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. Methods. We retrospectively analyzed a series of 51 patients with a thoracic adolescent idiopathic scoliosis. There were 26 patients in the convex pedicle screw group who had screws implanted periapically (Group 2) and a control group of 25 patients with bilateral pedicle screws (Group 1). The patients’ charts were reviewed and pre- and postoperative radiographs evaluated. Postoperative patient-reported outcome measures (PROMs) were recorded. Results. The number of implants (14.5 vs 17.1) and the implant density (1.5 vs 1.9) were significantly lower in Group 2 (p < 0.001). Operating time was 27 minutes shorter in Group 2 than in Group 1, with a mean of 217 minutes (SD 50.5; 120 to 346). The duration of surgery per instrumented vertebra was reduced by 19% in Group 2 (p = 0.011). No statistical difference was found in the postoperative Cobb angle, vertebral rotation, the relative correction achieved, or postoperative PROMs. Conclusion. Despite a lower implant density and achieving correction through a convex rod, surgical correction of the Cobb angle and vertebral body rotation was similar in both groups. Periapical pedicle screws and primary correction on the concave side do not seem to be mandatory in order to achieve good surgical results in idiopathic thoracic scoliosis. The operating time was shorter in the group with lower implant density. In conclusion, the technique provided good results and has the potential to reduce complications and costs. Cite this article: Bone Joint J 2021;103-B(3):536–541

Aims. We present the results of correcting a double or triple curve adolescent idiopathic scoliosis using a convex segmental pedicle screw technique. Patients and Methods. We reviewed 191 patients with a mean age at surgery of 15 years (11 to 23.3). Pedicle screws were placed at the convexity of each curve. Concave screws were inserted at one or two cephalad levels and two caudal levels. The mean operating time was 183 minutes (132 to 276) and the mean blood loss 0.22% of the total blood volume (0.08% to 0.4%). Multimodal monitoring remained stable throughout the operation. The mean hospital stay was 6.8 days (5 to 15). Results. The mean post-operative follow-up was 5.8 years (2.5 to 9.5). There were no neurological complications, deep wound infection, obvious nonunion or need for revision surgery. Upper thoracic scoliosis was corrected by a mean 68.2% (38% to 48%, p < 0.001). Main thoracic scoliosis was corrected by a mean 71% (43.5% to 8.9%, p < 0.001). Lumbar scoliosis was corrected by a mean 72.3% (41% to 90%, p < 0.001). No patient lost more than 3° of correction at follow-up. The thoracic kyphosis improved by 13.1° (-21° to 49°, p < 0.001); the lumbar lordosis remained unchanged (p = 0.58). Coronal imbalance was corrected by a mean 98% (0% to 100%, p < 0.001). Sagittal imbalance was corrected by a mean 96% (20% to 100%, p < 0.001). The Scoliosis Research Society Outcomes Questionnaire score improved from a mean 3.6 to 4.6 (2.4 to 4, p < 0.001); patient satisfaction was a mean 4.9 (4.8 to 5). . Conclusions. This technique carries low neurological and vascular risks because the screws are placed in the pedicles of the convex side of the curve, away from the spinal cord, cauda equina and the aorta. A low implant density (pedicle screw density 1.2, when a density of 2 represents placement of pedicle screws bilaterally at every instrumented segment) achieved satisfactory correction of the scoliosis, an improved thoracic kyphosis and normal global sagittal balance. Both patient satisfaction and functional outcomes were excellent. Cite this article: Bone Joint J 2017;99-B:1080–7

To determine whether spinal facet osteoblasts at the curve apex display a different phenotype to osteoblasts from outside the curve in patients with adolescent idiopathic scoliosis (AIS). Intrinsic differences in the phenotype of spinal facet bone tissue and in spinal osteoblasts have been implicated in the pathogenesis of AIS. However, no study has compared the phenotype of facet osteoblasts at the curve apex with the facet osteoblasts from outside the curve in patients with AIS. Facet bone tissue was collected from three sites, the concave and convex side at the curve apex and from outside the curve from three female patients with AIS (aged 13–16 years). Micro-CT analysis was used to determine the density and trabecular structure. Osteoblasts were then cultured from the sampled bone. Osteoblast phenotype was investigated by assessing cellular proliferation (MTS assay), cellular metabolism (alkaline phosphatase and Seahorse Analyser), bone nodule mineralisation (Alizarin red assay), and the mRNA expression of Wnt signalling genes (quantitative RT-PCR). Convex bone showed greater bone mineral density and trabecular thickness than did concave bone. The convex side of the curve apex exhibited a significantly higher proliferative and metabolic phenotype and a greater capacity to form mineralised bone nodules than did concave osteoblasts. mRNA expression of SKP2 was significantly greater in both concave and convex osteoblasts than in non-curve osteoblasts. The expression of SFRP1 was significantly downregulated in convex osteoblasts compared with either concave or non-curve. Intrinsic differences that affect osteoblast function are exhibited by spinal facet osteoblasts at the curve apex in patients with AIS

We previously reported that osteoblasts at the curve apex in adolescent idiopathic scoliosis (AIS) exhibit a differential phenotype, compared to non-curve osteoblasts(1). However, the Hueter-Volkmann principle on vertebral body growth in spinal deformities (2) suggests this could be secondary to altered biomechanics. This study examined whether non-curve osteoblasts subjected to mechanical strain resemble the transcriptomic phenotype of curve apex osteoblasts. Facet spinal tissue was collected perioperatively from three sites, (i) the concave and (ii) convex side at the curve apex and (iii) from outside the curve (non-curve) from six AIS female patients (age 13–18 years; NRES 19/WM/0083). Non-curve osteoblasts were subjected to strain using a 4-point bending device. Osteoblast phenotype was determined by RNA sequencing and bioinformatic pathway analysis. RNAseq revealed that curve apex osteoblasts exhibited a differential transcriptome, with 1014 and 1301 differentially expressed genes (DEGs; p<0.05, fold-change >1.5) between convex/non-curve and concave/non-curve sites respectively. Non-curve osteoblasts subjected to strain showed increased protein expression of the mechanoresponsive biomarkers COX2 and C-Fos. Comparing unstimulated vs strain-induced non-curve osteoblasts, 423 DEGs were identified (p<0.05, fold-change >1.5). Of these DEGs, only 5% and 6% were common to the DEGs found at either side of the curve apex, compared to non-curve cells. Bioinformatic analysis of these strain-induced DEGs revealed a different array of canonical signalling pathways and cellular processes, to those significantly affected in cells at the curve apex. Mechanical strain of AIS osteoblasts in vitro did not induce the differential transcriptomic phenotype of AIS osteoblasts at the curve apex

Aims. To clarify the asymmetrical ossification of the epiphyseal ring between the convex and concave sides in patients with adolescent idiopathic scoliosis (AIS). Patients and Methods. A total of 29 female patients (mean age, 14.4 years; 11 to 18) who underwent corrective surgery for AIS (Lenke type 1 or 2) were included in our study. In all, 349 vertebrae including 68 apical vertebrae and 87 end vertebrae in the main thoracic (MT) curve and thoracolumbar/lumbar (TL/L) curve were analysed. Coronal sections (anterior, middle and posterior) of the vertebral bodies were reconstructed from pre-operative CT scans (320-row detector; slice thickness, 0.5 mm) and the appearances of the ossification centre in the epiphyseal ring at four corners were evaluated in three groups; all vertebrae excluding end vertebrae, apical vertebrae and end vertebrae. The appearance rates of the ossification centre at the concave and convex sides were calculated and compared. Results. The appearance rates of the ossification centres in all vertebrae excluding end vertebrae and apical vertebrae were significantly lower on the concave side than on the convex side in both MT and TL/L curves irrespective of curve flexibility. There was no significant difference in the rate of appearance of the ossification centres on the concave or convex sides in end vertebrae. Conclusion. The asymmetric bony growth of vertebral body came into existence at both structural and non-structural curves, and was more apparent around the apical vertebrae. Evaluation of the ossification centre in the epiphyseal ring could be a measure of the effectiveness of brace treatment. Take home message: The ossification of the epiphyseal ring in patients with AIS was delayed or absent on the concave side particularly around the apical vertebrae. Cite this article: Bone Joint J 2016;98-B:666–71

Clinical, radiological, and Scoliosis Research Society-22 questionnaire data were reviewed pre-operatively and two years post-operatively for patients with thoracolumbar/lumbar adolescent idiopathic scoliosis treated by posterior spinal fusion using a unilateral convex segmental pedicle screw technique. A total of 72 patients were included (67 female, 5 male; mean age at surgery 16.7 years (13 to 23)) and divided into groups: group 1 included 53 patients who underwent fusion between the vertebrae at the limit of the curve (proximal and distal end vertebrae); group 2 included 19 patients who underwent extension of the fusion distally beyond the caudal end vertebra. A mean scoliosis correction of 80% (45% to 100%) was achieved. The mean post-operative lowest instrumented vertebra angle, apical vertebra translation and trunk shift were less than in previous studies. A total of five pre-operative radiological parameters differed significantly between the groups and correlated with the extension of the fusion distally: the size of the thoracolumbar/lumbar curve, the lowest instrumented vertebra angle, apical vertebra translation, the Cobb angle on lumbar convex bending and the size of the compensatory thoracic curve. Regression analysis allowed an equation incorporating these parameters to be developed which had a positive predictive value of 81% in determining whether the lowest instrumented vertebra should be at the caudal end vertebra or one or two levels more distal. There were no differences in the Scoliosis Research Society-22 outcome scores between the two groups (p = 0.17). In conclusion, thoracolumbar/lumbar curves in patients with adolescent idiopathic scoliosis may be effectively treated by posterior spinal fusion using a unilateral segmental pedicle screw technique. Five radiological parameters correlate with the need for distal extension of the fusion, and an equation incorporating these parameters reliably informs selection of the lowest instrumented vertebra. Cite this article: Bone Joint J 2014;96-B:1082–9

Aims. Vertebral body tethering (VBT) is a non-fusion technique to correct scoliosis. It allows correction of scoliosis through growth modulation (GM) by tethering the convex side to allow concave unrestricted growth similar to the hemiepiphysiodesis concept. The other modality is anterior scoliosis correction (ASC) where the tether is able to perform most of the correction immediately where limited growth is expected. Methods. We conducted a retrospective analysis of clinical and radiological data of 20 patients aged between 9 and 17 years old, (with a 19 female: 1 male ratio) between January 2014 to December 2016 with a mean five-year follow-up (4 to 7). Results. There were ten patients in each group with a total of 23 curves operated on. VBT-GM mean age was 12.5 years (9 to 14) with a mean Risser classification of 0.63 (0 to 2) and VBT-ASC was 14.9 years (13 to 17) with a mean Risser classification of 3.66 (3 to 5). Mean preoperative VBT-GM Cobb was 47.4° (40° to 58°) with a Fulcrum unbend of 17.4 (1° to 41°), compared to VBT-ASC 56.5° (40° to 79°) with 30.6 (2° to 69°)unbend. Postoperative VBT-GM was 20.3° and VBT-ASC Cobb angle was 11.2°. The early postoperative correction rate was 54.3% versus 81% whereas Fulcrum Bending Correction Index (FBCI) was 93.1% vs 146.6%. The last Cobb angle on radiograph at mean five years’ follow-up was 19.4° (VBT-GM) and 16.5° (VBT-ASC). Patients with open triradiate cartilage (TRC) had three over-corrections. Overall, 5% of patients required fusion. This one patient alone had a over-correction, a second-stage tether release, and final conversion to fusion. Conclusion. We show a high success rate (95%) in helping children avoid fusion at five years post-surgery. VBT is a safe technique for correction of scoliosis in the skeletally immature patient. This is the first report at five years that shows two methods of VBT can be employed depending on the skeletal maturity of the patient: GM and ASC. Cite this article: Bone Jt Open 2022;3(2):123–129

Introduction. 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 hemi-epiphysiodesis 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. Methods. Retrospective analysis of clinical and radiographic data of 20 patients between 2014 to 2016 with a mean 5 year follow (range 4–6). Results. There were 10 patients in each group with a total of 23 curves operated on. VBT-GM mean age was 12.5y with mean Risser 0.63 and VBT-ASC was14.9y with a Risser of 3.66. Mean preop VBT-GM Cobb was 46° with a Fulcrum unbend of 13.6° compared to VBT-ASC 56.9° with 32.2° unbend. Postop VBT-GM was 21° and VBT-ASC Cobb was 10.8°. The early postop Correction Rate was 54.3% vs 81% whereas FBCI was 77.1% vs 186.6%. The last XR at mean 5y was 22.2° (VBT-GM) and 16.9° (VBT-ASC) 95% avoided fusion. Open TRC group had 3 over corrections. 1 patient alone had overcorrection, unplanned second stage and conversion to fusion. Discussion and Conclusion. We show a high success rate (95%) in helping children avoid fusion. Vertebral body tethering is a safe technique for correction of scoliosis in the skeletally immature patient. This is the first report at 5 years that shows two modalities of VBT can be employed depending on the skeletal maturity of the patient: Growth Modulation and Anterior Scoliosis Correction

Costoplasty remains useful in the treatment of adolescent idiopathic scoliosis, rib hump and associated chest wall deformities. However traditional costoplasty increases morbidity and blood loss. We examine the feasibility and possible effectiveness of a more conservative costoplasty using an animal model. 4 fresh half Ovine rib cages from separate animals were obtained, stored at +4 °C and warmed to room temperature before testing. Each rib cage was randomly assigned to group 1, 2, 3 or 4. Ribs 2–10 were dissected out for testing. The ribs then underwent stepwise deconstruction according to their group. Beginning at the convexity, removing first the convex cortex, then the cancellous, then the cranial and caudal cortices to leave just the concave cortex. Testing for stiffness was by three-point bending on the concave side of each rib with the rib fixed at the head of the rib and 5 cm from the resected area. The ribs were deformed at a constant rate of 0.5 mm.sec . −. 1 up to a maximum load of 9.99 kg or until fracturing. Then stress was plotted against strain to find the Young's modulus of each group and statistics carried out with an ANOVA test. The ribs in each group were as follows: Group 1= control, group 2= 30 mm long convex side cortical bone removed 10 mm from lateral tubercle, group 3= convex, cortical and cancellous bone removal and group 4= removal of convex, caudal and cranial cortices with cancellous removal. The Young's Modulus of the groups were: 1= 3.38 N-m (+/− 0.84), 2= 2.65 N-m (+/− 1.58), 3= 1.55 N-m (+/− 0.55) and 4= 0.74 N-m (+/− 0.55). Groups 3 and 4 were significantly less stiff than group 1 (p< 0.01.) No ribs in groups 1, 2 and 4 fractured under the maximum load. 5/8 ribs in group 3 fractured before the maximum load was administered. By deconstructing the rib down to only the concave side it becomes significantly more flexible by approximately 4.5 times than the control Ribs. Coupled with its increase in flexibility it still retains its ability to withstand up to 10 kg of load without fracture. It may be possible to perform a costoplasty whilst preserving ventilatory integrity. This may improve rib hump correction, and curve correction due to increased flexibility of the stiff thoracic cage

Aims. Magnetically controlled growing rods (MCGRs) allow non-invasive correction of the spinal deformity in the treatment of early-onset scoliosis. Conventional growing rod systems (CGRS) need repeated surgical distractions: these are associated with the effect of the ‘law of diminishing returns’. The primary aim of this study was to quantify this effect in MCGRs over sequential distractions. . Patients and Methods. A total of 35 patients with a maximum follow-up of 57 months were included in the study. There were 17 boys and 18 girls with a mean age of 7.4 years (2 to 14). True Distraction (TD) was determined by measuring the expansion gap on fluoroscopy. This was compared with Intended Distraction (ID) and expressed as the ‘T/I’ ratio. The T/I ratio and the Cobb angle were calculated at several time points during follow-up. Results. The mean follow-up was 30 months (6 to 57). There was a significant decrease in the mean T/I ratio over time (convex rod at 3 months 0.81, . sd. 0.58 vs 51 months 0.17, . sd . 0.16, p = 0.0001; concave rod at 3 months 0.93, . sd. 0.67 vs 51 months 0.18, . sd. 0.15, p = 0.0001). A linear decline of the mean T/I ratios was noted for both convex rods (r. 2. = 0.90, p = 0.004) and concave rods (r. 2. = 0.81, p = 0.015) over 51 months. At the 24-month follow-up stage, there was a significant negative correlation between the mean T/I ratio of the concave rod with weight (r = -0.59, p = 0.01), age (r = -0.59, p = 0.01), and BMI of the child (r = -0.54, p = 0.01). Conclusions. The ‘law of diminishing returns’ is also seen after serial distraction using MCGR. Compared to previously published data for CGRS, there is a gradual linear decline rather than a rapid initial decline in lengthening. In older, heavier children a reduced distraction ratio in the concave rod of the MCGR device is noted over time. Cite this article: Bone Joint J 2017;99-B:1658–64

Aims. There is a paucity of information on the pre-operative coronal imbalance in patients with degenerative lumbar scoliosis (DLS) and its influence on surgical outcomes. Patients and Methods. A total of 284 DLS patients were recruited into this study, among whom 69 patients were treated surgically and the remaining 215 patients conservatively Patients were classified based on the coronal balance distance (CBD): Type A, CBD < 3 cm; Type B, CBD > 3 cm and C7 Plumb Line (C7PL) shifted to the concave side of the curve; Type C, CBD > 3 cm and C7PL shifted to the convex side. Results. A total of 99 of the 284 (34.8%) patient presented with a pre-operative coronal imbalance (mean CBD: 48.5, standard deviation 18.7 mm). More patients with a Type B malalignment were observed than with a Type C malalignment (62 versus 37). A total of 21 pf the 69 (30.4%) surgically treated patients had a post-operative coronal imbalance, which was found to be more prevalent in Type C patients (p < 0.001). At follow-up, less improvement was observed in terms of Short Form-36 Physical Component Score and visual analogue score for back pain (p = 0.034 and 0.025, respectively) in Type C patients. Conclusion. This study shows that patients with Type C coronal malalignment may be at greater risk of post-operative coronal imbalance following posterior osteotomy. Cite this article: Bone Joint J 2016;98-B:1227–33

SUMMARY. A retrospective cohort study of 19 patients of EOS who underwent MCGR rod instrumentation with subsequent serial distractions, measured using ultrasonography. The degree of distraction achieved during each session were analyzed and subgroup analysis done. HYPOTHESIS. The degree of distraction/ distractibility of the MCGR rod is closely linked to the etiology of EOS. The degree of distraction achieved at each session progressively diminishes with successive distractions. STUDY DESIGN. Retrospective cohort study. INTRODUCTION. MCGR rods have gained popularity as an alternative to traditional growing rods for the treatment of Early-onset scoliosis (EOS), serially distracting with an aim to mimic the normal spinal growth, which can be achieved in an outpatient setting using external remote controller. The use of ultrasound as a tool to measure the degree of distraction achieved has been validated previously. However the association between the etiological diagnosis of EOS and the degree of distraction achieved has not been studied previously. METHODS. We performed a retrospective cohort study of 19 patients with EOS of varying etiologies who underwent MCGR rod instrumentation at our institution since 2016. Their hospital records were analyzed to assess the demographics, distraction interval and the degree of distraction achieved at each session. RESULTS. 19 patients (12 females and 7 males) were included in the study. The average age of the study population was 7 years (4–13 years). The average follow up was 2.1 years (1–4). The following were the etiological diagnoses: Idiopathic EOS(8), Neuromuscular scoliosis(5), Syndromic(5), Congenital(1). The average interval between each distraction was 109.8days (88.2–140.6). The overall mean distraction was 1.66mm (0.6–3.427). The mean distraction achieved for the concave rod was 1.69mm (0.6–3.03) as against 1.59mm (0.2–3.427) for the convex rod. The degree of distraction achieved per session was the greatest in patients with neuromuscular scoliosis 2.79mm (0.94–4.62), while it was the least in Congenital scoliosis 0.99mm (0.8–2.93). The degree of distraction in Syndromic and Idiopathic scoliosis groups were 2.19mm (0.1–4.2) and 1.50mm (0.2–4.45) respectively. The mean distraction achieved during the first session after MCGR instrumentation was 2.82mm (0.4–9.8) as against 1.98mm (0.1–4.2) and 1.18mm (0.2–2.3), achieved during the 5. th. and 10. th. distractions respectively. CONCLUSIONS. The average distraction of the MCGR rod achieved per session depends upon the etiological diagnosis of EOS. Neuromuscular curves are the most amenable to MCGR distractions, while the congenital curves are the least. The degree of distraction achieved progressively diminishes with each successive distractions. The distraction achieved slumps to 70% of the initial distraction by the 5. th. session and further declines to 41% of the initial distraction by the 10. th. session. TAKE HOME MESSAGE. The distractibility of the MCGR rod is closely linked to the etiology of EOS. MCGR rods are most effective in cases of neuromuscular scoliosis, while least effective in congenital scoliosis. The law of diminishing returns holds true even with MCGR rods

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. Type 1 neurofibromatosis is a serious hereditary disease in which mainly skin, nervous, muscular, and bone systems are damaged. In bone systems the most common deformities are thoracic kyphosis and scoliosis. Data for morphological changes in the structural components of spine in neurofibromatosis are scarce. Thus our study aimed to investigate morphological changes in structural components of the spine in NF1 neurofibromatosis. Methods. Growth plates, intervertebral discs, and fragments of vertebral bodies from deformed and adjacent segments of the spine were obtained from 15 patients aged 10–14 years with scoliosis (Cobb angle 90–120°) caused by neurofibromatosis. Preoperative examination included MRI study of the spine and brain to exclude intracanal masses, and radiographic study of the spine. Patients did not present any neurological symptoms. All children underwent anterior release and interbody fusion. Structural spinal components from children aged 12–14 years collected at forensic autopsy were used as controls. Tissues were investigated by conventional histochemical and ultrastructural methods. The levels of aggrecan and NF1 gene expression were studied with the PCR method. Results. The study of growth plate and intervertebral disc specimens removed during surgery for scoliosis in neurofibromatosis showed a clear boundary between their convex and concave sides. Both growth plate and intervertebral disc in convex side retain their architectonic and histochemical characteristics. The concave side of the growth plate is presented by small chondroblasts densely spaced without a definite orientation and surrounded by homogeneous matrix, which is made up of chondroitin sulphates. These embryonic-type chondroblasts are poorly differentiated. Chondroblasts proliferate beyond the growth plate. Proliferating cells invade into vertebral body and are bordered by thin bone lamellae, causing the scalloping of vertebral body as a radiological symptom of the pathology. Changes occurring in the intervertebral disc are of considerable interest. Concave-side disc is characterised by isolated proliferation zones containing poorly differentiated chondroblasts and fibroblasts, and neurinoma-like masses. Bone trabeculae inside a concave-side vertebra are passing the stage of osteogenesis imperfecta. Detected morphological changes in spinal structures are consistent with findings of Stevenson, who registered cartilage and bone deficiencies in animal model (mice with NF1 genemutation). Thus, morphological studies testify to structural disorder in concave side of the growth plate, but unchanged regularities and stages of chondroblast differentiation and adequate osteogenesis in the convex side. NF1 gene regulates the growth, differentiation, and proliferation of chondroblasts at the early stage of embryogenesis. Gene inactivation at a somite stage results in altered development of definitive spinal structures. Continued growth with adequate proliferation, differentiation, osteogenesis, and topochemical characteristics occurs in the convex-side growth plate, and growth disorder in the concave-side part with continued load cause growth asymmetry and development of spinal deformity. Scoliosis associated with neurofibromatosis is notable for deformity progression and pseudoarthrosis development after surgery. Deformity progression (modulation) should be considered in connection with disorder in osteogenic potency of osteoblasts. Conclusions. The causal factor of spinal deformity development in NF1 neurofibromatosis is NF1 gene mutation. Inactivation of NF1 gene results in disorder in chondrogenesis and osteogenesis within structurally altered zones. A continued load causes development of scoliotic spinal deformity

Aims

To systematically evaluate whether bracing can effectively achieve curve regression in patients with adolescent idiopathic scoliosis (AIS), and to identify any predictors of curve regression after bracing.

Introduction. Sparing of the spinal growth and scoliotic deformity control in patients with early-onset scoliosis is a challenge in spinal surgery. Loss of the surgical correction, implant breakage, and revision surgeries are the main disadvantages of present treatment methods. The purpose of this study is to investigate whether growing transpedicular instrumentation spares achieved surgical correction during patient's growth. Methods. This is a prospective study of 12 consecutive patients with early-onset scoliosis from one clinical centre. All patients underwent anterior convex growth arrest and posterior transpedicular instrumentation with growing construct. Spinal derotation was used for the correction of the deformity. The diagnoses were infantile idiopathic (n=10) and congenital (n=2) scoliosis (formation failure). Follow-up was 3 years. Mean age at the time of surgery was 9·1 years. Results. Preoperative major Cobb angle was 74·3° (range 52–100°), minor Cobb angle was 32·2° (5–50°), and average preoperative thoracic kyphosis was 27·2° (0–63°). Mean number of the instrumented levels was 12·2. Postoperative major Cobb angle was 22·4° (0–40°), minor Cobb angle was 5·7° (0–23·5°), and postoperative thoracic kyphosis was 26·2° (6–41°). After 3 years of follow-up, primary curve was an average of 22·7° (10–40°), secondary curve was 5·4° (0–25°), and mean thoracic kyphosis was 28° (12–40°). Mean growth of the instrumented spine was 18 mm. We did not observe any gross complications in the patients. Two patients had pleural effusion, and one needed rod exchange 15 months after primary surgery because of insufficient length. Conclusions. The results of this study show that anterior convex growth arrest and polysegmental transpedicular spinal instrumentation with growing construct save spinal growth and anatomical values achieved after surgical correction. Rod derotation for the deformity correction favours spinal growth in skeletally immature patients

To present the results of surgical correction in patients with double or triple thoracic/lumbar AIS (Lenke types 2,3,4) with the use of a novel convex/convex unilateral segmental screw correction technique in a single surgeon's prospective series. We reviewed the medical records and spinal radiographs of 92 consecutive patients (72 female-20 male). We measured scoliosis, thoracic kyphosis, lumbar lordosis, scoliosis flexibility and correction index, coronal and sagittal balance before and after surgery, as well as at minimum 2-year follow-up. SRS-22 data was available preoperatively, 6-month, 12-month and 2-year postoperatively for all patients. Surgical technique. All patients underwent posterior spinal fusion using pedicle screw constructs. Unilateral screws were placed across the convexity of each individual thoracic or lumbar curve to allow for segmental correction. ‘Corrective rod’ was the one attached to the convexity of each curve with the correction performed across the main thoracic scoliosis always before the lumbar. Maximum correction of main thoracic curves was always performed, whereas the lumbar scoliosis was corrected to the degree required to achieve a balanced effect across the thoracic and lumbar segments and adequate global coronal spinal balance. Concave screws were not placed across any deformity levels. Bilateral screws across 2 levels caudally and 1–2 levels cephalad provided proximal/distal stability of the construct. Mean age at surgery was 14.9 years with mean Risser grade 2.8. The distribution of scoliosis was: Lenke type 2–26 patients; type 3–43 patients; type 4–23 patients. Mean preoperative Cobb angle for upper thoracic curves was 45°. This was corrected by 62% to mean 17° (p<0.001). Mean preoperative Cobb angle for main thoracic curves was 70°. This was corrected by 69% to mean 22° (p<0.001). Mean preoperative Cobb angle for lumbar curves was 56°. This was corrected by 68% to mean 18° (p<0.001). No patient lost >2° correction at follow-up. Mean preoperative thoracic kyphosis was 34° and lumbar lordosis 46°. Mean postoperative thoracic kyphosis was 45° (p<0.001) and lumbar lordosis 46.5° (p=0.69). Mean preoperative coronal imbalance was 1.2 cm. This corrected to mean 0.02 cm at follow-up (p<0.001). Mean preoperative sagittal imbalance was −2 cm. This corrected to mean −0.1 cm at follow-up (p<0.001). Mean theatre time was 187 minutes, hospital stay 6.8 days and intraoperative blood loss 0.29 blood volumes (1100 ml). Intraoperative spinal cord monitoring was performed recording cortical and cervical SSEPs and transcranial upper/lower limb MEPs and there were no problems. None of the patients developed neurological complications, infection or detected non-union and none required revision surgery to address residual or recurrent deformity. Mean preoperative SRS-22 score was 3.6; this improved to 4.6 at follow-up (p<0.001). All individual parameters also demonstrated significant improvement (p<0.001) with mean satisfaction rate at 2-year follow-up 4.9. The convex-convex unilateral pedicle screw technique can reduce the risk of neurological injury during major deformity surgery as it does not require placement of screws across the deformed apical concave pedicles which are in close proximity to the spinal cord. Despite the use of a lesser number of pedicle fixation points compared to the bilateral segmental screw techniques, in our series it has achieved satisfactory scoliosis correction and restoration of global coronal and sagittal balance with improved thoracic kyphosis and preserved lumbar lordosis. These results have been associated with excellent patient satisfaction and functional outcomes as demonstrated through the SRS-22 scores

Aims

This study aimed to evaluate rasterstereography of the spine as a diagnostic test for adolescent idiopathic soliosis (AIS), and to compare its results with those obtained using a scoliometer.

Aims

The aim of this study was to evaluate whether, after correction of an adolescent idiopathic scoliosis (AIS), leaving out the subfascial drain gives results that are no worse than using a drain in terms of total blood loss, drop in haemoglobin level, and opioid consumption.

Aim:. To Determine The Effect Of Posterior Instrumented Fusion On Lung Function In Patients With Idiopathic Scoliosis Aged 8–11. Method:. Lung Function (Fvc And Fev1) Was Measured Before Surgery In 13 Patients (Aged 8 To 11) With Idiopathic Scoliosis. All Patients Had Curves Greater Than 50 And Had Undergone Posterior Instrumented Scoliosis Correction And Fusion With (3 Patients) Or Without (10 Patients) Same Day Anterior Convex Growth Arrest. Lung Function Tests Were Repeated 1–8 Years (Mean 5.3 Years) After Surgery. The Data Was Normalised To Take Into Account Standing Height And Loss Of Stature Due To Lateral Curvature, Allowing A Direct Comparison Of Percent Predicted Fev1 And Fvc Before And After Surgery. Results:. Mean Fvc Was 75% Before Surgery And 79% At Longest Follow-Up (1.9l To 2.7l). Mean Fev1 Was 73% Before Surgery And 76% At Longest Follow-Up (1.7 To 2.4). The Change In Lung Function After Surgery Did Not Correlate With Length Of Time To Longest Follow-Up. The Ratio Of Fev1 To Fvc Was 0.86 Before And After Surgery. Discussion:. In Idiopathic Scoliosis Below The Age Of 8 Years, Most Would Accept That Instrumentation Should Allow Spinal Growth To Try And Maintain Lung Function. Above The Age Of 11, Lung Function Is Probably Sufficient To Allow Instrumented Fusion With Its Reduced Complication Rate And Reduced Need For Further Surgery. Between The Ages Of 8 And 11 Controversy Exists. This Pilot Study Suggests That A Larger (Possibly Rct) Study Should Be Performed To Evaluate This Group Of Patients As Fusion May Be Appropriate As Percent Lung Function Corrected For Loss Of Height Due To Curvature Appears To Be Maintained. Conflict Of Interest Statement: No conflict of interest