil A, et al, Spine, 2005 O’Brien MF, SRS 2008

3. INTRODUCTION LSE after fusion of main structural (MT) curve has been reported to be 39% in Lenke type 1 curves. Since 1999, traction x-ray under general anesthesia (TrUGA) is used to select fusion levels in AIS in our institute.

4. INTRODUCTION The decision whether to fuse PT in patients with RSE has been given according to changes in the level of left shoulder and T1 tilt at the TrUGA. Fusion of PT was decided if left shoulder was leveled or elevated compared to the right shoulder and if (-) T1 tilt was neutralized or reversed to (+) at the TrUGA.

5. To analyse if this criteria was efficient to obtain balanced shoulder levels in patients with RSE after surgery in patients with RSE preoperatively. Ninety-two among (82F, 10M) 250 Lenke type 1 and 3 patients who had a (–) T1 tilt and RSE were included in this study. PURPOSE PATIENT SAMPLE

6. METHODS Preop, postop, TrUGA and follow-up x-rays were evaluated. Cobb angles of all curves first rib angle (FRA) T1 tilt angle (TT) were measured.

7. RESULTS The average age at time of surgery was 15.2 years The average follow-up was 5.2 (range; 2 to 11) years. There were 71 patients with Lenke type 1 21 patients with Lenke type 3 curves.

8. RESULTS Fusion ended below the apex of upper thoracic curve in 18 patients. Preoperative FRA and TT was -7.4° and -6.1° respectively and changed to -2.3° and -2.6° in TrUGA and were found to be -1.3° and -1.6° postoperatively. Preoperative MT was 52° and corrected to 12° while preoperative PT was 24° and corrected to 8° postoperatively. None of the patients had clinically obvious LSE in this group postoperatively and at the final follow-up.

9. RESULTS Fusion ended above the apex (T2 or T3) of PT in the remaining 74 (75%) patients as all of them had LSE and neutral or (+) T1 tilt in TrUGA. Preoperative FRA and TT was -7° and -6.2° respectively and changed to +2.4° and +2.6° in TrUGA and were found to be +1.3° and -1.1° postoperatively. Preoperative MT was 56° and corrected to 10° while preoperative PT was 26° and corrected to 4° postoperatively.

10. RESULTS Ten (14%) patients in this group had radiographically and clinically obvious LSE postoperatively and LSE was persisting at the final follow-up. None of the patients who had LSE expressed dissatisfaction due to this problem.

12. GS, 15y, F 45° 25° 10° 14° 4°4° 45° 25° T4

13. GS, 15y, F 10° 45° 25° 45° 25° T4 14° 4°4° Since 1999; our approach in patients with right thoracic or double major curves with preoperative standing AP x-ray showing right shoulder elevation and negative T1 tilt and if T1 tilt and position of first ribs are reversed in traction X-ray taken under general anesthesia, we extend the fusion proximally up to T2 although the upper thoracic curve is non-structural to prevent shoulder imbalance.

14. CONCLUSION TrUGA was efficient to determine patients who will not have LSE after correction of MT without extension of fusion to PT. However, it may be overestimating the incidence (75%) of LSE and may be causing unnecessary extension of fusion regarding the 39% incidence reported in the literature. On the other hand, fusing UTC may not prevent LSE in a considerable number of patients.

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