Abstract
Dear Editor,
We commend Sardi et al. for their comprehensive systematic review on the role of limited fusions in adult scoliosis, which highlights both the potential benefits and inherent limitations of short-segment fusion (SSF) in carefully selected patients. 1 The authors’ emphasis on tailoring surgical extent to symptom predominance and spinopelvic parameters is particularly important in an era of patient-specific surgical planning.
However, we would like to underscore two points that merit further consideration before broadly adopting SSF as an alternative to long-segment fusion (LSF) in adult scoliosis. First, while the review notes lower complication rates and shorter operative times with SSF, it also reports a higher frequency of extension surgeries after SSF in at least one comparative cohort focused on fractional curves. In the absence of prospective, parameter-matched comparisons, it remains uncertain how the early reduction in perioperative morbidity with SSF balances against the risk of later extension surgery in patients with borderline sagittal alignment or early degeneration proximal to the intended upper instrumented vertebra.
Second, the paper acknowledges that current evidence does not define spinopelvic cut-off values that predict durable success after SSF. Given the established correlation between sagittal malalignment, pelvic tilt, PI–LL mismatch, and health-related quality of life,2-4 it is plausible that even modest baseline deformity could experience progressive imbalance if mechanical drivers are not addressed at the index surgery. In our experience and learning, this consideration is particularly relevant for active patients with high functional demands: while postoperative stiffness is undesirable, under-correction may compromise long-term outcomes.
Future studies, ideally prospective and stratified by both coronal and sagittal parameters, are needed to clarify the true durability of SSF in various subgroups. Until such thresholds are better defined, we advocate for a cautious, data-driven approach: consider SSF primarily in patients with isolated fractional curves, minimal PI–LL mismatch, and preserved global alignment, while maintaining a low threshold for LSF in those with early signs of structural progression.
Sardi et al. have provided a valuable synthesis that advances this discussion. By continuing to refine patient selection criteria, the spine community can better balance the immediate advantages of less-invasive constructs with the need for durable, alignment-preserving outcomes.
Footnotes
Acknowledgments
We thank the authors of the original article for their valuable contribution to the field and for stimulating further discussion on this important topic. We also acknowledge the assistance of Grammarly, used after the manuscript was initially drafted, to improve clarity and grammar without altering the scientific content.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.