Clinically significant proximal junctional kyphosis (PJK) occurs in 20% of children treated with posterior distraction-based growth friendly surgery. In an effort to identify modifiable risk factors, it has been theorized biomechanically that low radius of curvature (ROC) implants (i.e., more curved rods) may increase post-operative thoracic kyphosis, and thus may pose a higher risk of developing PJK. We sought to test the hypothesis that EOS patients treated with low ROC (more curved rods) distraction-based treatment will have a greater risk of developing PJK as compared to those treated with high ROC (straighter) implants. This is a retrospective review of prospectively collected data obtained from a multi-centre EOS database on children treated with rib-based distraction with minimum 2-year follow-up. Variables of interest included: implant ROC at index (220 mm or 500 mm), patient age, pre-operative scoliosis, pre-operative kyphosis, and scoliosis etiology. In the literature, PJK has been defined as clinically significant if revision surgery with superior extension of the upper instrumented vertebrae was performed. In 148 scoliosis patients, there was a higher risk of clinically significant PJK with low ROC (more curved) rods (OR: 2.6 (95%CI 1.09-5.99), χ2 (1, n=148) = 4.8, p = 0.03). Patients had a mean pre-operative age of 5.3 years (4.6y 220 mm vs 6.2y 500 mm, p = 0.002). A logistic regression model was created with age as a confounding variable, but it was determined to be not significant (p = 0.6). Scoliosis etiologies included 52 neuromuscular, 52 congenital, 27 idiopathic, 17 syndromic with no significant differences in PJK risk between etiologies (p = 0.07). Overall, patients had pre-op scoliosis of 69° (67° 220mm vs 72° 500mm, p = 0.2), and kyphosis of 48° (45° 220mm vs 51° 500mm, p = 0.1). The change in thoracic kyphosis pre-operatively to final follow up (mean 4.0 ± 0.2 years) was higher in patients treated with 220 mm implants compared to 500 mm implants (220 mm: 7.5 ± 2.6° vs 500 mm: −4.0 ± 3.0°, p = 0.004). Use of low ROC (more curved) posterior distraction implants is associated with a significantly greater increase in thoracic kyphosis which likely led to a higher risk of developing clinically-significant PJK in EOS patients

Proximal junctional kyphosis (PJK) is defined as adjacent segment kyphosis >10° between the upper instrumented vertebrae and the vertebrae 2 levels above following scoliosis surgery. There are few studies investigating the predictors and clinical sequelae involved with this relatively common complication. Our purpose was to determine the radiographic predictors of post-op PJK and to examine the association between PJK and pain/HRQOL following surgery for AIS. The Post-Operative Recovery after Scoliosis Correction: Home Experience (PORSCHE) study was a prospective multicenter cohort of AIS patients undergoing spinal fusion surgery. Pre-op and minimum 2 year f/u scoliosis and sagittal spinopelvic parameters (thoracic kyphosis–TK, lordosis–LL, pelvic tilt-PT, sacral slope-SS, pelvic incidence-PI) were measured and compared to numeric rating scale for pain (NRS) score, SRS-30 HRQOL and to the presence or absence of PJK (proximal junctional angle >100). Continuous and categorical variables were assessed using logistic regression and binomial variables were compared to binomial outcomes using chi-square. 163 (137 females) patients from 8 Canadian centers met inclusion criteria. At final f/u, PJK was present in 27 patients (17%). Pre-op means for PJK vs No PJK: Age 14.1 vs 14.7yr; females 85 vs 86%; scoliosis 57±22 vs 62±15deg; TK 28±18 vs 19±16deg ∗, LL 62±11 vs 60±12deg, PT 8±12 vs 10±10deg, SS 39±8 vs 41±9deg, PI 47±14 vs 52±13deg, SVA −9±30 vs −7±31mm. Final f/u for PJK vs No PJK: Scoliosis 20±11 vs 18±8deg, final TK 26±12 vs 19±10deg∗, LL 60±11 vs 57±12deg, PT 9±12 vs 12±13deg, SS 39±9 vs 41±9deg, PI 48±17 vs 52±14deg, SVA −23±26 vs −9±32mm∗. Significant findings: Pre-op kyphosis >40deg has an odds ratio (OR) of 4.41 (1.50–12.92) for developing PJK∗. The presence of PJK was not associated with any significant differences in NRS or SRS-30. ∗denotes p<0.05. This prospective multicenter cohort of AIS patients demonstrated a 17% risk of developing PJK. Pre-op thoracic kyphosis >40deg was associated with the development of PJK; however, the presence of PJK was not associated with increased pain or decreased HRQOL

Our prospective observational study of patients treated for Thoracolumbar Adolescent Idiopathic Scoliosis (AIS) by anterior instrumentation aimed at investigating the correlation between the radiographic outcome and the recently-developed scoliosis research society self-reported outcomes instrument (SRS-22) which has been validated as a tool for self-assessment in scoliosis patients. Previous patient based questionnaires demonstrated poor correlation with the radiological parameters. Materials and Methods. Pre-operative, post-operative and two years follow-up radiographs of 30 patients were assessed. Thirteen radiographic parameters including Cobb angles and balance were recorded. The percentage improvements for each were noted. The SRS-22 questionnaire was completed by all patients at final follow-up. Correlation was sought between each radiographic parameter, total SRS score and each of the five domains by quantifying Pearson's Correlation Coefficient (r). Results. Percentage improvement in primary Cobb angle (r = 0.052), secondary Cobb angle (r = 0.165), apical vertebra translation of the primary curve (r = -0.353), thoracic kyphosis (r = 0.043) and lumbar lordosis (r = 0.147) showed little or no correlation with the SRS-22 total score and its five individual domains. Significant inverse correlation was found between the upper instrumented vertebra angle and at follow-up and SRS-22 (r = -0.516). The same was true for Sagittal plumb line shift at final follow up (r = -0.447). Conclusion. SRS-22 is a validated tool for the self-assessment of health status in spinal deformity patients; however, it does not seem to correlate with most of the radiographic parameters commonly used by clinicians to assess patient outcome with the exception of upper instrumented vertebra angle and sagittal plumb line which do correlate significantly with the SRS-22 outcomes instrument. A comprehensive system of assessing the success of surgery both from the patient and clinicians perspective is required in the spinal deformity patient

Purpose. Spinopelvic parameters describe the orientation, shape, and morphology of the spine and pelvis. In children without spinal deformity, these parameters have been shown to change during the first ten years of life; however, spinopelvic parameters have yet to be defined in children with significant Early Onset Scoliosis (EOS). The purpose of this study is to examine the effects of EOS on sagittal spinopelvic alignment. Method. Standing, lateral radiographs of 82 untreated patients with EOS greater than 50 degrees were evaluated. Sagittal spine parameters (sagittal balance, thoracic kyphosis (TK), lumbar lordosis (LL)) and sagittal pelvic parameters (pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), modified pelvic radius angle (PR)) were measured. These results were compared to those reported by Mac-Thiong et al (Spine, 2004) for a group of asymptomatic (i.e. without spinal deformity) children of similar age. Results. These patients had a mean age of 5.17 years and mean scoliosis of 73.3 17.3. Mean sagittal spine parameters were: sagittal balance (+2.4 4.03 cm), TK (38.2 20.8), and LL (47.8 17.7). These values were similar to those reported for asymptomatic subjects. Mean sagittal pelvic parameters were measured for PI (47.1 15.6), PT (10.3 10.7), SS (35.5 12.2), and PR (57.1 21.2). Although PI was similar to age-matched normals, PT was significantly higher and SS trended lower in the study population. Conclusion. Sagittal plane spine parameters in children with EOS were similar to those found in children without spinal deformity. Likewise, pelvic parameters (PI, SS, PR) were similar; however, those children with EOS signs of pelvic retroversion (increased pelvic tilt). This data may be useful as a baseline in determining prognosis for children with EOS who are treated with growing systems

Thoracic kyphosis increases with age. The resultant increase in compression forces on the anterior vertebral bodies leads to further kyphotic deformity and, an increased likelihood of vertebral collapse. This study aimed to determine the relative efficacy of two therapeutic strategies commonly used to treat hyperkyphosis. 69 subjects (26 male: 43 female) were randomised into 4 groups: strengthening, postural re-education (PEd), both and control. The strengthening group attended a gym 3 times a week for 12 weeks to perform seated extension exercises. The PEd group had 3 physiotherapy sessions within a 12 week period in which they received postural assessment and a home exercise programme. The combined group received both interventions while the control group received neither. Outcome measurements were assessed at baseline and 12 weeks. They included static (inclinometer) and 6-hour angular measurements (using flexible electrogoniometer (FEG)) and physical function tests. There were no significant differences between the marginal means of the angular measurements for any of the intervention groups. However, the group which received both interventions demonstrated reduced kyphosis as measured by the FEG angles (apex of the curve between T3 and T11), while the strengthening group showed reduced inclinometer angles (between T1 and T12). The strengthening group showed improvement in back extensor strength (BES) (0.6 +/− 0.2 N/kg, p < 0.01), time to walk 10 metres (−0.3 +/− 0.6 s, p < 0.05), and time to stand and sit 5 times (−0.9 +/− 0.6 s, p < 0.05). However, there was no relationship between change in BES and change in kyphotic angle. The PEd group showed the greatest improvement in the timed up and go test but this was not significant. Improvement in inclinometer angle over the 12 weeks was associated with degree of kyphosis at baseline (upright inclinometer r = −0.47, p=0.0001) but this relationship was not apparent in the FEG measurements. Both the FEG and inclinometer angles showed a marked decrease in degree of improvement in subjects aged >70. (50/50). A combination of strengthening and PEd was most effective at reducing hyperkyphosis. BES was improved with resisted strengthening but not with home-based postural exercises. However, increased BES was not associated with decreased kyphosis. Larger baseline kyphosis was associated with greater angular improvement. Subjects aged >70 were less likely to improve