Multisurgeon assessment of surgical decision-making in adolescent idiopathic scoliosis - Curve classification, operative approach, and fusion levels

Study Design. A multisurgeon assessment of curve classification, selection of operative approach, and fusion levels via a case study presentation. Objectives. To evaluate the ability of a group of scoliosis surgeons, not i nvolved in the development of a new classification system, to accurately ch oose the corresponding curve classification of adolescent idiopathic scolio sis (AIS) cases and to evaluate the variability in the selection of operati ve approaches and both proximal and distal fusion levels in accordance with the new classification system in operative adolescent idiopathic scoliosis . Summary of Background Data. Recent evaluations using the King method for cl assifying AIS has shown poor intraobserver and interobserver reliability. A new, comprehensive classification system of AIS has been developed, but th e result of a scoliosis surgeon's ability to apply the objective classifica tion is unknown. In the :surgical treatment of AIS, there are three choices for the operative approach (anterior, posterior, or both) and multiple cho ices for the selection of fusion levels. Methods. During an AIS roundtable discussion at a spinal surgery meeting, 2 8 scoliosis surgeons were presented seven cases of operative AIS via good q uality slides. Standard preoperative radiographs and clinical photographs w ere presented, and the reviewers were asked to classify the cases by a new classification system, choose their preferred surgical approach, and classi fy both proximal and distal fusion levels. Results. For the seven cases presented, 84% of the curve types, 86% of lumb ar modifiers, and 90% of sagittal thoracic modifiers were classified by the reviewers as described in the new classification. The case study found wid ely variable operative approaches and fusion levels chosen by the! reviewer s. There was an average of five different proximal (range, 4-8) and four di fferent distal (range, 3-5) fusion levels chosen by the reviewers for each case. Conclusions. This case study assessment found a relatively high rate (84-90 %) of agreement in curve classification of the individual components of a n ew classification system of AIS. This suggests the ability of a group of sc oliosis surgeons to identify the specific criteria necessary for this new c lassification system of AIS. In addition, the high variability in selection of both operative approach and fusion levels confirms the current lack of standardized treatment paradigms. This further reinforces the need for a me thod to critically and objectively evaluate these variable treatments to de termine the "best" radiographic and clinical results.