Prevalence, Risk Factors, and Characteristics of the “Adding-On” Phenomenon in Idiopathic Scoliosis After Correction Surgery: A Systematic Review and Meta-Analysis

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Study Design.

A systematic review and meta-analysis.


To discuss the prevalence, risk factors, and characteristics of the “adding-on” phenomenon in idiopathic scoliosis (IS).

Summary of Background Data.

There are controversies on the prevalence and risk factors of the “adding-on” phenomenon. In addition, there is no comprehensive study to describe the characteristics of “adding-on” in IS patients.


We performed a systematic online search using PubMed, EMBASE, Web of Science, the Cochrane Library, and China WeiPu Library to identify eligible studies. Effect size (ES), odds ratios (OR), and weight mean difference (WMD) with 95% confidence interval (CI) were used to evaluate the incidence, characteristics, and risk factors for “adding-on,” respectively.


The overall pooled prevalence of “adding-on” was 14%. Subgroup analysis showed that the prevalence of “adding-on” in Lenke 1A adolescent idiopathic scoliosis (AIS), Lenke 2 AIS, Lenke 5 AIS, and mixed AIS was 15%, 12%, 9%, and 16%, respectively. AIS patients with the “adding-on” phenomenon had smaller proximal thoracic curve (PTC), main thoracic curve (MTC), clavicle angle, T1 tilt angle and radiographic shoulder height (RSH), and larger correction of PTC. Age, Risser sign, preoperative PTC, preoperative MTC, preoperative lumbar curve (LC), preoperative coronal balance and sagittal balance, and T4 tile were identified as risk factors of “adding-on.” Selection of lower instrumented vertebra (LIV) was also an important risk factor as LIV–Center Sacral Vertical Line (CSVL), LIV–end vertebra, LIV–Stable Vertebra, and LIV–Neutral vertebra, and deviation of LIV+1 was found to be significantly associated with “adding-on.” Besides, postoperative MTC was also significantly different between patients with and without “adding-on.”


The pooled prevalence varied differently in different types of IS. Patients with “adding-on” had smaller PTC, MTC, angle, T1 tilt angle and RSH, and larger correction of PTC. Younger age, less skeletal maturity, smaller preoperative PTC, smaller preoperative MTC, smaller preoperative LC, larger preoperative coronal, sagittal imbalance, selection of LIV, and overcorrection of coronal and sagittal alignment were risk factors for “adding-on.”


Level of Evidence: 4

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