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PubMed2000

Effectiveness of the boston brace in treatment of large curves in adolescent idiopathic scoliosis.

STUDY DESIGN: This is a retrospective study of 50 patients with adolescent idiopathic scoliosis with curves measuring 35 degrees to 45 degrees who were treated with a Boston brace. OBJECTIVES: The purpose of this study was to determine whether the Boston brace could effectively halt long-term progression in skeletally immature adolescents with idiopathic scoliosis who had a curve between 35 degrees and 45 degrees. SUMMARY OF BACKGROUND DATA: The Boston brace has been shown to be effective in preventing curve progression in adolescent idiopathic scoliosis, but its efficacy in large curves has not been fully studied. METHODS: Fifty adolescents were treated with a Boston brace for idiopathic scoliosis curves of 35-45 degrees (mean, 38.55 degrees ). All were judged to be skeletally immature based on menarcheal status (mean, 2.6 months before menarche), Risser sign (mean, 0.90; range, 0-2), and chronologic age (mean, 13 +/- 1 years). Patients were recalled for long-term follow-up at a mean of 9.7 years (range, 6.23-13.22 years) after brace discontinuation. Three well-matched patient subsets were then identified based on compliance. Group 1 (n = 24) consisted of patients who were compliant with the brace program and wore the brace 18 or more hours per day, Group 2 (n = 14) contained patients who wore the brace 12-18 hours per day, and Group 3 (n = 12) contained patients who wore the brace 0-12 hours per day. RESULTS: There was a significant difference in the amount of initial correction seen in the brace between the groups: 49%, 45%, and 33% curve correction in the brace for Groups 1, 2, and 3, respectively (P < 0.05). At long-term follow-up there was a statistically significant difference between Groups 1, 2, and 3 in the percentage of patients in whom the curve had progressed to more than 45 degrees (P < 0.001), who had more than 5 degrees of curve progression (P < 0. 05), or who had undergone posterior spinal fusion (P < 0.001). CONCLUSIONS: These long-term data confirm that the Boston brace when used 18 or more hours per day is effective in preventing progression of large curves at a mean of 9.8 years after bracing is discontinued.

Adolescent↗
PubMed2001

Visual deficiency and scoliosis.

STUDY DESIGN: A transversal study involving group comparison was performed. OBJECTIVE: To investigate whether children who are visually impaired have a higher rate of spinal deformity. SUMMARY OF BACKGROUND DATA: Evidence has accumulated pointing to an association between idiopathic scoliosis and postural control in which vision is involved. An association between scoliosis and ocular troubles is present in many diseases, but no study on a large blind population has yet been undertaken. METHODS: Data was obtained from an official school screening campaign involving two consecutive classes in a regional school for the visually handicapped and from two consecutive classes in three public vocational schools. This study included 75 children who were visually handicapped (mean age, 11 years and 7 months) and 728 healthy control participants (mean age, 10 years 2 months). Trunk deformity was assessed by Moire topography and measurement of any trunk hump by the forward bending test. The children with visual impairment who had evidence of trunk deformity underwent radiographs of the spine a few months after the back surface assessment, then again 12 to 24 months later. RESULTS: Occurrences of trunk deformity were significantly different in the two groups (P < 0.0001), with five times more back surface abnormalities in the blind population. Of the 26 children with both visual impairment and trunk deformity, 18 had a structural scoliosis on radiographs, with an average Cobb Meyer angle of 14.1 degrees (range, 10-28 degrees ), but there was evidence of an evolving condition in only three cases. CONCLUSIONS: These findings are compatible with a postural etiology of scoliosis in the visually impaired population.

Adolescent↗
PubMed2001

Extension of fusions to the pelvis in idiopathic scoliosis.

STUDY DESIGN: Retrospective study of patients after extension of previous scoliosis fusions to the pelvis. OBJECTIVE: To determine whether modern instrumentation and surgical techniques provide for increased fusion rates with fewer complications. SUMMARY OF BACKGROUND DATA: Traditionally, long fusions to the pelvis in adults with idiopathic scoliosis have resulted in high complication rates, including pseudarthrosis. METHODS: The hospital and clinic charts of 41 patients (40 female, 1 male) were reviewed 41 months (range: 24-116) after surgery for extension to the pelvis of previous scoliosis fusions. Thirty-nine of 41 had a combined anteroposterior fusion extension; two had posterior extension only. In 37 of 41 patients, Cotrel-Dubousset (CD) instrumentation was used; in two, Isola (Acromed Corp., Cleveland, OH), in one, TSRH; (Sofamor-Danek, Memphis, TN), and in one, Synergy (Cross Medical Products, Columbus, OH). Parameters analyzed were fusion rate, sagittal and coronal balance, lumbar lordosis, length of fusion extension, and distal fixation method. RESULTS: Complications were seen in 30 of 41 patients. The pseudarthrosis rate was 37% (15/41) and was significantly related to the method of distal posterior fixation. With sacral fixation only, the rate was 53% (8/15), with iliac fixation only 42% (3/7), and with both iliac and sacral fixation 21% (4/19; P < 0.05). This was not correlated with fusion rate, and the length of fusion extension did not affect the pseudarthrosis rate or sagittal balance. CONCLUSION: When fixed to the ilium and sacrum, modern instrumentation appears capable of maintaining sagittal balance with lower rates of pseudarthrosis when previous scoliosis fusions are extended to the pelvis. The complication rate remains significant.

Adult↗
PubMed2001

Does transverse apex coincide with coronal apex levels (regional or global) in adolescent idiopathic scoliosis?

STUDY DESIGN: Cross-sectional. OBJECTIVES: To identify the regional and global apexes of curves in adolescent idiopathic scoliosis and to compare the levels of those with the most rotated vertebral levels on computed tomography scans. SUMMARY OF BACKGROUND DATA: The terminology regarding the terms and definitions had been arbitrary until being refined and standardized by the Scoliosis Research Society Working Group on Three-Dimensional Terminology of Spinal Deformity. Apical vertebra or disc is defined as the most laterally deviated vertebra or disc in a scoliosis curve, but the most rotated vertebra (or disc) has not been included in this terminology. One study suggested that the most rotated vertebral level was always located at the apex. METHODS: Thirty-three structural curves of 25 consecutive patients scheduled for surgery for thoracic or thoracolumbar scoliosis were analyzed with standing anteroposterior radiographs and computed tomography scans covering the curve apexes and pelvis. Thoracic and lumbar curves were evaluated separately for all Type II curves. Vertebral rotations were normalized by the rotation of the pelvis. The most rotated vertebral (or disc) levels (transverse apex) were compared with the regional and global apex levels (vertebra or disc) (coronal apexes) of the corresponding curves separately. RESULTS: Regional and global apexes were at the same level in 18 (54.5%) curves, and within half a level in another 15 (45.4%), and the regional apex was one level higher in two curves (95% confidence levels: -0.82, +0.88). Comparison of the most rotated levels with regional and global apex levels revealed a higher variability, extending up to two levels for the global apex (95% confidence levels: -1.19, +1.54 levels for the global and -1.0, +1.41 levels for the regional apexes). CONCLUSION: This study demonstrated that the regional or global apex of a given curve is the most rotated level in only a minority of the curves. The most rotated level may be as far as two levels from the global apex and one level from the regional apex.

Adolescent↗
PubMed2001

Patent foramen ovale and brain microembolization during scoliosis surgery in adolescents.

STUDY DESIGN: A case series is reported. OBJECTIVE: To improve understanding of the potential mechanisms associated with cerebral microemboli during scoliosis surgery in adolescents. SUMMARY OF BACKGROUND DATA: Paradoxical cerebral fat microembolization during scoliosis surgery has been associated with right-to-left shunting through an undetected patent foramen ovale. The prevalence of this cardiac defect in the adult population may be as high as 15% to 25%. Although the clinical relevance of this embolic phenomenon during scoliosis surgery has not been investigated, a few reports have documented its fatal consequences. It has been suspected in some patients with postoperative reduced visual function, particularly after complex instrumented fusions. METHODS: Bilateral transcranial Doppler (2 MHz) was used to monitor cerebral microemboli in the right and left middle cerebral arteries during spinal instrumentation and fusion in four patients. Additionally, transthoracic or transesophageal echocardiography incorporating pulse and color Doppler (3.5-5 MHz) and a contrast test was used in these patients to detect atrial shunts. RESULTS: Intraoperative transcranial Doppler monitoring detected high rates of cerebral microemboli associated with the presence of an atrial communication in two adolescents. In two additional patients with no detected brain microembolization, echocardiographic examination indicated the absence of an atrial shunt. CONCLUSION: The study findings suggest that unrecognized atrial communications in adolescents undergoing scoliosis surgery contribute to higher rates of Doppler-detected cerebral microemboli than those found in adolescents without this congenital defect.

Adolescent↗
PubMed2001

Posterior-only unit rod instrumentation and fusion for neuromuscular scoliosis.

STUDY DESIGN: A retrospective study to determine the efficacy of posterior-only unit rod instrumentation and fusion in a skeletally immature neuromuscular scoliosis population. OBJECTIVE: To determine whether the posterior-only approach to this population adequately addresses the concerns of correction of scoliosis and pelvic obliquity, maintenance of that correction over time, and the incidence of crankshaft phenomenon. SUMMARY OF BACKGROUND DATA: Controversy exists regarding the need for anterior release to improve curve flexibility and the need to obtain an anterior arthrodesis in those skeletally immature patients at risk for crankshafting with continued anterior growth. METHODS: From 1992 through 1997, 28 consecutive skeletally immature patients with neuromuscular scoliosis underwent posterior-only unit rod instrumentation and fusion for the treatment of progressive, symptomatic spinal deformities. Preoperative, immediate postoperative, and final follow-up radiographs were analyzed with respect to scoliosis and pelvic obliquity correction, maintenance of that correction over time, and the development of the crankshaft phenomenon as evidenced by loss of correction and/or increased rib-vertebral angle difference. The average age of the patients was 12.8 years and the average follow-up was 58 months with a minimum of 2 years. RESULTS: Twenty-six patients were available for final follow-up. The initial Cobb angle correction averaged 66%, with 75% of the pelvic obliquity corrected. These corrections were maintained over time. Before surgery 27 of 28 patients were Risser 0, 1, or 2. The triradiate cartilage was open in nine patients, and five patients were < or =10 years of age. At the final follow-up 22 of the 26 patients were Risser 5 and 4 were Risser 4. There was one patient with increased rib-vertebral angle difference over the length of follow-up, with no loss of frontal or sagittal plane alignment. CONCLUSIONS: These results indicate that even in the very young neuromuscular patient, acceptable amounts of curve correction can be achieved and maintained with posterior-only unit rod instrumentation and fusion. The biomechanical stiffness of this construct seemed to be able to prevent the crankshaft phenomenon in the majority of those patients at risk.

Adult↗
PubMed2001

Scoliosis and severe pelvic obliquity in a patient with cerebral palsy: surgical treatment utilizing halo-femoral traction.

STUDY DESIGN: Case report of severe scoliosis and associated pelvic obliquity in a 14-year-old patient with cerebral palsy. OBJECTIVES: To report the presentation of the case, the operative considerations, and the management of this spinal deformity. SUMMARY OF BACKGROUND DATA: Spinal deformity in cerebral palsy may include scoliosis, kyphosis, and hyperlordosis. Pelvic obliquity is a frequent feature associated with neuromuscular scoliosis. The severity of the pelvic obliquity deformity presented here is unusual, and this case study delineates an effective surgical treatment plan for these patients using intraoperative halo-femoral traction. METHODS: A same-day, two-stage surgical reconstruction was performed to effectively correct this spinal deformity. The patient underwent an anterior spinal fusion from T10 to S1 and a posterior spinal fusion from T2 to the pelvis; the posterior procedure was performed with the patient in intraoperative halo-femoral traction. Sacral fixation was obtained using the Galveston technique bilaterally. RESULTS: The patient responded well to surgical intervention, had no complications, and continues to have stable correction of his pelvic obliquity deformity 2 years after surgery. CONCLUSION: It is concluded that scoliosis with associated severe pelvic obliquity deformities can be treated with anterior and posterior spinal fusion and instrumentation with intraoperative halo-femoral traction in the properly selected and prepared patient with cerebral palsy.

Adolescent↗
PubMed2001

Geometric torsion in idiopathic scoliosis: three-dimensional analysis and proposal for a new classification.

STUDY DESIGN: Three-dimensionally reconstructed spines of 62 subjects with idiopathic scoliosis were reviewed for three-dimensional pattern classification based on the measurement of geometric torsion. OBJECTIVES: To evaluate the relevance of geometric torsion as a three-dimensional index of scoliosis, and to develop a three-dimensional classification of deformity for idiopathic scoliosis as opposed to the current classifications based on two-dimensional frontal views. SUMMARY OF BACKGROUND DATA: Attempts have been made to measure the geometric torsional shape of scoliotic curves represented curvilinearly. However, the geometric torsion phenomenon has never been properly analyzed and thus has never been precisely defined. METHODS: Standardized stereoradiographs of 62 patients with idiopathic scoliosis were obtained and used to generate three-dimensional reconstructions. A continuous parametric form of the curved line that passes through the vertebrae was created by least square fitting of Fourier series functions. Frenet's formulas then were used to calculate the geometric torsion. RESULTS: Analysis of geometric torsion associated with 94 major scoliotic curves allowed three basic categories of torsion curve patterns to be identified. Scoliotic spines with multiple major curves are described by a combination of basic torsion patterns, one for each curve. CONCLUSIONS: A three-dimensional analysis of the spine in terms of geometric torsion has defined three distinct patterns of torsion in a group of scoliotic curves. Geometric torsion had extreme values at the levels of upper and lower vertebrae, but zero or nearly zero values at the levels of the apices. The torsional phenomenon can be unidirectional or bidirectional in both single and double major curves.

Adolescent↗
PubMed2001

Transpedicular eggshell osteotomies for congenital scoliosis using frameless stereotactic guidance.

STUDY DESIGN: Three cases of multiplanar congenital scoliosis corrected by a transpedicular eggshell osteotomy using frameless stereotactic guidance are reported. OBJECTIVE: To show an alternative surgical technique for correcting and fusing complex congenital spinal curves. SUMMARY OF BACKGROUND DATA: Children with congenital scoliosis can have progressive curves causing significant multiplanar deformities. In older children, traditional approaches to spinal corrective surgery including fusion in situ, convex growth arrest, and hemivertebra excision can achieve only limited corrections. METHODS: Three older patients who had congenital scoliosis with significant multiplanar curves underwent one-stage posterior transpedicular eggshell osteotomy. Three-dimensional reconstructive images and frameless stereotactic guidance were used for preoperative selection of osteotomy levels and accurate placement of pedicle screws. After completion of the osteotomy, closure was obtained with extension of the hips. RESULTS: The average coronal correction of the major curve was 28.7 degrees (range, 22-33 degrees ). The average correction of the plumb line or lateral displacement from the center of the trunk was 4.8 cm (range, 3-7.5 cm). A significant kyphotic deformity was corrected 38 degrees, and a pelvic tilt was reduced from 7 to 3 cm. CONCLUSIONS: One-stage posterior reduction eggshell osteotomy can be used to correct a sagittal and/or coronal congenital spinal curve imbalance. Frameless stereotactic guidance for solid pedicle screw fixation was essential to the achievement of rigid spinal stabilization before arthrodesis. Transpedicular eggshell osteotomy is a technique that should be considered for older patients who have congenital scoliosis with multiplanar spinal abnormalities.

Adolescent↗
PubMed2001

Subtransverse process wiring: a new technique of segmental spinal fixation of the thoracic spine or in the treatment of adolescent idiopathic scoliosis.

STUDY DESIGN: Segmental fixation is the preferred technique for the surgical treatment of adolescent idiopathic scoliosis. Sublaminar wiring is a widely used, strong type of segmental fixation. The most common drawback of the sublaminar wiring is the risk of neurologic injury. The authors have applied subtransverse wiring for 3 years, and the technique seems promising. OBJECTIVES: To show that subtransverse wiring is a technique strong enough to correct scoliosis curves and does not carry neurologic injury risks. SUMMARY OF BACKGROUND DATA: Sublaminar wiring is a commonly used fixation method for posterior fusion in the treatment of scoliosis. Because of its associated risk of neurologic injury, it is mostly recommended for long neuromuscular curves. METHODS: The authors used the subtransverse wiring technique in 12 cases of adolescent idiopathic scoliosis and followed them for an average of 22 months. RESULTS: The average correction rate was 65%, and correction loss at the end of the follow-up period was 5 degrees. No neurologic complications were encountered. CONCLUSIONS: Subtransverse wiring is strong enough to correct scoliotic curves. It requires less operative time and skill and is neurologically safe.

Adolescent↗
PubMed2002

Does instrumented anterior scoliosis surgery lead to kyphosis, pseudarthrosis, or inadequate correction in adults?

STUDY DESIGN: Retrospective review of cases in which a single solid rod was used for the anterior correction of thoracolumbar and lumbar idiopathic scoliosis in adults. OBJECTIVES: To evaluate the efficacy and outcomes in these patients. SUMMARY OF BACKGROUND DATA: Anterior spinal fusion with instrumentation has been found to be kyphogenic in the treatment of scoliosis. Recent reports have shown an extremely high rate of pseudarthrosis and implant failure even in adolescents who have undergone anterior spinal fusion with a single flexible or rigid rod. METHODS: Fifteen consecutive adult patients with (average age, 37.5 years) had undergone anterior spinal fusion with a rigid rod were included in this study. One was lost to follow-up, leaving 14 patients with a complete radiographic follow-up of 44 months and clinical follow-up of 61 months. Patients were sent the Modified Scoliosis Research Society (SRS) Outcomes Instrument, charts were reviewed, and preoperative, postoperative, and final follow-up films of the entire spine were evaluated by independent reviewers uninvolved in the care of the patients. RESULTS: The average preoperative major curve was 50 degrees, which improved to 16 degrees at follow-up (a 66% correction). The average correction of the upper compensatory curve and lower fractional curve were 40% and 61%, respectively. The thoracolumbar sagittal plane alignment was maintained or improved in all patients (i.e., this surgery did not induce kyphosis in any patient). On average 0.9 levels were "saved" compared with levels chosen by the authors for posterior surgery. All patients achieved a solid fusion. Follow-up Modified SRS questionnaires revealed a satisfaction score 4.5 out of a possible score of 5, a pain score of 4.1 out of 5, a self-image score of 4.1 out of 5, a function score of 4.1 out of 5, and a mental health score of 4.0 out of 5, with an overall score of 82%. All patients but one were satisfied or extremely satisfied with the results of surgery. There was no incidence of implant breakage. CONCLUSIONS: The results of anterior spinal fusion using a single solid rod in adults with idiopathic scoliosis in this series are excellent, with 100% fusion rate, no development of kyphosis, and no incidence of hardware failure.

Adult↗
PubMed2002

Sagittal plane correction in idiopathic scoliosis.

STUDY DESIGN: Patients with idiopathic scoliosis who had undergone posterior fusion by means of posterior multisegmented hook instrumentation were studied retrospectively. OBJECTIVES: To present the changes in projected thoracic hypokyphosis and the behavior of lumbar lordosis within and below the fusion. SUMMARY OF BACKGROUND DATA: Scoliosis is a three-dimensional deformity of the spine. The idiopathic cases usually exhibit a flattening of the sagittal curves, which had further deteriorated when the Harrington technique was used. The consequences included the flat back, angular increase of the lumbar lordosis below the fusion, and low back pain. Previous studies showed no or only moderate correction of thoracic hypokyphosis when using Cotrel-Dubousset instrumentation or its modifications were used. Harrington rod systems resulted in decreased lumbar lordosis in the fusion area and increased lordosis below the fusion. No background data were found concerning the effects of multisegmented hook instrumentation on the lumbar spine within and below the fusion. METHODS: For this study, 306 patients with idiopathic scoliosis who had undergone posterior spinal fusion with multisegmented hook systems using the derotation maneuver were analyzed after a mean follow-up period of 5 years and 4 months. The coronal plane curvature, the sagittal plane projection of the thoracic kyphosis, and the lumbar lordosis within and below the fusion were evaluated. RESULTS: The average coronal plane correction was 67.1%. Analysis of the sagittal contours demonstrated that the preoperative thoracic hypokyphosis (less than 20 degrees between T4 and T12) increased by an average of 12 degrees, and that 55.1% of hypokyphotic backs were corrected to the normal range (20 degrees to 40 degrees ). In patients with frank lordosis (kyphosis less than 10 degrees ), the degree of correction was higher (average, 16 degrees ), but complete correction was achieved in only 38.5% of the cases. In patients with mild lordosis (kyphosis between 10 degrees and 20 degrees ), the average correction was 8 degrees, and 71.3% of the patients were in the normal range after surgery. The normal preoperative thoracic kyphosis was preserved in 81.3% of the cases. In the lumbar area, the Cotrel-Dubousset instrumentation was capable of correcting the preoperative hypolordosis (less than -20 degrees between L1 and L5) in 94.4% of the cases. The normal preoperative lordosis (-20 degrees to -60 degrees ) was preserved in 97.9% of the cases. The hyperlordosis was corrected in all cases. Analysis of the data in terms of lower fusion limit showed that the lower the caudal hook, the greater the increase in the segmental lordosis within the fusion, without any increase distal to the fusion. No segmental hyperlordosis was observed below the fusion. CONCLUSIONS: The Cotrel-Dubousset technique ensures considerable sagittal correction of the spine. In the course of scoliosis correction, it is possible to preserve the normal preoperative sagittal profile of the spine, to correct the slightly flattened thoracic kyphosis, to increase materially the kyphosis of the frankly hypokyphotic spine, to preserve or restore normal lumbar lordosis in a considerable percentage of the cases, to avoid angular segmental hyperlordosis at the level of the first disc below the fusion, and to avoid retrolisthesis of the last fused vertebra.

Adolescent↗
PubMed2002

Interobserver and intraobserver reliability of Lenke's new scoliosis classification system.

STUDY DESIGN: The assignment of idiopathic scoliosis curves to the curve types,1-6 to the lumbar spine modifier (A, B, or C), and to the sagittal thoracic modifier (-, N, +), as recently described by Lenke et al, was evaluated by five observers on two occasions. OBJECTIVE: To determine the intraobserver and interobserver reliabilities of Lenke's new system for classifying idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Lenke et al recently introduced a new system for classifying idiopathic scoliosis. METHODS: Preoperative standing long cassette coronal and sagittal radiographs as well as side-bending radiographs of 51 consecutive patients who underwent surgery for idiopathic scoliosis were labeled with the Cobb angles for all the curves. The center sacral vertical line was marked as the bisection of the proximal sacrum perpendicular to the true horizontal line. Five observers independently assigned a curve type, a lumbar spine modifier, and a sagittal thoracic modifier to each curve following the guidelines as described by Lenke et al. Assignment of the curves was repeated 3 weeks later, with the curves presented in a different order. Kappa coefficients were used to determine the interobserver and intraobserver reliabilities. RESULTS: All five reviewers agreed on the overall classification in 21 (41%) of the 51 patients. A mean kappa value of 0.62 was determined for interobserver reliability, and a mean kappa of 0.73 for intraobserver reliability. Determination of an upper thoracic curve as structural or nonstructural and assignment of a lumbar spine modifier were the main reasons for disagreement. CONCLUSIONS: Lenke's new classification system is more reliable than the older King classification, but proper classification of high thoracic and lumbar curves seems to be difficult.

Humans↗
PubMed2002

Patient and parental perception of adolescent idiopathic scoliosis before and after surgery in comparison with surface and radiographic measurements.

STUDY DESIGN: This prospective 2-year follow-up study evaluated patients treated surgically for adolescent idiopathic scoliosis (AIS). OBJECTIVE: To report parents' perception, patients' perception, and pain and disability before and after surgery and to examine their relationship to anthropometric, back surface, and radiographic measurements. SUMMARY OF BACKGROUND DATA: No longitudinal studies have examined these factors and their interrelationships. METHODS: Between 1995 and 1999, 39 AIS patients treated by anterior or posterior USS (Universal Spine System, Stratec, Oberdorf, Switzerland) instrumentation had complete prospective questionnaire, back surface, and radiographic appraisal. RESULTS: The preoperative Visual Analogue Score (VAS) for pain-predominantly mild backache-was 24 mm (range, 0-78 mm), and the Oswestry Disability Index (ODI) score was 9.2% (0-44.4%). Patients and parents wanted surgery to correct spinal curvature, stop curve progression, and correct the rib-hump (thoracic) and hip and waist asymmetry (thoracolumbar curves). The maximum angle of trunk inclination correlated with VAS and with short-form McGill Pain Questionnaire scores for thoracic curves (P = 0.005, Spearman rank correlation coefficient). Apical vertebral translation correlated with short-form McGill scores and ODI for thoracolumbar curves (P < 0.006, Spearman rank correlation coefficient). Parents rated scoliosis problems more severely than did their children (P < 0.0001, repeated measures of multivariate analysis of variants). There was no change in body image, VAS, ODI, or short-form McGill scores by 2 years' follow-up. Parents and patients perceived scoliosis problems to be less by 2 years' follow-up (P < 0.0005, Wilcoxon matched-pairs signed ranks test). The preoperative surface asymmetry score correlated with the patients' grading of their rib-hump (P = 0.007). CONCLUSIONS: Back pain incidence was higher than reported for healthy adolescents. Oswestry Disability Index was within normal adult limits. Pain varied by curve type, related to the maximum angle of trunk inclination and the maximum apical vertebral translation. After surgery, back pain and ODI were unchanged, but concerns regarding scoliosis were reduced.

Adolescent↗
PubMed2002

The use of short and rigid anterior instrumentation in the treatment of idiopathic thoracolumbar scoliosis: a retrospective review of 24 cases.

STUDY DESIGN: The results of short anterior rigid rod instrumentation used to treat thoracolumbar scoliosis in 24 patients were reviewed retrospectively. OBJECTIVE: To assess the safety and efficiency of anterior correction of thoracolumbar scoliosis using a single rigid rod with segmental fixation. SUMMARY OF BACKGROUND DATA: This method of treatment results from the historical difficulties noted in obtaining adequate correction in both planes for this particular type of curve while saving as many segments as possible. This approach seems to combine the advantages and avoid the limitations of posterior segmental and previous anterior segmental techniques. METHODS: For this study, 24 patients with thoracolumbar scoliosis underwent anterior spinal correction and fusion using a single rigid rod and segmental fixation. Additionally, in five patients, this construct was supplemented by interbody titanium cages. The patients were assessed for the amount of correction obtained in the main curve, and for the spontaneous correction of the compensatory curves above and below. Trunk balance was measured on standing radiographs. The average age of the patients was 17.3 years (range, 10-43 years), and the average follow-up period was 3.6 years (range, 2-4.5 years). RESULTS: Correction of the major curve at follow-up assessment was 54%, with a 73% correction of the instrumented area. The upper compensatory curve showed a 21% correction, and the lower curve a 59% correction. Over the duration of the follow-up period, the instrumented area showed kyphosis progression of 6.5 degrees. The five patients who had insertion of Harms cages tended to have a lower rate of correction. The average number of intervertebral mobile segments fused was 2.9 (range, 2-5 segments). No intraoperative complication occurred in relation to the anterior approach. A temporary sympathectomy effect on the side of the approach was noted in most patients. Two radiologic pseudarthrosis and one loss of fixation at the top of the construct were observed. CONCLUSIONS: Anterior correction and fusion using solid rod instrumentation constitute effective and safe treatment of thoracolumbar scoliosis. As compared with posterior systems, it provides correction and rebalance of the trunk through a shorter fusion segment.

Adolescent↗
PubMed2002

Predictors of flexibility and pain patterns in thoracolumbar and lumbar idiopathic scoliosis.

STUDY DESIGN: A retrospective evaluation of radiographs in patients with idiopathic scoliosis was undertaken to assess predictors of flexibility. OBJECTIVE: To evaluate potential predictors of flexibility in patients with thoracolumbar and lumbar scoliosis. SUMMARY OF BACKGROUND DATA: Curve flexibility is an important consideration in the operative management of idiopathic scoliosis. Flexibility of the major curve is a useful predictor of expected surgical correction, and flexibility of compensatory curves determines whether they are structural or nonstructural. An accurate assessment of curve flexibility has important implications on surgical approaches and planning for deformity correction. The role of age and curve magnitude in predicting curve flexibility has not been well defined. A quantitative assessment of changes in curve flexibility with age and progression of deformity may yield important insight into the change in surgical management options over time. METHODS: A retrospective review of 75 patients with idiopathic thoracolumbar and lumbar scoliosis (age range 13-78 years) was undertaken. Preoperative standing and side-bending radiographs of thoracolumbar and lumbar curves were evaluated. Cobb angles of structural and fractional curves, curve flexibility, presence of lateral listhesis, and axial and radicular pain were documented. Predictors of structural and fractional curve flexibility were evaluated with correlation and regression analysis. Correlation analysis was used to demonstrate an association between radiographic findings and the clinical presentation. RESULTS: Seventy-five patients had an average major curve magnitude of 56 degrees (range 34-82 degrees ) with flexibility averaging 55% (range 20-93%). Structural curve flexibility was highly inversely correlated with both curve magnitude (r = -0.7; P< 0.001) and with age (r = -0.6; P< 0.001). Lumbar fractional curve (L4-S1) flexibility showed a high inverse correlation with age (r = -0.65; P< 0.001) but did not show correlation with Cobb angle. Thoracic compensatory curves showed a moderate correlation with Cobb angle (r = 0.53). Structural and fractional curve flexibility showed high correlation with each other (r = 0.5-0.66). Regression analysis yielded a formula to predict the flexibility of the structural curve (FSC): FSC = 130 - (Cobb + Age/2). Axial pain was correlated with age (r = 0.63); however, it was not correlated with curve magnitude. CONCLUSION: We have shown that curve magnitude and patient age are the main predictors of structural flexibility. Every 10 degrees increase in curve magnitude over 40 degrees results in a 10% decrease in flexibility; every 10-year increase in age decreases flexibility of the structural curve by 5% and the lumbosacral fractional curve by 10%. Curve magnitude and age of the patients are significant predictors of curve flexibility. The demonstration of this association offers useful information in estimating how surgical options for deformity correction may change over time.

Adolescent↗
PubMed2002

Sagittal plane analysis of adolescent idiopathic scoliosis: the effect of anterior versus posterior instrumentation.

STUDY DESIGN: Radiographic analysis of anterior and posterior instrumentation for adolescent idiopathic scoliosis. OBJECTIVES: To compare effects of anterior versus posterior instrumentation on sagittal plane parameters. SUMMARY OF BACKGROUND DATA: The sagittal plane is critical to the long-term success of scoliosis surgery, but few studies have compared the effect of anterior versus posterior instrumentation. METHODS: Standing, full spine lateral radiographs of 110 consecutive patients (mean age 14 years) who had surgery for adolescent idiopathic scoliosis between 1996 and 1998 at one institution with a minimum 24-month (mean 32 months) follow-up were evaluated. Fifty patients were instrumented anteriorly with single screw-rod constructs. Sixty patients were instrumented posteriorly with segmental implants (5.5 mm; hooks, wires, and/or pedicle screws). RESULTS: At the final follow-up, the proximal junctional measurement (measured between the proximal instrumented vertebra and the segment two levels cephalad) increased most with posterior instrumentation (+7 degrees increase for posterior thoracic +1 degrees increase for anterior thoracic instrumentation, P= 0.02; +9 degrees increase for posterior thoracic and lumbar instrumentation vs. +4 degrees for anterior thoracolumbar instrumentation, P= 0.03). Thoracic kyphosis (T5-T12) increased significantly with anterior versus posterior thoracic instrumentation (+4 degrees vs. -2 degrees change, P= 0.04). Lumbar lordosis (T12-S1) was enhanced with either anterior or posterior instrumentation. No significant changes in distal junctional measurement (measured between the distal instrumented vertebra and the segment two levels caudal) were noted. The C7 sagittal plumbline remained negative in all groups at the final follow-up. CONCLUSION: Anterior and posterior instrumentation had differential effects on the sagittal plane in patients with adolescent idiopathic scoliosis. However, the overall magnitude of the differences was small. Properly performed, both approaches can result in acceptable sagittal profiles.

Adolescent↗
PubMed2002

Association between estrogen receptor gene polymorphisms and curve severity of idiopathic scoliosis.

STUDY DESIGN: Analysis of the estrogen receptor gene of girls with idiopathic scoliosis. OBJECTIVES: To determine whether estrogen receptor gene polymorphisms correlate with curve severity of adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Studies suggest that idiopathic scoliosis is a familial condition and that curve progression is related to genetically determined factors, such as skeletal and sexual growth. METHODS: A total of 304 girls with idiopathic scoliosis were followed until growth maturation. Height, arm span, menarcheal age, and age at growth maturation were recorded, and curve severity was measured using Cobb's method. The estrogen receptor gene, which contains polymorphic PvuII and XbaI sites, was amplified from lymphocyte deoxyribonucleic acid by polymerase chain reaction. RESULTS: The mean maximum Cobb measurements for patients with genotypes XX and Xx were greater than for those with genotype xx (P = 0.002). The risk of curve progression, defined as progression of >5 degrees from initial evaluation, was higher with genotype Xx than with xx (P = 0.03). Patients with genotypes XX and Xx had a significantly higher risk for operative treatment than those with genotype xx (21.4%, 24.7% vs. 7.6%, P< 0.001). Growth examination around the time of the growth spurt revealed that the XbaI site polymorphism was also related to the age of growth maturation. The frequency of patients with growth maturation at >or=16 years was higher for genotypes XX and Xx than for genotype xx (33.3%, 29.9% vs. 16.8%, P= 0.013). CONCLUSION: Our results suggest that the XbaI site polymorphism is associated with curve severity. DNA analysis may predict curve progression.

Adolescent↗