Lawrence G Lenke

Washington University in St. Louis, San Luis, Missouri, United States

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Publications (484)1166.92 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Unlabelled: : Thoracic kyphosis tends to increase with age. Hyperkyphosis is defined as excessive curvature of the thoracic spine and may be associated with adverse health effects. Hyperkyphosis in isolation or as a component of degenerative kyphoscoliosis has important implications for the surgical management of adult spinal deformity. Our objective was to review the literature on the epidemiology, etiology, natural history, management, and outcomes of thoracic hyperkyphosis. We performed a narrative review of literature on thoracic hyperkyphosis and its implications for adult spinal deformity surgery. Hyperkyphosis has a prevalence of 20% to 40% and is more common in the geriatric population. The cause is multifactorial and involves an interaction between degenerative changes, vertebral compression fractures, muscular weakness, and altered biomechanics. It may be associated with adverse health consequences including impaired physical function, pain and disability, impaired pulmonary function, and increased mortality. Nonoperative management may slow the progression of kyphosis and improve function. Surgery is rarely performed for isolated hyperkyphosis in the elderly due to the associated risk, but is an option when kyphosis occurs in the context of significant deformity. In this scenario, increased thoracic kyphosis influences selection of fusion levels and overall surgical planning. Kyphosis is common in older individuals and is associated with adverse health effects and increased mortality. Current evidence suggests a role for nonoperative therapies in reducing kyphosis and delaying its progression. Isolated hyperkyphosis in the elderly is rarely treated surgically; however, increased thoracic kyphosis as a component of global spinal deformity has important implications for patient selection and operative planning. Abbreviations: ASD, adult spinal deformityBMD, bone mineral densityDDD, degenerative disc diseaseLL, lumbar lordosisOR, odds ratioPI, pelvic incidencePJK, proximal junctional kyphosisPT, pelvic tiltSSV, sagittal stable vertebraTK, thoracic kyphosisUIV, upper-most instrumented vertebra.
    Neurosurgery 09/2015; 77 Suppl 4:S164-72. DOI:10.1227/NEU.0000000000000944 · 3.62 Impact Factor
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    ABSTRACT: Unlabelled: : Degenerative spinal deformity afflicts a significant portion of the elderly and is increasing in prevalence. Recent evidence has revealed sagittal plane malalignment to be a key driver of pain and disability in this population and has led to a significant shift toward a more evidence-based management paradigm. In this narrative review, we review the recent literature on the epidemiology, evaluation, management, and outcomes of degenerative adult spinal deformity (ASD). ASD is increasing in prevalence in North America due to an aging population and demographic shifts. It results from cumulative degenerative changes focused in the intervertebral discs and facet joints that occur asymmetrically to produce deformity. Deformity correction focuses on restoration of global alignment, especially in the sagittal plane, and decompression of the neural elements. General realignment goals have been established, including sagittal vertical axis <50 mm, pelvic tilt <22°, and lumbopelvic mismatch <±9°; however, these should be tailored to the patient. Operative management, in carefully selected patients, yields satisfactory outcomes that appear to be superior to nonoperative strategies. ASD is characterized by malalignment in the sagittal and/or coronal plane and, in adults, presents with pain and disability. Nonoperative management is recommended for patients with mild, nonprogressive symptoms; however, evidence of its efficacy is limited. Surgery aims to restore global spinal alignment, decompress neural elements, and achieve fusion with minimal complications. The surgical approach should balance the desired correction with the increased risk of more aggressive maneuvers. In well-selected patients, surgery yields excellent outcomes. Abbreviations: ASD, adult spinal deformityC7PL, plumb line dropped from the C7 centroidCSVL, line drawn vertically through the center of the sacrumHRQOL, health-related quality of lifeLL, lumbar lordosisMIS, minimally invasive surgeryPA, posteroanteriorPI, pelvic incidencePI - LL, lumbopelvic mismatchPJF, proximal junction failurePJK, proximal junction kyphosisPSO, pedicle subtraction osteotomyPT, pelvic tiltSRS, Scoliosis Research SocietySS, sacral slopeSVA, sagittal vertical axisTK, thoracic kyphosisTLIF, transforaminal lumbar interbody fusionVCR, vertebral column resection.
    Neurosurgery 09/2015; 77 Suppl 4:S75-91. DOI:10.1227/NEU.0000000000000938 · 3.62 Impact Factor
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    ABSTRACT: A retrospective analysis. The purpose of this study was to determine whether the deformity angular ratio (DAR) can reliably assess the neurological risks of patients undergoing deformity correction. Identifying high-risk patients and procedures can help ensure that appropriate measures are taken to minimize neurological complications during spinal deformity corrections. Subjectively, surgeons look at radiographs and evaluate the riskiness of the procedure. However, 2 curves of similar magnitude and location can have significantly different risks of neurological deficit during surgery. Whether the curve spans many levels or just a few can significantly influence surgical strategies. Lenke et al have proposed the DAR, which is a measure of curve magnitude per level of deformity. The data from 35 pediatric spinal deformity correction procedures with thoracic 3-column osteotomies were reviewed. Measurements from preoperative radiographs were used to calculate the DAR. Binary logistic regression was used to model the relationship between DARs (independent variables) and presence or absence of an intraoperative alert (dependent variable). In patients undergoing 3-column osteotomies, sagittal curve magnitude and total curve magnitude were associated with increased incidence of transcranial motor evoked potential changes. Total DAR greater than 45° per level and sagittal DAR greater than 22° per level were associated with a 75% incidence of a motor evoked potential alert, with the incidence increasing to 90% with sagittal DAR of 28° per level. In patients undergoing 3-column osteotomies for severe spinal deformities, the DAR was predictive of patients developing intraoperative motor evoked potential alerts. Identifying accurate radiographical, patient, and procedural risk factors in the correction of severe deformities can help prepare the surgical team to improve safety and outcomes when carrying out complex spinal corrections. 3.
    Spine 08/2015; 40(15):E879-85. DOI:10.1097/BRS.0000000000000984 · 2.30 Impact Factor
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    ABSTRACT: Study Design/Setting: Cross-sectional. Objectives: To determine associations between cervical spine alignment and Lenke type for adolescent idiopathic scoliosis (AIS). Summary of Background Data: Although the lumbosacral spine and pelvis are standard considerations for evaluation of AIS, few studies have examined cervical spine alignment. These studies did not consider Lenke types upon which treatment decisions are based. Methods: Stratified random sampling from 3,654 full-length preoperative lateral films of patients in a multicenter database of surgically treated AIS was done to obtain a representative sample from all Lenke types and thoracic curve modifiers. The C2-C7 sagittal Cobb and C2-C7 sagittal vertical axis (SVA) distances were measured by reviewers unaware of the patient's Lenke classification. C2-C7 sagittal Cobb and C2-C7 SVA among curve types and thoracic modifiers was compared using analysis of variance. Results: There were 387 females and 84 males among patients in 471 randomly selected films; mean age at surgery was 14.8 ± 2.0 years. Significantly less cervical kyphosis was seen in Lenke 3 or 4 curves and greater cervical kyphosis in Lenke 1, 2, 5, and 6 curves. No significant differences in C2-C7 SVA were seen. Conclusions: Patients with AIS appear to compensate for abnormal thoracic sagittal alignment with changes in cervical sagittal alignment. This seems intuitive for Lenke 1 and 2 curves in which surgical restoration of thoracic kyphosis is a recognized goal and has been shown to improve cervical alignment. Cervical kyphosis was also noted in Lenke 5 and 6 curves, which suggests a need to consider compensatory thoracic and cervical sagittal alignment during surgical planning. Patients with Lenke 3 and 4 curves had more normal cervical alignment, which suggests that with the major portion of the curve located in the middle of the spine, there is more ability above and below to maintain a more normal sagittal alignment.
    07/2015; 3(4):327-331. DOI:10.1016/j.jspd.2014.11.008
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    ABSTRACT: The authors analyzed patients who underwent posterior vertebral column resection (PVCR). All patients had spinal cord monitoring (SCM) attempted but some did not have predictable and usable tracings.
    07/2015; 3(4):352-359. DOI:10.1016/j.jspd.2014.11.009
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    ABSTRACT: Studies have demonstrated sustained improvements in patient-reported outcomes (PROs) following 3-column osteotomies (3-CO), but no study has evaluated what factors impact long-term outcomes. To investigate factors associated with PROs in patients (pts) who underwent 3-CO at a minimum 5 years postoperatively. Retrospective review of prospective database. All pts who had a 3-CO at a single institution and completed clinical evaluations after at least 5 years postoperative were included. Oswestry disability index (ODI), Scoliosis Research Society (SRS) scores, and radiographic parameters were assessed at baseline and a minimum 5 years postoperatively. Analysis of 120 pts who underwent 3-CO (96-pedicle subtraction osteotomy/24-vertebral column resection) was performed. The mean age was 48 years (range 8-79) and clinical follow up was 7 years (range 5-14). Separate multivariable linear regression analyses were performed to determine factors associated with 1) ODI, 2) SRS average, and 3) SRS satisfaction while controlling for time since surgery and baseline outcome scores. Average PROs were significantly improved from baseline at a minimum 5 years follow up (ODI: 48 to 28, p<0.01; SRS: 2.8 to 3.5, p<0.01). The average SRS satisfaction score was 4.0. Average sagittal alignment (C7 plumb) improved 74 mm, with 81% of pts <95mm. Major surgical complications occurred in 32 pts (27%) with major reoperations in 30 pts (25%). Multivariable regression analysis found that prior surgery and major reoperations were risk factors for worse ODI scores. A diagnosis of adult idiopathic scoliosis and final sagittal alignment <95mm were associated with improved SRS scores. Improvement in major coronal cobb and final pelvic tilt <30° were associated with increased SRS satisfaction. With a minimum 5-year follow-up, PROs in patients undergoing 3-CO were associated with improvements in radiographic alignment, but negatively effected by prior surgery and complications necessitating revision surgery. Copyright © 2015 Elsevier Inc. All rights reserved.
    The spine journal: official journal of the North American Spine Society 06/2015; DOI:10.1016/j.spinee.2015.06.044 · 2.43 Impact Factor
  • Samuel K Cho · Yongjung J Kim · Lawrence G Lenke
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    ABSTRACT: Proper understanding and restoration of sagittal balance is critical in spinal deformity surgery, including conditions such as adolescent idiopathic scoliosis and Scheuermann kyphosis. One potential complication following spinal reconstruction is proximal junctional kyphosis. The prevalence of proximal junctional kyphosis varies in the literature, and several patient- and surgery-related risk factors have been identified. To date, the development of proximal junctional kyphosis has not been shown to lead to a negative clinical outcome following spinal fusion for adolescent idiopathic scoliosis or Scheuermann kyphosis. Treatment options range from simple observation in asymptomatic cases to revision surgery with extension of the fusion proximally. Several techniques and technologies are emerging that seek to address and prevent proximal junctional kyphosis. Copyright 2015 by the American Academy of Orthopaedic Surgeons.
    The Journal of the American Academy of Orthopaedic Surgeons 05/2015; 23(7). DOI:10.5435/JAAOS-D-14-00143 · 2.53 Impact Factor
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    ABSTRACT: Retrospective review of a multicenter database. To evaluate whether surgeon experience is associated with complication rates in adult spinal deformity (ASD) surgery. Multiple patient- and surgery-related factors have been shown to increase the risk of complications in ASD. No study exists evaluating surgeon experience as an associated factor with complications in ASD. The Scoliosis Research Society Morbidity and Mortality database was queried for patients aged >18 years who underwent ASD from 2004-2007. Patient demographics, surgical characteristics, complications and surgeon membership status were analyzed. Two-tailed t-test and chi-square tests were performed with p<0.05 considered significant. A total of 5,117 patients underwent ASD surgery. The average patient age was 51.8 years. Patients operated by candidate members were older than those operated by active members (53.1 versus 51.4, p = 0.003). Active members performed 3,836 (75%) cases while candidate members performed 1,281 cases. There were 1,110 (21.7%) revisions. A total of 681 (13.3%) complications were recorded, 498 (13.0%) for active and 183 (14.3%) for candidate members, respectively (p = 0.24). Mortality rate was 0.29%. Spinal cord complications accounted for 0.68% of all cases. Active members had 21 (0.55%) spinal cord complications, while candidates had 14 (1.1%) (p = 0.049). There were a total of 174 (3.4%) surgical site infections (SSI). Active members had 82 (2.1%) deep SSI, while candidate members had 36 (2.8%) deep SSI (p = 0.164). Active members had 33 (0.9%) superficial SSI while candidate members had 23 (1.8%) superficial SSI (p = 0.008). There was a statistically significant, two-fold increase in the rate of spinal cord complications and superficial SSI among candidate compared to active members. Overall complication rates were similar between candidate and active members.
    Spine 05/2015; 40(15). DOI:10.1097/BRS.0000000000000993 · 2.30 Impact Factor
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    ABSTRACT: To describe curve patterns in patients with Chiari malformation I (CIM) without syringomyelia, and compare to patients with Chiari malformation with syringomyelia (CIM + SM). Review of medical records from 2000 to 2013 at a single institution was performed to identify CIM patients with scoliosis. Patients with CIM were matched (1:1) by age and gender to CIM + SM. Radiographic curve patterns, MRI-based craniovertebral junction parameters, and associated neurological signs were compared between the two cohorts. Eighteen patients with CIM-associated scoliosis in the absence of syringomyelia were identified; 14 (78 %) were female, with mean age of 11.5 ± 4.5 years. Mean tonsillar descent was 9.9 ± 4.1 mm in the CIM group and 9.1 ± 3.0 mm in the CIM + SM group (p = 0.57). Average syrinx diameter in the CIM + SM group was 9.0 ± 2.7 mm. CIM patients demonstrated less severe scoliotic curves (32.1° vs. 46.1°, p = 0.04), despite comparable thoracic kyphosis (43.7° vs. 49.6°, p = 0.85). Two (11 %) patients with CIM demonstrated thoracic apex left deformities compared to 9/18 (50 %) in the CIM + SM cohort (p = 0.01). Neurological abnormalities were only observed in the group with syringomyelia (6/18, or 33 %; p = 0.007). In the largest series specifically evaluating CIM and scoliosis, we found that these patients appear to present with fewer atypical curve features, with less severe scoliotic curves, fewer apex left curves, and fewer related neurological abnormalities than CIM + SM. Notably, equivalent thoracic kyphosis was observed in both groups. Future studies are needed to better understand pathogenesis of spinal deformity in CIM with and without SM.
    European Spine Journal 05/2015; DOI:10.1007/s00586-015-4011-1 · 2.07 Impact Factor
  • Global Spine Journal 05/2015; 05(S 01). DOI:10.1055/s-0035-1554156
  • Global Spine Journal 05/2015; 05(S 01). DOI:10.1055/s-0035-1554345
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    ABSTRACT: Chiari Malformation, Type 1, with syringomyelia (CIM+SM) is often associated with spinal deformity. The safety of scoliosis surgery this population is controversial, and has never been directly compared with adolescent idiopathic scoliosis (AIS). Compare the safety and subjective outcomes of spinal deformity surgery between patients with Chiari Malformation I associated scoliosis and a matched Adolescent Idiopathic Scoliosis cohort. Retrospective matched cohort analysis PATIENT SAMPLE: Patients with CIM+SM and treated with spinal fusion for spinal deformity were identified in the surgical records of a single institution and were matched, 1:1, with AIS patients undergoing spinal fusion at the same institution. Neurological monitoring data quality and integrity, radiographic parameters, Scoliosis Research Society-22 Scores. A clinical database was reviewed for patients undergoing spinal reconstruction for CIM+SM associated spinal deformity at our institution from 2000 to 2012. Thirty-six CIM+SM patients were identified and matched to an AIS cohort (1:1) based on age, gender, major curve magnitude, fusion length, and revision status. Demographics, deformity morphology, surgical details, neuromonitoring data, and pre- and postoperative SRS-22 scores were recorded at a minimum 2-year followup. Changes in SRS-22 scores were compared within and between groups. Complications and neurological monitoring data issues were compared between groups. Mean age was 14.5±5 years (CIM+SM: 14.6±5; AIS: 14.4±5), and 42% of patients were male. Preoperative mean major coronal Cobb measured 58°±25 vs. 57°±17 (p=0.84) with mean kyphosis 52°±17 vs. 41°±20 (p=0.018). An average of 10.4±2.6 vertebral levels were fused (10.4±2.8 vs. 10.4±2.3, p=0.928). No differences existed in surgical approach (p=0.336), estimated blood loss (680mL±720 vs. 660±310, p=0.845), or duration of surgery (6.0 hours ±2.2 vs. 5.6 ± 2, p=0.434). Complication rate was comparable between the two groups (33% vs. 14%, p=0.052). CIM+SM experienced more neurological complications (11% vs. 0%, p=0.04) and neuromonitoring difficulties (28% vs. 3%, p=0.007) than the AIS cohort. Mean curve correction was comparable at 2 years (58% CIM+SM vs. 64% AIS, p=0.2). At follow-up, both CIM+SM and AIS groups demonstrated improved cumulative SRS-22 outcome subscores (CIM+SM: +0.4, p=0.027; AIS: +0.3, p<0.001). No difference in outcome subscores existed between CIM+SM and AIS groups. While CIM+SM patients undergoing spine reconstruction can expect similar deformity corrections and outcomes scores to AIS patients, they also experience higher rates of neuromonitoring difficulties and neurological complications related to surgery. Surgeons should be prepared for these difficulties, particularly in children with larger syrinx size. Copyright © 2015 Elsevier Inc. All rights reserved.
    The spine journal: official journal of the North American Spine Society 05/2015; 15(9). DOI:10.1016/j.spinee.2015.04.048 · 2.43 Impact Factor
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    ABSTRACT: Longitudinal cohort. To evaluate the relationship between Scoliosis Research Society-22R (SRS22-R) domains and satisfaction with management in patients who underwent surgical correction for adult spine deformity. The SRS-22R is used to measure clinical outcomes in adult spine deformity patients. The relationship between patient satisfaction and SRS-22R domain scores, the Oswestry Disability Index (ODI) and radiographic parameters has not been reported at 5-year follow-up. One hundred thirty five patients with adult spinal deformity at a single institution who underwent a posterior spinal fusion of 5 levels or more to the sacrum and had complete SRS-22R pre- and minimum 5 years post-op were identified. Wilcoxon tests were used to compare preop and 5-year postop scores. Spearman correlations were used to evaluate associations between the 5-year SRS-22R Satisfaction score and changes in SRS-22R domain scores, SubScore (SRS-22R Total - Satisfaction), ODI, and radiographic parameters. There were 125 females and 10 males with a mean BMI of 26.6 kg/m2 and mean age of 53.6 years. There were 74 primary and 61 revision surgeries with a mean 9.9 levels fused and mean follow-up of 67 months. There was a statistically significant improvement between paired pre- and 5-year post-op SRS-22R domain scores and most radiographic parameters, commonly p ≤ 0.001. The majority of patients had an SRS-22R Satisfaction score of ≥ 3.0 (88%) or ≥ 4.0 (67%), consistent with a moderate ceiling effect. Correlations for SRS-22R domain scores were all statistically significant and either weak (Mental (0.26), Activity (0.27), Pain (0.35)) or moderate (Appearance (0.59)). SRS-22R SubScore (0.54) and ODI (0.43) also had a moderate correlation. Correlations for all radiographic and operative parameters were either very weak or weak. SRS-22R Appearance, SubScore, and ODI correlate most with patient satisfaction in adult deformity patients undergoing ≥ 5 level fusion to the sacrum at 5-year follow-up.
    Spine 04/2015; 14(11). DOI:10.1097/BRS.0000000000000961 · 2.30 Impact Factor
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    ABSTRACT: Background: Scoliosis is a feature of several genetic disorders that are also associated with aortic aneurysm, including Marfan syndrome, Loeys-Dietz syndrome, and type-IV Ehlers-Danlos syndrome. Life-threatening complications of aortic aneurysm can be decreased through early diagnosis. Genetic screening for mutations in populations at risk, such as patients with adolescent idiopathic scoliosis, may improve recognition of these disorders. Methods: The coding regions of five clinically actionable genes associated with scoliosis (COL3A1, FBN1, TGFBR1, TGFBR2, and SMAD3) and aortic aneurysm were sequenced in 343 adolescent idiopathic scoliosis cases. Gene variants that had minor allele frequencies of <0.0001 or were present in human disease mutation databases were identified. Variants were classified as pathogenic, likely pathogenic, or variants of unknown significance. Results: Pathogenic or likely pathogenic mutations were identified in 0.9% (three) of 343 adolescent idiopathic scoliosis cases. Two patients had pathogenic SMAD3 nonsense mutations consistent with type-III Loeys-Dietz syndrome and one patient had a pathogenic FBN1 mutation with subsequent confirmation of Marfan syndrome. Variants of unknown significance in COL3A1 and FBN1 were identified in 5.0% (seventeen) of 343 adolescent idiopathic scoliosis cases. Six FBN1 variants were previously reported in patients with Marfan syndrome, yet were considered variants of unknown significance based on the level of evidence. Variants of unknown significance occurred most frequently in FBN1 and were associated with greater curve severity, systemic features of Marfan syndrome, and joint hypermobility. Conclusions: Clinically actionable pathogenic mutations in genes associated with adolescent idiopathic scoliosis and aortic aneurysm are rare in patients with adolescent idiopathic scoliosis who are not suspected of having these disorders, although variants of unknown significance are relatively common. Clinical Relevance: Routine genetic screening of all patients with adolescent idiopathic scoliosis for mutations in clinically actionable aortic aneurysm disease genes is not recommended on the basis of the high frequency of variants of unknown significance. Clinical evaluation and family history should heighten indications for genetic referral and testing.
    The Journal of Bone and Joint Surgery 04/2015; 97(97):1411-7. DOI:10.2106/JBJS.O.00290 · 5.28 Impact Factor
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    ABSTRACT: Study Design Retrospective radiographic benchmark study. Objective To evaluate the amount of instrumented correction obtained from a combined anterior/posterior (A/P) versus posterior-only (post-only) approach for Scheuermann's kyphosis. Summary of Background Data An A/P approach was thought to optimize correction; however, instrumentation advances using pedicle screws allow treatment through an all-posterior approach. Methods A total of 166 Scheuermann's kyphosis patients were treated between 2 centers: 90 by combined A/P approach at 1 center and 76 by post-only at the second center. From the 166 patients, a matched cohort of 92 (46 from each) was established according to preoperative sagittal (±10°) and hyperextension (HE) Cobb (±10°) measurements and matched for age and gender. Results In the matched-pair group, average preoperative sagittal Cobb angles were 75.9° for the A/P group versus 78.8° for the post-only group (p =.2). The HE Cobb angles were similar (52.4° vs. 51.1°; p =.6). They showed similar corrections (33.7° vs. 30.6°; p =.3) and postoperative Cobb measurements (43.4° vs. 47.1°; p =.2) as well. The number of fusion levels was 9 in the A/P group and 12 in the post-only group; the difference yielded significance (p =.02). Conclusions The A/P and post-only approaches averaged similar degrees of correction. The A/P patients were likely to correct more than their preoperative HE sagittal Cobb measurement, whereas the post-only group corrected close to their preoperative HE measurement. The number of fusion levels was larger with the post-only group.
    03/2015; 3(2). DOI:10.1016/j.jspd.2014.09.048
  • Scott C. Wagner · Ronald A. Lehman Jr · Lawrence G. Lenke
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    ABSTRACT: Without a complete understanding of the natural history of adolescent idiopathic scoliosis (AIS), the treating spine surgeon will be unable to effectively appreciate the indications for surgery, nor will the long-term management plan be appropriate. Basic evaluation of the patient with AIS should center on a thorough history and physical examination. It is crucial that applicable radiographic imaging is obtained as well, which must be tailored to each individual patient given the findings on history and physical examination. For patients in whom surgical correction is indicated, many factors comprise the ultimate treatment plan. The goals of surgery center on prevention of curve progression, adequate coronal and sagittal realignment, and the preservation of as much motion as possible. Vertebral level selection, curve reduction techniques, fixation strategies, post-operative protocols and potential complications each play a vital role in the successful surgical treatment of AIS. With an in-depth understanding of all of these variables, the spine surgeon can achieve excellent outcomes for his or her AIS patients.
    Seminars in Spine Surgery 02/2015; DOI:10.1053/j.semss.2015.01.008
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    ABSTRACT: Retrospective case series.

Publication Stats

14k Citations
1,166.92 Total Impact Points


  • 1992–2015
    • Washington University in St. Louis
      • • Department of Orthopaedic Surgery
      • • Department of Medicine
      • • Department of Anesthesiology
      San Luis, Missouri, United States
  • 1995–2014
    • Barnes Jewish Hospital
      San Luis, Missouri, United States
  • 2012
    • University of California, Los Angeles
      • Department of Orthopaedic Surgery
      Los Angeles, CA, United States
    • University of British Columbia - Vancouver
      • Department of Orthopaedics
      Vancouver, British Columbia, Canada
  • 2010
    • University of Washington Seattle
      Seattle, Washington, United States
  • 2008–2010
    • Saint Louis University
      • Department of Orthopaedic Surgery
      Сент-Луис, Michigan, United States
    • Chungnam National University
      • Department of Orthopaedic Surgery
      Daiden, Daejeon, South Korea
  • 2009
    • Shriners Hospitals for Children
      Tampa, Florida, United States
    • Keio University
      Edo, Tōkyō, Japan
    • Rady Children's Hospital
      San Diego, California, United States
  • 2005–2008
    • University of California, San Diego
      • Department of Orthopaedic Surgery
      San Diego, CA, United States
    • Inha University
      Chemulpo, Incheon, South Korea
    • California State University, Sacramento
      Sacramento, California, United States
    • Vibra Hospital of San Diego
      San Diego, California, United States
  • 2002–2008
    • Walter Reed National Military Medical Center
      • • Department of Orthopaedics and Rehabilitation
      • • Division of Orthopaedic Surgery
      Washington, Washington, D.C., United States
    • Madigan Army Medical Center
      Tacoma, Washington, United States
    • University of Missouri
      • Department of Orthopaedic Surgery
      Columbia, MO, United States
  • 2007
    • Wooridul Spine Hospital Group
      Sŏul, Seoul, South Korea
  • 2006
    • University of Utah
      Salt Lake City, Utah, United States
  • 2003
    • Loyola University Chicago
      Chicago, Illinois, United States
  • 2000
    • Children's Hospital of Richmond
      Ричмонд, Virginia, United States
    • Johns Hopkins Medicine
      • Department of Orthopaedic Surgery
      Baltimore, Maryland, United States
  • 1998
    • The Ohio State University
      Columbus, Ohio, United States