• M K Kwan and C Y W Chan.
• Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, 50603, Kuala Lumpur, Malaysia.
• Eur Spine J. 2016 Oct 1; 25 (10): 3065-3074.

PurposeTo investigate whether an optimal upper instrumented vertebra (UIV) tilt angle would prevent 'lateral' shoulder imbalance or neck tilt (with 'medial' shoulder imbalance) post-operatively.MethodsThe mean follow-up for 60 AIS (Lenke 1 and Lenke 2) patients was 49.3 ± 8.4 months. Optimal UIV tilt angle was calculated from the cervical supine side bending radiographs. Lateral shoulder imbalance was graded using the clinical shoulder grading. The clinical neck tilt grading was as follows: Grade 0: no neck tilt, Grade 1: actively correctable neck tilt, Grade 2: neck tilt that cannot be corrected by active contraction and Grade 3: severe neck tilt with trapezial asymmetry >1 cm. T1 tilt, clavicle angle and cervical axis were measured. UIVDiff (difference between post-operative UIV tilt and pre-operative Optimal UIV tilt) and the reserve motion of the UIV were correlated with the outcome measures. Patients were assessed at 6 weeks and at final follow-up with a minimum follow-up duration of 24 months.ResultsAmong patients with grade 0 neck tilt, 88.2 % of patients had the UIV tilt angle within the reserve motion range. This percentage dropped to 75.0 % in patients with grade 1 neck tilt whereas in patients with grade 2 and grade 3 neck tilt, the percentage dropped further to 22.2 and 20.0 % (p = 0.000). The occurrence of grade 2 and 3 neck tilt when UIVDiff was <5°, 5-10° and >10° was 9.5, 50.0 and 100.0 %, respectively (p = 0.005). UIVDiff and T1 tilt had a positive and strong correlation (r 2 = 0.618). However, UIVDiff had poor correlation with clavicle angle and the lateral shoulder imbalance.ConclusionAn optimal UIV tilt might prevent neck tilt with 'medial' shoulder imbalance due to trapezial prominence and but not 'lateral' shoulder imbalance.

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