Aim:. To evaluate the effect of intraoperative manoeuvres on the rib hump. Methods:. Patients with AIS and a thoracic rib hump that underwent a modified Suk technique of scoliosis correction were included. The Scoligauge (Ockenden net) scolimeter app was used to measure the rib hump in Adam's position and the prone position preoperatively. The Scoligauge was used again with the patient prone in theatre, at the end of exposure of the spine, after a 90 degree rod rotation manoeuvre (CD), after a segmental derotation manoeuvre (SDR) and finally at skin closure. The patients were consented for the use of the app on the senior author's mobile device. The device was double bagged for use in theatre. Results:. A sample of 15 patients were enrolled. The biggest difference to the preoperative rib hump measurement seemed to come from simply lying the patient prone. The 90 degree rod rotation manoeuvre did not make a significant further change. In contrast, the segmental derotation manoeuvre did have a positive trend to further correction of the rib hump. No infections occurred. Discussion:. The prone position makes the biggest correction to the rib hump. Further correction is achieved with the SDR. The CD manoeuvre seems to make little difference to the rib hump. In this small study, there was a definite trend to improving the rib hump by lying prone and pursuing SDR. The numbers in this study are small, and the significance of the additional correction to patient outcome is unknown. Conflict of interest:. Depuy-Synthes fund a fellow in our unit. Conflict Of Interest Statement: No conflict of interest

We described a technique of measuring the flexibility of the rib prominence clinically before surgery, and aimed to analyse the results in patients with adolescent idiopathic scoliosis who underwent posterior correction with pedicle screw instrumentation. This prospective study investigated the magnitude of rib humps before and after the operation when the patient was in Adam's forward bending posture. Also preoperatively, a flexion and derotation manoeuvre was performed and the corrected rib prominence was measured. This is compared to the magnitude of the rib hump present postoperatively at three months' follow up. Seven consecutive patients with adolescent idiopathic scoliosis that underwent posterior surgical correction. Clinical measurement of rib prominence using scoliometer. The magnitude of the curve improved from a mean preoperative Cobb angle of 53.6+/−11.2° (range 45.3–72.5°) to a mean postoperative Cobb angle of 7.8+/−9.3° (range 0.4–17.6°). The mean preoperative magnitude of the rib hump was 12.3+/−6.9° (range 5-20°) which was then corrected to a mean magnitude of 1.3+/−2.2° (range 0-5°) by performing the above described flexion derotation manoeuvre. The mean postoperative magnitude of the rib hump was 3.0+/−3.1° (range 0-8°) with the patient in Adam's forward bend position. There was positive correlation between the postoperative residual rib hump and the reduced rib hump measured preoperatively using our described technique (r=0.8,p=0.05). This flexion derotation test is a useful in assessing the amount of postoperative persistent rib hump after posterior correction of adolescent idiopathic scoliosis using pedicle screw instrumentation with derotation technique

Introduction. Adolescent idiopathic scoliosis accounts for 80–85% of all lateral curvatures, and negatively affects pulmonary functions. The concave rib osteotomy technique is designed to provide additional mobility and flexibility of the spine, especially for rigid curves during correction. Only a few studies have investigated the effect of concave rib osteotomy on pulmonary functions. Methods. We undertook a prospective study of 127 patients who underwent posterior spinal fusion for correction of adolescent idiopathic scoliosis. Patients were divided according to their Cobb angle into two groups: group 1 (n=78) with a Cobb angle greater than 70° who underwent an additional concave rib osteotomy (CRO); and group 2 (n=49) with a Cobb angle less than 70° who did not (NCRO). All patients received a programme of pulmonary rehabilitation immediately after the operation for 1 year. Vital capacity (VC) and peak expiratory flow rate (PEF) were measured preoperatively, at 3 months and 12 months postoperatively, and at 5 years postoperatively. Results. In group 1 (CRO), the mean Cobb angle was 82·2° (□}22·78°) preoperatively and 10·9°(□}8·33°) at 1 year follow-up (87% correction). In group 2 (NCRO), the mean Cobb angle was 62·77° (□}18·43°) preoperatively and 6·9°(□}7·69°) at 1 year follow-up (89% correction). Preoperatively there was no significant difference in pulmonary functions between the two groups, with mean VC of 85·2% (□}33·7) in the CRO group and 90·1% (□}38·9) in the NCRO group (p=0·22) and mean PEF of 59·8% (□}27·4) and 52·2% (□}30·3), respectively (p=0·32). Postoperatively, mean VC was 40·4% (□}23·74) in the CRO group (52% reduction) and 48·05% (□}29·13) in the NCRO group (47% reduction) (p=0·05). Mean PEF was 27·38% (□}17·35) in the CRO group (54% reduction) and 34·1% (□}21·8) in the NRCO group (45% reduction) (p=0·02). 12 months postoperatively, mean VC was 102·4% (□}31·5; 150% improvement) and 103·5% (□}40; 115% improvement), respectively (p=0·43). Mean PEF was 76·2% (□}24·5; 170% improvement) and 73·5% (□}35·6; 117% improvement), respectively (p=0·32). 5 years postoperatively, mean VC was 111·84% (□}33·95; 0·09% improvement) and 114% (□}29·6; 0·10% improvement), respectively (p=0·086). Mean PEF was 82·56% (□}36·8; 0·08% improvement) and 82·3% (□}27·1; 0·11% improvement), respectively (p=0·26). Conclusions. Concave rib osteotomy technique has a definite immediate effect on pulmonary functions postoperatively; however, this difference resolves with application of pulmonary rehabilitation programme in both groups and outcome is similar 1 year postoperatively. 5 years later we recorded no significant differences between groups

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?. Methods. A total of 45 patients with a thoracic AIS which needed surgical correction and fusion were included in a prospective study. All patients underwent pulmonary function testing (PFT) and low-dose biplanar radiographs both preoperatively and one year after surgery. The following measurements were recorded: forced vital capacity (FVC), slow vital capacity (SVC), and total lung capacity (TLC). Rib cage volume (RCV), maximum rib hump, main thoracic curve Cobb angle (MCCA), medial-lateral and anteroposterior diameter, and T4-T12 kyphosis were calculated from 3D reconstructions of the biplanar radiographs. Results. All spinal and thoracic measurements improved significantly after surgery (p < 0.001). RCV increased from 4.9 l (SD 1) preoperatively to 5.3 l (SD 0.9) (p < 0.001) while TLC increased from 4.1 l (SD 0.9) preoperatively to 4.3 l (SD 0.8) (p < 0.001). RCV was correlated with all functional indexes before and after correction of the deformity. Improvement in RCV was weakly correlated with correction of the mean thoracic Cobb angle (p = 0.006). The difference in TLC was significantly correlated with changes in RCV (p = 0.041). It was possible to predict postoperative TLC from the postoperative RCV. Conclusion. 3D rib cage assessment from biplanar radiographs could be a minimally invasive method of estimating pulmonary function before and after spinal fusion in patients with an AIS. The 3D RCV reflects virtual chest capacity and hence pulmonary function in this group of patients. Cite this article: Bone Joint J 2022;104-B(1):112–119

Use of ultrasonic bone scalpel (UBS) is becoming popular in spinal surgery. This study presents the safety profile of UBS for posterior release in surgical correction of adolescent idiopathic scoliosis (AIS). From 2016 to 2018, UBS (Misonix) was used by the senior author in a variety of spinal operations. Data for intraoperative complications when this devise was used for posterior correction of AIS were collected. Revision cases were excluded. UBS was used for posterior release of AIS in 65 patients (58 female, seven male) with an average age of 15.6 years (range 11–23). Average length of posterior instrumentation was 12 levels (range 6–14). Instrumentation was exclusively from T2 to L4. To achieve adequate release for correction, UBS was used to perform a total of 644 modified in-situ chevron osteotomies (average ten, range six to 12) and 31 rib osteotomies. Overall, three complications (4.6 %) were directly related to the use of UBS: one haemopneumothorax, which was successfully treated with a chest drain; and two loss of motor-evoked potentials during monitoring, which led to the postponement of the final correction. These two patients did not have any neurological problems and their surgery was completed successfully within 1 week of the initial surgery. One late deep infection was reported. This was not thought to be directly related to the use of UBS. Use of UBS in the posterior surgical treatment of AIS appears to be relatively safe with a low level of acceptable complications. However, appropriate training is required for the use of UBS

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

Aim:. To Determine Whether Maximal Rib Prominence Measured On Lateral Radiographs Can Be Used As A Surrogate To Rib Rotation Determined By Surface Tomography (Quantecscanning) In Assessment Of Spinal Rotation. Method:. Patients With Adolescent Idiopathic Scoliosis Underwent Plain Lateral Radiographs And Quantec Scans. Maximal Rib Prominence On The Lateral Radiograph Was Defined Pre- And Post-Operatively By Distance From Most Posterior Aspect Of The Rib To The Facet Joint And Instrumented Rod, Respectively. Rib Rotation Was Measured By Surface Tomography Quantec Scan Using The Suzuki Method. This Was Then Repeated At A Later Time And By An Additional Investigator To Assess Intra- Observer And Inter-Observer Variability. The Correlation Between Maximal Rib Prominence And The Suzuki Ratio Was Determined. Results:. 20 Patients, Median Age 15 Years, Were Evaluated. The Correlation Coefficient Between Radiograph Determined Maximal Rib Prominence And Quantec Derived Suzuki Ratio Was 0.68, R2=0.46 (See Figure). Discussion:. There Was A Weak Positive Correlation Between Radiograph Determined Maximal Rib Prominence And Quantec Derived Suzuki Ratio. Further Investigation In A Larger Cohort Is Warranted. Conflict Of Interest Statement: No conflict of interest

Introduction. The Hamann-Todd collection at the Cleveland Museum of Natural History (Cleveland, OH, USA) includes 63 paediatric skeletal specimens in varying condition and completeness. The initial data collection included representative skeletons of children aged 1–18 years. The aim of this study was to better understand the growth patterns of the paediatricspine and ribs. Methods. Data from vertebrae and corresponding ribs were collected. Data included 46 measurements from the vertebral body and ribs at T1, T4, T7, T10, and L3. Measurements were obtained with Vernier calipers, tape measures, and photographs of each bone. Several specimens were digitised with a Next Engine 3D laser scanner. The initial analysis used caliper-derived data, with some measurements obtained from photographs. The data were analysed by age, specific bone, and morphological features. More than 2000 cross correlations were studied. Linear regressions were done on scalar measurements with SAS (version 9.1.3) and JMP (version 8.0). Although the general demographics for each child were known, specifics such as height and weight or previous trauma were not. Results. Data analysis showed linear relationships in the ribs and growing spine. For example, the figure shows the data and linear regression for the right rib at T7 for each age. Rib width showed no significant increase with age (r2=0·001), whereas rib height had a linear increase (r2=0·754). Other measurements, such as costal length, were highly correlated with age. Conclusions. Direct measurements of paediatric cadaveric bones can be statistically analysed to provide insight into normal human growth. The data show a linear growth of the spine and rib cage from ages 1–18 years. Relatively little is known about the normal growth of human ribs and spine. This is the first known osteological data collection of the growing ribs and spine in non-scoliotic children. Understanding of chest growth will help to improve treatment of spine and chest-wall deformity in growing children

To determine the factors that influences the clinical outcomes in surgical correction of thoracic AIS. There are conflicting data regarding the effects of back shape and radiologic parameters on the self-reported outcomes of surgery in AIS. Prospective, cohort study; mean follow-up 29 months (range 9-88). 30 patients (5 males);. Rib hump 17 ° corrected to 7 °. Thoracic Cobb 66 ° corrected to 25 ° (63%). Lumbar Cobb 42 ° corrected to 17°. Thoracic apical vertebral translation (AVT) 48mm corrected to 18mm. Lumbar AVT 34mm corrected to 19mm. Thoracic kyphosis 29° preoperatively 23° postoperatively. Lumbo-sacral lordosis 57° preoperatively 49° postoperatively. Modified SRS Outcomes Instrument (MSRSI) filled out pre-operatively and at final follow up. Primary= rib hump, radiological (frontal Cobb correction, lumbar & thoracic AVT, sagittal profile), Modified SRS Outcomes Instrument (MSRSI) domain scores. The magnitude of the rib hump had a significant association with pain:. Rib hump vs. MSRSI pain r= -0.55 p<0.000. Similar correlations existed between rib hump and self-image (r=-0.64, p<0.0000), thoracic Cobb angle with pain (r=-0.48 p<0.0001) and self-image (r= -0.57, P<0.0000). The postoperative thoracic Cobb angle, and percentage thoracic Cobb correction had significant correlations with self-image (r=-0.55 p=0.003 & r=0.54 p0.004 respectively). The size of the rib hump has a significant impact on pain & self-image. These domains are also significantly influenced by the residual thoracic Cobb angle and overall scoliosis correction

Introduction. Children with early-onset scoliosis (EOS) with rib hump chest-wall distortion or fused/absent ribs have thoracic insufficiency syndrome (TIS). Commonly, respiration is adversely affected by loss of lung volume from chest-wall constriction and clinical loss of active rib cage expansion. The dynamic thoracic components of diaphragm or rib cage lung expansion during respiration is poorly characterised by radiograph or CT scan. Pulmonary function tests indicate only hemithorax performance. Dynamic lung MRI, however, can visualise both chest-wall and diaphragm motion, allowing assessment of each individual hemithorax performance, so that a dynamic classification system of the thoracic function can be developed. Methods. Ten patients with TIS underwent dynamic lung MRI testing as part of the routine clinical preoperative work-up. Each hemithorax was graded: 1=intact motion of both chest wall and diaphragm; 2=primarily loss of chest-wall motion with minimal diaphragm abnormality; 3=substantial loss of diaphragm excursion with minimal loss or compensatory hyperkinesis of chest wall; and 4=substantial loss of both diaphragm and chest-wall motion. The grades for each hemithorax were added and averaged to form the thoracic function score. Ranges of scores were grouped into levels of clinical thoracic performance: level I (score 1–1·5); level II (>1·5–2·5); level III (>2·5–3·5); and level IV(>3·5–4·0). Results. Of nine patients with EOS, two were level I, three were level II, and four were level III. In four patients there was marked posterior obstruction of diaphragmatic excursion by soft-tissue organs. One patient with hypoplastic thorax without scoliosis was level II. Conclusions. Thoracic function index is a new thoracic performance approach based on dynamic lung MRI that has potential to identify biomechanical abnormalities of the thorax in EOS that cause restrictive lung disease. This index could provide insight into how to reverse the abnormality with new types of surgeries. Posterior obstructive blockade of the diaphragm is identified as a new cause for restrictive lung disease in EOS

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The aim of this study was to report the long-term prognosis of patients with multiple Langerhans cell histiocytosis (LCH) involving the spine, and to analyze the risk factors for progression-free survival (PFS).

We reviewed 64 anterolateral decompressions performed on 63 patients with tuberculosis of the dorsal spine (D. 1. to L. 1. ). The mean age of the patients was 35 years (9 to 73) with no gender preponderance. All patients had severe paraplegia (two cases grade III, 61 cases grade IV). The mean number of vertebral bodies affected was 2.6; the mean pre-treatment kyphosis was 24.8° (7 to 84). An average of 2.9 ribs were removed in the course of 64 procedures. The mean time taken at surgery was 2.45 hours when two ribs were removed and 3.15 hours when three ribs were removed. Twelve patients (19%) showed signs of neurological recovery within seven days, 33 patients (52%) within one month and 12 patients (19%) after two months; but six patients (10%) showed no neurological recovery. Forty patients were followed up for more than two years. In 34 (85%) of these patients there was no significant change in the kyphotic deformity; two patients (5%) showed an increase of more than 20°

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The aim of this study was to compare outcomes after growth-friendly treatment for early-onset scoliosis (EOS) between patients with skeletal dysplasias versus those with other syndromes.

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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.

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Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in motor impairment affecting the upper limbs more than the lower, with occasional sensory impairment and urinary retention. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study was to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age.

To assess the effectiveness of unilateral sublaminar and concave rib tethering with convex rib resection through the period of peak growth in lambs. Morphometric growth data from 10 experimental Scottish Blackface sheep were compared to those from 5 control animals (no intervention) over 12 months. Standardized AP and Lateral radiographs were taken before and at monthly intervals after scoliosis creation. The Cobb angle was measured in the coronal and sagittal planes. Rotational mal-alignment was assessed by axial CT 7 months post surgery. In the supine position the control animals had no coronal plane deformity and a mean 5° lordosis (T4-T12). These figures did not alter with growth (doubling of body weight). Tethering (at age 5 weeks) produced an immediate scoliosis of 22±11° and a lordosis of 24±8° (means(sd). The degree of scoliosis was maintained over 7 months (at 20°) but lordosis increased (to 59±11°, p<0.01). There was an associated change in vertebral rotation. Surgery had no influence on rate of growth or animal development. Two animals died from Clostridium associated enterocolitis. There were no deaths associated with the surgical intervention. This ovine model gives a progressive spinal deformity in the sheep but primarily in the sagittal plane. This fact should be considered in studies designed to evaluate the effectiveness of surgical implants

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The aim of this study was to assess the ability of morphological spinal parameters to predict the outcome of bracing in patients with adolescent idiopathic scoliosis (AIS) and to establish a novel supine correction index (SCI) for guiding bracing treatment.

Injury to the spinal cord and kyphosis are the two most feared complications of tuberculosis of the spine. Since tuberculosis affects principally the vertebral bodies, anterior decompression is usually recommended. Concomitant posterior instrumentation is indicated to neutralise gross instability from panvertebral disease, to protect the anterior bone graft, to prevent graft-related complications after anterior decompression in long-segment disease and to correct a kyphosis. Two-stage surgery is usually performed in these cases. We present 38 consecutive patients with tuberculosis of the spine for whom anterior decompression, posterior instrumentation, with or without correction of the kyphus, and anterior and posterior fusion was performed in a single stage through an anterolateral extrapleural approach. Their mean age was 20.4 years (2.0 to 57.0). The indications for surgery were panvertebral disease, neurological deficit and severe kyphosis. The patients were operated on in the left lateral position using a ‘T’-shaped incision sited at the apex of kyphosis or lesion. Three ribs were removed in 34 patients and two in four and anterior decompression of the spinal cord was carried out. The posterior vertebral column was shortened to correct the kyphus, if necessary, and was stabilised by a Hartshill rectangle and sublaminar wires. Anterior and posterior bone grafting was performed. The mean number of vertebral bodies affected was 3.24 (2.0 to 9.0). The mean pre-operative kyphosis in patients operated on for correction of the kyphus was 49.08° (30° to 72°) and there was a mean correction of 25° (6° to 42°). All except one patient with a neural deficit recovered complete motor and sensory function. The mean intra-operative blood loss was 1175 ml (800 to 2600), and the mean duration of surgery 3.5 hours (2.7 to 5.0). Wound healing was uneventful in 33 of 38 patients. The mean follow-up was 33 months (11 to 74). None of the patients required intensive care. The extrapleural anterolateral approach provides simultaneous exposure of the anterior and posterior aspects of the spine, thereby allowing decompression of the spinal cord, posterior stabilisation and anterior and posterior bone grafting. This approach has much less morbidity than the two-stage approaches which have been previously described

The Walter Reed Visual Assessment Scale (WRVAS) is a valid and reliable tool, designed to measure physical deformity as perceived by patients with idiopathic scoliosis. It is unclear whether the type of treatment in patients with thoracic adolescent idiopathic scoliosis affects the patients' perception of cosmesis gain. We studied 40 patients with Adolescent Idiopathic Scoliosis treated with posterior spinal fusion with (20) and without thoracoplasty (20) aiming to assess correlation of improvement in radiological parameters to subjective cosmesis gain. Patients with Adolescent Idiopathic Scoliosis treated with posterior spinal fusion with thoracoplasty (20) and without thoracoplasty (20) filled out Walter Reed Visual Assessment Scale (WRVAS) forms with their perception of deformity before and after operation at the clinic follow-up. The WRVAS forms include seven aspects of the deformity i.e. spinal deformity, rib prominence, lumbar prominence, thoracic deformity, trunk imbalance, shoulder asymmetry and scapular asymmetry. Each aspect is shown with five figures of increasing severity of the deformity and scored from minimum (1) to maximum (5). Results are presented as the sum of the seven questions. The lowest possible score for the total is 7, while the highest possible total score is 35. The curve magnitude was divided into 5 subgroups as 30 and under, 30-40, 40-50, 50-60 and 70 and over. Floor and ceiling effects were analysed as percentage of cases with minimum and maximum scores. Our study confirmed that following posterior scoliosis surgery with and without thoracoplasty, there was significant improvement in perceived appearance. Overall spinal deformity and thoracic deformity correction were comparable in two groups. However, improvement in rib hump prominence, flank prominence, restoration of truncal, shoulder and scapular symmetry were much better rated by the patients with PSF and thoracoplasty group using Walter Reed Visual Assessment Scale

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Patients with differentiated thyroid carcinomas (DTCs) have a favourable long-term survival. Spinal metastases (SMs) cause a decline in performance status (PS), directly affecting mortality and indirectly preventing the use of systemic therapies. Metastasectomy is indicated, if feasible, as it yields the best local tumour control. Our study aimed to examine the long-term clinical outcomes of metastasectomy for SMs of thyroid carcinomas.