Idiopathic scoliosis: etiological concepts and hypotheses

"Real-Time Neuromonitoring" Increases the Safety and Non-Invasiveness and Shortens the Duration of Idiopathic Scoliosis Surgery

Introduction: A practical solution to the incidental unreliability of intraoperative neuromonitoring (IONM) may be the simultaneous neurophysiological recording and control of the surgical field through a camera (the concept of "Real-time" IONM). During "Real-time" IONM, the surgeon is immediately warned about the possibility of damage to the neural structures during, but not after, standard idiopathic scoliosis (IS) corrective surgery procedures (the concept of "Surgeon-neurophysiologist" interactive, verbal IONM). This study aimed to compare the advantages, utilities, reliabilities, and time consumption of the two IONM scenarios. Methods: Studies were performed in two similar groups of patients undergoing surgery primarily due to Lenke 2 idiopathic scoliosis (N = 120), when both IONM approaches were applied. Neurophysiological evaluations of the spinal transmission were performed pre- (T0), intra- (before (T1) and after (T2) surgery), and postoperatively (T3), as well as once in healthy volunteers (control, N = 60). Non-invasive and innovative recordings of the motor evoked potentials (MEPs) bilaterally from the peroneal (PER) nerve and tibialis anterior (TA) muscle were performed with surface electrodes as a result of transcranial magnetic stimulation (TMS) or electrical stimulation (TES) at T0-T3. Results: In both groups, the MEP amplitudes and latencies recorded from the PER nerve were approximately 67% lower and 3.1 ms shorter than those recorded from the TA muscle. The MEP recording parameters differed similarly at T0-T3 compared to the control group. In all patients, the MEP parameters induced by TMS (T0) and TES (T1) did not differ. The MEP amplitude parameters recorded from the TA and PER at T1 and T2 indicated a bilateral improvement in the neural spinal conduction due to the surgical intervention. The TMS-induced MEP amplitude at T3 further increased bilaterally. In both IONM groups, an average 51.8 BIS level of anesthesia did not affect the variability in the MEP amplitude, especially in the PER recordings when the applied TES strength was 98.2 mA. The number of fluctuations in the MEP parameters was closely related to the number of warnings from the neurophysiologist during the transpedicular screw implantation, corrective rod implantation, and distraction, derotation, and compression procedures, and it was higher in the "Surgeon-neurophysiologist" IONM group. The average duration of surgery was shorter by approximately one hour in the "Real-time" IONM group. The number of two-way communications between the surgeon and the neurophysiologist and vice versa in the "Real-time" IONM group decreased by approximately half. Conclusions: This study proves the superiority of using "Real-time" IONM over the standard "Surgeon-neurophysiologist" IONM procedure in increasing the safety and non-invasiveness, shortening the time, and lowering the costs of the surgical treatment of IS patients. The modifications of the MEP nerve-conduction-recording technology with surface electrodes from nerves enable precise and reliable information on the pediatric patient's neurological condition at every stage of the applied surgical procedures, even under conditions of slight fluctuations in anesthesia.

Compressive stress induces spinal vertebral growth plate chondrocytes apoptosis via Piezo1

Many clinical studies have indicated an association between biomechanical factors and the incidence and pathological progression of adolescent idiopathic scoliosis (AIS). However, at present, the research on AIS is mainly focused on the etiology, and there are few studies reporting the causes of progressive aggravation of AIS. In the present study, we aim to investigate the role of Piezo1 in compressive stress-induced mouse spinal vertebral growth plate chondrocytes apoptosis. First, a scoliosis mouse model was established, and the expression of Piezo1 as well as the degree of apoptosis were investigated. We found that the expression of Piezo1 and the degree of apoptosis were significantly higher on the concave sides than that on the convex sides of the vertebral growth plate in mice with scoliosis. Spinal vertebral growth plate chondrocytes were further isolated and treated with Yoda1 to mimic Piezo1 overload. Excess Piezo1 significantly promoted apoptosis of spinal vertebral growth plate chondrocytes. Moreover, static gas compressive stress was used to simulate the increased concave compressive stress in the process of scoliosis with or without GsMTx4, a Piezo inhibitor. It was observed that with the increase of static compressive stress, the expression of Piezo1 increased, and the chondrocytes of vertebral growth plate treated with Piezo1 inhibitor GsMTx4 weakened the above phenomena. In conclusion, our results indicated that compressive stress is strongly associated with the different degrees of apoptosis on both sides on the convex and concave sides of the vertebral growth plate in scoliosis via inducing different expressions of Piezo1. Reducing the expression of Piezo1 in the concave side of the vertebral growth plate and inhibiting the apoptosis of chondrocytes in the bilateral vertebral growth plate caused by asymmetric stress on both sides of the concave vertebral body may be a promising treatment strategy for AIS.

Efficacy of conservative treatment on exacerbation of adolescent idiopathic scoliosis

Scoliosis is defined as a deviation from the normal vertical line of the spine and consists of a lateral curvature in which the spine rotates within the curvature. Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis and the cause is unknown. In this study, it was investigated whether conservative treatment for adolescent idiopathic scoliosis (CONTRAIS) reduced the patient’s Cobb angle, and the effect of CONTRAIS according to the severity of idiopathic scoliosis and the efficacy of CONTRAIS by spinal region were also verified. Idiopathic scoliosis patients with a Cobb angle of 10° or more were recruited and classified into mild, moderate, and severe groups according to the Cobb angle (°). Cobb angle was measured radiographically before and after 10 weeks of treatment. A combination of CONTRAIS, including physical therapy, exercise therapy, manual therapy, and home exercise was prescribed for all patients. The patients visited the hospital 3 times a week for 10 weeks for treatment, and exercised at home for 20 min every day. In this study, the effect of reducing Cobb angle of CONTRAIS did not differ according to the spinal region. Also, the Cobb angle reduction effect of CONTRAIS was more effective in severe group. This study may suggest that early detection and treatment through CONTRAIS enables successful correction of AIS.

Locoregional lung ventilation distribution in girls with adolescent idiopathic scoliosis and healthy adolescents. The immediate effect of Schroth 'derotational breathing' exercise in a controlled-trial

BACKGROUND

Scoliosis curves present transverse plane deviations due to vertebral rotation. The Schroth method supports thoracic derotation by training patients to exert "derotational" breathing based on assumed enhanced ventilation in areas called "humps" in scoliosis and a patient's ability to voluntarily direct ventilation in less ventilated areas called "flats."

OBJECTIVE

To assess the asymmetric ventilation distribution and the ability of patients to direct their ventilation to perform derotational breathing.

METHODS

Twelve girls with adolescent idiopathic scoliosis and 12 healthy girls performed 3 × 3 min of rest, maximal, and derotational breathing. Electrical impedance tomography was used to record locoregional lung ventilation distribution (LLVD) within 4 thoracic regions of interest: anterior right (ROI 1), anterior left (ROI 2), posterior right (ROI 3), and posterior left (ROI 4) quadrants. Humps and flats were the sums of ROI '2 + 3' and ROI '1 + 4,' respectively.

RESULTS

Overall, no difference in LLVD was observed in the flats and humps between groups. At rest, the LLVD in the humps was more elevated than that in the flats (51.5 ± 8.1% versus 43.6 ± 7.9%; p = .021) when considering both groups. Maximal and derotational breathing led to a more homogeneous LLVD between the humps and flats.

CONCLUSION

The postulated derotational breathing effect was not confirmed.

Scoliosis with cognitive impairment in a girl with 8q11.21q11.23 microdeletion and SNTG1 disruption

Idiopathic scoliosis (IS) is an abnormality of the vertebral column with a spine curvature of at least 10 degrees. It is the most common spinal deformity in children with a prevalence of 2%-3%, and its aetiology is unknown. Genetic factors are known to play a role and a number of linkage analyses showed associations of various loci. Here we describe a new case of a de novo interstitial deletion 8q11.21q11.2 disrupting SNTG1 gene, identified by array-CGH in a girl with cognitive impairment and a scoliosis that 'appears' like to IS. SNTG1 encodes γ-1 Syntrophin protein that is part of the dystrophin associated protein complex and interacts directly with the C-terminal of dystrophin. Its expression is restricted to neurons and particularly in those areas of the brain that have been suggested to affect postural control. The involvement of SNTG1 gene in IS was already been reported in a family with a breakpoint between exons 10 and 11. Mutational analysis of SNTG1 exons in 152 sporadic IS patients had revealed changes in three patients. In conclusion, our data add a further line of evidence suggesting SNTG1 could represent an interesting candidate for its involvement in scoliosis.

Methylation of Estrogen Receptor 1 Gene in the Paraspinal Muscles of Girls with Idiopathic Scoliosis and Its Association with Disease Severity

Idiopathic scoliosis (IS) is a multifactorial disease with epigenetic modifications. Tissue dependent and differentially methylated regions (T-DMRs) may regulate tissue-specific expression of the estrogen receptor 1 gene (ESR1). This study aimed to analyze methylation levels within T-DMR1 and T-DMR2 and its concatenation with ESR1 expression of IS patients. The study involved 87 tissue samples (deep paravertebral muscles, both on the convex and the concave side of the curve, and from back superficial muscles) from 29 girls who underwent an operation due to IS. Patient subgroups were analyzed according to Cobb angle ≤70° vs. >70°. Methylation was significantly higher in the superficial muscles than in deep paravertebral muscles in half of the T-DMR1 CpGs and all T-DMR2 CpGs. The methylation level correlated with ESR1 expression level on the concave, but not convex, side of the curvature in a majority of the T-DMR2 CpGs. The T-DMR2 methylation level in the deep paravertebral muscles on the curvature's concave side was significantly lower in patients with a Cobb angle ≤70° in four CpGs. DNA methylation of the T-DMRs is specific to muscle tissue location and may be related to ESR1 expression regulation. Additionally, the difference in T-DMR2 methylation may be associated with IS severity.

Changes in Health-Related Quality of Life (HRQOL) of a Specific Group of Adolescent Idiopathic Scoliosis (AIS) Patients Who Came Across Both Bracing and Surgery

BACKGROUND/PURPOSE OF THE STUDY

Changes in health-related quality of life (HRQOL) of AIS patients coming across both bracing and surgery have not yet reported. These patients received two major clinical interventions and their HRQOL might be different from previous articles. The aim of this study is to evaluate the changes of HRQOL of a specific group of AIS patients who experienced both bracing and surgery.

METHODS

One hundred and twenty-eight patients requiring surgery with prior bracing treatment were identified from the electronic record. SRS-22 questionnaire was completed at 7 time points crossing both interventions (namely "Before", "Bracing ≤ 1 year", "Bracing > 1 year", "Pre-op", "Post-op", "Post-op ≤ 1 year, and "Post-op 1-2 years").

RESULTS

SRS-22 "Function", "Pain" and "Self-image" scores were decreased from "Before" to "Bracing ≤ 1 year" when started bracing and raised at "Bracing > 1 year". The 3 scores were dropped from "Bracing > 1 year" to "Pre-op", particularly on "Self-image". "Function" and "Pain" were significantly dropped from "Pre-op" to "Post-op" and kept raising until "Post-op 1-2 years". "Self-image" was improving after "Pre-op". "Mental" was relatively stable along the timeline.

CONCLUSION

This study described the changes in HRQOL of a specific group of AIS patients. Scores were dropped after the two major clinical interventions and recovered afterwards. Medical professionals were able to plan and provide appropriate supports on the expected changes in HRQOL, especially on function, pain and mental.

Case Report: Kaposiform Hemangioendothelioma With Spinal Involvement

Introduction: Kaposiform hemangioendothelioma (KHE) is a rare, locally invasive vascular tumor that mostly appears in infants and adolescents. KHE with spinal involvement is extremely rare. The aim of this study was to review the imaging features, clinical manifestations and treatment of KHE patients with spinal involvement. Materials and Methods: We reviewed patients with KHE who were admitted to Pediatric Surgery of West China Hospital of Sichuan University from April 2014 to August 2020, and the cases were evaluated. Results: Seven patients with spinal involvement were enrolled in the study, including four (57.1%) males and three (42.9%) females. The age at onset ranged from 1.0 day to 4.0 years, with an average of 1.6 years. Five (71.4%) had pain due to bone destruction, three patients (42.9%) had decreased range of motion (ROM), four (57.1%) patients had scoliosis, two (28.6%) patients developed claudication, and three patients (42.9%) presented with a soft tissue mass in the neck of the back. Five patients (71.4%) had the Kasabach-Merritt phenomenon (KMP), with a minimum platelet value of 8 × 10⁹/L. All patients were treated with sirolimus, and showed regression of the lesion and/or normalization of the hematologic parameters. Conclusion: KHE with spinal involvement is difficult to diagnose due to its rarity and variable symptoms, which need to be recognized to start early treatment. The management of KHE with spinal involvement should be performed by a multidisciplinary team. Sirolimus can improve outcomes in patients with KHE with spinal involvement.

Methylation of estrogen receptor 2 (ESR2) in deep paravertebral muscles and its association with idiopathic scoliosis

Idiopathic scoliosis (IS) is one of the most common spinal disorders in adolescents. Despite many studies, the etiopathogenesis of IS is still poorly understood. In recent years, the role of epigenetic factors in the etiopathogenesis of IS has been increasingly investigated. It has also been postulated that the development and progression of the disease is related to gender and puberty, and could be associated with estrogen action. Estrogen hormones act via estrogen receptor 1 (ESR1) and estrogen receptor 2 (ESR2). It has been suggested that ESR2 expression is dependent on methylation within its gene promoter. So far, no studies have evaluated local, tissue-specific DNA methylation in patients with IS. Thus, our study aimed to analyze the methylation and expression level of ESR2 in the paraspinal muscles of the convex and concave side of the IS curvature. The methylation level within ESR2 promoter 0N, but not exon 0N, was significantly higher on the concave side of the curvature compared to the convex side. There was no significant correlation between ESR2 expression and methylation level in the promoter 0N on the convexity of thoracic scoliosis, whereas, on the concave side of the curvature, we observed a moderate negative correlation. There was no difference in the methylation levels of the ESR2 promoter and exon 0N between groups of patients with Cobb angle ≤ 70° and > 70° on the concave and convex side of the curvature. We also found no statistically significant correlation between the Cobb angle value and the mean methylation level in either the ESR2 promoter or exon 0N on the convex or concave side of the curvature. Our findings demonstrate that DNA methylation at the ESR2 promoter in deep paravertebral muscle tissue is associated with the occurrence but not with the severity of idiopathic scoliosis.

Axial Skeletal Malformations in Genetically Modified Xenopus laevis and Xenopus tropicalis

Skeletal malformations in captive-bred, adult Xenopus spp., have not previously been reported. Here we describe 10 sexually mature, genetically modified laboratory frogs (6 Xenopus laevis and 4 Xenopus tropicalis) with axial skeletal abnormalities. The young adult frogs were described by veterinary staff as presenting with "hunchbacks," but were otherwise considered to be in good health. All affected frogs were genetically engineered using various techniques: transcription activator-like effector nucleases (TALEN) editing using thyroid hormone receptor α TALEN mRNA, restriction enzyme-mediated integration methods involving insertion of the inducible transgene pCAR/TRDN, or via I-SceI meganuclease transgenesis using either pDRTREdpTR-HS4 or pDPCrtTA-TREG-HS4 plasmid sequences. Radiographic findings (6 frogs) and gross necropsy (10 frogs) revealed vertebral column malformations and sacroiliac deformities that resulted in moderate to severe kyphosis and kyphoscoliosis. These findings were confirmed and additional skeletal abnormalities were identified using computed tomography to create a 3D reconstruction of 4 frogs. Additional findings visible on the 3D reconstructions included incomplete vertebral segmentation, malformed transverse processes, and a short and/or curved urostyle. Histopathologic findings included misshapen intervertebral joints with nonconforming articular surfaces, narrowed joint cavities, flattened or irregularly-formed articular cartilage, irregular maturation lines and nonpolarized chondrocytes, excess fibrocartilage, and evidence of irregular bone resorption and growth. While the specific etiology of the vertebral skeletal abnormalities remains unclear, possibilities include: 1) egg/oocyte physical manipulation (dejellying, microinjection, fertilization, etc.), 2) induction and expression of the transgenes, 3) inactivation (knockout) of existing genes by insertional mutagenesis, or 4) a combination of the above. Furthermore, the possibility of undetected changes in the macro or microenvironment, or a feature of the genetic background of the affected frogs cannot be ruled out.

Body Posture Defects and Body Composition in School-Age Children

The aim of the study was to assess the relationship between the shape of the anteriorposterior spinal curvature and body composition in schoolchildren. The study included 257 children, aged 11–12. Correct spinal curvature was established in 106 (41.08%) subjects. Other types included: decreased kyphosis and correct lordosis—40 participants (15.50%), correct kyphosis and decreased lordosis—24 individuals (9.30%), increased kyphosis and correct lordosis—17 subjects (6.59%), correct kyphosis and increased lordosis—22 children (8.53%), decreased kyphosis and decreased lordosis—32 people (12.40%), decreased kyphois and increased lordosis—four of the examined subjects (1.55%) increased kyphosis and lordosis—13 people (5.04%). In addition, 134 (51.94%) demonstrated scoliotic posture and eight (3.10%) scoliosis. There were significant relationships between the shape of the anteriorposterior curvatures and body composition in schoolchildren. Those with a strong body build (predominance of mesomorphs) were generally characterised by the correct formation of these curvatures. In contrast, lean subjects (with the predominance of ectomorphic factors) were more likely to experience abnormalities. No correlations with body composition were observed in the group with scoliotic posture or scoliosis. Both in the prevention and correction of postural defects, one should gradually move away from one-sided, usually one-system, therapeutic effects. An approach that takes into account both somatic and neurophysiological factors seems appropriate. With the correct body composition and structure, shaping the habit of correct posture is much easier.

The Postural Control Indexes during Unipodal Support in Patients with Idiopathic Scoliosis

Proper posture provides the best balance and body stability at minimal muscular effort. It is constantly controlled by the central nervous system, which integrates the stimuli from the proprioceptors (deep feeling sensors), vision receptors, and balance receptors through the subcortical structures. The main purpose of the study was to describe single stance stability and its correlation with the degree of scoliosis and trunk rotation among patients suffering from idiopathic scoliosis and in the control group without scoliosis. The study included 80 patients (69 girls and 11 boys) and 40 healthy children without scoliosis (21 girls and 19 boys). The Cobb angle technique was used to determine the magnitude of the deformity. All subjects were divided into three subgroups according to Bogdanov's classification. Single stance stability with eyes open and eyes closed was assessed with an electronic postural station-Delos Postural Proprioceptive System (DPPS). In case of multiple group comparisons for variables with normal distribution ANOVA with Scheffe, post hoc test was used or Kruskal-Wallis test was used as the nonparametric equivalent. The relationship between the two continuous variables was investigated using either Pearson product-moment correlation or Spearman's rank correlation. In all these calculations, the statistical significance level was set to p < 0.05. The single stance test showed a significant difference between the stability index with eyes open and stability index with eyes closed in study and control groups. The character of these alterations is influenced by the degree of trunk rotation. The degree of scoliosis according to Bogdanov classification does not determine the decrease in stability indexes. In summary, significantly lower values of the stability index during one-leg standing with eyes closed indicated balance impairment, which is mainly connected with inadequate functioning of the proprioceptive system.

Acute Onset Atypical Severe Scoliosis: A Case Report

BACKGROUND

Although most cases of scoliosis are idiopathic, scoliosis may also be congenital or associated with other diseases. Herniated Nucleus Pulposus (HNP) has been reported as a potential cause of non-structural scoliosis. HNP is unusual in adolescents and the clinical features are typically different from those in adults.

CASE PRESENTATION

An 18-year-old Caucasian male was referred to our ambulatory service for evaluation of scoliosis after orthopedic evaluation at another center. He had noticed left-sided low back pain in the previous 6 months, which had worsened over the last two months with the development of limp and left lower extremity (LLE) paresthesias. After an accurate clinical evaluation, the acute onset of the curvature with mild back pain and associated neurological findings were suggestive of an intraspinal lesion. The MRI examination showed an L4-L5 HNP compressing L4 nerve root and displacing the distal L5 nerve root. An L4-L5 laminectomy and discectomy were performed. His left leg pain was completely relieved the day after surgery. At 3 months follow-up complete resolution of scoliosis deformity and return to full activity was achieved.

CONCLUSIONS

Every child who presents with atypical scoliosis should have a complete physical examination and appropriate imaging studies seeking an underlying cause.Level of Evidence: V.

Predicting massive transfusion in adolescent idiopathic scoliosis patients undergoing corrective surgery: Association of preoperative radiographic findings

Corrective surgery with a posterior approach for adolescent idiopathic scoliosis (AIS) is often accompanied by considerable bleeding. Massive transfusion after excessive hemorrhage is associated with complications such as hypothermia, coagulopathy, and acid-base imbalance. Therefore, prediction and prevention of massive transfusion are necessary to improve the clinical outcome of AIS patients. We aimed to identify the factors associated with massive transfusion in AIS patients undergoing corrective surgery. We also evaluated the clinical outcomes after massive transfusion.We included and analyzed AIS patients who underwent corrective surgery with a posterior approach from January 2008 to February 2015. We retrospectively reviewed the electronic medical records of 765 consecutive patients. We performed multivariable logistic regression analysis to assess the factors related to massive transfusion. Furthermore, we compared the effects of massive transfusion on clinical outcomes, including postoperative morbidity and hospital stay.Of 765 patients, 74 (9.7%) received massive transfusion. Body mass index (odds ratio [OR] 0.782, 95% confidence interval [CI] 0.691-0.885, P < .001) and the number of fused vertebrae (OR 1.322, 95% CI 1.027-1.703, P = .03) were associated with massive transfusion. In the comparison among the different Lenke curve types, Lenke type 4 showed the highest prevalence of massive transfusion. Patients in the massive transfusion group showed a higher incidence rate of postoperative morbidity and prolonged hospital stay.Massive transfusion was required in 9.7% of AIS patients who underwent corrective surgery with a posterior approach. A lower body mass index and higher number of fused vertebrae were associated with massive transfusion. Massive transfusion is related to poor clinical outcomes in AIS patients.

T1-weighted MR imaging of bone marrow pattern in children with adolescent idiopathic scoliosis: a preliminary study

PURPOSE

Distinct normal physiological patterns of fat conversion in vertebrae were described both for children and adults. Our aim was to evaluate the T1-weighted bone marrow pattern of the vertebral bodies in various sites along the scoliotic spine of children with adolescent idiopathic scoliosis (AIS).

METHODS

We retrospectively evaluated spine MRI studies of children with AIS. Scoliosis radiographs were assessed for type of curvature according to the Lenke classification. A paediatric neuroradiologist assessed the T1-weighted signal of vertebral bodies in comparison with the adjacent disc and distinct patterns of fatty conversion within the apical and stable vertebral bodies. Statistical assessment was performed.

RESULTS

MRI study of the spines of 75 children with AIS were assessed, 59 (79%) of whom were female, with an age range of nine to 19 years. The relative overall T1-weighted signal intensity of the vertebral body bone marrow relative to the intervertebral disc was hyperintense in 76% and isointense in 24%. Fatty conversion grade of the stable vertebra was higher than the apex vertebra (p = 0.0001). A significant tendency to have more advanced fat conversion patterns in the apex vertebra up to age 13.5 years old compared with adolescents above that (p = 0.015) was seen.

CONCLUSION

This preliminary study suggests a different pattern of bone marrow conversion in AIS from the normal physiologic pattern described in the literature. Whether these changes are secondary to the biomechanics of the curved spine or may suggest that bone marrow maturation rate and content have a role in the pathogenesis of AIS remains to be further researched.

LEVEL OF EVIDENCE

Level III (Diagnostic Study).

Sexual Dimorphism and the Origins of Human Spinal Health

Recent observations indicate that the cross-sectional area (CSA) of vertebral bodies is on average 10% smaller in healthy newborn girls than in newborn boys, a striking difference that increases during infancy and puberty and is greatest by the time of sexual and skeletal maturity. The smaller CSA of female vertebrae is associated with greater spinal flexibility and could represent the human adaptation to fetal load in bipedal posture. Unfortunately, it also imparts a mechanical disadvantage that increases stress within the vertebrae for all physical activities. This review summarizes the potential endocrine, genetic, and environmental determinants of vertebral cross-sectional growth and current knowledge of the association between the small female vertebrae and greater risk for a broad array of spinal conditions across the lifespan.

A New Look at Etiological Factors of Idiopathic Scoliosis: Neural Crest Cells

Idiopathic scoliosis is one of the most common disabling pathologies of children and adolescents. Etiology and pathogenesis of idiopathic scoliosis remain unknown. To study the etiology of this disease we identified the cells' phenotypes in the vertebral body growth plates in patients with idiopathic scoliosis. Materials and methods: The cells were isolated from vertebral body growth plates of the convex and concave sides of the deformity harvested intraoperatively in 50 patients with scoliosis. Cells were cultured and identified by methods of common morphology, neuromorphology, electron microscopy, immunohistochemistry and PCR analysis. Results: Cultured cells of convex side of deformation were identified as chondroblasts. Cells isolated from the growth plates of the concave side of the deformation showed numerous features of neuro- and glioblasts. These cells formed synapses, contain neurofilaments, and expressed neural and glial proteins. Conclusion: For the first time we demonstrated the presence of cells with neural/glial phenotype in the concave side of the vertebral body growth plate in scoliotic deformity. We hypothesized that neural and glial cells observed in the growth plates of the vertebral bodies represent derivatives of neural crest cells deposited in somites due to alterations in their migratory pathway during embryogenesis. We also propose that ectopic localization of cells derived from neural crest in the growth plate of the vertebral bodies is the main etiological factor of the scoliotic disease.

Association of vitamin D receptor BsmI rs1544410 and ApaI rs7975232 polymorphisms with susceptibility to adolescent idiopathic scoliosis: A systematic review and meta-analysis

BACKGROUND

AIS is the most common spinal deformity disease, yet its etiology remains uncertain. Significant associations have been found between AIS risk and vitamin D receptor (VDR) gene polymorphisms; however, some of these results are controversial. The aim of this study was to determine whether VDR BsmI rs1544410 and ApaI rs7975232 polymorphisms are correlated with AIS.

METHODS

Databases, including PubMed, EMBASE, Web of Science, the Cochrane Library, the Chinese Biomedical Literature Database, and the Wanfang Database, were systematically searched, and eligible case-control studies that explored the association of VDR (BsmI and ApaI) and the susceptibility to AIS were selected. The pooled odds ratio (OR) with 95% confidence interval (95% CI) was calculated to assess the associations, and subgroup meta-analyses were performed according to the ethnicity of the study population.

RESULTS

A total of 5 studies with 717 cases and 554 controls fulfilled the inclusion criteria after assessment by 2 reviewers. Generally, significant correlations were found between the BsmI polymorphism and AIS risk in overall populations and in Asian populations (overall population: B vs b: OR = 2.12, 95% CI = 1.21-3.75, P = .009; BB vs bb: OR = 3.38, 95% CI = 1.08-10.57, P = .036; Bb vs bb: OR = 2.50, 95% CI = 1.29-4.82, P = .006; BB/Bb vs bb: OR = 2.71, 95% CI = 1.31-5.63, P = .007; Asian population: B vs b: OR = 2.42, 95% CI = 1.27-4.61, P = .007; BB vs bb: OR = 4.09, 95% CI = 1.03-16.22, P = .045; Bb vs bb: OR =  2.94, 95% CI = 1.42-6.10, P = .004; BB/Bb vs bb: OR = 3.23, 95% CI = 1.42-7.35, P = .005). There was no significant association observed in Caucasian populations (all P > .05). With regard to the ApaI polymorphism, we found that it significantly decreased the risk of AIS (Aa vs AA: OR = 0.43, 95% CI = 0.24-0.77, P = .004; Aa/aa vs AA: OR = 0.52, 95% CI = 0.30-0.91, P = .023); however, we could not draw a definitive conclusion for Caucasian populations, as no studies have been conducted in this group to determine the role of the VDR ApaI polymorphism in AIS etiology and development.

CONCLUSION

VDR BsmI was significantly associated with AIS susceptibility in the overall and Asian populations, while the VDR ApaI polymorphism only played a key role in AIS etiology and development in Asian populations.

Biomechanical Modeling of Spine Flexibility and Its Relationship to Spinal Range of Motion and Idiopathic Scoliosis

STUDY DESIGN

Cross-sectional.

OBJECTIVE

To examine the relationships between spine morphology, spine flexibility, and idiopathic scoliosis.

BACKGROUND

Girls have a higher incidence of clinically significant scoliosis than boys, along with smaller vertebrae and greater flexibility. Based on biomechanical modeling, we hypothesized that smaller vertebral width relative to intervertebral disc (IVD) height would be associated with both greater lateral flexibility of the spine and with idiopathic scoliosis.

METHODS

Magnetic resonance imaging was used to measure IVD height, vertebral width, and paraspinous musculature in 22 girls with mild and moderate idiopathic scoliosis and 29 girls without scoliosis ages 9-13 years. Clinical measurement of maximum lateral bending was also performed in the girls without scoliosis. A simple biomechanical model was used to estimate bending angle from the ratio of IVD height to vertebral half-width for L1-L4. The average ratio (R_avg) and calculated total bending angle (α_tot) for L1-L4 were compared to the clinical measurements of lateral bending flexibility in the control group. These measures were also compared between the scoliosis and control groups.

RESULTS

There was a significant positive relationship between clinical flexibility and both R_avg (p = .041) and α_tot (p = .042) adjusting for skeletal age, height, body mass index, and paraspinous muscle area as covariates. The ratio was significantly higher (R_avg = 0.45 vs. 0.38, p < .0001) and the bending angle was significantly greater (α_tot = 107° vs. 89°, p < .0001) for girls with scoliosis compared with controls.

CONCLUSION

These results suggest that differences in spine morphology and corresponding changes in spine flexibility may be related to idiopathic scoliosis. If these relationships can be corroborated in larger prospective studies, these easily measured morphologic traits may contribute to a better understanding of the etiology of idiopathic scoliosis and an improved ability to predict scoliosis progression.

LEVEL OF EVIDENCE

Level III.

Association of IL-6 and MMP-3 gene polymorphisms with susceptibility to adolescent idiopathic scoliosis: a meta-analysis

Recently, several institutions have investigated the associations of MMP-3-1171 5A/6A and IL-6-174-G/C gene polymorphisms with adolescent idiopathic scoliosis (AIS), while reports from different institutions are not consistent. Therefore, we, comprehensively and systematically performed this meta-analysis to detect whether the two gene polymorphisms are correlated with AIS. From January 1994 to October 2015, all case-control studies focussed on the relationship between the two aforementioned gene polymorphisms and the susceptibility to AIS were retrieved from bibliographic databases. A total of 16 articles were found, of which five consisted of 944 cases and 1177 controls, were finally included after being assessed by two reviewers. We calculated the pooled odds ratio (OR) with 95% confidence interval (95% CI) to assess the associations. The pooled data analyses were based on allele contrast, homozygote, heterozygote, dominant and recessive models. Overall, there was no significant association of IL-6-174-G/C gene polymorphism with AIS risk. Significant association was observed in homozygote model of MMP-3-1171-5A/6A gene polymorphism (5A5A versus 6A6A: OR = 1.69, 95% CI = 1.11-2.58, P = 0.02). When stratified into Caucasian and Asian populations, positive association was found in Caucasian population (5A versus 6A: OR = 1.43, 95% CI = 1.11-1.84, P = 0.006; 5A5A versus 6A6A: OR = 1.90, 95% CI = 1.13-3.19, P = 0.015); however, there was no significant association in Asian population. The present study concluded that 5A5A genotype of MMP-3-1171 5A/6A gene polymorphism was associated with AIS, especially in Caucasian population. However, no significant association was detected between IL-6-174-G/C gene polymorphism and AIS.

Review of Physical Activity Benefits and Potential Considerations for Individuals with Surgical Fusion of Spine for Scoliosis

Evidence-based recommendations for physical activity following spinal fusion surgeries for idiopathic scoliosis are limited, specifically in the adolescent population. Individuals with scoliosis treated operatively or non-operatively have been reported to participate in less than 1-3 days/week of even mildly strenuous physical exercises. Over 40% of individuals with scoliosis returned to sports at a level lower than pre-operative participation levels or did not return at all post spinal fusion. It is particularly important for human movement specialists, such as physical therapists, occupational therapists, athletic trainers and kinesiologists to assist these individuals effectively transition to and maintain engagement in physical activity. This review provides a snapshot of common considerations and potential factors influencing individuals with spinal-fusion for scoliosis to participate in safe physical activity.

[Scoliosis in the children: the new approaches to the treatment and rehabilitation]

Scoliosis is the most widespread orthopaedic condition affecting both the children and the adolescents. The electrostatic field is known to promote the development of vibrations of varying strength in the biological tissues and their penetration rather deep into their interior.

AIM

The objective of the present study was to elucidate the possibilities and practicability of the application of a low-frequency electrostatic field for the conservative treatment of grade I and II scoliosis in the children and to develop the scientifically sound substantiation for the use of this technique in the clinical practice.

MATERIAL AND METHODS

We examined and treated 94 children randomly divided into two groups (main and control) matched for the age and major clinical manifestation of the disease. All the patients received basic therapy. Those in the study group were additionally given low-frequency electrostatic therapy.

RESULTS AND DISCUSSION

The comparative analysis of the results of the treatment gave evidence that the application of a low-frequency electrostatic field for the conservative treatment of grade I and II scoliosis in the children resulted in the well apparent positive changes in their health status. These changes manifested themselves in the favourable dynamics of both the clinical symptoms of the disease and as the improvement of the topographic and thermographic characteristics. Of special importance is the alleviation of the symptoms of scoliotic deformation of the vertebral column under effect of the low-frequency electrostatic field.

CONCLUSION

The present study has demonstrated that the application of the low-frequency electrostatic field significantly increases the effectiveness of the treatment of grade I and II scoliosis in the children and adolescents and promotes regression of this pathological condition.

Calcium-induced calmodulin conformational change. Electrochemical evaluation

Calmodulin (CaM) is an essential protein present in all eukaryote cells, ranging from vertebrates to unicellular organisms. CaM is the most important Ca²⁺ signalling protein, composed of two domains, N- and C-terminal domains, linked by a flexible central α-helix, and is responsible for the regulation of numerous calcium-mediated signalling pathways. Four calcium ions bind to CaM, changing its conformation and determining how it recognizes and regulates its cellular targets. The oxidation mechanism of native and denatured CaM, at a glassy carbon electrode, was investigated using differential pulse voltammetry and electrochemical impedance spectroscopy. Native and denatured CaM presented only one oxidation peak, related to the tyrosine amino acid residue oxidation. Calcium-induced calmodulin conformational change and the influence of Ca²⁺ concentration on the electrochemical behaviour of CaM were evaluated, and significant differences, in the tyrosine amino acid residue peak potential and current, in the absence and in the presence of calcium ions, were observed. Gravimetric measurements were performed with a graphite coated piezoelectric quartz crystal with adsorbed CaM, and calcium aggregation by CaM was demonstrated.

Psychometric validation of the EuroQoL 5-Dimension 5-Level (EQ-5D-5L) in Chinese patients with adolescent idiopathic scoliosis

Background

Scoliosis is a common spinal deformity that occurs often during adolescence. Previous studies suggested that adolescent idiopathic scoliosis (AIS) patients can have various aspects of their lives being affected, due to disease presentation and/or treatment received. It is important to define a reliable instrument based on which the affected patients’ health-related quality of life can be assessed. This study aims to assess the validity, reliability and sensitivity of the EuroQoL 5-dimension 5-level (EQ-5D-5L) in Chinese patients with AIS.

Methods

Adolescent idiopathic scoliosis patients of Chinese descent were prospectively recruited to complete both the traditional Chinese versions of the EQ-5D-5L and the refined Scoliosis Research Society-22 (SRS-22r) questionnaires. Patients’ demographic profiles and corresponding clinical parameters including treatment modalities, spinal curve pattern and magnitude, and duration of bracing were recorded. Telephone interviews were then conducted at least two weeks later for the assessment of test-retest reliability. Statistical analysis was performed: construct validity of the EQ-5D-5L domains were assessed using Spearman’s correlation test against the SRS-22r; whereas intra-class correlation coefficient (ICC) was used to assess the test-retest reliability, and agreement over the test-retest period was expressed in percentages. Also, the sensitivity of the EQ-5D-5L in differentiating various clinical known groups was determined by effect size, independent t-test and analysis of variance.

Results

A total of 227 AIS patients were recruited. Scores of domains of the EQ-5D-5L correlated significantly (r: 0.57-0.74) with the scores of the SRS-22r domains that were intended to measure similar constructs, supporting construct validity. The EQ-5D-5L domain responses and utility scores showed good test-retest reliability (ICC: 0.777; agreement: 76.4 -98.1 %). Internal consistency was good (Cronbach’s α: 0.78) for the EQ-5D-5L utility score. The EQ-5D-5L utility score was sensitive in detecting differences between subjects who had different treatment modalities and bracing duration, but not for curve pattern and its magnitude.

Conclusions

The EQ-5D-5L is found to be a valid, reliable and sensitive measure to assess the health-related quality of life in Chinese AIS patients. This potentiates the possibility of utilizing the EQ-5D-5L to estimate AIS patients’ health-related quality of life, based on which the outcome of various treatment options can eventually be evaluated.

Electronic supplementary material

The online version of this article (doi:10.1186/s13013-016-0083-x) contains supplementary material, which is available to authorized users.

Abnormal osteogenic and chondrogenic differentiation of human mesenchymal stem cells from patients with adolescent idiopathic scoliosis in response to melatonin

Abnormalities of membranous and endochondral ossification in patients with adolescent idiopathic scoliosis (AIS) remain incompletely understood. To investigate abnormalities in the melatonin signaling pathway and cellular response to melatonin in AIS, a case-control study of osteogenic and chondrogenic differentiation was performed using human mesenchymal stem cells (hMSCs). AIS was diagnosed by physical and radiographic examination. hMSCs were isolated from the bone marrow of patients with AIS and control subjects (n=12 each), and purified by density gradient centrifugation. The expression levels of melatonin receptors (MTs) 1 and 2 were detected by western blotting. Osteogenic and chondrogenic differentiation was induced by culturing hMSCs in osteogenic and chondrogenic media containing vehicle or 50 nM melatonin. Alkaline phosphatase (ALP) activity assays, quantitative glycosaminoglycan (GAG) analysis, and reverse transcription-quantitative polymerase chain reaction analysis were performed. Compared with controls, MT2 demonstrated low expression in the AIS group. Melatonin increased ALP activity, GAG synthesis and upregulated the expression of genes involved in osteogenic and chondrogenic differentiation including, ALP, osteopontin, osteocalcin, runt-related transcription factor 2, collagen type II, collagen type X, aggrecan and sex-determining region Y-box 9 in the normal control hMSCs, but did not affect the AIS groups. Thus, AIS hMSCs exhibit abnormal cellular responses to melatonin during osteogenic and chondrogenic differentiation, which may be associated with abnormal membranous and endochondral ossification, and skeletal growth. These results indicate a potential modulating role of melatonin via the MT2 receptor on abnormal osteogenic and chondrogenic differentiaation in patients with AIS.

Association of Calcium and Phosphate Balance, Vitamin D, PTH, and Calcitonin in Patients With Adolescent Idiopathic Scoliosis

STUDY DESIGN

A cross-sectional study of 2 groups of patients with scoliosis, and an age-matched control group was conducted. Each of the groups such as patients with adolescent idiopathic scoliosis (AIS) as well as control group were divided additionally into 2 groups: premenarcheal and postmenarcheal girls.

OBJECTIVE

The aim of the study was to determine the levels of 25-OH-vitamin D3, calcium and phosphate, parathyroid hormone (PTH), and calcitonin in serum of pre- and postmenarcheal girls with AIS and corresponding groups of scoliosis-free controls.

SUMMARY OF BACKGROUND DATA

The primary etiology and pathogenesis of AIS remains unknown. It is assumed that vitamin D deficiency and genetic predisposition, for example, polymorphisms of vitamin D receptor, have a great significance. Vitamin D plays a key role in skeletal development and prevents bone atrophy, affects the absorption of calcium, maintains calcium-phosphate homeostasis, and the bone matrix mineralization. Its deficiency can result in a wide variety of skeletal deformities, low bone mass, and then leads to the disappearance of bone. Defects in trabecular bone structure and/or bone mineralization are the main features of scoliosis. Some studies have reported that Vitamin D deficiency is common among patients with AIS. The mechanism of Vitamin D action on scoliosis development is still unclear.

METHODS

Determination of serum 25-OH-D3 levels was performed using high-performance liquid chromatography chromatography; concentrations of calcium and phosphate were measured using colorimetric methods, and concentration of PTH and calcitonin was measured using ELISA system.

RESULTS

Reduction in the serum levels of 25-OH-D3 and calcitonin in girls with AIS compared with healthy girls was demonstrated.

CONCLUSION

The phosphate-calcium balance and PTH level seem to be normal in patients with AIS. The calcitonin level in girls with AIS is 2-fold lower than in healthy subjects. It is possible that the deficiency of vitamin D can be involved in AIS.

LEVEL OF EVIDENCE

4.

Online Curves: A Quality Analysis of Scoliosis Videos on YouTube

STUDY DESIGN

A cross-sectional study.

OBJECTIVE

The aim of this study was to evaluate the quality of online scoliosis information available on the video sharing site YouTube.

SUMMARY OF BACKGROUND DATA

The Internet is an increasingly utilized resource for accessing information about a variety of heath conditions. YouTube is a video sharing platform used to both seek and distribute information.

METHODS

A search for "scoliosis" was carried out using YouTube's search engine and data were collected on the first 50 videos returned. A JAMA score to determine currency, authorship, source and disclosure, and scoliosis-specific score that measures the amount of information on the diagnosis and treatment options (as devised by Mathur et al in 2005; scored 0-32) was recorded for each video to measure quality objectively. In addition, the number of views, number of comments, and feedback positivity was documented for each. Data analysis was conducted using R 3.1.4/R Studio 0.98 with control for the age of each video in analysis models.

RESULTS

The average number of views per video was 71,152 with an average length of 7 minutes 32  seconds. Thirty-six percent of the videos fell under the authorship category of personal experience. The average JAMA score was 1.32/4 and average scoliosis specific score was 5.38/32. There was a positive correlation between JAMA score and number of views (P = 0.003). However, in contrast, there was a negative correlation between scoliosis-specific score and number of views (P = 0.01).

CONCLUSIONS

Online health information has historically been poor and our study shows that in an environment like YouTube that lacks a peer review process, the quality of scoliosis information is low. Further work is needed to determine whether accessing information on YouTube can play a role in patient care other than simple education pertaining to the disease and its management.

LEVEL OF EVIDENCE

3.

Effects of mechanical loading on the expression of pleiotrophin and its receptor protein tyrosine phosphatase beta/zeta in a rat spinal deformity model

Mechanical loading of the spine is a major causative factor of degenerative changes and causes molecular and structural changes in the intervertebral disc (IVD) and the vertebrae end plate (EP). Pleiotrophin (PTN) is a growth factor with a putative role in bone remodeling through its receptor protein tyrosine phosphatase beta/zeta (RPTPβ/ζ). The present study investigates the effects of strain on PTN and RPTPβ/ζ protein expression in vivo. Tails of eight weeks old Sprague-Dawley rats were subjected to mechanical loading using a mini Ilizarov external apparatus. Rat tails untreated (control) or after 0 degrees of compression and 10°, 30° and 50° of angulation (groups 0, I, II and III respectively) were studied. PTN and RPTPβ/ζ expression were evaluated using immunohistochemistry and Western blot analysis. In the control group, PTN was mostly expressed by the EP hypertrophic chondrocytes. In groups 0 to II, PTN expression was increased in the chondrocytes of hypertrophic and proliferating zones, as well as in osteocytes and osteoblast-like cells of the ossification zone. In group III, only limited PTN expression was observed in osteocytes. RPTPβ/ζ expression was increased mainly in group 0, but also in group I, in all types of cells. Low intensity RPTPβ/ζ immunostaining was observed in groups II and III. Collectively, PTN and RPTPβ/ζ are expressed in spinal deformities caused by mechanical loading, and their expression depends on the type and severity of the applied strain.

[Adolescent scoliosis : From deformity to treatment]

Scoliosis affects up to 6 % of the population. The resulting spine deformity, the increasing risk of back pain, cosmetic aspects, pulmonary disorders if the Cobb angle is > 80°, and the progress of the deformity to > 50° after the end of growth indicate non-operative or operative therapy. In daily clinical practice, the classifications of scoliosis allow the therapy to be adapted. Classifications consider deformity, topography of the scoliosis, and the age at diagnosis. This publication gives an overview of the relevant and most common classifications in the treatment of adolescent scoliosis. For evaluation, the deformity measurement on the coronary radiographic projection of the total spine (Cobb angle) is relevant to therapy. The classification of topography, form, and the sagittal profile of the deformity of the spine are useful for preoperative planning of the fusion level. Classifications that take into account the age at the time of the diagnosis of scoliosis differentiate among early onset scoliosis (younger than 10 years of age), adolescent scoliosis (up to the end of growth), and adult scoliosis. Early onset scoliosis is subdivided by age and etiology. Therapy is derived from the classification of clinical and radiological findings. Classifications that take into account clinical and radiological parameters are essential components of modern scoliosis therapy.

Identification of the relationships between sagittal plane and coronal plane curvature in guppy models

OBJECTIVE

To explore the relationship between sagittal plane and coronal plane curvatures in guppies by investigating the curvature angles of sagittal and sagittal-coronal guppies.

METHODS

After mating between 1000 spinal curvature guppies, 124 guppies (3-month old) were screened from progenies for the present study. Photos of all fishes were taken and the sagittal and coronal angles were calculated via angle measure tool of Photoshop 12.0 software. All data were analyzed by SPSS 11.0.

RESULTS

In sagittal and sagittal-coronal curvature guppies, there was a significant linear correlation between sagittal angles and coronal angles. In 48 sagittal-coronal curvatures, their sagittal angles were above 40°, meanwhile, in 76 sagittal guppies, their sagittal angles were mostly below 40°.

CONCLUSIONS

These findings indicated that the occurrence of coronal curvature might be later than sagittal curvature and could be influenced by other factors. Sagittal angles 40° might be involved in the onset of coronal curvature.