{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T01:16:54Z","timestamp":1779931014194,"version":"3.53.1"},"reference-count":19,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2024,9,20]],"date-time":"2024-09-20T00:00:00Z","timestamp":1726790400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2024,9,20]],"date-time":"2024-09-20T00:00:00Z","timestamp":1726790400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/100006034","name":"University of Southern California","doi-asserted-by":"crossref","id":[{"id":"10.13039\/100006034","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Spine Deform"],"published-print":{"date-parts":[[2025,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n          <jats:sec>\n            <jats:title>Purpose<\/jats:title>\n            <jats:p>This study compared shoulder balance outcomes in \u201crule breakers\u201d (RB) vs. \u201crule followers\u201d (RF) based on commonly utilized upper instrumented vertebrae (UIV) selection guidelines.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Methods<\/jats:title>\n            <jats:p>Adolescent idiopathic scoliosis (AIS) patients (Lenke 1\u20134) who underwent posterior spine fusion (PSF) with minimum 2-year follow-up had radiographic measurement of shoulder balance including first rib angle (FRA), T1 tilt, coracoid process height difference (CPHD), and clavicle angle (CA) at preop, postop, 6-month, 1-year, and 2-year timepoints. Postoperative outcomes were compared between RB and RF groups defined based on the UIV selection guidelines of Rose and Lenke.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Results<\/jats:title>\n            <jats:p>Among 88 patients (43 RF, 45 RB), age, gender, preoperative T1 tilt, FRA, CA, and CPHD were not significantly different between groups (p\u2009&gt;\u20090.05). Immediately post-surgery, the RF group had more balanced shoulders (CPHD: 11.6\u00a0mm vs. 15.7\u00a0mm, p\u2009=\u20090.033; CA: 2.8\u00b0 vs. 3.6\u00b0, p\u2009=\u20090.045; FRA: 3.4\u00b0 vs. 5.1\u00b0, p\u2009=\u20090.009; T1 tilt: 4.7\u00b0 vs. 6.1\u00b0, p\u2009=\u20090.045). At 2\u00a0years, no difference was observed between RF vs. RB in CA (2.3 vs. 2.2\u00b0, p\u2009=\u20090.857) and CPHD (8.5 vs. 8.1\u00a0mm, p\u2009=\u20090.791). FRA and T1 tilt were higher in RB vs. RF (FRA: 4.6 vs. 2.9\u00b0, p\u2009=\u20090.002; T1 tilt: 5.6 vs. 3.9, p\u2009=\u20090.008). Shoulder balance (CPHD\u2009&lt;\u20091\u00a0cm) was achieved in 73.1% of RB and 69.9% of RF at 2-year follow-up (p\u2009=\u20090.216).<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Conclusion<\/jats:title>\n            <jats:p>Adherence to commonly accepted UIV selection guidelines did not predict better shoulder balance. The RB group had worse shoulder balance immediately post-surgery, but also improved more over time. These results suggest the need to refine current UIV selection and management.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Level of evidence<\/jats:title>\n            <jats:p>III.<\/jats:p>\n          <\/jats:sec>","DOI":"10.1007\/s43390-024-00961-5","type":"journal-article","created":{"date-parts":[[2024,9,24]],"date-time":"2024-09-24T09:25:13Z","timestamp":1727169913000},"page":"189-194","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Rule breakers achieve successful shoulder balance: unraveling the myth of upper instrumented vertebrae selection criteria"],"prefix":"10.1007","volume":"13","author":[{"given":"Luke C.","family":"Drake","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter W.","family":"D\u2019Amore","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bailli","family":"Fontenot","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tyler A.","family":"Tetreault","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Manaf","family":"Younis","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claudia","family":"Leonardi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jaquelyn","family":"Valenzuela-Moss","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lindsay M.","family":"Andras","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0632-3367","authenticated-orcid":false,"given":"Michael J.","family":"Heffernan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2024,9,20]]},"reference":[{"issue":"4","key":"961_CR1","doi-asserted-by":"publisher","first-page":"521","DOI":"10.1016\/j.ocl.2007.06.001","volume":"38","author":"PS Rose","year":"2007","unstructured":"Rose PS, Lenke LG (2007) Classification of operative adolescent idiopathic scoliosis: treatment guidelines. Orthop Clin N Am 38(4):521\u2013529. https:\/\/doi.org\/10.1016\/j.ocl.2007.06.001","journal-title":"Orthop Clin N Am"},{"key":"961_CR2","doi-asserted-by":"publisher","DOI":"10.1097\/BRS.0b013e31829e0309","author":"M Yagi","year":"2013","unstructured":"Yagi M, Takemitsu M, Machida M (2013) Chest cage angle difference and rotation of main thoracic curve are independent risk factors of postoperative shoulder imbalance in surgically treated patients with adolescent idiopathic scoliosis. Spine (Phila Pa 1976). https:\/\/doi.org\/10.1097\/BRS.0b013e31829e0309","journal-title":"Spine (Phila Pa 1976)"},{"issue":"18","key":"961_CR3","doi-asserted-by":"publisher","first-page":"2013","DOI":"10.1097\/01.BRS.0000024162.02138.F9","volume":"27","author":"TR Kuklo","year":"2002","unstructured":"Kuklo TR, Lenke LG, Graham EJ et al (2002) Correlation of radiographic, clinical, and patient assessment of shoulder balance following fusion versus nonfusion of the proximal thoracic curve in adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 27(18):2013\u20132020. https:\/\/doi.org\/10.1097\/01.BRS.0000024162.02138.F9","journal-title":"Spine (Phila Pa 1976)"},{"issue":"9","key":"961_CR4","doi-asserted-by":"publisher","first-page":"2251","DOI":"10.1007\/s00586-018-5669-y","volume":"27","author":"S Ohrt-Nissen","year":"2018","unstructured":"Ohrt-Nissen S, Kamath VHD, Samartzis D et al (2018) Fulcrum flexibility of the main curve predicts postoperative shoulder imbalance in selective thoracic fusion of adolescent idiopathic scoliosis. Eur Spine J 27(9):2251\u20132261. https:\/\/doi.org\/10.1007\/s00586-018-5669-y","journal-title":"Eur Spine J"},{"issue":"2","key":"961_CR5","doi-asserted-by":"publisher","first-page":"358","DOI":"10.1007\/s00586-017-5289-y","volume":"27","author":"SF Zhang","year":"2018","unstructured":"Zhang SF, Zhang L, Feng XM et al (2018) Incidence and risk factors for postoperative shoulder imbalance in scoliosis: a systematic review and meta-analysis. Eur Spine J 27(2):358\u2013369. https:\/\/doi.org\/10.1007\/s00586-017-5289-y","journal-title":"Eur Spine J"},{"issue":"17","key":"961_CR6","doi-asserted-by":"publisher","first-page":"E1031","DOI":"10.1097\/BRS.0000000000003088","volume":"44","author":"JA Sielatycki","year":"2019","unstructured":"Sielatycki JA, Cerpa M, Beauchamp EC et al (2019) The amount of relative curve correction is more important than upper instrumented vertebra selection for ensuring postoperative shoulder balance in Lenke Type 1 and Type 2 Adolescent Idiopathic Scoliosis. Spine (Phila Pa 1976) 44(17):E1031\u2013E1037. https:\/\/doi.org\/10.1097\/BRS.0000000000003088","journal-title":"Spine (Phila Pa 1976)"},{"key":"961_CR7","unstructured":"Ilharreborde B, Even J, Lefevre Y et al How to determine the upper level of instrumentation in Lenke types 1 and 2 adolescent idiopathic scoliosis a prospective study of 132 patients"},{"key":"961_CR8","doi-asserted-by":"publisher","DOI":"10.31616\/asj.2022.0020","author":"T Banno","year":"2022","unstructured":"Banno T, Yamato Y, Hasegawa T et al (2022) Preoperative less right shoulder elevation had a higher risk of postoperative shoulder imbalance when main thoracic curve shows higher correction regardless of the upper instrumented vertebra level for patients with adolescent idiopathic scoliosis Lenke Type 1. Asian Spine J. https:\/\/doi.org\/10.31616\/asj.2022.0020","journal-title":"Asian Spine J"},{"issue":"12","key":"961_CR9","doi-asserted-by":"publisher","first-page":"1028","DOI":"10.1097\/BRS.0000000000001442","volume":"41","author":"X Tang","year":"2016","unstructured":"Tang X, Luo X, Liu C et al (2016) The spontaneous development of cosmetic shoulder balance and shorter segment fusion in adolescent idiopathic scoliosis with Lenke i curve. Spine (Phila Pa 1976) 41(12):1028\u20131035. https:\/\/doi.org\/10.1097\/BRS.0000000000001442","journal-title":"Spine (Phila Pa 1976)"},{"issue":"3","key":"961_CR10","doi-asserted-by":"publisher","first-page":"216","DOI":"10.1007\/s11420-015-9451-y","volume":"11","author":"BT Bjerke","year":"2015","unstructured":"Bjerke BT, Cheung ZB, Shifflett GD et al (2015) Do current recommendations for upper instrumented vertebra predict shoulder imbalance? An attempted validation of level selection for adolescent idiopathic scoliosis. HSS J 11(3):216\u2013222. https:\/\/doi.org\/10.1007\/s11420-015-9451-y","journal-title":"HSS J"},{"issue":"1","key":"961_CR11","doi-asserted-by":"publisher","first-page":"35","DOI":"10.1159\/000520955","volume":"57","author":"TC McDonald","year":"2022","unstructured":"McDonald TC, Gnam A, Weaver KJ et al (2022) Does obesity affect preoperative shoulder balance in adolescent idiopathic scoliosis? Pediatr Neurosurg 57(1):35\u201339. https:\/\/doi.org\/10.1159\/000520955","journal-title":"Pediatr Neurosurg"},{"issue":"10","key":"961_CR12","doi-asserted-by":"publisher","first-page":"3065","DOI":"10.1007\/s00586-016-4529-x","volume":"25","author":"MK Kwan","year":"2016","unstructured":"Kwan MK, Chan CYW (2016) Is there an optimal upper instrumented vertebra (UIV) tilt angle to prevent post-operative shoulder imbalance and neck tilt in Lenke 1 and 2 adolescent idiopathic scoliosis (AIS) patients? Eur Spine J 25(10):3065\u20133074. https:\/\/doi.org\/10.1007\/s00586-016-4529-x","journal-title":"Eur Spine J"},{"issue":"6","key":"961_CR13","doi-asserted-by":"publisher","first-page":"707","DOI":"10.1016\/j.jspd.2018.03.010","volume":"6","author":"J Brooks","year":"2018","unstructured":"Brooks J, Bastrom T, Bartley C et al (2018) In search of the ever-elusive postoperative shoulder balance: is the T2 UIV the Key? Spine Deformity 6(6):707\u2013711","journal-title":"Spine Deformity"},{"issue":"1","key":"961_CR14","doi-asserted-by":"publisher","first-page":"45","DOI":"10.1007\/s00586-008-0833-4","volume":"18","author":"XS Qiu","year":"2009","unstructured":"Qiu XS, Ma WW, Li WG et al (2009) Discrepancy between radiographic shoulder balance and cosmetic shoulder balance in adolescent idiopathic scoliosis patients with double thoracic curve. Eur Spine J 18(1):45\u201351. https:\/\/doi.org\/10.1007\/s00586-008-0833-4","journal-title":"Eur Spine J"},{"key":"961_CR15","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2474-15-366","author":"M Matsumoto","year":"2014","unstructured":"Matsumoto M, Watanabe K, Kawakami N et al (2014) Postoperative shoulder imbalance in Lenke Type 1A adolescent idiopathic scoliosis and related factors. BMC Musculoskelet Disord. https:\/\/doi.org\/10.1186\/1471-2474-15-366","journal-title":"BMC Musculoskelet Disord"},{"issue":"1","key":"961_CR16","doi-asserted-by":"publisher","first-page":"027","DOI":"10.1055\/s-0031-1296054","volume":"1","author":"TA Elfiky","year":"2011","unstructured":"Elfiky TA, Samartzis D, Cheung WY et al (2011) The proximal thoracic curve in adolescent idiopathic scoliosis: surgical strategy and management outcomes. Global Spine J 1(1):027\u2013036. https:\/\/doi.org\/10.1055\/s-0031-1296054","journal-title":"Global Spine J"},{"issue":"2","key":"961_CR17","doi-asserted-by":"publisher","first-page":"401","DOI":"10.1007\/s00586-015-4016-9","volume":"25","author":"MK Kwan","year":"2016","unstructured":"Kwan MK, Wong KA, Lee CK et al (2016) Is neck tilt and shoulder imbalance the same phenomenon? A prospective analysis of 89 adolescent idiopathic scoliosis patients (Lenke type 1 and 2). Eur Spine J 25(2):401\u2013408. https:\/\/doi.org\/10.1007\/s00586-015-4016-9","journal-title":"Eur Spine J"},{"issue":"3","key":"961_CR18","doi-asserted-by":"publisher","first-page":"198","DOI":"10.1111\/os.12399","volume":"10","author":"YM Jian","year":"2018","unstructured":"Jian YM, Yang SH, Hu MH (2018) Assessment of change of shoulder balance in patients with adolescent idiopathic scoliosis after correctional surgery. Orthop Surg 10(3):198\u2013204. https:\/\/doi.org\/10.1111\/os.12399","journal-title":"Orthop Surg"},{"issue":"9","key":"961_CR19","doi-asserted-by":"publisher","first-page":"519","DOI":"10.5435\/JAAOS-21-09-519","volume":"21","author":"PD Trobisch","year":"2013","unstructured":"Trobisch PD, Ducoffe AR, Lonner BS et al (2013) Choosing fusion levels in adolescent idiopathic scoliosis. J Am Acad Orthop Surg 21(9):519\u2013528. https:\/\/doi.org\/10.5435\/JAAOS-21-09-519","journal-title":"J Am Acad Orthop Surg"}],"container-title":["Spine Deformity"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s43390-024-00961-5.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s43390-024-00961-5\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s43390-024-00961-5.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,1,13]],"date-time":"2025-01-13T10:52:53Z","timestamp":1736765573000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s43390-024-00961-5"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,9,20]]},"references-count":19,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2025,1]]}},"alternative-id":["961"],"URL":"https:\/\/doi.org\/10.1007\/s43390-024-00961-5","relation":{},"ISSN":["2212-134X","2212-1358"],"issn-type":[{"value":"2212-134X","type":"print"},{"value":"2212-1358","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,9,20]]},"assertion":[{"value":"29 April 2024","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"22 August 2024","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"20 September 2024","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Lindsay M. Andras, MD has Stock or stock Options in Eli Lilly, is part of a Editorial or governing board of Journal of Pediatric Orthopedics; a Paid consultant; Paid presenter or speaker for Nuvasive; has Publishing royalties, financial or material support from Orthobullets; has received Royalties from Orthopediatrics; a Board or committee member of Pediatric Orthopaedic Society of North America; a Board or committee member of Scoliosis Research Society; and a Paid presenter or speaker for Zimmer Biomet. Luke C. Drake, Peter W. D\u2019Amore, Bailli Fontenot, Tyler A. Tetreault, Manaf Younis, Claudia Leonardi, Jacquelyn Valenzuela-Moss, and Michael J. Heffernan have no disclosures to report.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}},{"value":"This study has been carried out with approval from the Institutional Review Board at Children\u2019s Hospital Los Angeles.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical approval"}},{"value":"Informed consent was obtained from all individual participants included in the study.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent to participate"}}]}}