title: Five major controversial issues about fusion level selection in corrective surgery for adolescent idiopathic scoliosis: a narrative review.
abstract: Shoulder imbalance, coronal decompensation, and adding-on phenomenon following corrective surgery in patients with adolescent idiopathic scoliosis are known to be related to the fusion level selected. Although many studies have assessed the appropriate selection of the proximal and distal fusion level, no definite conclusions have been drawn thus far.
  
  
  
  We aimed to assess the problems with fusion level selection for corrective surgery in patients with adolescent idiopathic scoliosis, and to enhance understanding about these problems.
  
  
  
  This study is a narrative review.
  
  
  
  We conducted a literature search of fusion level selection in corrective surgery for adolescent idiopathic scoliosis. Accordingly, we selected and reviewed five debatable topics related to fusion level selection: (1) selective thoracic fusion; (2) selective thoracolumbar-lumbar (TL-L) fusion; (3) adding-on phenomenon; (4) distal fusion level selection for major TL-L curves; and (5) proximal fusion level selection and shoulder imbalance.
  
  
  
  Selective fusion can be chosen in specific curve types, although there is a risk of coronal decompensation or adding-on phenomenon. Generally, wider indications for selective fusions are usually associated with more frequent complications. Despite the determination of several indications for selective fusion to avoid such complications, no clear guidelines have been established. Although authors have suggested various criteria to prevent the adding-on phenomenon, no consensus has been reached on the appropriate selection of lower instrumented vertebra. The fusion level selection for major TL-L curves primarily focuses on whether distal fusion can terminate at L3, a topic that remains unclear. Furthermore, because of the presence of several related factors and complications, proximal level selection and shoulder imbalance has been constantly debated and remains controversial from its etiology to its prevention.
  
  
  
  Although several difficult problems in the diagnosis and treatment of adolescent idiopathic scoliosis have been resolved by understanding its mechanism and via technical advancement, no definite guideline for fusion level selection has been established. A review of five major controversial issues about fusion level selection could provide better understanding of adolescent idiopathic scoliosis. We believe that a thorough validation study of the abovementioned controversial issues can help address them.
authors.affiliation: Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, PungNap-2-dong, SongPa-gu, Seoul 05505, Republic of Korea.
authors.forename: Choon Sung
authors.initials: CS
authors.lastname: Lee
authors.affiliation: Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, PungNap-2-dong, SongPa-gu, Seoul 05505, Republic of Korea.
authors.forename: Chang Ju
authors.initials: CJ
authors.lastname: Hwang
authors.affiliation: Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, PungNap-2-dong, SongPa-gu, Seoul 05505, Republic of Korea.
authors.forename: Dong-Ho
authors.initials: DH
authors.lastname: Lee
authors.affiliation: Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, PungNap-2-dong, SongPa-gu, Seoul 05505, Republic of Korea. Electronic address: spinecjh@gmail.com.
authors.forename: Jae Hwan
authors.initials: JH
authors.lastname: Cho
mesh_terms: D000293:Adolescent; D006801:Humans; D008159:Lumbar Vertebrae / Q000601:surgery; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control; D012600:Scoliosis / Q000601:surgery*; D013123:Spinal Fusion / Q000009:adverse effects / Q000379:methods*; D013904:Thoracic Vertebrae / Q000601:surgery
keywords: Adding-on; Adolescent idiopathic scoliosis; Coronal decompensation; Fusion level; Shoulder imbalance; Surgical treatment