Acute spinal cord injury (SCI) is most often secondary to trauma, and frequently presents with associated injuries. A neurological examination is routinely performed during trauma assessment, including through Advanced Trauma Life Support (ATLS). However, there is no standard neurological assessment tool specifically used for trauma patients to detect and characterize SCI during the initial evaluation. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive and popular tool for assessing SCI, but it is not adapted to the acute trauma patients such that it is not routinely used in that setting. Therefore, the objective is to develop a new tool that can be used routinely in the initial evaluation of trauma patients to detect and characterize acute SCI, while preserving basic principles of the ISNCSCI.

The completion rate of the ISCNSCI during the initial evaluation after an acute traumatic SCI was first estimated. Using a modified Delphi technique, we designed the Montreal Acute Classification of Spinal Cord Injuries (MAC-SCI), a new tool to detect and characterize the completeness (grade) and level of SCI in the polytrauma patient. The ability of the MAC-SCI to detect and characterize SCI was validated in a cohort of 35 individuals who have sustained an acute traumatic SCI. The completeness and neurological level of injury (NLI) were assessed by two independent assessors using the MAC-SCI, and compared to those obtained with the ISNCSCI.

Only 33% of patients admitted after an acute traumatic SCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI includes 53 of the 134 original elements of the ISNCSCI which is 60% less. There was a 100% concordance between the severity grade derived from the MAC-SCI and from the ISNCSCI. Concordance of the NLI within two levels of that obtained from the ISNCSCI was observed in 100% of patients with the MAC-SCI and within one level in 91% of patients. The ability of the MAC-SCI to discriminate between cervical (C0 to C7) vs. thoracic (T1 to T9) vs. thoraco-lumbar (T10 to L2) vs. lumbosacral (L3 to S5) injuries was 100% with respect to the ISNCSCI.

The rate of completion of the ISNCSCI is low at initial presentation after an acute traumatic SCI. The MAC-SCI is a streamlined tool proposed to detect and characterize acute SCI in polytrauma patients, that is specifically adapted to the acute trauma setting. It is accurate for determining the completeness of the SCI and localize the NLI (cervical vs. thoracic vs. lumbar). It could be implemented in the initial trauma assessment protocol to guide the acute management of SCI patients.

To compare preoperative and postoperative Health Related Quality of Life (HRQoL) scores in operated Adolescent Idiopathic Scoliosis (AIS) patients with and without concomitant isthmic spondylolisthesis.

A retrospective study of a prospective cohort of 464 individuals undergoing AIS surgery between 2008 and 2018 was performed. All patients undergoing surgery for AIS with a minimum 2-year follow-up were included. We excluded patients with prior or concomitant surgery for spondylolisthesis. HRQoL scores were measured using the SRS-22 questionnaire. Comparisons were performed between AIS patients with vs. without concomitant spondylolisthesis treated non-surgically.

AIS surgery was performed for 36 patients (15.2 ±2.5 y.o) with concomitant isthmic spondylolisthesis, and 428 patients (15.5 ±2.4 y.o) without concomitant spondylolisthesis. The two groups were similar in terms of age, sex, preoperative and postoperative Cobb angles. Preoperative and postoperative HRQoL scores were similar between the two groups. HRQoL improved significantly for all domains in both groups, except for pain in patients with spondylolisthesis. There was no need for surgical treatment of the spondylolisthesis and no slip progression during the follow-up duration after AIS surgery.

Patients undergoing surgical treatment of AIS with non-surgical management of a concomitant isthmic spondylolisthesis can expect improvement in HRQoL scores, similar to that observed in patients without concomitant spondylolisthesis.

Acute spinal cord injury (SCI) is most often secondary to trauma, and frequently presents with associated injuries. A neurological examination is routinely performed during trauma assessment, including through Advanced Trauma Life Support (ATLS). However, there is no standard neurological assessment tool specifically used for trauma patients to detect and characterize SCI during the initial evaluation. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive and popular tool for assessing SCI, but it is not adapted to the acute trauma patients such that it is not routinely used in that setting. Therefore, the objective is to develop a new tool that can be used routinely in the initial evaluation of trauma patients to detect and characterize acute SCI, while preserving basic principles of the ISNCSCI.

The completion rate of the ISCNSCI during the initial evaluation after an acute traumatic SCI was first estimated. Using a modified Delphi technique, we designed the Montreal Acute Classification of Spinal Cord Injuries (MAC-SCI), a new tool to detect and characterize the completeness (grade) and level of SCI in the polytrauma patient. The ability of the MAC-SCI to detect and characterize SCI was validated in a cohort of 35 individuals who have sustained an acute traumatic SCI. The completeness and neurological level of injury (NLI) were assessed by two independent assessors using the MAC-SCI, and compared to those obtained with the ISNCSCI.

Only 33% of patients admitted after an acute traumatic SCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI includes 53 of the 134 original elements of the ISNCSCI which is 60% less. There was a 100% concordance between the severity grade derived from the MAC-SCI and from the ISNCSCI. Concordance of the NLI within two levels of that obtained from the ISNCSCI was observed in 100% of patients with the MAC-SCI and within one level in 91% of patients. The ability of the MAC-SCI to discriminate between cervical (C0 to C7) vs. thoracic (T1 to T9) vs. thoraco-lumbar (T10 to L2) vs. lumbosacral (L3 to S5) injuries was 100% with respect to the ISNCSCI.

The rate of completion of the ISNCSCI is low at initial presentation after an acute traumatic SCI. The MAC-SCI is a streamlined tool proposed to detect and characterize acute SCI in polytrauma patients, that is specifically adapted to the acute trauma setting. It is accurate for determining the completeness of the SCI and localize the NLI (cervical vs. thoracic vs. lumbar). It could be implemented in the initial trauma assessment protocol to guide the acute management of SCI patients.

Acute spinal cord injury (SCI) is most often secondary to trauma, and frequently presents with associated injuries. A neurological examination is routinely performed during trauma assessment, including through Advanced Trauma Life Support (ATLS). However, there is no standard neurological assessment tool specifically used for trauma patients to detect and characterize SCI during the initial evaluation. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive and popular tool for assessing SCI, but it is not adapted to the acute trauma patients such that it is not routinely used in that setting. Therefore, the objective is to develop a new tool that can be used routinely in the initial evaluation of trauma patients to detect and characterize acute SCI, while preserving basic principles of the ISNCSCI.

The completion rate of the ISCNSCI during the initial evaluation after an acute traumatic SCI was first estimated. Using a modified Delphi technique, we designed the Montreal Acute Classification of Spinal Cord Injuries (MAC-SCI), a new tool to detect and characterize the completeness (grade) and level of SCI in the polytrauma patient. The ability of the MAC-SCI to detect and characterize SCI was validated in a cohort of 35 individuals who have sustained an acute traumatic SCI. The completeness and neurological level of injury (NLI) were assessed by two independent assessors using the MAC-SCI, and compared to those obtained with the ISNCSCI.

Only 33% of patients admitted after an acute traumatic SCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI includes 53 of the 134 original elements of the ISNCSCI which is 60% less. There was a 100% concordance between the severity grade derived from the MAC-SCI and from the ISNCSCI. Concordance of the NLI within two levels of that obtained from the ISNCSCI was observed in 100% of patients with the MAC-SCI and within one level in 91% of patients. The ability of the MAC-SCI to discriminate between cervical (C0 to C7) vs. thoracic (T1 to T9) vs. thoraco-lumbar (T10 to L2) vs. lumbosacral (L3 to S5) injuries was 100% with respect to the ISNCSCI.

The rate of completion of the ISNCSCI is low at initial presentation after an acute traumatic SCI. The MAC-SCI is a streamlined tool proposed to detect and characterize acute SCI in polytrauma patients, that is specifically adapted to the acute trauma setting. It is accurate for determining the completeness of the SCI and localize the NLI (cervical vs. thoracic vs. lumbar). It could be implemented in the initial trauma assessment protocol to guide the acute management of SCI patients.

There is a significant positive association between hours of brace wear and rate of success in the treatment of Adolescent Idiopathic Scoliosis (AIS). The abandon rate reported in the literature averages 18%. In a recent randomized trial conducted at our center; the abandon rate was 4%. We aim to document the abandon rate towards brace treatment during the COVID-19 pandemic and its impact on AIS progression.

We reviewed a database of AIS patients recruited between March and September 2020. Inclusion criteria were patients with AIS under brace treatment according to SRS criteria. The patients were divided in 2 cohorts: those with a self-reported good adherence to treatment and those who voluntarily abandoned treatment during follow-up. Patients with irregular adherence were excluded. Data analysis included age, gender, Risser stage, type of brace, Cobb angles at first visit and last follow-up (mean 11 months) and % of progression. Unpaired student tests were used for comparison.

154 patients met inclusion criteria. 20 patients were excluded due to irregular adherence. 89 patients (age: 12.1 y.o. ±1.4) reported good adherence to treatment, while 45 patients (age: 12.6 y.o. ±1.5) abandoned treatment, an abandon rate of 29%. The cohort of compliant patients started treatment with a mean main thoracic (MT) curve of 26° and finished with 27°. The mean difference between measurements was +0.65°±7.5; mean progression rate was −4.6%. However, patients who abandoned treatment started with a mean MT curve of 28° and finished with 33°, with a mean increase of +5°±8 and a mean progression rate of −11%. The differences between the 2 cohorts were statistically significant (p=0.002). Five (5) patients from the abandon group were offered for surgery because of curve progression.

The abandon rate of brace treatment in AIS significantly increased during the first wave of COVID-19 pandemic. Patients who voluntarily discontinued treatment had significant increases in curve progression and surgical indication rates.

Proximal junctional kyphosis (PJK) is defined as adjacent segment kyphosis >10° between the upper instrumented vertebrae and the vertebrae 2 levels above following scoliosis surgery. There are few studies investigating the predictors and clinical sequelae involved with this relatively common complication. Our purpose was to determine the radiographic predictors of post-op PJK and to examine the association between PJK and pain/HRQOL following surgery for AIS.

The Post-Operative Recovery after Scoliosis Correction: Home Experience (PORSCHE) study was a prospective multicenter cohort of AIS patients undergoing spinal fusion surgery. Pre-op and minimum 2 year f/u scoliosis and sagittal spinopelvic parameters (thoracic kyphosis–TK, lordosis–LL, pelvic tilt-PT, sacral slope-SS, pelvic incidence-PI) were measured and compared to numeric rating scale for pain (NRS) score, SRS-30 HRQOL and to the presence or absence of PJK (proximal junctional angle >100). Continuous and categorical variables were assessed using logistic regression and binomial variables were compared to binomial outcomes using chi-square.

163 (137 females) patients from 8 Canadian centers met inclusion criteria. At final f/u, PJK was present in 27 patients (17%). Pre-op means for PJK vs No PJK: Age 14.1 vs 14.7yr; females 85 vs 86%; scoliosis 57±22 vs 62±15deg; TK 28±18 vs 19±16deg ∗, LL 62±11 vs 60±12deg, PT 8±12 vs 10±10deg, SS 39±8 vs 41±9deg, PI 47±14 vs 52±13deg, SVA −9±30 vs −7±31mm. Final f/u for PJK vs No PJK: Scoliosis 20±11 vs 18±8deg, final TK 26±12 vs 19±10deg∗, LL 60±11 vs 57±12deg, PT 9±12 vs 12±13deg, SS 39±9 vs 41±9deg, PI 48±17 vs 52±14deg, SVA −23±26 vs −9±32mm∗. Significant findings: Pre-op kyphosis >40deg has an odds ratio (OR) of 4.41 (1.50–12.92) for developing PJK∗. The presence of PJK was not associated with any significant differences in NRS or SRS-30. ∗denotes p<0.05.

This prospective multicenter cohort of AIS patients demonstrated a 17% risk of developing PJK. Pre-op thoracic kyphosis >40deg was associated with the development of PJK; however, the presence of PJK was not associated with increased pain or decreased HRQOL.

Referral patterns in spine clinic of young patients with suspected scoliosis is suboptimal with 19% of late referrals and 42% of inappropriate referrals. Patients' triage and prioritisation in spine clinic is a strategy to ensure that health care allocation is done according to the level of health needs, favoring effective management and efficient use of health care resources use. The objective of the study is to elaborate a model for triage and prioritisation of young patients in spine clinic based on expert consensus and literature on best practices.

This projects was structured in three parts: 1)We documented best evidence. We conducted a review of empirical studies evaluating triage and prioritisation initiatives in order to identify key components for intervention success. 2)We elaborate a model of health care delivery with the professionals of a local paediatric spine clinic. In this model, the triage and prioritisation algorithm was developed from list of potential factors (demographics, signs and perceived symptoms, provisional diagnoses and known co-morbidities, results of preliminary physical examination and radiological findings) that was submitted to five paediatric orthopaedic surgeons for rating according to their potential relevance to orient prioritisation decisions. 3) We compared the professionals' model of health care delivery to the literature synthesis in order to propose the best model.

Seven key components of triage and prioritisation systems were identified: centralised review of referral requests, list of consensual objectives criteria for triage, fast track evaluation of urgent cases, selection of cases for management at point of triage, cases prioritisation to main consultant, multidisciplinary evaluation and alternatives pathways. The consensual decision algorithm confirmed that cases who should be seen in priority are immature patients presenting with a significant trunk deformity. In addition, presence of persisting neurological symptoms, severe incapacitating pain or night pain, as well as abnormal scan or MRI findings were considered as urgent/PI priority. Cases characteristics for evaluation by nurse practitioners as well as alternative pathways of management were defined. Acceptability, compatibility, clinical relevance and discriminant capacity of the new model of health care delivery were satisfactorily demonstrated.

Consensus was easily reached between the five respondents on factors supporting decisions to prioritise patients in spine clinic for suspected spinal deformity. Refinements to the initially proposed model according the identified key features from the literature, led to a final model of health care delivery that is evidence-base, feasible and coherent with the local context. Future implementation of this model should facilitate timely and appropriate health care delivery and best use of health care resources according to patients' needs.

Background Context

Different minimally invasive approaches to the lumbar spine have been proposed but they can be associated with increased risk of complications, steep learning curve and longer operative time.

Purpose: To determine the reliability of six measurement techniques for lumbosacral kyphosis.

Method: Using custom computer software, four raters evaluated 60 standing lateral radiographs of the lumbosacral spine during two sessions at a one week interval. The sample size consisted of 20 normal, 20 low and 20 high grade spondylolisthetic subjects. Six parameters were included for analysis: Boxall’s slip angle; Dubousset’s lumbosacral angle (LSA); the Spinal Deformity Study Group’s (SDSG) LSA; dysplastic SDSG LSA; sagittal rotation (SR); kyphotic Cobb angle (k-Cobb). Intra- and inter- rater reliability for all parameters was assessed using intra-class correlation coefficients (ICC). Correlations between parameters and slip percentage were evaluated with Pearson coefficients.

Results: The intra-rater ICC’s for all the parameters ranged between 0.81 and 0.97 and the inter-rater ICC’s were between 0.74 and 0.98. All parameters except sagittal rotation showed a medium to large correlation with slip percentage. Dubousset’s LSA and the kyphotic Cobb angle showed the largest correlations (r=−0.78 and r=−0.50, respectively). Sagittal rotation was associated with the weakest correlation (r=−0.10). All other parameters had medium correlations with percent slip (r=0.31 to 0.43).

Conclusion: All measurement techniques provided substantial to almost perfect inter- and intra- rater reliability. Dubousset’s LSA showed the strongest correlation with slip grade. However, this parameter does not reflect the local dysplastic changes that occur in lower L5 and upper S1 endplates. A longitudinal study evaluating the best suited parameter for predicting the risk of progression and response to surgical treatment is warranted.

Purpose: To determine the relationship between sacral morphology and developmental L5/S1 spondylolisthesis in children and adolescent.

Method: A radiographic study was conducted to investigate sacral morphology in developmental L5/S1 spondylolisthesis in a pediatric and adolescent population. The lateral standing radiographs of 131 subjects, aged 6 to 20 years old with developmental L5-S1 spondylolisthesis (91 low grade and 40 high grade) were analyzed with a dedicated software allowing to measure the following parameters, which were analyzed for each subject by the same individual and compared to an age and sex-matched cohort of 120 asymptomatic subjects: the sacral table index (STI), the sacral table angle (STA), the sacral kyphosis (SK), S1 superior angle, S2 inferior angle, and grade of spondylolisthesis. Student t tests were used to compare the parameters between the curve types.

Results: This study demonstrated that STA is significantly smaller (p< 0.01) in children and adolescents with L5-S1 spondylolisthesis compared to a similar control group. Furthermore, STA is significantly smaller in high grade spondylolisthesis when compared to subjects with low grade. There is also a significant difference in segmental sacral morphology (S1 and S2 anatomy) in the spondylolisthesis group. Increasing sacral kyphosis is also found to be significantly associated with spondylolisthesis.

Conclusion: The sagittal sacral morphology is a constant anatomic variable specific to each normal individual. The anatomy of the sacrum in children and aldolescentss with L5-S1 spondylolisthesis is particular and different from a control group. This study suggests that sacral anatomy may have a direct influence on the development of spondylolisthesis: a lower STA and higher sacral kyphosis may be two factors predisposing to vertebral slip in developmental spondylolisthesis.

This study evaluated the sagittal alignment of the spine and pelvis in adolescent idiopathic scoliosis. The pelvic configuration influenced the lumbar lordosis but was not associated with the thoracic kyphosis or with the curve type. The pelvic incidence in adolescent idiopathic scoliosis was higher than that reported in the literature for normal adolescents and was closer to the values of pelvic incidence found in adults. The role of the PI in the pathogenesis of AIS needs to be explored in a comparative study involving AIS patients and normal adolescents.

The purpose of this study was to evaluate the sagittal alignment of the spine and pelvis in adolescent idiopathic scoliosis (AIS) based on the curve type.

Five sagittal parameters were retrospectively evaluated on lateral radiographs for one hundred and sixty AIS patients: thoracic kyphosis (TK), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT) and pelvic incidence (PI). The patients were classified according to their coronal curve type. ANOVA was used to compare the parameters between the curve types and Pearson’s coefficients were used to investigate the relationship between all parameters.

The TK was significantly lower for King I, II and III curves as compared to lumbar curves. The LL was higher for lumbar curves, although not significantly. No significant change between the groups was observed for SS, PT and PI. The PI was significantly correlated to LL, SS and PT for all groups. The LL was strongly related to the SS in all cases but not with the TK, except for thoracolumbar curves.

The TK mostly depended on the spinal deformity while the LL was mainly influenced by the pelvic configuration. The scoliotic curve type was not associated with a specific pattern of sagittal pelvic configuration. The PI was significantly higher than that reported in the literature for normal adolescents.

The role of the PI in the pathogenesis of AIS needs to be explored in a comparative study involving AIS patients and normal adolescents.

Further study is needed to evaluate the prognostic value of the PI in AIS.

Funding: This research was funded by the Canadian Institute of Health Research.

Please contact author for figures and/or diagrams.

This research sought a mathematical model to relate the postero-anterior (PA) and lateral (LAT) views of the spinal curve in scoliosis in an attempt to justify the acquisition of only One X-ray, thereby reducing patient exposure to harmful X-radiation while preserving complete 3D characterization of the spine. Using powerful developments in functional statistics and machine learning, no such relation could be found. Thus, this research sustained the clinical decision to acquire two biplanar X-rays and supported current research in 3D spinal curvature analysis.

Scoliosis is monitored through full spinal X-rays, and this serial protocol causes an increased incidence of cancer development. This research sustains the clinical decision at Hôpital Sainte-Justine in Montréal and elsewhere to acquire postero-anterior (PA) and lateral (LAT) X-rays, despite the increased exposure to X-radiation. Indeed, geometrically, these two views are required to reconstruct the spine in 3D. However, under the assumption of strong physiological patterns between the PA and LAT views of the spinal curve, one of these X-rays may be redundant for some or all patients. The purpose of this study was to seek this a priori assumption.

To this end, a database consisting of three hundred and sixty-nine spinal reconstructions from distinct patients was used. Two powerful geometric modeling approaches were exploited: functional data analysis and minimum noise fractions. These resulted in five comprehensive, uncorrelated and noise-insensitive features in each plane. Simple linear regression yielded no relation that was statistically significant (p< 0.05) and genereralizable to a set of previously unseen samples. Therefore, nonlinear relational modeling was attempted using support vector regression, a recent advance in machine learning theory. This tool was incapable of identifying a robust regression, suggesting that the PA and LAT views are mathematically independent. Thus, this study highlights the necessity of two biplanar X-rays to evaluate scoliotic deformities and fully characterize spinal shape. Further, this study supports the practical insufficiency observed by clinical staff with respect to current 2D scoliosis classifications that has resulted in current efforts to propose 3D classification schemes.

When evaluating and treating patients with spinal disorders, a significant knowledge of the normal spinopelvic balance is of primary importance. This study documents the spinopelvic balance in normal children and adolescents, and describes a scheme of correlations between morphological, shape and orientation parameters of the spine and pelvis. It is found that the pelvic incidence regulates the sacral slope and pelvic tilt. In addition, shape and orientation parameters of adjacent anatomical regions are interdependent, and their relationships result in a stable posture with minimum energy expenditure.

Evaluate the correlations between spinopelvic parameters in normal children and adolescents.

Seven parameters were evaluated from the lateral standing radiographs of two hundred and eighty-two normal subjects aged three to eighteen years old: thoracic kyphosis (TK), thoracic tilt (TT), lumbar lordosis (LL), lumbar tilt (LT), sacral slope (SS), pelvic tilt (PT) and pelvic incidence (PI). Statistical analysis was performed using Pearson’s coefficients.

The mean PI (morphological parameter) was 49.0±11.3°. The mean values for shape parameters were 41.4±8.5°, 48.0±12.0° and 44.3±11.2° for SS, LL and TK, respectively. The mean values for orientation parameters were 7.5±8.1°, −7.0±5.1° and −2.6±5.0° for PT, LT and TT, respectively. There was no significant difference between males and females. PI was significantly related to SS and PT. Significant correlations were found between orientation and shape parameters of adjacent anatomical regions.

This study describes a scheme of correlations between morphological, shape and orientation parameters of the spine and pelvis. It is found that the pelvic incidence regulates the sacral slope and pelvic tilt. In addition, shape and orientation parameters of adjacent anatomical regions are interdependent, and their relationships result in a stable posture with minimum energy expenditure.

This study presents a postural model in order to better understand the spinopelvic balance in normal children and adolescents. This model could help to evaluate the influence of pelvic morphology on the progression and treatment of pediatric spinal deformities.

This research was funded by an educational/research grant from Medtronic Sofamor Danek, by the Canadian Institute of Health Research, by the Fonds de Recherche en Santé du Québec and by the Fondation de recherche et d’éducation en orthopédie de Montréal (FREOM).