Factors influencing upper-most instrumented vertebrae selection in adult spinal deformity patients: qualitative case-based survey of deformity surgeons.



The decision upper-most instrumented vertebrae (UIV) in a multi-level fusion procedure can dramatically influence outcomes of corrective spine surgery. We aimed to create an algorithm for selection of UIV based on surgeon selection/reasoning of sample cases.


The clinical/imaging data for 11 adult spinal deformity (ASD) patients were presented to 14 spine deformity surgeons who selected the UIV and provided reasons for avoidance of adjacent levels. The UIV chosen was grouped into either upper thoracic (UT, T1-T6), lower thoracic (LT, T7-T12), lumbar or cervical. Disagreement between surgeons was defined as ≥3 not agreeing. We performed a descriptive analysis of responses and created an algorithm for choosing UIV then applied this to a large database of ASD patients.


Surgeons agreed in 8/11 cases on regional choice of UIV. T10 was the most common UIV in the LT region (58%) and T3 was the most common UIV in the UT region (44%). The most common determinant of UIV in the UT region was proximal thoracic kyphosis and presence of coronal deformity. The most common determinant of UIV in the LT region was small proximal thoracic kyphosis. Within the ASD database (236 patients), when the algorithm called for UT fusion, patients fused to TL region were more likely to develop proximal junctional kyphosis (PJK) at 1 year post-operatively (76.9% vs. 38.9%, P=0.025).


Our algorithm for selection of UIV emphasizes the role of proximal and regional thoracic kyphosis. Failure to follow this consensus for UT fusion was associated with twice the rate of PJK.





Published Version (Please cite this version)


Publication Info

Virk, Sohrab, Uwe Platz, Shay Bess, Douglas Burton, Peter Passias, Munish Gupta, Themistocles Protopsaltis, Han Jo Kim, et al. (2021). Factors influencing upper-most instrumented vertebrae selection in adult spinal deformity patients: qualitative case-based survey of deformity surgeons. Journal of spine surgery (Hong Kong), 7(1). pp. 37–47. 10.21037/jss-20-598 Retrieved from https://hdl.handle.net/10161/28121.

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Peter Passias

Instructor in the Department of Orthopaedic Surgery

Christopher Ignatius Shaffrey

Professor of Orthopaedic Surgery

I have more than 25 years of experience treating patients of all ages with spinal disorders. I have had an interest in the management of spinal disorders since starting my medical education. I performed residencies in both orthopaedic surgery and neurosurgery to gain a comprehensive understanding of the entire range of spinal disorders. My goal has been to find innovative ways to manage the range of spinal conditions, straightforward to complex. I have a focus on managing patients with complex spinal disorders. My patient evaluation and management philosophy is to provide engaged, compassionate care that focuses on providing the simplest and least aggressive treatment option for a particular condition. In many cases, non-operative treatment options exist to improve a patient’s symptoms. I have been actively engaged in clinical research to find the best ways to manage spinal disorders in order to achieve better results with fewer complications.

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