To analyze the dynamics of the thoracic spine during deep breathing in AIS patients and in healthy matched controls. Case-control cross-sectional study. 20 AIS patients (18 girls, Cobb angle, 54.7±7.9°; Risser 1.35±1.2) and 15 healthy volunteers (11 girls) matched in age (12.5 versus 15.8 yr. mean age) were included. In AIS curves, the apex was located in T8 (14) and T9 (6). Conventional sagittal radiographs of the whole spine were performed at maximal inspiration and expiration. The ROM of each spinal thoracic functional segment (T1-T7, T7-T10, T10-T12), the global T1–T12 ROM were measured. Respiratory function was assess by forced vital capacity (FVC), expiratory volume (FEV1), FEV1/FVC, inspiratory vital capacity (IVC) and peak expiratory flow (PEF). In healthy subjects, the mean T1–T12 ROM during forced breathing was 16.7±3.8. AIS patients showed a T1-T12 ROM of 1.1±1.5 (p<0.05) indicating a sagittal stiffness of thoracic spine. A wide T7–T10 ROM (15.3±3.0) was found in healthy controls (91.6% of the T1–T12 ROM). AIS patients showed only 0.4±1.4 ROM at T7-T10 (36.4% of the T1–T12 ROM) (p<0.001). There was a significant correlation between T7-T10 ROM and IVC. Lenke 1A AIS patients show a restriction of the thoracic spine motion with an almost complete abolition of T7-T10 ROM, a crucial segment participating in the deep breathing. T7-T10 stiffness could explain the ventilatory limitations found in AIS patients

In healthy subjects, respiratory maximal volumes are highly dependent on the sagittal range of motion of the T7-T10 segment. In AIS, the abolition of T7-T10 dynamics related to the stiffness induced by the apex region in Lenke IA curves could harm ventilation during maximal breathing. The aim of this study was to analyze the dynamics of the thoracic spine during deep breathing in AIS patients and in healthy matched controls. This is a cross-sectional, case-control study. 20 AIS patients (18 girls, Cobb angle, 54.7±7.9°; Risser 1.35±1.2) and 15 healthy volunteers (11 girls) matched in age (12.5 versus 15.8 yr. mean age) were included. In AIS curves, the apex was located at T8 (14) and T9 (6). Conventional sagittal radiographs of the whole spine were performed at maximal inspiration and exhalation. The ROM of each spinal thoracic functional segment (T1-T7, T7-T10, T10-T12) and the global T1-T12 ROM were measured. In healthy subjects, the mean T1-T12 ROM during forced breathing was 16.7±3.8. AIS patients showed a T1-T12 ROM of 1.1±1.5 (p<0.05), indicating a sagittal stiffness of the thoracic spine. A wide T7-T10 ROM (15.3±3.0) was found in healthy controls (91.6% of the T1–T12 ROM). AIS patients showed only 0.4±1.4 ROM at T7-T10 (36.4% of the T1-T12 ROM) (p<0.001). There was a significant positive correlation between the magnitude of T7-T10 kyphosis in maximal exhalation and both FVC (% of predicted FVC) and FEV1. In conclusion, Lenke 1A AIS patients show a restriction of the thoracic spine motion with an almost complete abolition of T7-T10 ROM, a crucial segment for deep breathing. T7-T10 stiffness could explain the ventilatory limitations found in AIS patients

Background. After surgical correction of thoracic scoliosis, an improvement in the cardio-respiratory adaptation to exercise would be expected because of the correction of the rib cage associated with the spinal deformity. This work intended to evaluate the physiologic responses to incremental exercise in patients undergoing surgical correction of adolescent idiopathic scoliosis (AIS). The hypothesis of this study was that the exercise limitations described in patients with AIS could be related with the physical deconditioning instead of being linked to the severity of the vertebral deformity. Methods. Cross-sectional study of the exercise tolerance in a series of patients with AIS type Lenke 1A, before and 2 years after surgical correction. Twenty patients with AIS and 10 healthy adolescents aged between 12 and 17 years old were evaluated. The average magnitude of the curves was 60.3±12.9 Cobb. Cardio-respiratory function was assessed before surgery and at 2-year follow-up by maximal exercise tolerance test on treadmill following a Bruce standard protocol. Maximal oxygen uptake (VO2), VCO2, expiratory volume (VE), and VE/VO2 ratio were registered. Results. Before surgery, AIS patients showed lower values than healthy controls in all cardio-respiratory parameters. The most important restrictions were the VO2max in ml/kg/min. (30.3±5.4 vs 49.9±7.5), VE (43.2±10.3 vs 82.3±10.7) and VE/CO2 ratio (25.0±3.9 vs 29.6±4.2). Contrary to expectations, two years after surgery most of these parameters decreased but differences with preoperative data were no statistically significant. Besides the great correction of the deformity (coronal plane, 71.5%; axial rotation, 49.3%), the cardio-respiratory tolerance to the exercise was not modified by surgery. Conclusions. Patients with moderate-severe AIS showed a limited tolerance to maximal exercise that does not change 2 years after surgery. This findings suggests that the reduced cardio-pulmonary function during exercise is not strictly associated to the spinal deformity, since great corrections of the spinal curves does not improve functional ventilatory parameters. In addition, the results point out a severe exercise deconditioning in AIS patients. Level of evidence. Level IV

The aim of this study was to report the restauration of the normal vertebral morphology and the absence of curve progression after removal the instrumentation in AIS patients that underwent posterior correction of the deformity by common all screws construct whitout fusion. A series of 36 AIS immature patients (Risser 3 or less) were include in the study. Instrumentation was removed once the maturity stage was complete (Risser 5). Curve correction was assessed at pre and postoperative, before instrumentation removal, just post removal, and more than two years after instrumentation removal. Epiphyseal vertebral growth modulation was assessed by a coronal wedging ratio (WR) at the apical level of the main curve (MC). The mean preoperative coronal Cobb was corrected from 53.7°±7.5 to 5.5º±7.5º (89.7%) at the immediate postop. After implants removal (31.0±5.8 months) the MC was 13.1º. T5–T12 kyphosis showed a significant improvement from 19.0º before curve correction to 27.1º after implants removal (p<0.05). Before surgery, WR was 0.71±0.06, and after removal WR was 0.98±0.08 (p<0.001). At the end of follow-up, the mean sagittal range of motion (ROM) of the T12-S1 segment was 51.2±21.0º. SRS-22 scores improved from 3.31±0.25 preoperatively to 3.68±0.25 at final assessment (p<0.001). In conclusion, fusionless posterior approach using a common all pedicle screws construct correct satisfactory scoliotic main curves and permits removal of the instrumentation once the bone maturity is reached. The final correction was highly satisfactory and an acceptable ROM of the previously lower instrumented segments was observed

Introduction. From the many human studies that attempt to identify genes for adolescent idiopathic scoliosis (AIS), the view emerging is that AIS is a complex genetic disorder with many predisposing genes exhibiting complex phenotypes through environmental interactions. Although advancements in genomic technology are transforming how we undertake genetic and genomic studies, only some success has been reached in deciphering complex diseases such as AIS. Moreover, the present challenge in AIS research is to understand the causative and correlative effects of discovered genetic perturbations. An important limitation to such investigations has been the absence of a method that can easily stratify patients with AIS. To overcome these challenges, we have developed a functional test that allows us to stratify patients with AIS into three functional subgroups, representing specific endophenotypes. Interestingly, in families with multiple cases of AIS, a specific endophenotype is shared among the affected family members, indicating that such a transmission is inherited. Moreover, increased vulnerability to AIS could be attributable to sustained exposure to osteopontin (OPN), a multifunctional cytokine that appears to be at the origin of the Gi-coupled receptor signalling dysfunction discovered in AIS. We examined the molecular expression profiles of patients with AIS and their response to OPN. Methods. Osteoblasts isolated from patients with AIS were selected for each functional subgroup and compared with osteoblasts obtained from healthy matched controls. We used the latest gene chip human genome array Affymetrix (HuU133 Plus 2.0 array) that allows for the analysis of the expression level of 38 000 well characterised human genes. Raw data were normalised with robust multiarray analysis method. Statistical analysis was done by the EB method with FlexArray software. Selection criteria for in-depth analysis include the magnitude of change in expression (at least □} 3-fold) and 5% false discovery rate as stringency selection. Validation of selected candidate genes was done by qPCR and at the protein level by Western blot and ELISA methods. Plasma OPN concentrations were measured by ELISA on a group of 683 consecutive patients with AIS and were compared with 262 healthy controls and 178 asymptomatic offspring, born from at least one scoliotic parent, and thus considered at risk of developing the disorder. The regulation of OPN signalling pathway in normal and AIS cells were validated in vitro by cellular dielectric spectroscopy (CDS). Results. Of 38 000 human genes tested, we have found eight genes specifically associated with the functional subgroup 1, 16 genes with the functional subgroup 2, and 11 genes with the functional subgroup 3. Interestingly, only 19 genes were shared and affected to the same extent in all AIS functional subgroups exhibiting a similar curve pattern (double major), suggesting their role in the formation of this curve pattern. Indeed, most of these genes encode for regulatory proteins such as transcription factors regulating axial skeleton, somite development, and extracellular matrix proteins. Mean plasma OPN concentrations were significantly increased in patients with AIS and correlated with disease severity. Increased plasma OPN concentrations were also detected in the asymptomatic at-risk group, suggesting that these changes precede scoliosis onset. CDS experiments clearly showed that OPN exposure triggers a Gi-coupled receptor signalling dysfunction, which is exacerbated by oestrogens. Conclusions. Our data further support our functional method of stratification of patients with AIS and allow the identification of genes triggering scoliosis onset versus those predisposing to the development of a specific curve pattern. Furthermore, our clinical and experimental data show that OPN is essential for scoliosis onset and curve progression, thus offering a first molecular concept to explain the pathomechanism leading to the asymmetrical growth of the spine in AIS. Acknowledgments. This research project was supported by grants from La Fondation Yves Cotrel de l'Institut de France, Canadian Institutes of Health Research, and Paradigm Spine LLC

Aim:. AIS causes a loss of trunk height. This paper documents this loss against sitting height standards and assesses formulae for adjusting height loss back to the standard. Methods:. A total of 334 patients (84% female) with AIS and no other known systemic disease had sitting height measured. This was compared to standards of sitting height with age and the ratio of height to sitting height with age (HSH). The corrected height was calculated using published formulae and replotted against these standards. Results:. Both sexes had significant numbers of patients under the 5th centile compared to those above the 95th centile for sitting height (p<0.05 in males and females) and for HSH centiles (p<0.05 in males and females). All formulae increased the sitting height back to within the standards. In males only the Ylikoski formula demonstrated any significant difference in sitting height and HSH. In females the Kono formula gave the least significant difference between those above and below the 95th and 5. th. centiles for sitting height and the Hwang formula for HSH. Discussion:. Scoliosis causes a loss of sitting height seen with the centile standards for sitting height and height to sitting height ratios. This can be corrected, the most accurate formula being Hwang, correcting the data to lie between the 5th and 95th centiles for sitting height with no significant difference between the number of outliers to these centiles. Outliers after use of this formula may suggest alternative pathology. Conflict Of Interest Statement: No conflict of interest

Introduction: Spinal deformities and scoliosis in particular, represent the most prevalent type of orthopaedic deformities in children and adolescents. At present, the most significant problem for clinicians is that there is no proven method or test available to identify children or adolescents at risk of developing AIS or to identify which of the affected individuals are at risk of progression. As a consequence, the application of current treatments, such as bracing or surgical correction, has to be delayed until a significant deformity is detected or until a significant progression is clearly demonstrated, resulting in a delayed and less optimal treatment. Among patients with AIS needing treatment, 80% to 90% will be treated by brace and 10% will need surgery to correct the deformity by spinal instrumentation and fusion of the thoracic and/or lumbar spine. About 15000 such surgeries are done every year in North America, resulting in significant psychological and physical morbidity. Moreover, there is no pharmacotherapy available to either prevent or reduce spinal deformities due mainly to our limited knowledge of AIS aetiopathogenesis. We have recently reconciled the role of melatonin in AIS aetiopathogenesis by demonstrating a melatonin signalling dysfunction occurring in a cell autonomous manner in cells derived from AIS patients exhibiting severe scoliotic deformities. This defect could potentially explain the majority of abnormalities reported in AIS since melatonin receptors and signalling activities are normally found in all tissues and systems affected in AIS, thus offering a very innovative and unifying concept to explain the aetiology of AIS. Moreover, several lines of evidence suggested that inactivation of Gi proteins by an increased phosphorylation of serine residues could be at the source of this signalling defect in AIS. The goals of that study were to assess the possibility to establish a molecular classification of AIS patients and to demonstrate the feasibility to correct this melatonin signalling defect in cells of AIS patients using therapeutic compounds. Methods: Primary cell cultures were prepared from musculoskeletal tissues of AIS patients (n=150) and age- and gender-matched controls (n=35) obtained intra-operatively. An informed consent was obtained for each subject as approved by our Institutional Ethical Committee. The osteoblasts, the bone-forming cells, were selected to assess whether or not an alteration of melatonin signalling pathway occurs in AIS and accordingly to identify which component of the melatonin transduction machinery could be involved. Co-immunoprecipitation experiments with membrane extracts were performed to identify interacting molecules with key components of melatonin signal transduction machinery. The functionality of melatonin signalling was assessed by investigating the ability of Gi proteins to inhibit stimulated adenyl cyclase activity in osteoblast cultures. Inhibition curves of cAMP production were generated by adding melatonin to the forskolin-containing samples in concentrations ranging from 10-11M to 10-5M in a final volume of 1 ml of _-MEM media containing 0.2% bovine serum albumin (BSA) alone or in presence of 2.5 _M of therapeutic compound A or therapeutic compound B (the nature of both compounds tested cannot be disclosed at this stage). The cAMP content was determined using an enzyme immunoassay kit (Amersham-Pharmacia Biosciences). All assays were performed in duplicate. A non-parametric test, the Wilcoxon matched pairs test was performed to verify the significance between 2 means. Significance was defined as P< 0.05. Results: Osteoblasts from patients with AIS showed a lack or a markedly reduced inhibition of forskolin-stimulated adenyl cyclase activity by melatonin generating three distinct response-curves corresponding to three functional groups. In order to identify candidate genes involved in AIS aetiopathogenesis, we focused our attention on known kinases and phosphatases modulating Gi protein functions and characterised their interacting partners. Interestingly, PKC_ was initially targeted owing to its property to phosphorylate Gi proteins in vitro. Indeed, in normal osteoblast interactions occurring between MT2 melatonin receptor and RACK1 (a cytosolic protein that bind to and stabilises the actives form of PKC and permits its translocation to different sites within the cells) and PKC_ were detected although those interactions among different AIS patients were altered. Interestingly, treatment with compound A or B rescued melatonin signal defect in cells derived from 36% and 47% of AIS patients respectively. Overall, melatonin signal transduction was restored in cells of 64% of AIS patients (23/36) when treated by one of these therapeutic compounds. Conclusions: The functional classification of AIS patients is correlated at the molecular level by distinct interactions between key molecules normally involved in melatonin signal transduction in spite that these patients exhibited the same curve type (right thoracic, Lenke type 1). Collectively, these data strongly argue that traditional curve pattern classification is not a relevant stratification of AIS patients to identify its genetic causes. Moreover, using that molecular system we have demonstrated also the possibility to identify therapeutic compounds to rescue the melatonin signalling defect observed in AIS without any prior knowledge of mutations in any defective genes causing AIS because we are measuring a function. Research project supported by La Fondation Yves Cotrel de l’Institut de France

Purpose: Few studies have analyzed spinal cord monitoring (SCM) during spine deformity surgery when neural axis abnormalities (NAA) are present. Our purpose was to compare the effectiveness of SCM between NAA and AIS patients. Methods: This is a retrospective review of all patients from 1993–2002 with an isolated NAA who had SCM during spinal deformity surgery. These were compared to a randomly selected group of AIS patients during the same time period when techniques for somatosensory-evoked potentials (SSEP) and motor-evoked potential (MEP) monitoring remained the same. Results: There were 41 NAA patients and 139 AIS patients. The age at surgery was similar (14.4 vs. 14.5 yrs), but there were more males (48.8 vs. 18.7%)* in the NAA group. For NAA patients, the most common abnormalities were syringomyelia (n=29) and tethered cord (n=5) for which 68% required neurosurgery. The preoperative curve magnitude was greater in the NAA group (65.9° vs 59.6°)* but there were no differences in surgical time (39.6 vs. 35.9 min/level) and estimated blood loss (99.4 vs. 82.0 cc/level) between the groups. There was a trend towards more surgical complications in the NAA group (7.3 vs. 3.6%). Good baseline values were achieved less often in the NAA group for SSEPs (85% vs 99%)* and MEPs (83% vs 100%)*. Significant deviations from baseline values were seen more often in the NAA group for SSEP (5.0% vs. 1.4%)* and MEP (4.0% vs. 2.5%)*. * (p< 0.05). Conclusions: Obtaining baseline SCM values was more difficult and deviations from baseline were more common in the NAA patients when compared to AIS patients. However, SCM did not miss a neurologic injury and was found to be very useful and necessary during spine deformity surgery in the NAA population

Introduction. Morphological parameters are used to describe curve characters in AIS like curve location, curve magnitude, stiffness etc. Like all other morphological metrics the accuracy is more when digital imaging, archiving and extraction of features is used rather than manual measurements. The content Based Image Retrieval system is anew software that allows rapid, accurate documentation of AIS images and their retrieval by visual content. Classification systems and their shortcomings. Traditional classifications only looked at curve location (Ponsetti/Friedman); this was enhanced to add curve flexibility (to include or exclude secondary curves in fusion) (PUMC, King/Moe etc). Newer classifications like the Lenke have added sagittal profile into the decision making equation. From 5 basic curve types the subtypes have increased to 42 potential curve patterns by the addition of one parameter!! In future as we understand the 3-D geometry of these curves better we may want to add more measureable items (like degree of rotation) and by adding one term the subtypes would be 128!!! This suggests that we need to have a simple easy to remember way of classifying or eliminate classifications altogether. Experimental evidence. Several experiments were conducted with the new CBIR software which showed that similar images of scoliosis cases could be retrieved without resorting to a classification scheme. Even surgical planning can be made by downloading all similar cases operated before. The variability can be set to any level of precision desired. Significance. In future we may eliminate classifications to decide on curve types and for surgical planning and recall from a large multicentre database similar curves and their surgical plan

The defining weapon of the conflicts in Iraq and Afghanistan has been the Improvised Explosive Device (IEDs). When detonated under a vehicle, they result in significant axial loading to the lower limbs, resulting in devastating injuries. Due to the absence of clinical blast data, automotive injury data using the Abbreviated Injury Score (AIS) has been extrapolated to define current NATO injury thresholds for Anti-vehicle (AV) mine tests. We hypothesized that AIS, being a marker of fatality rather than disability would be a worse predictor of poor clinical outcome compared to the lower limb specific Foot and Ankle Severity Score (FASS). Using a prospectively collected trauma database, we identified UK Service Personnel sustaining lower leg injuries from under-vehicle explosions from Jan 2006–Dec 2008. A full review of all medical documentation was performed to determine patient demographics and the severity of lower leg injury, as assessed by AIS and FASS. Clinical endpoints were defined as (i) need for amputation or (ii) poor clinical outcome. Statistical models were developed in order to explore the relationship between the scoring systems and clinical endpoints. 63 UK casualties (89 limbs) were identified with a lower limb injury following under-vehicle explosion. The mean age of the casualty was 26.0 yrs. At 33.6 months follow-up, 29.1% (26/89) required an amputation and a further 74.6% (41/89) having a poor clinical outcome (amputation or ongoing clinical problems). Only 9(14%) casualties were deemed medically fit to return to full military duty. ROC analysis revealed that both AIS=2 and FASS=4 could predict the risk of amputation, with FASS = 4 demonstrating greater specificity (43% vs 20%) and greater positive predictive value (72% vs 32%). In predicting poor clinical outcome, FASS was significantly superior to AIS (p<0.01). Probit analysis revealed that a relationship could not be developed between AIS and the probability of a poor clinical outcome (p=0.25). Foot and ankle injuries following AV mine blast are associated with significant morbidity. Our study clearly demonstrates that AIS is not a predictor of long-term clinical outcome and that FASS would be a better quantitative measure of lower limb injury severity. There is a requirement to reassess the current injury criteria used to evaluate the potential of mitigation technologies to help reduce long-term disability in military personnel. Our study highlights the critical importance of utilising contemporary battlefield injury data in order to ensure that the evaluation of mitigation measures is appropriate to the injury profile and their long-term effects

Introduction: Studies suggest pedicle screw constructs are more effective than hybrid or hook constructs for AIS correction. This study assessed the efficacy of three methods of spinal instrumentation in patients treated at the WCH. Methodology: 30 AIS patients who underwent posterior spinal surgery were matched according to age, fusion levels, and Lenke curve. Three constructs were assessed, hook-exclusive, screw-exclusive and hybrid constructs, with 10 patients in each group. Endpoints included radiographic measures, operative time and complications. Results: Mean pre-operative Cobb angle was 56.1°, 52.2° and 56.7° for the screw, hybrid and hook group respectively. Structural curve correction was 63.6°, 60.2° and 58.5° for each group respectively. Compensatory curve correction favoured the hybrid and screw groups. Thoracic kyphosis correction was 20.7° (most improved), 19.9°, and 15.5° for the screw, hook, and hybrid groups respectively. Coronal alignment favoured the screw construct group. Comparison of operative time revealed no significant difference, and complication rates were similar in nature and incidence for all three groups. Conclusions: Results demonstrate improved correction of structural curve, kyphosis, and coronal alignment in the screw instrumentation group. No additional complications were observed with this method of AIS curve correction

To compare the ability of fulcrum bend and traction radiographs to predict correction of AIS using screw only implants and to assess the fulcrum bending correction index (FBCI) with a new measurement: the traction correction index (TCI). Retrospective radiographic analysis of case series (Level IV). Radiographic correction of scoliosis based on correction rate does not take into consideration the curve flexibility. It has been suggested that fulcrum bending radiographs predict curve correction in AIS [1]. This has been questioned [2] and has been suggested that traction radiographs are more predictive in a mixed group of patients with hybrid and screw only constructs. Twenty three patients average age 15, who underwent posterior correction of scoliosis using pedicle screw only construct. Analysis was carried out on the pre-op and immediate post-op AP radiographs and the pre-op fulcrum bend and traction radiographs. Correction rate, fulcrum flexibility, traction flexibility, FBCI and TCI was calculated. Preoperative mean Cobb angle of 66 degrees was corrected to 25 degrees postoperatively. The mean fulcrum bending Cobb angle was 38 degrees and traction Cobb angle 28 degrees. The mean fulcrum flexibility was 45%, traction flexibility 59% and correction rate 63%. The mean FBCI was 182% and TCI was112%. When comparing fulcrum bend and traction radiographs, we found the latter to be more predictive of curve correction in AIS using pedicle screw constructs. The TCI better takes into account the curve flexibility than the FBCI

Aim:. To compare the ability of fulcrum bend and traction radiographs to predict correction of AIS using pedicle screw only constructs and to compare the fulcrum bending correction index (FBCI) with a new measurement: the traction correction index (TCI). Method:. Retrospective radiographic analysis of eighty patients, average age 14 yrs, who underwent posterior correction of scoliosis using pedicle screw only construct. Analysis was carried out on the pre-op and immediate post-op PA radiographs and the pre-op fulcrum bend and traction radiographs. Correction rate, fulcrum flexibility, traction flexibility, FBCI and TCI was calculated. Results:. Preoperative mean Cobb angle of 63.9 degrees was corrected to 25.8 degrees postoperatively. The mean fulcrum bending Cobb angle was 37.6 degrees and traction Cobb angle 26.6 degrees. The mean fulcrum flexibility was 41.1%, traction flexibility 58.4% and correction rate 59.6%. The mean FBCI was 144.9% and TCI was 102.1%. Discussion:. Radiographic correction of scoliosis based on correction rate does not take into consideration the curve flexibility. It has been suggested by Cheung et al, that fulcrum bending radiographs predict curve correction in AIS. Ibrahim et al, have questioned this, and they suggested that traction radiographs are more predictive in a mixed group of patients with hybrid and screw only constructs. Conclusions:. When comparing fulcrum bend and traction radiographs, we found the latter to be more predictive of curve correction in AIS using pedicle screw constructs. The TCI better takes into account the curve flexibility than the FBCI. Conflict Of Interest Statement: No conflict of interest

Introduction: With the advent of thoracoscopy, anterior release procedures in adolescent idiopathic scoliosis (AIS) have come into more frequent use, however, the indication criteria for an anterior release in thoracic AIS are still controversial in the literature. The aim is to achieve a better coronal correction but the benefit as compared to a single posterior approach is not yet clarified. Material and Methods: Two groups of 15 patients each were matched for sex, age and cobb angle. Patients of group 1 were operated with a staged procedure of an anterior release followed by posterior instrumentation (anterior-posterior spinal fusion, APSF) and patients of group 2 were operated by a single posterior spinal fusion (PSF) with performance of concave sided rib osteotomies (concave thoracoplasty, CTP). Results: Mean age: 16.2 y (APSF), 17.6 y (PSF). Mean preop curve: 81.7° ± 10.1° (APSF), 84.2° ± 14.1° (PSF). Mean postop curve: 34.9° ± 15.5° (APSF), 34.3° ± 12.2° (PSF) (p=0,49). Conclusion: The single posterior approach gave the same coronal correction rate as compared to patients operated with a two stage procedure with preceding anterior release. A posterior release with CTP is more effective in increasing spinal flexibility than disc excision. According to our clinical experience, an anterior release prior to posterior instrumentation in AIS should only be considered in hyperkyphosis, coronal imbalance or massive curves

Background: Although the clinical relevance still remains unclear there is an increased interest in the incidence of proximal junctional kyphosis (PJK) following posterior spinal scoliosis surgery. Several authors suppose patients with hybrid instrumentation (cranial laminar hooks, caudal pedicle screws and sublaminar wires) to be at greater risk for developing PJK. The aim of our study was to evaluate the incidence of PJK and to determine risk factors in our series of AIS patients with hybrid instrumentation after a minimum follow up of 5 years. Methods: 60 consecutive AIS patients (56 female, 4 male, average age 16 years, range 14 to 18 years) underwent scoliosis surgery using pedicle screws caudal and laminar hooks cranial at our institution. Pre - and postoperative Cobb angle, junctional kyphosis angle, number of fused levels and upper instrumented vertebra were assessed on lateral and anteriorposterior standing long cassette radiographs after an average follow up of 8 years (range 5 to 12 years). As published by Glattes et al. proximal junction was defined as the caudal end-plate of the upper instrumented vertebra to the cranial endplate two vertebrae proximal. A Cobb angle of the proximal junction greater than 10° and at least 10° greater than preoperative was defined abnormal. Results: Average number of fused levels was 10.2 (range 8.1 to 12.3). Average Cobb angle decreased from pre-operative 65° (range 50° to 80°) to 32° (range 22° to 40°). T 4 was the upper instrumented vertebra in 30 patients, T 5 in 18 and below T 6 in 12 patients. Average Preoperative saggital PJK Cobb was 7° (range 4° to 13°). 5 patients (12%) showed abnormal proximal junctional kyphosis angel at latest follow up (average 18°, range 14 to 28°). There was no positive correlation found between upper instrumented vertebra and abnormal PJK (r. 2. = 0.01). A greater preoperative PJK angle however showed positive correlation (r. 2. = 0.8). Conclusion: Compared to literature our data show a low rate (12%) of PJK after an average follow up of 8 years. We could not find any positive correlation between upper instrumented vertebra and incidence of PJK, a preoperative increased proximal kyphosis however seems to be a risk factor for developing PJK

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

Study Design: Prospective study cohort describing lung function, exercise tolerance and strength inspiratory and expiratory muscles. Objective: To analyze lung function and ventilatory response to exercise in adolescents with thoracic curves > 45, candidates to surgery. Summary of background: Adolescents with symptomatic scoliosis have little or no impairment of resting lung volumes. We have limited information about moderates scoliosis. In some series not found abnormalities and in others ones report little restrictive pulmonary function and lower exercise tolerance. We have found no one study that it have valuated the strength of the respiratory muscles. Methods: From 2002 until 2003. They were evaluated 19 patients with AIS (4 males and 15 females) who were indicated to surgical treatment. Mean age of 16 (13–26). The mean Cobb angle was 61 (45–105). Flow curves were obtained by maximal forced expirations. Incremental exercise was performed by cycloergometry using the protocol described by Neder et al. Muscle strength was measured by one system of valve with incremental weight. Results: The mean values of spirometry were FEV 1 81 (+/−14% ref), %FEV 1/FVC 82 +/−6, TLC 86 +/− 11%ref, RV 106 +/− 20% ref. The strength of respiratory muscles was significant lower, Pimax. 67% (p=0’030), Pemax 65% (p< 0’0001). In the exercise capacity the VO2 max was significantly lower (54’5 % ref., p< 0’05) but without to be the VE max and the heart rate the restricted factor. Conclusions:. The rest lung volumes are into the normal values but in the lower side. The strength of respiratory muscles is significant lower. The patients have impaired exercise capacity, probably from deconditioning

Aims

Only a few studies have investigated the long-term health-related quality of life (HRQoL) in patients with an idiopathic scoliosis. The aim of this study was to investigate the overall HRQoL and employment status of patients with an idiopathic scoliosis 40 years after diagnosis, to compare it with that of the normal population, and to identify possible predictors for a better long-term HRQoL.

Aims

The aim of this retrospective study was to compare the correction achieved using a convex pedicle screw technique and a low implant density achieved using periapical concave-sided screws and a high implant density. We hypothesized that there would be no difference in outcome between the two techniques.

Brace correction based upon mechanical action requires appropriate interface pressure between the body and the brace.

A smart orthotic was developed to record how much time (quantity) a brace was used, how well (quality) it was used and maintain the interface pressure to the prescribed level. Six subjects were recruited and they all used Boston style braces. Each subject used the system for two weeks without the force maintenance system activated to serve as the control period, and the remaining two weeks with the force maintenance system activated. During the automatic feedback mode, the pressure maintenance system was activated only during the daytime (8:00–22:00hrs) to avoid disturbing the patients during sleep. The subject could either return the system to us after one month or continue to use the system until the next clinic.

The time that the pressure level was in the target level range during the study period was increased from 53 +/− 9% to 68 +/− 14% with the feedback activated. The average brace wear time for the study period was 72 +/− 15% (12.6hr/day) of the prescribed time (17.5 +/− 3.8 hours). The curve severity of all subjects on the following clinical visit was the same (within measurement error) as the first visit (32 +/− 5 vs 31 +/− 5 degrees). Compliance was not affected when wearing the monitor.

The smart orthotic was able to improve the efficiency of a conventional brace by maintaining the prescribed interface pressure automatically. This proposed work helps brace candidates wear their braces more effectively and gets the most benefit from the brace treatment. As a result, all participated subjects maintained their Cobb angle within ± two degrees during the study period.