Aims

The prevalence of scoliosis is not known in patients with idiopathic short stature, and the impact of treatment with recombinant human growth hormone on those with scoliosis remains controversial. We investigated the prevalence of scoliosis radiologically in children with idiopathic short stature, and the impact of treatment with growth hormone in a cross-sectional and retrospective cohort study.

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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.

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.

Aims

The aim of this study was to determine whether there is an increased prevalence of scoliosis in patients who have suffered from a haematopoietic malignancy in childhood.

Aims. The aim of the present study was to answer the question whether curve morphology and location have an influence on rigid conservative treatment in patients with adolescent idiopathic scoliosis (AIS). Methods. We retrospectively analyzed AIS in 127 patients with single and double curves who had been treated with a Chêneau brace and physiotherapeutic specific exercises (B-PSE). The inclusion criteria were the presence of structural major curves ≥ 20° and < 50° (Risser stage 0 to 2) at the time when B-PSE was initiated. The patients were divided into two groups according to the outcome of treatment: failure (curve progression to ≥ 45° or surgery) and success (curve progression < 45° and no surgery). The main curve type (MCT), curve magnitude, and length (overall, above and below the apex), apical rotation, initial curve correction, flexibility, and derotation by the brace were compared between the two groups. Results. In univariate analysis treatment failure depended significantly on: 1) MCT (p = 0.008); 2) the apical rotation of the major curve before (p = 0.007) and during brace treatment (p < 0.001); 3) the initial and in-brace Cobb angles of the major (p = 0.001 and p < 0.001, respectively) and minor curves (p = 0.015 and p = 0.002); 4) major curve flexibility (p = 0.005) and the in-brace curve correction rates (major p = 0.008, minor p = 0.034); and 5) the length of the major curve (LoC) above (p < 0.001) and below (p = 0.002) the apex. Furthermore, MCT (p = 0.043, p = 0.129, and p = 0.017 in MCT comparisons), LoC (upper length p = 0.003, lower length p = 0.005), and in-brace Cobb angles (major p = 0.002, minor p = 0.027) were significant in binary logistic regression analysis. Conclusion. Curve size, location, and morphology were found to influence the outcome of rigid conservative treatment of AIS. These findings may improve future brace design and patient selection for conservative treatment. Cite this article: Bone Joint J 2021;103-B(2):373–381

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The aim of this study was to investigate whether including the stages of ulnar physeal closure in Sanders stage 7 aids in a more accurate assessment for brace weaning in patients with adolescent idiopathic scoliosis (AIS).

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To report the mid-term results of a modified self-growing rod (SGR) technique for the treatment of idiopathic and neuromuscular early-onset scoliosis (EOS).

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The health-related quality of life (HRQoL) of paediatric patients with orthopaedic conditions and spinal deformity is important, but existing generic tools have their shortcomings. We aim to evaluate the use of Paediatric Quality of Life Inventory (PedsQL) 4.0 generic core scales in the paediatric population with specific comparisons between those with spinal and limb pathologies, and to explore the feasibility of using PedsQL for studying scoliosis patients’ HRQoL.

Aims

It is uncertain whether instrumented spinal fixation in nonambulatory children with neuromuscular scoliosis should finish at L5 or be extended to the pelvis. Pelvic fixation has been shown to be associated with up to 30% complication rates, but is regarded by some as the standard for correction of deformity in these conditions. The incidence of failure when comparing the most caudal level of instrumentation, either L5 or the pelvis, using all-pedicle screw instrumentation has not previously been reported. In this retrospective study, we compared nonambulatory patients undergoing surgery at two centres: one that routinely instrumented to L5 and the other to the pelvis.

Aims

Intraoperative 3D navigation (ION) allows high accuracy to be achieved in spinal surgery, but poor workflow has prevented its widespread uptake. The technical demands on ION when used in patients with adolescent idiopathic scoliosis (AIS) are higher than for other more established indications. Lean principles have been applied to industry and to health care with good effects. While ensuring optimal accuracy of instrumentation and safety, the implementation of ION and its associated productivity was evaluated in this study for AIS surgery in order to enhance the workflow of this technique. The aim was to optimize the use of ION by the application of lean principles in AIS surgery.

Adolescent idiopathic scoliosis (AIS) is a complex 3D deformity of the spine. Its prevalence is between 2% and 3% in the general population, with almost 10% of patients requiring some form of treatment and up to 0.1% undergoing surgery. The cosmetic aspect of the deformity is the biggest concern to the patient and is often accompanied by psychosocial distress. In addition, severe curves can cause cardiopulmonary distress. With proven benefits from surgery, the aims of treatment are to improve the cosmetic and functional outcomes. Obtaining correction in the coronal plane is not the only important endpoint anymore. With better understanding of spinal biomechanics and the long-term effects of multiplanar imbalance, we now know that sagittal balance is equally, if not more, important. Better correction of deformities has also been facilitated by an improvement in the design of implants and a better understanding of metallurgy. Understanding the unique character of each deformity is important. In addition, using the most appropriate implant and applying all the principles of correction in a bespoke manner is important to achieve optimum correction.

In this article, we review the current concepts in AIS surgery.

Cite this article: Bone Joint J 2018;100-B:415–24.

Aims

We present the results of correcting a double or triple curve adolescent idiopathic scoliosis using a convex segmental pedicle screw technique.

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

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

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

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

We reviewed 31 consecutive patients with Friedreich’s ataxia and scoliosis. There were 24 males and seven females with a mean age at presentation of 15.5 years (8.6 to 30.8) and a mean curve of 51° (13° to 140°). A total of 12 patients had thoracic curvatures, 11 had thoracolumbar and eight had double thoracic/lumbar. Two patients had long thoracolumbar collapsing scoliosis with pelvic obliquity and four had hyperkyphosis. Left-sided thoracic curves in nine patients (45%) and increased thoracic kyphosis differentiated these deformities from adolescent idiopathic scoliosis. There were 17 patients who underwent a posterior instrumented spinal fusion at mean age of 13.35 years, which achieved and maintained good correction of the deformity. Post-operative complications included one death due to cardiorespiratory failure, one revision to address nonunion and four patients with proximal junctional kyphosis who did not need extension of the fusion. There were no neurological complications and no wound infections. The rate of progression of the scoliosis in children kept under simple observation and those treated with bracing was less for lumbar curves during bracing and similar for thoracic curves. The scoliosis progressed in seven of nine children initially treated with a brace who later required surgery. Two patients presented after skeletal maturity with balanced curves not requiring correction. Three patients with severe deformities who would benefit from corrective surgery had significant cardiac co-morbidities.

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

In order to determine the epidemiology of adult scoliosis in the elderly and to analyse the radiological parameters and symptoms related to adult scoliosis, we carried out a prospective cross-sectional radiological study on 1347 adult volunteers. There were 615 men and 732 women with a mean age of 73.3 years (60 to 94), and a mean Cobb angle of 7.55° (sd 5.95).

In our study, 478 subjects met the definition of scoliosis (Cobb angle ≥10°) showing a prevalence of 35.5%. There was a significant difference in the epidemiological distribution and prevalence between the age and gender groups. The older adults showed a larger prevalence and more severe scoliosis, more prominent in women (p = 0.004). Women were more affected by adult scoliosis and showed more linear correlation with age (p < 0.001). Symptoms were more severe in those with scoliosis than in the normal group, but were similar between the mild, moderate and severe scoliosis groups (p = 0.224) and between men and women (p = 0.231).

Adult scoliosis showed a significant relationship with lateral listhesis, vertebral rotation, lumbar hypolordosis, sagittal imbalance and a high level of the L4–5 disc (p < 0.0001, p < 0.0001, p = 0.002, p = 0.002, p < 0.0001 respectively). Lateral listhesis, lumbar hypolordosis and sagittal imbalance were related to symptoms (p < 0.0001, p = 0.001, p < 0.0001 respectively).

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