Update on the management of idiopathic scoliosis

Subject matter predicts where top pediatric spine articles are shared: citations vs. social media

STUDY DESIGN

Systematic review. The purpose of this study was to compare the top 25 articles on pediatric spine surgery by number of citations and Altmetric score. All published articles pertaining to pediatric spine surgery from 2010 to 2021 were assessed for: Altmetric scores, Altmetric score breakdown (e.g. Twitter, News), citation counts, and article topics. The top 25 Altmetric articles and top 25 cited articles were identified. Out of the 50 total articles, only 3 (6.0%) overlapped between the two groups. The top Altmetric articles had averages (mean ± SD) of 167 ± 130 Altmetric score and 66 ± 135 citations, while the top citation articles had averages of 22 ± 45 Altmetric score and 196 ± 114 citations. When evaluating article topics, articles on 'back pain' (36% vs. 4%; P  = 0.003) and 'backpacks' (16% vs. 0%; P  = 0.030) were published significantly more in the top Altmetric group, while articles on 'scoliosis' (93% vs. 36%; P  < 0.001) and 'growth friendly surgery' (24% vs. 4%; P  = 0.041) were published significantly more in the top citation group. The total number of citations and online mentions for both groups are presented in Table 2. The biggest differences were the top Altmetric score articles receiving greater percentages of Twitter mentions relative to overall mentions (87% vs. 57%). The most socially popular articles focused on back pain and backpacks, and the most cited articles focused on scoliosis and growth-friendly surgery. Twitter had the most mentions of all social media for both the top cited articles and the top Altmetric articles.

Increasing Cervical Kyphosis Correlates With Cervical Degenerative Disk Disease in Patients With Adolescent Idiopathic Scoliosis

STUDY DESIGN

Retrospective review.

OBJECTIVE

Our goal was to investigate the incidence of cervical degenerative disk disease (DDD) in patients with adolescent idiopathic scoliosis (AIS), before surgical intervention.

SUMMARY OF BACKGROUND DATA

AIS is often associated with thoracic hypokyphosis and compensatory cervical kyphosis. In adults, cervical kyphosis is associated with DDD. Although cervical kyphosis has been reported in up to 60% AIS patients, the association with cervical DDD has not been reported.

MATERIALS AND METHODS

A retrospective review was conducted from January 2014 to December 2019 of all consecutive AIS patients. Inclusion criteria were AIS patients over 10 years of age with cervical magnetic resonance imaging and anterior-posterior and lateral spine radiographs within 1 year of each other. Magnetic resonance imaging were reviewed for evidence of cervical DDD. Severity of cervical changes were graded using the Pfirrmann classification and by a quantitative measure of disk degeneration, the magnetic resonance signal intensity ratio.

RESULTS

Eighty consecutive patients were included (mean age: 14.1 years, SD=2.5 years). Increasing cervical kyphosis was significantly correlated to decreasing thoracic kyphosis ( r =0.49, P <0.01) and increasing major curve magnitude ( r =0.22, P =0.04). Forty-five patients (56%) had the presence of DDD (grades 2-4) with a mean cervical kyphosis of 11.1° (SD=9.5°, P <0.01). More cervical kyphosis was associated with more severe cervical DDD as graded by Pfirrmann classification level ( P <0.01). Increasing cervical kyphosis was also positively associated with increasing magnetic resonance signal intensity ratio ( P <0.01). Nine patients had ventral cord effacement secondary to DDD with a mean cervical kyphosis of 22.8° (SD=8.6°) compared with 2.6° (SD=11.2°) in those who did not ( P <0.01).

CONCLUSIONS

Cervical kyphosis was significantly associated with increasing severity of cervical DDD in patients with AIS. Patients with evidence of ventral cord effacement had the largest degree of cervical kyphosis with a mean of 22.8±8.6°. This is the first study to evaluate the association between cervical kyphosis in AIS with cervical DDD.

Effect of Prophylactic Fibrinogen Concentrate In Scoliosis Surgery (EFISS): a study protocol of two-arm, randomised trial

INTRODUCTION

Fibrinogen is one of the essential coagulation factors. Preoperative lower plasma fibrinogen level has been associated with higher blood loss. Scoliosis surgery presents a challenge for the anaesthetic team, one of the reasons being blood loss and transfusion management. Recently, the prophylactic fibrinogen administration has been a debated topic in various indications. It has been described for example, in urological or cardiovascular surgery, as well as in paediatrics. This pilot study is focused on verifying the feasibility of potential large randomised trial and verifying the safety of prophylactic fibrinogen administration in paediatric scoliosis surgery.

METHODS AND ANALYSIS

A total of 32 paediatric patients indicated for scoliosis surgery will be recruited. Participants will be randomised into study groups in a 1:1 allocation ratio. Patients in the intervention group will receive prophylactic single dose of fibrinogen, in addition to standard of care. Patients in the control group will receive standard of care without study medication prior to skin incision. The primary aim is to assess the safety of prophylactic fibrinogen administration during scoliosis surgery in children, the incidence of any adverse events (AEs) and reactions will be monitored during participation in the study. The secondary objective is to investigate the additional safety information, feasibility and efficacy of a prophylactic fibrinogen administration. The incidence of AEs and reactions according to selected adverse events of special interest will be monitored. All collected data will be subjected to statistical analysis according to a separate statistical analysis plan.

ETHICS AND DISSEMINATION

This trial follows the applicable legislation and requirements for good clinical practice according to the International Conference on Harmonisation E6(R2). All essential trial documents were approved by the relevant ethics committee and national regulatory authority (State Institute for Drug Control) and their potential amendments will be submitted for approval.

TRIAL REGISTRATION NUMBER

NCT05391412.

Acute‑on‑chronic slipped femoral epiphysis following posterior spinal fusion due to idiopathic scoliosis: Case report

The aim of this case report is to present a rare case of acute slipped femoral capital on a chronic slipped capital femoral epiphysis (SCFE) after spinal fusion due to idiopathic scoliosis. A 14 year old male patient underwent posterior spinal fusion due to idiopathic thoracic scoliosis. Post-operatively, the patient presented with acute pain in the left hip and a reduced range of motion, which revealed acute SCFE. The patient was then referred to the Second Orthopaedic Department of Agia Sofia Children Hospital in Athens, and underwent percutaneous pinning of the left femur, after which he was discharged uneventfully. The follow up was excellent with no impact on the patient's daily life. The case described is extremely rare in the current literature. The significance of the pre-operative planning is underlined by this case, as well as the need for the spinal surgeon to be aware of the possibility of acute pain in the hip in young adolescents, as SCFE is more common amongst this demographic.

Predictors of persistent postoperative pain after surgery for idiopathic scoliosis

PURPOSE

To identify factors contributing to persistent postoperative pain in patients treated surgically for idiopathic scoliosis.

METHODS

In total, 280 patients aged ten through 25 years at surgery, were identified in the Swedish Spine registry; all having preoperative and postoperative visual analogue scale (VAS) for back pain scores. The patients were divided into a high and low postoperative pain group based on the reported postoperative VAS for back pain scores (by using 45 mm on the 0 mm to 100 mm VAS scale as a cut-off). The patient-reported questionnaire included VAS for back pain, the 3-level version of EuroQol 5-dimensional (EQ-5D-3L) instrument, the EuroQol VAS (EQ-VAS) and the Scoliosis Research Society 22r instrument (SRS-22r). Predictors of postoperative back pain were searched in the preoperative data.

RESULTS

The 67 (24%) patients that reported high postoperative VAS back pain (> 45 mm) also reported lower postoperative EQ-5D-3L, EQ-VAS and SRS-22r than patients with low postoperative VAS back pain (all p < 0.001). Two preoperative variables were independently associated with postoperative pain; each millimetre increase in preoperative VAS back pain (on the 0 mm to 100 mm scale) was associated with a higher risk of being in the high postoperative back pain group (odds ratio (OR) 1.03; 95% confidence interval (CI) 1.02 to 1.05) and each 1 point decrease on the preoperative SRS-22r mental health (scale from 1 to 5) was associated with a higher risk of being in the high postoperative back pain group (OR 1.68; 95% CI 1.03 to 2.73).

CONCLUSION

High preoperative back pain and low preoperative mental health are independent predictors of back pain after surgery for idiopathic scoliosis.

LEVEL OF EVIDENCE

III.

A finite element analysis of different pedicle screw placement strategies for treatment of Lenke 1 adolescent idiopathic scoliosis: which is better?

OBJECTIVE

To simulate the process of curve correction with different strategies of pedicle screws placement, and then explore the ideal strategy. Materials and methods: A three-dimensional model was constructed using CT data from a Lenke 1 AIS patient for finite element analysis. Five screw-placement strategies were designed, including collocation of consecutive, interval and alternate screws instrumentation in convex or concave side. The whole surgical procedures of screw-placement strategies were simulated. And their influences in the curve correction as well as the biomechanics of the implants and implant-bone interface were analyzed. Results: The densities of pedicle screws were 100%, 79%, 64%, 57% and 50%, respectively. During curve correction, interval and alternate screws instrumentation demonstrated higher screws stress, while the higher rods and screw-rod interface was observed in consecutive screws instrumentation. When it referred to the interaction force between screws and vertebrae, a lower stress was observed in in consecutive screws instrumentation. After the fixation of rod at convex side, the maximum stress on screws in each strategy was observed in interval screws instrumentation. The higher stress of rods was observed in alternate screws instrumentation in both sides. However, the correction rate of each strategy was similar. Conclusion: There was little distinction on the curve correction rate in different screw-placement strategies. The screw-placement strategy with interval and alternate screws instrumentation has better biomechanics properties than others, except for higher maximum interaction force between screws and vertebrae.

Deformity correction using proximal hooks and distal screws (PHDSs) improves radiological metrics in adolescent idiopathic scoliosis

PURPOSE

Surgical correction for AIS has evolved from all hooks to hybrids or all screw constructs. Limited literature exists reporting outcomes using PHDS for posterior spinal fusion (PSF). This is the largest series in evaluating results of PHDS technique.

METHODS

A retrospective review of consecutive AIS patients undergoing PSF by a single surgeon between 2006 and 2015 was performed. All eligible patients met a minimum 2-year follow-up. Patient demographics and radiographical parameters (radiographic shoulder height (RSH), T1 tilt, clavicle angle) at baseline, 6-week and 2-year post-operation were recorded. The primary outcome was difference in RSH from baseline measurements evaluated using repeated measures one-way analysis of variance with Bonferroni correction.

RESULTS

A total of 219 patients (mean age at surgery: 13.68 years; 82% female) were included. The mean follow-up was 41.2 months (range 24-108 months). The RSH was significantly improved from - 14.7 ± 10.38 mm to 8.0 ± 6.9 mm (P < 0.0001). Clavicle angle was improved from 2.13° to 1.31° (P < 0.0001). T1 tilt was improved from 5.6° to 2.2° (P < 0.0001). At last follow-up, 95.8% of patients were shoulder balanced. There was a significant improvement of Cobb angle with an average correction of the upper thoracic curve of 42% and main thoracic curve of 67%.

CONCLUSION

The PHDS demonstrates the potential for additional shoulder balance improvement. Extension of fusion to structural proximal thoracic spine is the key to success for shoulder balance. It remains to be seen whether these improvements will translate into improved clinical outcomes in the longer term.

Two for One: A Change in Hand Positioning During Low-Dose Spinal Stereoradiography Allows for Concurrent, Reliable Sanders Skeletal Maturity Staging

STUDY DESIGN

Prospective survey.

OBJECTIVES

To evaluate the reliability of low-dose stereoradiography compared to standard hand bone age films for assessing Sanders skeletal maturity stage in patients with idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

The Sanders skeletal maturity staging system is a valuable tool in the care of juvenile and adolescent spine scoliosis, but obtaining dedicated hand films adds additional time, radiation, and expense to the clinic visit. A change in patient hand positioning for routine full-length PA spine low-dose stereoradiography may offer a viable alternative.

METHODS

A survey consisting of 30 standard bone age hand films and 26 posteroanterior spine low-dose stereoradiography images (magnified view of hands only) was created in REDCap and distributed to two pediatric spine surgeons and two fellows. The graders were asked to classify the images according to the Sanders skeletal maturity classifications. Images were graded in two trials conducted one week apart. Inter- and intraobserver reliability was assessed using the mean linearly weighted kappa to provide an overall index of agreement.

RESULTS

In Trial 1, the interobserver reliability was similar for both the standard bone age films (κ = 0.82) and for the low-dose stereoradiography films (κ = 0.79) (p = .501). In Trial 2, reliability was similar between imagine modalities and slightly improved for both standard bone age films (κ = 0.85) and low-dose stereoradiography films (κ = 0.82) (p = .192). Intraobserver reliability was strong for both standard films (κ=0.89) and low-dose stereoradiography films (κ = 0.86) (p = .446).

CONCLUSION

A simple change in patient hand positioning for low-dose stereoradiography allows clinicians to simultaneously assess a patient's spinal deformity and skeletal maturity with excellent reliability. Given the frequency of scoliosis surveillance visits, this simple change could lead to significant savings of time, money, and radiation exposure for the growing child.

LEVEL OF EVIDENCE

Level III.

Understanding muscle-immune interactions in adolescent idiopathic scoliosis: a feasibility study

Background

Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis in children, and its cause remains unknown. The Immune-metabolic CONnections to Scoliosis (ICONS) Study was designed to elucidate the potential mechanisms by which immune system-paraspinal muscle crosstalk contributes to the development of AIS. In this report, we document the evaluation of ICONS Study feasibility.

Methods

This study was conducted at a tertiary pediatric academic center in Hamilton, Ontario, Canada. We included boys and girls, aged 10–17 years with a diagnosis of AIS requiring corrective spinal surgery. Exclusion criteria included patients on high-dose steroids, immunosuppressive therapy, anti-thrombotic medications, those with an active infection for 15 days before participation, autoimmune disease, pregnancy, and patients who were unwilling to consent.

Pre-determined feasibility criteria included permission to approach participants and recruitment rates of 80%, consenting of at least 80% of participants to provide biological samples, 90% or higher case report form and questionnaire completion, resources to be sufficient in at least 80% of recruitments, and the ability to successfully collect and process 80% or more of the biological samples needed for this study.

Results

Between August 2013 and October 2014, we identified 32 potential participants with AIS, but had the resources to approach only 16, of which 12 (75%) agreed to be approached by the research team, and all consented to participate. Of the 12 participants recruited, 11 questionnaire packages and muscle biopsies (91.7% for each objective) were collected, while other biological samples (serum, plasma, whole blood for DNA and RNA processing, urine) were collected from all participants.

Conclusions

The ICONS study protocols and procedures are feasible. However, recruitment rates were less than predicted. For the full study, we plan on prolonging the recruitment phase and the inclusion of additional centers to achieve recruitment targets.

Rapidly increasing incidence in scoliosis surgery over 14 years in a nationwide sample

PURPOSE

Severe scoliosis is primarily managed with surgery. This cohort study describes the incidence of surgically treated scoliosis among Swedish youth and young adults, stratified by age, sex, scoliosis type, and surgical approach and identifies changes in incidence rate and hospital length of stay (LOS), infections requiring re-surgery and mortality within 90 days.

METHODS

Swedish youth, 0-21 years, (n = 3062) with a diagnostic code for scoliosis and spine surgery between 2000 and 2013 were selected from the National Patient Register. Incidence was computed by comparing individuals with surgically treated scoliosis to the total at risk population. Linear regression models and Spearman correlation coefficients analyzed trends over time.

RESULTS

Overall annual incidence per 100,000 individuals was 9.1 (5.9 males/12.5 females). Annual incidence increased over 14 years from 5.1 to 9.8; an average 4.6% per year (p < 0.001). Adolescent idiopathic scoliosis was most common (4.5 per 100,000; n = 1516) followed by neuromuscular 2.7 (n = 913) and congenital 0.7 (n = 236). Average LOS decreased among scoliosis types except infantile and neuromuscular scoliosis. Posterior fusion was the most common surgical approach (75%) followed by anterior (18%) and anteroposterior fusion (7%). Posterior fusions significantly increased with a resultant decrease in anterior and anteroposterior fusion over time. Individuals with neuromuscular scoliosis exhibited the highest mortality (n = 12; 1.3%) and (n = 59; 6%) of individuals with neuromuscular scoliosis and (n = 12; 15%) with scoliosis related to MMC required revision surgery due to post-op infection.

CONCLUSIONS

Surgical management of scoliosis is increasing with a concurrent decrease in hospital LOS. Surgical management of neuromuscular scoliosis is associated with high 90-day post-operative infections and mortality rate.

Assessment of Vertebral Curves Using the Manual Post-It Technique

STUDY DESIGN

A prospective study of a new technique.

OBJECTIVE

The aims of this study were to report a manual technique for measuring vertebral curves on digital spine radiographs, and to assess the agreement of this technique with that of digital software for measuring vertebral curves.

SUMMARY OF BACKGROUND DATA

Modern picture archiving and communication systems (PACS) typically include software for evaluating radiographic measurements. However, in the outpatient spine setting, patients may present with radiographs stored on a physical disc, which may not include software for measuring vertebral curves. Certain smartphone applications may be used to determine curve magnitude; however, the need exists for an accurate manual technique to measure vertebral curves on digital radiographs in the absence of available analytic software or smartphone technology.

METHODS

We prospectively reviewed anteroposterior and lateral spine radiographs of 24 spinal deformity patients. Two independent observers measured Cobb angles for: (1) the major coronal curve; (2) the thoracic kyphosis (T2-T12); and (3) the lumbar lordosis (T12-S1). Measurements were made: (1) digitally using our institution's PACS; and (2) by a manual technique, which involves placement of an adhesive Post-It note directly on the computer screen, transcribing the angle onto the Post-It note with a pencil, and measuring the angle with a handheld goniometer. Intraclass correlation coefficients (ICCs) were calculated to determine the agreement between the 2 methods.

RESULTS

For both observers, the agreement between the digital PACS and manual Post-It techniques was graded as excellent for both coronal and sagittal plane curves (all ICCs>0.9). Interobserver reliability between the 2 observers was also graded as excellent for both the PACS and Post-It techniques (all ICCs>0.9).

CONCLUSIONS

The Post-It technique for measuring Cobb angles demonstrated excellent agreement with the PACS system in our series of spinal deformity patients. Curves on digital radiographs can be accurately measured using a convenient manual technique.

Micro CT Analysis of Spine Architecture in a Mouse Model of Scoliosis

OBJECTIVE

Mice homozygous for targeted deletion of the gene encoding fibroblast growth factor receptor 3 (FGFR3(-/-)) develop kyphoscoliosis by 2 months of age. The first objective of this study was to use high resolution X-ray to characterize curve progression in vivo and micro CT to quantify spine architecture ex vivo in FGFR3(-/-) mice. The second objective was to determine if slow release of the bone anabolic peptide parathyroid hormone related protein (PTHrP-1-34) from a pellet placed adjacent to the thoracic spine could inhibit progressive kyphoscoliosis.

MATERIALS AND METHODS

Pellets loaded with placebo or PTHrP-1-34 were implanted adjacent to the thoracic spine of 1-month-old FGFR3(-/-) mice obtained from in house breeding. X rays were captured at monthly intervals up to 4 months to quantify curve progression using the Cobb method. High resolution post-mortem scans of FGFR3(-/-) and FGFR3(+/+) spines, from C5/6 to L4/5, were captured to evaluate the 3D structure, rotation, and micro-architecture of the affected vertebrae. Un-decalcified and decalcified histology were performed on the apical and adjacent vertebrae of FGFR3(-/-) spines, and the corresponding vertebrae from FGFR3(+/+) spines.

RESULTS

The mean Cobb angle was significantly greater at all ages in FGFR3(-/-) mice compared with wild type mice and appeared to stabilize around skeletal maturity at 4 months. 3D reconstructions of the thoracic spine of 4-month-old FGFR3(-/-) mice treated with PTHrP-1-34 revealed correction of left/right asymmetry, vertebral rotation, and lateral displacement compared with mice treated with placebo. Histologic analysis of the apical vertebrae confirmed correction of the asymmetry in PTHrP-1-34 treated mice, in the absence of any change in bone volume, and a significant reduction in the wedging of intervertebral disks (IVD) seen in placebo treated mice.

CONCLUSION

Local treatment of the thoracic spine of juvenile FGFR3(-/-) mice with a bone anabolic agent inhibited progression of scoliosis, but with little impact on kyphosis. The significant improvement in IVD integrity suggests PTHrP-1-34 might also be considered as a therapeutic agent for degenerative disk disorders.

Radiographic and functional evaluation of the iliac bone graft in the treatment of adolescent idiopathic scoliosis

This study aimed to assess the impact of the use of an additional iliac bone graft on functional and radiographic results after thoracic spine arthrodesis with pedicle screws in patients with adolescent idiopathic scoliosis. Participants were divided into two groups: a control group that received only local bone (n=19) and a second group that, in addition to this procedure, received an iliac graft (n=22). The evaluations were performed on preoperative, immediate postoperative, and last follow-up (mean 29.7 months; minimum 12 months). Radiographic evaluations included the loss of correction and the presence of nonunion. The functional outcome was evaluated using the Scoliosis Research Society-30 questionnaire. Surgical complications and the presence of iliac donor site pain were also described. There were no significant differences between groups in the pseudoarthrosis rate, loss of correction over time, and quality of life. We concluded that the addition of bone graft from the iliac yielded no benefit in terms of the fusion rate and functional outcomes. The appropriate facetectomy, bed preparation, and filling with a local bone graft must be adequate to achieve an adequate fusion on surgical treatment of adolescent idiopathic scoliosis.

Pre- and postoperative quality of life in patients treated for scoliosis

BACKGROUND AND PURPOSE

There have been few prospective reports on quality of life in patients treated surgically for scoliosis. We compared patients with idiopathic, congenital, and neuromuscular scoliosis.

METHODS

Data on 9- to 20-year-old patients were collected from the SweSpine registry. EQ-5D and (for a subset) SRS-22r were assessed preoperatively and after 1 and 2 years.

RESULTS

211 patients had preoperative data: 168 with idiopathic, 11 with congenital, and 32 with neuromuscular scoliosis. Of the total, 158 patients responded to the 1-year follow-up and 149 responded to the 2-year follow-up. Preoperatively, the mean (SE) EQ-5D index was 0.76 (0.02) in the idiopathic group, 0.74 (0.07) in the congenital group, and 0.10 (0.06) in the neuromuscular group, and the SRS-22r index was 3.8 (0.1) in the idiopathic group, 4.0 (0.3) in the congenital group, and 3.3 (0.2) in the neuromuscular group. The mean EQ-5D increased by 0.06 points at 2 years in the idiopathic group, by 0.16 points in the congenital group, and by 0.15 points in the neuromuscular group. The mean SRS-22r index increased by 0.4 points at 2 years in the idiopathic group, by 0.4 points in the congenital group, and by 0.5 points in the neuromuscular group. The changes were statistically significant, with the exception of the congenital group. The number of patients who sustained at least 1 complication was 13 in the idiopathic group, 2 in the congenital group, and 9 in the neuromuscular group (p = 0.003).

INTERPRETATION

The general quality of life in the idiopathic and neuromuscular group improved after surgery.

Diagnosis and treatment of adolescent idiopathic scoliosis

Scoliosis is defined as a lateral curvature of the spine greater than 10 degrees on radiography that is typically associated with trunk rotation. The three major types of scoliosis are congenital, idiopathic, and neuromuscular. Idiopathic scoliosis is divided into three subcategories based on the age of onset. Infantile idiopathic scoliosis affects patients younger than 3 years, juvenile idiopathic scoliosis appears in children between 3 and 10 years, and adolescent idiopathic scoliosis (AIS) occurs in skeletally immature patients older than 10 years. AIS is the most common form of idiopathic scoliosis. Approximately 2% to 4% of children aged 10 to 16 years have some degree of spinal curvature. Although some researchers view routine screening for AIS as controversial, well-child examinations and sports physicals are an optimal time to evaluate for AIS in the clinical setting. In 2008, the American Academy of Orthopaedic Surgeons, the Scoliosis Research Society, the Pediatric Orthopaedic Society of North America, and the American Academy of Pediatrics convened a task force to review the issues related to scoliosis screening and issued an information statement concluding that although screening has limitations, the potential benefits that patients with idiopathic scoliosis receive from early treatment can be substantial. Recommendations are now that females are screened twice, at age 10 and 12 years, and males once at age 13 or 14 years. Screening during routine well-child examinations and/or school-based evaluations will help identify patients who need ongoing monitoring. The evaluation of curvatures in conjunction with the level of skeletal maturity will help to guide the management of the curvature.

Development of the lumbar lordotic curvature in children from age 2 to 20 years

STUDY DESIGN

Cross-sectional retrospective study.

OBJECTIVE

The purpose of this study was to provide data for the normal values of the lumbar lordotic curvature and segmental angles throughout childhood and to explore the relative contribution of the vertebral bodies and intervertebral discs to the developing lordosis during childhood.

SUMMARY OF BACKGROUND DATA

Although early detection of spinal abnormalities such as hyper lordosis or scoliosis is important for preventative intervention, published data regarding normal lordosis development is sparse. The lumbar lordotic curvature is formed by the wedging of the lumbar vertebral bodies and of the intervertebral discs, but there are no data to indicate how these 2 components changes during childhood development.

METHODS

Spinal angle parameters were measured on midsagittal reformatted images from 210 abdominal computed tomographic scans of children aged 2 to 20 years. Four different angles were measured: the lordosis angle, the body wedge angle (B), the total segmental angle (S), and the intervertebral disc angle (D). Measurements B, S, and D were taken for each of the 5 lumbar segments. Measurements B and D were used to calculate ΣB, the sum of the lumbar L1-L5 body angles; and ΣD, the sum of the lumbar L1-L5 intervertebral disc angles. Computed tomographic scans were divided into 6 groups according to patients' ages. RESULTS.: The lordosis angle increased from 30° ± 6° in the 2- to 4-year-old group to 44° ± 9° in the 17- to 20-year-old group. The ΣB slightly decreased (less lordotic wedging) with age, whereas the ΣD increased significantly with age.

CONCLUSION

Our results indicate that the lordosis angle continues to develop at least until 14 to 16 years of age and that this increase is the result of the increased lordotic wedging of the intervertebral discs.

LEVEL OF EVIDENCE

N/A.

All-pedicle-screw versus hybrid hook-screw instrumentation for posterior spinal correction surgery in adolescent idiopathic scoliosis: a curve flexibility matched-pair study

INTRODUCTION

Comparisons of all-pedicle-screw (PS) and hybrid hook-screw (HS) instrumentation for the treatment of adolescent idiopathic scoliosis (AIS) have produced conflicting results. The aim of this study was to compare all-pedicle-screw and hybrid hook-screw instrumentation for the treatment of AIS using a matched-pair study design in which preoperative flexibility was matched.

METHODS

In this retrospective study conducted at one medical center, 21 all-pedicle-screw/hybrid hook-screw pairs of Lenke type I AIS patients matched for age, height, weight, body mass index, sex, and preoperative curve flexibility who had been treated at our institution from January 2000 to October 2006 were selected. Postoperative and 2-year postoperative coronal curve correction, postoperative kyphosis, blood transfusion needs, operation time, and hospital cost were measured and analyzed statistically.

RESULTS

The PS group compared with the HS group had better postoperative correction (P = 0.0231) and 2-year coronal curve correction (P = 0.016). While statistically significant (P = 0.0073), the postoperative Cobb angle was only 3° less in the PS group, Maintenance of correction after 2 years was better in the PS group (P = 0.0016). The PS group had less blood loss (P < 0.0001) and shorter operation time (P < 0.0001), but the hospital cost for the PS group was higher (P < 0.0001).

CONCLUSIONS

All-pedicle-screw and hybrid hook-screw instrumentations are comparable with regard to curve correction, but all-pedicle screw instrumentation reduces blood loss during surgery and shortens the operation time, which may help shorten healing time.

Anatomical study of the pelvis in patients with adolescent idiopathic scoliosis

Standing posterior-anterior (PA) radiographs from our clinical practice show that the concave and convex ilia are not always symmetrical in patients with adolescent idiopathic scoliosis (AIS). Transverse pelvic rotation may explain this observation, or pelvic asymmetry may be responsible. The present study investigated pelvic symmetry by examining the volume and linear measurements of the two hipbones in patients with AIS. Forty-two female patients with AIS were recruited for the study. Standing PA radiographs (covering the thoracic and lumbar spinal regions and the entire pelvis), CT scans and 3D reconstructions of the pelvis were obtained for all subjects. The concave/convex ratio of the inferior ilium at the sacroiliac joint medially (SI) and the anterior superior iliac spine laterally (ASIS) were measured on PA radiographs. Hipbone volumes and several distortion and abduction parameters were measured by post-processing software. The concave/convex ratio of SI-ASIS on PA radiographs was 0.97, which was significantly < 1 (P < 0.001). The concave and convex hipbone volumes were comparable in patients with AIS. The hipbone volumes were 257.3 ± 43.5 cm(3) and 256.9 ± 42.6 cm(3) at the concave and convex sides, respectively (P > 0.05). Furthermore, all distortion and abduction parameters were comparable between the convex and concave sides. Therefore, the present study showed that there was no pelvic asymmetry in patients with AIS, although the concave/convex ratio of SI-ASIS on PA radiographs was significantly < 1. The clinical phenomenon of asymmetrical concave and convex ilia in patients with AIS in preoperative standing PA radiographs may be caused by transverse pelvic rotation, but it is not due to developmental asymmetry or distortion of the pelvis.

Biomechanical examination of the thoracic spine--the axial rotation moment and vertical loading capacity of the transverse process

Our objective was to examine the load-bearing capacity of the transverse processes of human cadaveric thoracic vertebrae to vertical loads and axial rotation moments (i.e., moment applied in the transverse plane). A secondary objective was to examine the effect of the attached rib stumps. We wanted to demonstrate that the transverse process is durable enough to support the CAB hook--a complementary hook to the CD system--and can handle the vertical load or axial rotation moment during correction of scoliosis. We used 107 thoracic vertebrae removed from 10 cadavers. They were prepared in vertebral pairs, and were fixed into a material testing apparatus. Superoinferior vertical loads and axial rotation moments were applied to the transverse process using the CAB hooks at a rate of 30 mm/min and 8.5°/s respectively until it fractured. We recorded 142 measurements, 99 were for vertical load and 43 for axial rotation moment. The average ultimate vertical load was 338 (SD = 128) N and the average ultimate axial rotation moment was 14.4 (SD = 4.52) Nm. The ultimate axial rotation moment for specimens with rib stumps attached was significantly greater than for specimens without rib stumps 15.9 (SD = 4.1) Nm versus 12.5 (SD = 4.4) Nm. Our results showed that both the vertical and axial rotation loading capability of the transverse process are large enough to withstand significant correctional forces, without fracture, through the CAB hooks.

Correlations of adolescent idiopathic scoliosis and pectus excavatum

STUDY DESIGN

Radiologic study of scoliosis in pectus excavatum patients.

OBJECTIVES

To determine the relation between pectus excavatum deformity and adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

AIS may be related to other whole body deformities, but few reports have addressed the relation between chest deformity and scoliosis.

METHODS

A total of 248 patients with a diagnosis of pectus excavatum were enrolled in this study. All study patients underwent whole spine anteroposterior radiographs and chest computed tomography. Severity and type of scoliosis and chest deformity were measured using radiographs, and relations between pectus deformity and AIS were analyzed.

RESULTS

Overall, 56 of the 248 study patients had scoliosis (Cobb angle > 10 degrees)--a prevalence of 22.58%. The incidence of scoliosis was significantly higher in female patients (38.46%) (P = 0.002), and Lenke type 1 predominated in pectus patients (48.2%, P < 0.0001). Mean age was greater in the scoliosis group than in the nonscoliosis group (P < 0.0001), and the asymmetry of pectus deformity was more prominent in the scoliosis group (P = 0.007). However, pectus deformity severity was similar in the 2 groups (P = 0.061). Furthermore, although the scoliosis group showed a higher proportion of female patients (P = 0.002), the severities of chest and spinal deformities were similar in the 2 groups for both sexes (P = 0.314, P = 0.227).

CONCLUSIONS

Pectus excavatum and AIS were found to have a high concomitant incidence. And, the age, sex, and type of disease were significantly different in the scoliosis and pectus excavatum groups. Surgeons should consider these relationships when deciding upon treatment in patients with chest and spinal deformities.

Biochemistry of adolescent idiopathic scoliosis

This chapter reviews the biochemical, hormonal, and hematological factors in the onset and development of adolescent idiopathic scoliosis (AIS), an orthopedic entity of unknown etiology. Briefly, AIS is defined as a lateral curvature of the spine combined with vertebral rotation that occurs in patients of 10 years of age or older until bone maturity (18-20 years of age). AIS is predominant in females. If untreated, the curvature could evolve with negative long-term prognosis including psychosocial impact, back pain, pulmonary compromise, cor pulmonale, and even death due to respiratory failure. Causes of the disease have been postulated to involve genetics, abnormal muscle, connective tissue and bone structures, and neuroendocrine disorders. Psychological pathways have also been studied. Little data, however, have been collected on bone turnover in these patients. Some studies demonstrated decreased bone mineral density which may be suggestive of increased osteoblast activity. Other studies suggested a correlation to abnormal platelet morphology. Alterations in the spinal muscle contractile function may be responsible for spinal curvature. Measurement of trace elements in serum revealed impaired zinc and selenium metabolism, probably secondary to hormonal deregulation. Subsequent endocrine studies suggested a role for leptin and growth hormone in AIS. Recently, a neuroendocrine hypothesis has been proposed. This theory involves a unique melatonin-signaling dysfunction and opens new frontiers in the elucidation of the pathologic mechanisms for onset and progression of this disease.

Early onset scoliosis: what the primary care provider needs to know and implications for practice

PURPOSE

The purpose of this article is to discuss the role of the primary care provider in the detection of and referral for early onset scoliosis. An overview of scoliosis including etiology, natural history, guidelines for physical examination, current practice for scoliosis screening, and available treatments will be discussed.

DATA SOURCES

PubMed, OVID Medline, Psychinfo. Search terms: juvenile scoliosis, childhood onset scoliosis, early onset scoliosis, idiopathic scoliosis, and infantile scoliosis.

CONCLUSIONS

Scoliosis is classified depending on the magnitude, location, direction, and cause of the curve, and can lead to a variety of health effects if not treated. The greater the scoliosis curve and the earlier it presents, the more likely it may affect thoracic growth, inhibit cardiopulmonary function, and cause psychosocial distress.

IMPLICATIONS FOR PRACTICE

Routine scoliosis screening should be incorporated into each healthcare maintenance visit beginning in infancy and continue into adolescence until the child reaches skeletal maturity. Curves with a scoliometer reading greater than 5° should be referred, and conservative treatment should be considered for curves that surpass 20°. If scoliosis is detected early, it may be possible to stabilize the curve from progressing and even prevent thoracic deformity and secondary complications from occurring.

Effectiveness and outcomes of brace treatment: a systematic review

Bracing has been widely used for the treatment of adolescent idiopathic scoliosis (AIS). However, effectiveness of brace treatment remains controversial. A systematic review was conducted to investigate evidence that brace treatment is effective in the treatment of AIS. A total of 20 studies, including randomized controlled trials, nonrandomized clinical controlled trials, or case-control studies, were included. Studies comparing the results of brace treatment with no-treatment, other conservative treatments, or surgical treatment were included. Outcomes of the studies included radiological curve progression, incidence of surgery, pulmonary function, quality of life (QOL), and psychological state. The results from the systematic review are difficult to interpret. There are quite a number of varying parameters between studies that make it very difficult to reach any firm conclusions. In addition, the quality of evidence is limited because most of the studies included in this review were of low methodological quality. However, the available data suggest that, compared to observation, bracing is more potent in preventing the progression of scoliosis and may not have a negative impact on patients' QOL. Therefore, bracing can be recommended for the treatment of AIS, at least for female patients with a Cobb angle of 25-35°. Compared to other conservative treatments, bracing seems to be more effective than electrical stimulation, although an advantage of bracing over side-shift exercise or casting has not been established. Comparison between bracing and surgery is difficult because in most studies, the curve magnitude at baseline was considerably larger in the surgery group. We recommend that future studies have clearer and more consistent guidelines.

The diagnostic challenge of primary dystonia: evidence from misdiagnosis

Although the understanding of dystonia has improved in recent years, primary dystonia is still insufficiently recognized and patients may not receive the correct diagnosis, leading to transient or permanent misclassification of their symptoms. We reviewed cases of primary dystonia who were at first misdiagnosed and analyzed the reasons why the correct diagnosis was first missed and later retained. Primary dystonia is misdiagnosed mainly, but not exclusively, in favor of other movement disorders: Parkinson's disease (PD), essential tremor, myoclonus, tics, psychogenic movement disorder (PMD), and even headache or scoliosis. Accounts are more numerous for PD and PMD, where diagnostic tests, such as DAT scan and psychological assessment, support clinical orientation. The correct diagnosis was achieved in all cases following the recognition of inconsistencies in the first judgment and of distinctive clinical features of dystonia. These clues have been collected here and assembled into a diagnostic epitome.

Prevalence of diagnosis and direct treatment costs of back disorders in 644,773 children and youths in Germany

Background

Many authors have reported about the high prevalence rates of self-reported back pain in children. Nevertheless, little is known about the diagnosis of back disorders - regardless of whether the diagnosis is associated with back pain or not. Therefore, the aim of this study was to analyse the prevalence rates and costs of diagnosis of back disorders in childhood and youth.

Methods

We conducted a secondary data analysis of a large, population based German data set (2,300,980 insurants of statutory health insurance funds) which allowed for identification of prevalence rates of diagnoses of back disorders in children (age group 0-14 years) and youths (age group 15-24 years) using three digit ICD-10 codes for dorsopathies (M40 - M54: kyphosis and lordosis; scoliosis; spinal osteochondrosis; other deforming dorsopathies; ankylosing spondylitis; other inflammatory spondylopathies; spondylosis; other spondylopathies; spondylopathies in diseases classified elsewhere; cervical disc disorders; other intervertebral disc disorders; other dorsopathies, not elsewhere classified; dorsalgia). Direct treatment costs were calculated based on the real incurred costs for cases with a singular diagnosis of a back disorder. Wherever possible, the results of the random sample were extrapolated to all insurants of statutory health insurance funds (i. e., about 90% of the German population).

Results

We found prevalence rates for the diagnosis of back disorders to range between 0.01 - 12.5%. "Scoliosis" (M41) and "dorsalgia" (M54) were the most frequent diagnoses in both age groups. Based on these results, it was calculated that in 2002 alone, approximately 1.4 million children/youths in Germany were diagnosed with "dorsalgia" (M54), and that the direct costs for back disorders in childhood and youth accounted for at least 100 million Euros.

Conclusions

Instead of focusing on the individual, and self-reported disorder or disability, this analysis allowed for the detailed evaluation of medical experts' opinion on back disorders in childhood and youth and for a more objective or public health oriented insight in the topic of diagnosis of back pain and other back disorders. However, due to the methodological limitations by using ICD-10 coding, standardized random validity checks of population based data sets should be mandatory.