Aims. This systematic review aims to identify 3D predictors derived from biplanar reconstruction, and to describe current methods for improving curve prediction in patients with mild adolescent idiopathic scoliosis. Methods. A comprehensive search was conducted by three independent investigators on MEDLINE, PubMed, Web of Science, and Cochrane Library. Search terms included “adolescent idiopathic scoliosis”,“3D”, and “progression”. The inclusion and exclusion criteria were carefully defined to include clinical studies. Risk of bias was assessed with the Quality in Prognostic Studies tool (QUIPS) and Appraisal tool for Cross-Sectional Studies (AXIS), and level of evidence for each predictor was rated with the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. In all, 915 publications were identified, with 377 articles subjected to full-text screening; overall, 31 articles were included. Results. Torsion index (TI) and apical vertebral rotation (AVR) were identified as accurate predictors of curve progression in early visits. Initial TI > 3.7° and AVR > 5.8° were predictive of curve progression. Thoracic hypokyphosis was inconsistently observed in progressive curves with weak evidence. While sagittal wedging was observed in mild curves, there is insufficient evidence for its correlation with curve progression. In curves with initial Cobb angle < 25°, Cobb angle was a poor predictor for future curve progression. Prediction accuracy was improved by incorporating serial reconstructions in stepwise layers. However, a lack of post-hoc analysis was identified in studies involving geometrical models. Conclusion. For patients with mild curves, TI and AVR were identified as predictors of curve progression, with TI > 3.7° and AVR > 5.8° found to be important thresholds. Cobb angle acts as a poor predictor in mild curves, and more investigations are required to assess thoracic kyphosis and wedging as predictors. Cumulative reconstruction of radiographs improves prediction accuracy. Comprehensive analysis between progressive and non-progressive curves is recommended to extract meaningful thresholds for clinical prognostication. Cite this article: Bone Jt Open 2024;5(3):243–251

Adolescent idiopathic scoliosis is a three-dimensional deformity of the spine, affecting 1–3% of the population. Most cases are treated conservatively. Curves exceeding 45° in the thoracic spine and 40° in the lumbar spine may require correction and fusion surgery, to limit the progression of the curve and prevent restrictive pulmonary insufficiency (curves above 70°). When fusion is required, it may be performed either by posterior or anterior approaches. Posterior is useful for thoracic (Lenke I) curves, notably to correct the thoracic hypokyphosis frequently observed in AIS. Anterior approaches by thoraco-lombotomies allow an effective correction of thoraco-lumbar and lumbar curves (Lenke V and VI), with fewer levels fused than with posterior approaches. However, the approach requires diaphragm splitting and one may be concerned about the long-term pulmonary consequences. The literature provides conflicting insight regarding the consequences of the approach in anterior scoliosis correction, the interpretation of the results being difficult knowing that the correction of the scoliosis itself may improve pulmonary function. This is a retrospective observational study done at a Tertiary Institution. The HRQOL scores have been collected as a prospective cohort. Clinical and radiographic data was collected from patients charts and analysed by two senior surgeons. A cohort of 64 patients were operated in the given time period. 50 patients met the inclusion criteria. No major complications were reported. The Union rate was 100% and no post operative complications were noted. Pre and post SRS scores improved in all patients. The Anterior approach for Lenke V AIS gives great surgical exposure and allows for excellent correction of Cobb angle with minimal risk to the patient

Adolescent idiopathic scoliosis (AIS), defined by an age at presentation of 11 to 18 years, has a prevalence of 0.47% and accounts for approximately 90% of all cases of idiopathic scoliosis. Despite decades of research, the exact aetiology of AIS remains unknown. It is becoming evident that it is the result of a complex interplay of genetic, internal, and environmental factors. It has been hypothesized that genetic variants act as the initial trigger that allow epigenetic factors to propagate AIS, which could also explain the wide phenotypic variation in the presentation of the disorder. A better understanding of the underlying aetiological mechanisms could help to establish the diagnosis earlier and allow a more accurate prediction of deformity progression. This, in turn, would prompt imaging and therapeutic intervention at the appropriate time, thereby achieving the best clinical outcome for this group of patients.

Cite this article: Bone Joint J 2022;104-B(8):915–921.

Aims

This study addressed two questions: first, does surgical correction of an idiopathic scoliosis increase the volume of the rib cage, and second, is it possible to evaluate the change in lung function after corrective surgery for adolescent idiopathic scoliosis (AIS) using biplanar radiographs of the ribcage with 3D reconstruction?

Aims

High-grade dysplastic spondylolisthesis is a disabling disorder for which many different operative techniques have been described. The aim of this study is to evaluate Scoliosis Research Society 22-item (SRS-22r) scores, global balance, and regional spino-pelvic alignment from two to 25 years after surgery for high-grade dysplastic spondylolisthesis using an all-posterior partial reduction, transfixation technique.

Aims. Significant correction of an adolescent idiopathic scoliosis in the coronal plane through a posterior approach is associated with hypokyphosis. Factors such as the magnitude of the preoperative coronal curve, the use of hooks, number of levels fused, preoperative kyphosis, screw density, and rod type have all been implicated. Maintaining the normal thoracic kyphosis is important as hypokyphosis is associated with proximal junctional failure (PJF) and early onset degeneration of the spine. The aim of this study was to determine if coronal correction per se was the most relevant factor in generating hypokyphosis. Methods. A total of 95 patients (87% female) with a median age of 14 years were included in our study. Pre- and postoperative radiographs were measured and the operative data including upper instrumented vertebra (UIV), lower instrumented vertebra (LIV), metal density, and thoracic flexibility noted. Further analysis of the post-surgical coronal outcome (group 1 < 60% correction and group 2 ≥ 60%) were studied for their association with the postoperative kyphosis in the sagittal plane using univariate and multivariate logistic regression. Results. Of the 95 patients, 71.6% (68) had a thoracic correction of > 60%. Most (97.8%) had metal density < 80%, while thoracic flexibility > 50% was found in 30.5% (29). Preoperative hypokyphosis (< 20°) was present in 25.3%. A postoperative thoracic hypokyphosis was four times more likely to occur in patients with thoracic correction ≥ 60% (odds ratio (OR) 4.08; p = 0.005), after adjusting for confounding variables. This association was not affected by metal density, thoracic flexibility, LIV, UIV, age, or sex. Conclusion. Our study supports the ‘essential lordosis’ hypothesis of Roaf and Dickson, i.e. with a greater ability to translate the apical vertebra towards the midline, there is a commensurate lengthening of the anterior column due to the vertebral wedging. Cite this article: Bone Joint J 2020;102-B(4):513–518

Aims. To compare the rates of sagittal and coronal correction for all-pedicle screw instrumentation and hybrid instrumentation using sublaminar bands in the treatment of thoracic adolescent idiopathic scoliosis (AIS). Methods. We retrospectively reviewed the medical records of 124 patients who had undergone surgery in two centres for the correction of Lenke 1 or 2 AIS. Radiological evaluation was carried out preoperatively, in the early postoperative phase, and at two-year follow-up. Parameters measured included coronal Cobb angles and thoracic kyphosis. Postoperative alignment was compared after matching the cohorts by preoperative coronal Cobb angle, thoracic kyphosis, lumbar lordosis, and pelvic incidence. Results. A total of 179 patients were available for analysis. After matching, 124 patients remained (62 in each cohort). Restoration of thoracic kyphosis was significantly better in the sublaminar band group than in the pedicle screw group (from 23.7° to 27.5° to 34.0° versus 23.9° to 18.7° to 21.5°; all p < 0.001). When the preoperative thoracic kyphosis was less than 20°, sublaminar bands achieved a normal postoperative thoracic kyphosis, whereas pedicle screws did not. In the coronal plane, pedicle screws resulted in a significantly better correction than sublaminar bands at final follow-up (73.0% versus 59.7%; p < 0.001). Conclusion. This is the first study to compare sublaminar bands and pedicle screws for the correction of a thoracic AIS. We have shown that pedicle screws give a good coronal correction which is maintained at two-year follow-up. Conversely, sublaminar bands restore the thoracic kyphosis better while pedicle screws are associated with a flattening of the thoracic spine. In patients with preoperative hypokyphosis, sublaminar bands should be used to restore a proper sagittal profile. Cite this article: Bone Joint J 2020;102-B(3):376–382

Aims. The aim of this study was to determine the influence of pelvic parameters on the tendency of patients with adolescent idiopathic scoliosis (AIS) to develop flatback deformity (thoracic hypokyphosis and lumbar hypolordosis) and its effect on quality-of-life outcomes. Patients and Methods. This was a radiological study of 265 patients recruited for Boston bracing between December 2008 and December 2013. Posteroanterior and lateral radiographs were obtained before, immediately after, and two-years after completion of bracing. Measurements of coronal and sagittal Cobb angles, coronal balance, sagittal vertical axis, and pelvic parameters were made. The refined 22-item Scoliosis Research Society (SRS-22r) questionnaire was recorded. Association between independent factors and outcomes of postbracing ≥ 6° kyphotic changes in the thoracic spine and ≥ 6° lordotic changes in the lumbar spine were tested using likelihood ratio chi-squared test and univariable logistic regression. Multivariable logistic regression models were then generated for both outcomes with odds ratios (ORs), and with SRS-22r scores. Results. Reduced T5-12 kyphosis (mean -4.3° (. sd. 8.2); p < 0.001), maximum thoracic kyphosis (mean -4.3° (. sd. 9.3); p < 0.001), and lumbar lordosis (mean -5.6° (. sd. 12.0); p < 0.001) were observed after bracing treatment. Increasing prebrace maximum kyphosis (OR 1.133) and lumbar lordosis (OR 0.92) was associated with postbracing hypokyphotic change. Prebrace sagittal vertical axis (OR 0.975), prebrace sacral slope (OR 1.127), prebrace pelvic tilt (OR 0.940), and change in maximum thoracic kyphosis (OR 0.878) were predictors for lumbar hypolordotic changes. There were no relationships between coronal deformity, thoracic kyphosis, or lumbar lordosis with SRS-22r scores. Conclusion. Brace treatment leads to flatback deformity with thoracic hypokyphosis and lumbar hypolordosis. Changes in the thoracic spine are associated with similar changes in the lumbar spine. Increased sacral slope, reduced pelvic tilt, and pelvic incidence are associated with reduced lordosis in the lumbar spine after bracing. Nevertheless, these sagittal parameter changes do not appear to be associated with worse quality of life. Cite this article: Bone Joint J 2019;101-B:1370–1378

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.

We describe 13 patients with cerebral palsy and lordoscoliosis/hyperlordosis of the lumbar spine who underwent a posterior spinal fusion at a mean age of 14.5 years (10.8 to 17.4) to improve sitting posture and relieve pain. The mean follow-up was 3.3 years (2.2 to 6.2).

The mean pre-operative lumbar lordosis was 108^° (80 to 150^°) and was corrected to 62^° (43^° to 85^°); the mean thoracic kyphosis from 17^° (-23^° to 35^°) to 47^° (25^° to 65^°); the mean scoliosis from 82^° (0^° to 125^°) to 22^° (0^° to 40^°); the mean pelvic obliquity from 21^° (0^° to 38^°) to 3^° (0^° to 15^°); the mean sacral slope from 79^° (54^° to 90^°) to 50^° (31^° to 66^°). The mean pre-operative coronal imbalance was 5 cm (0 cm to 8.9 cm) and was corrected to 0.6 cm (0 to 3.2). The mean sagittal imbalance of -8 cm (-16 cm to 7.8 cm) was corrected to -1.6 cm (-4 cm to 2.5 cm). The mean operating time was 250 minutes (180 to 360 minutes) and intra-operative blood loss 0.8 of estimated blood volume (0.3 to 2 estimated blood volume). The mean intensive care and hospital stay were 3.5 days (2 to 8) and 14.5 days (10 to 27), respectively. Three patients lost a significant amount of blood intra-operatively and subsequently developed chest or urinary infections and superior mesenteric artery syndrome.

An increased pre-operative lumbar lordosis and sacral slope were associated with increased peri-operative morbidity: scoliosis and pelvic obliquity were not. A reduced lumbar lordosis and increased thoracic kyphosis correlated with better global sagittal balance at follow-up. All patients and their parents reported excellent surgical outcomes.

Lordoscoliosis and hyperlordosis are associated with significant morbidity in quadriplegic patients. They are rare deformities and their treatment is challenging. Sagittal imbalance is the major component: it can be corrected by posterior fusion of the spine with excellent functional results.

Cite this article: Bone Joint J 2014;96-B:800–6.

Aim:. To evaluate the effect of a stiffer rod in normalising thoracic hypokyphosis in adolescent idiopathic scoliosis (AIS). Methods:. A retrospective review of AIS cases performed at our institution was carried out. In order to reduce variability, the analysis included only Lenke 1 cases which had all pedicle screw constructs, with similar constructs and implant density. Cases that underwent anterior release were excluded. All cases had the same implant (Expedium 5.5, Depuy-Synthes, Raynham, USA). The rod material differed in that some cases had 5.5 titanium, whilst others had 5.5 cobalt chrome. The preoperative and postoperative sagittal Cobb angle was measured. Results:. 35 patients met the inclusion criteria. 15 had titanium rods and 20 had cobalt chrome rods. The mean fulcrum correction index was similar between groups. The preoperative coronal and sagittal Cobb was similar between the two groups. There was no statistically significant difference in the postoperative sagittal Cobb between the two groups (ANOVA one way test). Discussion:. Despite the theoretical advantage of a stiffer construct improving the sagittal profile in AIS, this study identified no such benefit despite closely matching the two groups. All pedicle screw constructs do not seem to improve the sagittal profile despite the use of a stiffer rod. Conflict of interest:. Depuy-Synthes fund a fellow in this unit. Conflict Of Interest Statement: No conflict of interest

We determined the frequency, rate and extent of development of scoliosis (coronal plane deformity) in wheelchair-dependent patients with Duchenne muscular dystrophy (DMD) who were not receiving steroid treatment. We also assessed kyphosis and lordosis (sagittal plane deformity). The extent of scoliosis was assessed on sitting anteroposterior (AP) spinal radiographs in 88 consecutive non-ambulatory patients with DMD. Radiographs were studied from the time the patients became wheelchair-dependent until the time of spinal fusion, or the latest assessment if surgery was not undertaken. Progression was estimated using a longitudinal mixed-model regression analysis to handle repeated measurements.

Scoliosis ≥ 10° occurred in 85 of 88 patients (97%), ≥ 20° in 78 of 88 (89%) and ≥ 30° in 66 of 88 patients (75%). The fitted longitudinal model revealed that time in a wheelchair was a highly significant predictor of the magnitude of the curve, independent of the age of the patient (p <  0.001). Scoliosis developed in virtually all DMD patients not receiving steroids once they became wheelchair-dependent, and the degree of deformity deteriorated over time.

In general, scoliosis increased at a constant rate, beginning at the time of wheelchair-dependency (p < 0.001). In some there was no scoliosis for as long as three years after dependency, but scoliosis then developed and increased at a constant rate. Some patients showed a rapid increase in the rate of progression of the curve after a few years – the clinical phenomenon of a rapidly collapsing curve over a few months.

A sagittal plane kyphotic deformity was seen in 37 of 60 patients (62%) with appropriate radiographs, with 23 (38%) showing lumbar lordosis (16 (27%) abnormal and seven (11%) normal).

This study provides a baseline to assess the effects of steroids and other forms of treatment on the natural history of scoliosis in patients with DMD, and an approach to assessing spinal deformity in the coronal and sagittal planes in wheelchair-dependent patients with other neuromuscular disorders.

Cite this article: Bone Joint J 2014;96-B:100–5.

A combined anterior and posterior surgical approach is generally recommended in the treatment of severe congenital kyphosis, despite the fact that the anterior vascular supply of the spine and viscera are at risk during exposure. The aim of this study was to determine whether the surgical treatment of severe congenital thoracolumbar kyphosis through a single posterior approach is feasible, safe and effective.

We reviewed the records of ten patients with a mean age of 11.1 years (5.4 to 14.1) who underwent surgery either by pedicle subtraction osteotomy or by vertebral column resection with instrumented fusion through a single posterior approach.

The mean kyphotic deformity improved from 59.9° (45° to 110°) pre-operatively to 17.5° (3° to 40°) at a mean follow-up of 47.0 months (29 to 85). Spinal cord monitoring was used in all patients and there were no complications during surgery. These promising results indicate the possible advantages of the described technique over the established procedures. We believe that surgery should be performed in case of documented progression and before structural secondary curves develop. Our current strategy after documented progression is to recommend surgery at the age of five years and when 90% of the diameter of the spinal canal has already developed.

Cite this article: Bone Joint J 2013;95-B:1527–32.

Pedicle screw constructs (PSC) in scoliosis are a recently established and widely accepted method of managing scoliotic curves posteriorly. There is a perceived improved coronal and rotational correction when compared to other posterior only constructs. With continued use of this method, the authors and deformity surgeons in general have become aware of persistent thoracic hypokyphosis. This review of 3 years of scoliosis cases using PSC looks at four different implant strategies utilised to manage this problem and our current practice. These strategies were:. All titanium 5.5 mm rod diameter (Expedium, Depuy spine). All titanium 5.5 mm rod diameter with periapical washers (Expedium, Depuy spine). All titanium 6.0 mm rod diameter (Pangea, Synthes). Titanium pedicle screws with 5.5 mm diameter cobalt chrome rods (Expedium Depuy spine). We have reviewed our outcomes with these strategies with respect to thoracic hypokyphosis. Strategy 1 had the highest rate of hypokyphosis on postoperative radiographs. Strategy 4 seems to have the best correction of coronal and sagittal plane abnormality post operatively. As a consequence, our current practice is the use of titanium pedicle screws and 5.5 mm diameter cobalt chrome rods when managing scoliosis with a pedicle screw construct

Purpose of the study: The in situ contournage technique can be used to correct the 3D spinal deformity resulting from scoliosis; the manoeuvres enable rotational corrections, medialisation, and kyphosis and lordosis of strategic segments of the spine. A preliminary study identified a prolonged zone of thoracolumbar sagittal rectitude in thoracic, double major and lumbar scoliosis, indicating the vertebrae with the maximal rotation and the zones of hypokyphosis and hypolordosis. The purpose of the present study was to analyse the correction and sagittal balance of these segments after in situ contournage. Material and methods: The pre- and postoperative radiographs of 54 patients (48 female, 6 male, mean age 21 years, mean follow-up 8 years) with idiopathic scoliosis (36–104) were analysed with Spineview. The types of curvatures, the levels included in the sagittal rectitude and the vertebrae with the maximal rotation were determined. The kyphosis was measured on T4-T12, T4-T8 and T9-T12. Lordosis was measured on L1-S1, T12-L2, L3-S1. Tilt on T1 and T9 and sacral slop as well as pelvic version and incidence were determined. Results: Three characteristic configurations were analysed: thoracic curvature with sagittal rectitude T8-L1 and maximal rotation at T7-T8, double major curvatures with sagittal rectitude T9-L2 and maximal rotation at T8-T9 and L2-L3, and lumbar curvatures with sagittal rectitude T12-L4 and maximal rotation at L1-L2. After posterior instrumentation, the T4-T12 hyperkyphosis decreased on average from 24.1 to 17.4° (p=0.0001) and the T9-T12 hypokyphosis increased from 3.6 to 8.6° (p=0.0001) for the thoracic and double major curvatures. The T12-L2 hyperlordosis increased from 6.6 to 10.3° (p=0.027) and the L3-S1 lordosis decreased from 42.1 to 38.9° (p=0.463) in the lumbar and double major curvatures. Tilts, sacral slope, and pelvic version and incidence did not vary significantly. Conclusion: The prolonged thoracolumbar sagittal rectitude exhibits three distinctive configurations. Each configuration indicates the level of maximal rotation at the superior or inferior end. It enables a decomposition of the overall thoracic kyphosis into a superior segment of hyperkyphosis and an inferior segment of hypokphosis and to identify a zone of superior lumbar hypolordosis. In situ contournage corrects the vertebral rotation, the kyphosis and the lordosis and acts on the strategic vertebrae. The rectitude can be used to better identify the zones requiring correction in order to optimise the balance between the thoracic kyphosis and the lumbar lordosis while improving vertebral rotation by traction or compression

Purpose of the study: Prolongation of the phyisiological sagittal rectitude of the thoracolumbar junction (T11-T1) is often observed in thoracic, double major and lumbar idiopathic scoliosis. The purpose of this study was to check the potential relationship between vertebral rotation, type of curvature in the frontal plane, and the observation of sagittal rectitude exceeding four vertebrae. Material and methods: The preoperative radiographs of 54 patients (48 female, 6 male, mean age 21 years) with idiopathic scoliosis were analysed with Spineview. The type of curvature: thoracic, double major or lumbar (Lenke 1, 3 or 5) and the Cobb angles were noted. The levels included in the zone of sagittal rectitude, the thoracic kyphosis, the lumbar lordosis, the sacral slope, the pelvic incidence and version, the T1 to T9 tilts were noted on the lateral view. Vertebral rotation was analysed for all thoracic and lumbar vertebrae using the method described by Perdriolle, Nash and Moe on the anteroposterior radiographs. The axial rotation was measured on the scanner. Results: Curvatures ranged from 36 to 104° (mean 59°). Fifty-two patients had a flat or concave back. Mean T1 tilt was 3°; it was 6° at T9. The pelvic incidence was 49°, the sacral slope 40°, the pelvic version 9°. The detailed analysis demonstrated zones of inferior thoracic hypokyphosis, and superior lumbar hypolordosis resulting in sagittal rectitude (5–7 vertebrae). The maximal vertebral rotation was situated at the superior part of the hypokyphosis or the inferior part of the hypolordosis. Three configurations were identified: 27 thoracic curvatures (Lenke 1) with cranial prolongation of the sagittal rectitude (T8-L1) and maximal rotation at T7-T8; 21 double major curvatures (Lenke 3 with cranial and caudal prolongation (T9-L2 and maximal rotation at T8-T9 and L2-L3 respectively; and 6 lumbar curvatures (Lenke 5) with caudal prolongation (T12-L4) and maximal rotation at L1-L2. Conclusion: Thoracolumbar sagittal rectitude can be prolonged with three geometric configurations related to the type of thoracic, double major and lumbar curvatures. This zone of rectitude indicates the level of the maximal vertebral rotation at is superior or inferior extremity. It also reflects the zones of segmental hyperkyphosis and hypolordosis that need to be corrected during the surgical treatment of the scoliosis

Purpose of the study: The long-term results after surgical treatment of idiopathic scoliosis depends not only on the correction in the coronal plane but also the restoration of good sagittal balance and thus satisfactory sagittal curvatures. Recent publications have shown moderate correction of the thoracic hypokyphosis of idiopathic scoliosis with instrumentations using hooks and pedicular screws. We report results in the coronal and sagittal play with a reduction technique by simultaneous translation on two rods (ST2R). Material and method: The radiographic parameters were measured preoperatively, at 6 weeks, at 1 year, and at last follow-up (range 2 – 7.4 years) in a consecutive series of 72 patients treated with posterior instrumentation and reduction using the ST2R system. The same operator performed all procedures using stable anchors (pedicle screws or self-stabilizing clamps). Screws and clamps had a threaded polyaxial extension which was linked to the rod by a connector. The deformity was reduced by progressively tightening the two rods alternatively using the nuts on the threaded extensions. This manoeuvre enabled the vertebrae to migrate progressively toward the rods, producing an anteroposterior translation. Results: In the coronal plane, the mean main curvature was reduced from 54 to 17 and was maintained (70%) without loss of angle at last follow-up. There was not difference between the 56 patients with thoracic scoliosis (Lenke 1–4) and the 16 patients with thoracolumbar or lumbar scoliosis (Lenke 5 and 6). In the sagittal plane, for the patients with preoperative hypokyphosis (32 patients < 20), the mean kyphosis was significantly improved from 9 to 30 and remained stable at last follow-up (31) with a mean gain of 21 (p< 0.001). One patient still had hypokyphosis (18) at last follow-up. For patients with normal kyphosis preoperatively (> 20), the mean gain was 7. Conclusion: In this consecutive series of 72 adolescents with idiopathic scoliosis, reduction by simultaneous translation on two rods was a simple and effect method which restored normal thoracic kyphosis

The Universal Clamp (U-Clamp) is based in a sub-laminar ribbon and one titanium clamp. The ribbon is passed under the lamina and the clamp is fixed to the rod. The correction is obtained in a very similar way to the old Luque system. This system allows a gradual force of traction on the lamina (translation) like the Luque’s type system without some of its inconvenience (pullout, the irritation that the tip of wires could cause in the soft tissue, not compatible with the MRI). But also added some advantages, such us a higher capability of traction force, and we can perform the MRI after surgery. And in some severe cases, that in the past we had to do in the same patient, an anterior and a posterior approach, now we can achieve the same amount of correction using only posterior approach with the U-Clamps. Our department acquired, throughout more than two decades, a wide experience in the surgical correction of the most severe deformities of the spine, using the sub-laminar steel wiring (Luque’s technique). Although we got satisfactory results, the system had some problems that we already mentioned. The new systems using pedicle screws with or without hooks (considered by most spine surgeons as the “gold standard”) have also some limitations comparing with the Luque system, as Vora, Lenke and al. showed (“Spine” Jan. 2008). It causes frequently hypokyphosis. We tried a hybrid system to correct the spine deformities in the adolescent and children, some with severe curves. Since January 2007, 42 patients were operated using proximal hooks and distal screws and the “U-Clamp” in the apex. In our series the mean age was 15 years old, the youngest was 8 and the oldest 19. Most of them were girls (33). The most common aetiology was AIS (24), three were Cerebral Palsy and the rest had different aetiologies. The instrumentation we used was Incompass. ®. (23) or CD Legacy. ®. (14). The mean deformity angle before surgery was 78.81° (measured by Cobb method), with the maximum deformity 117° and minimum 53°. After correction the mean angle of deformity was 38.56 (maximum 77 e minimum 18). The preoperative flexibility (PF) (%) was 21.56. The postoperative correction (POC) (%) was 52.42. And the Cincinnati correction index (CCI) (%) was 3.7. Comparing our patients with the Vora, Lenke and al. (Spine Jan. 2008), our patients had a more severe deformity and where more stiff with the CCI=3.7 (Vora and Lenke, CCI < 1.95). This new system allows much greater correcting force over the lamina with less wire pullout. Also it doesn’t have the inconvenience of the steel wire if we need to study the patient after surgery with a MRI. The Kyphosis is preserved with this system contrary to the all screw construct. This system has its place in the spine instrumentation, namely, in situations where the deformity is severe and the osteoporosis is important

A review of the current literature shows that there is a lack of consensus regarding the treatment of spondylolysis and spondylolisthesis in children and adolescents. Most of the views and recommendations provided in various reports are weakly supported by evidence. There is a limited amount of information about the natural history of the condition, making it difficult to compare the effectiveness of various conservative and operative treatments. This systematic review summarises the current knowledge on spondylolysis and spondylolisthesis and attempts to present a rational approach to the evaluation and management of this condition in children and adolescents.