|Year : 2022 | Volume
| Issue : 4 | Page : 390-400
Surgical treatment of severe adolescent idiopathic scoliosis through one-stage posterior-only approach: A systematic review and meta-analysis
Matteo Traversari, Alberto Ruffilli, Francesca Barile, Giovanni Viroli, Marco Manzetti, Fabio Vita, Cesare Faldini
IRCCS Istituto Ortopedico Rizzoli, 1st Orthopaedics and Traumatology Clinic, University of Bologna, Bologna, Italy
|Date of Submission||21-Jun-2022|
|Date of Acceptance||19-Oct-2022|
|Date of Web Publication||7-Dec-2022|
IRCCS Istituto Ortopedico Rizzoli, 1st Orthopaedics and Traumatology Clinic, University of Bologna, Bologna
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The aim of this meta-analysis was to analyze the results of one-stage all-posterior spinal fusion for severe adolescent idiopathic scoliosis (AIS). A systematic search of articles about one-stage posterior spinal fusion for severe AIS was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data about population, pre-and postoperative radiographical data, surgical procedure details, and complications were extracted. Meta-analyses were performed when possible. Fourteen studies (640 patients) were included. The mean Cobb angle of the major curve varied from 80.0 ± 7.3 to 110.8 ± 12.1. The meta analysis showed a comprehensive coronal correction rate of the major curve of 58.6%, a comprehensive operative time of 274.5 min, and a comprehensive estimated intraoperative blood loss of 866.5 mL (95% confidence interval: 659.3–1073.6, I2 ≈ 0%). A total of 48 complications (5.4%) were reported. Overall, the meta-analysis showed a major complication rate of 4%. In seven cases, revision surgery was needed. Posterior-only approach is effective enough to correct severe curves and can spare the patient possible adverse events due to anterior approach. However, when choosing this approach for severe AIS, screw density needs to be high and posterior column osteotomies may need to be planned to mobilize the spine and maximize correction.
Keywords: Adolescent idiopathic scoliosis, pedicle screw, Ponte osteotomy, posterior spinal fusion, severe scoliosis
|How to cite this article:|
Traversari M, Ruffilli A, Barile F, Viroli G, Manzetti M, Vita F, Faldini C. Surgical treatment of severe adolescent idiopathic scoliosis through one-stage posterior-only approach: A systematic review and meta-analysis. J Craniovert Jun Spine 2022;13:390-400
|How to cite this URL:|
Traversari M, Ruffilli A, Barile F, Viroli G, Manzetti M, Vita F, Faldini C. Surgical treatment of severe adolescent idiopathic scoliosis through one-stage posterior-only approach: A systematic review and meta-analysis. J Craniovert Jun Spine [serial online] 2022 [cited 2023 Jan 27];13:390-400. Available from: https://www.jcvjs.com/text.asp?2022/13/4/390/362883
| Introduction|| |
Severe adolescent idiopathic scoliosis (AIS) is a complex, stiff, three-dimensional spinal deformity whose treatment remains controversial. In fact, the management of scoliotic patients with severe curves may lead to significant complications related to extended exposure and blood loss, cord injury, and pulmonary compromise. The goal of operative treatment is to obtain an acceptable correction of the deformity, to improve the patient's quality of life and cardiopulmonary status, and to prevent painful degeneration and curve progression.
Historically, severe AIS has often been treated with combined anterior release, followed by posterior correction and instrumentation,,,,,, resulting in good three-dimensional curve correction, but with high risk of pulmonary complications., Some authors have also used preoperative traction or internal distraction as a part of a staged correction, in order to achieve better correction and shorter fusion.,,,,,, However, preoperative traction implies an increased risk of perioperative complications such as pin loosening, pin tract infection, and cranial nerve palsies.,,,,,, Combined anterior and posterior or all-posterior vertebral column resection has also been used to treat severe and rigid scoliosis, but this demanding procedure is affected by a considerably high rate of perioperative complications.,, Then, the introduction of all pedicle screws constructs allowed the all-posterior procedures to gradually gain popularity due to the high reliability of three-columnar fixation systems. In fact, powerful corrective forces were exerted and spine mobilization through anterior release was not necessarily needed.
The aim of this meta-analysis was to systematically review the literature and analyze the results of one-stage all-posterior fusion for severe AIS.
| Methods|| |
A systematic review of the literature regarding surgical treatment of severe AIS was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA guidelines).
Only peer-reviewed publications were considered for inclusion. Studies were included if they involved patients affected by severe AIS who underwent surgical correction through one-stage posterior-only approach and if they described perioperative outcomes including correction rate and complications. Only articles in English who met the population, intervention, comparison, and outcomes criteria on systematic reviews were included.
Randomized controlled trials, prospective and retrospective cohort studies, and case series (CS) were considered for inclusion.
Studies eligible for this systematic review have been identified through an electronic systematic search of PubMed and Cochrane Central Registry of Controlled Trials until May, 1 2022.
The search strings utilized were:
- PubMed: “Severe scoliosis AND (surgery OR treatment OR surgical)”; “(Spine deformity OR Spinal deformity) AND coronal AND (surgery OR treatment OR surgical)”; “Severe scoliosis AND fusion;” “Scoliosis AND (VCR OR Vertebral column resection)”
- Cochrane: “Severe scoliosis AND surgery.”
Articles considered relevant by electronic search were retrieved in full-text, and a hand search of their bibliography was performed to find further related articles. Reviews and meta-analyses were also analyzed to identify potentially missed eligible papers. Duplicates were removed. The study selection process was carried out in accordance with the PRISMA flowchart [Figure 1].
|Figure 1: PRISMA flow diagram and the selection of studies. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses|
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Included studies were categorized by type, according with the Oxford Centre for Evidence-Based Medicine. Quality of the included studies was evaluated using the National Institutes of Health tool [Figure 2].
|Figure 2: Quality assessment of the included study in meta-analysis according to the National Institutes of Health tool|
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Data collection process
All the included studies were analyzed, and the data related to the following outcomes of interest were extracted and summarized [Table 1]: study design, number of patients (total and severe AIS), mean age, cutoff parameters of severe AIS, curve types according to Lenke classification, mean follow-up, gender, surgical technique, mean pre and postoperative Cobb angle, correction rate, flexibility of the curves, surgical time, estimated intraoperative blood loss (EBL), length of stay, average number of fused levels, and perioperative complications.
|Table 1: Characteristics of patients, surgical treatments, and perioperative complications of the studies analyzed in this review|
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When studies involved both patients with severe and nonsevere AIS, data about severe scoliosis patients group were pooled: if this was not possible, the study was excluded.
Heterogeneity between studies was assessed using the inconsistency statistic (I2 > 75% was considered as highly heterogeneity). Publication bias was assessed with Egger's test and represented with forest plots. Correction rate, EBL, and surgical time were used as measure of effect size. A random-effects model was applied. All statistical analyses were conducted with Jamovi version 2.2 (The Jamovi Project, Sydney, Australia) software.
| Results|| |
Baseline studies' characteristics and quality assessment
A total of 1337 studies were found through electronic search; after screening, 14 studies (1 prospective cohort study, 3 retrospective comparative studies,,, 1 retrospective cohort study, 6 retrospective studies,,,,,, 1 prospective CS, and 2 retrospective CS,) were included.,,,,,,,,,,, The quality of the papers was good in 13 cases,,,,,,,,,, and fair in 1 case.
The included studies chose different criteria for the definition of severe scoliosis: Seven authors used a major curve Cobb >90° as a cutoff,,,,,, (1 of them used major curve Cobb >90° and flexibility index <30%), 4 used a major curve Cobb >80°,,, (2 of them, used major curve Cobb >80° and flexibility index <25%), 3 used a major curve Cobb >70°,, [Table 1].
Results and complications
A total of 640 patients affected by severe AIS and treated with one-stage posterior-only approach were included. The mean age at surgery ranged from 14.4 to 19 years and the mean follow-up ranged from 12 months to 80.4 months.
The included studies are heterogeneous in Lenke distribution of the curves, internal fixation devices, and use of Schwab >1 osteotomies [Table 1]. Lenke type was reported on 549 patients: ,,,,,,,,,,,, 157 Lenke 1 (28.6%), 252 Lenke 2 (45.9%), 50 Lenke 3 (9.1%), 59 Lenke 4 (10.7%), 1 Lenke 5 (0.2%), and 30 Lenke 6 (5.4%). As for constructs, 11 authors used all pedicle screws constructs,,,,,,,,,,,, while 3 preferred hybrid constructs.,, As for osteotomies, most of the authors only performed partial facetectomies, while Mirzashahi et al. and Dobbs et al., chose periapical Ponte osteotomies and Di Silvestre et al. performed pedicle subtraction osteotomies at the apex of scoliosis in curves with Cobb angle of more than 100°.
The mean Cobb angle of the major curve varied from 80.0 ± 7.3 to 110.8° ± 12.1, with a flexibility index range between 21.4% ± 3.8% and 38.6% ± 11.8%. The meta-analysis showed a comprehensive coronal correction rate of the major curve of 58.6% (95% confidence interval [CI]: 53.0–64.1, I2 ≈ 0%, [Figure 3] and [Figure 4]).
|Figure 3: Funnel plot of observed outcomes for publication bias of the included study in meta-analysis|
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|Figure 4: Forest plot of overall meta-analysis of the included studies with data about coronal correction rate of main scoliotic curve after one stage PSF. PSF: Posterior-only spinal fusion|
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A total of 48 complications (5.4%) were reported; complication rate varied widely, from 0% ,,,,, to 14.8%. Overall, the meta-analysis showed a major complication rate of 4% [95% CI: 3–6, I2 ≈ 0%, [Figure 5]]. In seven cases, revision surgery was needed: one hook replacement due to hook dislodgement, one partial implant removal due to screw pull-out, two revision procedures due to pseudoarthrosis causing loss of correction, one implant removal for late operative site pain, one hook removal due to hook dislodgement causing implant prominence, and one implant removal for late deep infection.
|Figure 5: Forest plot of overall meta-analysis of the included studies with data about perioperative complications after one stage PSF. PSF: Posterior-only spinal fusion|
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The meta-analysis showed a comprehensive operative time of 274.5 min (95% CI: 225.1–324.0, I2 = 74.4%) [Figure 6], and a comprehensive EBL of 866.5 mL (95% CI: 659.3–1073.6, I2 ≈ 0%) [Figure 7].
|Figure 6: Forest plot of overall meta-analysis of the included studies with data about EBL after one stage PSF. PSF: Posterior-only spinal fusion, EBL: Estimated intraoperative blood loss|
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|Figure 7: Forest plot of overall meta-analysis of the included studies with data about surgical time of one stage PSF. PSF: Posterior-only spinal fusion|
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Length of hospital stay was reported in a minority of the studies, ranging from a mean of 3.1 to 10 days.
| Discussion|| |
The aim of the present study was to evaluate the efficacy and safety of one-stage posterior-only spinal fusion (PSF) in the treatment of severe AIS. This procedure resulted to be as effective as more invasive techniques (such as anterior/posterior combined techniques or preoperative Halo traction), with a lower complications rate [Figure 8].
|Figure 8: Female, 18 years old present with severe adolescent idiopathic scoliosis with pre-operative Cobb angle of main curve of 94°, underwent one-stage PSF with multiple periapical asymmetrical Ponte osteotomies. Postoperative Cobb angle was 38° with a coronal correction rate of 59.6%. PSF: Posterior-only spinal fusion|
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As for efficacy, the meta-analysis showed a comprehensive coronal correction rate of the major curve of 58.6%. The highest correction rate was reported by Kuklo et al. in 2005, who described the first series of severe AIS patients (mean preoperative major curve Cobb angle 100.2 ± 10.8°, mean flexibility index of 29%) treated with one-stage PSF obtaining a coronal correction rate of 68%. After that, several other studies reported very good results (around 55%–60% of major curve correction rate) with one-stage PSF.,,,,,,,,,, This is in line with the current literature. In fact, most of the studies on the surgical treatment of severe AIS show contained correction rate values, often lower than 60% regardless of the technique used:,,,,,,,, in these cases, the aim was not to maximize correction but to obtain an acceptable balance of the spine and save levels of fusion. When comparing one-stage PSF to combined anterior/posterior techniques, studies conducted by Dobbs et al. and Shi et al. both demonstrated no statistically significant difference in terms of curve correction between the two techniques. Finally, Burton et al. also showed that curves between 70° and 90° curves do not need anterior release to achieve good results.
However, it is important to highlight that, when choosing a posterior-only approach for severe AIS, a suitable implant density needs to be selected: when thoracic Cobb angle is >70°–80° and an anterior stage is not planned, screw density needs to be at least 60% in order to obtain an acceptable correction and to avoid screws pull-out and pedicles breakage.,,
Another major issue of severe AIS treatment is safety. Perioperative complications are reported to be much higher than in nonsevere AIS; the most frequent are respiratory complications, massive blood loss, neurological deficits, implant-related failures, and wound infections., In one-stage PSF, our meta-analysis showed a major complication rate of 4%. This is inferior to combined techniques, such as anterior/posterior approaches and preoperative halo traction that are prone to the same complications as one-stage PSF, but also present some intrinsic issues. The main problem of the combined anterior/posterior procedure is the risk of pulmonary complications;, moreover, even if intraoperative complications do not occur, the anterior release has always a negative impact on pulmonary function when compared to posterior only approach, determining a significant decrease of forced expiratory volume and forced expiratory volume in 1 s values at 5 years postoperatively. As for preoperative traction, it implies an increased risk of perioperative complications such as pin loosening, pin tract infection, and cranial nerve palsies.
It is important to notice that performing osteotomies to increase spine flexibility and maximize correction may affect complication rate. In our results, two studies described the use of multilevel Ponte osteotomies,, with a complication rate of 1% and 10% and a coronal correction rate similar or higher than cohorts treated with single-stage PSF only. The use of pedicle subtraction osteotomies was described by Di Silvestre et al., obtaining acceptable results in terms of deformity correction at the price of the highest reported perioperative complication rate (14.8%). This study presented several limitations. First of all, there was no agreement in the definition of severe scoliosis: this represented a major bias in comparing the results of the included studies. Then, only a few studies are comparative, while the vast majority are CS where only one technique is used.
| Conclusion|| |
Our results suggest that posterior-only approach is effective enough to correct both moderate and severe curves and can spare the patient possible adverse events due to anterior approach. However, when choosing this approach for severe AIS, screw density needs to be high and posterior column osteotomies may need to be planned to mobilize the spine and maximize correction.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mirzashahi B, Moosavi M, Rostami M. Outcome of posterior-only approach for severe rigid scoliosis: A retrospective report. Int J Spine Surg 2020;14:232-8.
Nemani VM, Kim HJ, Bjerke-Kroll BT, Yagi M, Sacramento-Dominguez C, Akoto H, et al.
Preoperative halo-gravity traction for severe spinal deformities at an SRS-GOP site in West Africa: Protocols, complications, and results. Spine (Phila Pa 1976) 2015;40:153-61.
Ren C, Liu L, Song Y, Zhou C, Liu H, Li T. Comparison of anterior and posterior vertebral column resection versus anterior release with posterior internal distraction for severe and rigid scoliosis. Eur Spine J 2014;23:1237-43.
Zhou C, Liu L, Song Y, Feng G, Yang X, Wang L. Comparison of anterior and posterior vertebral column resection versus anterior and posterior spinal fusion for severe and rigid scoliosis. Spine J 2018;18:948-53.
Zhou C, Liu L, Song Y, Liu H, Li T, Gong Q, et al.
Anterior release internal distraction and posterior spinal fusion for severe and rigid scoliosis. Spine (Phila Pa 1976) 2013;38:E1411-7.
Suk SI, Kim JH, Cho KJ, Kim SS, Lee JJ, Han YT. Is anterior release necessary in severe scoliosis treated by posterior segmental pedicle screw fixation? Eur Spine J 2007;16:1359-65.
Bullmann V, Halm HF, Schulte T, Lerner T, Weber TP, Liljenqvist UR. Combined anterior and posterior instrumentation in severe and rigid idiopathic scoliosis. Eur Spine J 2006;15:440-8.
Kandwal P, Vijayaraghavan GP, Nagaraja UB, Jayaswal A. Severe rigid scoliosis: Review of management strategies and role of spinal osteotomies. Asian Spine J 2017;11:494-503.
Lenke LG, Bridwell KH, Blanke K, Baldus C. Analysis of pulmonary function and chest cage dimension changes after thoracoplasty in idiopathic scoliosis. Spine (Phila Pa 1976) 1995;20:1343-50.
Vedantam R, Lenke LG, Bridwell KH, Haas J, Linville DA. A prospective evaluation of pulmonary function in patients with adolescent idiopathic scoliosis relative to the surgical approach used for spinal arthrodesis. Spine (Phila Pa 1976) 2000;25:82-90.
Koller H, Mayer M, Koller J, Ferraris L, Wiedenhöfer B, Hitzl W, et al.
Temporary treatment with magnetically controlled growing rod for surgical correction of severe adolescent idiopathic thoracic scoliosis greater than 100. Eur Spine J 2021;30:788-96.
Librianto D, Saputra R, Djaja YP, Phedy P, Fachrisal, Saleh I. Preoperative skull tongs-femoral traction versus cotrel longitudinal traction for rigid and severe scoliosis: Cohort study. Ann Med Surg (Lond) 2021;63:102177.
Grabala P, Helenius IJ. Clinical and radiological outcomes of less invasive temporary internal distraction followed by staged pedicle screw instrumentation in adolescents with severe idiopathic scoliosis at 2-year minimum follow-up. World Neurosurg 2020;143:e464-73.
Di Silvestre M, Zanirato A, Greggi T, Scarale A, Formica M, Vallerga D, et al.
Severe adolescent idiopathic scoliosis: Posterior staged correction using a temporary magnetically-controlled growing rod. Eur Spine J 2020;29:2046-53.
Mehrpour S, Sorbi R, Rezaei R, Mazda K. Posterior-only surgery with preoperative skeletal traction for management of severe scoliosis. Arch Orthop Trauma Surg 2017;137:457-63.
Lewis SJ, Gray R, Holmes LM, Strantzas S, Jhaveri S, Zaarour C, et al.
Neurophysiological changes in deformity correction of adolescent idiopathic scoliosis with intraoperative skull-femoral traction. Spine (Phila Pa 1976) 2011;36:1627-38.
Teixeira da Silva LE, de Barros AG, de Azevedo GB. Management of severe and rigid idiopathic scoliosis. Eur J Orthop Surg Traumatol 2015;25 Suppl 1:S7-12.
Bradford DS, Tribus CB. Vertebral column resection for the treatment of rigid coronal decompensation. Spine (Phila Pa 1976) 1997;22:1590-9.
Suk SI, Kim JH, Kim WJ, Lee SM, Chung ER, Nah KH. Posterior vertebral column resection for severe spinal deformities. Spine (Phila Pa 1976) 2002;27:2374-82.
Lenke LG, O'Leary PT, Bridwell KH, Sides BA, Koester LA, Blanke KM. Posterior vertebral column resection for severe pediatric deformity: Minimum two-year follow-up of thirty-five consecutive patients. Spine (Phila Pa 1976) 2009;34:2213-21.
Crostelli M, Mazza O, Mariani M, Mascello D. Treatment of severe scoliosis with posterior-only approach arthrodesis and all-pedicle screw instrumentation. Eur Spine J 2013;22 Suppl 6:S808-14.
Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med 2009;6:e1000097.
Tarrant RC, Queally JM, O'Loughlin PF, Sheeran P, Moore DP, Kiely PJ. Preoperative curves of greater magnitude (>70) in adolescent idiopathic scoliosis are associated with increased surgical complexity, higher cost of surgical treatment and a delayed return to function. Ir J Med Sci 2016;185:463-71.
Dobbs MB, Lenke LG, Kim YJ, Luhmann SJ, Bridwell KH. Anterior/posterior spinal instrumentation versus posterior instrumentation alone for the treatment of adolescent idiopathic scoliotic curves more than 90 degrees. Spine (Phila Pa 1976) 2006;31:2386-91.
Di Silvestre M, Bakaloudis G, Lolli F, Vommaro F, Martikos K, Parisini P. Posterior fusion only for thoracic adolescent idiopathic scoliosis of more than 80 degrees: Pedicle screws versus hybrid instrumentation. Eur Spine J 2008;17:1336-49.
Cinnella P, Rava A, Mahagna AA, Fusini F, Masse A, Girardo M. Over 70 thoracic idiopathic scoliosis: Results with screws or hybrid constructs. J Craniovertebr Junction Spine 2019;10:108-13.
Chung WH, Lee YJ, Chiu CK, Hasan MS, Chan CY, Kwan MK. Severe Lenke 1 and 2 adolescent idiopathic scoliosis had poorer perioperative outcome, higher complication rate, longer fusion and higher operative cost compared to non-severe scoliosis. Eur Spine J 2022;31:1051-9.
Kuklo TR, Lenke LG, O'Brien MF, Lehman RA Jr, Polly DW Jr., Schroeder TM. Accuracy and efficacy of thoracic pedicle screws in curves more than 90 degrees. Spine (Phila Pa 1976) 2005;30:222-6.
Lucas B, Asher M, McIff T, Lark R, Burton D. Estimation of transverse plane pelvic rotation using a posterior-anterior radiograph. Spine (Phila Pa 1976) 2005;30:E20-7.
Chan CY, Chung WH, Mihara Y, Lee SY, Ch'ng PY, Hasan MS, et al.
Perioperative outcome of severe rigid idiopathic scoliosis: Single-staged posterior spinal fusion utilizing a dual attending surgeon strategy. A report of 41 patients. J Orthop Surg (Hong Kong) 2020;28:1-12. https://doi.org/10.1177/2309499020936005
Mihara Y, Chung WH, Chiu CK, Hasan MS, Lee SY, Ch'ng PY, et al.
Perioperative outcome of severe idiopathic scoliosis (Cobb Angle ≥90°): Is there any difference between “Daytime” Versus “After-hours” surgeries? Spine (Phila Pa 1976) 2020;45:381-9.
Mihara Y, Chung WH, Mohamad SM, Chiu CK, Chan CY, Kwan MK. Predictive factors for correction rate in severe idiopathic scoliosis (Cobb angle≥90): An analysis of 128 patients. Eur Spine J 2021;30:653-60.
Chan CY, Lee SY, Ch'ng PY, Chung WH, Chiu CK, Hasan MS, et al.
Learning curve for a dual attending surgeon strategy in posterior spinal fusion (PSF): An analysis of 105 severe adolescent idiopathic scoliosis patients (Cobb Angle ≥90). Spine (Phila Pa 1976) 2021;46:E663-70.
Gatam L, Luthfi AP, Fachrisal, Phedy, Gatam AR, Djaja YP. A posterior-only approach for treatment of severe adolescent idiopathic scoliosis with pedicle screw fixation: A case series. Int J Surg Case Rep 2020;77:39-44.
Burton DC, Sama AA, Asher MA, Burke SW, Boachie-Adjei O, Huang RC, et al.
The treatment of large (>70 degrees) thoracic idiopathic scoliosis curves with posterior instrumentation and arthrodesis: When is anterior release indicated? Spine (Phila Pa 1976) 2005;30:1979-84.
Schwab F, Blondel B, Chay E, Demakakos J, Lenke L, Tropiano P, et al.
The comprehensive anatomical spinal osteotomy classification. Neurosurgery 2014;74:112-20.
Shi Z, Chen J, Wang C, Li M, Li Q, Zhang Y, et al.
Comparison of thoracoscopic anterior release combined with posterior spinal fusion versus posterior-only approach with an all-pedicle screw construct in the treatment of rigid thoracic adolescent idiopathic scoliosis. J Spinal Disord Tech 2015;28:E454-9.
Quan GM, Gibson MJ. Correction of main thoracic adolescent idiopathic scoliosis using pedicle screw instrumentation: Does higher implant density improve correction? Spine (Phila Pa 1976) 2010;35:562-7.
Zhou C, Liu L, Song Y, Liu H, Li T, Gong Q, et al.
Anterior and posterior vertebral column resection for severe and rigid idiopathic scoliosis. Eur Spine J 2011;20:1728-34.
Cheng MF, Ma HL, Lin HH, Chou PH, Wang ST, Liu CL, et al
. Anterior release may not be necessary for idiopathic scoliosis with a large curve of more than 75 and a flexibility of less than 25%. Spine J 2018;18:769-75.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]