Criteria for Ending the Distal Fusion at the L3 Vertebra vs. L4 in Surgical Treatment of Adolescent Idiopathic Scoliosis Patients with Lenke Type 3C, 5C, and 6C Curves: Results After Ten Years of Follow-up.

Introduction The selection of the most distal caudal vertebra in spinal fusion surgeries in adolescent idiopathic scoliosis patients with structural lumbar curvatures is still a matter of debate. The aim of this study was to determine the preoperative radiological criteria on the traction X-rays under general anesthesia (TrUGA) for selection between the L3 and L4 vertebrae and to assess the efficacy of these criteria via the long-term results of patients with Lenke Type 3C, 5C, and 6C curves. Methods Radiological data of 93 patients (84 females, 9 males) who met the inclusion criteria were retrospectively evaluated. The relationship between the L3 vertebra and the central sacral vertebral line, the portion of the L3 vertebra in the stable zone of Harrington, the parallelism of the L3 with the sacrum, and the tilt and rotation of the L3 on TrUGA radiographs were evaluated for the selection of the lowest instrumented vertebrae (LIV). Clinical results were analyzed using the Scoliosis Research Society-22 (SRS-22) questionnaire. Results The mean follow-up period of the study group was 149.3 months. According to the Lenke classification, 29 patients had Type 3C, 33 had Type 5C, and 31 had Type 6C curves. The preoperative analysis was based on standing anteroposterior (AP), supine traction, and bending X-rays, and the L3 vertebra was selected as the LIV in 37 patients (40%). These X-rays suggested L4 as the LIV in 56 patients (60%); however, based on our study criteria, the L3 vertebra was selected. No significant loss of correction was observed nor additional surgery due to decompensation was required in the follow-up period. Conclusion  The use of TrUGA radiographs with the identified criteria is an efficient alternative method in the selection of the LIV in patients with Lenke Type 3C, 5C, and 6C curves.