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PubMed2002

Curve prevalence of a new classification of operative adolescent idiopathic scoliosis: does classification correlate with treatment?

STUDY DESIGN: A retrospective multicenter consecutive case review of operative adolescent idiopathic scoliosis. OBJECTIVES: To define the curve prevalence of a large consecutive series of cases with operative adolescent idiopathic scoliosis as classified by a new system and to test the ability of this new classification system to correlate with regions of the scoliotic spine to be instrumented/fused. SUMMARY OF BACKGROUND DATA: A new comprehensive, two-dimensional classification system, intended to be treatment based, has been developed. However, it has not been tested whether all presenting operative cases of adolescent idiopathic scoliosis are classifiable in a large consecutive series, nor has the prevalence of specific curve types been determined. In addition, it is unknown whether this classification is truly treatment based, as to whether it can correlate with regions of the spine to be instrumented/fused. METHODS: A multicenter retrospective review of 606 consecutive operative cases of adolescent idiopathic scoliosis was performed. All cases were classified by a new triad classification system, which included the following: a curve type (1-6), a lumbar spine modifier (A, B, C), and a sagittal thoracic modifier (-, N, +). Prevalence of the individual three components of the system and the classification grouping of all three components together were performed. In addition, the authors assessed whether this system could correlate with regions of the spine that should be included in the instrumentation and fusion, based on exactly which regions were fused during the operative procedure. RESULTS: All 606 cases were classifiable by this system. Prevalence of the six curve types noted was as follows: Type 1, main thoracic (n = 305, 51%); Type 2, double thoracic (n = 118, 20%); Type 3, double major (n = 69, 11%); Type 4, triple major (n = 19, 3%); Type 5, thoracolumbar/lumbar (n = 74, 12%); and Type 6, thoracolumbar/lumbar-main thoracic (n = 17, 3%). The five most common curve classifications noted were as follows: 1AN, 1BN, 2AN, 5CN, and 1CN, which accounted for 58% of all curve classifications noted. An average of 90% of the operative cases had surgically structural regions of the spine included in the instrumentation and fusion as predicted by the curve type. CONCLUSIONS: A new comprehensive classification system for operative adolescent idiopathic scoliosis found all 606 consecutive cases of adolescent idiopathic scoliosis classifiable, with the Type 1, main thoracic curve pattern, the most common curve type found (51%). This new classification system appears to correlate with treatment of surgically structural regions of the spine fused in 90% of cases by the objective radiographic criteria used.

Adolescent↗
PubMed2002

Myolysis of the erector spinae muscles as the cause of scoliosis in osteoid osteoma of the spine.

STUDY DESIGN: A case of an osteoid osteoma at the lower thoracic spine with scoliosis is reported. OBJECTIVES: To suggest that myolysis of the erector spinae muscles reflected by signal abnormalities on magnetic resonance images causes back pain, protective muscle contraction, and scoliosis. SUMMARY OF BACKGROUND DATA: Osteoid osteomas of the spine are frequently accompanied by scoliosis. The proposed mechanism of the scoliosis has been explained as a postural adaptation of the spine through predominant muscle spasm on the concave side. METHODS: The history of the patient and radiologic, magnetic resonance imaging, and histologic findings of the peritumoral area were reviewed. RESULTS: Magnetic resonance images showed signal abnormalities on muscles surrounding the tumor, and use of gadopentetate dimeglumine resulted in an enhancement. The microscopic examination of the erector spinae muscles that demonstrated high intensities on T2-weighted images showed derangement or destruction of the muscle fibers and replacement of the muscle fibers with fat tissue and infiltrating inflammatory cells. CONCLUSION: These findings were interpreted as those of myolysis. The suggested mechanism of the induction of scoliosis by the present osteoid osteoma is that the unaffected iliocostalis and quadratus lumborum muscles on the tumor side predominantly contracted over those on the opposite side to decrease the tension of the erector spinae muscles involved in myolysis, thereby producing a functional scoliosis.

Adult↗
PubMed2002

The destroyed lung syndrome: report of a case after Harrington rod instrumentation and fusion for idiopathic scoliosis.

STUDY DESIGN: A case report is described. OBJECTIVE: To describe the very rare complication of destroyed lung syndrome after scoliosis correction. SUMMARY OF BACKGROUND DATA: The destroyed lung syndrome has, to our knowledge, never been associated with scoliosis in the literature. Bronchial kinking and compression by the vertebral column have been described in severe scoliosis cases. METHODS: The patient, a 40-year-old woman was operated on in 1976 for a thoracic scoliosis and hypokyphosis using Harrington rod instrumentation and fusion with autologous bone graft. With a follow-up of 26 years, she has developed a very severe functional defect of the right lung, the so-called destroyed lung syndrome. RESULTS: After the index procedure, the patient developed various episodes of pneumonia and abscess formation in the right lung because of kinking and obstruction of the bronchial tree of the right lung. This seemed to be caused by a severe hypokyphosis and by residual scoliosis of the thoracic spine with direct compression of the right bronchus by the vertebral column. Eventually two stents were placed, but this prevented further deterioration only temporarily. CONCLUSIONS: After Harrington instrumentation and fusion for thoracic hypokyphotic idiopathic scoliosis, kinking and obstruction of a main bronchus are possible. In this patient, this complication gave rise to recurrent infections of the right lung, eventually progressing to destroyed lung syndrome.

Adolescent↗
PubMed2002

Surgical treatment of idiopathic scoliosis in adults: an age-related analysis of outcome.

STUDY DESIGN: A retrospective outcome study was conducted. OBJECTIVE: To analyze the clinical and radiographic outcome of surgical treatment for idiopathic scoliosis in patients treated at the age of 20 years or older. SUMMARY OF BACKGROUND DATA: Idiopathic scoliosis continues to pose problems in many patients after adolescence. Surgical treatment of idiopathic scoliosis in adults still is a challenging subject, but no outcome analysis in terms of different age groups had been performed. METHODS: In this study, 58 adult patients with idiopathic scoliosis who underwent surgery using Cotrel-Dubousset instrumentation were followed up for 2 to 7 years, and the results were studied clinically and radiographically. RESULTS: The prevalence of pain that requires specific treatment decreased from 16% to 5%, and the pain improvement was reliably obtained in the older patients. Radiographically, the mean rate of Cobb angle correction was 53% for both the thoracic and lumbar curves, whereas it decreased age dependently, especially in relation to the thoracic curve. The sagittal plane correction generally was satisfactory in patients younger than 50 years, but appropriate lumbar lordosis was difficult to maintain after the age of 50 years. Frontal and sagittal balance often was difficult to achieve in patients older than 50 years. CONCLUSIONS: This study clarified specific characteristics and problems in the surgical treatment of adult idiopathic scoliosis according to different age groups. Although pain was the most important indication for surgery in patients older than 40 years, it was improved reliably by surgery in most of these patients. On the other hand, the radiographic results tended to be less satisfactory in the older patients in an age-dependent manner. These results provide useful information concerning the indications and strategies of adult scoliosis surgery.

Adult↗
PubMed2002

Changes in scoliotic curvature and lordotic angle during the early phase of degenerative lumbar scoliosis.

STUDY DESIGN: Longitudinal radiographic measurements of the lumbar alignment in clinical cases were performed. OBJECTIVE: To clarify the progressive process of degenerative lumbar scoliosis during its early phase by conducting a longitudinal study. SUMMARY OF BACKGROUND DATA: Previous studies on the alignment changes of degenerative lumbar scoliosis have been conducted only on patients with seriously symptomatic lumber scoliosis, such as those who have undergone surgical treatment. With these patients, who manifest wedging at several levels, it is difficult to determine where the curving initially begins, and to understand the wedging process. Thus, there is much to clarify regarding the process of this symptom's early phase. Furthermore, such data may be useful in anticipating future symptoms. METHODS: The subjects selected for this study were 243 patients who had low back pain without lumbar scoliosis at the initial examination, which took place between 1985 and 1989. Anteroposterior and lateral radiographic examinations of the lumber spine were performed with the subject in a standing position. All of these patients went through at least three sets of examinations. The Cobb method was used to measure the scoliotic angle, defined as the largest angle between any two lines of the lumbar vertebrae. The 47 subjects who manifested a scoliotic angle increase exceeding 10 degrees were reselected for further prospective analyses. The scoliotic and lordotic wedging of these remaining 47 subjects were studied prospectively. RESULTS: The degree of change in scoliotic and lordotic wedging was studied in the 47 patients who manifested a scoliotic angle increase of 10 degrees or more. Of the 47 subjects, 8 showed initial wedging at L1-L2, 9 at L2-L3, 7 at L3-L4, 10 at L4-L5, and 16 at L5-S. During later examinations, 69 discs of 34 patients showed initial wedging exceeding 3 degrees, both in progression and retrogression. On the other hand, changes in the segmental lordotic wedging also were observed during these examinations. Of the 79 discs that showed more than a 5 degrees decrease in segmental lordotic wedging, progression of scoliotic wedging at the same level was observed in 56 cases, either simultaneously or at previous examinations. CONCLUSIONS: Degenerative lumbar scoliosis was triggered by any disc degeneration at the lumbar level. Loss of segmental lordosis usually occurs at the same disc level as segmental wedging. In the early phase of degenerative lumbar scoliosis, the scoliotic curvature not only progresses, but also may retrogress.

Adult↗
PubMed2005

Comparative evaluation of luque and isola instrumentation for treatment of neuromuscular scoliosis.

Surgical treatment of neuromuscular scoliosis is controversial. Owing to the presumed improvements of the newer instrumentation, we hypothesized that the Isola-Asher instrumentation would have better radiographic results that the Luque-Galveston instrumentation and that these differences would be reflected by the patients' subjective assessment of activities of daily living. We retrospectively reviewed patients with neuromuscular scoliosis who were treated using Luque-Galveston or Isola-Asher instrumentation to compare the outcomes. Preoperative, postoperative, and followup radiographs were evaluated for change in scoliosis angle, lordosis angle, and pelvic tilt. Subjective and functional results of surgery were evaluated with questionnaires. We found no difference in the degree of scoliosis correction, correction of lumbar hypolordosis or hyperlordosis, pelvic tilt, or complication rate between the two groups of patients with neuromuscular scoliosis treated with Luque-Galveston or Isola-Asher instrumentation. Patient satisfaction based on the response to the questionnaires was similar in both groups. Luque-Galveston and Isola-Asher instrumentation were comparable and equally reliable methods for surgical stabilization and correction of neuromuscular scoliosis.

Activities of Daily Living↗
PubMed2003

Sagittal plane analysis of the spine and pelvis in adolescent idiopathic scoliosis according to the coronal curve type.

STUDY DESIGN: A retrospective study investigated the sagittal alignment in adolescent idiopathic scoliosis (AIS). OBJECTIVE: To evaluate the sagittal alignment of the spine and pelvis in adolescent idiopathic scoliosis on the basis of curve type. SUMMARY OF BACKGROUND DATA: The relation between the spine and pelvis highly influences the sagittal balance in adults. However, the sagittal alignment of the spine and pelvis in adolescent idiopathic scoliosis is poorly defined in the literature. METHODS: Five sagittal parameters were evaluated on lateral radiographs of 160 patients with adolescent idiopathic scoliosis: thoracic kyphosis, lumbar lordosis, sacral slope, pelvic tilt, and pelvic incidence. The patients were classified according to their coronal curve type. Analysis of variance was used to compare the parameters between the curve types, and Pearson coefficients were used to investigate the relation between all parameters (alpha = 0.05). RESULTS: The thoracic kyphosis was significantly lower for King I, II, and III curves than for lumbar curves. The lumbar lordosis was higher for lumbar curves, although not significantly. No significant change between the groups was observed for the sacral slope, pelvic tilt, or pelvic incidence. The pelvic incidence was significantly correlated with the lumbar lordosis, sacral slope, and pelvic tilt for all the groups. The lumbar lordosis was strongly related to the sacral slope in all cases, but not with the thoracic kyphosis, except in the case of thoracolumbar curves. CONCLUSIONS: Thoracic kyphosis depended mostly on the spinal deformity, whereas lumbar lordosis was influenced mainly by the pelvic configuration. The scoliotic curve type was not associated with a specific pattern of sagittal pelvic morphology and balance. The pelvic incidence found in this study was significantly higher than that reported in the literature for normal adolescents. The role of the pelvic incidence in the pathogenesis of adolescent idiopathic scoliosis needs to be explored in a longitudinal study involving patients with adolescent idiopathic scoliosis and normal adolescents.

Adolescent↗
PubMed2003

Comparison of reliability between the Lenke and King classification systems for adolescent idiopathic scoliosis using radiographs that were not premeasured.

STUDY DESIGN: Multisurgeon comparison of two radiographic scoliosis curve classification systems was performed. OBJECTIVE: To determine the reliability of the King and Lenke classifications systems for adolescent idiopathic scoliosis using radiographs that had not been premeasured. SUMMARY OF BACKGROUND DATA: Recent studies introducing the new Lenke classification system for idiopathic scoliosis have reported reliability improved over that of the King classification system. This newer classification system evaluates three different parameters (curve type, lumbar modifier, and sagittal thoracic modifier) and then combines them. The reliability of both classification systems had been determined using radiographs in which all of the curves had been premeasured (recorded on the radiographs) before review by examiners. However, in a normal clinical situation, spine surgeons need to determine the Cobb angles independently, thus introducing another variable. METHODS: On two separate occasions, four orthopedic surgeons independently evaluated preoperative radiographs (standing posteroanterior, lateral, and two supine side-bending views) of 50 patients with adolescent idiopathic scoliosis. All measurements had been removed on every radiograph before each evaluation. The results were determined by calculating the average percentage of intraobserver and interobserver agreement. Reliability was quantified using kappa statistics. RESULTS: The King classification demonstrated good intraobserver and fair interobserver reliability. Intraobserver percentage of agreement averaged 83.5% (kappa coefficient, 0.81). Interobserver percentage of agreement averaged 68.0% (kappa coefficient, 0.61). All three parameters of the overall Lenke curve classification demonstrated fair reliability. Intraobserver percentage of agreement averaged 65.0% (kappa coefficient, 0.60). Interobserver percentage of agreement averaged 55.5% (kappa coefficient, 0.50). When the Lenke curve type was examined separately, intraobserver percentage of agreement averaged 81.5% (kappa coefficient, 0.76) and interobserver percentage of agreement averaged 71.5% (kappa coefficient, 0.64). The results for this variable (curve type) were similar to those for the King classification. For the Lenke lumbar modifier, the percentage of agreement and reliability were excellent. For the sagittal thoracic modifier, the percentage of agreement was good, but the kappa values were low because of an extreme imbalance in the grouping of hypokyphotic, normal, and hyperkyphotic spines. CONCLUSIONS: In this study, with each investigator performing the radiographic measurements, the King classification was found to be better than had been reported recently. The Lenke classification system for adolescent idiopathic scoliosis was found to be less reliable than previously reported when the radiographs were premeasured. This was particularly true when all three parameters of this new classification system were combined. This difference in reliability of the Lenke classification between studies can be attributed to the additional variable of determining the Cobb measurements on each of the unmarked radiographs. Although this new classification system has limitations with respect to interobserver and intraobserver reliability, for planning operative treatment, it offers a more comprehensive radiographic evaluation of patients with adolescent idiopathic scoliosis than previous systems.

Adolescent↗
PubMed2003

Experimental scoliosis in an immature goat model: a method that creates idiopathic-type deformity with minimal violation of the spinal elements along the curve.

STUDY DESIGN: Experimental scoliosis was created in an immature goat model. OBJECTIVES: To create a progressive, structural, idiopathic-type, lordoscoliotic curve convex to the right in the thoracic spine of the immature goat while maintaining the anterior and posterior elements of the spine along the maximal curve in a pristine state. SUMMARY OF BACKGROUND DATA: Progressive scoliotic curves in a small animal model have been created using a posterior asymmetric tether. However, attempts in larger animal models have had less success and typically required violation of the spinal elements. METHODS: Scoliosis was created in 40 Spanish Cross X female goats (age 1-2 months, weight 8-12 kg) using a left posterior asymmetric tether from T5 to L1. Convex rib resection and concave rib tethering from T8 to T13 were performed before compression across the rigid construct. Goats were followed over a 6- to 15-week period with serial radiographs to document progression of the deformity. RESULTS: Of the 40 goats that underwent posterior assymetric tethering with rib procedures, 7 (18%) encountered substantial complications (five deaths and two neurologic injuries). Of the 33 available for analysis, 27 goats (82%) developed progressive, structural, idiopathic-type, lordoscoliotic curves in convex to the right in the thoracic spine. All curves demonstrated characteristic radiographic features of idiopathic scoliosis including significant displacement of the apical vertebra from the midline, wedging of both the vertebral bodies and discs, rotation, and decreased flexibility. Initial scoliosis after posterior asymmetric tethering measured 42 degrees on average (range 33-50 degrees ) and progressed to 60 degrees on average (range 44-73 degrees ) over 6 to 15 weeks. The average progression of +18 degrees (range 6-37 degrees ) was statistically significant (P < 0.001). CONCLUSIONS: This study establishes an experimental model for scoliosis that creates progressive, structural, idiopathic-type, lordoscoliotic curves convex to the right in the thoracic spine of the immature goat with high statistical significance (P < 0.001). In addition, this method of experimental scoliosis creation avoids violation of the spinal elements throughout the maximal portion of the curve providing an ideal opportunity subsequent study of the deformity.

Animals↗
PubMed2003

Cantilever bending technique for treatment of large and rigid scoliosis.

STUDY DESIGN: Retrospective review of a consecutive clinical series. OBJECTIVES: To assess the efficacy and clinical value of cantilever bending technique as a technique for correcting large (> or =70 degrees ) and rigid (flexibility < or =30%) scoliosis. SUMMARY OF BACKGROUND DATA: Scoliosis correction by current methods is a compromise between the rigidity of the deformity and corrective forces provided by these methods. For large and rigid scoliosis, the rigidity of the deformity cannot be overcome enough to achieve satisfactory correction. Thus, anterior release procedures are usually necessary to make the curves more flexible and thus improve correction. The cantilever bending technique provides powerful corrective forces for overcoming the rigidity of the deformity and obviates the need for anterior release procedures. The utility and efficacy of the method alone without anterior release for treating large and rigid deformity has not been demonstrated. METHODS: A total of 41 consecutive patients undergoing cantilever bending technique for the management of large and rigid scoliosis of any etiology (congenital, idiopathic, or neuromuscular) were included. Radiographic studies, complications, and satisfaction assessment using the modified Scoliosis Research Society Instrument were used to assess outcomes. RESULTS: The mean Cobb angle of the major curves was 98 degrees (range 75-133 degrees ). The deformity correction was 67.1% (range 51-74%). Coronal imbalance was 2.5 cm before and 0.8 cm after surgery. No major complication occurred. Satisfactory correction was achieved in all patients and without anterior release in all but one patient. Regardless of the etiology of their deformities, all patients were very satisfied with their outcomes. CONCLUSIONS: The cantilever bending technique is an effective procedure for the management of large and rigid scoliosis regardless of etiology. The clinical value of the procedure was demonstrated by reduced need for anterior release, fewer complications, and high rates of patient satisfaction.

Adolescent↗
PubMed2004

The effect of amicar on perioperative blood loss in idiopathic scoliosis: the results of a prospective, randomized double-blind study.

STUDY DESIGN: A prospective, randomized, double-blind Institutional Review Board-approved study evaluating the efficacy of Amicar (epsilon aminocaproic acid), an antifibrinolytic agent, in decreasing perioperative blood loss in idiopathic scoliosis. OBJECTIVES: To compare the perioperative (intraoperative and postoperative) blood loss and the need for autologous and homologous blood replacement in two groups of essentially identical patients undergoing a posterior spinal fusion for idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Reducing perioperative blood loss and the need for transfusion in patients undergoing spinal surgery is important to orthopedic surgeons. Recently, there has been interest in pharmacologic agents, particularly Amicar and Aprotinin, to assist in decreasing perioperative blood loss. In 2001, in a preliminary study, we demonstrated that Amicar appeared to be effective in reducing perioperative blood loss in patients with idiopathic scoliosis undergoing a posterior spinal fusion and segmental spinal instrumentation. This was a study of 28 consecutive patients receiving Amicar compared to a historical control group of the 31 previous consecutive patients with the same study criteria. The current study was performed to confirm our preliminary findings. METHODS: We analyzed the perioperative blood loss of 36 patients with idiopathic scoliosis who were blindly randomized by the operating room pharmacy into an Amicar and control group. The criteria to be included in the study was the same as the preliminary study: diagnosis of idiopathic scoliosis, age at surgery 11 to 18 years, posterior spinal fusion and segmental spinal instrumentation only, autogenous iliac crest bone graft or homologous cancellous bone graft, and a signed agreement to participate in the study. The patients in both groups had the same anesthetic technique, intraoperative procedure, instrumentation, postoperative management, and standardized indications for transfusions. RESULTS: Before surgery, the patients in both groups were essentially identical. The distribution of patients and their results was not known until the completion of the study. Patients in the Amicar group demonstrated a statistically significant decrease in perioperative blood loss and the need for autologous blood transfusion. Interestingly, this decrease was predominantly in the postoperative suction drainage. This may be due to elevated fibrinogen levels induced by Amicar. The patients taking Amicar had no intraoperative or postoperative thromboembolic complications. CONCLUSIONS: The results of this study confirmed that the use of intraoperative Amicar is a safe, effective, and inexpensive method to significantly reduce perioperative blood loss in patients with idiopathic scoliosis undergoing posterior spinal fusion and segmental spinal instrumentation. The results have allowed us to reduce our recommendation for perioperative autologous blood donation, thereby further decreasing costs.

Adolescent↗
PubMed2004

Results of thoracoscopic instrumented fusion versus conventional posterior instrumented fusion in adolescent idiopathic scoliosis undergoing selective thoracic fusion.

STUDY DESIGN: Retrospective review of 31 consecutive female patients with adolescent idiopathic scoliosis undergoing selective thoracic fusion. OBJECTIVE: To compare safety and efficacy of two techniques in treating adolescent idiopathic scoliosis undergoing selective thoracic fusion. SUMMARY OF BACKGROUND DATA: There is paucity in the literature comparing posterior versus thoracoscopic instrumented fusion in scoliosis. METHODS: Nineteen patients (group 1) underwent posterior instrumented fusion. Twelve patients (group 2) had thoracoscopic anterior instrumented fusion. All patients had a minimum of 25 months of follow-up observation. RESULTS: Both groups were similar in terms of age at menarche and surgery. Preoperative Cobb angles in the coronal (erect and bending) and sagittal planes did not differ between the two groups. Group 1 patients had higher estimated blood loss (P = 0.006). Operative time (P < 0.001) and intensive care unit stay (P = 0.01) were longer in group 2 patients. There was no difference in parenteral analgesia requirement. There were no complications in group 1. Complications in group 2 included lobar collapse (1) and scapula winging (1). Improvement in scoliosis among group 1 patients averaged 77 (1 week), 72 (6 months), and 67% (most recent follow-up review). In group 2 patients, mean improvement in scoliosis was 66 (1 week), 62 (6 months), and 62% (most recent follow-up review). The differences between the two groups in terms of scoliosis improvement were not significant. Thoracic kyphosis (T2-T12) did not increase significantly with thoracoscopic versus posterior instrumentation. No significant change in lumbar lordosis (T12-S1) was noted with either procedure. CONCLUSIONS: The efficacy of thoracoscopic surgery was similar to standard posterior procedures. Advantages included lower intraoperative blood loss. The longer operative time and intensive care unit stay were attributed to the steep learning curve of this technique.

Adolescent↗
PubMed2004

Scoliosis in cystic fibrosis: is it idiopathic?

STUDY DESIGN: This is a retrospective study of all the patients registered with the Yorkshire Regional Cystic Fibrosis unit from 1982 to 1997. Of the 316 patients, there were 184 adults (age 17 years and above) and 132 children (age 0-6 years). OBJECTIVES: This study was aimed at determining the prevalence of scoliosis in people with cystic fibrosis and describes the characteristics and progression of scoliosis in these patients and highlights predictive factors, which account for high prevalence of scoliosis in this condition. SUMMARY OF THE BACKGROUND DATA: Two previous North American studies (1978 and 1982) have indicated a high prevalence of scoliosis in patients with cystic fibrosis. METHODS: The patients were divided into 3 groups based on their chronologic age as on January 1998. Chest, abdomen, and whole spine radiographs were studied for the presence of any spinal deformity, and measurements were made using the Oxford Cobbmeter (Oxford Metrics). The extent, apex, and the side of the curves were described. The disease-specific scores, ie, Chrispin-Norman score (score for radiologic severity of lung disease) and Shwachman score (score for general condition), were noted from the patient follow-up database maintained by the Regional Cystic Fibrosis Unit. Multiple linear regression analysis was used to study the correlation between Cobb angle and the previously mentioned scores. RESULTS: In the 4- to 16-year age group, the prevalence of scoliosis was 15.6%, which is 20 times the prevalence in 15,793 school children with a similar age and sex distribution from the same geographic area. The majority of curves were single-thoracic, apical around T6-T8 with no side predilection. In the adult population (above 16 years), the prevalence was 9.8%, which is higher than that of the general population. These curves were thoracic, apical around T7-T8, and approximately two thirds of them were right-sided. Infantile curves are described for the first time in our study; these tend to be nonprogressive, right-sided, upper thoracic curves. CONCLUSION: Our study shows a high prevalence of scoliosis in people with cystic fibrosis. These are benign short midthoracic curves, apical between T6-T8 with no side predilection.

Adolescent↗
PubMed2004

Muscle activation strategies and symmetry of spinal loading in the lumbar spine with scoliosis.

STUDY DESIGN: Biomechanical analysis of muscle and spinal forces in a lumbar spine with scoliosis. OBJECTIVES: To calculate spinal loading asymmetry and its dependence on muscle activation strategy. SUMMARY OF BACKGROUND DATA: It is commonly assumed that a spine with scoliosis experiences greater loading on the concave side and that this asymmetric loading causes asymmetric growth and progression of deformity. However, neither the magnitude of the asymmetric loading imposed on the spine as a function of the scoliosis curve nor the resulting mechanically altered vertebral growth and disc remodeling have been quantified. METHODS: Spinal loading was estimated in a lumbar spine model with increasing degrees of scoliosis. External loading was each of three pure moments or forces acting at T12, with magnitudes of either 50% or 75% of maximum effort. For each external loading, the muscle activation patterns were determined with each of three different muscle activation strategies in an optimization model: 1) minimize the sum of cubed muscle stresses; 2) minimize spinal asymmetric load (i.e., "follower load"); and 3) reverse the spinal load asymmetry (increased compression on convex side) at the level of the apex. RESULTS: The first strategy produced loading that tended to increase the curve magnitude, with the resultant force acting at up to 15 mm lateral to the intervertebral disc center. Both Strategies 2 and 3 had increased muscle stress averaging between 42% and 75%. CONCLUSIONS: We speculate that individuals with scoliosis can adopt different muscle activation strategies and that these strategies may determine whether or not the spinal loading causes scoliosis progression during growth. Muscle activation patterns generating spinal loading that does not promote curve progression during growth have greater physiologic cost.

Biomechanical Phenomena↗
PubMed2004

Seated postural control in adolescents with idiopathic scoliosis.

STUDY DESIGN: The center of pressure (COP) path in 14 adolescents with idiopathic scoliosis and 12 age-matched able-bodied adolescents was compared using traditional measures and a two-level decomposition. OBJECTIVES: To investigate whether asymmetries in the spines of children with idiopathic scoliosis are reflected in altered sway patterns in quiet sitting. SUMMARY OF BACKGROUND DATA: Previous studies have studied the sway of children with scoliosis while standing. However, the standing posture is typically controlled at the ankle joint. To date, there are no studies with this population of sitting sway, where the movement is controlled by the trunk muscles. METHODS: Traditional measures of the COP of the trunk were analyzed. The COP was also decomposed into an approximation of the center of mass path and deviations around this path. RESULTS: COP movement in sitting, reflecting the postural control of the spine, was decreased in adolescents with idiopathic scoliosis. Children with scoliosis had symmetric sitting COP trajectories and most measures were similar between the two groups. CONCLUSIONS: The results suggest a control strategy for maintaining a sitting posture that does not change with the development of scoliosis but does adapt by decreasing movement to maintain the trunk in a region where the it can remain "passively" stable.

Adolescent↗
PubMed2005

Down syndrome and scoliosis: a review of a 50-year experience at one institution.

STUDY DESIGN: Retrospective review case series. OBJECTIVE: To evaluate the incidence, patterns, and treatment of scoliosis in a Down syndrome population. SUMMARY OF BACKGROUND DATA: Despite a preponderance of literature concerning cervical abnormalities in Down syndrome, there is little information concerning scoliosis in this patient group. We examined the 50-year history of treating scoliosis at our institution in patients with Down syndrome. METHODS: Following institutional review board approval, chart review identified patients with Down syndrome with scoliosis. We performed a radiographic review of curve pattern, and determined results of brace and operative treatment. RESULTS: A total of 379 patients were identified as having Down syndrome. There were 33 patients diagnosed with scoliosis, for an incidence of 8.7%. Mean follow-up was 4.15 years (range 0-12). The double major curve predominated with 18 (55%). Of 33 patients, 16 (49.5%) had previously undergone thoracotomy for congenital heart defects. There were 8 (24%) patients who were braced for an average of 26.5 months (range 12-63), with an average progression in brace of 10 degrees (range 0 degrees-44 degrees), 3 of whom went on to spinal fusion. There were 7 (21.2%) patients who underwent spinal fusion, including 6 posterior spinal fusions and 1 anterior spinal fusion. Four patients had complications, including 3 pseudarthroses, 4 implant failures, 3 superior junctional kyphosis, and 1 infection, for a 57% complication rate. CONCLUSIONS: Scoliosis developed in 8.7% of patients with Down syndrome. There was a high rate of cardiac surgery within this population. Bracing was ineffective for the majority of the patients treated. Although surgery has a high rate of complications, there was only one patient who underwent reoperation.

Adolescent↗
PubMed2005

Clinical usefulness of somatosensory evoked potentials for detection of brachial plexopathy secondary to malpositioning in scoliosis surgery.

STUDY DESIGN: A retrospective longitudinal study of 434 consecutive pediatric patients who underwent surgical correction of scoliosis, while being monitored for positional brachial plexopathy. OBJECTIVE: To evaluate the effectiveness of intermittent monitoring of ulnar nerve somatosensory evoked potentials (SSEPs) for detecting brachial plexus injury caused by malpositioning during scoliosis surgery. SUMMARY OF BACKGROUND DATA: Continuous intraoperative SSEP monitoring for spinal cord function has been well reported, and is widely accepted as the standard for spinal deformity correction surgery to detect and avoid neurologic injury. The use of SSEPs for the monitoring of ulnar nerve function intraoperatively as an indicator of brachial plexus function is becoming more accepted as a valid and useful technique to minimize intraoperative neurologic injuries during deformity corrections. METHODS: A review was conducted to assess the effect of ulnar nerve SSEP monitoring, as a measure of brachial plexus function, during anterior, posterior, or combined approach surgeries. The type of scoliosis, type of surgery and positioning, and surgical event at noted amplitude decrease were included in an analysis of variance for repeated measures, and a Student t test was performed for significant differences. RESULTS: A total of 27 patients had ulnar nerve amplitude decreases of > or =30%, resulting in a point prevalence of 6.2% for positional brachial plexopathy during positioning for all scoliosis surgeries. A significant difference was noted between the types of positioning, with prone positioning accounting for a higher rate of brachial plexopathy compared with anterior approach positioning (P < 0.01). No statistical difference exists as to the type of scoliosis present and the incidence of brachial plexopathy (P < 0.01). CONCLUSIONS: Avoidance of neurologic injury to the brachial plexus during scoliosis surgery is possible by early detection with ulnar nerve SSEP monitoring.

Brachial Plexus↗
PubMed2005

Long-term follow-up of functioning after spinal surgery in patients with neuromuscular scoliosis.

STUDY DESIGN: A prospective study of 100 consecutive preoperative patients with neuromuscular scoliosis whose activities and function were evaluated in a long-term follow-up. OBJECTIVES: To evaluate long-term follow-up of functioning in patients with neuromuscular scoliosis. SUMMARY OF BACKGROUND DATA: Few studies of patients operated for neuromuscular scoliosis are prospective, with long-term follow-up based on assessments of activities and function. METHODS: The follow-up included 82 patients with neuromuscular scoliosis who were evaluated before surgery from 1992 to 1996. The follow-up time was 84.5 months on average. The assessments comprised sitting, angle of scoliosis, lung function, reaching, pain estimation, activities of daily living (ADL), care given, and time used for resting. A follow-up questionnaire as well two open-ended questions about the positive and negative effects of the surgery were sent to the patients/parents. RESULTS: Improvements after surgery were shown in the Cobb angle, lung function, seating position, ADL, and time used for resting. In a comparison between the 1-year follow-up and the long-term follow-up, there were further improvements in sitting, ADL, and care given but an increased Cobb angle. These results were in line with the assessments reported by patients and relatives. Only minor differences were shown in long-term outcome in subgroups according to understand/not understand verbal instructions. Patient age 21 years or less seemed more improved than those age 22 years and older at the time of surgery. CONCLUSIONS: The comparison of the preoperative and long-term follow-ups showed that patients were mostly improved. Further improvements were shown beyond the 1-year follow-up. The subjective assessments also confirmed the results. The heterogeneity of patients with neuromuscular scoliosis makes it important to evaluate the patients in subgroups and in relation to age.

Activities of Daily Living↗