STUDY DESIGN A study was done to evaluate the use of voluntary supine side bending radiographs and Risser table traction radiographs in adolescent patients undergoing posterior spinal fusion for idiopathic scoliosis. OBJECTIVES To compare the usefulness of supine side bending and traction radiographs in assessing curve flexibility and determining fusion levels in patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA Supine side bending radiographs have been used in the preoperative evaluation of idiopathic scoliosis to determine curve flexibility and fusion area. Traction films have been used to determine the flexibility of large curves and neuromuscular curves where active side bending is not possible. No study to date has compared the use of these films in patients with adolescent idiopathic scoliosis undergoing surgery. METHODS Seventy-five patients with more than a 2-year follow-up period after surgery were included in this study. Preoperative radiographs included a standing posteroanterior and lateral film and both supine maximal voluntary side bending films and a traction film done on a Risser table. A preoperative review of these radiographs was done to determine curve flexibility and fusion levels. At follow-up evaluation, the patients were examined for any evidence of decompensation or "adding-on" of levels. RESULTS For curves less than 60 degrees, side bending radiographs showed greater curve correction than traction radiographs, whereas the opposite was true for curves greater than 60 degrees. For King I and II curves, side bending radiographs were superior for determination of lumbar curve flexibility and for distinguishing these two types of curves. On traction radiographs, the stable vertebra was 1.4 vertebral levels higher than on the standing film. When the fusion level was moved proximally because of the traction radiograph, decompensation or "adding-on" commonly occurred. CONCLUSIONS Supine bending radiographs are superior to traction radiographs for assessing curve flexibility except for curves more than 60 degrees. The selection of the distal extent of fusion based on the traction radiograph gave a large number of poor results. The selection of fusion levels in adolescent Idiopathic scoliosis is best determined by a combination of standing posteroanterior and lateral radiographs and the supine maximum voluntary bend films.

Comparison of the use of supine bending and traction radiographs in the selection of the fusion area in adolescent idiopathic scoliosis

Aim: To determine how accurately pre-operative stress radiographs predict the final outcome in adolescent idiopathic scoliosis surgery. Methods: Records of 20 patients were reviewed retrospectively. Pre-operative correction was measured by comparing the initial Cobb angle of the main structural curves on plain standing radiographs to values measured at corresponding levels after correction on traction and fulcrum bending radiographs. Post-operative correction was obtained by measurements at corresponding levels of the instrumented and uninstrumented curves. Results: Mean correction of the main instrumented curve by traction was 24.2° (40.9%), and by fulcrum bending 32.3° (56.0%). Post-operative correction yielded a mean value of 41.1° (68.2%). Expressing pre-operative values as a percentage of final correction, traction views predicted 60%, and fulcrum bending radiographs 82% of the final correction. If agreement within 10° of preand post-operative values is regarded as clinically significant, only 18% of traction and 45% of fulcrum bending views came within that range. Discussion: We concluded that fulcrum bending views are of superior predictive value in terms of surgical correction to be expected, but still correlate poorly with final surgical correction achieved. Introduction Pre-operative assessment of the flexibility of scoliotic curves provides the surgeon with some information regarding the levels to be included in arthrodesis, the amount of correction that can be achieved safely if an anterior release is required, and whether a secondary curve should be treated with arthrodesis or not. Unfortunately the results of these stress views often bear little relation to the final surgical correction achieved. Methods employed to determine the flexibility of the curves include Cobb angle comparisons between standing and supine radiographs, traction radiographs, push prone radiographs, lateral bending radiographs with the patient supine or standing, and fulcrum bending radiographs. SAOJ Summer 2009 11/26/09 4:35 PM Page 18

Comparison of pre-operative correction X-rays with post-operative correction achieved in adolescent idiopathic scoliosis

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Comparison of pre-operative correction X-rays with post-operative correction achieved in adolescent idiopathic scoliosis