CHAPTER
Daniel J. Sucato
83
Anterior Lumbar and Thoracolumbar
Correction and Fusion for AIS
INTRODUCTION
The anterior approach in the treatment of thoracolumbar/
lumbar (TL/L) adolescent idiopathic scoliosis has a long his-
tory and continues to be the most common approach to these
curves today although the posterior approach offers another
good option. The anterior approach utilizes an open thoraco-
tomy approach to remove the disc and end plate material,
which significantly increases the flexibility of the spine. Through
a variety of implant options and correction strategies, the three-
dimensional spinal deformity can be corrected while fusing
only the Cobb levels of the spine. The challenges with the ante-
rior approach are the visibility of the anterior incision, achiev-
ing solid arthrodesis especially of the distal-most intended
fused level, and maintaining or restoring lumbar lordosis.
Stiffer implant constructs utilizing a single large rod or the use
of the dual-rod system and the use of anterior structural sup-
port have improved the radiographic success of achieving
arthrodesis and restoring the sagittal profile. Careful surgical
technique to completely remove the disc and end plate to
increase the flexibility of the spine while providing for exposed
bone for arthrodesis is critical to achieve good results. The use
of the posterior approach for these curves continues to increase
in popularity with overall good results; however, the ability to
fuse only the Cobb levels is not proven and requires further
study. In addition, the problems of proximal junctional kypho-
sis, sequelae of paraspinal muscle stripping to gain access to the
spine, and scarring distal to the posterior fusion levels are
concerning.
This chapter will review the history and evolution of the
anterior approach to these thoracolumbar and lumbar curves,
the indications for anterior surgery for TL/L curves, surgical
technique, and the radiographic and clinical outcomes seen
with this approach.
EVOLUTION OF THE ANTERIOR
APPROACH FOR TL/L SCOLIOSIS
Correction and stabilization of scoliosis deformity via an ante-
rior approach was introduced by Dwyer in 1964 and was a major
addition to the field of spine deformity surgery2 (Table 83.1).
Dwyers original idea was inspired by the principle of modulat-
ing growth such as the stapling of the medial epiphysis of the
848
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Hong Zhang
Charles E. Johnston
distal femur in a knock-knee deformity. Tethering the convexity
of a scoliosis, using a flexible titanium cable attached to screws
in the vertebral bodies, produced shortening of the convex side
and effectively corrected thoracolumbar and lumbar curves.
Although the concept was sound, the disadvantages and limita-
tions soon became apparent, and included the lack of adjust-
ability after crimping of the screw cable connection, lack of
segmental stiffness inherent to a flexible cable, and the kyphos-
ing nature of a purely anterior compressive correction maneu-
ver.2,10 Implant failure, unacceptable pseudarthrosis rates, and
sagittal plane derangement as a result of lumbar kyphosis were
frequently reported.10
In 1973, Zielke advanced Dwyers concept by introducing
derotation of the instrumented segment.3,30 Instead of using a
flexible cable, a derotation lordosator bar manipulated a
threaded 1/8-in. rod fixed to screws on the convexity of the
curve. The enthusiasm with which Zielke technique was
received was also eventually tempered by the occurrence of the
same problems seen with Dwyer instrumentationnamely a
9% to 23% incidence of pseudarthrosis or implant failure and
up to 25% average loss of correction, along with persistent
kyphosis in the instrumented segment.8 Eventually, it was shown
that the only technique that avoided instrumentational kypho-
sis with the Zielke implants involved the use of specific struc-
tural bone grafting anteriorly combining it with posterior
instrumentation.
A stiffer solid-rod system was introduced in 1989 as part of
the Texas Scottish Rite Hospital (TSRH) instrumentation,
extending the concepts of Zielke and adding a rotation maneu-
ver later popularized by Cotrel and Dubousset.7,25 This method,
still in use currently, utilizes solid rods of varying diameters (5.5
and 6.4 mm) with a hexagonal end to central rod rotation.
Vertebral body screws, usually 6.5 or 7.5 mm in diameter,
anchored by two-pronged staples provided additional resis-
tance to cantilever and rotational pullout, were connected to a
solid rod contoured for the appropriate lordosis in the intended
instrumented segment. After seating the rod in each screw via
preplaced eyebolts, which are then provisionally tightened to
maintain the rodscrew connection, the rod is rotated from
scoliosis to lordosis, aided by a nonslipping wrench fitting over
the hexagonal end of the rod (Fig. 83.1A). The stiffness of the
solid rod imposes lordosis on the instrumented segment, and
the ventrally pulled vertebrae simultaneously derotate and
translate toward the concavity (Fig. 83.1B). Compression can
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 Chapter 83 Anterior Lumbar and Thoracolumbar Correction and Fusion for AIS 849

TABLE 83.1 Anterior Approach for Thoracolumbar/Lumbar Scoliosis

Advantages
Dwyer system 1960s
Zielke system 1970s
Texas Scottish Rite
Hospital (TSRH)
system 1980s
Single solid rod with
structural interbody
support 1990s
Dual-rod dual-screw
1990s
Rod-plate (L-plate)
system 2006
First time to develop an anterior cable and screw
instrumentation system for anterior correction and
stabilization of scoliosis deformity
Shortening the convex side of the curve effectively
corrected the scoliosis
Modified the Dwyer system to a semirigid threaded
rod and screw system
First time to develop a derotation device for anterior
correction of scoliosis deformity
Significant improvement in the ability of derotate,
correct, and stabilize scoliosis deformities
Offers larger diameter, stiffer solid rod
Rod contouring possible
Improved derotation ability and maintenance of
correction
Increase construct stiffness in flexion maintaining
sagittal profile during the immediate postoperative
period
Improved stiffness of the construct limits
pseudarthrosis
Significantly increase construct stiffness compared
with a single rod
Improved fixation at the bonescrew interface
compared with the single-rod construct
Extend the concepts of TSRH single solid rod
Provide two points fixation at the critical end
vertebrae to augment the construct stiffness at the
cephalad- and caudal-end segments
Lower profile with less complex intraoperative
assembly than the double-screw double-rod
construct
Disadvantages
Iatrogenic kyphosis
Flexible cable had a tendency to fray and break,
resulting in loss of correction and pseudarthrosis
Implant failure with screw loosening and plowing at
the end vertebrae of the construct also leads to
pseudarthrosis
Progressive kyphosis secondary to small rod
Rod fracture was common, resulting in loss of
correction and pseudarthrosis
Screw loosening and plowing at the end vertebrae of
the construct
Screw loosening and plowing at the end vertebrae
Pseudarthrosis at the caudal-end segments secondary
to increased flexibility at this segment
Loss of sagittal correction
The instrumented vertebral bodies still lack two
points of fixation, which may minimize the bone
screw interface loosening during cyclical loading
Single screw fixation of the individual vertebral
bodies may fail by migration or pullout during
longer-term cyclical loading, especially at the
critical end segments
Technically demanding
Higher profile and may not be suited for the young
adolescent patients
The increasing stiffness is more concentrated at the
intermediate segments and is relatively less toward
the critical end segments
The additional rod has no effect on construct
stability in lateral bending
Clinical practice and more studies are needed

A B

Figure 83.1. Texas Scottish Rite Hospital (TSRH) instrumentation. (A) Rod rotation using the TSRH
-inch solid stainless steel rod to correct the coronal and sagittal plane deformity. (B) The final rod position
has straightened the spine in the coronal plane while maintaining lordosis.

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 850 Section VII Idiopathic Scoliosis

be applied segmentally if desired, prior to final tightening of
the eyebolt nuts to lock the rodscrew connection. Since
gradual rotation of the rod reduces the entire scoliosis, correc-
tive forces are evenly distributed along the construct, rather
than acutely focused at one segment, decreasing the possibility
of bonescrew interface loosening. Full visualization of the
implants during correction of the spine provides safety against
screw pullout or other intraoperative disassembly.
The 300% to 400% increased stiffness of a 6.4-mm rod solid
over the Dwyer or Zielke longitudinal members was original
thought to be adequate to maintain correction without exter-
nal immobilization.7 However, a review of 50 consecutive cases
(1992 through 1996) demonstrated that structural rib grafts
failed to maintain sagittal alignment better than morselized
interbody graft, as measured by an increase of greater than 10
of kyphosis in the instrumented segment during the postopera-
tive period. In addition, the percentage of patients losing more
than 10 correction postoperatively in the frontal plane (16%)
remained unimproved over the earlier experience (pre-1992)
in spite of what was believed to be better grafting technique,
and the incidence of radiographic pseudarthrosis (30%) con-
tinued to be alarming.25 This pseudarthrosis occurred 93% of
the time at the most caudal disc space, usually L2-3in the
typical thoracolumbar construct, confirming that bone graft
alone, of any type, might be inadequate to achieve fusion at all
segments with the single anterior solid-rod construct, and that
additional construct stiffness would be particularly appropriate
at the most caudal segment to improve fusion rates (Fig. 83.2).
Biomechanical evaluations have confirmed that the draw-
backs of the single-rod anterior construct are concentrated at the
both end segments.18,19,20 There is not only significantly higher
strain at the bonescrew interface of the cephalad- and caudal-
end screws but also higher rod stresses occur at both end seg-
ments.21 The combination of less screw fixation strength and
increased rod loading stress may serve as causative factors result-
ing in bonescrew interface failure at these critical end vertebrae
during intraoperative correction maneuvers and/or from post-
operative fatigue. Segmental range of motion determinations
reported by Zhang et al29 further supported these hypotheses,
in that the initial and postfatigue motion of the single solid-rod
anterior construct segments was significantly greater in the
cephalad- and caudal-end segments.29 These biomechanical
findings correlated precisely with the high incidence of compli-
cations (e.g., correction loss, kyphosis, and pseudarthrosis)
observed at the most cephalad- and caudal-end segments in
clinical practice.
The addition of an interbody fusion cage, to address the
inadequate stability of the single-rod construct, has produced
controversy.24 Sweet et al24 on the use of cages at every level to
augment the single-rod construct, with only 5% of patients los-
ing 10 coronal or sagittal correction and low incidence of
pseudarthrosis. However, Lowe et al13 found that interbody
structural cages were not necessary to maintain an appropriate
sagittal profile or to maximize coronal curve correction when a
rigid rod construct with interbody fusion and packed morsel-
ized bone is used. Interbody cages are known to increase con-
struct stiffness in flexion and thus maintain the sagittal profile
during the immediate postoperative period by virtue of the ante-
rior column support provided by the spacer effect (Fig. 83.3).
However, the instrumented vertebral bodies still lack two points

A B C D

Figure 83.2. Pseudarthrosis of the distal fusion level following anterior instrumentation and attempted
fusion of an adolescent idiopathic scoliosis patient by using a single -inch Texas Scottish Rite Hospital
rod with autograft and no anterior structural support. (A and B) Preoperative radiographs demonstrating a
48 lumbar curve and a compensatory 20 thoracic curve. (C and D) Radiographs at 3 years from surgery
demonstrating a hypertrophic nonunion at the L2-3 disc level (arrow) although rod fracture has not
occurred.

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A B C D

Figure 83.3. Single-rod construct with anterior structural support. (A and B) Preoperative radiographs
demonstrating a 46 thoracolumbar curve with a compensatory thoracic curve. (C and D) Two-year postop-
erative radiographs demonstrating excellent coronal plane correction and maintenance of the sagittal plane
following anterior instrumentation and fusion from T10 to L2 with a single rod and anterior structural sup-
port at the T12-L1 and L1-L2 levels using titanium mesh cages filled with autograft rib.

of fixation, which would minimize the bonescrew interface
loosening during cyclical loading. Single screw fixation of the
individual vertebral bodies may fail by migration or pullout
during longer-term cyclical loading, especially at the critical
end segments.29
The concept of dual-rod constructs for anterior scoliosis sur-
gery was popularized by Kaneda as a method of addressing the
shortcomings of the single-rod construct. Dual-rod anterior con-
structs for the treatment of TL/L scoliosis maintain better correc-
tion than single-rod constructs, combined with no pseudarthrosis
or implant failure8 (Fig. 83.4). Biomechanically, double-screw
fixation for each vertebra increases construct stiffness and affords
improved fixation at the bonescrew interface.18,21 Although the
addition of the second rod enhances the overall construct stiff-
ness over the single-rod construct, increased stiffness is more con-
centrated at intermediate segments and is relatively less toward
the critical end segments. Moreover, the number of rods has no
effect on construct stability in lateral bending. Cyclical testing
of dual-rod constructs demonstrated that postfatigue flexion
extension range of motion at intermediate segments was signifi-
cantly less than the caudal-end segment, similar to findings for
the single-rod anterior cage construct.29 Regardless of the con-
struct tested, the cephalad- and caudal-end segments remain rela-
tively flexible and are most at risk for pseudarthrosis.29
A rodplate anterior instrumentation system for TL/L
deformity was conceived in 2006, extending the concepts of
single solid rod and adding two rod-plate implants (L-plate) at
the critical caudal- and cephalad-end segments (Fig. 83.5).29
The L-plate was designed to remedy the end vertebrae screw
fixation instability and augment the construct stiffness at the
end segments. The L-plate provides two points of fixation at the
end segments and rigidly connects the two end vertebrae in a
quadrangular frame, relying only partially on a longitudinal
rod to achieve this segmental stability. Thus, the cephalad- and
caudal-end vertebral pairs are linked so as to ameliorate any
cyclical fatigue loosening of the screwbone interface, the
desired solution to prevent loss of correction as observed clini-
cally in single-rod instrumentation outcomes. The rod-plate
construct is significantly stiffer and provides greater stability of
the bonescrew interface than the single-rod with interbody
fusion cage construct, and it has achieved similar stiffness and
improved bonescrew interface stability compared with the
dual-rod construct.29 This system is of lower profile with less
complex intraoperative assembly than the dual-rod construct.
INDICATIONS
Operative treatment of TL/L adolescent idiopathic scoliosis
(AIS) curves is generally indicated when the curve magnitude is
greater than 45 since curve progression into adulthood is likely.
Smaller curve magnitudes associated with truncal imbalance

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 852 Section VII Idiopathic Scoliosis

A B C D

Figure 83.4. Dual-rod anterior instrumentation. (A and B) Preoperative radiographs demonstrating a

47 thoracolumbar curve and a 29 compensatory right thoracic curve. (C and D) Two-year radiographs
following anterior instrumentation and fusion from T11 to L2 by using a dual-rod construct and anterior
structural support at T12-L1 and L1-2.

that is especially recognized by the patient and family is another
indication for surgical treatment.
The ideal candidate for anterior instrumentation is an ado-
lescent with a single thoracolumbar or lumbar curve without a
structured thoracic curve (Lenke type 5 curve). This assumes
that the thoracic curve is compensatory and will respond appro-
priately to correction of the lumbar spine to provide a balanced
coronal plane correction without unmasking the thoracic
curve and its deformity. The assessment of the thoracic curve is
important clinically and radiographically to ensure that balanced

A B C D
Figure 83.5. Anterior constructs. (A) A single-rod anterior construct demonstrating the possible
mechanism of loss of correction in the sagittal plane over the instrumented segments. Screw loosening at the
bonescrew interface will occur at the most cephalad and caudal segments first, and then each vertebra will
loosen and rotate about its screw axis. A single rod with structural interbody support (B) and dual-rod
anterior constructs (C) may effectively reduce such instability by decreasing bonescrew interface strain.
(D) A rodplate anterior construct extends the concept of the single-rod construct and adds two rod-plate
implants (L-plate) at the critical cephalad- and caudal-end segments to augment the construct stiffness at the
end segments.

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A C

Figure 83.6. The preoperative clinical examination of this 13-year-old girl with an isolated thoracolumbar
curve demonstrates a trunk shift to the left, waistline asymmetry (A) and a lumbar rotational prominence
without much thoracic prominence (B and C). The shoulders are level.

trunk and pelvis are achieved following surgery. The clinical
characteristics of the thoracic curve that imply flexibility and
help define whether a curve is compensatory include minimal
rib prominence especially when compared with the lumbar
flank prominence; a trunk shift to the left, which generally indi-
cates that the coronal plane deformity of the lumbar curve is
greater than the thoracic curve; and thoracic curve flexibility
on a clinical examination when the patients is asked to bend to
the right (Fig. 83.6). A push-prone examination in which the
patients thoracic prominence is pushed from back to front and
right to left while positioned prone on the examining room
table provides some information as to the flexibility of the
spine. The radiographic criteria indicating proper flexibility of
the thoracic curve that allow for a selective fusion of the lumbar
spine include those of the Lenke classification in which the
supine best-effort bend radiograph demonstrates a Cobb mea-
surement less than 25 and T10 to L2 kyphosis measured less
than 20. It should be noted that in general, the response of the
thoracic curve to lumbar correction, fusion, and instrumenta-
tion for a Lenke 5 curve pattern is not as predictable as the
lumbar response to a selective thoracic fusion for Lenke 1 pat-
terns.
Although the Lenke 6 curve pattern is defined as a double
major curve pattern with the primary curve being the TL/L
curve with a smaller thoracic curve, which is considered struc-
tural, there are some curves of this type that can undergo a
selective TL/L fusion. It is important to assess the clinical
appearance of the patient to ensure that the thoracic curve
does not result in a significant clinical deformity that will be
worse postoperatively. The patients and parents perception of
the deformity should also be noted to determine whether the
thoracic deformity is concerning to them. It is less common
that the Lenke 6 pattern is amenable to applying the selective
fusion strategy when compared with choosing selective thoracic
fusion for a Lenke 1 curve.
FUSION/INSTRUMENTATION LEVELS
The standard radiographs obtained prior to surgery include the
standing anteroposterior or posteroanterior and lateral views to
measure coronal Cobb measurements of the proximal thoracic,
main thoracic, and TL/L curves. The supine best-bend radio-
graphs are used to determine the flexibility of the planned
instrumented levels but more importantly are utilized to assist in
determining those curves requiring inclusion in the fusion (Fig.
83.7). In general, anterior fusion levels for TL/L curves are
from the proximal end vertebra to the distal end vertebra, or
Cobb to Cobb. These traditional fusion levels have worked
very well to obtain excellent coronal, axial, and sagittal plane
correction while usually leaving the disc levels proximal and dis-
tal to the fusion in a fairly horizontal position. Variation in this
general rule for choosing fusion levels include the concept of
the short segment fusion; the situation of performing a selective
TL/L fusion when a flexible thoracic curve is present; and,
finally, the scenario of having a parallel disc caudal to the distal
end vertebra of the curve that makes choosing the lowest instru-
mented vertebra (LIV) challenging (Table 83.2).
The short segment fusion, as popularized by John Hall
and colleagues,4 relies on overcorrection of fewer thoracolum-
bar segments to provide adequate overall coronal plane correc-
tion. This strategy works best when an isolated TL/L curve is

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 854 Section VII Idiopathic Scoliosis

A B C

Figure 83.7. The radiographs of the patient in Figure 83.6 with a primary
thoracolumbar curve. (A and B) The preoperative anteroposterior radio-
graph demonstrates a 52 lumbar curve and a 28 thoracic curve demonstrat-
ing a large discrepancy in the curve magnitudes of the two curves. The
translation of the apex of the lumbar curve from the center sacral vertebral
line (CVSL) is significantly greater than the translation of the apex of the
thoracic curve from the C7 plumb line. (C and D) The supine best-bend
radiographs demonstrate significant curve flexibility of both the thoracolum-
bar and, importantly, the thoracic curve, which is a good indication that
D
inclusion of this curve is not necessary.

present without any significant thoracic curve and when the
TL/L curve is moderate in magnitude (<60). The fusion levels
are chosen on the basis of whether the apex of the deformity is
a vertebra or a disc. If there is an apical vertebra, the fusion
levels span from one above to one below the apical vertebra.
When the apex of the curve is at a disc level, the fusion levels
include two vertebrae proximal and two vertebrae distal to the
apex. Overcorrection of the curve is mandatory and is achieved
following complete discectomy to include thinning of the con-
cave annulus, placing anterior structural support on the con-
cave side of the disc space, and several rounds of convex com-
pression. When applying this technique, one needs to accept
that disc wedging proximal to the upper instrumented vertebra
(UIV) and distal to the LIV will occur.
When performing a selective fusion of the TL/L curve when
a thoracic curve is present, it is generally agreed that leaving

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 Chapter 83 Anterior Lumbar and Thoracolumbar Correction and Fusion for AIS 855

Comparison of the Cobb-to-Cobb Method Versus Short

TABLE 83.2
Segment Fusion

Cobb-to-Cobb Method Short Segment Fusion

Indications Any curve magnitude or Curves 60 with moderate translation
deformity
Fusion levels Proximal end vertebra to If disc is the apex: two above and two
distal end vertebra below
If vertebra is the apex: one above and one
below apical vertebra
Correction strategy Correction to straight spine Overcorrection
Disc space wedging below the Relatively common but mild Always present since overcorrection of
lowest instrumented the deformity is the goal
vertebra

residual tilt of the UIV allows for better response of the tho-
racic curve. An additional strategy to maintain coronal balance
is to instrument to a level that is just short of the proximal end
vertebra to provide more proximal thoracic levels to respond to
the correction achieved in the thoracolumbar spine (Fig. 83.8).
This should probably be done only for those curves in which
both the TL/L and thoracic curves are relatively small and
flexible.
Choosing the LIV when a parallel disc is present preopera-
tively or when the disc below the end vertebra is wedged only
slightly into the fractional lumbosacral curve is challenging and
usually involves deciding between L3 and L4. This situation
risks significant disc wedging below the LIV if the vertebra
proximal to the parallel disc is chosen. Several factors should
be considered when attempting to fuse to this level including
the flexibility of the TL/L curve but, more importantly, the
flexibility of the fractional lumbosacral curve especially of the
vertebra distal to the intended level of fusion/instrumentation.
For example, when L3 is chosen and the disc below L3 is paral-
lel, the flexibility of L4 on a right side-bending radiograph
should demonstrate that L4 becomes nearly horizontal or par-
allel to the intercrestal line. Residual tilt of L4 postoperatively,
especially when L3 is horizontalized with surgical treatment,
will result in a wedged disc at L3-4. In addition, significant pre-
operative rotation of the intended LIV risks significant postop-
erative distal disc wedging.14

SURGICAL TECHNIQUE
PATIENT POSITIONING
The patient is placed into the lateral decubitus position with
the convex side of the patient up to gain access to this side of
the spine. The arms are generally positioned at 90 at the shoul-
der and 60 to 70 at the elbows with padding to protect the
ulnar nerve. The hips and knees are gently flexed and padding
protects the peroneal nerve. Ideally, an operative table that can
be manually flexed to allow for greater access to the convex
side is used during exposure and implant placement. The table
is then flattened during the correction of the spine.

A B
Figure 83.8. Selective fusion of a thoracolumbar curve. (A) The
preoperative radiograph demonstrates a 62 lumbar curve with a com-
pensatory 45 thoracic curve. The patient has a large trunk shift to
the left. Clinically, the right shoulder prominence was not significant.
(B) The radiograph at 3 years following a selective lumbar fusion
from T10 to L3 with a single -inch Texas Scottish Rite Hospital rod
and anterior structural support. The lumbar curve was purposely
undercorrected to achieve coronal curve correction while leaving
some tilt of the upper end vertebra to prevent decompensation. The
CSVL passes through the C7 level, indicating overall excellent coronal
balance.
SURGICAL APPROACH
A thoracoabdominal transthoracic/retroperitoneal approach
is used by excising the rib just proximal to the intended UIV.
The incision is begun over the rib and extended anteriorly and
directed in a vertical direction to end just lateral to the umbili-
cus (Fig. 83.9). The muscles of the chest and flank are incised
and dissection is carried onto the rib (Fig. 83.10). Subperiosteal
dissection is performed around the rib, and the costochondral
junction is incised in a longitudinal direction. This usually leads
to identification of the retroperitoneal fat and easy entrance
into the retroperitoneal space (Fig. 83.11). The abdominal

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 856 Section VII Idiopathic Scoliosis
Figure 83.9. The patient is in the right lateral decubitus position
with the left side up and the head to the right and the feet to the left.
A curvilinear incision is made over the 10th rib for this planned
fusion from T11 to L3.
contents are then bluntly dissected off the undersurface of the
diaphragm and abdominal wall. The diaphragm is then incised
approximately 2 cm proximal to its insertion on the chest wall.
Marking sutures are placed to provide guidance when reap-
proximation is performed at the completion of the surgery
(Fig. 83.12). Incision of the diaphragm is carried down to the
spine, and the parietal pleura is incised, leaving the segmental
blood vessels intact (Fig. 83.13). Distally, the anterior edge of
the psoas is sharply dissected off the spine and retracted poste-
riorly. The segmental vessels are then ligated individually with
silk sutures to allow for placement of implants (Fig. 83.14).
With normotensive anesthesia, it is safe to sacrifice the segmen-
tal blood vessels without concern that spinal cord perfusion will
be compromised.28 Alternatively, the segmental blood vessels
can be temporarily ligated with observation of spinal cord mon-
itoring to determine whether a significant decline in amplitude
or increase in latency is seen.12
Thorough annulectomies and discectomies are performed
at each motion segment to be fused. The discectomies can be
Figure 83.10. Following incision of the muscle layers, subpe-
riosteal dissection is performed circumferentially around the rib.
Medially a self-retaining retractor is near the costochondral junction.
LWBK836_Ch83_p848-865.indd 856
Figure 83.11. Following incision of the costochondral junction as
indicated by the tip of the forceps, the retroperitoneal fat is identi-
fied, which allows one to gain entrance into the retroperitoneal space.
This is easily identified when removing the 10th rib and is more dif-
ficult when more proximal ribs are resected.
performed initially with an incision in the annulus by using a
box-shaped incision, and the annulus and nucleus are removed
with a rongeur (Fig. 83.15). An incision along the periosteum
allows one to then utilize a Cobb elevator to snap off the end
plate from the vertebral body, which is quite easy to do in the
very young patient. The entire cartilaginous end plate can be
removed to include the posterior and contralateral annulus
(Fig. 83.16). It is not necessary to remove the posterior longitu-
dinal ligament (PLL) in the typical AIS patient since the curve
will be very flexible following removal of the annulus and
nucleus at each level. Thrombotic agents are generally placed
in the disc space to maintain hemostasis.
Figure 83.12. The diaphragm has been incised beginning medi-
ally, and marking sutures have been placed to allow for reapproxima-
tion of the diaphragm at the completion of the procedure. The two
last marking sutures are identified just adjacent to the parietal pleura
proximally into the chest. The diaphragm is noted with an open arrow.
The lung is noted with a closed arrow. The psoas muscle (P) lies over
the lumbar spine.
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 Chapter 83 Anterior Lumbar and Thoracolumbar Correction and Fusion for AIS
Figure 83.13. The parietal pleura is then incised superficial to
the segmental vessels. A hemostat is placed under the parietal pleura
and electrocautery is utilized to incise this. The lung is identified
proximally.
SCREW PLACEMENT
For single-rod systems, the vertebral body screws are positioned
in the central aspect of the vertebra and are placed through a
staple to primarily resist plowing of the screw in the coronal
plane. A sharp awl, placed through the aperture of the staple,
is used to accurately place the starting hole for the screw. The
awlstaple complex is then advanced together, and either the
screw can then be advanced or a separate step of drilling
the vertebral body can be performed with penetration through
the far cortex. The length of the screw can then be accurately
measured by using a depth gage that penetrates both cortices.
Alternatively, a blunt-tipped caliper can be placed around the
vertebral body to determine the width of each vertebral body.
There are anatomic studies that provide accurate measure-
ments of the width of the vertebral body in AIS patients, and
these can be used as a guide when choosing screw lengths.22
Bicortical purchase of screws is necessary, especially for single-
rod constructs to allow or maximum deformity correction.
Figure 83.14. The segmental vessel is ligated following parietal
pleural incision. A right-angle hemostat is placed beneath the seg-
mental vessel, and silk sutures are used to tie off the segmental vessel.
LWBK836_Ch83_p848-865.indd 857
857
Figure 83.15. Following incision of the annulus fibrosis, in a
box-type fashion, a Lexcel rongeur is utilized to remove the annulus
and nucleus. The cartilaginous end plates on the proximal distal
aspect of the vertebra remain.
The trajectory of the screw should be parallel with the end
plates of each vertebral body, which should be visualized when
the screw is placed and requires removal of any hemostatic agents
placed following the discectomy. The proximal and distal end
screws should be directed toward the center of the construct to
allow for some screw plow during correction of the deformity. It
is often challenging to place the screws in this manner due to the
constraints of the ribs proximally and the soft tissue dissection or
the pelvis distally. The screws should be aligned in the axial plane
so they are in the midvertebral body, which requires an under-
standing of the rotational component of the deformity. The
screws at the apex should start more posteriorly and have a more
anteriorly directed trajectory due to the apical rotation com-
pared with the more proximal and distal screws that are directed
in more of a true axial plane to the body.
When a dual screwdual rod system is utilized, a staple that
has two holes is used to guide the placement of the screws
(Fig. 83.17). The posterior screw is placed initially and begins
Figure 83.16. A Cobb elevator is used to sharply dissect the
cartilaginous end plate off the bony end plate to allow complete
removal as one segment without creating significant osseous end
plate bleeding.
8/26/11 2:56:40 PM
 858 Section VII Idiopathic Scoliosis
Figure 83.17. The dual-rod system utilizes a staple with two
apertures. The central aspect is placed in the midvertebral body. A
clear visualization of the end plates is necessary to obtain accurate
trajectory of the screws.
just anterior to the posterior edge of the vertebral body and is
directed in-line with the posterior cortex (Fig. 83.18). The
anterior screw is next placed and is directed slightly posteriorly
so that there is triangulation between the anterior and the pos-
terior screw, which best resists pullout (Fig. 83.19).
DEFORMITY CORRECTION
Once screws are placed, the heights of the screws should be
similar and adjacent screws should be aligned to ensure that
the rod(s) can be easily placed without significant lateral trans-
lation of the screws during rod seating. Once confirmation of
good screw position is achieved, there are two basic sequences
to place the implants: first, the rod(s) can be placed initially
followed by the anterior structural support so that the spine
correction can be maximally achieved without obstruction by
Figure 83.18. The posterior screw is placed first and is directed
parallel with the posterior cortex of the vertebral body. The axial
plane rotation of the vertebrae should be taken into account during
screw placement. The authors prefer to begin at the apex of the curve
to fully identify the rotational deformity to allow for safe screw
placement.
LWBK836_Ch83_p848-865.indd 858
Figure 83.19. The anterior screw is placed in an anterior to slight
posterior trajectory so that triangulation of the posterior and anterior
screws is achieved. The posterior and anterior screws are visualized at
the apex of this curve.
interbody grafts; the second, is to place the interbody grafts
before placing the rods and achieving spine correction. The
authors prefer to place the rod(s) initially (Fig. 83.20) and per-
form a correction maneuver to improve the coronal, sagittal,
and axial plane of the spine (Fig. 83.21). This is followed by
placement of the anterior structural support (Fig. 83.22) and
then compression to maintain lordosis while correcting the
coronal plane deformity. The anterior rod can be placed fol-
lowing the initial round of traction by using the posterior rod
(Fig. 83.23). It is important to place the structural support in
the anterior portion of the disc space (to maintain or improve
lordosis) and on the concavity of the curve (to improve the
coronal plane deformity). There are no studies analyzing which
levels require anterior structural support; however, it is gener-
ally felt that, at least, all segments below T12 require anterior
structural support to prevent the flexion instability seen in the
lumbar spine. Anecdotally, the authors have seen rod fracture
and presumed pseudarthrosis at the T11-12 disc level in a
T11-L3 anterior fusion and instrumentation in which anterior
structural support was used at all levels except the T11-12 space.
The pseudarthrosis most likely occurred because of the excess
Figure 83.20. Following placement of all screws and staples, the
posterior rod is placed after contouring lumbar lordosis into the rod.
8/26/11 2:56:42 PM
 Chapter 83 Anterior Lumbar and Thoracolumbar Correction and Fusion for AIS
Figure 83.21. A 90 rod rotation maneuver is then performed to
obtain coronal plane correction and to improve or obtain lordosis.
Note the anterior disc space wedging, which confirms that lordosis
has been achieved.
motion at the adjacent level to the relatively stiff segment from
T12-L3.
The correction maneuvers utilized include rod rotation,
which improves the coronal plane deformity while restoring or
maintaining lumbar lordosis since the rod is contoured with
preplanned lumbar lordosis. The thoracolumbar junction
between T10 and L1 is relatively straight with a gradual lordosis
beginning at the T12-L1 segment with maximum lordosis seen
at the L2-3 level. By using a single-rod system, the rod rotation
is followed by placement of the anterior structural support,
which is then followed by compression across each segment to
gain the desired coronal plane correction while also stabilizing
the anterior structural support. Sequential rounds of compres-
sion can dial in the desired coronal plane correction. It is
important to refrain from overcorrection since this leads to sig-
nificant disc wedging distal to the construct and may lead to
truncal imbalance when a thoracic curve is present. Residual
coronal plane tilt of the UIV will limit this problem.
Correction by using a two-rod system can be performed in a
variety of ways. The authors preferred technique is to first place
Figure 83.22. Anterior structural support can then be placed at
the chosen levels. The authors prefer to place the anterior structural
support over those segments distal to T12 that require lordosis.
This is especially important since these levels are normally lordotic.
They improve the stiffness of the construct and maintain lordosis over
time. The anterior support should be placed anteriorly and onto the
concave side to assist in coronal plane correction as well.
LWBK836_Ch83_p848-865.indd 859
859
Figure 83.23. Following placement of the second rod, the final
construct is visualized with nice coronal, sagittal, and axial plane
correction.
a rod in the posterior screws followed by a 90 rod rotation
maneuver to correct both the coronal and the sagittal planes.
Anterior structural support is then added at the intended levels
and compression is performed. The anterior rod is then placed
to maintain the correction and increase the overall stiffness of
the construct. Alternatively, screwdrivers can be placed in the
anterior screws and an anteriorly directed force is applied to
correct the spine deformity while a contoured rod is placed in
the posterior screws to maintain the correction. This has the
advantage of having the posterior rod precontoured with
lumbar lordosis in the mid lumbar spine while maintaining a
neutral sagittal plane at the thoracolumbar junction. Often the
smaller rod in these two-rod systems will bend out, especially
for stiffer curves, when pure rod rotation is utilized. Once the
posterior rod is in place, the steps noted above are utilized to
improve correction to the desired degree.
The goals of surgical treatment of scoliosis are deformity
correction and arthrodesis. To effectively obtain solid fusion
across the anterior column of the lumbar spine, a complete dis-
cectomy and preparation of the end plate is necessary. The
large space created by a well-executed discectomy is then filled
with the rib autograft resected during the thoracotomy
approach. This is usually not enough to completely fill the disc
space and should be supplemented with allograft or demineral-
ized bone products.
Closure begins with reapproximation of the parietal pleura
in the thoracic spine, which then extends to the closure of the
diaphragm with interrupted Nurolon sutures (Fig. 83.24). The
costochondral junction is then reapproximated medially. A
large chest tube is placed and secured to the skin with nylon
suture. The ribs can then be approximated by using a large #1
absorbable suture, and the periosteum of the resected rib is
sutured. The abdominal muscles should be closed in layers,
beginning with the deep rectus sheath, followed by the external
oblique abdominal muscles and the latissimus dorsi.
The postoperative plan of care should include the chest tube
placed to wall suction until the drainage appears serous and is
less than 80 cm3 per 12 hours. Usually, the tube is able to be
removed on the second or third postoperative day when there
has been adequate pleural closure. The patients activities and
diet are advanced, and the patient does not require postopera-
tive external immobilization. Strenuous activities are generally
8/26/11 2:56:45 PM
 860 Section VII Idiopathic Scoliosis
Figure 83.24. The diaphragm closure is performed with
interrupted Nurolon sutures. The marking sutures are utilized to
obtain reapproximation of the diaphragm in the normal anatomical
state.
limited until solid anterior arthrodesis is visualized, which usu-
ally occurs between 4 and 8 months postoperatively.
RESULTS OF ANTERIOR
INSTRUMENTATION AND FUSION
FOR TL/L CURVES
DEFORMITY CORRECTION
In general, the anterior approach to instrument and fuse tho-
racolumbar and lumbar curves achieves outstanding coronal
and axial plane correction. The challenge has been the diffi-
culty in restoring or maintaining lumbar lordosis and the high
incidence of pseudarthrosis. Coronal plane correction is due to
the ability to improve the flexibility of the spine by removal of
the disc material, and the powerful implants allow one to obtain
correction while maintaining that correction over time. The
coronal plane correction has ranged from 50% to 80%, depend-
ing on many factors, including the flexibility of the spine, the
type of implant utilized, and the intended amount of correc-
tion desired.24 Anterior surgery significantly improves axial
plane correction by first, improving flexibility secondary to
complete excision of the disc and the direct derotation maneu-
ver during rod rotation. Improvements in functional outcomes
for anterior surgery are generally seen.
FUSION LEVELS
Improved flexibility of the spine due to disc excision and
improved construct stiffness allows for fusion of fewer levels. It
is uncertain whether this advantage is actually realized, how-
ever, because a significant number of patients treated with pur-
posefully short fusion develop wedging of the disc immediately
caudal to the LIV as if the disc has been asymmetrically pulled
open by the compressive force applied to the last screw(s) (Fig.
83.25). This phenomenon occurs not only in the single-rod
construct but also in the dual-rod construct. The long-term out-
come of such iatrogenic disc wedging is unknown and may not
be significant.4 Recently, a 17-year follow-up study on 31 patients
demonstrated early radiographic degenerative changes in the
LWBK836_Ch83_p848-865.indd 860
Figure 83.25. Following an anterior instrumentation and fusion
from T11 to L3, the 2-year radiograph demonstrates disc space wedg-
ing at the L3-4 level. Clinically, the patient is doing very well without
symptoms; however, the long-term health of the spine is uncertain.
caudal adjacent levels in most patients; however, there was no
correlation with SRS score or Oswestry data, and patients were
able to pursue careers and families. Although these results
really are promising, longer follow-up is necessary to determine
whether the disc will suffer accelerated degeneration as a result
of this obliquity.
SAGITTAL CORRECTION AND MAINTENANCE
Sagittal plane correction to maintain lumbar lordosis has also
significantly improved with the use of anterior structural sup-
port. Since the correction strategies for correcting scoliosis are
rotation of the rod followed by compression across the disc
spaces, this provides a kyphogenic force that may result in the
loss of lumbar lordosis. In addition, loss of lumbar lordosis over
time was seen. Ouellet and Johnston14 demonstrated excellent
initial correction from 3 of lumbar kyphosis to 1 of lordosis
immediately following surgery; however, settling in the sagittal
plane occurred over time, resulting in a final kyphosis of 7.
When anterior structural support was added to these single
6.35-mm rod constructs, the lordosis was maintained at 6.3 at
2-year follow-up.23 Others have demonstrated similar results
when anterior structural support is used in single- or dual-rod
constructs for these curves.
COMPARISON WITH THE POSTERIOR APPROACH
Shufflebarger et al20 presented the results of posterior instru-
mentation and spinal fusion in adolescent idiopathic lumbar
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 Chapter 83 Anterior Lumbar and Thoracolumbar Correction and Fusion for AIS
TABLE 83.3 Comparison of the Anterior and Posterior Approach
Anterior Approach
Indications Thoracolumbar/lumbar curves
Proximal fusion Proximal end vertebra
level
Distal fusion level Distal end vertebra
Correction strategy Rod rotation and compression
Surgical time 3 to 4 hours average
Disadvantages 1. Need for general surgeon for
approach (?)
2. Anterior incision visible to patient
3. Need for chest tube
4. Sympathectomy effect of approach
with leg temperature differences
5. Need for revision is more difficult
and thoracolumbar scoliosis in 2004 (Table 83.3). The authors
reported coronal correction rates of 80% and normalization of
lumbar lordosis from a wide range of 20 to 70 to a normal
range of 34 to 47. The authors performed the fusion from the
proximal end vertebrae to the distal end vertebrae (Cobb lev-
els), which was possible due to the wide posterior releases per-
formed primarily on the convex side of the curve. The release
included a complete facetectomy with excision of the ligamen-
tum flavum to provide a gap for closure on the convex side
during the compression corrective maneuver. There were no
pseudarthroses, reoperations, infections, or problems with
screw placement, and excellent maintenance of correction at a
mean of 37-month follow-up was seen. The posterior approach
obviates the need for a general surgeon if the spine deformity
surgeon is not familiar with the approach and the use of a chest
tube. These all may lead to shorter lengths of surgery and hos-
pital stay.5 From patients perspective, the location of the inci-
sion plays an important role, and studies have demonstrated
that patients prefer a posterior incision, which is well hidden,
compared with an anterior incision. One of the potential disad-
vantages and reported complications associated with posterior
correction and fusion is proximal junctional kyphosis, which is
higher than reported for anterior surgery.5 A direct compari-
son of the anterior and posterior approach for these curves
demonstrates similar coronal and sagittal plane correction with
shorter hospital stay for the posterior group but a higher inci-
dence of proximal junctional kyphosis.5
COMPLICATIONS
In addition to the medical complications that may occur imme-
diately postoperatively, such as atelectasis, pneumothorax with
pulling of the chest tube, and ileus, the most common orthope-
dic complications are pseudarthrosis with implant failure and
symptoms, loss of anterior fixation, loss of lumbar lordosis with
sagittal plane imbalance, or adding on to the curve above the
construct or revealing the thoracic curve deformity when per-
forming a selective fusion. In comparison with posterior instru-
mentation and fusion, the likelihood of having infection or
implant prominence issues is very low.
LWBK836_Ch83_p848-865.indd 861
861
Posterior Approach
Same
Same
Usually distal end vertebra but not
when significantly oblique and
translated
Convex compression
1.5 to 2.5 hours
Less rotational correction (?)
Unable to reproducibly stop at the
distal end vertebra
Disturbance of the paraspinal muscles
increased back pain(?)
NONUNION
Pseudarthrosis continues to plague anterior surgery in both
the thoracic and the thoracolumbar spines. This is most likely
related to deficient disc and end plate removal and the use of
single rods without anterior structural support.15,16 The initial
reports of single-rod constructs with morselized autologous rib
graft support demonstrated a 40% incidence of pseudarthro-
sis. Ouellet and Johnston13 later reviewed a second series of
patients treated with a single rod using rib strut graft to
improve the flexion stiffness of the construct and demon-
strated improvement in radiographic pseudarthrosis rate to
30.0% with 10% of patients experiencing implant failure
requiring operation. At TSRH, we have recently reviewed the
experience of a single 6.4-mmdiameter rod with anterior
structural support demonstrating a further decline in the inci-
dence of radiographic pseudarthrosis to 8.3%, which were all
asymptomatic and did not require revision surgery. Other
single-rod case series demonstrate pseudarthrosis rates between
2.4% and 23.5%.
Further stiffness of the entire construct is seen when a sec-
ond rod is placed, and this was popularized by Kaneda and col-
leagues.9 They initially described outstanding coronal plane
correction averaging 83% without evidence of pseudarthrosis.
Lenke and Bridwell11 reviewed their experience using titanium
mesh cages for TL/L curves in 130 patients and demonstrated
a pseudarthrosis rate of 3% and recommended anterior struc-
tural support for those patients using either single or dual rods.
A direct comparison of single and dual rods for the treatment
of thoracic and thoracolumbar scoliosis demonstrates a
decreased incidence of pseudarthrosis for the dual rod con-
structs (0% vs. 5.5%).
It should be remembered that arthrodesis relies not only on
the stiffness of the construct but, as importantly, the degree of
disc removal that should be complete to provide ample room
for fusion mass. It is critical to remove the disc completely back
to the PLL and all the way to the concave aspect of the spine to
thin out the annulus. Careful surgical technique to achieve disc
excision and place bone graft and the utilization of stiff implants
will maximize the likelihood of achieving a successful arthrod-
esis (Table 83.4).
8/26/11 2:56:47 PM
 862 Section VII Idiopathic Scoliosis

stiffer and do not respond as readily to selective thoracolumbar

Methods to Limit the
TABLE 83.4 fusions and the thoracic curves are more prominent visually
Incidence of Nonunion (Fig. 83.26). The risk factors for developing a decompensation
situation have been reviewed by Sanders et al15 who defined a
Anterior Posterior
good result as a thoracic curve measuring 40 or less, and coro-
Preparation of Complete disc excision Complete and wide nal and sagittal balance were maintained at final follow-up.
spine (may only thin the facetectomies Those patients who had a satisfactory result were more likely to
contralateral have a smaller preoperative thoracic curve (40 vs. 49), a TL/L
annulus) to thoracic Cobb ratio of more than 1.25, and a thoracic curve
Bone graft Autologous rib from Autologous iliac
that corrected to less than 20 on a bend radiograph and those
the approach crest or allograft
Implant type Single 6.35-mm rod or Dual rods with
patients who had a closed triradiate cartilage. Others have dem-
dual-rod system segmental onstrated increased thoracic prominence and adjacent-level
pedicle screw disc angulation with continued follow-up when a selective tho-
fixation racolumbar or lumbar fusion has been performed. Wang et al26
Supplemental Anterior structural Use of cross-links analyzed 35 Lenke 5 curves treated with a selective anterior
implant support (controversial) fusion, resulting in improvement of the 46 lumbar curve to
Postoperative Limit full activities until Full activities at 3 10 postoperatively, with a good response of the uninstru-
regimen solid arthrodesis to 6 months mented thoracic curve from 30 to 17. Most of these patients
seen on lateral
had relatively small TL/L and thoracic curves and most likely
radiographs
met the criteria outlined by Sanders et al15. The authors did
demonstrate worsening of disc angulation above and below the
instrumented segments, which is commonly seen with anterior
fusion of TL/L curves; however, the long-term outcome of this
POSTOPERATIVE KYPHOSIS disc angulation is unknown. Satake et al16 attempted to predict
postoperative disc wedging following anterior fusion of these
The development of postoperative kyphosis following single- curves demonstrating a higher likelihood when the preopera-
rod anterior instrumentation was common with the Zielke sin- tive subjacent disc is parallel or when the LIV is not included in
gle-rod systems and was seen with even larger single-rod systems the instrumented levels. Although disc wedging is something
with morselized rib graft. The addition of rib strut grafts was that is common following anterior instrumentation and fusion,
intended to improve and maintain the sagittal plane; however, most feel that disc wedging less than 10 to 15 provides a bet-
the initial gain in lumbar lordosis over the instrumented seg- ter outcome than extending fusion down to the next level,
ments was lost with follow-up. However, the addition of a solid which is usually L4. Further study and long-term outcomes are
anterior structural support in the form of a mesh cage stiffens necessary to fully define the natural history of disc wedging is
the construct in the sagittal plane and prevents settling of the necessary.
spine into kyphosis with time.23,24 Adequate disc excision with
rod rotation to increase the anterior space between vertebral
UNUSUAL COMPLICATIONS
bodies further improves the likelihood of achieving lumbar lor-
dosis. Watkins et al27 demonstrated improved maintenance of Rare complications, including hydronephrosis from retroperi-
lordosis when structural grafts were placed in the disc spaces toneal scarring, splenic injuries, humeral artery occlusion, and
below T12 compared with those patients who had only morsel- deep vein thrombosis, are seen with the anterior approach to
ized rib grafts. Maintenance of lumbar lordosis has also been the spine, more common in the adult population. Care in plac-
seen with dual-rod systems, which provide increased stiffness ing implants is important to stay free of the spinal canal while
compared with a single rod without anterior structural support. not encroaching on intraabdominal organs. Huitema et al6
The double-rod systems of Kaneda and Halm-Zielke have been recently reviewed anterior screws placed for thoracolumbar
well studied, demonstrating excellent maintenance of correc- scoliosis demonstrating 23% of the screws were malpositioned
tion in the sagittal plane over time with a low pseudarthrosis with screws in the spinal canal without neurologic deficit and
rate.1 screws adjacent to the aorta without sequelae.

DECOMPENSATION
Selective fusion of TL/L curves when a compensatory thoracic
curve is present is challenging. Careful evaluation of patients
with Lenke 5 curve patterns is critical to avoid decompensation
with increased, or apparent increased, prominence of the com-
pensatory thoracic curve. Shulte et al17 demonstrated that a
selective fusion of the TL/L curve performed anteriorly results
in an increase of rotation of the uninstrumented thoracic curve
by 30% by using radiographic criteria and 28% by using scoli-
ometer readings. Selective fusion of the these curves in the face
of a compensatory thoracic curve poses a greater challenge to
the surgeon than the more common selective thoracic fusion
for Lenke 1B or 1C curves since the thoracic curves are generally
CONCLUSION
The anterior approach in the treatment of thoracolumbar or
lumbar curves has been the traditional method achieving over-
all outstanding three-plane correction with excellent patient
satisfaction. Selection of fusion levels is usually from proximal
end vertebra to distal end vertebra, which has previously been
thought to save motion segments when compared with the
posterior approach, although the greater use of pedicle screws
and posterior releases may minimize these approach differ-
ences. Careful radiographic and clinical evaluation of the rela-
tive size and flexibility of the thoracic spine is necessary when
deciding when a selective fusion of the TL/L spine is possible.

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 Chapter 83 Anterior Lumbar and Thoracolumbar Correction and Fusion for AIS 863

B C

Figure 83.26. (A) The preoperative radiographs of a 12 8-year-old girl, Risser 0 with a 35 curve that
bend to 13 and a thoracolumbar curve of 48 that bends to 9. The lateral radiograph demonstrates a
normal sagittal profile. (B) A single 6.35-mm diameter rod was used to perform an anterior fusion and
instrumentation from T10 to L2 by using anterior mesh cages at below T12. (C) Six months from surgery,
the thoracic curve is progressed to 44. (continued)

A greater understanding of the biomechanical properties of
implants has resulted in greater stiffness in three planes to
decrease the likelihood of developing kyphosis over the instru-
mented levels and the occurrence of pseudarthrosis. Contribut-
ing factors to the development of a pseudarthrosis are the use
of single-rod constructs, which had inferior stiffness in flexion
and perhaps inadequate discectomy. More aggressive and
complete discectomies and the use of anterior structural sup-
port and/or dual-rod systems have decreased the incidence of
these complications and lead to good results.
The future treatment of TL/L curves will most likely utilize
the anterior approach less often since posterior techniques are
faster, utilize an incision hidden to the patient, provide similar
correction in general, and may have shorter hospital stays.

LWBK836_Ch83_p848-865.indd 863 8/26/11 2:56:47 PM

 864 Section VII Idiopathic Scoliosis
D F
E surgery.
However, greater study to determine the correct LIV is neces-
sary before considering this approach for all curves since the
anterior approach allows one to stop at the distal end vertebra
in all cases. The use of minimally invasive techniques for both
the anterior and the posterior approaches may be more com-
monly used in the future to achieve the same radiographic
results with shorter hospital stays, more rapid return to normal
activities, and improved functional outcomes.
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Figure 83.26. (Continued) (D) At 1 year, the
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