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PubMed1999

Three-dimensional computed tomography in the assessment of congenital scoliosis.

OBJECTIVE: Patients with congenital vertebral anomalies frequently are afflicted with kyphoscoliosis, with the curvatures often being severe and progressive. Spinal fusion almost always is the treatment of choice in such patients. This report examines the use of three-dimensional computed tomography (3D CT) in the preoperative investigation of patients with congenital scoliosis. DESIGN AND PATIENTS: Twelve spinal CT examinations on 11 pediatric patients with congenital scoliosis underwent image processing to produce 3D images. The 3D images were compared with both the axial sections from the CT examinations and multiplanar reformations with regard to the detection of malformations liable to cause progression of scoliosis (i. e., hemivertebrae and unsegmented bars). RESULTS AND CONCLUSIONS: In six of the 12 cases, the 3D images provided improved depiction of the congenital anomalies and their interrelationships compared with planar CT images. This work suggests that 3D CT can be a useful tool in the assessment of patients with congenital scoliosis.

Adolescent↗
PubMed2004

Thoracoscopic techniques for the treatment of scoliosis.

STUDY DESIGN: To determine the effectiveness of an endoscopic option in an anterior approach to the thoracolumbar spine for scoliosis treatment, 50 patients with follow-ups of 24-45 months were studied retrospectively. OBJECTIVE: The objective was to develop a safe, reproducible, and effective endoscopic technique for the treatment of scoliosis that will provide equal or better outcomes compared with formal open surgical techniques. Techniques for endoscopic treatment of spinal disorders have been under development since 1993. The benefits of thoracoscopic surgery in treating spinal deformities have been documented as improved visualization of the spine, enhanced access to the extremes of the curve, decreased operative times and blood loss, shorter hospital stays and recuperative periods, and decreased overall costs. Following more than 150 endoscopic procedures for the treatment of these spinal deformities, the next progression was to develop a thoracoscopic technique of instrumentation, correction, and fusion for primary thoracic scoliosis. The goals are to gain comparable results, fusion rates, and degrees of correction that meet or exceed the current gold standards of an open procedure. METHODS: From October 1996 to October 1998, 50 patients with a diagnosis of primary thoracic scoliosis were selected to undergo a thoracoscopic technique of instrumentation, correction, and fusion. Postoperatively, patients were assessed for restoration of spinal alignment, axial derotation, pain management, and incidence of complications. RESULTS. Successful endoscopic instrumentation occurred in all patients. Curve correction averaged 50.2%, improving to 68.6% in the last ten cases. Patients with hypokyphosis averaged 20.7 degrees of correction. The preoperative axial rotation, based on the scoliometer, averaged 16 degrees , which was corrected to 5 degrees postoperatively. Postoperative pain was less; patients were off all pain medication by 1-3 weeks compared with patients with a formal open procedure requiring pain medication for 6-12 weeks. The hospital stay averaged 2.9 days. Our initial complication rate was high, which can be attributed to the development of a new technique. The keys to successful fusions included total discectomy, complete endplate removal, and autogenous bone graft. CONCLUSIONS: Although still in early development, the initial results of thoracoscopic techniques are promising. With experience, surgical times are decreasing and fusion and curve correction rates are improving. With further evolution, patients should realize shortened hospitalization, decreased rehabilitation times, and decreased levels of postoperative pain. This is a technically demanding procedure and requires demonstrated skills in endoscopic discectomy and fusion.

Endoscopy↗
PubMed2001

Length of the ribs in patients with idiopathic scoliosis.

There have been few reports of actual measurements of rib length in patients with idiopathic scoliosis. We measured the lengths of the 7th to 12th ribs in 28 patients with idiopathic scoliosis with right convex single thoracic curve. The measurements were performed by the multi-projection volume reconstruction method of computed tomography. A significant difference between the left and right side length (laterality) was observed in the 11th and 12th ribs. Laterality was not observed in the 7th, 8th, 9th, and 10th ribs. In this study, it appeared inadequate to conclude that the laterality of rib length caused the scoliosis. Since the 11th and 12th ribs were floating ribs, we speculated that, on the contrary, the scoliosis affected the laterality of the rib length.

Adolescent↗
PubMed2004

Familial adolescent-onset scoliosis and later segmental dystonia in an Irish family.

Adolescent-onset scoliosis occurs more frequently than expected in primary adult-onset cervical dystonia and a genetic association between the conditions has been postulated. The authors report a family in which four members have adult-onset cervical and/or brachial dystonia, two of whom have coexistent scoliosis. Four other individuals have isolated childhood- or adolescent-onset scoliosis. Adolescent-onset scoliosis may represent part of the dystonia phenotype in this family.

Adolescent↗
PubMed2002

Comparative analysis of pedicle screw and hook instrumentation in posterior correction and fusion of idiopathic thoracic scoliosis.

Posterior correction and fusion with segmental hook instrumentation represent the gold standard in the surgical treatment of progressive idiopathic thoracic scoliosis. However, there is a debate over whether pedicle screws are safe in scoliosis surgery and whether their usage might enable a better curve correction and a shorter fusion length. The details of curve correction, fusion length and complication rate of 99 patients with idiopathic thoracic scoliosis treated with either hook or pedicle screw instrumentation were analyzed. Forty-nine patients had been operated with the Cotrel-Dubousset system using hooks exclusively ("hook group"). Fifty patients had been operated with either a combination of pedicle screws in the lumbar and lower thoracic and hooks in the upper thoracic spine or exclusive pedicle screw instrumentation using the Münster Posterior Double Rod System ("screw group"). The preoperative Cobb angle averaged 61.3 degrees (range 40 degrees-84 degrees ) in the hook group and 62.5 degrees (range 43 degrees-94 degrees ) in the screw group. Average primary curve correction was 51.7% in the hook group and 55.8% in the screw group ( P>0.05). However, at follow-up (2-12 years later) primary curve correction was significantly greater ( P=0.001) in the screw group (at 50.1%) compared to the hook group (at 41.1%). Secondary lumbar curve correction was significantly greater ( P=0.04) in the screw group (54.9%) compared to the hook group (46.9%). Correction of the apical vertebral rotation according to Perdriolle was minimal in both groups. Apical vertebral translation was corrected by 42.0% in the hook group and 55.6% in the screw group ( P=0.008). Correction of the tilt of the lowest instrumented vertebra averaged 48.1% in the hook group and 66.2% in the screw group ( P=0.0004). There were no differences concerning correction of the sagittal plane deformity between the two groups. Fusion length was, on average, 0.6 segments shorter in the screw group compared to the hook group ( P=0.03). With pedicle screws, the lowest instrumented vertebra was usually one below the lower end vertebra, whereas in the hook group it was between one and two vertebrae below the lower end vertebra. Both operative time and intraoperative blood loss were significantly higher in the hook group ( P<0.0001). One pedicle screw at T5 was exchanged due to the direct proximity to the aorta. There were no neurologic complications related to pedicle screw instrumentation. Pedicle screw instrumentation alone or in combination with proximal hook instrumentation offers a significantly better primary and secondary curve correction in idiopathic thoracic scoliosis and enables a significantly shorter fusion length.

Adolescent↗
PubMed2003

A new concept for the etiopathogenesis of the thoracospinal deformity of idiopathic scoliosis: summary of an electronic focus group debate of the IBSE.

There is no generally accepted scientific theory for the etiology of idiopathic scoliosis, and treatment is pragmatic and unrelated to such knowledge. As part of its mission to widen understanding of scoliosis etiology, the International Federated Body on Scoliosis Etiology (IBSE) introduced the electronic focus group (EFG) as a means of increasing debate of extant knowledge on important topics. This has been designated as an on-line Delphi discussion, and has proven very successful. The text for this EFG was written by Professor Sevastik and drawn from the extensive research carried out by himself and his co-workers. The thoracospinal concept of etiopathogenesis applies only to girls with right thoracic adolescent idiopathic scoliosis (Rcx-T-AIS-F). According to this concept, increased longitudinal growth of the left periapical ribs triggers the thoracic curve simultaneously in the three cardinal planes. The concept does not deal with factors involved in curve progression. Sevastik advocates mini-invasive operations on the ribs as a treatment for early progressive thoracic curves. Areas of controversy include whether or not there is overgrowth of the left periapical ribs in Rcx-T-AIS-F, and the question of whether there should be a clinical trial of mini-invasive operations on the ribs.

Adolescent↗
PubMed2003

Preoperative radiological and electrophysiological evaluation in 100 adolescent idiopathic scoliosis patients.

This is a prospective study of spinal magnetic resonance imaging (MRI), electrophysiological recordings, and neurological examinations of 100 patients admitted for surgery for adolescent idiopathic scoliosis (AIS), which was conducted to assess the prevalence of structural and functional abnormalities within the spinal cord in patients with clinically normal neurologic condition. In all patients the clinical diagnosis and intact neurological condition was ascertained by a spinal orthopedic surgeon. Full-length spinal axis MRI studies (T1/T2 sequences) and somato-sensory evoked potentials of the tibial nerves (tSSEPs) were preoperatively assessed by independent evaluators blinded to the patients' medical histories. Structural spinal cord abnormalities were found in three of 100 AIS patients on MR imaging. In one patient a Chiari malformation type 1 with an accompanying syringomyelia was diagnosed, which required a suboccipital decompression. In the other two patients small thoracic syringomyelias were diagnosed. Abnormalities of spinal cord function were detected in 68% of the 100 patients: tSSEP latencies corrected for body height were increased in 56% of the patients; pathological differences between tSSEPs on the left and right sides were present in 17% (12% in combination with a prolongation of the latency). The findings of this study indicate that MRI and electrophysiological examinations are essential to assess spinal cord abnormalities that are clinically not detectable in AIS patients. Even in patients with intact neurologic condition and clinically typical right-curved thoracic scoliosis, the possibility of intraspinal pathologies should be ruled out by MRI. It is especially important to detect structural pathologies like syringomyelia and Chiari malformation before proceeding with scoliosis surgery, as these conditions are associated with a higher neurological risk during scoliosis surgery. The electrophysiological recordings made in the present study, with the high number of pathological tSSEPs, are indicative of functional abnormalities with a subclinical involvement of the recorded neuronal pathways. The relevance of the latter findings is not yet clear, but pre-operative tSSEP examinations offer the possibility of assessing alterations in spinal cord function that are undetectable by clinical examination.

Adolescent↗
PubMed2004

Demonstration of vertebral and disc mechanical torsion in adolescent idiopathic scoliosis using three-dimensional MR imaging.

This study was designed to demonstrate and measure mechanical torsion in patients with adolescent idiopathic scoliosis using three-dimensional magnetic resonance (MR) imaging. Ten patients with adolescent idiopathic scoliosis were imaged with three-dimensional MR imaging, and the data post-processed through multiplanar reconstruction to produce images angled through individual endplates. Transverse rotation was measured at each endplate and these measurements used to calculate the amount of vertebral and disc mechanical torsion present. A test object was imaged in order to validate the measurement technique. Mechanical torsion was demonstrated within the vertebral bodies and discs of the imaged subjects, with vertebral mechanical torsion contributing on average 45% of the overall transverse plane deformity. It is concluded that deformation occurs in the transverse plane within the vertebrae and discs of subjects with idiopathic scoliosis, and a significant proportion of the rotation present in the scoliotic spine occurs as a result of plastic deformation within the vertebrae themselves. We believe that this is the first systematic demonstration of mechanical torsion in idiopathic scoliosis.

Adolescent↗
PubMed2005

Pre-and postoperative psychological characteristics in mothers of patients with idiopathic scoliosis.

The purpose of the present study was to clarify changes in the psychological state of mothers of patients with idiopathic scoliosis, and to clarify relationships between the psychological states of the mothers and patients. The Maudsley personality inventory (MPI) was administered to 30 patients with idiopathic scoliosis who underwent surgery and their mothers preoperatively and at about 1 year postoperatively. We investigated the relationships between preoperative MPI scores and postoperative scores in patients and their mothers, respectively, and the relationships between MPI scores for patients and mothers. The results of the present study revealed that patients became more extroverted following surgery, while mothers displayed reduced neurotic tendencies. In conclusion, the mothers of patients who undergo corrective treatment for scoliosis may have experienced a substantial psychological burden before surgery, and doctors who treat patients with scoliosis should bear this point in mind.

Adult↗
PubMed2005

Primary thoracoplasty and pedicle screw instrumentation in thoracic idiopathic scoliosis.

Thoracoplasty in combination with spine fusion is an established method to address the rib cage deformity in idiopathic scoliosis. Most reports about thoracoplasty and scoliosis correction focused on Harrington or CD instrumentation. We report a retrospective analysis of 21 consecutive patients, who were treated with pedicle screw instrumentation for idiopathic thoracic scoliosis and concomitant thoracoplasty. Minimal follow up was 24 (24-75) months. Indication for thoracoplasty was clinical rib prominence of more than 15 degrees . In average there was a 44% correction of clinical rib hump, from 18 (15-25 degrees ) to 10 degrees (0-18 degrees ) (p<0.0001) and a 40% correction of radiological rib hump, from 15 (5-20 degrees ) to 9 degrees (2-15 degrees ) (p<0.0001). The preoperative pulmonary function, accessed by forced vital capacity (FVC) and one-second forced expiratory volume (FEV1), remained unchanged at the last follow up. The distal end of fusion was the end vertebra of the curve in 83.3% and the end vertebra plus one in 16.7% of the patients. There was a 68% correction of instrumented primary thoracic curves, from 60 (45-85 degrees ) to 19 degrees (5-36 degrees ) (p<0.0001), and a 45% correction of non-instrumented secondary lumbar curves, from 40 (28-60 degrees ) to 22 degrees (8-38 degrees ) (p<0.0001). Apical vertebral rotation (AVR) of the thoracic curves improved 54%, from 24 (10-35 degrees ) to 11 degrees (5-20 degrees ) (p<0.0001). The tilt of lowest instrumented vertebra (LIV) improved 68%, from 28 (20-42 degrees ) to 9 degrees (3-20 degrees ) (p<0.0001). There was no significant change in sagittal profile of the spine. Analysis with SRS-24 questionnaire showed that the majority of the patients were very satisfied with the outcome. A matched control group (n=21) operated by the same surgeon with the same operation technique but without concomitant thoracoplasty was chosen for comparison. The scoliosis correction in the two groups was comparable. The patients without thoracoplasty had 37% spontaneous improvement of the clinical rib hump.

Bone Screws↗
PubMed2006

MW construct in fusion for neuromuscular scoliosis.

A retrospective case control review was conducted to determine if the MW construct offers a superior means of correction of Cobb angles and pelvic obliquity in neuromuscular scoliosis. Posterior spinal fusion (PSF) in patients with neuromuscular scoliosis presents a surgical challenge. Particularly difficult is the correction of pelvic obliquity. Numerous instrumentation techniques have sought to address these difficulties. Most recently Arlet et al have introduced the MW construct. (in Eur Spine 8(3):229-231, 1999). They theorize that this construct may allow for superior spinopelvic fixation. Six patients with neuromuscular scoliosis who underwent PSF with the MW construct were compared with six subjects undergoing PSF utilizing the Galveston technique. Subjects were matched on the basis of preoperative Cobb angles and similar amounts of preoperative pelvic obliquity. Individuals who underwent PSF utilizing the MW construct obtained nearly 30% better correction of pelvic obliquity than did those who received a Galveston construct. A trend toward superior correction of Cobb angles with the MW construct was also observed. The MW construct may be a superior construct for curve correction in PSF for neuromuscular scoliosis, particularly those cases with excessive pelvic obliquity.

Adolescent↗
PubMed2000

Segmental pedicle screw instrumentation in idiopathic thoracolumbar and lumbar scoliosis.

The role of posterior correction and fusion in thoracolumbar and lumbar scoliosis as well as pedicle screw instrumentation in scoliosis surgery are matters of debate. Our hypothesis was that in lumbar and thoracolumbar scoliosis, segmental pedicle screw instrumentation is safe and enables a good frontal and sagittal plane correction with a fusion length comparable to anterior instrumentation. In a prospective clinical trial, 12 consecutive patients with idiopathic thoracolumbar or lumbar scolioses of between 40 degrees and 60 degrees Cobb angle underwent segmental pedicle screw instrumentation. Minimum follow-up was 4 years (range 48-60 months). Fusion length was defined according to the rules for Zielke instrumentation, normally ranging between the end vertebrae of the major curve. Radiometric analysis included coronal and sagittal plane correction. Additionally, the accuracy of pedicle screw placement was measured by use of postoperative computed tomographic scans. Major curve correction averaged 64.6%, with a loss of correction of 3 degrees. The tilt angle was corrected by 67.0%, the compensatory thoracic curve corrected spontaneously according to the flexibility on the preoperative bending films, and led to a satisfactory frontal balance in all cases. Average fusion length was the same as that of the major curve. Pathological thoracolumbar kyphosis was completely corrected in all but one case. One patient required surgical revision with extension of the fusion to the midthoracic spine due to a painful junctional kyphosis. Eighty-five of 104 screws were graded "within the pedicle", 10 screws had penetrated laterally, 5 screws bilaterally and 4 screws medially. No neurological complications were noted. In conclusion, despite the limited number of patients, this study shows that segmental pedicle screw instrumentation is a safe and effective procedure in the surgical correction of both frontal and sagittal plane deformity in thoracolumbar and lumbar scoliosis of less than 60 degrees, with a short fusion length, comparable to anterior fusion techniques, and minimal loss of correction.

Adolescent↗
PubMed2000

Can hindbrain decompression for syringomyelia lead to regression of scoliosis?

Scoliosis in childhood develops secondary to syringomyelia in some children. The existing literature does not provide a clear answer as to whether surgical treatment of the syrinx can allow subsequent improvement of the spinal deformity, thus preventing the need for scoliosis surgery. This series comprised 16 patients with syringomyelia who presented with significant scoliosis in the absence of major neurological deficit. All underwent a hindbrain decompression, and follow-up ranged from 1 to 6 years (mean 2.5 years). Subsequent deformity surgery was necessary in eight cases, but the scoliosis was seen to improve or arrest its progression in six (37.5%). Improvement was found to be statistically more likely in children of younger age at the time of syrinx surgery and in those with left thoracic curves. Improvement occurred in 71.4% of those under the age of 10 at the time of hindbrain decompression.

Adolescent↗
PubMed2000

Relationship between gibbosity and Cobb angle during treatment of idiopathic scoliosis with the SpineCor brace.

The objective of this study was to quantify the relationship between gibbosity and spinal deformation expressed by the angle of Cobb before and during treatment with a brace for different classes of idiopathic scoliosis patients. As part of the standard treatment with the Dynamic Corrective Brace (SpineCor), 89 idiopathic scoliosis patients underwent an initial radiological examination and gibbosity measurement with a scoliometer wearing and not wearing the brace. The 89 patients were classified in relation to the apex of the scoliosis curves: thoracic (n = 29); thoracolumbar (n = 40); lumbar (n = 7) and double (n = 13). With the dynamic corrective brace, the patients showed a mean decrease of 8.3 degrees for the major Cobb angle, and a mean decrease of 2.3 degrees for their gibbosity. There was a significant positive relationship between gibbosity and Cobb angle with and without the brace for the thoracic and thoracolumbar curves. A linear regression analysis identified a small mean estimation error for the thoracic curves (7.4 degrees no-brace; 2.7 degrees with brace) and thoracolumbar curves (5.2 degrees no-brace; 5.3 degrees with brace), indicating a predictive potential of the scoliometer. The measure of gibbosity with the scoliometer provides a fairly reliable estimation of Cobb angle at the initial clinical examination of a scoliosis patient. However, when initial Cobb angle and gibbosity are considered, the measure of gibbosity when wearing a brace provides the clinician with a highly reliable estimation of the Cobb angle while in a brace. This relationship also exists for the follow-up with a brace, permitting a judgement of the patient's evolution under the treatment with SpineCor.

Adolescent↗
PubMed1998

Thoracic scoliosis and restricted neck motion: a new syndrome? A report of six cases.

The cases of six adolescent males with a mild thoracic scoliosis of unknown etiology and a marked limitation of neck flexion are reported. All six complained of mild thoracic spine pain and were 13-17 years old at the onset of their symptoms. In addition to the thoracic scoliosis, all were found to have a marked limitation of neck flexion. They were unable to touch their chest wall with their chin. None had a positive family history of scoliosis. Radiological examination revealed a thoracic scoliosis of 10 degrees-40 degrees, no abnormalities were detected on cervical spine plain radiographs. Extensive investigations, including MRI of the entire spine, failed to disclose the cause of the spinal deformity or the mechanism causing the limitation of neck motion. Apart from the limited cervical flexion and mild pain, this condition was found to be benign and the spine deformity to be mild or moderate in nature and with limited progression. Review of the literature failed to identify similar cases.

Adolescent↗
PubMed1999

A new approach to scoliosis.

Despite the advantages that new derotation-based systems have brought to the treatment of scoliosis, the debate continues, especially regarding adolescent idiopathic scoliosis. Problems like decompensation, junctional kyphosis, and insufficient sagittal plane alignment are met with new proposals. We now are using a technique and system, the Ibn-I Sina Spinal System (IBS), that we think is able to overcome these problems. It makes use of sublaminar wires, hooks, screws, and rods for correction. The main innovation is that the major corrective force is a controlled translation force acting simultaneously on all segments of the curve. A retrospective assessment of 25 patients treated with this system showed that besides dealing well with decompensation and junctional kyphosis problems, the technique was superior in sagittal plane adjustments, mainly in that it carried the normal kyphosis to its physiologic location. IBS has proved easy and successful in scoliosis treatment, especially with lordotic rigid curves. We encountered no neurologic injury or instrument failure. In addition to these advantages, ease of preoperative planning and application, decreased operation time, easy removal or revision, and versatility and safety of the system has made the Ibn-I Sina Spinal System (IBS) a treatment of choice, especially for adolescent idiopathic scoliosis cases, in some centers in Turkey.

Adolescent↗
PubMed1999

Dorsal instrumentation for idiopathic adolescent thoracic scoliosis: rod rotation versus translation.

The radiographic and clinical outcomes and complications among two groups of adolescent patients treated for idiopathic thoracic scoliosis with dorsal instrumentation using a unified implantation system (Universal Spinal System) were compared retrospectively. A total of 69 patients were included in the study. In 30 patients an intraoperative correction of the scoliosis was performed by translation and segmental correction (translation group, Helsinki). In 39 patients the correction was achieved according to the Cotrel-Dubousset rod rotation maneuver (rod rotation group, Berlin). The goal of the present study is to investigate whether one of the operative procedures leads to a better correction of idiopathic adolescent thoracic scoliosis than the other. The mean follow-up interval was 30 months, with a minimum of 12 months. There were no significant preoperative differences in age (15+/-2 years in both groups), gender, or type of scoliosis (King types 2, 3, and 4). The preoperative radiographic measurements showed no significant differences between the two groups. In both patient groups, the thoracic primary curve, the lumbar secondary curve and the thoracic apical rotation were improved by the operation. Lumbar apical rotation and the sagittal profile were unchanged in both groups. The thoracic primary curve was corrected from 50 degrees +/-6 degrees to 24 degrees +/-7 degrees in the translation group and from 54 degrees +/-11 degrees to 220 degrees +/-11 degrees in the rod rotation group. The extent of the correction of the thoracic curve was significantly greater in the rod rotation group than in the translation group (59% vs. 52% correction). In contrast, the translation procedure seems to have a more beneficial effect on spinal balance than rod rotation. Neurological complications did not occur. In both patient groups an increase in the non-instrumented lumbar curve was noted, in two cases each. In three patients from the rod rotation group the instrumentation had to be removed due to a late infection with negative microbiological results.

Adolescent↗
PubMed2005

Results of the section of the filum terminale in 20 patients with syringomyelia, scoliosis and Chiari malformation.

BACKGROUND: Spinal cord traction caused by a tight filum terminale may be considered a pathogenic mechanism involved in the development of syringomyelia, the Chiari malformation (type I) and scoliosis. Section of the filum terminale is proposed as a useful surgical approach in these conditions. METHODS: Between April 1993 and July 2003, a total of 20 patients (8 men and 12 women) with a mean age of 33.5 years underwent section of the filum terminale with or without opening of the dural sac through a standard sacrectomy. Eight patients suffered from scoliosis, 5 from syringomyelia, 2 from Chiari malformation and 5 with a combination of these conditions. FINDING: After section of the filum terminale, patients with syringomyelia showed an early clinical improvement of dysaesthesia, thermo-anaesthesia, hypo-aesthesia and walking difficulties. Rising of the medullary conus was also observed. In patients with scoliosis, back pain improved dramatically and a curve reduction was noticed, although progression of the curve was observed in one case. In patients with Chiari malformation, headache, dysaesthesia and paraparesis disappeared. CONCLUSIONS: Section of the filum terminale is a useful strategy in the treatment of scoliosis, syringomyelia and the Chiari malformation, and offers a new aetiological basis for the understanding of these three disorders.

Adolescent↗