Psychosocial interventions for teenagers with adolescent idiopathic scoliosis: A systematic literature review

OBJECTIVES

Psychosocial interventions can improve teenagers' self-esteem, mental health and bracing compliance. There is a need to compile available evidence of psychosocial care in adolescent idiopathic scoliosis. This systematic review aimed to identify and evaluate the effects of existing interventional studies of psychosocial care for the adolescent idiopathic scoliosis population.

METHODS

A comprehensive search of relevant literature published from the inception to March 2023 was conducted using nine databases. A google scholar search was performed on 1 July 2023, to update the searching results. Two reviewers independently assessed the methodological quality and extracted details of the included studies. Given the heterogeneity of the selected articles, the findings were synthesized narratively without conducting a meta-analysis.

RESULTS

Four randomized controlled trials reported in six articles involving 385 teenagers were included. The interventions appeared acceptable with high recruitment rates and low dropout rates reported. Psychosocial interventions had shown significant positive effects on postoperative pain, engagement in daily and social activities as well as brace use, coping abilities and anxiety.

CONCLUSION

Psychosocial interventions are generally feasible and acceptable among the adolescent idiopathic scoliosis population and have produced positive effects on a variety of physical and psychosocial outcomes. Study findings need to be interpreted with caution due to the limited number of available articles and the methodological concerns of the reviewed articles.

PRACTICAL IMPLICATIONS

Well-designed clinical trials are warranted in people from cultural backgrounds to develop and implement effective psychosocial interventions for teenagers with adolescent idiopathic scoliosis, not only for those at the post-surgery stage but also for those receiving conservative treatment.

Assessment of reliability and validity of a handheld surface spine scanner for measuring trunk rotation in adolescent idiopathic scoliosis

PURPOSE

To assess the reliability and validity of a handheld scanner (SpineScan3D) for trunk rotation measurement in adolescent idiopathic scoliosis (AIS) subjects, as compared with Scoliometer.

METHODS

This was a cross-sectional study with AIS subjects recruited. Biplanar spine radiographs were performed using an EOS imaging system with coronal Cobb angle (CCA) determined. The angle of trunk rotation (ATR) was measured using Scoliometer. SpineScan3D was employed to assess the axial rotation of subjects' back at forward bending, recorded as surface tilt angle (STA). Intra- and inter-examiner repeats were conducted to evaluate the reliability of SpineScan3D.

RESULTS

97 AIS patients were recruited. Intra- and inter-examiner reliability of STA measures were good to excellent in major thoracic and lumbar curves (p < 0.001). A strong correlation was found between STA and ATR measures in both curve types (p < 0.001) with a standard error of the ATR estimate of between 1 and 2 degrees from linear regression models (R squared: 0.8-0.9, p < 0.001). A similar correlation with CCA was found for STA and ATR measures (r: 0.5-0.6, p < 0.002), which also demonstrated a similar sensitivity (72%-74%) and specificity (62%-77%) for diagnosing moderate to severe curves.

CONCLUSION

SpineScan3D is a handheld surface scanner with a potential of wide applications in subjects with AIS. The current study indicated that SpineScan3D is reliable and valid for measuring trunk rotation in AIS subjects, comparable to Scoliometer. Further studies are planned to investigate its measurements in coronal and sagittal planes and the potential of this device as a screening and monitoring tool.

TRIAL REGISTRATION NUMBER (DATE OF REGISTRATION)

HKUCTR-2288 (06 Dec 2017).

LEVEL OF EVIDENCE

Level III.

Clinical and radiographic outcomes following correction of idiopathic scoliosis in adolescence vs young adulthood

PURPOSE

The natural history of adolescent idiopathic scoliosis (AIS) has been well documented, but the impact of age at the time of surgical correction is relatively understudied. In this study, we matched patients undergoing surgical correction of adult idiopathic scoliosis (AdIS) with a cohort of AIS patients to compare: (1) coronal and sagittal radiographic correction, (2) operative variables, and (3) postoperative complications.

METHODS

A single-institution scoliosis registry was queried for patients undergoing idiopathic scoliosis surgery from 2000-2017.

INCLUSION CRITERIA

patients with idiopathic scoliosis, no previous spine surgery, and 2-year follow-up. AdIS patients were matched 1:2 with AIS patients based on Lenke classification and curve characteristics. Independent sample t-test and Chi-square test was used to analyze the data.

RESULTS

31 adults underwent surgical correction of idiopathic scoliosis and were matched with 62 adolescents. Mean age of adults was 26.2 ± 11.05, mean BMI was 25.6 ± 6.0, and 22 (71.0%) were female. Mean age of adolescents was 14.2 ± 1.8, mean BMI was 22.7 ± 5.7, and 41(66.7%) were female. AdIS had significantly less postoperative major Cobb correction (63.9% vs 71.3%, p = 0.006) and final major Cobb correction (60.6% vs 67.9%, p = 0.025). AdIS also had significantly greater postoperative T1PA (11.8 vs 5.8, p = 0.002). AdIS had longer operative times (p = 0.003), higher amounts of pRBCs transfused (p = 0.005), longer LOS (p = 0.016), more ICU requirement (p = 0.013), higher overall complications (p < 0.001), higher rate of pseudarthrosis (p = 0.026), and more neurologic complications (p = 0.013).

CONCLUSION

Adult patients undergoing surgical correction of idiopathic scoliosis had significantly worse postoperative coronal and sagittal alignment when compared with adolescent patients. Adult patients also had higher rates of complications, longer operative times, and longer hospital stays.

LEVEL OF EVIDENCE

III.

Translation and validation of the French version of the adolescent idiopathic scoliosis Truncal Anterior Asymmetry Scoliosis Questionnaire (TAASQ)

PURPOSE

Scoliosis is an abnormality which causes anterior trunk asymmetry. The Truncal Anterior Asymmetry Scoliosis Questionnaire-adolescent idiopathic scoliosis (AIS) (TAASQ) measures the feeling about anterior trunk appearance in girls with AIS. It comprises 14 questions which evaluate frontal asymmetry of breasts, shoulders, and waist as well as behavioral attitude. There is currently no validated questionnaire in French to evaluate truncal asymmetry in AIS girls. The aim of this study was to translate and validate the French version of the TAASQ (TAASQ-VF).

METHODS

The study reports the translation and transcultural adaptation of the TAASQ into French. The translation was tested on 20 patients to verify comprehension and modify if necessary. To assess the reliability of the translated version, each domain as well as the total measure were tested for internal consistency. Convergent validity was evaluated on 63 patients and test-retest on a sample of 15.

RESULTS

The translation and content validation process resulted in a French version of the TAASQ. Internal consistency was over 0.80 for each item, over 0.70 for each domain, and 0.88 for the total scores. SAQ were used to perform convergent validity with TAASQ-VF. The TAASQ-FV correlated well with many of the SAQ domains (p < 0.05) and every TAASQ-FV domain correlated with at least one SAQ domain (p < 0.05). Test-retest reliability for the total score and for each domain was good.

CONCLUSION

The translation and cross-cultural adaptation of the TAASQ questionnaire provides a French version that can measure the feeling about frontal appearance in girls with idiopathic scoliosis.

[Correlation analysis of Cobb angle and linear spinous process angle in adolescent idiopathic scoliosis]

OBJECTIVE

To analyze the correlation between Cobb angle and spinous process angle (SPA) on X-ray film and body surface in patients with mild to moderate adolescent idiopathic scoliosis(AIS). To explore the possibility of linear SPA to assess scoliosis.

METHODS

Retrospective study for correlation of Cobb angle and linear SPA on X-ray film. AIS patients treated and taken full spine anteroposterior X-ray from January 2019 to December 2021 were analyzed correlation of Cobb angle and linear SPA on X-ray film. Prospective study for correlation of Cobb angle and body linear SPA. AIS patients treated and taken full spine anteroposterior X-ray from December 1 to December 9 this year were analyzed correlation of Cobb angle and body linear SPA.

RESULTS

A total of 113 AIS patients with age an average of (14.02±2.16) years old(ranged from 10 to 18 years old) were recruited in retrospective study, involving 26 males and 87 females;there were 71 patients with mild AIS and 42 patients with moderate AIS. Cobb angle in AIS patients was significantly inversely associated with SPA(r=-0.564, P<0.001), the linear regression equation was:Cobb angle=169.444-0.878×SPA. Cobb angles in patients with mild scoliosis were significantly and inversely associated with SPA(r=-0.269, P=0.012), the linear regression equation was:Cobb angle=46.832-0.185×SPA. Cobb angles in patients with moderate scoliosis were also clearly correlated with SPA(r=-0.417, P=0.003), the linear regression equation was:Cobb angle=113.889-0.516×SPA. Thirty-eight patients were recruited in prospective study. The mean Cobb angle and body linear SPA were(18.70±6.98)°, ranged from 11.3° to 36.0° and (170.34±4.57)°, ranged from 162.1° to 177.7° respectively. There was significantly negative correlation(r=-0.651, P<0.001), the linear regression equation is:Cobb angle=187.91-0.99×SPA.

CONCLUSION

Linear SPA on X-ray film or on the body was significantly negatively correlated with Cobb angles, but the regression equation fits poorly, so it's not suitable for diagnosis of scoliosis;however, linear SPA is appropriate for self-controlled assessment of scoliotic therapy or for dynamic assessment of spinal flexibility.

Pregnancy and childbirth after adolescent idiopathic scoliosis surgery: A study of 80 pregnancies

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is a common spinal disease affecting 2% of adolescents, and women in 90% of the cases. When a surgical treatment is opted for, many questions are frequently asked by families and patients about the course of pregnancy and childbirth after the spinal fusion. This subject remains little studied in the literature, especially with modern instrumentation techniques.

HYPOTHESIS

The goal was to describe pregnancy and childbirth after AIS surgery in terms of access to epidural analgesia, need for cesarean section (c-section), and low back pain during and after pregnancy. We thus hypothesized that women undergoing spinal surgery for AIS have subsequently uncomplicated pregnancies and childbirths, and have access to epidural analgesia as women without AIS do.

PATIENTS AND METHODS

In this retrospective multicenter study, 198 women who underwent surgery between 1984 and 2014 were reviewed from two university hospitals. Among them, 50 women became pregnant, for a total of 80 pregnancies. Surgical data were collected [approach, uppermost and lowermost instrumented vertebra (UIV, LIV)]. Pregnancy characteristics were evaluated: time between surgery and pregnancy, number of births, mode of analgesia, type of delivery, weight gain. Occurrence of low back pain during pregnancy and at follow-up was recorded using ODI.

RESULTS

Of the 50 women, 34 had posterior surgery and 16 had anterior surgery. Deliveries took place from 1988 to 2018. Of the 80 pregnancies, 81% were delivered by vaginal route (n=65/80), and an effective epidural anesthesia was performed for 49% of them (n=39/80). Epidural analgesia failed in 9% of pregnancies (n=7/80), and was denied in 35% of cases (n=28/80), half of the time by anesthesiologists (n=15/80). Patients refused epidural in 13 pregnancies (16%, n=13/80). A general anesthesia was used in six pregnancies (8%, n=6/80), for c-sections only. Back pain was reported in 48% of the pregnancies (n=38/80). The level of fusion was correlated with c-section, and conversely with epidural anesthesia.

DISCUSSION

A normal pregnancy with vaginal delivery seems to be the rule for women undergoing spinal fusion for AIS. The c-section rate in AIS women was similar to the general population (19%). Yet, access to epidural anesthesia still seems problematic with only 49% of births in this series, compared with 81% in the French population.

LEVEL OF EVIDENCE

IV, retrospective cohort.

Enhanced recovery following posterior spinal fusion for adolescent idiopathic scoliosis: A medical and economic study in a French private nonprofit pediatric hospital

INTRODUCTION

Little data exist on the efficacy of enhanced recovery after surgery (ERAS) protocols in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

HYPOTHESIS

ERAS reduces hospital costs (HC) and length of stay (LOS) without increasing pain or complications.

MATERIALS AND METHODS

This was a retrospective comparative medical and economic study of 2 cohorts of patients who underwent PSF for AIS: a prospective group who underwent surgery with an ERAS protocol without a specially assigned care coordinator from 2020 to 2021 (n=30) and a retrospective group (control) who received standard care from 2017 to 2018 (n=30). The key amendments to the ERAS protocol were reduced preoperative investigations, opioid-sparing analgesia, ambulation starting on postoperative day (POD) 1, early resumption of oral diet, and early transition to oral analgesics. Moreover, an intensive care unit (ICU) stay, surgical drainage, and the postoperative CT scan were no longer routine. The discharge criteria were the same for both groups: normal bowel function, independent walking, pain Visual Analog Scale (VAS)<3 without strong opioids, and no signs of complications. The endpoints were: decreased HC (calculated by subtracting the costs of hospital days and complementary exams that were not carried out) and LOS, complications, and postoperative pain according to the VAS on POD 1, POD 3, and discharge. All means were reported with the standard deviation.

RESULTS

The mean age of patients undergoing surgery (14.5±1.7 years), sex ratio, curve type according to the Lenke classification, mean Cobb angle (54±12°), and the number of instrumented vertebrae (9±2) were similar in both groups (p>0.5). The HC decreased on average by 3029€ per patient. The mean LOS was 5±0.9 days in the ERAS group versus 6.5±0.6 days in the control group (p<0.001). The VAS scores on POD 1 and POD 3 were lower in the ERAS group. One postoperative complication was noted in each group.

CONCLUSION

Implementing an ERAS protocol without a specifically assigned care coordinator for patients with AIS undergoing PSF significantly decreased HC, LOS, and early postoperative pain.

LEVEL OF EVIDENCE

III; retrospective comparative study.

Static sitting posture control during writing tasks in idiopathic scoliosis among freshmen

BACKGROUND

The posture control deficit is one important dysfunction in adolescent idiopathic scoliosis (AIS) patients, which is related to the development of the disease. However, it is not apparent whether AIS could affect static sitting posture control in late adolescence.

OBJECTIVE

This study aims to compare static sitting posture control in idiopathic scoliosis freshmen with normal peers to reveal possible differences in posture stability between them during writing tasks.

METHODS

In total, there were 10 AIS patients and 11 normal college students chosen for the writing task test. Data on the distribution of gluteal pressure during sitting were gathered. The comparison between these two groups was made using the independent sample t-test.

RESULTS

The total excursion (TE) of the center of pressure (COP) of the AIS group considerably increased in comparison with the control group (CON) (p = 0.029). The AIS group's average COP velocity in the anteroposterior (AP) direction was significantly higher than the CON group (p = 0.048). The peak gluteal pressure on the right side was significantly higher in the AIS group than in the CON group (p = 0.039). The right gluteal contact area dynamic variation was significantly higher in the AIS group compared to the CON group (p = 0.025).

CONCLUSIONS

AIS patients showed increased gluteal pressure and lower sitting posture stability during writing tasks.

A targeted antibody-based array reveals a serum protein signature as biomarker for adolescent idiopathic scoliosis patients

BACKGROUND

Evident adolescent idiopathic scoliosis (AIS) incurs high treatment costs, low quality of life, and many complications. Early screening of AIS is essential to avoid progressing to an evident stage. However, there is no valid serum biomarker for AIS for early screening.

METHODS

Antibody-based array is a large-scale study of proteins, which is expected to reveal a serum protein signature as biomarker for AIS. There are two segments of the research, including biomarkers screening and validation. In the biomarkers screening group, a total of 16 volunteers participated in this study, and we carried out differentially expressed proteins screening via protein array assay between No-AIS group and the AIS group, through which GeneSet enrichment analysis was performed. In the validation group with a total of 62 volunteers, the differentially expressed proteins from screening group were verified by Enzyme-Linked immunosorbent assay (ELISA), and then multiple regression analysis.

RESULTS

In our study, there were twenty-nine differentially expressed proteins in AIS, through Protein array assay and GeneSet enrichment analysis in the biomarkers screening group. Then the expression of FAP, CD23 and B2M decreased as the degree of AIS increased via ELISA in validation group (FAP, p < 0.0001; CD23, p = 0.0002; B2M, p < 0.0001). Further, the results of multiple regression analysis showed that FAP, CD23 are linked to Cobb angle, whereas B2M were excluded because of multicollinearity.

CONCLUSIONS

Altogether, we found that serum protein FAP and CD23 are intimately related to AIS, suggesting FAP and CD23 are expected to serve as the serum biomarkers, which significantly facilitate frequent longitudinal monitoring as to keep track of disease progression and tailor treatment accordingly.

Can anterior vertebral body tethering provide superior range of motion outcomes compared to posterior spinal fusion in adolescent idiopathic scoliosis? A systematic review

PURPOSE

Anterior vertebral body tethering (AVBT) was introduced as a fusionless alternative to treating adolescent idiopathic scoliosis (AIS) while preserving range of motion (ROM). This is the first systematic review to compare the ROM outcomes between AVBT and PSF in treating AIS.

METHODS

We conducted a comprehensive search on PubMed, EMBASE, MEDLINE, and Cochrane Library. Inclusion criteria were patients with AIS treated with AVBT or PSF or both, and clearly defined ROM outcomes; exclusion criteria were scoliosis other than AIS, biomechanical or cadaveric studies, non-English publications, case reports, conference summaries, unpublished literature, commentaries, and reviews. Primary outcome was ROM. Secondary outcomes included Cobb angle correction, quality of life (QOL), complications, and muscle strength and endurance.

RESULTS

Twelve studies were included in this review. We found moderate evidence to support that AVBT results in superior ROM outcomes than PSF while achieving comparable Cobb angle correction with low evidence. The comparison of QOL outcomes between AVBT and PSF remained inconclusive. In addition to the complications noted conventionally in PSF, AVBT could result in over-correction and distal adding-on. We also found very low evidence to support that AIS patients treated with AVBT have superior muscle strength and endurance when compared to those treated with PSF.

CONCLUSIONS

AVBT provides better preservation of ROM and muscle strength postoperatively when compared with PSF, while achieving comparable curve correction. Future studies should explore the spinal growth trajectory to determine the window of opportunity for AVBT in AIS.

Vertebral body tethering in adolescent idiopathic scoliosis with more than 2 years of follow-up- systematic review and meta-analysis

BACKGROUND CONTEXT

Whilst spinal fusion remains the gold standard in the treatment of adolescent idiopathic scoliosis (AIS), anterior vertebral body tethering (AVBT) is gaining momentum with relatively few studies on its efficacy thus far.

PURPOSE

To conduct a systematic review reporting on the early results of AVBT for patients undergoing surgery for AIS. We aimed to systematically evaluate the relevant literature pertaining to the efficacy of AVBT with respect to degree of correction of the major curve Cobb angle, complications and revision rates.

STUDY DESIGN/SETTING

Systematic review.

PATIENT SAMPLE

Of a total of 259 articles, 9 studies met the inclusion criteria and were analysed. Overall, 196 patients of (mean age 12.08 years) underwent an AVBT procedure for correction of AIS with a mean follow-up of 34 months.

OUTCOME MEASURES

Degree of Cobb angle correction, complications and revision rates were used as outcome measures.

METHODS

A systematic review of the literature on AVBT was performed for studies published between Jan 1999-March 2021 applying the PRISMA guidelines. Isolated case reports were excluded.

RESULTS

Overall, 196 patients of (mean age 12.08 years) underwent an AVBT procedure for correction of AIS with a mean follow-up of 34 months. There was a significant correction of the main thoracic curve of scoliosis (mean preoperative Cobb angle 48.5°, post-operative Cobb angle at final follow-up of 20.1°, P = 0.01). Overcorrection and mechanical complications were seen in 14.3% and 27.5% of cases, respectively. Pulmonary complications including atelectasis and pleural effusion were seen in 9.7% of patients. Tether revision was performed in 7.85%, and revision to a spinal fusion in 7.88%.

CONCLUSION

This systematic review incorporated 9 studies of AVBT and 196 patients with AIS. The complication and revision to spinal fusion rates were 27.5% and 7.88%, respectively. The current literature on AVBT is restricted largely to retrospective studies with non-randomised data. We would recommend a prospective, multi-centre trial of AVBT with strict inclusion criteria and standardised outcome measures.

The relationship between physical activity, structural deformity, and spinal mobility in adolescent idiopathic scoliosis patients

PURPOSE

Adolescent idiopathic scoliosis (AIS) patients experience structural spinal deformity, but the impact of AIS on physical activity is not widely studied. Reports of physical activity levels between children with AIS and their peers are mixed. This study sought to characterize the relationship between spinal deformity, spinal range of motion, and self-reported physical activity in AIS patients.

METHODS

Patients aged 11-21 completed self-reported measures of physical activity using the HSS Pedi-FABS and PROMIS Physical Activity questionnaires. Radiographic measures were obtained from standing biplanar radiographic imaging. Surface topographic (ST) imaging data was obtained using a whole-body ST scanning system. Hierarchical linear regression models analyzed the relationship between physical activity, ST, and radiographic deformity while controlling for age and BMI.

RESULTS

149 patients with AIS (mean age 14.5 ± 2.0 years, mean Cobb angle 39.7° ± 18.9°) were included. In the hierarchical regression predicting physical activity from Cobb angle, no factors were significant predictors of physical activity. When predicting physical activity from ST ROM measurements, age and BMI served as covariates. No covariates or ST ROM measurements were significant predictors of physical activity levels for either activity measure.

CONCLUSIONS

Physical activity levels of patients with AIS were not predicted by levels of radiographic deformity or surface topographic range of motion. Although patients may experience severe structural deformity and range of motion limitations, these factors do not appear to be associated with decreased physical activity level utilizing validated patient activity questionnaires.

LEVEL OF EVIDENCE

Level II.

The evolution of pre-operative SRS scores over time in patients with adolescent idiopathic scoliosis

PURPOSE

To determine if preoperative Health Related Quality of Life (HRQoL) has declined in the past two decades for patients with Adolescent Idiopathic Scoliosis (AIS), as measured by the Scoliosis Research Society (SRS) questionnaire.

METHODS

A retrospective review was conducted on AIS patients that underwent surgery at a single institution between 2002 and 2022. Patients were included if they completed an SRS questionnaire preoperatively. A multivariate linear regression was performed with the SRS domains as the dependent variables. The independent variables were surgery year, gender, race/ethnicity, BMI, Lenke type, and major Cobb angle. A second regression was performed where the SRS scores for AIS patients were dichotomized as being above or below normal based on a threshold set at two standard deviations below the mean SRS scores of a healthy adolescent population. The binary SRS scores were used as the outcome of interest in a second regression.

RESULTS

A total of 1380 patients (79.2% female, mean age 14.9 ± 2.0 years old) were included for analysis. Surgery year had a negative association with Pain (coefficient = - 0.03, p < 0.0001), Activity (coefficient = - 0.02, p < 0.0001), Mental Health (coefficient = - 0.01, p < 0.0001), and Total score (coefficient = - 0.01, p < 0.0001), indicating declining HRQoL over time. Similarly, AIS patients became more likely to fall below 2SD of the healthy adolescent means in Pain (OR: 1.061, p < 0.0001), Appearance (OR: 1.023, p = 0.0301), Activity (OR: 1.044, p = 0.0197), and Total score (OR: 1.06, p < 0.0001).

CONCLUSION

Over the past two decades, patients with surgical AIS have experienced a significant decline in various HRQoL domains preoperatively.

Reduction in CT scan number with the reference frame middle attachment method in intraoperative CT navigation for adolescent idiopathic scoliosis

PURPOSE

Elucidate whether it is preferable to use the reference frame (RF) middle attachment (RFMA) method over the edge of the planned pedicle screw (PS) insertion area for RF placement in the surgery for adolescent idiopathic scoliosis (AIS) with intraoperative computed tomography (CT) navigation.

METHODS

Eighty-six consecutive patients (76 female and 10 male; mean age: 15.9 years) with AIS who underwent posterior spinal fusion using intraoperative CT navigation were enrolled. The group with the RF placed at the most distal part of the CT scan range was defined as the distal group (Group D), with other placements classified into the middle group (Group M). PS perforation rate and surgical outcome were compared between the groups.

RESULTS

There was no significant difference in perforation rate between Group M and Group D (3.4% vs. 3.0%, P = 0.754). The mean ± standard deviation number of instrumented vertebrae at the first CT scan was significantly higher in Group M (8.2 ± 1.2 vs. 6.3 ± 1.2, P < 0.001), while mean blood loss was significantly lower (266 ± 185 mL vs. 416 ± 348 mL, P = 0.011). The frequency of needing a second CT scan for PS insertion was significantly lower in Group M (38% vs. 69%, P = 0.04).

CONCLUSION

The RFMA method in thoracic scoliosis surgery for AIS with intraoperative CT navigation could significantly decrease the number of CT scans and blood loss while maintaining a comparable PS perforation rate to RF placement at the distal end of the planned PS insertion range.

Health-related quality of life of adult, non-surgically treated patients with idiopathic scoliosis and curves above 45°: a cross-sectional study at an average follow-up of 30 years

BACKGROUND CONTEXT

Previous studies on the natural history of moderate to severe idiopathic scoliosis show contradictory results. Some studies reported an increased incidence of back pain and disability in severe curves, while other studies reported no difference in health-related quality of life (HRQoL) compared to age-matched adult controls. None of these studies addressed HRQoL using currently recommended and validated questionnaires.

PURPOSE

To examine the long-term HRQoL in non-surgically treated adult idiopathic scoliosis patients with a curve of 45° or higher.

METHODS

In this retrospective cohort study, all patients were retrospectively identified in the hospital's scoliosis database. Patients (1) with idiopathic scoliosis; (2) born before 1981 (to ensure 25-year follow-up after skeletal maturity); (3) with a curve of 45° or more by Cobb's method at the end of growth; and (4) no spinal surgical treatment were selected. Patients received digital questionnaires of the Short Form-36, Scoliosis Research Society-22, Oswestry Disability Index and Numeric Rating Scale. Outcomes of the SF-36 were compared with a national reference cohort. Additional measures with questions regarding choice of education and occupation were used.

RESULTS

Forty-eight of 79 (61%) eligible patients completed the questionnaires, at an average follow-up time of 29.9 ± 7.7 years. Their average age was 51.9 ± 8.0, and median Cobb angle at adolescence was 48.5°. Five of the eight SF-36 subdomains were significantly lower in the scoliosis group compared to the nationwide cohort: physical functioning (73 vs 83, p = 0.011), social functioning (75 vs 84, p = 0.022), role physical functioning (63 vs 76, p = 0.002), role emotional functioning (73 vs 82, p = 0.032), and vitality (56 vs 69, p =  < 0.001). The scoliosis-specific SRS-22r score of the patients was 3.7 ± 0.7 on a 0-5 scale. The mean NRS score for pain of all patients was 4.9 ± 3.2, and eight patients (17%) reported a NRS of 0 and 31 (65%) a NRS above 3. At the Oswestry Disability Index, 79% of the patients reported minimal disabilities. Thirty-three patients (69%) reported that their scoliosis had influenced their choice of education. Fifteen patients (31%) reported that their scoliosis had influenced their choice of work.

CONCLUSION

Patients with idiopathic scoliosis and curves of 45° or higher have reduced HRQoL. Although many patients experience back pain, the disability reported on the ODI was limited. Scoliosis had noteworthy effect on choice of education.

Does Risser stage accurately predict the risk of curve progression in patients with adolescent idiopathic scoliosis treated with night-time bracing?

PURPOSE

Risser stage is widely used as a marker for skeletal maturity (SM) and thereby an indirect measure for the risk of progression of adolescent idiopathic scoliosis (AIS). The Scoliosis Research Society recommends bracing for Risser stages 0-2 as Risser stage 3 or above is considered low risk. Very few studies have assessed the risk of progression during bracing in Risser stages 3-4. The objective of the current study is to determine if Risser stages 3-4 provide a meaningful cutoff in terms of progression risk in patients with AIS treated with night-time bracing.

METHODS

AIS patients treated with night-time brace from 2005 to 2018 with a Cobb angle between 25 and 40 degrees and Risser stages 0-4 were retrospectively included. Curve progression (> 5 degrees increase) was monitored until surgery or SM. Skeletal maturity was defined as either 2 years postmenarchal, no height development or closed ulnar epiphyseal plates on radiographs.

RESULTS

One hundred and thirty-five patients were included (Risser stages 0-2: n = 86 and 3-4: n = 49). Overall, radiographic curve progression occurred in 52% while progression beyond 45 degrees was seen in 35%. The progression rate in the Risser 0-2 group was 60% and 37% in the Risser 3-4 group (p = 0.012). In multivariate logistic regression analysis, adjusted for Risser stages and age, only premenarchal status showed a statistically significant association with progression (OR: 2.68, 95%CI 1.08-6.67).

CONCLUSION

Risser stage does not provide a clinically meaningful differentiation of progression risk in AIS patients treated with a night-time brace. Risk assessment should include other more reliable measures of skeletal growth potential.

Selection of Optimal Lower Instrumented Vertebra for Adolescent Idiopathic Scoliosis Surgery

Adolescent idiopathic scoliosis (AIS) affects approximately 2% of adolescents across all ethnicities. The objectives of surgery for AIS are to halt curve progression, correct the deformity in 3 dimensions, and preserve as many mobile spinal segments as possible, avoiding junctional complications. Despite ongoing development in algorithms and classification systems for the surgical treatment of AIS, there is still considerable debate about selecting the appropriate fusion level. In this study, we review the literature on fusion selection and present current concepts regarding the lower instrumented vertebra in the selection of the fusion level for AIS surgery.

Three- instead of two-dimensional evaluation of key parameters alters the choice of the lowest instrumented vertebra in Lenke 1 and 2 AIS patients

PURPOSE

Treatment of AIS, a three-dimensional spinal (3D) deformity, is guided by a two-dimensional (2D) evaluation. Novel 3D approaches that address the 2D limitations have not been adopted in AIS care due to their lengthy and complex 3D reconstruction procedures. This study aims to introduce a simple 3D method that translates the 2D key parameters (Stable vertebra (SV), Lenke lumbar modifier, Neutral vertebra (NV)) into 3D and to quantitively compare these 3D corrected parameters to the 2D assessment.

METHODS

The key parameters of 79 surgically treated Lenke 1 and 2 patients were measured in 2D by two experienced spine surgeons. Next, these key parameters were measured in 3D by indicating relevant landmarks on biplanar radiographs and using the 'true' 3D CSVL which was perpendicular to the pelvic plane. Differences between the 2D and 3D analysis were examined.

RESULTS

A 2D-3D mismatch was identified in 33/79 patients (41.8%) for at least one of the key parameters. More specifically, a 2D-3D mismatch was identified in 35.4% of patients for the Sag SV, 22.5% of patients for the SV and 17.7% of patients for the lumbar modifier. No differences in L4 tilt and NV rotation were found.

CONCLUSION

The findings highlight that a 3D evaluation alters the choice of the LIV in Lenke 1 and 2 AIS patients. Although, the true impact of this more precise 3D measurement on preventing poor radiographic outcome needs further investigation, the results are a first step toward establishing a basis for 3D assessments in daily practice.

Does spinal deformity affect adolescents' quality of life before we tell them it should?

PURPOSE

The Scoliosis Research Society 22r Questionnaire(SRS-22r) is the standard for assessing health-related quality of life(HRQoL) in patients with adolescent idiopathic scoliosis. Here we investigate whether patients' perceptions of their HRQoL are influenced by knowledge of scoliosis and counseling by an orthopedic surgeon.

METHODS

Patients ages 10-18 years referred for their first visit with an orthopaedic surgeon for scoliosis were enrolled from 9/30/19 to 10/22/20. Patients completed the SRS-22r pre- and post-visit. A Wilcoxon signed-rank test was used to analyze the SRS-22r scores.

RESULTS

52 patients participated in the study at a mean age of 14.3 years (95% CI 13.8-14.8 years) with an average major curve magnitude of 23.2 degrees (95% CI 19.4-27.0 degrees). SRS-22r scores were not correlated to curve magnitude pre- or post-visit. The SRS-22r Satisfaction with care domain exhibited a small increase from pre- to post-visit (pre: 3.3, post: 3.6). All other SRS-22r domains and total scores did not exhibit clinically significant differences.

CONCLUSION

Among new adolescent referrals for scoliosis, it is unlikely that counseling by a surgeon influences perceptions of HRQoL as measured by the SRS-22r.

LEVEL OF EVIDENCE

III.

Lowest instrumented vertebrae selection in posterior fusion of Lenke 3C/6C adolescent idiopathic scoliosis: L3 versus L4, when LEV is L4

INTRODUCTION

In structural thoracolumbar/lumbar (TL/L) curves, lowest instrumented vertebra is selected mostly as the lower end vertebra (LEV). To save more lumbar mobile segments, fusion may be stopped one level proximal. This study aimed to compare the radiologic and functional outcomes of Lenke type 3C and 6C adolescent idiopathic scoliosis patients according to distal fusion level.

MATERIALS AND METHODS

109 patients with Lenke 3C and 6C AIS, which had L4 as LEV and underwent posterior fusion were retrospectively evaluated. Lowest instrumented vertebra (LIV) was selected intraoperatively either as L3 or L4 depending on the disc alignment below LIV. In 49 patiens LIV was L3, while 60 patients were fused to L4. Two groups were compared according to radiologic and clinical outcomes preoperatively and two years postoperatively. Operation times were recorded.

RESULTS

Preoperative values of both groups were similar. Regarding postoperative radiographic values, only LIV disc angle was different between groups, which was significantly higher in L3 group at two years follow-up. Coronal or sagittal imbalance was not observed. Surgical times and postoperative clinical outcomes were also similar.

CONCLUSIONS

In TL/L curves which have L4 as LEV, satisfactory results can be achieved with stopping the fusion at L3, if a proper disc alignment below LIV can be obtained intraoperatively. Higher amount of LIV disc angle in L3 group did not cause coronal and sagittal imbalance. Although clinical outcomes are similar with stopping at L3 or L4, fusion to L3 may be prefered to save one more mobile disc.

Lower socioeconomic status is not associated with severity of adolescent idiopathic scoliosis: a matched cohort analysis

PURPOSE

Assessing the influence of socioeconomic status (SES) on the severity of adolescent idiopathic scoliosis (AIS) on initial presentation to the spinal surgeon remains a challenge. The area deprivation index (ADI) is a validated measure of SES that abstracts multiple domains of disadvantage into a single score. We hypothesized that patients with low SES (high ADI) present to the orthopedic clinic with more advanced curve pathology.

METHODS

We retrospectively reviewed patients diagnosed with AIS. Subjects were assigned ADI scores based on Zip codes. Matched cohorts of high and low ADI were generated using propensity scores. Bivariate and multivariate analyses were performed to identify factors impacting the magnitude of the curve at presentation.

RESULTS

A total of 425 patients with appropriate imaging were included. After matching, the study population was 69.2% female and 92.3% Black. The mean BMI percentile was 61.9. Medicaid covered 57.3% of subjects, and 42.7% had commercial insurance. The mean ADI was 55.5. The mean Cobb angle at presentation was 33.6 degrees. Cobb angle was significantly greater among female patients (36.0 degrees vs 28.0) and among patients with greater BMI percentile (β = 0.127), but was not significantly associated with ADI, race, or insurance type. ADI was not associated with the rate of surgery.

CONCLUSION

ADI is not predictive of curve severity in pediatric patients presenting to the clinic for AIS. Female sex and BMI are independently associated with advanced curvature. Public health workers, primary care providers, and surgeons should remain aware of the complex interactions of socioeconomic factors, BMI and sex when addressing barriers to timely care.

LEVEL OF EVIDENCE

Prognostic Level III.

Patient-specific guide systems decrease the major perforation rate of pedicle screw placement in comparison to the freehand technique for adolescent idiopathic scoliosis

PURPOSE

This study aimed to compare the accuracy of pedicle screw (PS) placement between a low-profile three-dimensional (3D) printed patient-specific guide system and freehand technique for adolescent idiopathic scoliosis (AIS) surgery.

METHODS

Patients with AIS who underwent surgery between 2018 and 2023 at our hospital were included in the study. The 3D-printed patient-specific guide was used since 2021 (guide group). PS perforation was classified using Rao and Neo's classification (grade 0, no violation; grade 1, < 2 mm; grade 2, 2-4 mm; grade 3, > 4 mm). Major perforations were defined as grades 2 or 3. The major perforation rate of PS, operative time, estimated blood loss (EBL), and correction rate were compared between the two groups.

RESULTS

A total of 576 PSs were inserted in 32 patients (20 patients in the freehand (FH) group and 12 patients in the guide group). The major perforation rate was significantly lower in the guide group than in the FH group (2.1% vs. 9.1%, p < 0.001). Significantly fewer major perforations were observed in the guide group than in the FH group in the upper thoracic (T2-4) region (3.2% vs. 20%, p < 0.001) and lower thoracic (T10-12) region (0% vs. 13.8%, p = 0.001). The operative time, EBL, and correction rate were equivalent between the two groups.

CONCLUSION

The 3D-printed patient-specific guide notably reduced the major perforation rate of PS without increasing EBL and operative time. Our findings indicate that this guide system is reliable and effective for AIS surgery.

Correlation of radiographic parameters and patient satisfaction in adolescent idiopathic scoliosis treated with posterior screw-dual-rod instrumentation

PURPOSE

In surgical treatment of adolescent idiopathic scoliosis (AIS), only a few studies measure both, radiological parameters and PROMs and correlate them.

METHODS

Prospectively collected AIS-data of one scoliosis-center within a multicenter German-Spine-Society-Study. All patients underwent instrumented posterior spinal correction and fusion with pedicle-screw-dual-rod-systems from 05/2019 to 01/2021. The data were retrospectively analyzed.

INCLUSION CRITERIA

age 11-17 years, follow-up (FU) at least 12 months. Clinical data, radiographic parameters, and PROMs (SRS-30-questionnaire) were collected. 100% of patients had X-ray images, 88.2% completed SRS-30. Parameters were given as mean ± SD. Differences and subdivision by lower instrumented vertebra (LIV) were analyzed by students t-test (significancy a = 0.05), associations by Pearson's correlation.

RESULT

Total of 51 patients: 15 ± 1.4 years, BMI 20.7 ± 3.7 kg/m2, FU 16.6 ± 6.1 months, fusion length 9.2 ± 2.3 segments, implant density 93 ± 9%, surgical time 215 ± 71 min, mean blood loss 504 ± 360 ml. Mean preoperative Cobb angle of main curve 64 ± 14°, of secondary main curve 46 ± 12°, corrected by 68 ± 11%, 56 ± 17%, respectively. Mean thoracic rib and lumbar hump significantly decreased by - 8.5 ± 7.0° and - 7.7 ± 8.9° (p < 0.5). High thoracic rib hump almost unchanged, - 0.4 ± 2.8° (p = 0.3). Thoracic kyphosis (- 0.9 ± 12.8°, p = 0.6), lumbar lordosis (1.5 ± 10.1°, p = 0.3), clavicle angle (- 0.5 ± 2.7°) and spinopelvic parameters (p > 0.5) did not significantly change, only LIV-tilt from 24.5 ± 6.7° to 6.5 ± 4.3° (p < 0.05). PROMs significantly improved (p < 0.05), no significant improvement for function/activity (p = 0.4). Preoperative mean total-score was 3.6 ± 0.5, 4.2 ± 0.3 at FU(p < 0.05). Self-image improved in 67%. Moderately strong correlation for PROMs: the better LIV-tilt (r = - 0.5) correction and the shorter surgery time (r = - 0.4), the better SRS-30 total-score. No correlation for curve correction and patient's satisfaction.

CONCLUSION

In summary, results of this study demonstrate good surgical correction and significant improvement of most PROMs.

An intelligent composite model incorporating global / regional X-rays and clinical parameters to predict progressive adolescent idiopathic scoliosis curvatures and facilitate population screening

BACKGROUND

Adolescent idiopathic scoliosis (AIS) affects up to 5% of the population. The efficacy of school-aged screening remains controversial since it is uncertain which curvatures will progress following diagnosis and require treatment. Patient demographics, vertebral morphology, skeletal maturity, and bone quality represent individual risk factors for progression but have yet to be integrated towards accurate prognostication. The objective of this work was to develop composite machine learning-based prediction model to accurately predict AIS curves at-risk of progression.

METHODS

1870 AIS patients with remaining growth potential were identified. Curve progression was defined by a Cobb angle increase in the major curve of ≥6° between first visit and skeletal maturity in curves that exceeded 25°. Separate prediction modules were developed for i) clinical data, ii) global/regional spine X-rays, and iii) hand X-rays. The hand X-ray module performed automated image classification and segmentation tasks towards estimation of skeletal maturity and bone mineral density. A late fusion strategy integrated these domains towards the prediction of progressive curves at first clinic visit.

FINDINGS

Composite model performance was assessed on a validation cohort and achieved an accuracy of 83.2% (79.3-83.6%, 95% confidence interval), sensitivity of 80.9% (78.2-81.9%), specificity of 83.6% (78.8-84.1%) and an AUC of 0.84 (0.81-0.85), outperforming single modality prediction models (AUC 0.65-0.78).

INTERPRETATION

The composite prediction model achieved a high degree of accuracy. Upon incorporation into school-aged screening programs, patients at-risk of progression may be prioritized to receive urgent specialist attention, more frequent follow-up, and pre-emptive treatment.

FUNDING

Funding from The Society for the Relief of Disabled Children was awarded to GKHS.

Optimal lowest instrumented vertebra selection with consideration of coronal and sagittal planes to prevent distal junctional complications in patients with Lenke type 1A and 2A adolescent idiopathic scoliosis

PURPOSE

Postoperative distal adding-on and distal junctional kyphosis are major distal junctional complications after selective thoracic fusion in patients with adolescent idiopathic scoliosis (AIS). This study aimed to investigate the incidence of distal adding-on and distal junctional kyphosis and evaluate the validity of our selection criteria for the lowest instrumented vertebra (LIV) in patients with Lenke type 1A and 2A AIS.

METHODS

We retrospectively analyzed the data of patients with Lenke type 1A and 2A AIS, who underwent posterior fusion surgery. LIV selection included the followings: (1) stable vertebra on traction film, (2) disc space neutralization below the LIV on the side-bending film, and (3) lordotic disc below the LIV on the lateral film. Radiographic parameters and the revised 22-item Scoliosis Research Society Questionnaire (SRS-22r) were evaluated. The incidence of postoperative distal adding-on and distal junctional kyphosis was also investigated.

RESULTS

Ninety patients (83 women and 7 men; 64 with type 1A and 26 with type 2A) were included. After the operation, each curve and the SRS-22r of self-image, mental health, and subtotal domains were significantly improved. Distal adding-on occurred in three patients (3.3%, one in type 1A and two in type 2A) at 2 years postoperatively. No patients exhibited distal junctional kyphosis.

CONCLUSIONS

Our LIV selection criteria could reduce the incidence of postoperative distal adding-on and distal junctional kyphosis in patients with Lenke type 1A and 2A AIS.

LEVEL OF EVIDENCE

Level IV.

Can placement of hook at the upper instrumented level decrease the proximal junctional kyphosis risk in adolescent idiopathic scoliosis?

OBJECTIVE

Proximal junctional kyphosis is a commonly encountered clinical and radiographic phenomenon after pediatric and adolescent spinal deformity surgery that may lead to postoperative deformity, pain, and dissatisfaction. The purpose of the study was to identify whether the placement of transverse process hooks is an effective way to prevent PJK.

METHODS

Adolescent idiopathic scoliosis patients who underwent posterior spinal fusion between November 2015 and May 2019 were retrospectively analyzed. A minimum 2-year follow-up was required. Demographic and surgical data included UIV level type of instrumentation (hook vs screw) were reported. Radiologic parameters included main curve Cobb angle, thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), and proximal junctional angle (PJA) were assessed. Patients were divided into two groups based on the type of instrumentation at the UIV level whether placement of hook versus pedicle screw.

RESULTS

Three hundred and thirty-seven patients were included with the mean age 14.2 ± 1.9 years. Thirty patients (8.9%) were diagnosed with proximal junctional kyphosis radiographically. PJK incidence was found 3.2% (5/154) in the hook group and 13.3% (23/172) in the screw group and the difference found statistically significant. In the PJK group, preoperative thoracic kyphosis and the degree of kyphosis correction were also significantly higher than non-PJK patients.

CONCLUSION

Placement of transverse process hooks at the UIV level in posterior spinal fusion surgery for AIS patients was associated with decreased risk of PJK. A larger preoperative kyphosis and greater degree of kyphosis correction correlated with PJK.

Association between lean mass and adolescent idiopathic scoliosis: a meta-analysis

OBJECTIVE

The objective of this meta-analysis was to evaluate the association between lean mass and adolescent idiopathic scoliosis (AIS).

METHODS

English databases CENTRAL (The Cochrane Library and the Cochrane Back Review Group Trials Register), MEDLINE, EMBASE, PubMed, Web of Science and Chinese databases CBM, CNKI, VIP, WANGFANG DATA were searched for the relevant case control studies and cross-sectional studies. Two authors selected studies and extracted data independently. Data analysis was performed by Stata15.0.

RESULTS

Eight studies were included, with a total of 1771 cases of AIS and 6340 controls. AIS group had a lower lean mass compared to control group [MD =  - 1.95, 95% CI (- 2.96, - 0.93)]. In the subgroup analysis, female AIS patients had a lower lean mass than the control group [MD =  - 1.76, 95% CI (- 2.63, - 0.88)]. The mean difference of lean mass between AIS patients and control group in studies with adults [MD =  - 3.96, 95% CI (- 7.26, - 0.67)] is much greater than studies without adults [MD =  - 1.04, 95% CI (- 1.59, - 0.49)]. There was not statistically significant in European studies [MD =  - 2.10, 95% CI (- 4.35, 0.14)], but in Asian studies lean mass in AIS patients was lower than the control group [MD =  - 2.26, 95% CI (- 3.98, - 0.54)]. Study type, gender, age, and geography condition were thought to have no effect on the primary outcome of lean mass by subgroup analysis.

CONCLUSION

In the meta-analysis, AIS group had a lower lean mass compared to control group, which indicated that lean mass may be involved in the pathogenesis of AIS. But limited by the number of studies we included; the above conclusions need to be validated by more high-quality studies.

Accuracy of 3D printed spine models for pre-surgical planning of complex adolescent idiopathic scoliosis (AIS) in spinal surgeries: a case series

Adolescent idiopathic scoliosis (AIS) is a noticeable spinal deformity in both adult and adolescent population. In majority of the cases, the gold standard of treatment is surgical intervention. Technological advancements in medical imaging and 3D printing have revolutionised the surgical planning and intraoperative decision making for surgeons in spinal surgery. However, its applicability for planning complex spinal surgeries is poorly documented with human subjects. The objective of this study is to evaluate the accuracy of 3D printed models for complex spinal deformities based on Cobb angles between 40° to 95°.This is a retrospective cohort study where, five CT scans of the patients with AIS were segmented and 3D printed for evaluating the accuracy. Consideration was given to the Inter-patient and acquisition apparatus variability of the CT-scan dataset to understand the effect on trueness and accuracy of the developed CAD models. The developed anatomical models were re-scanned for analysing quantitative surface deviation to assess the accuracy of 3D printed spinal models. Results show that the average of the root mean square error (RMSE) between the 3DP models and virtual models developed using CT scan of mean surface deviations for the five 3d printed models was found to be 0.5±0.07 mm. Based on the RMSE, it can be concluded that 3D printing based workflow is accurate enough to be used for presurgical planning for complex adolescent spinal deformities. Image acquisition and post processing parameters, type of 3D printing technology plays key role in acquiring required accuracy for surgical applications.

Radiographical Results of Adolescent Idiopathic Scoliosis with Major Curve at Proximal Thoracic Spine

Introduction

Adolescent idiopathic scoliosis (AIS) with a major curve at the main thoracic (MT) area is classified as Lenke type 1, 2, or 3 depending on the flexibility of the proximal thoracic (PT) curve and lumbar curve. No definite classification has been established for a major curve at the PT spine. The purpose of this study is to investigate the radiographic characteristics before and after correction surgery for AIS with a major curve at the PT area.

Methods

This is a retrospective cohort study at a single academic institution. Twelve patients with a major curve at the PT spine participated in our study and followed for at least two years after surgery. We evaluated the pre- and postoperative Cobb angles of the curve, curve range, location of the apex, sagittal parameters, and shoulder balance-related parameters. All patients were treated by posterior correction and fusion surgery using pedicle screw constructs.

Results

The patients were classified as having a double-curve (DC) type, in which the MT curve was structural, or a single-curve (SC) type, in which the MT curve was corrected to less than 25° on supine side-bending films. The mean correction rates for the PT curve were favorable in both groups (DC, 65.7%±9.6%; SC, 39.2%±4.9%). The mean Cobb angle of the lumbar curve improved in the DC group (preoperative, 17.1°±4.0°; postoperative, 5.0°±4.2°) but deteriorated in the SC group (preoperative, 7.1°±1.2°; postoperative, 12.4°±4.4°) after surgery.

Conclusions

We illustrated the postoperative radiographical changes of 12 consecutive patients with the major curve at the PT curve. Although posterior correction and fusion surgery corrected the PT curve satisfactorily in both DC and SC patients, the Cobb angle of the lumbar curve deteriorated after surgery in all SC patients. Surgeons need to pay attention to the fusion area, especially LIV, when operating the SC curve type.

FTO-dependent m6A regulates muscle fiber remodeling in an NFATC1-YTHDF2 dependent manner

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is characterized by low lean mass without vertebral deformity. The cause-and-effect relationship between scoliosis and paraspinal muscle imbalance has long puzzled researchers. Although FTO has been identified as a susceptibility gene for AIS, its potential role in the asymmetry of paraspinal muscles has not been fully elucidated.

METHODS

We investigated the role of Fto in murine myoblast proliferation, migration, and myogenic differentiation. We examined its precise regulatory influence on murine muscle fiber remodeling in vitro and in vivo. We identified the downstream target gene of Fto by screening key regulators of murine muscle fiber remodeling and identified its m⁶A reader. Deep paraspinal muscle samples were obtained from the concave and convex sides of AIS patients with or without Schroth exercises, and congenital scoliosis served as a control group. We compared the content of type I fibers, expression patterns of fast- and slow-type genes, and levels of FTO expression.

RESULTS

FTO contributed to maintain the formation of murine slow-twitch fibers both in vitro and in vivo. These effects were mediated by the demethylation activity of FTO, which specifically demethylated NFATC1 and prevented YTHDF2 from degrading it. We found a significant reduction in type I fibers, mRNA levels of MYH7 and MYH7B, and expression of FTO on the concave side of AIS. The percentage of type I fibers showed a positive correlation with the expression level of FTO. The asymmetric patterns observed in AIS were consistent with those seen in congenital scoliosis, and the asymmetry of FTO expression and fiber type in AIS was largely restored by Schroth exercises.

CONCLUSIONS

FTO supports the formation of murine slow-twitch fibers in an NFATC1-YTHDF2 dependent manner. The consistent paraspinal muscle features seen in AIS and congenital scoliosis, as well as the reversible pattern of muscle fibers and expression of FTO in AIS suggest that FTO may contribute to the muscle fiber remodeling secondary to scoliosis.

Outcomes of vertebral body tethering in the lumbar spine

PURPOSE

The use of vertebral body tethering (VBT) for the treatment of main thoracic deformities in adolescent idiopathic scoliosis patients is becoming increasingly more common, but limited data exist on its safety and efficacy in thoracolumbar deformities. We aimed to evaluate the postoperative outcomes of patients with thoracolumbar (TL) deformities that were treated with VBT.

METHODS

We assessed clinical and radiographic data from twenty-eight consecutive patients that were surgically managed with VBT, all of whom exhibited a TL deformity with at least two years (mean: 44.7 ± 14.5 months) of postoperative follow-up. Standard radiographic parameters were extracted from left hand wrist and standing posterior-anterior and lateral spine radiographs at various timepoints. Outcome variables were assessed based on preoperative Lenke Classification and included: deformity measures, complications, surgical revisions, and postoperative success.

RESULTS

The mean age at the time of instrumentation was 13.4 ± 1.3 years, with an average preoperative Sanders Stage of 4.6 ± 1.4. A significant reduction in preoperative deformities was observed at most postoperative timepoints. A perioperative complication was observed in three patients and surgical revision was required in another four patients. A suspected broken tether was observed in sixteen patients, most of which occurred at the apex of the lumbar deformity. Only one patient required surgical revision due to a suspected broken tether. We observed an overall success rate of 57%, regardless of Lenke Classification.

CONCLUSIONS

These data indicate that VBT can successfully correct TL deformity patterns in 57% of patients without an increase in the rate of perioperative complications, suspected broken tethers, or surgical revisions.

Anterior vertebral body tethering for adolescent idiopathic scoliosis associated with less early post-operative pain and shorter recovery compared with fusion

PURPOSE

While posterior spinal instrumentation and fusion (PSIF) for severe adolescent idiopathic scoliosis (AIS) is the gold standard, anterior vertebral body tethering (AVBT) is becoming an alternative for select cases. Several studies have compared technical outcomes for these two procedures, but no studies have compared post-operative pain and recovery.

METHODS

In this prospective cohort, we evaluated patients who underwent AVBT or PSIF for AIS for a period of 6 weeks after operation. Pre-operative curve data were obtained from the medical record. Post-operative pain and recovery were evaluated with pain scores, pain confidence scores, PROMIS scores for pain behavior, interference, and mobility, and functional milestones of opiate use, independence in activities of daily living (ADLs), and sleeping.

RESULTS

The cohort included 9 patients who underwent AVBT and 22 who underwent PSIF, with a mean age of 13.7 years, 90% girls, and 77.4% white. The AVBT patients were younger (p = 0.03) and had fewer instrumented levels (p = 0.03). Results were significant for decreased pain scores at 2 and 6 weeks after operation (p = 0.004, and 0.030), decreased PROMIS pain behavior at all time points (p = 0.024, 0.049, and 0.001), decreased pain interference at 2 and 6 weeks post-operative (p = 0.012 and 0.009), increased PROMIS mobility scores at all time points (p = 0.036, 0.038, and 0.018), and faster time to functional milestones of weaning opiates, independence in ADLs, and sleep (p = 0.024, 0.049, and 0.001).

CONCLUSION

In this prospective cohort study, the early recovery period following AVBT for AIS is characterized by less pain, increased mobility, and faster recovery of functional milestones, compared with PSIF.

LEVEL OF EVIDENCE

IV.

Long-term adjacent segment degeneration at average 21-year follow-up of posterior instrumented fusion for adolescent idiopathic scoliosis

INTRODUCTION

Posterior instrumented fusion for progressive adolescent idiopathic scoliosis (AIS) is generally considered to have good outcomes, but very long-term reviews are rare. Data on adjacent segment degeneration (ASD) following posterior instrumented thoracic fusion for AIS are lacking. The primary aim was to assess the incidence of ASD and to correlate this with radiographic measures and patient-reported outcome measures (PROMs). The secondary aim was to assess maintenance of curve correction at very long-term follow-up.

METHODS

This single-surgeon consecutive case series of 47 AIS patients was identified from a prospectively collated dataset. As the primary outcome, ASD was assessed radiographically using the Mimura grading system. Pulmonary function tests and PROMs were assessed along with secondary radiographic outcome measures.

RESULTS

Radiographic follow-up was achieved in 77% (36/47) of patients at an average of 21 years (range, 16.5-26.5 years) after surgery. Radiographic evidence of ASD was seen in 64%. PROMs showed a mean Oswestry disability index of 12.1% with an overall Scoliosis Research Society 22 score averaging at 3.7 out of 5. The Coronal Cobb Angle was corrected from an average of 57° preoperatively to 19° immediately postoperatively, deteriorating to 22° at final review, maintaining a 61% curve correction.

CONCLUSIONS

Radiographic evidence of ASD was found in 64% of the cohort. The patient-reported outcome measures were good, with few limitations to activities.

Efficacy of perioperative gabapentin use in patients with idiopathic scoliosis undergoing fusion surgery: a systematic review and meta-analysis

PURPOSE

This study aimed to assess whether the perioperative use of gabapentin was associated with decreased opioid use.

METHODS

A meta-analysis was performed using PubMed, Embase, Scopus, and Cochrane Library. The randomized clinical trials included were focused on patients with adolescent idiopathic scoliosis who underwent posterior fusion surgery and were treated with gabapentin versus placebo medicine. The primary outcomes were opioid consumption at 24, 48, 72, and 96 h; time to introduction of oral medication, length of hospital stay, and period of urinary catheterization were also recorded. Data were combined using the Review Manager 5.4 software.

RESULTS

Four randomized clinical trials with a pool of 196 adolescent patients (mean age: 14.8 ± 2.0 years) were included. At 24 and 48 h after surgery, opioid consumption was significantly lower in the gabapentin group: (standardized mean difference [SMD]: -0.50; 95% confidence interval [CI] - 0.79 to - 0.22) and (SMD: - 0.59; 95% CI - 0.88 to - 0.30), respectively. At 72 and 96 h, there were no significant differences between studies: (SMD: - 0.19; 95% CI - 0.52 to 0.13) and (SMD: 0.12; 95% CI - 0.25 to 0.50), respectively. Regarding the administration type, there were significant differences in favor of the 15 mg/kg subgroup with 600 mg at 48 h (SMD: - 0.69; 95% CI - 1.08 to - 0.30). There were no significant differences concerning the time to introduction of oral medication (MD: - 0.08; 95% CI - 0.39 to 0.23), hospitalization time (MD: - 0.12; 95% CI - 0.40 to 0.16), or period of urinary catheterization (SMD: - 0.27; 95% CI - 0.58 to 0.05).

CONCLUSIONS

Gabapentin decreased opioid consumption during the first 48 h. Doses of 15 mg/kg showed superiority in reducing opioid consumption in the first 48 h.

LEVEL OF EVIDENCE I

Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

Satisfactory immediate spontaneous correction may not mean satisfactory final results for moderate TL/L curves after selective thoracic fusion in AIS patients

BACKGROUND

Few studies have focused on the chronic spontaneous behavior of the unfused TL/L curve during follow-up. The purpose of the present study was to explore the behavior of the unfused TL/L curve during a long-term follow-up to identify the risk factors for correction loss.

METHODS

Sixty-four age-matched female AIS patients undergoing selective thoracic fusion were enrolled. Patients were divided into 2 groups according to whether there was correction loss. Risk factors for correction loss of the unfused TL/L curves were analyzed. The relationship and difference between the immediate postoperative thoracic and TL/L Cobb angles were explored.

RESULTS

The TL/L Cobb angle was 28.17° before surgery, 8.60° after surgery, and 10.74° at the final follow-up, with a correction loss of 2.14°. Each subgroup contained 32 cases. A smaller postoperative TL/L Cobb angle was the only risk factor that was independently associated with TL/L correction loss. In the LOSS group, there was a significant difference and no correlation between the immediate postoperative TL/L and the thoracic Cobb angle. In the NO-LOSS group, there was a moderate correlation and no difference between them.

CONCLUSION

A smaller immediate postoperative TL/L Cobb angle may have been associated with TL/L correction loss during the long-term follow-up. Thus, good immediate postoperative spontaneous correction may not mean a satisfactory outcome at the final follow-up after STF. Mismatch between thoracic and TL/L Cobb angles immediately after surgery may also be related to correction loss of the unfused TL/L curves. Close attention should be paid in case of deterioration.

Biomechanics of the tether breakage: tensile behaviour of a single-unit vertebral body tethering construct

PURPOSE

Tether breakage was reported as the most common complication of vertebral body tethering. However, as the literature suggests the physiological loads do not have the potential to cause the failure of the tether. Currently, the biomechanical reason behind the tether breakage is unknown. The current study aims to elucidate the effects of the tension forces on the failure mechanisms of the VBT and provide mechanical justification for how it can be identified radiographically.

METHODS

Tensile tests (20%/min strain rate) were performed on single-unit VBT samples. Failure modes and mechanical characteristics were reported.

RESULTS

The failure took place prematurely due to the slippage of the tether at the screw-tether junction where the tether is damaged significantly by the locking cap. Slippage was initiated at 10-13% tensile strain level where the tensile stress and tension force were 50.4 ± 1.5 MPa and 582.2 ± 30.8 N, respectively.

CONCLUSION

The failure occurs because of high-stress concentrations generated within the locking region which damages the tether surface and leads to the slippage of the tether. We observed that the loads leading to failure are within the physiological limits and may indicate the high likelihood of the tether breakage. The failure mode observed in our study is shown to be the dominant failure mode, and a design improvement on the gripping mechanism is suggested to avoid failure at the screw-tether junction. We observed that the tether elongates 10-13% prior to the breakage, which can be employed as a diagnostic criterion to screen for tether breakages radiographically.

Radiograph-comparable image synthesis for spine alignment analysis using deep learning with prospective clinical validation

Background

Adolescent idiopathic scoliosis (AIS) is the most common type of spinal disorder affecting children. Clinical screening and diagnosis require physical and radiographic examinations, which are either subjective or increase radiation exposure. We therefore developed and validated a radiation-free portable system and device utilising light-based depth sensing and deep learning technologies to analyse AIS by landmark detection and image synthesis.

Methods

Consecutive patients with AIS attending two local scoliosis clinics in Hong Kong between October 9, 2019, and May 21, 2022, were recruited. Patients were excluded if they had psychological and/or systematic neural disorders that could influence the compliance of the study and/or the mobility of the patients. For each participant, a Red Green Blue-Depth (RGBD) image of the nude back was collected using our in-house radiation-free device. Manually labelled landmarks and alignment parameters by our spine surgeons were considered as the ground truth (GT). Images from training and internal validation cohorts (n = 1936) were used to develop the deep learning models. The model was then prospectively validated on another cohort (n = 302) which was collected in Hong Kong and had the same demographic properties as the training cohort. We evaluated the prediction accuracy of the model on nude back landmark detection as well as the performance on radiograph-comparable image (RCI) synthesis. The obtained RCIs contain sufficient anatomical information that can quantify disease severities and curve types.

Findings

Our model had a consistently high accuracy in predicting the nude back anatomical landmarks with a less than 4-pixel error regarding the mean Euclidian and Manhattan distance. The synthesized RCI for AIS severity classification achieved a sensitivity and negative predictive value of over 0.909 and 0.933, and the performance for curve type classification was 0.974 and 0.908, with spine specialists' manual assessment results on real radiographs as GT. The estimated Cobb angle from synthesized RCIs had a strong correlation with the GT angles (R² = 0.984, p < 0.001).

Interpretation

The radiation-free medical device powered by depth sensing and deep learning techniques can provide instantaneous and harmless spine alignment analysis which has the potential for integration into routine screening for adolescents.

Funding

Innovation and Technology Fund (MRP/038/20X), Health Services Research Fund (HMRF) 08192266.

Clinical differences in preoperative symptoms and surgical outcomes between early and late-teen patients with Lenke type 5C adolescent idiopathic scoliosis

PURPOSE

This study aimed to compare the clinical features and postoperative outcomes in patients with Lenke type 5C AIS in the early and late teens.

METHODS

The study included eligible patients with AIS aged < 20 years with Lenke type 5C curves who underwent selective thoracolumbar/lumbar (TL/L) fusion. The patients were divided into two groups according to the age: younger (11-15 years) and older (16-19 years). Demographic data, radiographic parameters, and 22-item scoliosis research society questionnaire (revised) (SRS-22r) scores were compared.

RESULTS

Seventy-three (female: 69, male: 4, mean age: 15.1 years) patients were included. There were 45 and 28 patients in the younger and older groups, respectively. The older group exhibited a significantly smaller TL/L curve than the younger group, whereas no between-group differences were identified regarding curve flexibility and fusion length. The change in coronal balance and subjacent disc angle from preoperative to 2 years after surgery was significantly greater in the younger group, although each curve was equally corrected. Preoperative SRS-22r scores in the older group were significantly worse; however, they improved to the level of the younger group at 2 years after surgery. Postoperative coronal malalignment was observed in six patients (21.4%) in the older group, whereas no cases in the younger group (p < 0.05).

CONCLUSION

In patients with Lenke type 5C AIS, we showed that late teens had significantly worse SRS-22r scores than did early teens. Postoperative coronal malalignment was frequently observed in the late teens due to the reduced ability of compensation by subjacent disc wedging.

Minimalistic approach to enhanced recovery after pediatric scoliosis surgery

PURPOSE

Prior studies of enhanced recovery protocols (ERP) have been conducted at large institutions with abundant resources. These results may not apply at institutions with less resources directed to quality improvement efforts. The purpose of this study was to assess the value of a minimalistic enhanced recovery protocol in reducing length of stay (LOS) following PSF for adolescent idiopathic scoliosis. We hypothesized that accelerated transition to oral pain medications and mobilization alone could shorten hospital length of stay in the absence of a formal multimodal pain regimen.

METHODS

AIS patients aged 10-18 who underwent PSF at a tertiary pediatric hospital between January 1, 2014 and December 31, 2017 were reviewed. The study population was further narrowed to consecutive patients from a single surgeon's practice that piloted the modified ERP. Reservation from key stakeholders regarding the feasibility of implementing widespread protocol change led to the minimal alterations made to the postoperative protocol following PSF. Patients were divided into either the Standard Recovery Protocol (SRP) or Enhanced Recovery Protocol (ERP). Primary variables analyzed were hospital LOS, complications, readmissions, and total narcotic requirement.

RESULTS

A total of 92 patients met inclusion criteria. SRP and ERP groups consisted of 44 (47.8%) and 48 (52.2%) patients. There was no difference between the two groups with regard to age, sex, and ASA score (p > 0.05). Fusion levels and EBL did not differ between treatment groups (p > 0.05). PCA pumps were discontinued later in the SRP group (39.5 ± 4.3 h) compared to the ERP group (17.4 ± 4.1 h, p < 0.0001). Narcotic requirement was similar between groups (p = 0.94) Patients in the SRP group had longer hospital stays than patients in the ERP group (p < 0.0001). 83% of the ERP group had LOS ≤ 3 days compared to 0% in the SRP group, whose mean LOS was 4.2 days. There was no difference in complications between the groups (2.2% vs 6.0%, p = 0.62). Readmission to the hospital within 30 days of surgery was rare in either group (2 SRP patients: 1 superior mesenteric artery syndrome, 1 bowel obstruction vs 0 ERP patients, p = 0.23).

CONCLUSION

In this cohort, minor changes to the postoperative protocol following surgery for AIS led to a significant decrease in hospital length of stay. This minimalistic approach may ease implementation of an ERP in the setting of stakeholder apprehension.

Inter-screw index as a novel diagnostic indicator of tether breakage

PURPOSE

Tether breakage is the most common complication of Vertebral Body Tethering (VBT) occurring in up to 52% of Adolescent Idiopathic Scoliosis (AIS) patients and risks continued progression and revision. Radiographical diagnosis of tether breakage is commonly defined by a 5° increase in inter-screw angle and associates breakage with loss of correction. However, the sensitivity of this method was 56% only, suggesting that tethers can break without an increase in angulation, which was supported by other studies. To our knowledge, current literature lacks a method merely focusing on the diagnosis of tether breakage radiographically that does not associate the breakages with loss of correction.

METHODS

This was a retrospective review of prospectively collected data of AIS patients who underwent VBT. The "inter-screw index" is defined as the percentage increase in inter-screw distance since post-op, with ≥ 13% increase defined as tether breakage as suggested by our mechanical tests. CTs were reviewed to identify the breakages and compared with inter-screw angle and inter-screw index.

RESULTS

94 segments from 13 CTs were reviewed, and 15 tether breakages were identified. Use of inter-screw index correctly identified 14 breakages (93%), whereas ≥ 5° increase in inter-screw angle only identified 12 breakages (80%).

CONCLUSION

Use of inter-screw index is proven to be more sensitive than inter-screw angle in identifying tether breakages. Therefore, we propose the use of inter-screw index to diagnose tether breakages radiographically. Tether breakages were not necessarily accompanied by a loss of segmental correction leading to an increase in inter-screw angle, especially after skeletal maturity.

LEVEL OF EVIDENCE

Level 3.

Influence of the thoracolumbar junction flexibility on the risk of adding-on after posterior vertebral arthrodesis for thoracic idiopathic adolescent scoliosis

PURPOSE

The objective was to analyze the role of the thoracolumbar sagittal flexibility on the outcome after posterior spinal fusion of Lenke 1 and 2 adolescent idiopathic scoliosis with last touched vertebra as the lowest instrumented vertebra.

METHODS

We included 105 thoracic AIS patients who had a posterior spinal fusion with a 2 years minimum follow-up. Thoracolumbar junction flexibility was assessed on dynamic sagittal X-rays and compared to the standing position. Adding-on was defined according to radiographic Wang criteria. The junction was considered flexible if the variability from the static position to flexion and/or extension was greater than 10°.

RESULTS

Mean age of the patients was 14 ± 2 years. The preoperative mean Cobb angle was 61 ± 12.7° and 27.5 ± 7.7° after surgery. Mean follow-up was 3.1 years. Twenty-nine patients (28%) developed an adding-on. Thoracolumbar junction range of motion was higher (p = 0.017) with higher flexibility in flexion (p < 0.001) in the no adding-on group. In no adding-on group, 53 patients (70%) had a flexible thoracolumbar junction, and 23 patients (30%) had a stiff thoracolumbar junction in flexion and flexible in extension. In adding-on group, 27 patients (93%) had a stiff thoracolumbar junction, and 2 patients (7%) had a flexible junction in flexion and stiff in extension.

CONCLUSION

The flexibility of the thoracolumbar junction is a determining factor in the surgical outcome after posterior spinal fusion for AIS and should be considered in correlation with the frontal and sagittal alignment of the spine.

3D surface topographic measurements for idiopathic scoliosis are highly correlative to patient self-image questionnaires

PURPOSE

Adolescent idiopathic scoliosis (AIS) is a deformity of the spine that results in external asymmetry of the torso in the shoulder, waist, and rib hump. Several patient reported outcome measures (PROMS) including the Trunk Appearance Perception Scale (TAPS) and SRS-22r self-image domain are used to measure the patient's self-perception. The purpose of this study is to investigate the relationship between objective surface topographic measurements of the torso to subjective patient self-perception.

METHODS

131 AIS subjects and 37 controls participated in this study. All subjects completed TAPS and SRS-22r PROMS followed by whole body 3d surface topographic scanning. An automated analysis pipeline was used to compute 57 measurements. Multivariate linear models were developed to predict TAPS and SRS-22r self-image using each unique combination of 3 parameters and leave one out validation where the best combinations were selected.

RESULTS

Back surface rotation, waist crease vertical asymmetry and rib prominence volume were most predictive of TAPS. The final predicted TAPS values from leave one out cross validation was correlated to ground truth TAPS scores with an R value of 0.65. Back surface rotation, silhouette centroid deviation, and shoulder normal asymmetry were most predictive of SRS-22r self-image with a correlation of R = 0.48.

CONCLUSION

Surface topographic measurements of the torso are correlated to TAPS and SRS-22r self-image scores in AIS patients and controls, with TAPS exhibiting a stronger relationship, better reflecting the patient's external asymmetries.

Saudi patients outcomes after surgical treatment of adolescent idiopathic scoliosis

BACKGROUND

In order to improve post-operative patient's quality-of-life, attention must be paid to the identification of factors that play a role in patient's satisfaction with surgical treatment. Patient satisfaction with the outcomes of scoliosis surgery has not been addressed so comprehensively in Saudi literature, as well as the effect of patient satisfaction on the different domains of the SRS-22 questionnaire and radiographic parameters is yet to be reported locally. The aim of this study is to explore such findings especially in our population.

METHODS

A retrospective cohort study was conducted at two of the largest centers of spine surgery in the Kingdom of Saudi Arabia. A total of 316 eligible patients were selected via consecutive sampling technique. Data were collected from eligible patients who fit our inclusion criteria, which includes patients with adolescent idiopathic scoliosis aged from 10 to 21 years. Student t test, Pearson's and Spearman's correlation coefficients statistical tests were used.

RESULTS

There were 283 (89.6%) females and 33 (10.4%) male patients with a mean age of 15.09 (± 2.27 SD) years. All the domains of SRS-22 showed significantly higher scores 2-year postoperatively, when compared with preoperative values (P < 0.001). The change in all SRS-22 domains correlated positively and significantly with the 2-year postoperative satisfaction using Pearson's correlation coefficient (P < 0.05); the total score showed the highest correlation followed by the self-image domain. The major Cobb angle correction percentage correlated significantly (P < 0.05) solely with the change in pain domain.

CONCLUSION

Self-image correlated highly and significantly with patient satisfaction postoperatively. It also had the biggest influence SRS-22 scores postoperatively in conjunction with satisfaction scores. That is an indication of the role it plays in patient satisfaction and quality-of-life postoperatively, which may influence the surgical decision making.

Can the proximal humeral ossification system (PHOS) effectively guide brace weaning in patients with adolescent idiopathic scoliosis?

PURPOSE

The proximal humeral epiphyses can be conveniently viewed in routine spine radiographs. This study aimed to investigate whether the proximal humeral epiphyseal ossification system (PHOS) can be used to determine the timing of brace weaning in adolescent idiopathic scoliosis (AIS), as assessed by the rate of curve progression after brace weaning.

METHODS

A total of 107 patients with AIS who had weaned brace-wear at Risser Stage  ≥  4, no bodily growth and post-menarche  ≥  2 years between 7/2014 and 2/2016 were studied. Increase in major curve Cobb angle > 5° between weaning and 2-year follow-up was considered curve progression. Skeletal maturity was assessed using the PHOS, distal radius and ulna (DRU) classification, Risser and Sanders staging. Curve progression rate per maturity grading at weaning was examined.

RESULTS

After brace-wear weaning, 12.1% of the patients experienced curve progression. Curve progression rate for weaning at PHOS Stage 5 was 0% for curves < 40°, and 20.0% for curves ≥ 40°. No curve progression occurred when weaning at PHOS Stage 5 with radius grade of 10 for curves ≥ 40°. Factors associated with curve progression were: Months post-menarche (p = 0.021), weaning Cobb angle (p = 0.002), curves < 40° versus ≥ 40° (p = 0.009), radius (p = 0.006) and ulna (p = 0.025) grades, and Sanders stages (p = 0.025), but not PHOS stages (p = 0.454).

CONCLUSION

PHOS can be a useful maturity indicator for brace-wear weaning in AIS, with PHOS Stage 5 having no post-weaning curve progression in curves < 40°. For large curves ≥ 40°, PHOS Stage 5 is also effective in indicating the timing of weaning together with radius grade ≥ 10.

Relationship between lumbosacral transitional vertebra and postoperative outcomes of patients with Lenke 5C adolescent idiopathic scoliosis: a minimum 5-year follow-up study

PURPOSE

To assess the incidence of lumbosacral transitional vertebra (LSTV) in Lenke 5C adolescent idiopathic scoliosis (AIS) and evaluate the relationship between postoperative outcomes and LSTV when the lowest instrumented vertebra (LIV) is fixed at L3.

METHODS

The study included 61 patients with Lenke 5C AIS who underwent fusion surgery of L3 as the LIV who were followed-up for a minimum of 5 years. Patients were divided into two groups: LSTV + and LSTV-. Demographic, surgical, and radiographic data, including L4 tilt and thoracolumbar/lumbar (TL/L) Cobb angle, were obtained and analyzed.

RESULTS

LSTV was observed in 15 patients (24.5%). The L4 tilt was not significantly different between the two groups preoperatively (P = 0.54); however, it was significantly greater in the LSTV group postoperatively (2 weeks: LSTV +  = 11.7 ± 3.1, LSTV -  = 8.8 ± 3.2, P = 0.013; 2 years: LSTV +  = 11.5 ± 3.5, LSTV -  = 7.9 ± 4.1, P = 0.006; 5 years: LSTV +  = 9.8 ± 3.1, LSTV -  = 7.3 ± 4.5,  P= 0.042). The postoperative TL/L curve was greater in the LSTV + group, with significant differences at 2 weeks and 2 years postoperatively (preoperative: LSTV +  = 53.5 ± 11.2, LSTV -  = 51.7 ± 10.3,P = 0.675; 2 weeks: LSTV +  = 16.1 ± 5.0, LSTV- = 12.2 ± 6.6, P = 0.027; 2 years: LSTV +  = 21.7 ± 5.9, LSTV -  = 17.6 ± 5.9, P = 0.035; 5 years: LSTV +  = 18.7 ± 5.8, LSTV -  = 17.0 ± 6.1, P = 0.205).

CONCLUSION

The prevalence of LSTV in Lenke 5C AIS patients was 24.5%. Lenke 5C AIS patients with LSTV with the LIV at L3 had a significantly greater postoperative L4 tilt than those without LSTV and retained the TL/L curve.

Intermittent pedicle screw application provides better kyphosis restoration in adolescent idiopathic scoliosis for Lenke type 1 and type 2 curves

PURPOSE

There is still no consensus on the optimum pedicle screw density required for the desired thoracic kyphosis restoration in adolescent idiopathic surgery (AIS). The aim of this study to evaluate the effect of pedicle screw density on thoracic kyphosis restoration in AIS surgery.

METHODS

The data of 106 patients from two centers that operated for Lenke type 1 and 2 AIS were retrospectively reviewed. Two groups were constituted according to the pedicle screw density: intermittent pedicle screw constructs (IPSC) (n = 52 patients) and consecutive pedicle screw construct (CPSC) (n = 54 patients) groups. The preoperative and at least 24-month follow-up radiographs and SRS-22 scores were evaluated. The Cobb angle of the main and concomitant curves in the coronal plane and the sagittal plane were measured and compared.

RESULTS

The mean follow-up period for the IPSC and CPSC groups was 72.3 ± 37.2 and 62.9 ± 28.8 months, respectively. In the SRS-22 questionnaire, there was no significant difference between the two groups in terms of self-image/appearance domain scores (p = 0.466), but better results were obtained in the IPSC group in terms of treatment satisfaction domain scores (p = 0.010) and better thoracic kyphosis restoration was achieved in IPSC group radiologically for Lenke type 1 curves with - 81.4 ± 81.4% in the IPSC group and 6.8 ± 83.8% in the CPSC group (p < 0.001).

CONCLUSION

It was considered that better thoracic kyphosis restoration could be achieved with the less lordotic effect of IPSC in Lenke type 1 curves. Although the current situation had a significant impact on radiological outcomes, its effect on SRS-22 scores was limited.

Patient and surgical predictors of 3D correction in posterior spinal fusion: a systematic review

BACKGROUND

Restoration of three-dimensional (3D) alignment is critical in correcting patients with adolescent idiopathic scoliosis using posterior spinal fusion (PSF). However, current studies mostly rely on 2D radiographs, resulting in inaccurate assessment of surgical correction and underlying predictive factors. While 3D reconstruction of biplanar radiographs is a reliable and accurate tool for quantifying spinal deformity, no study has reviewed the current literature on its use in evaluating surgical prognosis.

PURPOSE

To summarize the current evidence on patient and surgical factors affecting sagittal alignment and curve correction after PSF based on 3D parameters derived from reconstruction of biplanar radiographs.

METHODS

A comprehensive search was conducted by three independent investigators on Medline, PubMed, Web of Science, and Cochrane Library to obtain all published information on predictors of postoperative alignment and correction after PSF. Search items included "adolescent idiopathic scoliosis," "stereoradiography," "three-dimensional," "surgical," and "correction." The inclusion and exclusion criteria were carefully defined to include clinical studies. Risk of bias was assessed with the Quality in Prognostic Studies tool, and level of evidence for each predictor was rated with the Grading of Recommendations, Assessment, Development, and Evaluations approach. 989 publications were identified, with 444 unique articles subjected to full-text screening. Ultimately, 41 articles were included.

RESULTS

Strong predictors of better curve correction included preoperative normokyphosis (TK > 15°), a corresponding rod contour, intraoperative vertebral rotation and translation, and upper and lower instrumented vertebrae selected based on sagittal and axial inflection points. For example, for Lenke 1 patients with junctional vertebrae above L1, fusion to NV-1 (1 level above the neutral vertebra) achieved optimal curve correction while preserving motion segments. Pre-op coronal Cobb angle and axial rotation, distal junctional kyphosis, pelvic incidence, sacral slope, and type of instrument were identified as predictors with moderate evidence. For Lenke 1C patients, > 50% LIV rotation was found to increase spontaneous lumbar curve correction. Pre-op thoracolumbar apical translation and lumbar lordosis, Ponte osteotomies, and rod material were found to be predictors with low evidence.

CONCLUSIONS

Rod contouring and UIV/LIV selection should be based on preoperative 3D TK in order to achieve normal postoperative alignment. Specifically, Lenke 1 patients with high-lying rotations should be fused distally at NV-1, while hypokyphotic patients with large lumbar curves and truncal shift should be fused at NV to improve lumbar alignment. Lenke 1C curves should be corrected using > 50% LIV rotation counterclockwise to the lumbar rotation. Further investigation should compare surgical correction between pedicle-screw and hybrid constructs using matched cohorts. DJK and overbending rods are potential predictors of postoperative alignment.

Chinese validation of the quality of life profile for spinal deformities (QLPSD)

We aimed to translate and validate the Quality of Life Profile for Spine Deformities (QLPSD), an age-specific tool assessing the individuals' health-related quality of life (HRQoL), into a Chinese version for adolescent individuals with adolescent idiopathic scoliosis (AIS). The Chinese version was translated from the original Spanish QLPSD following widely accepted guidelines and evaluated by both individuals with AIS and experts. 172 Chinese-speaking individuals between 9 and 18 years of age with Cobb angles between 20° and 40° were included. Internal consistency, test-retest reliability, and floor and ceiling effects were all analyzed. Convergent validity was evaluated by correlating the measures in the Chinese QLPSD with those in the 22-item Scoliosis Research Society Questionnaire (SRS-22). Known-groups construct validity was assessed by comparing the QLPSD scores of two groups of individuals divided by their Cobb angles. The internal consistency (total Cronbach's alpha = 0.917) and the test-retest reliability (total intra-class correlation coefficient = 0.896) were both satisfactory. The Chinese QLPSD correlated well with the SRS-22 in the total score and in relevant subscales (r = -0.572, p < 0.01). The questionnaire was able to differentiate between individuals with different Cobb angles. No floor or ceiling effects were shown in the total score, neither were there ceiling effects in the subscales, but floor effects were observed in four of the five subscales, between 20.0% and 45.7%. The Chinese version of the QLPSD shows adequate transcultural adaptation, reliability, and validity, and is useful as a clinical evaluation tool for the HRQoL of adolescent Chinese-speaking individuals with AIS.

Prospective analysis of home narcotic consumption and management of excess narcotic prescription following adolescent idiopathic scoliosis surgery

PURPOSE

The aim of this study was to identify factors associated with the outpatient narcotic intake of patients following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and to introduce a safe and effective method of disposing of unused narcotics.

METHODS

Following Institutional Review Board approval, retrospective review of prospectively collected data from patients undergoing PSF for AIS took place. Pain scores, narcotic use, patient demographic data, pre-, intra-, and postoperative parameters, and discharge data were gathered via chart review. Patients were divided into two groups according to home narcotic use, high use (top 25th percentiles) and low use (bottom 75th percentiles), and multivariate statistical analysis was conducted. Narcotic surplus was collected during postoperative clinic visits and disposed of using biodegradable bags.

RESULTS

Statistical analysis of 27 patients included in the study showed that patients with a higher home narcotic use correlated with increased length of hospitalization with an average of 3.4 days compared to the lower-use group of 2.8 day (p = 0.03). Higher-use group also showed increased inpatient morphine milligram equivalent than the lower-use group. There was no significant difference of home narcotic use when looking at patient age, height, weight, BMI, levels fused, intraoperative blood loss, or length of surgery. A total of 502 narcotic doses were disposed of in the clinic.

CONCLUSION

Our study suggests that there are not a significant number of patient- or surgical-level factors predisposing patients to increased home narcotic usage following spinal fusion for adolescent idiopathic scoliosis.

LEVEL OF EVIDENCE

Level I, prospective study.

Estimated cumulative radiation exposure in patients treated for adolescent idiopathic scoliosis

PURPOSE

Adolescent idiopoathic scoliosis (AIS) is a progressive spinal deformity, most often observed in female patients of pubescent age. The deformity's severity, its progression through time, its treatment and subsequent follow-up are assessed with routine radiological evaluation of the patient's full spine. This study aimed to determine the cumulative radiation exposure in average patients with AIS treated by brace or surgery throughout their treatment.

METHODS

The average number of imaging procedures and corresponding radiation doses were retrospectively obtained from the medical charts of AIS patients treated conservatively and/or surgically at our institution. The median radiation exposure of all imaging modalities was stated in effective dose (mSv). The estimated cumulative effective radiation dose of the each treatment group was determined by multiplication of the average number of imaging conducted, and the median effective radiation dose per imaging modality.

RESULTS

In total, 73 AIS patients were included (28 brace, 45 surgically). Patients treated with a brace were subjected to an average of 9.03 full spine radiographs, resulting in an estimated effective cumulative dose of 0.505 mSv over a median treatment period of 3.23 years. Patients treated surgically received an average of 14.29 full spine radiographs over a median treatment period of 2.76 years. The estimated effective cumulative dose amounted from 0.951 to 1.841 mSv, depending on the surgical technique.

CONCLUSION

The cumulative effective radiation doses rendered to AIS patients as part of their treatment and follow-up were relatively low. However, every exposure to ionising radiation for medical imaging purposes should be minimised.