How to Select the Lower Instrumented Vertebra in Traditional Growing Rods Index Surgery

Background There are still no consensus criteria on how to select the lower instrumented vertebra (LIV) for traditional growing rods (TGRs) at index surgery. The aim was to evaluate whether the criteria used for adolescent idiopathic scoliosis fusion adapts to early onset scoliosis (EOS).

Methods Retrospective analysis of prospectively longitudinal collected data in a consecutive cohort of patients with EOS treated with TGR, expanding from index surgery to 2 years after graduation. The LIV was analyzed regarding its relation to the stable vertebra (SV), substantially touched vertebra (STV), and not STV (NSTV). Failure of LIV selection was considered when revision surgery with distal extension was needed during follow up, due to adding on (ΔLIV tilt > 10°).

Results A total of 25 patients met inclusion criteria. Mean age was 8.6 ± 3 (at index surgery), 15.1 ± 1.8 (at graduation), and 17.8 ± 1.6 (at final follow up). The most frequent LIV at index surgery was L3 (13/25); in 13 cases, STV was selected as LIV; in 7, it was NSTV; and in 5, SV on the standard postero-anterior radiographs. During follow up, a significant increase in the mean LIV tilt (P = .049) and distal junctional angle (P = .017) was found. Nine of the 25 patients (36%) developed adding on: 20% (1/5) of those with LIV at SV, 38.5% (5/13) at STV, and 42.8% (3/7) at NSTV. Of those 9 cases of adding on, only four needed distal extension (mean LIV tilt = 17.6°): 2 STV patients (15.4%), and 2 NSTV patients (28.6%). None of the patients with the LIV chosen at SV needed distal extension due to adding on.

Conclusions The cranial the selection of the LIV above the SV, the higher the risk of adding on and of revision surgery with distal extension during follow up. Saving motion segments could be justified by choosing STV as LIV because the need for distal extension is not high, and it can be scheduled during lengthening procedures or at graduation surgery.

Level of Evidence 4.

Clinical Relevance Choosing the LIV in TGR index surgery is crucial to have a secure distal foundation, control and correct the deformity during growth, and save distal segments to allow growth and mobility.