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PubMed2004

The posterior approach for lumbar and thoracolumbar adolescent idiopathic scoliosis: posterior shortening and pedicle screws.

STUDY DESIGN: Prospective clinical case series. BACKGROUND DATA: Lumbar and thoracolumbar adolescent idiopathic scoliosis has traditionally been treated with an anterior approach and instrumentation. This anterior method often has had problems with kyphosis, pseudarthrosis, and loss of correction. The senior author has had good results treating these same lumbar and thoracolumbar curves posteriorly with wide posterior release and segmental instrumentation. In this series of his evolving technique, he adds pedicle screws as the sole anchor in the thoracolumbar/lumbar curves. OBJECTIVES: To prospectively evaluate outcomes, coronal and sagittal radiographic results, balance parameters, complications, and reoperations in a group of consecutive patients with lumbar and thoracolumbar adolescent idiopathic scoliosis. These patients were surgically treated with wide posterior release and segmental posterior screw instrumentation with 2-year minimum follow-up (range 26-47 months). METHODS: Sixty-two consecutive patients with thoracolumbar and lumbar adolescent idiopathic scoliosis were treated with a wide posterior release and segmental pedicle screw instrumentation limited to the curve defined by the Cobb measurement. The patients were evaluated clinically and radiographically at intervals up to 36 months. There was 2-year minimum follow-up. RESULTS: One patient was lost to follow-up. Of the remaining 61 patients, there were 51 Lenke 5 Type curves, 7 Lenke Type 3C curves, and 3 Lenke Type 6 curves. Only the curve defined by the Cobb measurement was fused. A total of 613 pedicle screws were placed safely. Average coronal correction of the thoracolumbar/lumbar curves was from 52 degrees to 10 degrees (80%). In the sagittal plane, lumbar lordosis was normalized from 41 degrees with a wide range (20 degrees -70 degrees ) to 42 degrees with a normal range (34 degrees -47 degrees ). There were no pseudoarthroses, no reoperations, no infections, no problems with screw placement, and excellent maintenance of correction at last follow-up. The lowest instrumented vertebrae had 81% correction of coronal angulation, center sacral line to lowest instrumented vertebrae was improved from 2.4 cm to 0.7 cm, and apex to center sacral line was improved from 5.2 cm to 1.5 cm. The C7 plumb line to center sacral line was also improved from 2.5 cm to 0.6 cm, illustrating the centering of the trunk. CONCLUSIONS: Wide posterior release and segmental pedicle screw instrumentation has excellent radiographic and clinical results with minimal complications. There were no pseudoarthroses and no reoperations.

Adolescent↗
PubMed2004

Predictors of progression of scoliosis after decompression of an Arnold Chiari I malformation.

STUDY DESIGN: Retrospective study of patients with scoliosis and an Arnold Chiari I malformation requiring operative management. OBJECTIVES: Determine the factors that could predict whether a particular spinal deformity might progress despite neurosurgical management of Arnold Chiari I malformation. SUMMARY OF BACKGROUND DATA: Few studies have documented the relationship between diagnosis and treatment of Arnold Chiari I malformation and associated spinal deformities. Most studies mix neural axis abnormalities and contain limited information about the spinal deformity. METHODS: Medical records, radiographs, and magnetic resonance images of patients were evaluated focusing on age and findings at presentation, characteristics of presenting and follow-up spinal deformities, and the specifics of neurosurgical and orthopedic management. Patients were divided into two groups: those whose curves progressed >10 degrees or to surgical range (largest curve >45 degrees ) after neurosurgical intervention (progressors) and those whose curves stabilized or decreased (nonprogressors). RESULTS: Eight progressors presented at an average age of 11.4 years (range 2-19) and were followed for 6.3 years (range 2-15). Seven nonprogressors presented at 6.5 years of age (range 5-10) and were followed for 6.6 years (range 3.5-14). Neurosurgical procedures were equivalent in both groups; however, surgical revisions were required in 3 out of 8 progressors and 1 out of 7 nonprogressors. All progressors had a double scoliosis curve; but only one nonprogressor had a double curve. Six out of 8 progressors and 0 out of 7 nonprogressors had a rotation >or=2+ and 50% of progressors had a thoracic kyphosis >50 degrees compared to 1 out of 7 nonprogressors. CONCLUSIONS: In this series, progression of spinal deformity after neurosurgical management of Arnold Chiari I malformation was associated with later age at neurosurgical decompressions and initial neurologic symptoms, double scoliosis curve patterns, kyphosis, rotation, and larger curve at presentation.

Adolescent↗
PubMed2004

Direct vertebral rotation: a new technique of three-dimensional deformity correction with segmental pedicle screw fixation in adolescent idiopathic scoliosis.

STUDY DESIGN: A prospective study. OBJECTIVES: To introduce a new technique, direct vertebral rotation, and to compare the surgical results of direct vertebral rotation with those of simple rod derotation. SUMMARY OF BACKGROUND DATA: Pedicle screw fixation with a simple rod derotation maneuver enables a powerful coronal and sagittal plane correction in scoliosis surgery. However, the ability of achieving rotational correction is still unclear. METHODS: Thirty-eight adolescent idiopathic scoliosis patients treated with segmental pedicle screw fixation were analyzed. The first group (n = 17) was treated by direct vertebral rotation; the second group (n = 21) was treated by simple rod derotation. All patients had a minimum follow-up of 2 years. Having similar preoperative curve patterns, both groups were evaluated for the deformity correction, lower instrumented vertebral tilt, and spinal balance. Apical vertebral rotation was evaluated by computed tomography scans. Surgical techniques of direct vertebral rotation were as follows: a precontoured rod was inserted into segmental screws on the concave side in thoracic scoliosis; a simple rod derotation was performed; and then the screws on the juxta-apical vertebrae, both on concave and convex sides, were rotated opposite direction to the rod derotation. Then, all the screws were sequentially tightened. RESULTS: In the direct vertebral rotation group, the average preoperative apical vertebral rotation of 16.7 degrees was corrected to 9.6 degrees, showing 42.5% correction, whereas in the simple rod derotation group, the correction was negligible from 16.1 degrees to 15.7 degrees (2.4%). In the direct vertebral rotation group, the average preoperative thoracic curve of 55 degrees was corrected to 12 degrees (79.6%), and the lumbar curve of 39 degrees was corrected to 7 degrees (80.5%). In the simple rod derotation group, the preoperative thoracic curve of 53 degrees was corrected to 17 degrees (68.9%), and the lumbar curve of 39 degrees was corrected to 16 degrees (62.2%). The average lower instrumented vertebral tilt correction was 80.6% and 66.3% in the directvertebral rotation and the simple rod derotation group, respectively. There were statistically significant differences in the coronal curve, lower instrumented vertebral tilt, and rotational correction (P < 0.05, Mann-Whitney U test). Thoracic kyphosis was improved in both groups. CONCLUSIONS: Segmental pedicle screw fixation with "direct vertebral rotation" showed better rotational and coronal correction than "simple rod derotation."

Adolescent↗
PubMed2004

Selective thoracic fusion for adolescent idiopathic scoliosis with C modifier lumbar curves: 2- to 16-year radiographic and clinical results.

STUDY DESIGN: Retrospective clinical and radiographic review with functional outcome assessment. OBJECTIVES: To evaluate outcome of selective thoracic fusion for adolescent idiopathic scoliosis in the presence of widely deviated compensatory lumbar curves. SUMMARY OF BACKGROUND DATA: Previous reports on the results of selective thoracic scoliosis fusion have not specifically focused on deformities with widely deviated lumbar curves. Whether these challenging deformities are best treated with selective thoracic fusion or fusion of both curves remains unclear. METHODS: Forty-four consecutive patients with adolescent idiopathic scoliosis with main thoracic, compensatory minor lumbar "C" modifier curves underwent selective thoracic fusion at a single institution (1987-2000). Radiographs were analyzed before surgery, at 1 week, 2 years, and latest follow-up (2-16 years; mean 5.0 years). RESULTS: A mean 36% thoracic correction was closely matched by a 34% lumbar correction at latest follow-up. A majority of spontaneous lumbar correction occurred at its cephalad segments (P = 0.001). Spontaneous correction of lumbar apical translation occurred in a majority of patients (prognostic factors identified). Global coronal imbalance (2-5 cm) was common before surgery and was a significant risk factor (P = 0.04) for global imbalance at latest follow-up. Postoperative bracing was not utilized, and there were no reoperations. Patients with coronal imbalance (2-5 cm) at latest follow-up had slightly inferior SRS-24 results. CONCLUSIONS: Satisfactory results are achieved with selective thoracic fusion of properly selected C modifier lumbar curves. Correction of the lumbar curve results principally from a decrease in the tilt of its upper vertebrae, but not necessarily improved apical translation. Mild coronal imbalance was well tolerated and has not necessitated distal extension of the fusion.

Adolescent↗
PubMed2004

Late complications of adult idiopathic scoliosis primary fusions to L4 and above: the effect of age and distal fusion level.

UNLABELLED: STUDY DESIGN A retrospective analysis of primary cases of adult idiopathic scoliosis treated with long instrumented fusions from the thoracic spine proximally to segments that range from T11 to L4 distally. OBJECTIVE: To analyze whether patients requiring revision surgery had lower postoperative SRS-24 scores; age >or=40 years correlated with higher rates of revision surgery; disc degeneration below the fusion occurred more commonly with a more distal lowest instrumented vertebra or older patient age (>or=40 years); and whether smokers had higher rates of major complications or revision surgery. SUMMARY OF BACKGROUND DATA: Few reports describe complications related to primary long fusions using modern 2+ rods, hook/pedicle screw instrumentation methods in the treatment of adult idiopathic scoliosis. METHODS: Sixty-seven patients were analyzed with an average age of 38.8 years (range 21-61 years). The average clinical follow-up was 7.8 years (range 2-16 years): 42 patients had >5 years follow-up, including 23 patients with >10 years follow-up. Patients were categorized by age (< or >or=40 years) and level of the lowest instrumented vertebra (T11-L2 vs. L3-L4). Upright radiographs and postoperative SRS-24 questionnaires from the latest follow-up date were analyzed. RESULTS: Patients requiring revision surgery had lower total score (average 72.0) than those that did not (total score = 94.2; P = 0.01). More specifically, patients with pseudarthrosis had lower total scores (average 74.7) than those without (average total score = 93.5; P = 0.02). When analyzing age, there were similar rates of pseudarthrosis, but higher rates of transition syndrome (2) and sagittal/coronal imbalance (1 each) in patients >or=40 years. Subsequent distal disc degeneration did not correlate significantly with more distal lowest instrumented vertebra or older patient age. Smokers did not have higher rates of major complications or revision surgery than nonsmokers. CONCLUSIONS: Patients with adult idiopathic scoliosis and long fusions had similar pseudarthrosis rates, but higher rates of transition syndrome when lowest instrumented vertebra was L3-L4 relative to levels T11-L2. When categorized by age, complication rates were similar in each group. Patients with pseudarthroses or other diagnoses requiring revision surgery had lower SRS-24 total scores than those without (P = 0.02 and P = 0.01, respectively).

Adult↗
PubMed2004

Use of the Rosenberger brace in the treatment of progressive adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: To evaluate the efficacy of the Rosenberger thoracic lumbar sacral orthosis in preventing curve progression in adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Radiographic outcomes of patients using the Rosenberger thoracic lumbar sacral orthosis have never been reported in the literature, but reports of other thoracic lumbar sacral orthoses conflict concerning the ability braces to improve on the natural history of adolescent idiopathic scoliosis. METHODS: Seventy-one patients with progressive adolescent idiopathic scoliosis treated with the Rosenberger were evaluated at an average of 2.3 years following brace discontinuation. Initial curves averaged 29 degrees. Braces were prescribed for 16 to 20 hours per day and worn for an average of 3.2 years. Patients were between 9 and 16 years of age, and all were skeletally immature at the time of bracing. RESULTS: Twenty-one patients (30%) underwent instrumentation and arthrodesis despite bracing. Forty (56%) had more than 5 degrees of progression. Overall, 43 (61%) had surgery and/or progressed by the time of follow-up. The average curve correction was 33% in patients who did not have surgery and 21% in those patients who did (P < 0.04). Other significant factors associated with brace failure included absence of menarche before treatment, younger age at presentation and initial bracing, increased apical rotation of the primary curve at presentation, and a thoracic curve pattern. CONCLUSIONS: The Rosenberger brace demonstrated an overall failure rate similar to untreated rates from published natural history studies, although subgroups of patients had lower failure rates. These findings suggest the need for further refinement of the indications for the Rosenberger brace.

Adolescent↗
PubMed2004

Traction radiography performed under general anesthetic: a new technique for assessing idiopathic scoliosis curves.

STUDY DESIGN: A prospective review of 24 patients with late-onset idiopathic scoliosis. OBJECTIVES.: To compare curve flexibility measured using supine bending radiography and traction radiography; to examine the correlation of each technique with postoperative correction; and to determine the influence of each technique on the decision to perform concomitant anterior release surgery with posterior instrumentation. SUMMARY OF BACKGROUND DATA: Assessment of curve flexibility is important in decision making before surgical correction of scoliosis. Supine bending radiographs are presently the gold standard technique by which flexibility is assessed, but their reliability has been questioned. No literature has shown a conclusively superior role for traction radiography in assessing idiopathic scoliosis curves. METHODS: Each patient had erect anteroposterior radiographs and supine bending radiographs. On the day of surgery, traction radiography was performed under general anesthetic. The correction obtained in the Cobb angle between the bending and traction radiographs was compared. The influence of the traction radiography on the decision for anterior release surgery and its correlation with postoperative result was examined. RESULTS: Traction radiography demonstrated significantly greater curve flexibility than supine bending radiographs (P < 0.001). Eleven of 13 patients planned for anterior release surgery and posterior instrumentation avoided anterior release after review of the traction radiography. No significant difference was demonstrated between the traction radiography and postoperative correction (P = 0.13). CONCLUSION: Traction radiography is superior to supine bending radiography in assessing curve mobility before surgery. This method benefits patients by allowing them to avoid anterior release surgery and helps predict postoperative correction.

Adolescent↗
PubMed2004

New technique in congenital scoliosis involving fixation to the pelvis after hemivertebra excision.

STUDY DESIGN: The authors conducted a retrospective study involving description of a new surgical technique. OBJECTIVES: The objective of this study was to describe and evaluate the efficacy of a new technique to stabilize the spine of young and small patients with congenital scoliosis after lumbosacral hemivertebra excision. SUMMARY OF BACKGROUND DATA: Congenital scoliosis develops as the result of anomalous vertebral development and asymmetric growth. The vertebral anomalies include congenital fusions and congenital hemivertebrae. With lumbosacral hemivertebrae at the lumbosacral junction, surgical excision followed by instrumentation to close the resulting space is frequently the best way to correct the deformity and obtain spinal balance. Surgical stabilization is required for preventing recurrent deformity and restoration of spinal balance. METHODS: A new surgical technique for spinal correction and stabilization in congenital scoliosis is described. The technique involves hemivertebra excision followed by fixation of the adjacent normal vertebra to the ilium with screws and cables. This technique allows efficient correction in both the coronal and sagittal planes. RESULTS: This construct was prospectively studied in 3 cases over a 3- to 5(1/2)-year period. All cases had solid fusion and well-balanced spine at latest follow up. CONCLUSIONS: This prospective study demonstrates a successful surgical technique for spinal stabilization after congenital hemivertebra excision in infants and young children with relatively small and soft bones when standard constructs like pedicle screws may not be optimal devices. Coronal and sagittal balance (restoration with improvement of lordosis) was successfully achieved in all cases.

Child↗
PubMed2005

Growth and curve stabilization in girls with adolescent idiopathic scoliosis.

STUDY DESIGN: A retrospective study of a cohort of 132 girls with adolescent idiopathic scoliosis (AIS). OBJECTIVES: Evaluate the changes in height and scoliosis angle over time by the use of a mathematical model and determine a relationship between height and angle values in patients with AIS. SUMMARY OF BACKGROUND DATA: The influence of growth on idiopathic scoliosis (IS) is still not fully understood. Although it has not been completely demonstrated, it is accepted that a relationship exists between height growth and curve progression, as well as that curve stabilization occurs when growth ends, but it has not yet been demonstrated whether both occur at the same time. METHOD: One hundred thirty-two girls were included in a retrospective study. Inclusion criteria were: adolescent IS, Cobb angle > or =10 degrees , menarche age well documented, and follow-up of at least 2 years in 6-month controls. Main variables were: menarche age, height, Cobb angle, and treatment. Height and angle changes over the time were adjusted by several curvilinear regression models. Calculations were made of the gradient between each consecutive time point (first derivative function). Growth was considered as tending to stabilize when the function gradient changed its sign or was negligible. Height and Cobb angle correlation coefficients for repeated measures were estimated within patients for curves managed with observation and curves managed with a brace. Comparisons among these correlations were based on the Fisher-Z transformation. RESULTS: Height function gradient changed sign at 1 year postmenarche, and Cobb angle function gradient was negligible around menarche. There was a correlation between mean heights and mean angles, being higher for girls managed only with observation. When comparing mean heights in one semester with the mean heights of the previous one, there were statistically significant differences until 2.5 years postmenarche, although after the first year, these differences were clinically irrelevant. A significant increase for angle values was observed in the same period for the group of girls managed with observation and in the 6 months before menarche for the girls managed with a brace. CONCLUSIONS: A mathematical model was used to demonstrate when height and angle growths tend to stabilize (1 year after menarche for height values and at the time of menarche for angle values) in AIS. In the absence of a brace effect, a significant correlation between both growth rates was noted up until 2.5 years after menarche.

Adolescent↗
PubMed2005

Reliability analysis for manual adolescent idiopathic scoliosis measurements.

STUDY DESIGN: Manual radiographic measurement analysis. OBJECTIVES: To determine the intraobserver and interobserver reliability of numerous radiographic process measures used in the assessment of adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Analysis of scoliosis requires a thorough radiographic evaluation to completely assess the deformity. Numerous radiographic process measures have been studied extensively and used for outcomes assessment and thus become the de facto standard of care. However, many of these measures have not been evaluated to determine the reliability and reproducibility. Validation of radiographic process measures is necessary to compare these measures with patient-focused outcome measures, as well as to permit valid comparison of different surgical techniques. METHODS: Thirty complete sets of long-cassette scoliosis radiographs (anteroposterior [AP], lateral and side-bending preoperative and AP, and lateral postoperative) were analyzed by three independent experienced observers on two separate occasions. Coronal image measures included the coronal Cobb angles, side-bending Cobb, apical vertebral translation, coronal balance, T1 tilt, lowest instrumented vertebrae (LIV) tilt, angulation of the disc below the LIV, apical vertebral rotation (Nash-Moe),and Risser sign; sagittal measures included T2-T5, T5-T12, T2-T12, T10-L2, T12-S1, and sagittal balance. Intraobserver and interobserver reliability for each measure was then assessed. RESULTS: The vast majority of the radiographic process measures assessed demonstrated good to excellent or excellent intraobserver and interobserver reliability. However, the angulation of the disc below the LIV demonstrated only fair interobserver reliability for postoperative measurements (rho = 0.59). Likewise, Risser grade measurements reflected good intraobserver (0.81-0.99) but only fair interobserver reliability (0.60-0.70). Apical vertebral rotation assessed by the technique of Nash and Moe produced good intraobserver reliability before surgery (0.74-0.85) but only fair reliability after surgery (0.50-0.85). The interobserver reliability for apical Nash-Moe rotation was fair to poor (0.53-0.59). For T2-T5 regional kyphosis, intraobserver (0.22-0.83) and interobserver (0.33-0.47) reliability was generally poor. Overall, the reliability of postoperative measurements tended to be decreased relative to preoperative values, likely due to instrumentation overlying radiographic landmarks. CONCLUSIONS: Most of the radiographic process measures evaluated in this study demonstrated good or excellent reliability. The reliability of measuring the angulation of the disc below the LIV, the apical Nash-Moe rotation, and Risser grading was decreased relative to other measures. The reliability of measuring T2-T5 regional kyphosis was disappointing and poor. With regards to the other 13 measures assessed, our findings support the use of these process measures obtained by experienced deformity surgeons via manual measurement for routine clinical and academic purposes.

Adolescent↗
PubMed2005

Perioperative halo-gravity traction in the treatment of severe scoliosis and kyphosis.

STUDY DESIGN: A retrospective analysis of patients that underwent perioperative halo-gravity traction as an adjunct to modern instrumentation methods in the treatment of severe scoliosis and kyphosis. OBJECTIVE: To review the clinical and radiographic results of perioperative halo-gravity traction in several time periods. SUMMARY OF BACKGROUND DATA: Few reports to our knowledge review the use of perioperative and intraoperative halo-gravity traction in this patient population. METHODS: A total of 33 patients with severe operative scoliosis, kyphoscoliosis, or kyphosis were studied based on hospital records, standing pretreatment, traction (before anterior/posterior fusion), postoperative (each stage), and final radiographs. Patients were analyzed by age at date of examination (range, 2-20 years; mean, 13.8 years), gender (18 male, 15 female), major coronal curve magnitude (range, 22 degrees-158 degrees; average, 84 degrees), major compensatory coronal curve magnitude (range, 8 degrees-123 degrees; average, 51 degrees), major sagittal curve magnitude (range, 13 degrees-143 degrees; average, 78 degrees), traction protocol, and procedure type. Halo-traction-related, short- and long-term complications were noted in each case. RESULTS: The major coronal curve reduced 38 degrees or 46% after posterior spinal fusion compared to pretreatment radiographs. At an average of 44 months radiographic follow-up (range, 24-107 months), the loss of correction averaged 7 degrees for major coronal curves and 4 degrees of thoracic kyphosis. Clinical complications were noted in the perioperative and long-term time periods. CONCLUSIONS: The treatment of severe scoliosis can be very challenging despite the benefits of modern instrumentation methods, especially if there is a significant kyphosis or a history of intraspinal pathology. Halo-gravity traction is a safe, well-tolerated method of applying gradual, sustained traction to maximize postoperative correction in this difficult population. There were no permanent neurologic deficits in this series.

Adolescent↗
PubMed2005

Validity of the Spanish version of the Scoliosis Research Society-22 (SRS-22) Patient Questionnaire.

STUDY DESIGN: A cross-sectional multicenter study was performed to validate the Spanish version of the Scoliosis Research Society-22 (SRS-22) Patient Questionnaire. OBJECTIVES: To determine the construct validity and convergent validity of the instrument. METHODS: The Spanish version of the SRS-22 was given to 175 patients with scoliosis (mean age, 19 years old and 86% women). A subgroup of 31 patients also received the Quality of Life for Spine Deformities Profile (QLSDP). Construct validity was studied by factor analysis. Discriminant validity was assessed analyzing the relation between SRS-22 scores and the variables of deformity severity. Convergent validity as related to the QLSDP was studied with a multitrait-multimethod matrix analysis. RESULTS: Factor analysis offered a solution of four factors coherent with the dimensions of the original instrument. SRS-22 scores were worse in older patients (r = -0.34); patients using analgesics demonstrated lower scores (P < 0.001). Patients treated with a brace had a poorer self-image and were less satisfied with their treatment (P < 0.001) than the other treatment groups. Angular improvement of the curves was associated with better self-image scores (r = 0.34). The SRS-22 and QLSDP demonstrated high correlation coefficients in the convergent validity tests (r = 0.84). CONCLUSION: The Spanish version of the SRS-22 is valid. It has a factorial structure similar to that of the original questionnaire. Moreover, it relates to known severity characteristics of the disease, distinguishes among scoliosis patient groups, and shows concordant values with another valid instrument for measuring self-perceived health.

Adult↗
PubMed2005

Correlation of radiographic parameters and clinical symptoms in adult scoliosis.

STUDY DESIGN: This study is a retrospective review of the initial enrollment data from a prospective multicentered study of adult spinal deformity. OBJECTIVES: The purpose of this study is to correlate radiographic measures of deformity with patient-based outcome measures in adult scoliosis. SUMMARY OF BACKGROUND DATA: Prior studies of adult scoliosis have attempted to correlate radiographic appearance and clinical symptoms, but it has proven difficult to predict health status based on radiographic measures of deformity alone. The ability to correlate radiographic measures of deformity with symptoms would be useful for decision-making and surgical planning. METHODS: The study correlates radiographic measures of deformity with scores on the Short Form-12, Scoliosis Research Society-29, and Oswestry profiles. Radiographic evaluation was performed according to an established positioning protocol for anteroposterior and lateral 36-inch standing radiographs. Radiographic parameters studied were curve type, curve location, curve magnitude, coronal balance, sagittal balance, apical rotation, and rotatory subluxation. RESULTS: The 298 patients studied include 172 with no prior surgery and 126 who had undergone prior spine fusion. Positive sagittal balance was the most reliable predictor of clinical symptoms in both patient groups. Thoracolumbar and lumbar curves generated less favorable scores than thoracic curves in both patient groups. Significant coronal imbalance of greater than 4 cm was associated with deterioration in pain and function scores for unoperated patients but not in patients with previous surgery. CONCLUSIONS: This study suggests that restoration of a more normal sagittal balance is the critical goal for any reconstructive spine surgery. The study suggests that magnitude of coronal deformity and extent of coronal correction are less critical parameters.

Adolescent↗
PubMed2005

Center of gravity and radiographic posture analysis: a preliminary review of adult volunteers and adult patients affected by scoliosis.

STUDY DESIGN: This is a prospective radiographic and force plate analysis involving adult volunteer and patients with scoliosis. OBJECTIVE: To assess accurately the center of pressure in standing volunteers and patients with scoliosis, and correlate these finding with radiographic data. SUMMARY OF BACKGROUND DATA: A simple and commonly applied parameter of global balance is the plumbline offset. This radiographic measurement refers to the center of C2 (or C7) drawn vertically downward. Although this measurement is simple, it may not accurately reflect the balance of the spine. METHODS: This study included adult volunteers (n = 41) and patients with scoliosis (n = 45). Full-length, freestanding spine radiographs were obtained with subjects on a force plate. Simultaneous assessment of the radiologic spinal posture and the floor projection of the center of pressure (gravity line) was possible. The latter was projected on the full spine images and correlated to common radiographic parameters. RESULTS: The position of the gravity line differed significantly from the plumbline in frontal and sagittal planes (P < 0.001). This difference was maintained in both study populations. The mean frontal plane alignment of the gravity line was consistently to the right of the plumbline. The mean sagittal plane alignment of the gravity in relation to the plumbline revealed an offset anteriorly. CONCLUSIONS: The data analysis of offsets between the gravity line and radiographic parameters revealed a frontal plane mean displacement of the gravity line to the right. In the sagittal plane, a highly significant lack of correlation between the gravity line and plumbline was noted. The plumbline represents a common and convenient visual display of apparent sagittal plane imbalance, but its value as a marker of true postural balance must be questioned.

Adult↗
PubMed2005

Reliability of end, neutral, and stable vertebrae identification in adolescent idiopathic scoliosis.

STUDY DESIGN: Analysis of radiographic interpretation and vertebral level identification. OBJECTIVES: To assess the intra- and interobserver reliability by observer training level used for selecting the end vertebra (EV), neutral vertebra (NV), and stable vertebra (SV) in adolescent idiopathic scoliosis patients. SUMMARY OF BACKGROUND DATA: Various radiographic and clinical factors are important in surgical planning. For adolescent idiopathic scoliosis, an analysis of the end, neutral, and stable vertebrae are of paramount importance for understanding spinal deformity management and determining the distal fusion level. Additionally, the development and comparison of optimal surgical techniques requires reliable, reproducible radiographic parameters. METHODS: One hundred consecutive radiographs of operative cases of adolescent idiopathic scoliosis were evaluated on three separate occasions by three surgeons (2700 data points) at various levels of training (fellowship-trained spine surgeon, fellow in-training, orthopedic surgery resident). For each iteration, the observers attempted to identify the distal structural Cobb curve EV, NV, and SV. The radiographs included preselected Lenke type 1, 3, and 5 curves in random order. The average main thoracic curve was 53 degrees (range, 30-82 degrees) with a T8-T9 average apex, whereas the average thoracolumbar curve was 33 degrees (range, 18-65 degrees). Intra- and interobserver reliability was assessed by means of Cohen's Kappa correlation coefficient, and raw percentages of agreement were recorded. RESULTS: Intraobserver reliability was good to excellent for determining the EV (kappaa = 0.69-0.88), good for determining the NV (kappaa = 0.65-0.73), and good to excellent for determining the SV (kappaa = 0.74-0.91) with 83.5, 72.2, and 85.6% intraobserver agreement, respectively. A trend was noted towards greater intraobserver reliability with increasing levels of observer experience. Interobserver reliability was poor (kappaa = 0.26-0.39) for each vertebral level, with interobserver agreement for only 48.7% of EV, 41.7% of NV, and 51.0% of SV. However, interobserver agreement increased significantly when concurrence within one vertebral level was assessed, with 91, 73, and 76% agreement for identifying the EV, NV, and SV, respectively. CONCLUSIONS: Radiographic determination of the EV, NV, and SV demonstrated good to excellent intraobserver, but poor interobserver, reliability. Interobserver agreement was fair to good when concurrence within one adjacent level was assessed. Observer experience level may be a factor. The difficulties in identifying these vertebral levels represent a potential obstacle to reproducible patient-specific fusion level determination and to the optimization and uniformity of patient care.

Adolescent↗
PubMed2005

Long-term results of Schollner costoplasty in patients with idiopathic scoliosis.

STUDY DESIGN: A retrospective analysis of patients with idiopathic scoliosis treated with Schollner costoplasty. OBJECTIVE: To evaluate the long-term effects of Schollner costoplasty on rib hump and respiratory function SUMMARY BACKGROUND DATA: Costoplasty is an established technique to improve chest wall deformity in patients with scoliosis. Concerns have been raised of the long-term effects of costoplasty on respiratory function in adults. No long-term studies of this procedure exist. METHODS: A total of 25 patients with idiopathic scoliosis rib hump deformity underwent Schollner costoplasty. There were 12 patients who underwent surgery on the convexity alone, and 13 underwent additional "concave surgery" (6 Silastic [Dow Corning Corp., Midland, MI] implants, 7 concave lengthenings). Five patients underwent simultaneous spinal arthrodesis. The remaining patients underwent delayed procedures (0.4 -19 years) following the index operation. Vital capacity (VC) and rib hump were measured before and after surgery, and at each attendance thereafter. RESULTS: Mean follow-up was 10.8 years. Average reduction in rib hump was 38 mm at 6 months and 29 mm at long-term. There was no significant difference in the preoperative and long-term VC (P = 0.4), although at 6 months after surgery, there was a significant reduction in VC of 5.1%(P = 0.03). Subgroup analysis (convex only, concave lengthening, concave Silastic) revealed a similar pattern for rib hump correction and maintenance of VC in the long-term for each group. There was no significant difference between adults and adolescents in terms of both the reduction in rib hump and the VC (P = 0.2 and 0.3) CONCLUSIONS: Rib hump correction and lung function are preserved in the long-term following Schollner costoplasty in both adults and adolescents.

Adolescent↗
PubMed2005

Radiographic outcomes of anterior spinal fusion versus posterior spinal fusion with thoracic pedicle screws for treatment of Lenke Type I adolescent idiopathic scoliosis curves.

STUDY DESIGN: Analysis of radiographic outcomes following surgical correction of scoliosis. OBJECTIVES: To compare the curve correction and derotation following anterior spinal fusion (ASF) versus posterior spinal fusion (PSF) with thoracic pedicle screws. SUMMARY OF BACKGROUND DATA: The benefits of ASF in adolescent idiopathic scoliosis include saving distal fusion levels and historically greater correction and derotation compared with PSF. However, comparative studies between ASF and PSF have generally consisted only of posterior hook instrumentation or hybrid constructs, with no direct comparisons between anterior fusion and thoracic pedicle screw (TPS) series. METHODS: We performed a retrospective review of the radiographic and medical records of 40 patients (two curve-matched groups) with Lenke Type I main thoracic adolescent idiopathic scoliosis. There were 20 patients who underwent open ASF with single-rod instrumentation with a mean age at surgery of 15 years + 6 months (range, 12-20 years) and 20 patients who underwent PSF with TPS constructs with a mean age at surgery of 13 + 6 (range, 12-15). Radiographic follow-up averaged 44.1 month (24-80) for the ASF group and 55.1 month (25-83) for the PSF/TPS group. We evaluated the sagittal alignment, Cobb angles, rib hump deformity (RH), apical rib spread difference (ARSD), and apical vertebral body-rib ratio (AVB-R), measures of rotation and thoracic torsion, between both groups. RESULTS: Before surgery, the main thoracic curve was 55.1 degrees (range, 47-66 degrees) for the ASF group and 52.5 degrees (range, 46-68 degrees ) for the PSF/TPS group (P = 0.16). Additionally, there was no difference in the pelvic tilt curves, thoracic kyphosis, lumbar lordosis, RH, or ARSD. However, there was a slightly greater preoperative thoracolumbar-lumbar (TL/L) curve (34.6 degrees versus 29.5 degrees , P = 0.04) and AVB-R (1.75 versus 1.5, P = 0.003) in the ASF group. After surgery, an average of 6.5 levels (range, 6-8) were fused in the ASF group, compared with 7.7 levels (range, 5-12) in the PSF/TPS group (P = 0.001) or 1.2 additional levels for PSF/TPS. At final postoperative follow-up, spontaneous pelvic tilt curve correction was greater in the ASF group (47% versus 35%), although this difference did not reach statistical significance (P = 0.07). For the main thoracic and TL/L curves, there was greater correction in the PSF/TPS group (62% versus 52%, P = 0.009; and 56% versus 41%, P = 0.03), respectively. Additionally, the PSF/TPS group demonstrated significantly greater RH correction (51% versus 26%, P = 0.005) and AVB-R ratio improvement (73% versus 32%, P < 0.0001). We also noted a trend towards increased correction of the ARSD in the PSF/TPS group (58% versus 32%, P = 0.07). Further, the postoperative thoracic kyphosis decreased 4.4 degrees in the PSF/TPS group (postop avg. 25.0 degrees ) and increased 5.7 degrees (average, 30.6 degrees ) in the ASF group (P = 0.04). CONCLUSIONS: In this curve-matched cohort of Lenke Type I curves, PSF with TPS provided superior instrumented correction of main thoracic curves and spontaneous correction of TL/L curves. Perhaps more importantly, PSF/TPS demonstrated improved correction of thoracic torsion and rotation as compared with ASF in terms of RH (P = 0.005) and AVB-R ratio (P= 0.0001), with only one additional spinal segment fused on average.

Adolescent↗
PubMed2005

Standardization of criteria for adolescent idiopathic scoliosis brace studies: SRS Committee on Bracing and Nonoperative Management.

STUDY DESIGN: Literature review. OBJECTIVE: To establish consistent parameters for future adolescent idiopathic scoliosis bracing studies so that valid and reliable comparisons can be made. SUMMARY OF BACKGROUND DATA: Current bracing literature lacks consistency for both inclusion criteria and the definitions of brace effectiveness. METHODS: A total of 32 brace treatment studies and the current bracing in adolescent idiopathic scoliosis proposal were analyzed to: (1) determine inclusion criteria that will best identify those patients most at risk for progression, (2) determine the most appropriate definitions for bracing effectiveness, and (3) identify additional variables that would provide valuable information. RESULTS: Early brace studies lacked clarity in their inclusion criteria. In more recent studies, inclusion criteria have narrowed considerably to include primarily those patients most at risk for curve progression who may benefit from the use of a brace. Brace effectiveness was usually defined by various degrees of curve progression at maturity. Less frequently, it was defined by the resultant curve magnitude at maturity, whether or not surgical intervention was needed, or if there was change to another brace. CONCLUSIONS: Optimal inclusion criteria for future adolescent idiopathic scoliosis brace studies consist of: age is 10 years or older when brace is prescribed, Risser 0-2, primary curve angles 25 degrees -40 degrees , no prior treatment, and, if female, either premenarchal or less than 1 year postmenarchal. Assessment of brace effectiveness should include: (1) the percentage of patients who have < or =5 degrees curve progression and the percentage of patients who have > or =6 degrees progression at maturity, (2) the percentage of patients with curves exceeding 45 degrees at maturity and the percentage who have had surgery recommended/undertaken, and (3) 2-year follow-up beyond maturity to determine the percentage of patients who subsequently undergo surgery. All patients, regardless of subjective reports on compliance, should be included in the results (intent to treat). Every study should provide results stratified by curve type and size grouping.

Adolescent↗