Showing papers on "Cobb angle published in 2002"

Adult scoliosis: a quantitative radiographic and clinical analysis.

Abstract: STUDY DESIGN Prospective analysis of a consecutive series of adult patients with adolescent idiopathic scoliosis of the adult and de novo degenerative scoliosis. OBJECTIVES To clinically and radiographically study two populations of adult patients with either adolescent idiopathic scoliosis of the adult or de novo degenerative scoliosis in a quantitative manner to identify reliable radiographic parameters that correlate with clinical symptoms. SUMMARY AND BACKGROUND Although there are many causes of spinal deformity in the adult, there are two main categories of adult scoliosis: adolescent idiopathic scoliosis of the adult and de novo degenerative scoliosis. Unlike pediatric scoliosis, in adults there are no established radiographic parameters or classification systems that reliably provide a clinical correlation or offer a useful language for communication among specialists. This study gathered complete clinical and radiographic information on 95 patients with adult scoliosis and established several radiographic parameters that correlated with clinical symptoms. METHODS Each of the 95 patients completed a clinical questionnaire that included a self-reported visual analog scale and underwent full-length standing anteroposterior and lateral radiography. Radiographic analysis was performed by use of digital analysis and included measurement of the Cobb angle, the number of vertebrae in each curve, plumbline offset from T1 to the midsacral line, the upper endplate obliquities of L3 and L4, and maximal lateral olisthy between two adjacent lumbar vertebrae. Sagittal plane measurements included lumbar lordosis, thoracolumbar kyphosis, and the Sagittal Pelvic Tilt Index. Statistical analysis of both radiographic and clinical parameters of pain was performed to determine any significant correlations between the two. RESULTS This study showed that lateral vertebral olisthy, L3 and L4 endplate obliquity angles, lumbar lordosis, and thoracolumbar kyphosis were significantly correlated with pain. CONCLUSION This quantitative analysis identified several clinically relevant radiographic parameters in adult scoliosis patients. Additionally, excellent predictive formulas for self-reported pain levels were obtained.

Comparative analysis of pedicle screw and hook instrumentation in posterior correction and fusion of idiopathic thoracic scoliosis.

Abstract: Posterior correction and fusion with segmental hook instrumentation represent the gold standard in the surgical treatment of progressive idiopathic thoracic scoliosis. However, there is a debate over whether pedicle screws are safe in scoliosis surgery and whether their usage might enable a better curve correction and a shorter fusion length. The details of curve correction, fusion length and complication rate of 99 patients with idiopathic thoracic scoliosis treated with either hook or pedicle screw instrumentation were analyzed. Forty-nine patients had been operated with the Cotrel-Dubousset system using hooks exclusively ("hook group"). Fifty patients had been operated with either a combination of pedicle screws in the lumbar and lower thoracic and hooks in the upper thoracic spine or exclusive pedicle screw instrumentation using the Munster Posterior Double Rod System ("screw group"). The preoperative Cobb angle averaged 61.3° (range 40°–84°) in the hook group and 62.5° (range 43°–94°) in the screw group. Average primary curve correction was 51.7% in the hook group and 55.8% in the screw group (P>0.05). However, at follow-up (2–12 years later) primary curve correction was significantly greater (P=0.001) in the screw group (at 50.1%) compared to the hook group (at 41.1%). Secondary lumbar curve correction was significantly greater (P=0.04) in the screw group (54.9%) compared to the hook group (46.9%). Correction of the apical vertebral rotation according to Perdriolle was minimal in both groups. Apical vertebral translation was corrected by 42.0% in the hook group and 55.6% in the screw group (P=0.008). Correction of the tilt of the lowest instrumented vertebra averaged 48.1% in the hook group and 66.2% in the screw group (P=0.0004). There were no differences concerning correction of the sagittal plane deformity between the two groups. Fusion length was, on average, 0.6 segments shorter in the screw group compared to the hook group (P=0.03). With pedicle screws, the lowest instrumented vertebra was usually one below the lower end vertebra, whereas in the hook group it was between one and two vertebrae below the lower end vertebra. Both operative time and intraoperative blood loss were significantly higher in the hook group (P<0.0001). One pedicle screw at T5 was exchanged due to the direct proximity to the aorta. There were no neurologic complications related to pedicle screw instrumentation. Pedicle screw instrumentation alone or in combination with proximal hook instrumentation offers a significantly better primary and secondary curve correction in idiopathic thoracic scoliosis and enables a significantly shorter fusion length.

Correlation of Radiographic, Clinical, and Patient Assessment of Shoulder Balance Following Fusion Versus Nonfusion of the Proximal Thoracic Curve in Adolescent Idiopathic Scoliosis

Abstract: Study Design. Retrospective clinical, radiographic, and patient outcome review of surgically treated adolescent idiopathic scoliosis. Objectives. To correlate radiographic and clinical features of shoulder balance and the proximal thoracic curve with patient satisfaction outcomes at a minimum 2-year follow-up. of Background Data. Traditionally, radiographic features of a structural proximal thoracic curve have been T1 tilt, proximal thoracic Cobb angle, and proximal thoracic side-bending Cobb; however, these do not always correlate with clinical shoulder balance. Methods. A total of 112 patients (single surgeon) with adolescent idiopathic scoliosis and a proximal thoracic curve ≥20° (average 32°, range 20-78°) were evaluated in terms of shoulder balance and curve flexibility/correction. Four groups were analyzed: Group 1, posterior spinal fusion to T2 (proximal thoracic curve included, n = 24); Group 2, posterior spinal fusion to T3 (proximal thoracic curve partially included, n = 23); Group 3, posterior spinal fusion to T4 or T5 (proximal thoracic curve not included, n = 21); and Group 4, anterior spinal fusion to T4 or below (proximal thoracic not included, n = 44). Proximal thoracic, main thoracic, and thoracoiumbar-lumbar upright coronal, side-bending, and sagittal Cobb measurements were assessed before surgery, 1 week after surgery, and at a minimum 2-year postoperative follow-up (average 3.8 years, range 2.0-7.6 years). In addition to T1 tilt, clavicle angle (intersection of a horizontal line and the tangential line connecting the highest two points of each clavicle), coracoid height difference, trapezius length (horizontal distance of the T2 pedicle to second rib-clavicle intersection), first rib-clavicle height difference (vertical distance of first rib apex to superior clavicle), and proximal thoracic, main thoracic, and thoracolumbar-lumbar apical vertical translation were determined. Shoulder asymmetry as measured by the radiographic soft tissue shadow was graded as balanced ( 3 cm). A postoperative patient questionnaire addressed shoulder balance and overall appearance at most recent follow-up. Results. The four groups were found to be statistically equivalent in terms of preoperative proximal thoracic curve (P = 0.4146), proximal thoracic side-bending Cobb (P = 0.2199), main thoracic curve (P = 0.6999), and main thoracic side-bending curves (P = 0.7307). Radiographic. Preoperative proximal thoracic measurements correlating with postoperative shoulder balance (P < 0.05) included the clavicle angle (three of four groups with a trend toward statistical significance in the fourth group, P - 0.07) and coracoid height (two of four groups). No other measurement, including T1 tilt and proximal thoracic side-bending Cobb, correlated in more than one group. Proximal thoracic curve correction was greatest in Group 1 (posterior spinal fusion to T2; average 12°) and Group 4 (anterior spinal fusion to T4 or below; average 12°). Clinical. Shoulder balance improved in all four groups (range 0.38-1.00 grades). There was no difference in shoulder balance between groups (P = 0.2723). Patient assessment All four groups also reported improvement in self-perceived shoulder balance (63% up to one grade, 37% over two-grade improvement), whereas no patient reported worsening of shoulder balance. There was no significant difference in patient outcomes between the four groups (P = 0.3654). Conclusion. The clavicle angle, not T1 tilt, upright proximal thoracic, or side-bending proximal thoracic Cobb, provided the best preoperative radiographic prediction of postoperative shoulder balance. in each of the four groups, postoperative shoulder balance and clinical appearance also improved and correlated with patient postoperative assessments.

Hemivertebra resection by a posterior approach: innovative operative technique and first results.

Abstract: Study design A retrospective study was conducted, with clinical evaluation of hemivertebra resection using transpedicular instrumentation by a posterior approach in young children. Objective To assess a new method of early intervention in congenital scoliosis by a posterior approach. Summary of background data Previously described surgical procedures are fusion in situ, hemiepiphyseodesis and arthrodesis, "growing" instrumentations, and hemivertebra resections performed by a combined anterior and posterior approach. Methods For this study, 21 consecutive cases of congenital scoliosis managed by hemivertebra resection using a posterior approach only with transpedicular instrumentation were investigated retrospectively, with at least a 2-year follow-up period. Surgery was performed in patients who had congenital scoliosis with proven or expected deterioration, or pain resulting from the malformation. Results The mean Cobb angle of the main curve was 41 degrees before surgery, 14 degrees after surgery, and 15 degrees at the latest follow-up assessment. The angle of kyphosis was 24 degrees before surgery, but improved to 11 degrees after surgery. There was one infection, one pedicle fracture, and two failures of the initially used wire instrumentation. Conclusions Posterior resection of hemivertebrae with transpedicular instrumentation is a safe and promising procedure that offers significant advantages for controlling congenital deformity: excellent correction in both the frontal and sagittal planes, short segment of fusion, high stability, no need for an anterior approach, and low neurologic risk. Surgery should be performed as early as possible to avert severe local deformities, to prevent secondary structural changes, and to avert extensive fusions.

Quality of life in women with idiopathic scoliosis.

Abstract: STUDY DESIGN The health-related quality of life of 226 female patients with idiopathic scoliosis was compared with that in age-matched general population norms. OBJECTIVES To describe and characterize health-related quality of life in women with idiopathic scoliosis, taking into account age, Cobb angle, and brace use. SUMMARY OF BACKGROUND DATA Scoliosis may lead to multiple physical and psychosocial impairments depending on its severity. Previous studies have assessed generic health measures, functional status, body image, and self-image. Health-related quality of life data from patients with idiopathic scoliosis are still lacking. METHODS Women with idiopathic scoliosis completed an age-appropriate health-related quality of life questionnaire (either the 36-Item Short-Form Health Status Survey, SF-36, or the Berner Questionnaire for Well-Being). The results from this sample were compared with general population norms. In univariate and multivariate analyses it was determined whether age, Cobb angle, and brace use had an impact on health-related quality of life. RESULTS Compared with the age-matched general population norm, juvenile patients with idiopathic scoliosis were unhappier with their lives (P = 0.001). They reported more physical complaints (P < 0.001) and had lower self-esteem (P = 0.01) and higher depression scores (P = 0.021). Adult patients reported more psychologic (P < 0.001) and physical impairment than in the population norm (P < 0.001). These results were largely independent of age and Cobb angle. CONCLUSION The results show that health-related quality of life can be impaired in patients with idiopathic scoliosis. Therefore, the psychosocial situation should be taken into account in the treatment of these patients.

Subcutaneous rodding for progressive spinal curvatures: early results.

Abstract: This study retrospectively reviewed the clinical records and radiographs of 11 patients with progressive early-onset scoliosis who failed to respond to nonoperative management and who underwent consecutive distraction of subcutaneous rods. Eleven children were treated by consecutive distraction of subcutaneous rods, and in two patients with rodding and anterior apical fusion. At surgery, the average patient age was 5.66 years, with a mean Cobb angle of 74 degrees and an average Pedriole angle of 39 degrees. The etiology of the scoliosis included four syndromic and one each congenital, post-rib resection, post-spinal tumor resection, neurofibromatosis, myelomeningocele, infantile idiopathic, and juvenile idiopathic. Subcutaneous rodding halted curve progression in all patients. At an average of 5.1 years after surgery, one patient showed no deterioration of the curve and nine patients showed an improvement of > or =40% in the magnitude of the original curvature. Eight of these patients had already had definitive surgery performed with segmental spinal instrumentation and fusion. Spinal growth occurred in all 11 patients and ranged from 0.5 to 4.5 cm (mean 2.0). Early results from these patients show that subcutaneous rodding with consecutive distraction allows correction of progressive early-onset scoliosis that failed to respond to nonsurgical management, preserving the individual growth potential of the spinal column and delaying definitive surgical treatment. Rotational deformity did not deteriorate radiographically, but clinical deformity increased subjectively. The amount of growth achieved and the number of procedures required to obtain these results raises the question of whether patients would be better served by a single anterior, posterior fusion and instrumentation at a young age.

Predictors of Flexibility and Pain Patterns in Thoracolumbar and Lumbar Idiopathic Scoliosis

Abstract: STUDY DESIGN A retrospective evaluation of radiographs in patients with idiopathic scoliosis was undertaken to assess predictors of flexibility. OBJECTIVE To evaluate potential predictors of flexibility in patients with thoracolumbar and lumbar scoliosis. SUMMARY OF BACKGROUND DATA Curve flexibility is an important consideration in the operative management of idiopathic scoliosis. Flexibility of the major curve is a useful predictor of expected surgical correction, and flexibility of compensatory curves determines whether they are structural or nonstructural. An accurate assessment of curve flexibility has important implications on surgical approaches and planning for deformity correction. The role of age and curve magnitude in predicting curve flexibility has not been well defined. A quantitative assessment of changes in curve flexibility with age and progression of deformity may yield important insight into the change in surgical management options over time. METHODS A retrospective review of 75 patients with idiopathic thoracolumbar and lumbar scoliosis (age range 13-78 years) was undertaken. Preoperative standing and side-bending radiographs of thoracolumbar and lumbar curves were evaluated. Cobb angles of structural and fractional curves, curve flexibility, presence of lateral listhesis, and axial and radicular pain were documented. Predictors of structural and fractional curve flexibility were evaluated with correlation and regression analysis. Correlation analysis was used to demonstrate an association between radiographic findings and the clinical presentation. RESULTS Seventy-five patients had an average major curve magnitude of 56 degrees (range 34-82 degrees ) with flexibility averaging 55% (range 20-93%). Structural curve flexibility was highly inversely correlated with both curve magnitude (r = -0.7; P< 0.001) and with age (r = -0.6; P< 0.001). Lumbar fractional curve (L4-S1) flexibility showed a high inverse correlation with age (r = -0.65; P< 0.001) but did not show correlation with Cobb angle. Thoracic compensatory curves showed a moderate correlation with Cobb angle (r = 0.53). Structural and fractional curve flexibility showed high correlation with each other (r = 0.5-0.66). Regression analysis yielded a formula to predict the flexibility of the structural curve (FSC): FSC = 130 - (Cobb + Age/2). Axial pain was correlated with age (r = 0.63); however, it was not correlated with curve magnitude. CONCLUSION We have shown that curve magnitude and patient age are the main predictors of structural flexibility. Every 10 degrees increase in curve magnitude over 40 degrees results in a 10% decrease in flexibility; every 10-year increase in age decreases flexibility of the structural curve by 5% and the lumbosacral fractional curve by 10%. Curve magnitude and age of the patients are significant predictors of curve flexibility. The demonstration of this association offers useful information in estimating how surgical options for deformity correction may change over time.

A multicenter study analyzing the relationship of a standardized radiographic scoring system of adolescent idiopathic scoliosis and the Scoliosis Research Society outcomes instrument.

Abstract: STUDY DESIGN A multicenter study examining the association between radiographic and outcomes measures in adolescent idiopathic scoliosis. OBJECTIVES To evaluate the association between an objective radiographic scoring system and patient quality of life measures as determined by the Scoliosis Research Society outcomes instrument. SUMMARY OF BACKGROUND DATA Although surgical correction of scoliosis has been reported to be positively correlated with patient outcomes, studies to date have been unable to demonstrate an association between radiographic measures of deformity and outcomes measures in patients with adolescent idiopathic scoliosis. METHODS A standardized radiographic deformity scoring system and the Scoliosis Research Society outcome tool were used prospectively in seven scoliosis centers to collect data on patients with adolescent idiopathic scoliosis. A total of 354 data points for 265 patients consisting of those with nonoperative or preoperative curves >or=10 degrees, as well as those with surgically treated curves, were analyzed. Correlation analysis was performed to identify significant relationships between any of the radiographic measures, the Harms Study Group radiographic deformity scores (total, sagittal, coronal), and the seven Scoliosis Research Society outcome domains (Total Pain, General Self-Image, General Function, Activity, Postoperative Self-Image, Postoperative Function, and Satisfaction) as well as Scoliosis Research Society outcomes instrument total scores. Radiographic measures that were identified as significantly correlated with Scoliosis Research Society outcome scores were then entered into a stepwise regression analysis. RESULTS The coronal measures of thoracic curve and lumbar curve magnitude were found to be significantly correlated with the Total Pain, General Self-Image, and total Scoliosis Research Society scores (P < 0.0001). The thoracic and upper thoracic curve magnitudes were also correlated with General Function (P < 0.002). The "coronal" subscore as well as the "total" score of the Harms Study Group radiographic scoring system were also significantly correlated with these Scoliosis Research Society domain and total scores. No radiographic measures taken after surgery were significantly correlated with the postoperative domains of the Scoliosis Research Society outcomes instrument. Stepwise regression analysis of these radiographic measures as predictors of Scoliosis Research Society scores resulted in adjusted R2 values of 0.03-0.07 (P < 0.0001). Although these results show that a significant association exists between the radiographic Cobb angle measure of the scoliosis and the Scoliosis Research Society outcomes scores, the low R2 values indicate that variables other than the radiographic appearance of the deformity (e.g., psychosocial, functional) must also be affecting these scores. CONCLUSION The Cobb angle measure of the major deformity has a small, but statistically significant, correlation with the reported Total Pain, General Self-Image, and General Function as measured by the Scoliosis Research Society outcomes instrument. None of the radiographic measures in this population correlated with postoperative domain scores of the Scoliosis Research Society outcomes tool.

Simulation of progressive deformities in adolescent idiopathic scoliosis using a biomechanical model integrating vertebral growth modulation.

Abstract: While the etiology and pathogenesis of adolescent idiopathic scoliosis are still not well understood, it is generally recognized that it progresses within a biomechanical process involving asymmetrical loading of the spine and vertebral growth modulation. This study intends to develop a finite element model incorporating vertebral growth and growth modulation in order to represent the progression of scoliotic deformities. The biomechanical model was based on experimental and clinical observations, and was formulated with variables integrating a biomechanical stimulus of growth modulation along directions perpendicular (x) and parallel (y, z) to the growth plates, a sensitivity factor beta to that stimulus and time. It was integrated into a finite element model of the thoracic and lumbar spine, which was personalized to the geometry of a female subject without spinal deformity. An imbalance of 2 mm in the right direction at the 8th thoracic vertebra was imposed and two simulations were performed: one with only growth modulation perpendicular to growth plates (Sim1), and the other one with additional components in the transverse plane (Sim2). Semi-quantitative characterization of the scoliotic deformities at each growth cycle was made using regional scoliotic descriptors (thoracic Cobb angle and kyphosis) and local scoliotic descriptors (wedging angle and axial rotation of the thoracic apical vertebra). In all simulations, spinal profiles corresponded to clinically observable configurations. The Cobb angle increased non-linearly from 0.3 degree to 34 degrees (Sim1) and 20 degrees (Sim2) from the first to last growth cycle, adequately reproducing the amplifying thoracic scoliotic curve. The sagittal thoracic profile (kyphosis) remained quite constant. Similarly to clinical and experimental observations, vertebral wedging angle of the thoracic apex progressed from 2.6 degrees to 10.7 degrees (Sim1) and 7.8 degrees (Sim2) with curve progression. Concomitantly, vertebral rotation of the thoracic apex increased of 10 degrees (Sim1) and 6 degrees (Sim2) clockwise, adequately reproducing the evolution of axial rotation reported in several studies. Similar trends but of lesser magnitude (Sim2) suggests that growth modulation parallel to growth plates tend to counteract the growth modulation effects in longitudinal direction. Overall, the developed model adequately represents the self-sustaining progression of vertebral and spinal scoliotic deformities. This study demonstrates the feasibility of the modeling approach, and compared to other biomechanical studies of scoliosis it achieves a more complete representation of the scoliotic spine.

Surgical treatment of idiopathic scoliosis in adults: an age-related analysis of outcome.

Abstract: Study design A retrospective outcome study was conducted Objective To analyze the clinical and radiographic outcome of surgical treatment for idiopathic scoliosis in patients treated at the age of 20 years or older Summary of background data Idiopathic scoliosis continues to pose problems in many patients after adolescence Surgical treatment of idiopathic scoliosis in adults still is a challenging subject, but no outcome analysis in terms of different age groups had been performed Methods In this study, 58 adult patients with idiopathic scoliosis who underwent surgery using Cotrel-Dubousset instrumentation were followed up for 2 to 7 years, and the results were studied clinically and radiographically Results The prevalence of pain that requires specific treatment decreased from 16% to 5%, and the pain improvement was reliably obtained in the older patients Radiographically, the mean rate of Cobb angle correction was 53% for both the thoracic and lumbar curves, whereas it decreased age dependently, especially in relation to the thoracic curve The sagittal plane correction generally was satisfactory in patients younger than 50 years, but appropriate lumbar lordosis was difficult to maintain after the age of 50 years Frontal and sagittal balance often was difficult to achieve in patients older than 50 years Conclusions This study clarified specific characteristics and problems in the surgical treatment of adult idiopathic scoliosis according to different age groups Although pain was the most important indication for surgery in patients older than 40 years, it was improved reliably by surgery in most of these patients On the other hand, the radiographic results tended to be less satisfactory in the older patients in an age-dependent manner These results provide useful information concerning the indications and strategies of adult scoliosis surgery

Effectiveness of the Charleston bending brace in the treatment of single-curve idiopathic scoliosis.

Abstract: The purpose of this study was to determine the effectiveness of the Charleston bending brace when compared with the thoracolumbosacral orthosis (TLSO or Boston) brace in the treatment of single-curve adolescent-type idiopathic scoliosis. The Charleston and TLSO braces were applied for approximately 8 nighttime hours and 18 to 22 hours per day, respectively. Treatment success was defined as improvement of curve deterioration with <5 degrees progression from the start of brace therapy until the conclusion of treatment, as well as the absence for the need to perform corrective surgery. The success rates were determined by Risser stage, initial angle, type of curvature, and sex of the patient. In addition, the success rate of the Charleston brace was assessed by analyzing the degree of initial correction. One hundred twenty-two patients (94 girls, 28 boys) were studied. Eighty-five patients were treated with the Charleston brace and 37 with the TLSO brace. Mean Cobb angle of curvature before bracing was 30.4 degrees. The curvature was lumbar in 60 patients, thoracic in 56, and thoracolumbar in 6. The average follow-up time was 23 months, with a minimum follow-up of 1 year. Surgery was performed in 11.8% and 13.5% of patients in the Charleston and TLSO groups, respectively. In this patient population, no significant difference in success rate was found between the groups.

The reliability of quantitative analysis on digital images of the scoliotic spine.

Abstract: Although analysis of scoliotic deformity is still studied extensively by means of conventional roentgenograms, computer-assisted digital analysis may allow a faster, more accurate and more complete evaluation of the scoliotic spine. In this study, a new computer-assisted measurement method was evaluated. This method uses digital reconstruction images for quantitative analysis of the scoliotic spine. The aim of the current study was to determine the reliability of the computer-assisted measuring method, which was done by establishing coefficients of repeatability for a variety of measurements. Measurements were carried out by five observers on 30 frontal and 10 lateral scoliotic digital reconstruction images. Each image was measured on three separate occasions by placing anatomical vertebral landmarks and drawing lines with a computer pointing device. The computer then calculated a number of geometrical shape parameters from scale calibration, landmarks and lines. The intra- and interobserver results were subjected to an analysis of variance to assess the level of agreement, and the means and standard deviations were calculated. The coefficient of repeatability (CR) was taken to be equal to two standard deviations. The mean intraobserver CR was found to be 3.1° for the Cobb angle on the frontal digital image and 3.3° for the kyphosis Cobb angle on the lateral overview. The mean difference in the intraobserver CR of the Cobb angle between measurements made by placing landmarks and those made by drawing lines was not statistically significant (P>0.05). The mean intraobserver CR for the other parameters can be summarized as follows: for lateral deviation it was 0.8 mm, for axial rotation 4.0° and for length of the spine 3.3 mm. The interobserver bias was negligible. It can be concluded that the reliability of our new method for quantifying geometrical variables on digital reconstruction images is better than measurements on conventional roentgenograms in previously published reports. The presented method is therefore considered to be more accurate for research of spinal deformities and more adequate for clinical management of scoliosis.

Quality of life and back pain: outcome 16.7 years after Harrington instrumentation.

Abstract: Study Design A study on the quality of life of 82 patients with idiopathic scoliosis treated with Harrington instrumentation Objective To analyse long-term health-related quality of life and low back pain an average of 187 years after surgery Summary and Background Data Quality of the evaluated by self-assessment questionnaires is an accepted outcome measure of surgical procedures The purpose of this study was to evaluate the health status with the German version of internationality accepted and psychometricatly tested questionnaires Methods Quality of life was measured with the Short Form-28 health profile Low back pain was assessed using the Roland-Morris Questionnaire Demographic date (age, sex, follow-up time), radiographic analysis (Kings classification, Cobb angle, extension and site of fusion), and rib cage deformity were correlated with these data Radiologic parematers were analyzed longitudinally Results In comparison with the age-matched healthy population, there was no significant difference in the physical Short Form-36 scale (P = 098) Surgically treated patients showed significantly lower scores than at baseline in the psychologic Short Form-36 scale (P = 0065), vitality (P < 0001), general mental health (P = 0003), and role activities because of emotional problems (P < 0001) were significantly different from these of the age-matched population Sixty-five (793%) of the 82 patients reported no or occasional back pain in the Roland-Morris Questionnaire Five patients (61%) reported chronic back pain Neither patient age at the time of surgery (P = 074) nor time of follow-up (P = 044), type of scoliosis (P = 074), or extent of fusion (P = 012) was associated with health-related quality of life or pain The size of the preoperative (P = 006) and postoperative (P = 012) curves and preoperative (P = 028) and postoperative (P = 07) rib cage deformities did not correlate with the data of the Short Form-20 scale and the Roland-Morris Questionnaire Conclusions In comparison with the age-matched population, the long-term effect of surgery does not affect the physical quality of life The psychologic health status is, however, significantly impaired Neither the type of curve, the size of scoliosis, nor the rib cage deformity influences the data

Pelvic or lumbar fixation for the surgical management of scoliosis in duchenne muscular dystrophy.

Abstract: Study design This retrospective study evaluates two groups of patients with scoliosis and Duchenne muscular dystrophy, treated with two different surgical stabilization methods. Objective To determine whether fixation to the sacropelvis is always necessary for adequate stabilization of scoliosis in Duchenne muscular dystrophy. Summary of background data Pelvic fixation is generally recommended for scoliosis in Duchenne muscular dystrophy. Recent studies describe a more selective approach toward lumbar or pelvic fixation. Pelvic fixation is reserved for larger curves and established pelvic tilt. Methods Fifty cases of Duchenne muscular dystrophy, operated in two different centers and followed up for a minimum of 3 years, were reviewed. In the first group (Oswestry), 31 patients had fixation to the pelvis, using standard Luque instrumentation and pelvic fixation. The Galveston technique was used in 9 cases and L-rod configuration in 22 cases. In the second group (Nottingham), 19 cases had fixation to L5 using pedicle screws in the lumbar spine and sublaminar wires in the thoracic spine. These cases were operated on early, usually shortly after becoming wheelchair dependent. Results In the pelvic fixation group, the mean age at the time of surgery was 14 years, and forced vital capacity was 44%. The mean Cobb angle and pelvic obliquity were 48 degrees and 19.8 degrees at the time of surgery, 16.7 degrees and 7.2 degrees immediately after surgery, and 22 degrees and 11.6 degrees at the final follow-up (mean 4.6 years), respectively. The mean blood loss was 4.1 L, and the average hospital stay was 17 days. There were five major complications, including a deep wound infection in one case, revision of instrumentation prominence at the proximal end in two cases, and loosening of pelvic fixation in two cases. In the lumbar fixation group, the mean age at the time of surgery was 11.7 years, and forced vital capacity was 58%. The mean Cobb angle and pelvic obliquity were 19.8 degrees and 9 degrees at the time of surgery, 3.2 degrees and 2.2 degrees immediately after surgery, and 5.2 degrees and 2.9 degrees at the final follow-up (mean 3.5 years), respectively. The mean estimated blood loss (3.3 L) and mean hospital stay (7.7 days) were much less compared with the pelvic fixation group. Pelvic obliquity was corrected and maintained below 10 degrees in all but two cases, who had an initial pelvic obliquity exceeding 20 degrees. One patient had instrumentation failure at the proximal end, and one had a deep wound infection. Conclusion Lumbar fixation to L5 is adequate if the surgery is performed early, soon after becoming wheelchair bound, and with smaller curves and minimal pelvic obliquity. Use of pedicle screws in lumbar spine provides a solid foundation to maintain the correction over the period of relatively short life expectancy of these children. Pelvic fixation may be necessary in older children, who have larger curves and established pelvic obliquity. In the presence of deteriorating lung function, this is associated with a greater morbidity and higher complication rate.

Scoliosis correction with shape-memory metal: results of an experimental study

Abstract: The biocompatibility and functionality of a new scoliosis correction device, based on the properties of the shape-memory metal nickel-titanium alloy, were studied. With this device, the shape recovery forces of a shape-memory metal rod are used to achieve a gradual three-dimensional scoliosis correction. In the experimental study the action of the new device was inverted: the device was used to induce a scoliotic curve instead of correcting one. Surgical procedures were performed in six pigs. An originally curved squared rod, in the cold condition, was straightened and fixed to the spine with pedicle screws. Peroperatively, the memory effect of the rod was activated by heating the rod to 50°C by a low-voltage, high-frequency current. After 3 and after 6 months the animals were sacrificed. The first radiographs, obtained immediately after surgery, showed in all animals an induced curve of about 40° Cobb angle – the original curve of the rod. This curve remained constant during the follow-up. The postoperative serum nickel measurements were around the detection limit, and were not significantly higher compared to the preoperative nickel concentration. Macroscopic inspection after 3 and 6 months showed that the device was almost overgrown with newly formed bone. Corrosion and fretting processes were not observed. Histologic examination of the sections of the surrounding tissues and sections of the lung, liver, spleen and kidney showed no evidence of a foreign body response. In view of the initiation of the scoliotic deformation, it is expected that the shape-memory metal based scoliosis correction device also has the capacity to correct a scoliotic curve. Moreover, it is expected that the new device will show good biocompatibility in clinical application. Extensive fatigue testing of the whole system should be performed before clinical trials are initiated.

The Double Rib Contour Sign (DRCS) in lateral spinal radiographs: aetiologic implications for scoliosis.

Abstract: UNLABELLED All lateral spinal radiographs in idiopathic scoliosis show a DRC sign of the thoracic cage, a radiographic expression of the rib hump. The outline of the convex overlies the contour of the concave ribs. The aim of this study is to assess this DRC sign in children with and without Late Onset Idiopathic Scoliosis (LOIS) with 10 degrees -20 degrees Cobb angle, and to examine whether in scoliosis the deformity of the thorax or that of the spine develops first. METHODS AND MATERIAL The radiographs of 133 children referred to hospital in a school screening study were examined. There were 47 boys and 86 girls, 13.28 and 13.39 years old respectively. The Cobb angle was measured and the radiological lateral spinal profile (LSP) was appraised from an angle made by a line drawn down the posterior surface of each vertebral body (T1-L5) and by the vertical. The children, boys and girls, were divided in 5 groups, namely: 1) with straight spines, 2) with spinal curvature having a Cobb angle or = 7 degrees), the thorax deformity, in terms of the DRC sign, has already been developed. 70% of these children were scoliotic. The others had a curvature of less than 9 degrees of Cobb angle (10%) or they were children with straight spines (20%) who were followed because of their existing rib hump. The non-scoliotics were 1,5-2 years younger than the ones who had already developed scoliosis, and they had both approximately a "rib index" of 1,5. The DRC sign is present in all referrals. In contrary, there is no scoliotic spine without it, as the DRC sign is always present in scoliotic lateral spinal radiographs with no exception. This observation supports our hypothesis that in idiopathic scoliosis, the deformity of the thorax develops first and then the deformity of the spine follows.

Sports Activity of Patients With Idiopathic Scoliosis at Long-Term Follow-Up

Abstract: OBJECTIVE The aim of the study was to assess long-term the sports activities of operatively and nonoperatively treated patients with idiopathic scoliosis and compare these activities with those of controls. STUDY DESIGN Cross-sectional case-control study, performed at The Orthopaedic University Hospital Heidelberg. PATIENTS AND METHODS The study enrolled 59 patients (53 female, 6 male; mean age 43 years) with idiopathic scoliosis and a minimum follow-up of 5 years (mean 22 years) since treatment (28 nonoperative, 31 operative). Mean Cobb angle at the time of the study was 54 degrees. An age-adjusted control group (n = 33) with no history of spinal disorder was evaluated at the same time. All participants in the study (n = 92) completed a questionnaire assessing spinal function (Spine Score) and sporting activity (Sport Score). In addition, the scoliosis patients underwent radiographic evaluation of their spine. The groups were compared by analysis of variance. In order to assess the relationship between two variables, Spearman's correlation coefficient was calculated. RESULTS Both groups of scoliosis patients attained a lower Sport Score than the controls (p < 0.015 and p < 0.006, respectively). There was no difference between the two scoliosis groups. Reduced spinal function correlated with reduced sports activity (p < 0.001). In both scoliosis groups, the subscales "back pain" and "physical activity" correlated with sporting activity (p < 0.03 and p < 0.02, respectively). In the surgically treated patients, Cobb angle correlated with reduced sports activity (p < 0.03). The extent of the spinal arthrodesis (number of segments) in surgically treated patients had no effect on their sports activity. CONCLUSIONS Over the long term, patients with idiopathic scoliosis suffer impairment of their sports activities compared with age-matched controls. The main reasons for this are functional impairment and the frequency of back pain. Sports activity is not more restricted after extended spinal fusion than it is after nonoperative treatment.

The Pediatric Outcomes Data Collection Instrument (PODCI) and functional assessment in patients with adolescent or juvenile idiopathic scoliosis and congenital scoliosis or kyphosis.

Abstract: Study design An initial examination of functional assessment scores in scoliosis and kyphosis populations. Objective Examination of scores from the Pediatric Outcomes Data Collection Instrument for patients with idiopathic scoliosis, congenital scoliosis, and congenital kyphosis, comparing scores with those of children without orthopedic disabilities. Summary of background data Little information has been presented regarding performance of scoliosis patients on the Pediatric Outcomes Data Collection Instrument. Methods A total of 102 patients with adolescent idiopathic scoliosis, 47 with congenital scoliosis without kyphosis, and 9 with congenital kyphosis completed the Pediatric Outcomes Data Collection Instrument. Responses were compared with those from a "normal" population. Subgroup analyses were performed for patients with adolescent idiopathic scoliosis. A P value Results Scores in Transfers, Sports, Comfort, and Happiness were significantly lower than "normal" in adolescent idiopathic scoliosis. In congenital scoliosis without kyphosis, scores in all categories except Happiness were significantly lower than "normal." All category scores were significantly lower than "normal" in congenital kyphosis. In adolescent idiopathic scoliosis, age and curve location did not influence Comfort scores. Comfort scores were significantly lower than "normal" for all curve locations and for all ranges of Cobb angle. Happiness scores were significantly lower in adolescent idiopathic scoliosis patients with Cobb angles >50 degrees who had not received surgery when compared with either patients who had received surgery or patients with Cobb angles Conclusion These findings provide some normative values for the Pediatric Outcomes Data Collection Instrument for three specific diagnoses. Patients with adolescent idiopathic scoliosis, congenital scoliosis, and congenital kyphosis gave responses significantly different from "normal" children. Pain appeared to be a common finding with these diagnoses.

Genetic algorithm-neural network estimation of Cobb angle from torso asymmetry in scoliosis

Abstract: Scoliosis severity, measured by the Cobb angle, was estimated by artificial neural network from indices of torso surface asymmetry using a genetic algorithm to select the optimal set of input torso indices. Estimates of the Cobb angle were accurate within 5 degrees in two-thirds, and within 10 degrees in six-sevenths, of a test set of 115 scans of 48 scoliosis patients, showing promise for future longitudinal studies to detect scoliosis progression without use of X-rays.

Hemi-epiphysiodesis for unclassified congenital scoliosis: immediate results and mid-term follow-up.

Abstract: Complex spinal anomalies involved in congenital scoliosis consist of a jumble of vertebral defects. Progressive scoliotic curves are frequently encountered in these patients. We evaluated the results of hemi-epiphysiodesis for this patient population. A series of ten patients with unclassified scoliosis, involving multiple hemivertebrae and/or bars, was reviewed retrospectively. Hemi-epiphysiodesis was the primary treatment in all patients. Mortality, complications and wound healing problems did not occur. The average Cobb angle for all patients changed from 54 degrees (range: 40 degrees -74 degrees), preoperatively, to 58 degrees (range: 30 degrees -104 degrees), postoperatively. Applying the criterion of a minimum change of 20 degrees, to take into account measurement variability, an epiphysiodesis effect was achieved in two procedures, progression was arrested in six procedures and failure occurred in two procedures. The mean rate of Cobb angle change per annum decreased from 2.9 degrees (range: -35 degrees to 14 degrees), preoperatively, to 2.4 degrees (range: -4 degrees to 13 degrees), following surgery. Repeat surgery was necessitated by coexisting progressive kyphosis and pseudoarthrosis in one patient, and involved extension of primary epiphysiodesis in two patients. A mean intervention-free period of 58 months was established. These results suggest that hemi-epiphysiodesis stabilized the unclassified congenital scoliosis. Being under 5 years of age, having a thoracolumbar curve location, and the absence of coexisting kyphosis were found to be associated with a more favorable outcome.

Identifying sources of variability in scoliosis classification using a rule-based automated algorithm.

Abstract: STUDY DESIGN Use of a rule-based automated algorithm to determine sources of variability in radiographic classification. OBJECTIVES To determine whether unambiguous rules encoded in a computer program would ensure reliable classification. SUMMARY OF BACKGROUND DATA Reliability problems have been identified in classifications used in surgical planning for patients with thoracic idiopathic scoliosis, but the sources of unreliability are not understood. METHODS Objective classification methodology was tested on the King et al (1983) scheme. There were two novel components: 1) positions of the corners of vertebrae in radiographs were digitized relative to a defined axis system and used in automated evaluation of spinal shape parameters required for classification; and 2) the assignment of a classification was done with a rule-based algorithm. The algorithm was implemented after some ambiguities and absence of precise definitions in the King et al classification scheme had been resolved. The algorithm was tested with radiographs of patients having adolescent idiopathic scoliosis. RESULTS The automated procedure could encounter reliability problems in cases in which a lumbar curve was very close to crossing the midline, thoracic and lumbar curves were of approximately equal value, when the apex level in the thoracolumbar region was ambiguous, when a Cobb angle was close to 10 degrees, or when the flexibility index was close to unity. CONCLUSION Objective measurements and rule-based algorithms can eliminate some sources of interobserver and intraobserver errors in classification of spinal deformity. When classification parameters fall close to the boundaries for classification, reliability problems will persist.

Long-term results from in situ fusion for congenital vertebral deformity.

Abstract: Study Design. Retrospective review of long-term outcome of fusion in situ for congenital vertebral anomaly with particular emphasis on cosmesis and the incidence of reoperation. Objective. Examination of the success rate of this procedure and of risk factors for failure. Background. Fusion in situ is the accepted prophylactic treatment to prevent deformity in congenital vertebral anomalies that have a high risk of progression or have been shown to be deteriorating. Methods. Records of patients who were at least 15 years of age at last examination were reviewed retrospectively. Consideration was given to cosmetic outcome and to the incidence of reoperation. Results. There were 43 patients in this category, 19 boys and 24 girls, who were at least 15 years of age when last seen. Reoperation had been performed in 11 cases (25.6%). The main finding was that, although the Cobb angle of the fused segment of spine remained constant after fusion, a curve sometimes developed in the whole spine, sometimes (but by no means always) centered on that fused segment. Cosmetic deformity continued to progress in a number of cases. Conclusions. Localized fusion, whether posterior alone or anterior and posterior combined, was effective in preventing progression of the Cobb angle of the congenitally malformed area but did not control the overall deformity that developed or progressed with growth. Current concepts of the pathomechanism of deformity do not adequately explain the observations, and a more biologic approach is suggested.

Idiopathic scoliosis and quality of life.

Abstract: Scoliosis may lead to multiple impairments depending on its seriousness. Here we have to make the distinction between direct impairments in the physical field and indirect impairments in the psychosocial field. The findings of different studies indicate that the psychosocial situation in juvenile and adult scoliotic patients is characterized by increased strain. The present study is meant to answer the question in which fields of quality of life female scoliotic patients are impaired and if these impairments are dependent of age or seriousness of illness (Cobb angle). Between May 1998 and February 1999, 226 female patients with idiopathic scoliosis were surveyed in a special clinic for spinal deformities with the help of different quality of life measuring instruments (SF-36, BFW, STAIK) and were compared with norm values. Women with idiopathic scoliosis were questioned with the help of an age adapted set of questionnaires containing questions referring to the health related quality of life (SF-36, BFW, STAIK). The results were compared to the norm values and examined in uni- and multivariat procedures (MANOVA) in order to find out if age and seriousness of illness (Cobb angle) have any impact on the quality of life. In comparison to the norm random sample, the juvenile female scoliosis patients showed a less positive point of view towards life (p = .001) and were easier subject to depressive moods (p = .021). The increased strain of adult patients was shown both in the psychic field (p < .001) and in the physical field (p < .001) (SF-36). These results are largely independent of the seriousness of illness (Cobb angle) and of the patients' age. The results indicate that idiopathic scoliosis in children, adolescents and adults can be regarded as a risk factor for the impairment of health related quality of life and thus stress the importance of psychosocial offers during a patient-orientated scoliosis treatment in order to improve the management of scoliosis.

Adolescent idiopathic scoliosis: natural history and prognosis.

Abstract: Retrospective review of the scoliosis database showed adolescent idiopathic scoliosis to be the most common but least significant variety of spinal deformity. Data from 112 girls diagnosed on repeat screening showed the importance of menarche as a date in the natural history. In the whole database, there were 514 aged at least 15 years at last review, 45 boys and 469 girls. Braces were prescribed for a total of 38, mostly during the early part of the period and gradually abandoned without an increase in surgical rate. Progression depended on the age and maturity of the patient as well as the initial Cobb angle. Surgery was recommended for 27% overall. A sub-group with more complete data diagnosed after bracing had been discontinued confirmed the findings.

Retrospective results in immature idiopathic scoliotic patients treated with a Chêneau brace.

Abstract: This paper reports a retrospective series which includes 105 idiopathic scoliotic patients treated with a Cheneau brace. With an average age of 12.5 years old and a mean Risser sign of 0.9, the initial major Cobb angle was 36.8 degrees corrected to 25.9 degrees in the brace (31.1% of the primary correction), and the major torsion angle was 16.8 degrees corrected to 12.9 degrees in the brace (22.2% of the primary correction). 37 patients have finished the treatment with a mean follow-up of 16.8 months. For this group, the initial Cobb and torsion angles were not significantly changed (36.4 degrees Cobb to 34.1 degrees Cobb at follow-up, and 16.9 degrees Perdriolle to 15.7 degrees Perdriolle at follow-up). The proportion of patients without progression greater than 5 degrees Cobb (n=20) and with an improved final Cobb angle (n=10) was greater than failures (n=7). However, due to the catastrophic nature of some progressions which generally coincide with a high Cobb angle right from the start, with low primary correction, and with non-compliance, the final Cobb angle showed a slight tendency to decrease but without reaching high significance. These preliminary results demonstrate that the Cheneau brace can effectively prevent the progression of Cobb and torsion angles, even in cases of bad prognosis.

The incidence of idiopathic scoliosis in Greece--analyais of domestic school screening programs.

Abstract: Introduction The aim of the study is the documentation of the national incidence of idiopathic scoliosis (IS) based on the School Screening programs performed at the various geographical departments of the country, and the estimation of the probable number of children who will need to be conservatively or surgically treated. Material-methods During the years 1975 - 1999, 17 School Screening programs were performed in Greece and their results were analyzed and published in the book "School Screening in Greece". These studies had in common the children age distribution, the clinical examination, the radiological definition of IS when the Cobb - angle was > or = 5 degrees or > or = 10 degrees after SRS. The standing forward bending test was used. An Orthopaedic surgeon always participated in the scientific screening team. 215899 children aged 5.5 - 15 years were screened. When there was suspicion of scoliosis, the child was further assessed radiolographically (standing postero - anterior spinal radiographs), for Cobb angle appraisal. Results In 130689 screened children, scoliosis was considered when the consequent radiological assessment revealed Cobb angle of > or = 10 degrees, (a), and in 85210 children when it revealed Cobb angle of > or = 5 degrees respectively, (b). In (a) studies the scoliosis incidence was 2.9% (range 1.1 - 5.7%), and (b) 4.9% (range 2.7 - 9.5%) respectively. The right thoracic curves dominated in both (a) and (b) studies and thoraco - lumbar, lumbar and double curves followed. Among 7965 scoliotics out of the total sample of 215899 children, 4.5% were conservatively treated with the use of a brace, and only 0.19% was treated surgically. Conclusions From data of 1998 national census, the population of children aged 8 to 14 years old was approximately 751000. With the above -mentioned datum and with a national mean scoliosis incidence of 2.9%, (Cobb angle > or = 10 degrees), 21781 children will be found with scoliosis. 980 will need conservative treatment using a brace while 41 children will need surgical treatment.

Three-dimensional shape analysis of the scoliotic spine using MR tomography and rasterstereography.

Abstract: Rasterstereography delivers only indirect information about the three-dimensional shape of the spine. Therefore, validation with radiologic methods is necessary, in particular in severe scolioses above 50 AE Cobb. Comparison with conventional a.p. radiographs yielded satisfactory results for scolioses up to 50 AE Cobb, but only in frontal view, i.e. in two dimensions. A true three-dimensional validation is possible only with MR tomography, however this is difficult due to severe technical limitations. In the present study 26 patients with Cobb angles between 26 AE and 116 AE were examined both with MR tomography and rasterstereography. Comparing the shape of the spinal midline as measured by the two methods we found that a) the gross 3-d shape of the spinal midline is well reproduced by the rasterstereographic model, b) the lateral rms error is about twice as large as with conventional radiographs and c) that the rms errors increase with increasing Cobb angle. This means that the rasterstereographic model reconstruction must be modified for severe scolioses.

Study of the rib cage deformity in children with 10°-20° of Cobb angle Late Onset Idiopathic Scoliosis, using Rib-Vertebra Angles Aetiologic implications

Abstract: UNLABELLED The aim of the study is to compare the rib-vertebra angles (RVAs) between children with 10 degrees - 20 degrees of Cobb angle late onset idiopathic scoliosis (LOIS) and non-scoliotic children. MATERIALS AND METHOD The RVAs of 47 children, with mean age 12.4 years, who presented LOIS with a Cobb angle 10 degrees - 20 degrees, were studied. The children were classified into three groups according to the site of the scoliotic curve: 17 children had thoracic (T), 14 children had thoracolumbar (TL) and 16 children had lumbar (L) curves. The RVAs of the scoliotic children were compared to the RVAs of 60 non-scoliotic children of a similar age group, who were studied in the past. RESULTS The comparison of the right and left RVAs within each group showed that the children who had: T curves differ at the level T4, T5, T6, T7 and T8, TL curves differ at the level T3, and L curves differ at the level T7 and T12. The comparison of the ipsilateral RVA's between the scoliotic groups showed that between: T and TL curves there are no differences at any thoracic level, between T and L curves the RVAs differ at the T7 level on the right side, whereas there are no differences between the RVAs on the left side, between TL and L curves the RVAs differ at the level T5, T6, and T7 on the right and at the level T5 on the left side. Comparing the RVAs between the scoliotic and nonscoliotic children, it was apparent that the scoliotic children rib cage had lower RVAs (p<0.01) at almost all thoracic levels. DISCUSSION It has been reported that RVAs is an expression of the resultant muscle forces, which act on each rib. It was also suggested that RVA asymmetries by weakening the spinal rotation-defending system are aetiological for idiopathic scoliosis, (Burwell et al 1992). This study shows that scoliotic children with small curves have underdeveloped thoracic cage compared to nonscoliotic counterparts. The differences are more apparent in the scoliotic children with thoracic curves. It is suggested that the differences of the RVAs between right and left side in this group are an expression of asymmetric muscle forces acting on the thoracic cage. It is concluded that asymmetric muscle forces participate in the pathogenesis of idiopathic scoliosis on the thoracic cage, which deforms early.