A Review of the Methods on Cobb Angle Measurements for Spinal Curvature

Deep learning classification of pediatric spinal radiographs for use in large scale imaging registries

PURPOSE

The purpose of this study is to develop and apply an algorithm that automatically classifies spine radiographs of pediatric scoliosis patients.

METHODS

Anterior-posterior (AP) and lateral spine radiographs were extracted from the institutional picture archive for patients with scoliosis. Overall, there were 7777 AP images and 5621 lateral images. Radiographs were manually classified into ten categories: two preoperative and three postoperative categories each for AP and lateral images. The images were split into training, validation, and testing sets (70:15:15 proportional split). A deep learning classifier using the EfficientNet B6 architecture was trained on the spine training set. Hyperparameters and model architecture were tuned against the performance of the models in the validation set.

RESULTS

The trained classifiers had an overall accuracy on the test set of 1.00 on 1166 AP images and 1.00 on 843 lateral images. Precision ranged from 0.98 to 1.00 in the AP images, and from 0.91 to 1.00 on the lateral images. Lower performance was observed on classes with fewer than 100 images in the dataset. Final performance metrics were calculated on the assigned test set, including accuracy, precision, recall, and F1 score (the harmonic mean of precision and recall).

CONCLUSIONS

A deep learning convolutional neural network classifier was trained to a high degree of accuracy to distinguish between 10 categories pre- and postoperative spine radiographs of patients with scoliosis. Observed performance was higher in more prevalent categories. These models represent an important step in developing an automatic system for data ingestion into large, labeled imaging registries.

Deep Learning-Based Prediction Model for the Cobb Angle in Adolescent Idiopathic Scoliosis Patients

Scoliosis, characterized by spine deformity, is most common in adolescent idiopathic scoliosis (AIS). Manual Cobb angle measurement limitations underscore the need for automated tools. This study employed a vertebral landmark extraction method and Feedforward Neural Network (FNN) to predict scoliosis progression in 79 AIS patients. The novel intervertebral angles matrix format showcased results. The mean absolute error for the intervertebral angle progression was 1.5 degrees, while the Pearson correlation of the predicted Cobb angles was 0.86. The accuracy in classifying Cobb angles (<15°, 15-25°, 25-35°, 35-45°, >45°) was 0.85, with 0.65 sensitivity and 0.91 specificity. The FNN demonstrated superior accuracy, sensitivity, and specificity, aiding in tailored treatments for potential scoliosis progression. Addressing FNNs' over-fitting issue through strategies like "dropout" or regularization could further enhance their performance. This study presents a promising step towards automated scoliosis diagnosis and prognosis.

Strategies for Minimizing the Effects of Observer Variability on Sagittal Parameter Measurements of the Spine

STUDY DESIGN

Exploratory-descriptive study.

OBJECTIVE

Evaluate the influence of observer variability on the measurements of both thoracic kyphosis (TK) and lumbar lordosis (LL) obtained with anatomic and functional spinal segmentation methods.

BACKGROUND

Parametric analysis for spinal surgery planning typically relies on anatomic parameters. However, incorporating functional parameters that consider the vertebrae orientation is important to minimizing surgical calculation errors.

METHODS

The authors developed parametric analysis software that integrates traditional and functional methodologies. The proposed method included functional thoracic kyphosis and functional lumbar lordosis calculated from the lines normal to the inflection points of the spine model. Using a synthetic lateral X-ray, the observer variability was computer-simulated generating 20 landmark sets that replicate the annotations of 20 observers. The analysis also included 10 clinical X-rays, annotated twice by 3 judges with a minimum 1-week interval. The spinal curvature angles were derived using the anatomic and functional methods. Statistical analysis were performed for comparison.

RESULTS

For the synthetic X-ray, the proposed method presented significantly less variability: TK (<±2.5 degrees, P=0.00023) and LL (<±5 degrees, P=0.00012). For the clinical X-rays, the interobserver reliability analysis yielded higher intraclass correlation coefficients (ICC) for functional TK (ICC>0.97) and functional LL (ICC>0.87) than for TK (ICC<0.91) and LL (ICC<0.89). Statistically significant differences were observed for both TK (P=0.001) and LL (P=0.030). Under the traditional method, observer variability led to measurement differences surpassing ±19 degrees, whereas differences with the proposed method were within ±10 degrees for both parameters.

CONCLUSION

The vertebral endplate is not the most suitable place to measure spinal sagittal curvatures. Small changes in landmark position significantly alter the measured Cobb angle. The proposed method offers a substantial advantage regarding the influence of observer variability, in addition to the more individualized analysis.

Association between incorrect postures and curve magnitude of adolescent idiopathic scoliosis in china

BACKGROUND

Despite advancements in school scoliosis screening (SSS), there are still no effective indicators to estimate the severity of spinal curvature. We aim to investigate the association between incorrect postures and curve magnitude of adolescent idiopathic scoliosis (AIS) among Chinese adolescents.

METHODS

In this SSS program, we examined the incorrect posture, Adam's forward bending test (FBT) results, and angle of trunk rotation (ATR) in adolescents. Those with suspected scoliosis were referred for a standing anteroposterior whole-spine radiography as outpatients. The radiographic data of 426 students with lateral Cobb angles were collected from 2016 to 2022 and the associations were studied using logistic regression (LR) models and receiver operating characteristic (ROC) curves.

RESULTS

Univariate LR revealed that female gender [odds ratio (OR) = 2.92, 95% confidence interval (CI) 1.67-5.09, P < 0.001], age 16-19y (OR = 2.83, 95%CI 1.10-7.28, P = 0.031), right shoulder height (OR = 2.15, 95%CI 1.23-3.75, P = 0.007), right scapula tilt (OR = 2.03, 95%CI 1.18-3.50, P = 0.010), right rib hump (OR = 1.88, 95%CI 1.23-2.85, P = 0.003), right thoracic rotation ≥ 5° (OR = 2.14, 95%CI 1.43-3.20, P < 0.001), and left thoracolumbar kyphosis (OR = 3.79, 95%CI 1.06-13.56, P = 0.041) were all significantly associated with the severity of the curve magnitude. Multivariate LR showed that female gender [adjusted OR (AOR) = 3.23, 95%CI 1.81-5.73, P < 0.001], those aged 16-19y (AOR = 5.08, 95%CI 1.86-13.91, P = 0.002), and with a right rib hump (AOR = 1.72, 95%CI 1.11-2.64, P = 0.015) presented with a higher risk of severe curve magnitude than men, those aged 7-12y, and without a rib hump, respectively. ROC curves further proved that sex, age, shoulder-height difference, scapula tilt, flat back, rib hump, angle of thoracic rotation were the risk predictors for curve magnitude.

CONCLUSION

Incorrect posture and ATR, especially the right rib hump, were significantly associated with the curve magnitude of AIS. Early screening for incorrect postures and ATR could be an effective and economical strategy to predict the severity of AIS through SSS in Chinese adolescents.

Reliability of a New Digital Tool for Photographic Analysis in Quantifying Body Asymmetry in Scoliosis

Background: Advancements in non-ionizing methods for quantifying spinal deformities are crucial for assessing and monitoring scoliosis. In this study, we analyzed the observer variability of a newly developed digital tool for quantifying body asymmetry from clinical photographs. Methods: Prospective observational multicenter study. Initially, a digital tool was developed using image analysis software, calculating quantitative measures of body asymmetry. This tool was integrated into an online platform that exports data to a database. The tool calculated 10 parameters, including angles (shoulder height, axilla height, waist height, right and left waistline angles, and their difference) and surfaces of the left and right hemitrunks (shoulders, waists, pelvises, and total). Subsequently, an online training course on the tool was conducted for twelve observers not involved in its development (six research coordinators and six spine surgeons). Finally, 15 standardized back photographs of adolescent idiopathic scoliosis patients were selected from a multicenter image bank, representing various clinical scenarios (different age, gender, curve type, BMI, and pre- and postoperative images). The 12 observers measured the photographs at two different times with a three-week interval. For the second round, the images were randomly mixed. Inter- and intra-observer variabilities of the measurements were analyzed using intraclass correlation coefficients (ICCs), and reliability was measured by the standard error of measurement (SEM). Group comparisons were made using Student's t-test. Results: The mean inter-observer ICC for the ten measurements was 0.981, the mean intra-observer ICC was 0.937, and SEM was 0.3-1.3°. The parameter with the strongest inter- and intra-observer validity was the difference in waistline angles 0.994 and 0.974, respectively, while the highest variability was found with the waist height angle 0.963 and 0.845, respectively. No test-retest differences (p > 0.05) were observed between researchers (0.948 ± 0.04) and surgeons (0.925 ± 0.05). Conclusion: We developed a new digital tool integrated into an online platform demonstrating excellent reliability and inter- and intra-observer variabilities for quantifying body asymmetry in scoliosis patients from a simple clinical photograph. The method could be used for assessing and monitoring scoliosis and body asymmetry without radiation.

Intraobserver and Interobserver Reliability of Pelvic Obliquity Measurement Methods in Patients With Idiopathic Scoliosis

BACKGROUND

Despite the importance of the assessment of pelvic obliquity, especially in the planning of surgery, there is no consensus on the pelvic obliquity measurements. The purpose of this study is to assess the intraobserver and interobserver reliability of 4 different pelvic obliquity measuring methods in patients with idiopathic scoliosis (IS): the Osebold, O'Brien, Maloney, and Allen&Ferguson methods.

METHODS

A retrospective cohort of 85 posteroanterior full-spine radiographs in the standing position of patients with IS involving the pelvic obliquity was evaluated by a team of 3 raters. The same researcher recorded the curve magnitude, apical vertebral rotation, Risser grade, curve pattern, and femoral head height difference. The pelvic obliquity angle was measured using the Osebold, O'Brien, Maloney, and Allen&Ferguson methods. The same graders were asked to regrade the same radiographs after at least 1 month.

RESULTS

The Osebold method showed the highest interobserver reliability with an ICC of 0.994 and 0.983. The Allen&Ferguson method had the lowest reliability with an ICC of 0.911 and 0.934, but all of the methods were considered having excellent reliability. The Osebold method also showed the highest intraobserver reliability, ranging from 0.909 to 0.997. The Allen&Ferguson method had the lowest intraobserver reliability, with a range of 0.741 to 0.960. Also, all observers preferred the Osebold Method. The observers reported that the Allen&Ferguson method was considered the most time-consuming method, while the least time-consuming method was specified as the Osebold method.

CONCLUSIONS

To the best of our knowledge, this study is the first to evaluate the intraobserver and interobserver reliability of pelvic obliquity among common measurement methods in patients with idiopathic scoliosis. All methods were evaluated as having excellent to good reliability in this study, but the Osebold method is the most reliable method of measuring pelvic obliquity on a frontal view radiograph in idiopathic scoliosis. The Osebold method is easier to use as it requires only the iliac crests to be visualized.

LEVEL OF EVIDENCE

Level III-Retrospective cohort study.

Unsupervised local center of mass based scoliosis spinal segmentation and Cobb angle measurement

Scoliosis is a medical condition in which a person's spine has an abnormal curvature and Cobb angle is a measurement used to evaluate the severity of a spinal curvature. Presently, automatic Existing Cobb angle measurement techniques require huge dataset, time-consuming, and needs significant effort. So, it is important to develop an unsupervised method for the measurement of Cobb angle with good accuracy. In this work, an unsupervised local center of mass (LCM) technique is proposed to segment the spine region and further novel Cobb angle measurement method is proposed for accurate measurement. Validation of the proposed method was carried out on 2D X-ray images from the Saudi Arabian population. Segmentation results were compared with GMM-Based Hidden Markov Random Field (GMM-HMRF) segmentation method based on sensitivity, specificity, and dice score. Based on the findings, it can be observed that our proposed segmentation method provides an overall accuracy of 97.3% whereas GMM-HMRF has an accuracy of 89.19%. Also, the proposed method has a higher dice score of 0.54 compared to GMM-HMRF. To further evaluate the effectiveness of the approach in the Cobb angle measurement, the results were compared with Senior Scoliosis Surgeon at Multispecialty Hospital in Saudi Arabia. The findings indicated that the segmentation of the scoliotic spine was nearly flawless, and the Cobb angle measurements obtained through manual examination by the expert and the algorithm were nearly identical, with a discrepancy of only ± 3 degrees. Our proposed method can pave the way for accurate spinal segmentation and Cobb angle measurement among scoliosis patients by reducing observers' variability.

Association Between Two Methods of Spinal and Pelvic Analysis Among Children With Cerebral Palsy

OBJECTIVES

Children with cerebral palsy have weak muscles, which may impair postural adjustments. These postural adjustments are required for gait and dynamic balance during the daily living activities. The aim of this study was to investigate the association between Cobb's angle and Formetric 4D surface topography system in evaluating spinal and pelvic deformity in children with cerebral palsy.

METHODS

One hundred children with spastic diplegia (6 to 8 years old) diagnosed as cerebral palsy participated in this study and selected from the Outpatient Clinic of Faculty of Physical Therapy. Digital x- ray and formetric analysis were used to measure spinal deformities and pelvic deviation in children with cerebral palsy.

RESULTS

There were positive correlations between Cobb's angle and formetric parameters, including trunk imbalance, lateral deviation, and pelvic tilt. Also, Formetric parameters were significant predictors of Cobb's angle, including trunk imbalance (for a one-degree increase, Cobb's angle increases by 0.227, lateral deviation (for a one-degree increase, Cobb's angle increases by 0.665), and pelvic tilt (for a one-degree increase, Cobb's angle increases by 0.252).

CONCLUSION

Formetric 4D surface topography system was effective in evaluating spinal and pelvic deformity in children with cerebral palsy when compared with Digital x-ray.

Deep learning algorithm for automatically measuring Cobb angle in patients with idiopathic scoliosis

PURPOSE

The Cobb angle is a standard measurement to qualify and track the progression of scoliosis. However, the Cobb angle has high inter- and intra-observer variability. Consequently, its measurement varies with vertebrae and may even differ when the same vertebra is measured. Therefore, it is not constant and differs with measurements. This study aimed to develop a deep learning model that automatically measures the Cobb angle. The deep learning model for identifying vertebrae on spine radiographs was developed.

METHODS

The dataset consisted of 297 images that were divided into two subsets for training and validation. Two hundred and twenty-seven images (76.4%) were used to train the model, while 70 images (23.6%) were used as the validation dataset. Absolut error between the measurements by the observer and developed deep learning model and intraclass correlation coefficient (ICC).

RESULTS

The average absolute error between the measurements was 1.97° with a standard deviation of 1.57°. In addition, 95.9% of the angles had an absolute error of less than 5°. The ICC was calculated to assess the model's reliability further. The ICC was 0.981, indicating excellent reliability.

CONCLUSIONS

The authors believe the model will be useful in clinical practice by relieving clinicians of the burden of having to manually compute the Cobb angle. Further studies are needed to enhance the accuracy and versatility of this deep learning model.

Novel Screw Placement Method for Extremely Small Lumbar Pedicles in Scoliosis

Study Design: Consecutive case series. Objective: To propose a screw placement method in patients with extremely small lumbar pedicles (ESLPs) (<2 mm) to maintain screw density and correction power, without relying on the O-arm navigation system. Summary of Background Data: In scoliosis surgery, ESLPs can hinder probe passage, resulting in exclusion or substitution of the pedicle screws with a hook. Screw density affects correction power, making it necessary to maximize the number of screw placements, especially in the lumbar curve. Limited studies provide technical guidelines for screw placement in patients with ESLPs, independent of the O-arm navigation system. Methods: We enrolled 19 patients who underwent scoliosis correction surgery using our novel screw placement method for ESLPs. Clinical, radiological, and surgical parameters were assessed. After posterior exposure of the spine, the C-arm fluoroscope was rotated to obtain a true posterior-anterior view and both pedicles were symmetrically visualized. An imaginary pedicle outline was presumed based on the elliptical or linear shadow from the pedicle. The screw entry point was established at a 2 (or 10) o'clock position in the presumed pedicle outline. After adjusting the gear-shift convergence, both cortices of the transverse process were penetrated and the tip was advanced towards the lateral vertebral body wall, where an extrapedicular screw was placed with tricortical fixation. Results: Out of 90 lumbar screws in 19 patients, 33 screws were inserted using our novel method, without correction loss or complications during an average follow-up period of 28.44 months, except radiological loosening of one screw. Conclusions: Our new extrapedicular screw placement method into the vertebral body provides an easy, accurate, and safe alternative for scoliosis patients with ESLPs without relying on the O-arm navigation system. Surgeons must consider utilizing this method to enhance correction power in scoliosis surgery, regardless of the small size of the lumbar pedicle.

One-stage posterior transpedicular debridement, hemi-interbody and unilateral-posterior bone grafting, and instrumentation for the treatment of thoracic spinal tuberculosis: a retrospective study

PURPOSE

To investigate the clinical efficacy and feasibility of the surgical treatment of thoracic spinal tuberculosis using one-stage posterior instrumentation, transpedicular debridement, and hemi-interbody and unilateral posterior bone grafting.

METHODS

Fifty-six patients with thoracic spinal tuberculosis who underwent surgery performed by a single surgeon between September 2009 and August 2020 were enrolled in this study. Based on data from the erythrocyte sedimentation rate (ESR), Visual Analog Scale (VAS), and Cobb angle before surgery, after surgery, and at the most recent follow-up, clinical effectiveness was assessed using statistical analysis. The variables investigated included operating time, blood loss, complications, neurological function, and hemi-interbody fusion.

RESULTS

None of the patients experienced significant surgery-associated complications. At the last follow-up, 23 of the 25 patients (92%) with neurological impairment showed improvement. The thoracic kyphotic angle was significantly decreased from 24.1 ± 9.9° to 13.4 ± 8.6° after operation (P < 0.05), and the angle was 14.44 ± 8.8° at final follow-up (P < 0.05). The Visual Analog Scale significantly decreased from 6.7 ± 1.4 preoperatively to 2.3 ± 0.8 postoperatively (P < 0.05) and finally to 1.2 ± 0.7 at the last follow-up (P < 0.05). Bone fusion was confirmed in 56 patients at 3-6 months postoperatively.

CONCLUSIONS

One-stage posterior transpedicular debridement, hemi-interbody and unilateral posterior bone grafting, and instrumentation are effective and feasible treatment methods for thoracic spinal tuberculosis.

Investigatıon of the effect of weight loss after laparoscopic sleeve gastrectomy on cobb angle, waist and back pain: a prospective study

BACKGROUND

In many studies, it has been stated that obesity causes severe increases in the risks of disc degeneration, vertebral fracture, low back, and back pain. One of the most effective treatment options for obesity is bariatric surgery.

OBJECTIVES

In this study, the effect of weight loss on these parameters was investigated by evaluating the Cobb angle, low back, and back pain.

SETTING

University Hospital METHODS: A total of 89 patients were included in the study. Laparoscopic sleeve gastrectomy (SG) was performed on all patients. In addition, Cobb angle, height, weight, and body mass index (BMI) measurements were recorded at each visit. Investigating the quality and quantity of low back pain and the loss of function caused by the patients; visual analog scale (VAS), Oswestry Low Back Pain Disability Questionnaire (OLBPDQ), Roland-Morris Disability Questionnaire (RMDQ), and SF-36 Quality of Life Questionnaire (SF36) were administered.

RESULTS

According to the preoperative Cobb angles, the decrease in the 6th month (P = .029) and 12th month (P = .007) measurements after the operation was found to be statistically significant (P < .05), but it was found to be clinically insignificant. When the changes in RMDQ, OLBPDQ, VAS, and SF-36 scores were examined, the decrease in the 6th month (P = .001) and 12th month (P = .001) scores after the operation was found to be significant compared to the preoperative scores (P < .01).

CONCLUSIONS

In this study, weight loss after SG improved for patients with chronic low back and back pain and significantly improved their quality of life.

Deep learning model for measuring the sagittal Cobb angle on cervical spine computed tomography

PURPOSES

To develop a deep learning (DL) model to measure the sagittal Cobb angle of the cervical spine on computed tomography (CT).

MATERIALS AND METHODS

Two VB-Net-based DL models for cervical vertebra segmentation and key-point detection were developed. Four-points and line-fitting methods were used to calculate the sagittal Cobb angle automatically. The average value of the sagittal Cobb angle was manually measured by two doctors as the reference standard. The percentage of correct key points (PCK), matched samples t test, intraclass correlation coefficient (ICC), Pearson correlation coefficient, mean absolute error (MAE), and Bland‒Altman plots were used to evaluate the performance of the DL model and the robustness and generalization of the model on the external test set.

RESULTS

A total of 991 patients were included in the internal data set, and 112 patients were included in the external data set. The PCK of the DL model ranged from 78 to 100% in the test set. The four-points method, line-fitting method, and reference standard measured sagittal Cobb angles were - 1.10 ± 18.29°, 0.30 ± 13.36°, and 0.50 ± 12.83° in the internal test set and 4.55 ± 20.01°, 3.66 ± 18.55°, and 1.83 ± 12.02° in the external test set, respectively. The sagittal Cobb angle calculated by the four-points method and the line-fitting method maintained high consistency with the reference standard (internal test set: ICC = 0.75 and 0.97; r = 0.64 and 0.94; MAE = 5.42° and 3.23°, respectively; external test set: ICC = 0.74 and 0.80, r = 0.66 and 0.974, MAE = 5.25° and 4.68°, respectively).

CONCLUSIONS

The DL model can accurately measure the sagittal Cobb angle of the cervical spine on CT. The line-fitting method shows a higher consistency with the doctors and a minor average absolute error.

A method for measuring the angle between left atrial and left ventricular long axes using 3D echocardiography

BACKGROUND

Left ventricle (LV) optimized views are routinely used for left atrial (LA) volume and strain measurements on 2D echocardiography. This might be a source of the error because of the variation of the angle between the left atrial and left ventricle long axes (LA-LV angle), leading to foreshortening of the LA.

METHODS

We investigated two novel parameters: the angle between the left atrial and left ventricle long axes (LA-LV angle) and its deviation from the 4-chamber plane. To accurately measure the angles in 3D space, these measurements were performed using 3D echocardiography. We developed a method for the measurement based on marking anatomic points of reference in the 3D echocardiogram and measuring the angles between these points. We used three types of phantoms made of wood and agar-agar to investigate the repeatability and reproducibility of these measurements and performed measurements on human subjects.

RESULTS

The ultrasound measurements were in excellent agreement with the true angles of the phantoms: LA-LV angle bias was .5 degrees (95% CI -1.8 to +2.7) in the wooden phantoms and 1.2 degrees (-.7 to +3.1) in the agar-agar phantoms, while the angle deviation from the 4-chamber plane was -.9 degrees (-4.3 to +4.1) in the wooden phantoms and .0 degrees (-3.3 to +3.3) in the agar-agar phantoms. The measurements demonstrated good repeatability and reproducibility (Pearson correlation coefficients ranging from .91 to .99). The measurements from human hearts showed good repeatability (Pearson correlation was .81 for repeated LA-LV angle measurements and .97 for repeated measurements of the deviation from the 4-chamber plane).

CONCLUSION

The measurement of the LA-LV angle is a feasible tool to investigate one eventual error of 2D echocardiography.

Revolutionizing Spinal Care: Current Applications and Future Directions of Artificial Intelligence and Machine Learning

Artificial intelligence (AI) and machine learning (ML) are rapidly becoming integral components of modern healthcare, offering new avenues for diagnosis, treatment, and outcome prediction. This review explores their current applications and potential future in the field of spinal care. From enhancing imaging techniques to predicting patient outcomes, AI and ML are revolutionizing the way we approach spinal diseases. AI and ML have significantly improved spinal imaging by augmenting detection and classification capabilities, thereby boosting diagnostic accuracy. Predictive models have also been developed to guide treatment plans and foresee patient outcomes, driving a shift towards more personalized care. Looking towards the future, we envision AI and ML further ingraining themselves in spinal care with the development of algorithms capable of deciphering complex spinal pathologies to aid decision making. Despite the promise these technologies hold, their integration into clinical practice is not without challenges. Data quality, integration hurdles, data security, and ethical considerations are some of the key areas that need to be addressed for their successful and responsible implementation. In conclusion, AI and ML represent potent tools for transforming spinal care. Thoughtful and balanced integration of these technologies, guided by ethical considerations, can lead to significant advancements, ushering in an era of more personalized, effective, and efficient healthcare.

Anesthesia and Perioperative Management for Surgical Correction of Neuromuscular Scoliosis in Children: A Narrative Review

Scoliosis is the most frequent spinal deformity in children. It is defined as a spine deviation of more than 10° in the frontal plane. Neuromuscular scoliosis is associated with a heterogeneous spectrum of muscular or neurological symptoms. Anesthesia and surgery for neuromuscular scoliosis have a higher risk of perioperative complications than for idiopathic scoliosis. However, patients and their relatives report improved quality of life after the surgery. The challenges for the anesthetic team result from the specifics of the anesthesia, the scoliosis surgery itself, or factors associated with neuromuscular disorders. This article includes details of preanesthetic evaluation, intraoperative management, and postoperative care in the intensive care unit from an anesthetic view. In summary, adequate care for patients who have neuromuscular scoliosis requires interdisciplinary cooperation. This comprehensive review covers information about the perioperative management of neuromuscular scoliosis for all healthcare providers who take care of these patients during the perioperative period, with an emphasis on anesthesia management.

A new method for measuring penile curvature based on digital images

INTRODUCTION AND OBJECTIVE

Accurate and objective assessment of penile curvature is considered a critical evaluation in patients with hypospadias, as it often determines if a 1 or 2-stage procedure should be done. Due to the ease of acquisition and reusability of digital images, more research is focused on digital images; however, the current method based on digital images is not an easily accurate and objective evaluation of penile curvature amongst surgeons. In scoliosis, the Cobb method is a standard method to quantify spinal curvature. Therefore, this study introduces a new accurate, and standardized method for measuring penile curvature based on the digital image concerning the Cobb method.

METHODS

Twenty-two subjects were randomly selected, including 11 pediatric urologists with experience in goniometry(professional group)and 11 non-pediatric urologists without experience in goniometry (non-professional group). A total of 9 two-dimensional images of penile curvatures from 10° to 90°were obtained and stored in the research project notebook. Subjects measured 9 digital images using the new method (fixed anatomical position method) and classical method (the angle created by the interception of two ideal lines, one passing along the proximal portion of the corpora and a second passing through the tip of the penis), respectively. Measurement error was calculated as the absolute difference between the true curvature and the subject estimation. A t-test was used to evaluate the significant differences between the methods.

RESULTS

A total of 22 subject measurement data were obtained. Mean errors using the new method ranged from 1.06° to 3.50°, compared to 3.84°to 11.83°for classical method. Mean errors were significantly lower (p < 0.05) when using the new method compared to the classical method. A subgroup comparing subjects with and without prior experience with goniometry showed a statistically significant difference only for the classical method when the penis curvature is 10-40°, the mean error range of the professional group was 7.8°-9.56°, compared to 10.34°-13.02°for nonprofessional group.

DISCUSSION

We emphasize the importance of penile curvature measurement and urgent need for an accurate measurement method, and then we focus on the new method compare with the previously described methods looking at mean errors and explain the reason that the new method why is accurate. Subsequently, we focus on explain the impact of experience measurement methods. Finally, the shortcomings of this paper and the prospective points are discussed:1) how to obtain more photos in practical situations; 2) using artificial intelligence methods for automatic marking of key points to achieve efficient measurement of penile curvature.

CONCLUSIONS

In this preliminary study, we demonstrated better penile curvature estimations using the new method compared to the classical methods currently used by pediatric urologists.

Effect of cervical suspensory traction in the treatment of severe cervical kyphotic deformity

Objective

This study aimed to investigate a new noninvasive traction method on the treatment of severe cervical kyphotic deformity.

Methods

The clinical data of patients with severe cervical kyphosis (Cobb > 40°) treated in Peking University Third Hospital from March 2004 to March 2020 were retrospectively summarized. 46 cases were enrolled, comprising 27 males and 19 females. Fifteen patients underwent skull traction, and 31 patients underwent suspensory traction. Among them, seven used combined traction after one week of suspensory traction. Bedside lateral radiographs were taken every two or three days during traction. The cervical kyphosis angle was measured on lateral radiographs in and extended position at each point in time. The correction rate and evaluated Japanese Orthopedic Association (JOA) scoring for the function of the spinal cord were also measured. The data before and after the operation were compared with paired sample t-test or Wilcoxon signed-rank test.

Results

No neurological deterioration occurred during the skull traction and the cervical suspensory traction. There were 12 patients with normal neurological function, and the JOA score of the other 34 patients improved from 11.5 ± 2.8 to 15.4 ± 1.8 at the end of follow up (P < 0.05). The average kyphotic Cobb angle was 66.1° ± 25.2, 28.7° ± 20.1 and 17.4° ± 25.7 pre-traction, pre-operative, and at the final follow-up, respectively (P < 0.05). The average correction rate of skull traction and suspensory traction was 34.2% and 60.6% respectively. Among these, the correction rate of patients with simple suspensory traction was 69.3%. For patients with a correction rate of less than 40% by suspensory traction, combined traction was continued, and the correction rates after suspensory traction and combined traction were 30.7% and 67.1% respectively.

Conclusions

Pre-correction by cervical suspensory traction can achieve good results for severe cervical kyphotic deformity, with no wound and an easy process. Combined traction is effective for supplemental traction after suspensory traction.