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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

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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 - PowerPoint PPT Presentation

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Page 1: Ahmet ALANAY, MD Cagatay OZTURK, MD Meric ENERCAN, MD Ibrahim ORNEK, MD Mehmet TEZER, MD

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, MDCagatay OZTURK, MDMeric ENERCAN, MDIbrahim ORNEK, MDMehmet TEZER, MD

Azmi HAMZAOGLU, MD

Istanbul Spine CenterFlorence Nightingale Hospital

Istanbul-TURKEY

Page 2: Ahmet ALANAY, MD Cagatay OZTURK, MD Meric ENERCAN, MD Ibrahim ORNEK, MD Mehmet TEZER, MD

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 250

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, 1994Suk SI, et al, Spine, 2000

Kuklo TR, et al, Spine, 2002Cil A, et al, Spine, 2005

O’Brien MF, SRS 2008

Page 3: Ahmet ALANAY, MD Cagatay OZTURK, MD Meric ENERCAN, MD Ibrahim ORNEK, MD Mehmet TEZER, MD

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.

Page 4: Ahmet ALANAY, MD Cagatay OZTURK, MD Meric ENERCAN, MD Ibrahim ORNEK, MD Mehmet TEZER, MD

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.

Page 5: Ahmet ALANAY, MD Cagatay OZTURK, MD Meric ENERCAN, MD Ibrahim ORNEK, MD Mehmet TEZER, MD

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

Page 6: Ahmet ALANAY, MD Cagatay OZTURK, MD Meric ENERCAN, MD Ibrahim ORNEK, MD Mehmet TEZER, MD

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.

Page 7: Ahmet ALANAY, MD Cagatay OZTURK, MD Meric ENERCAN, MD Ibrahim ORNEK, MD Mehmet TEZER, MD

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.

Page 8: Ahmet ALANAY, MD Cagatay OZTURK, MD Meric ENERCAN, MD Ibrahim ORNEK, MD Mehmet TEZER, MD

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.

Page 9: Ahmet ALANAY, MD Cagatay OZTURK, MD Meric ENERCAN, MD Ibrahim ORNEK, MD Mehmet TEZER, MD

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.

Page 10: Ahmet ALANAY, MD Cagatay OZTURK, MD Meric ENERCAN, MD Ibrahim ORNEK, MD Mehmet TEZER, MD

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.

Page 11: Ahmet ALANAY, MD Cagatay OZTURK, MD Meric ENERCAN, MD Ibrahim ORNEK, MD Mehmet TEZER, MD
Page 12: Ahmet ALANAY, MD Cagatay OZTURK, MD Meric ENERCAN, MD Ibrahim ORNEK, MD Mehmet TEZER, MD

GS, 15y, F

45°

25°

25°

10° 14°

4°

14°

45°

25°

25°T4

Page 13: Ahmet ALANAY, MD Cagatay OZTURK, MD Meric ENERCAN, MD Ibrahim ORNEK, MD Mehmet TEZER, MD

GS, 15y, F

10°

45°

25°

25°

45°

25°

25°T4

14°

4°

14°

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.

Page 14: Ahmet ALANAY, MD Cagatay OZTURK, MD Meric ENERCAN, MD Ibrahim ORNEK, MD Mehmet TEZER, MD

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.

Page 15: Ahmet ALANAY, MD Cagatay OZTURK, MD Meric ENERCAN, MD Ibrahim ORNEK, MD Mehmet TEZER, MD

THANK YOU


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