Indications for Lumbar Fusion in the Skeletally Mature Adolescent: How to Address Oblique Takeoff and Limb Length Discrepancy.

BACKGROUND: Indications for posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI) of a scoliotic deformity in a skeletally mature individual are based on the balance between the anticipated benefit of stopping future curve progression and the potential downside of loss of spinal mobility. The dilemma regarding PSF with SSI in the adolescent population is exacerbated by the patient's participation in athletics requiring flexibility and motion of the spine, the location of the curve, the presence of pelvic obliquity, and the impact of a limb length discrepancy. The purpose of this review is to discuss the potential advantages and disadvantages of PSF with SSI in a hypothetical skeletally mature adolescent with a 45-degree lumbar curve, pelvic obliquity, and limb length discrepancy.

DISCUSSION: Natural history studies of untreated adolescent idiopathic scoliosis (AIS) have shown that slow curve progression throughout adulthood is likely. Adults with untreated AIS may also have more back pain and dissatisfaction with their appearance. Although the clinical and radiographic outcomes of PSF with SSI are excellent, patients should be counseled about the impact of fusing the lumbar spine on back pain, decreased spinal mobility, and potential inability to return to athletics at the same level. Adults who undergo surgery for AIS have greater operative morbidity and number of levels fused compared with adolescents.

CONCLUSION: These factors should be presented when discussing observation versus PSF with SSI with patients and families. Delaying surgery until formal athletic participation is complete should be considered.