Introduction: Spine and trunk deformity are different; trunk deformity is probably more important to the patient, and trunk deformity has received much less attention. This study was designed to determine the extent and stability of trunk deformity correction and is part of an ongoing effort to study trunk deformity. Material and methods: This is a prospective case series the inclusion criteria being pre-, post- and follow-up surface topography evaluation of idiopathic scoliosis patients undergoing posterior instrumentation and arthrodesis. Twenty-eight patients (25 female, 3 male) met these inclusion criteria. The average age at surgery was 15 years 3 months (11 years 3 months – 38 years 2 months). Spine deformity measurement and classification were done from standing 36” PA and lateral scoliosis radiographs. Trunk asymmetry was determined from standing posterior rastersterography. Coronal plane asymmetry was calculated utilising the Posterior Trunk Symmetry Index (POTSI), threshold for change being ±8. Transverse plane asymmetry was determined by the Suzuki Hump Sum (SHS), threshold for change being ±3.5. Curve classification and number in each category were King Moe I – three; IIA – two; IIB – three; III – ten; IV – four;V – five and Triple – one. Initial follow-up averaged 2.3 months (±7) and latest follow-up 15.8 months (±8.1). Results: Pre-operative; post-operative; and 1atest follow-up spine deformity measurements with percent correction (for spine and trunk deformity) were as follows: Major scoliosis-63°, 19° (69%) and 21° (66%); POTSI 52, 26 (50%), and 24 (54%); and SHS 18, 11 (38%), and 12 (37%). Thus, spine deformity (Cobb) and trunk deformity (POTSI and SHS) correction appeared to be stable over the follow-up period. Spine deformity correction was better than coronal trunk plane asymmetry correction which was better than transverse plane asymmetry correction. At latest follow-up, spine deformity correction for single curves was similar to multiple curve, 69% versus 64% as was transverse plane trunk asymmetry correction 34% versus 37%. However, coronal plane trunk asymmetry correction was better for single curves than double curves 63% versus 42%. At follow-up POTSI was better in all patients with single curves whereas in double curves it was better in nine, same in three, and worse in two. Transverse plane trunk asymmetry for single curves was better in ten, same in three, and worse in one, whereas for double curves it was better in eight, same in four and worse in two. Discussion and conclusion: The obvious weaknesses in this study are the small numbers and relative short follow-up. However, the trend seems clear. Trunk deformity correction is not as good as spine deformity correction. This is especially true for the transverse plane for all curves and the coronal plane for double curves in comparison to single curves

Abstract: The effect of a modified Boston Brace with antirotatory blades upon the fate of idiopathic scoliotic (IS) curves, mainly right thoracic with a compensatory left lumbar, is studied. This report refers to curves within the generally accepted range of Cobb angle (20° – 40°) appropriate for conservative treatment. Method and Material: Out of 166 children suffering IS with Cobb angle > 10°, 67 (61 girls, and 6 boys), having a mean follow up 2,3 years (4 months to 7 years), were studied. A brace of Boston type with antirotatory blades was applied in 36 scoliotic children. The curve type was: 18 thoracic (T) right (rt) + Lumbar (L) left (lt) in children with a mean age 13,1 years, 3 T lt + L rt in children with a mean age 16,3 years, 7 T rt in children with a mean age 13 years and 8 thoracolumbar (TL) rt curves in children with a mean age 12,1 years. Full documentation during the FU had 23 out of the 36 children with 14 T rt + L lt, 1 T lt + L rt (15 in total – double curve group), 4 T rt (thoracic group) and 4 TL curves (thora-columbar group). Traditionally deterioration (increase) or improvement (decrease) of a curve is considered a change of 5ï Cobb compared with the initial reading. Results: In the 15 double curve group children the mean FU was 28 months. In this group 5 curves were improved, 6 remained stable and 4 were increased. For the 4 thora-columbar curves with a mean FU 8 months, 3 remained stable and 1 improved. For the 4 thoracic curves with a mean FU 9 months, 2 were stable and 2 improved. During the final FU of the above 23 scoliotic children, when the assessment of Cobb angle was made with children out of the brace, 8 curves were improvement, 11 remained stable and 4 deteriorated (one patient out of 4 (4,3%) was operated upon). All the deteriorated curves were double (T rt + L lt). When the assessment of Cobb angle was made with children in the brace, 10 curves were improved, 12 remained stable and 1 deteriorated. Discussion: The brace treatment affected more the double curves while single curves remained unaffected. Rotation remained unchanged in all curve types except in the lumbar component of double (right thoracic-left lumbar) curves. A composite spiral trunk rotator muscle has been proposed, (consisted of the ipsilateral scapular elevator and rhomboid, the anterior serrated, external oblique and contralateral internal oblique abdominal muscle, (Benninghoff 1985, Wemyss-Holden 1990), which is considered that have an effect on the trunk rotation during gait. Asymmetry of one or more constituent muscles creates scoliosis. These findings are consistent with the view that neuromuscular factors are responsible for the initiation of idiopathic scoliosis. The antirotatory blades of the brace are acting upon the above described composite spiral trunk rotator muscle blocking the deterioration of the scoliotic curve or improving the double curves thus supporting the above aetiologic view. In conclusion the conservative treatment using this brace is beneficially affecting the natural history of the IS in children 12–15 years of age

Summary: Radiographic and clinical outcomes of anterior thoraco-lumbar and posterior instrumented spinal fusion in patients with double major (AIS) curves are evaluated in this retrospective study. The average thoracic curve was 68 degrees before surgery and 29.2 degrees at follow-up (mean correction 58.3%). The average preoperative lumbar curve was 73 degrees, decreasing to 18 degrees postoperatively (mean correction 77.5%). Instrumented anterior lumbar fusion followed by posterior instrumented fusion is a successful technique with low morbidity in AIS with double curve pattern. Introduction: Options exist for the surgical treatment of double major AIS curves. With the introduction of multi-level pedicle screw fixation in the thoracic and lumbar spines the role of anterior surgery is being questioned. This series demonstrates the results obtained by anterior thoraco-lumbar and posterior instrumented spinal fusion. Methods: 28 patients with double major curves who underwent anterior spinal release and instrumented fusion, with staged posterior instrumented spinal fusion between 1999 and 2005 were included for analysis. The minimum follow-up was 2 years after surgery (mean, 5 years; range, 2–8 years). The mean age of patients was 17,3 years (range, 13–21 years). Multiple radiographic parameters were assessed. Results: Successful selective thoraco-lumbar instrumented fusion and posterior instrumented fusion was performed in 28 consecutive patients with adolescent idiopathic scoliosis. The average thoracic curve was 68 degrees before surgery and 29,2 degrees at final follow-up (mean correction 58,3%). The average pre-operative lumbar curve was 73 degrees, decreasing to 18 degrees postoperatively (mean correction 77,5%), with good coronal and sagittal balance achieved. Tilt of the lower instrumented vertebra (LIV) improved from 28.2 degrees to 4.6 degrees on last follow-up. Disc angulation below the LIV averaged 6.1 degrees preoperatively and 3.6 degrees on last follow-up. Translation of the LIV from the center sacral vertical line averaged 34.5 mm preoperatively and 13.6 mm on last follow-up. Discussion: Instrumented anterior lumbar fusion followed by posterior instrumented fusion is a successful technique in adolescent idiopathic scoliosis with double curve pattern. These results show that this technique is able to restore normal coronal alignment of the distal unfused lumbar segment and saves fusion levels compared to posterior instrumentation only. Despite the extensive surgery, there is a very low morbidity in this population, with no evidence of pseudarthrosis. Significance: This represents a large unique series of patients treated for double major curve pattern in adolescent idiopathic scoliosis with low morbidity and excellent balanced corrections in both coronal and sagital planes

Purpose: The purpose of this study was to detect any possible prognostic factors which may affect the spinal deformity progression and their relationships in idiopathic scoliosis. Methods: The stereo-radiograph of whole spine at each visit was reconstructed with two spinal x-ray images in PA 0° and 20° using DLT techniques. Sequential data sets with 3, 4 or 5 successive values of prognostic factors were extracted from 111 consecutive patients (12.3±2.3 yrs, Cobb angle 30.2±12.4°) and separated into the stable and the progressed groups, based on a progression threshold of Cobb angle 5° and 10°. The prognostic factors included gender, curve pattern, age, curve magnitude, apex location, lateral deviation and spinal growth. Effects of those factors were conducted by comparing them between two groups (statistical significances p< 0.05) and the relationships were determined using Pearson’s correlation coefficient (r). Results: The progressed subjects were predominantly females (50–79%) with double curves. Double curves progressed on both curves RT and LL at the same times and alternatively. There were no significant differences of initial ages and ages with maximum curve magnitudes between two groups. Initial and maximum curve magnitudes were significantly large in the progressed group, but no significantly different between maximum curve magnitudes in the stable group and initial curve magnitude in the progressed group. High curve apex locations were observed in the progressed group. Initial and maximum apex lateral deviations were clearly different in two groups and correlated with curve magnitudes from well to excellent (r = 0.43–0.98). The relationships between the spinal growth and the curve progressing were not consistent (r = −0.6 – +0.6). There were no evidences to show the significant differences of spinal growths between groups and genders. Conclusions: Scoliosis progression is case dependent. Double curves dynamically progress between curve regions. Initial curve magnitudes have more significant effect on the progression than initial ages. A great progression can be expected from curves with high apex location. Apex lateral deviations are changing with curve magnitudes and spinal growths and, however, the curve magnitudes are not always increased with spinal growths. Funding: 2 Funding Parties: Alberta Provincial CIHR Training Program in Bone and Joint Health

Background: In lumbar scoliosis curves of school screening referrals were evaluated (1) for the possible relation of pathomechanisms to standard and non-standard vertebral rotation (NSVR) [. 1. ], and (. 2. ) the relation between apical lumbar axial vertebral rotation and the frontal plane spinal offset angle (FPTA) [. 2. ]. Methods: Consecutive patients referred to hospital during routine school screening using the Scoliometer were examined in 1996–9. None had surgery for their scoliosis. There are 40 subjects with either pelvic tilt scoliosis (11), idiopathic lumbar scoliosis (19), or double curves (10)(girls 31, postmenarcheal 25, boys 9, mean age 15.3 years). One observer (RGB) measured: 1) in AP spinal radiographs Cobb angles (CAs), apical vertebral rotations (Perdriolle AVRs), and trigonometrically sacral alar tilt angle (SATA), and FPTA as the tilt of the T1–S1 line to the vertical; and 2) total leg lengths (tape). Results: Excluding the double curves there are 16 left and 14 right lumbar curves mean CA 11 degrees (range 4–24 degrees), mean AVR 9 degrees (concordant to CA in 18/30, discordant in 7/30), SATA 2.8 degrees (range 0.2–7.7 degrees associated with CA side and severity, p=0.0003), and leg-length inequality 0.7 cm (significantly shorter on left, p< 0.0001 and associated with SATA (p=0.02) but not CA). Neither CA nor AVR in each of the laterality concordant and discordant lumbar or thoracic curves is significantly different. Twenty-six subjects have thoracic curves (16 right) 22 with AVR (mean CA 11 degrees, range 4–17 degrees, AVR 9 degrees, n=22) the CA being associated with each of lumbar CA and SATA (respectively p< 0.0001, p=0.003, n=26). Thoracic curve laterality of CA and AVR is concordant in 12/26 curves and discordant in 10/26 and for concordance/discordance neither is significantly different; thoracic AVR sides with laterality of lumbar curve AVR shown by thoracic AVR (but not CA) being greater in lumbar discordant than in lumbar concordant curves (14 & 7 degrees respectively, p=0.03, n=18 & 7). Both for lumbar curves alone and for lumbar with double curves, AVR by side is significantly associated with FPTA by side (r= −0.568, p=0.001, n=30; r=−0.560, p=0.0002, n=40). Conclusion: (1) It is hypothesized that different pathomechanisms may separately affect the frontal (CA) and transverse (AVR) planes: in discordant curves these mechanisms may neutralize each other and limit curve progression; concordant curves require these biplanar mechanisms to summate and facilitate curve progression. (2) The association of frontal plane spinal tilt angle and lumbar AVR may result from balance mechanisms affecting trunk muscles – mechanisms that may underlie the complication of post-operative frontal plane spinal imbalance or decompensation [. 2. ]

Introduction. Previous work has shown that C57BL/6 mice develop scoliosis when rendered bipedal. Our previous work suggested that tamoxifen (TMX) might change the natural course of scoliosis when administered before scoliotic curves develop. We analysed whether the incidence of scoliosis or the magnitude of curves may be decreased by the administration of tamoxifen after curves are observed. Methods. 20 female, 3-week-old C57BL/6 mice underwent amputations of forelimbs and tails at 3 weeks, 18 of which were included in analyses. Posteroanterior scoliosis radiographs were obtained at week 20, and scoliotic curves were recorded. After week 20, all mice received 10 mg TMX per L of daily water supply for 20 weeks. The course of deformities in this group (week 20 group) was compared with that of previous study groups (receiving TMX from week 3; week 3 group). Results. At week 20, overall, upper thoracic (UT), thoraco-lumbar (TL), and double curve scoliosis rates were similar in both groups, but the thoracic (T) scoliosis rate was lower in the week 3 group. At week 40, although T, TL, and double curve scoliosis rates were similar between groups, overall rate and the rates of UT scoliosis were significantly lower in week 3 group (table). We recorded no significant change of curve rates in week 20 group apart from the TL rate, which showed a significant increase (p=0·025). Mean Cobb angles were similar in both study groups (p>0·05) at 20 and 40 weeks. Conclusions. This study has shown that TMX administered after scoliotic changes are observed seems to be less effective compared with prior TMX protocol in C57BL/6 mice model. This information is important for the planning of possible pharmacological intervention in human beings

Both posterior and anterior surgery have potential for complete scoliosis correction. Significant difference in judging the procedures still persists. Aim. To establish objective advantages and risks of the procedures, basing upon long term results. Method. From 1982–2007, 859 anterior(A) and 388 posterior(P) instrumentations were performed by the same surgeon. Single level thoracotomy used even in double curves. Spinal canal was never opened, rib heads left intact, ribs were fractured at the top of rib hump. Zielke rod was used for correction, and another rod added for aditional correction and stabilisation. Various posterior instrumentations were used. Results. CORRECTION (A)frontal 67-45-16(76%), sagital +6, (P)frontal 66-44-29(56%), sag+3; OP. TIME (A)140(50–300), (P)155(110–350); BLOOD REPL. (A)18%, (P)92%; HOSP STAY (A)10, (P)13; VC (A)-10%, (P)0%; SPORT ACT. (A)3mths, (P)12mths; MAJOR COMPLICATIONS: no deaths, (A)1 aorta rupture, 1 bronchus penetration, 0,7% haematothorax, 0,6% reinstrumentation, 0,7% infections demanding op, (P)2 paraplegia (0,5%), 3.9% infections, 4.9% reinstrumentation. Discussion. (A)required no neuromonitoring, no intensive care unit. Blood replacement was occasionally used only for double curves (11 segm), and in preop. anemia. Most of the complications were preventable. Hospitalisation was longer in (P) group due to wound problems. Pulmonary decrease was found only in curves greater than 100 °. Halo traction improved VC, but both instr. had no influence on further improv. In (A)VC recovered in 6 months. Conclusions. (A) can be performed in less radical and agressive way. Anterior release significantly mobilizes the spine and decreases necessary corrective forces. Infection was more frequent in (P) but consequences were more dramatic in (A). All major complications in (A) were preventable. There is temporary decrease in pulmonary function after (A). We could not find objectives for (A) to have more morbidity than (P). Due to superior results we still prefer (A) in surgery of AIS. Our indications for (P) is VC<40%, age, poor bone quality, surgery in upper thoracic spine

To determine factors such as age, sex and curve severity in patients with idiopathic scoliosis presenting for the first time to a spine deformity clinic. A prospective study at a regional spine clinic. Patients with idiopathic scoliosis presenting for the first time to the scoliosis clinic were entered into a database recording information such as age, symptoms, severity of scoliosis as measured by the Cobb angle (CA), spine rotation measured by Scoliometer, geographical region, person detecting the curve, neurological findings etc. The study period was from June 2008 to September 2009 inclusive. Fifty consecutive patients with all required information in the database were included in the analysis. All eligible patients were not entered due to logistical reasons. 13 males and 37 females, average age 13.96 (range 1 to 23). 68% were unhappy with the shape of their back, 48% presented with significant pain and 32% had both. The mother first saw the scoliosis in 52%, the rest were seen by either the patient, friends or doctors. 36 were single curves with a mean CA of 34 degrees ranging from 10 to 80 degrees. 52% of patients presented with a curve of 40 degrees or more. 14 had double curves. None of the patients were found to have any abnormal neurological findings. There are few epidemiological studies in the recent literature. This data was not previously available in our region and initial presentation with a severe curve is a worrying trend which triggered this study

Introduction. Calmodulin probably has a regulatory role in muscle contraction and its antagonism may decrease the magnitude and progression of scoliosis. A separate study has shown that tamoxifen (TMX), a known antagonist, is effective in altering the natural history in an avian model; however, whether the same effect is conceivable in mammals is unknown. We aimed to analyse whether the natural course of scoliosis in mice may be altered by the administration of TMX. Methods. 60 female, 3-week-old, C57BL/6 mice underwent amputations of forelimbs and tails. 57 mice were assigned to three groups: control group, no medications; TMX group, 10 mg TMX/L drinking water; and combined group, 10 mg TMX plus 10 mg trifluoperazine (TFP)/L drinking water. PA scoliosis radiographs were taken at 20 and 40 weeks and evaluated for presence and magnitude of spinal curves. Results. Four mice were lost to follow-up in the TMX group. Overall scoliosis rate was significantly lower in the TMX group (33%) than in the control (90%) and combined (68%) groups (p=0·001) at week 40. Similarly, upper thoracic scoliosis rate was lower in the TMX group (27%) than in control (74%) and combined (47%) groups (p=0·01). The thoracic scoliosis rate was also lower in the TMX group (7%) group than in control (63%) and combined (26%) groups (p=0·001). Combined drug group had lower thoracic and lumbar Cobb angles (17·50° [□}3·45]) than did the control group (29·40° [□}5·98]; p=0·031). Furthermore, double curve incidence at week 40 was lower in TMX group (12%) than in control (74%) and combined (47%) groups (p=0·001). Triple curve incidence was lower in combined (0%) and TMX (6%) groups than in the control group (15%), but this result was not significant (p=0·167). Conclusions. TMX effectively decreased the incidence and magnitude of the scoliotic curves in C57BL/6 mice scoliosis model. This is a novel finding, and could be very important in opening a pathway for the conservative treatment of idiopathic scoliosis by oral drugs

Double scoliotic curves usually demand long posterior fusion and limitation of lumbar motion. The purpose of the study was to determine a possibility of one stage surgery, 3D correction, balanced spine and maximum of lumbar mobility. Method: 47 patients in the age of 14±1.6 yrs with double IAS curves were operated from 1995–99 with an average follow up of 50±9 months. Untill 1998 all the patients (31) were fused from Th4 to Th12, leaving the fused curve in balance with compensatory lumbar curve (group1). From 1998–00, 16 patients underwent a single stage anterior surgery of boh curves from Th4-L3 if lower curve averaged 50û (group 2). Two independent observers analyzed the results. Results: G1 (Th 67û±10;L41û±11) was corrected to Th19û±4; L17û±4. Balance changed from 11 mm pre op. to 2.4 mm post op. However, 6 patients (avr. 70û+60û), were corrected to 25û+38û. One year of bracing was necessary to partially correct the disballance, with satisfactory overall results. In 3 patients (Th> 80, L> 50) a balanced spine resulted, but with problematic correction rate. In G2, correction was made from Th68û±17;L63û±10û, to Th23û±12;L21û±8. Mean op. time was 260 min., blood loss 640 ml, post.op. stay 12 days. Conclusion: Fusion down to Th12 showed good results if Th< 80 and L< 50 degrees. In greater curves, an extended single stage fusion down to L3 offered better overall results, better correction, no balance problems and good lumbar mobility

Introduction and Aims: The aim of this paper is to review an innovative anterior technique to address double major scoliotic deformities in paediatric patients. This technique, which utilises modified lumbar anterior rod placement followed by an overlapped thoracic rod placed in the concavity of the thoracic curve, may have a considerable role in managing double major scoliotic deformities. Method: All patients undergoing double anterior rod instrumentation for idiopathic scoliosis at the author’s institution were reviewed. They were closely assessed and reviewed for any negative effects. Radiographs were evaluated for correction of the scoliotic deformity and correction of the obliquity of the end vertebra. Disc space fusion was also evaluated on follow-up films. Results: Patients requiring thoracic and lumbar instrumentation were considered for the technique. Mean pre-operative curve sizes were 53 and 59 degrees for the thoracic and lumbar curves, respectively. The described operative technique utilises a modified lumbar anterior rod placement followed by an overlapped thoracic rod placed in the concavity of the thoracic curve. Thoracic vessels are preserved in this technique. Mean operative time was 7.5 hours. Anterior instrumentation has been completed in five patients at the author’s institution. Obliquity of L3 was corrected from a mean of 29 degrees pre-operatively to five degrees post-operatively. No patients had significant decompensation nor did they require any further procedure. No post-operative complications occurred. The technique allows for one incision instrumentation of double major curves to the lower end vertebra, preserving the L3-4 motion segment. Conclusion: Anterior instrumentation is useful in patients with double major scoliotic deformities who require thoracic and lumbar instrumentation. This new technique may have a significant role in the management of a subset of idiopathic scoliosis patients as it preserves the L3-L4 motion segment, while allowing one-incision instrumentation of double major curves

Side shift exercise was originally described by Mehta. Since 1986, we adopted it for the treatment of idiopathic scoliosis. Outcome of the side shift exercise for the patients with idiopathic scoliosis after skeletal maturity was evaluated retrospectively. Fifty-three patients with idiopathic scoliosis whose curve was greater than 20 degrees by the Cobb’s method were included in the study. All the patients were treated only by the side shift exercise and their treatment was started after skeletal maturity. Skeletal maturity was diagnosed by Risser’s method as either grade IV or grade V. The study comprised five men and forty-eight women. Twenty-six patients had thoracic curve, eight had thoracolumbar curve, and nineteen had double major curve. Patients were instructed to shift their trunk to the concavity of the curve repetitively while they were standing and to maintain the side shift position while they were sitting. In double major curve, larger curve was the subject of the treatment. The average age at the beginning of the treatment was 16.3 years (range, 13 to 27 years), and the average age at final follow-up was 19.8 years (range, 14 to 33 years). The average follow-up period was 3.5 years (range, one to 11 years). The average Cobb angle at the beginning of the treatment was 33.3 degrees (range, 20 to 74 degrees), and the average Cobb angle at final follow-up was 32.2 degrees (range, 10 to 73 degrees). Curves of four patients decreased 10 degrees or more. Most of long term follow-up studies reported that untreated idiopathic scoliosis progressed even after skeletal maturity. Although the follow-up period was much shorter, results of the present study suggested that the side shift exercise was a useful treatment option for the management of idiopathic scoliosis after skeletal maturity

Introduction: Veldhuizen (2002) developed a new flexible Scoliosis-Brace for effective curve correction in Idiopathic Scoliosis. This new Brace is characterised by a improved cosmetic appearance and wearing comfort compared to conventional ortheses (Cheneau, Boston). We investigated the effectiveness of the TriaC™-Brace regarding the primary curve correction in Idiopathic Scoliosis (IS). Materials and Method: Following the guidelines given by Veldhuizen (2002) we have treated 20 patients (15 girls, 5 boys, average age: 12,43) with diagnosis of IS (King I:6, King II:4, King III:8, King IV:1, lumbar:1) with the TriaC™-Brace from 2002–2004. At the beginning of the therapy with the new orthesis the Risser sign was 2,68 at an average. The daily wearing time was instructed with 22–23 hours. Lumbar curves showed an average cobb angle of 26,1 degrees (standard deviation=8,6) and thoracic curves of 24,4 degrees (standard deviation=6,5). The radiological assessment of primary curve correction (cobb-angle) was performed 6,2 weeks after the beginning of the therapy (anterior posterior radiograph of the spine in standing position with orthesis). Further radiological controls were performed every six months. We evaluated the wearing time, comfort and leisure activity with a valid scoring system (Quality of Life Profile for Spine Deformities). The overall mean wearing time of the Triac™-Brace was 14,7 months. Results: For lumbar curves (n=12) we measured a primary correction of 9,9 degrees (40%; statistically significant, t-test, p=0,01) and for thoracic curves (n=20) of 2,2 degrees (8,4%; not statistically significant, t-test, p=0,42). A insufficient primary curve correction (defined as < 30% of the initial cobb-angle) was observed in 16 thoracic curves (89%) and in 4 lumbar curves (30%). An increasing correction during the therapy as reported by Veldhuizen (2002) could not be observed. There was a curve progression of at least 5 degrees of the cobb-angle in 4 cases. The evaluation by the scoring system (response in 85%) resulted in a high score for cosmetics (4,2/5) and mobility of the back (4,6/5). The wearing time was reported by 90% of the patients with 22–23h. Conclusion: We do not recommend the conservative therapy of thoracic or double curves (King III, King I and II) with the TriaC™-Brace. Larger studies are necessary to investigate the effectiveness of the orthesis in lumbar curves. The improved wearing comfort and cosmetics are a potential advantages of this new orthesis

Introduction. The potential structural effect of the sacral tilt on the development of disc wedging adjacent to lowest instrumented vertebra (LEV), and consequent postoperative coronal trunk decompensation in the surgical treatment of idiopathic scoliosis are well known. The aim of this study is firstly to establish the possible role of sacral tilt, limb length inequality, and associated pelvic girdle anomalies in the cause of idiopathic scolisosis, and secondly to determine the effect of sacral tilt on adjacent disc wedging below LEV in some idiopathic curves such as thoracolumbar/lumbar curves, and double major curves postoperatively. Methods. Between 2006 and 2008, 159 patients with idiopathic scoliosis from outpatient clinics were included in analyses. In all patients, standing posteroanterior and lateral spinal column and Ferguson radiographs were routinely taken. If direct radiographs suggested iliac bone asymmetry, hemi-pelvis volume measurements were done with CT scan. Curve type, sacral tilt, L5 tilt, iliac asymmetry, and limb-length differences were measured. As a second part of study, 87 surgically treated patients with double major curves were examined retrospectively in terms of adjacent subjacent disc wedging below LEV and sacral tilt. Results. In the first part of the study, the mean age of patients was 14·21 years (range 2–25) and all but 14 were female. The curve types were lumbar in 31 patients, thoracolumbar in 42, double major in 55, thoracic in 27, and triple in four. Sacral tilt towards the convex side of TL/L curve was present in 117 (74%) patients with an average of 8° measured from Ferguson graphs. L5 tilt towards the convex side of TL/L curve, and limb length inequality of less than 5 mm on the convex side of TL/L curve were more prevalent in patients with sacral tilt (57%) than in those without sacral tilt (p=0·021). On hemi-pelvis volume measurement, patients with no sacral tilt (n=42) had no difference in both sides whereas patients with sacral tilt (n=117) showed significant difference, with the convex side being smaller. We noted a correlation between L5 tilt and sacral tilt (p=0·048) and between sacral tilt and hemi-pelvis volume (p=0·024). There was no correlation between sacral tilt and pelvic asymmetry, age, sex, curve type, or amount of limb length inequality. In the second part of the study, disc wedging adjacent to LEV was present in 75 of 87 patients and sacral tilt was present in 72 of 75 (96%) (p=0·008). Six patients had limb length inequality of more than 1 cm, showing the postoperative trunk decompensation, which was corrected by elevating the shorter leg by shoe-lift. Conclusions. This study revealed significant association between sacral tilt and hemi-pelvis hypoplasia independent from age. This association may have a primary role in the cause of this disease. Although LEV is paralel to pelvis, intervertebral disc adjacent to LEV is often wedged and there is lumbosacral hemicurve distally below the instrumentation in patients treated by either anterior or posterior surgery. We believe that lumbosacral hemicurve due to sacral tilt behaves like hemivertebra, which is impossible to detect with preoperative standing anteroposterior radiographs. Ferguson view is necessary to detect the sacral tilt. The postoperative trunk decompensation is greater with presence of sacral tilt and limb length inequality

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.

Objective. To evaluate the relation of ribs to the spine in the transverse plane (TP) at the curve apex in preoperative AIS using a real-time ultrasound method and radiographs (Burwell et al 2002). Design. With the subject in a prone position and head supported, readings of laminal rotation (LR) and rib rotation (RR) were made on the back by one of two observers (RKA, ASK) using an Aloka SSD 500 portable u/s machine with a veterinary long (172mm) 3.5 MHz linear array transducer. The maximal difference between LR and RR about the curve apex was calculated as the apical spine-minus-rib rotation difference (SRRD). The SRRD eliminates the effect of any anterior chest wall asymmetry on the ultrasound measurements and, assuming no movement of ribs in the TP at the costotransverse joints, is considered to be a measure of TP rib deformity. The radiographic Cobb angle (CA), apical Perdriolle rotation (AR), and apical vertebral translation (AVT) were measured by one observer (RGB). In an attempt to separate mechanical axial vertebral rotation from axial vertebral deformity a derivative was calculated as Perdriolle rotation minus ultrasound LR with the latter corrected for the positional effect of lying prone and termed the axial vertebral difference (AVD) The correction factor (CF) used is maximal Scoliometer angle of trunk rotation obtained in the standing forward bending position minus that in the prone position. Subjects. Thirty-three preoperative patients with AIS were studied (thoracic curves 20, thoracolumbar curves 8, double curves 5). Results. The mean figures in degrees or mm (AVT) are shown in the Table. All curves combined. The LR is significantly greater than the RR (p< 0.001) and correlates with RR (r=0.358, p=0.041), SRRD (r=0.713, P< 0.001) but not with CA (p=0.088), AR (p=0.166), AVT or AVD. AR does not correlate significantly with CA. Thoracolumbar and thoracic curves. In the thoracolumbar curves the SRRDs are significantly greater than those in the thoracic curves (p=0.031) implying more TP rib deformity in the thoracolumbar curves. In the thoracic curves the SRRDs correlate negatively with the AVDs (r= −0.470, p=0.036) suggesting that rib deformity and intravertebral deformity contribute reciprocally and together with axial spinal rotation to determine the overall spinal deformity of AIS. Conclusions. The findings are consistent with the hypothesis that in preoperative AIS the axial RR and TP rib deformities are adaptations to rotational and lateral forces imposed by the scoliotic spine (Wever et al 1999). Might surgical stiffening of the posterior ends of the apical convex ribs – in an attempt to prevent TP convex rib deformity – constrain axial spinal rotation, vertebral translation and intravertebral deformity and limit curve progression? #Supported by AO/ASIF Research Commission Project 96-W21

Background Data: Radiography has been the mainstay of patient monitoring in scoliosis, but there is an increasing demand for its reduction to specific situations where treatment is to be decided or modified. There is concern that substitution of traditional methods with clinical impression and surface topography might not be feasible or safe. Study Design: An outcome study of a year’s intake of new patients with adolescent idiopathic scoliosis using a protocol derived from experience with surface topography. Method: Tolerance limits for observer and subject variation and observed changes over time were established and correlated with recorded Cobb angle changes. A “derived Cobb angle” was calculated from topographic spinal angles and radiographs of 75 patients with non-congenital scoliosis and tested against 141 similar patients. Cobb angle = 15.3 + 1.22* topographic spinal angle. A protocol was adopted with topography at every clinic visit, radiography reserved for cases with severe deformity, additional symptoms or where surgical intervention was considered. This protocol was tested on new adolescent idiopathic scoliosis (AIS) presentations to the general clinic in a single year (2001) with regard to status at presentation and outcome (n=49). Results: Measurement error, on the average of four repositioned scans on 105 consecutive patients rounded up to 10 units on all parameters. In 75 patients with non-congenital scoliosis, change ≥10° in Cobb angle was always accompanied by a similar change on at least one topographic parameter. The mean difference was −3.9°, SD 14.7, and was greater in very small, larger or double curves and in obese patients. There was significant correlation (p< 0.01) between changes in the Cobb angle over time and that derived from the spinal angle. 49 girls presenting with a presumptive diagnosis of AIS were diagnosed thus: Normal, n=8, 4 after radiograph, all now discharged; Asymmetry, n=24, no radiographs, 11 discharged immediately, 10 after 0.5 – 1.5 years, 3 lost; AIS, n=17, Cobb angle 10–93°, 5 surgery, 6 discharged, 4 currently followed, 2 non-attendees. Discussion: The incomplete correlation is acceptable, since within-subject variation of the Cobb angle is unknown but the observer variation was shown by Carman et al (JBJS 72(A):328–333) to be over 8°. The discrepancy between actual and derived Cobb angles at the extremes is understandable as small curves are inflated by the obligatory constant, while increased subcutaneous tissue smoothes the surface, and both double and large curves show more rotation of vertebral bodies than of spinous processes. This can be tolerated because in small curves, prediction is made on maturity indicators rather than Cobb angle, while at higher values, cosmesis is the issue, small changes in Cobb angle are less relevant, and pubertal status determines progression potential more effectively than radiographic measures. Conclusion: Topography and reduced use of radiography allows safe monitoring of adolescent idiopathic scoliosis. It provides a validated cosmetic score which documents deformity progression, is an adjunct to clinical decision making and is mathematically related to the Cobb angle. Basic clinical modalities and careful consideration of every patient on an individual basis are still essential

Background: Unclear aetiology in scoliotic and kyphotic deformities of the spine are responsible for uncertainty in treatment options. To clarify aetiology a constant reference to what normal growth and optimal construction of the entire spine should be at the end of growth is lacking. Examination of sitting children and consequent testing of muscular tightness can be useful in understanding the different disturbances of growth that keep the spine apparently away from an optimal configuration and thereby optimal function. Prolonged sitting of children exists only 200 years or less. Goal:. - Better understanding of the role of the central nervous system, especially the cord and roots in proper and improper growth of the human spine. - Clarifying that lordosis and good function at the tho-racolumbar junction at the end of growth can be a condition sine qua non for normal configuration and function of the spine in adult life. Methods:. - Present obvious important and consistent clinical observations in children in sitting and supine position with early and advanced adolescent deformities, both kyphotic and scoliotic by photographic studies and video fragments. - Present results of own study in which a lordotic force give significant correction of all curves in Adolescent Idiopathic Scoliosis. - Revisit the, for the greater part unknown, experimental work on growth and deformation of the spine by Milan Roth in German and Czech literature to disclose a tension-based balancing system between central cord and the osseous and discoligamentary spine (uncoupled neuro-osseous growth). - Relate these clinical and experimental findings with common knowledge about adolescent spinal deformities and mechanical laws on tensile and compressive forces in structures. Results: We discovered by alteration of our brace-configuration that applying lordotic forces exclusively on the thoracolumbar spine gives excellent correction of kyphotic and scoliotic deformities progressing in adolescence. In a study of 32 patients with double curves > 25° all scoliotic curves significantly (p< 0,001) reduced by correcting with a forced lordotic fulcrum. Extended clinical examination of children with proven or suspected spinal deformities revealed a complex of consistent findings in different sitting positions and functional tests in supine and standing positions. Discussion: By looking for scientific support for these phenomena in (bio-)mechanical literature the work of Milan Roth was disclosed in his complete width. His embryologic studies, (neuro) anatomical and radiological findings with their explanations, alongside interesting cadaver-, mechanical- and neuro-anatomical experiments and models can bring his concept of neuro-spinal relationship in growth and misgrowth back to orthopaedic daylight. Even Nicoladoni saw a century ago that a cascade of structural alterations take place around the “core”-unit of the spine: the boundaries of the central canal to let it stay on its place and in the shortest configuration possible in scoliosis, by suspected tensile and compressive forces. Anatomical and biomechanical consequences of keeping the spine upright in standing, but more important in the sitting positions seems to fit. Children do sit for prolonged periods only in the last one or two centuries!. It can be shown that the presence of these tension related clinical signs are easily leading to high compressive forces with deformation of the ventral parts in the TL-junction while sitting In literature evidence of torsion facilitating anatomical features can be found to clarify why some spines deform in scoliosis an not in pure kyphosis. Conclusions: By recognising positive effects of creating lordosis at the thoracolumbar junction of the spine and consistent clinical findings in early deformations scientific support was found by early experimental work of Roth. With a leading role of the central nervous system in growth of the spine of standing and sitting vertebrates by steering a tension based system, deformation can be understood as adaptations. Consequences for preventive measures and therapeutic strategies in deformities seems inevitable

Aims

Vertebral body tethering (VBT) is a non-fusion technique to correct scoliosis. It allows correction of scoliosis through growth modulation (GM) by tethering the convex side to allow concave unrestricted growth similar to the hemiepiphysiodesis concept. The other modality is anterior scoliosis correction (ASC) where the tether is able to perform most of the correction immediately where limited growth is expected.

A 14 year-old-female, underwent a T3-L3 instrumented posterior spinal fusion for a double major curve. Surgery under controlled hypotensive anesthesia was uneventful, with normal somatosensory and motor potentials. After instrumentation, patient underwent a normal wake-up test. The preoperative haemoglobin and haematocrit was 15.1g/dl with 41%, respectively. Estimated blood loss was 400cc and postoperative haemoglobin and haematocrit were 9.7g/dl and 31% respectively. Clinical examination was normal immediately postoperatively, on the first postoperative day and the beginning of the second postoperative day. At the end of POD 2, the patient started to feel both lower extremities “heavy” and sensitive to touch. She developed generalized proximal lower extremity weakness and was unable to stand. She was also unable to void after catheter removal. At this stage, her hemoglobin had dropped from 10 g/dl on POD 1 to 7.3 g/dl. Her haemoglobin fell to 6.2 g/dl the next day with a haematocrit of 18%. No significant bleeding was noticed, and other than lightheadedness, no haemodynamic changes were noted. Transfusion was performed correcting the haemoglobin to 9.3 g/dl and haematocrit to 27%. Compressive etiology was ruled out by post-operative myelogram-CT. Patient was discharged on POD 13 and was neurologically intact at three month follow-up. Discussion: Delayed neurological deficits have been reported, and are associated most frequently with epidural haematomas. Postoperative hypotension as the etiological factor has been reported only in an adult patient. As cord compression was ruled-out the only event we can correlate with the beginning of the neurological deficit is the unexplained acute drop in haemoglobin levels on the second day, possibly impairing normal cord oxygenation. If this is not the case, we would have to accept false negative results for the three standard methods currently available for spinal cord monitoring during surgery. In this case, the normal postoperative neurological exams, performed during the first 48 hours after surgery, and the subjective symptoms the patient experienced associated with the beginning of motor deficit, leads us to conclude that the injury happened on the second day in relation to the postoperative anaemia. Although we believe children tolerate low levels of haemoglobin, transfusion policies might have to be reconsidered as the cord may be transiently at risk for ischemic events after deformity correction