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Showing papers on "Cobb angle published in 2015"


Journal ArticleDOI
TL;DR: The proposed classification provides a mechanism to assess CSD within the framework of global spinopelvic malalignment and clinically relevant parameters and suggest moderate agreement and serve as the basis for subsequent improvement and study of the proposed classification.
Abstract: OBJECT Despite the complexity of cervical spine deformity (CSD) and its significant impact on patient quality of life, there exists no comprehensive classification system. The objective of this study was to develop a novel classification system based on a modified Delphi approach and to characterize the intra- and interobserver reliability of this classification. METHODS Based on an extensive literature review and a modified Delphi approach with an expert panel, a CSD classification system was generated. The classification system included a deformity descriptor and 5 modifiers that incorporated sagittal, regional, and global spinopelvic alignment and neurological status. The descriptors included: “C,” “CT,” and “T” for primary cervical kyphotic deformities with an apex in the cervical spine, cervicothoracic junction, or thoracic spine, respectively; “S” for primary coronal deformity with a coronal Cobb angle ≥ 15°; and “CVJ” for primary craniovertebral junction deformity. The modifiers included C2–7 sagit...

210 citations


Journal ArticleDOI
01 Feb 2015-Medicine
TL;DR: There did not appear to be a benefit to using 3DRP technology with respect to complication rate and postoperative radiological outcomes; however, 3D technology could reduce the misplacement rate in patients whose preoperative mean Cobb angle was >50°.

96 citations


Journal ArticleDOI
TL;DR: The results suggested that the ultrasound volume projection imaging method can be a promising approach for the assessment of scoliosis, and further research should be followed up to demonstrate its potential clinical applications for mass screening and curve progression and treatment outcome monitoring ofScoliosis patients.
Abstract: The standing radiograph is used as a gold standard to diagnose spinal deformity including scoliosis, a medical condition defined as lateral spine curvature ${>}10^{\circ}$ . However, the health concern of X-ray and large inter-observer variation of measurements on X-ray images have significantly restricted its application, particularly for scoliosis screening and close follow-up for adolescent patients. In this study, a radiation-free freehand 3-D ultrasound system was developed for scoliosis assessment using a volume projection imaging method. Based on the obtained coronal view images, two measurement methods were proposed using transverse process and spinous profile as landmarks, respectively. As a reliability study, 36 subjects (age: $30.1 \pm 14.5$ ; male: 12; female: 24) with different degrees of scoliosis were scanned using the system to test the inter- and intra-observer repeatability. The intra- and inter-observer tests indicated that the new assessment methods were repeatable, with ICC larger than 0.92. Small intra- and inter-observer variations of measuring spine curvature were observed for the two measurement methods (intra-: $1.4 \pm 1.0^{\circ}$ and $1.4 \pm 1.1^{\circ}$ ; inter-: $2.2 \pm 1.6^{\circ}$ and $2.5 \pm 1.6^{\circ}$ ). The results also showed that the spinal curvature obtained by the new method had good linear correlations with X-ray Cobb's method ( ${\rm R}^{{{2}}} = 0.8, {\rm p} , 29 subjects). These results suggested that the ultrasound volume projection imaging method can be a promising approach for the assessment of scoliosis, and further research should be followed up to demonstrate its potential clinical applications for mass screening and curve progression and treatment outcome monitoring of scoliosis patients.

92 citations


Journal ArticleDOI
TL;DR: The authors' results provide a valuable reference for counseling patients preoperatively about what improvements or worsening in back or leg pain they may experience after surgical intervention for ASD.
Abstract: OBJECT Back and leg pain are the primary outcomes of adult spinal deformity (ASD) and predict patients' seeking of surgical management. The authors sought to characterize changes in back and leg pain after operative or nonoperative management of ASD. Outcomes were assessed according to pain severity, type of surgical procedure, Scoliosis Research Society (SRS)-Schwab spine deformity class, and patient satisfaction. METHODS This study retrospectively reviewed data in a prospective multicenter database of ASD patients. Inclusion criteria were the following: age > 18 years and presence of spinal deformity as defined by a scoliosis Cobb angle ≥ 20°, sagittal vertical axis length ≥ 5 cm, pelvic tilt angle ≥ 25°, or thoracic kyphosis angle ≥ 60°. Patients were grouped into nonoperated and operated subcohorts and by the type of surgical procedure, spine SRS-Schwab deformity class, preoperative pain severity, and patient satisfaction. Numerical rating scale (NRS) scores of back and leg pain, Oswestry Disability Index (ODI) scores, physical component summary (PCS) scores of the 36-Item Short Form Health Survey, minimum clinically important differences (MCIDs), and substantial clinical benefits (SCBs) were assessed. RESULTS Patients in whom ASD had been operatively managed were 6 times more likely to have an improvement in back pain and 3 times more likely to have an improvement in leg pain than patients in whom ASD had been nonoperatively managed. Patients whose ASD had been managed nonoperatively were more likely to have their back or leg pain remain the same or worsen. The incidence of postoperative leg pain was 37.0% at 6 weeks postoperatively and 33.3% at the 2-year follow-up (FU). At the 2-year FU, among patients with any preoperative back or leg pain, 24.3% and 37.8% were free of back and leg pain, respectively, and among patients with severe (NRS scores of 7-10) preoperative back or leg pain, 21.0% and 32.8% were free of back and leg pain, respectively. Decompression resulted in more patients having an improvement in leg pain and their pain scores reaching MCID. Although osteotomies improved back pain, they were associated with a higher incidence of leg pain. Patients whose spine had an SRS-Schwab coronal curve Type N deformity (sagittal malalignment only) were least likely to report improvements in back pain. Patients with a Type L deformity were most likely to report improved back or leg pain and to have reductions in pain severity scores reaching MCID and SCB. Patients with a Type D deformity were least likely to report improved leg pain and were more likely to experience a worsening of leg pain. Preoperative pain severity affected pain improvement over 2 years because patients who had higher preoperative pain severity experienced larger improvements, and their changes in pain severity were more likely to reach MCID/SCB than for those reporting lower preoperative pain. Reductions in back pain contributed to improvements in ODI and PCS scores and to patient satisfaction more than reductions in leg pain did. CONCLUSIONS The authors' results provide a valuable reference for counseling patients preoperatively about what improvements or worsening in back or leg pain they may experience after surgical intervention for ASD.

89 citations


Journal ArticleDOI
TL;DR: A methodology for measuring the 3-D segmental sagittal alignment of the spine in patients with adolescent idiopathic scoliosis (AIS) is defined and the effect of axial plane rotation on differences between3-D and 2-D measures of deformity is assessed.
Abstract: BACKGROUND Obtaining accurate measurements of scoliosis from two-dimensional (2-D) radiographs can be challenging because of the three-dimensional (3-D) nature of the deformity. Previous studies have shown that the sagittal plane, in particular, is misrepresented on 2-D radiographs because of the influence of axial plane rotation. The purpose of the current study was to define a methodology for measuring the 3-D segmental sagittal alignment of the spine in patients with adolescent idiopathic scoliosis (AIS) and to assess the effect of axial plane rotation on differences between 3-D and 2-D measures of deformity. METHODS Preoperative and postoperative EOS images of 120 consecutive patients with AIS (primary thoracic curves) treated with segmental thoracic pedicle-screw instrumentation were analyzed in the "3-D sagittal plane." The technique measured 3-D kyphosis or lordosis in the specific plane of sagittal motion for each spinal motion segment. The kyphosis (+) and lordosis (-) values of the segments from T5 to T12 were summed to give the 3-D measurement of T5-T12 kyphosis. These values were compared with the standard 2-D measurements of T5-T12 kyphosis on lateral radiographs, and a correlation analysis with regard to axial plane rotation of the apex was performed. RESULTS The average age (and standard deviation) of the patients was 14 ± 2 years. The mean preoperative Cobb angle on the standard 2-D view was 55° ± 10° and on the 3-D view was 52° ± 9° (p ≤ 0.001). On the 3-D view, the mean preoperative T5-T12 kyphosis was 6° ± 14°, and the kyphosis significantly increased to 26° ± 6° postoperatively (p < 0.001). The T5-T12 kyphosis on the standard 2-D view measured 18° ± 13° preoperatively and 27° ± 6° postoperatively (p < 0.001). The difference between the 2-D and 3-D measurements of T5-T12 kyphosis strongly correlated with apical vertebral rotation (r = 0.85; p < 0.01). CONCLUSIONS Routine 2-D measurements of thoracic kyphosis erroneously underestimate the preoperative loss of kyphosis in AIS because of errors associated with axial plane rotation, an inherent component of thoracic scoliosis.

84 citations


Journal ArticleDOI
TL;DR: Early-onset scoliosis, which appears before the age of 10, can be due to congenital vertebral anomalies, neuromuscular diseases, or idiopathic causes as discussed by the authors.
Abstract: Early-onset scoliosis, which appears before the age of 10, can be due to congenital vertebral anomalies, neuromuscular diseases, scoliosis-associated syndromes, or idiopathic causes. It can have serious consequences for lung development and significantly reduce the life expectancy compared to adolescent scoliosis. Extended posterior fusion must be avoided to prevent the crankshaft phenomenon, uneven growth of the trunk and especially restrictive lung disease. Conservative (non-surgical) treatment is used first. If this fails, fusionless surgery can be performed to delay the final fusion procedure until the patient is older. The gold standard delaying surgical treatment is the implantation of growing rods as described by Moe and colleagues in the mid-1980s. These rods, which are lengthened during short surgical procedures at regular intervals, curb the scoliosis progression until the patient reaches an age where fusion can be performed. Knowledge of this technique and its complications has led to several mechanical improvements being made, namely use of rods that can be distracted magnetically on an outpatient basis, without the need for anesthesia. Devices based on the same principle have been designed that preferentially attach to the ribs to specifically address chest wall and spine dysplasia. The second category of surgical devices consists of rods used to guide spinal growth that do not require repeated surgical procedures. The third type of fusionless surgical treatment involves slowing the growth of the scoliosis convexity to help reduce the Cobb angle. The indications are constantly changing. Improvements in surgical techniques and greater surgeon experience may help to reduce the number of complications and make this lengthy treatment acceptable to patients and their family. Long-term effects of surgery on the Cobb angle have not been compared to those involving conservative "delaying" treatments. Because the latter has fewer complications associated with it than surgery, it should be the first-line treatment for most cases of early-onset scoliosis.

80 citations


Journal ArticleDOI
TL;DR: The results support the efficacy of minimally invasive LLIF in improvements of clinical and radiographic features.
Abstract: STUDY DESIGN Retrospective case series. OBJECTIVE To determine the clinical and radiographic outcomes of patients undergoing minimally invasive lateral lumbar interbody fusion (LLIF) with a minimum 2-year follow-up. SUMMARY OF BACKGROUND DATA Minimally invasive LLIF is performed through a lateral, retroperitoneal, transpsoas approach. This procedure is characterized by the use of a tubular retractor to minimize tissue damage and real-time neuromonitoring to ensure safe passage through the psoas muscle. To date, advantages of minimal invasive LLIF, compared with open procedures, has been limited to early postoperative outcomes and complications, with the longest mean follow-up duration of 22 months. METHODS A total of 118 patients who underwent minimally invasive LLIF with a minimum of 2 years follow-up were included in this study. Clinical outcomes were determined by using Visual Analog Score for the degree of pain (trunk or lower extremity), and Oswestry Disability Index and Short Form-12 scoring methods for patient function. Radiographic evaluations included (i) disk height; (ii) segmental coronal angulation; (iii) segmental lordotic angulation; (iv) Cobb angle; (v) cage subsidence; and (vi) fusion status. Data were statistically tested using either paired Students t test or Wilcoxon matched-pair test. Significance level was set at P<0.05. RESULTS We found that (i) the Visual Analog Score for pain, Oswestry Disability Index, and the physical components summary, but not the mental components summary of Short Form-12 improved significantly at the follow-up; (ii) disk height, coronal angulation, and lordotic angulation at each level and the Cobb angle were restored at the statistically significant extent; (iii) successful fusion was achieved in 209 levels (88%); and (iv) transient thigh pain was the most frequent complication seen in 36% of the patients. CONCLUSIONS Our results support the efficacy of minimally invasive LLIF in improvements of clinical and radiographic features.

78 citations


Journal ArticleDOI
01 Jul 2015-Spine
TL;DR: A larger cohort shows a strong predictive correlation between SS and initial Cobb angle for probability of curve progression in idiopathic scoliosis.
Abstract: STUDY DESIGN Retrospective case series. OBJECTIVE This study aimed to validate the Sanders Skeletal Maturity Staging System and to assess its correlation to curve progression in idiopathic scoliosis. SUMMARY OF BACKGROUND DATA The Sanders Skeletal Maturity Staging System has been used to predict curve progression in idiopathic scoliosis. This study intended to validate that initial study with a larger sample size. METHODS We retrospectively reviewed 1100 consecutive patients with idiopathic scoliosis between 2005 and 2011. Girls aged 8 to 14 years (<2 yr postmenarche) and boys aged 10 to 16 years who had obtained at least 1 hand and spine radiograph on the same day for evaluation of skeletal age and scoliosis curve magnitude were followed to skeletal maturity (Risser stage 5 or fully capped Risser stage 4), curve progression to 50° or greater, or spinal fusion. Patients with nonidiopathic curves were excluded. RESULTS There were 161 patients: 131 girls (12.3 ± 1.2 yr) and 30 boys (13.9 ± 1.1 yr). The distribution of patients within Sanders stage (SS) 1 through 7 was 7, 28, 41, 45, 7, 31, and 2 patients, respectively; modified Lenke curve types 1 to 6 were 26, 12, 63, 5, 38, and 17 patients, respectively. All patients in SS2 with initial Cobb angles of 25° or greater progressed, and patients in SS1 and SS3 with initial Cobb angles of 35° or greater progressed. Similarly, all patients with initial Cobb angles of 40° or greater progressed except those in SS7. Conversely, none of the patients with initial Cobb angles of 15° or less or those in SS5, SS6, and SS7 with initial Cobb angles of 30° or less progressed. Predictive progression of 67%, 50%, 43%, 27%, and 60% was observed for subgroups SS1/30°, SS2/20°, SS3/30°, SS4/30°, and SS6/35° respectively. CONCLUSION This larger cohort shows a strong predictive correlation between SS and initial Cobb angle for probability of curve progression in idiopathic scoliosis. LEVEL OF EVIDENCE 3.

71 citations


Journal ArticleDOI
TL;DR: This review did not reveal any methods for the prediction of progression in AIS that could be recommended for clinical use as diagnostic criteria and the levels of evidence were low.
Abstract: AIM: To evaluate published data on the predictors of progressive adolescent idiopathic scoliosis (AIS) in order to evaluate their efficacy and level of evidence. METHODS: Selection criteria: (1) study design: randomized controlled clinical trials, prospective cohort studies and case series, retrospective comparative and none comparative studies; (2) participants: adolescents with AIS aged from 10 to 20 years; and (3) treatment: observation, bracing, and other. Search method: Ovid MEDLINE, Embase, the Cochrane Library, PubMed and patent data bases. All years through August 2014 were included. Data were collected that showed an association between the studied characteristics and the progression of AIS or the severity of the spine deformity. Odds ratio (OR), sensitivity, specificity, positive and negative predictive values were also collected. A meta-analysis was performed to evaluate the pooled OR and predictive values, if more than 1 study presented a result. The GRADE approach was applied to evaluate the level of evidence. RESULTS: The review included 25 studies. All studies showed statistically significant or borderline association between severity or progression of AIS with the following characteristics: (1) An increase of the Cobb angle or axial rotation during brace treatment; (2) decrease of the rib-vertebral angle at the apical level of the convex side during brace treatment; (3) initial Cobb angle severity (> 25o); (4) osteopenia; (5) patient age < 13 years at diagnosis; (6) premenarche status; (7) skeletal immaturity; (8) thoracic deformity; (9) brain stem vestibular dysfunction; and (10) multiple indices combining radiographic, demographic, and physiologic characteristics. Single nucleotide polymorphisms of the following genes: (1) calmodulin 1; (2) estrogen receptor 1; (3) tryptophan hydroxylase 1; (3) insulin-like growth factor 1; (5) neurotrophin 3; (6) interleukin-17 receptor C; (7) melatonin receptor 1B, and (8) ScoliScore test. Other predictors included: (1) impairment of melatonin signaling in osteoblasts and peripheral blood mononuclear cells (PBMC); (2) G-protein signaling dysfunction in PBMC; and (3) the level of platelet calmodulin. However, predictive values of all these findings were limited, and the levels of evidence were low. The pooled result of brace treatment outcomes demonstrated that around 27% of patents with AIS experienced exacerbation of the spine deformity during or after brace treatment, and 15% required surgical correction. However, the level of evidence is also low due to the limitations of the included studies. CONCLUSION: This review did not reveal any methods for the prediction of progression in AIS that could be recommended for clinical use as diagnostic criteria.

66 citations


Journal ArticleDOI
Shengrong Lin1, Feifei Zhou1, Yu Sun1, Zhongqiang Chen1, Fengshan Zhang1, Shengfa Pan1 
TL;DR: Open-door laminoplasty significantly affected postoperative cervical sagittal balance, with the cervical vertebra appearing to tilt forward.
Abstract: The aim of this study was to investigate how the severity of operative invasion to the posterior muscular-ligament complex impacts postoperative cervical sagittal balance. Ninety cases of open-door expansive laminoplasty due to cervical spondylotic myelopathy were reviewed. Fifty-three patients underwent laminoplasty with unilateral preservation of the muscular-ligament complex (unilateral elevation group). Thirty-seven patients underwent traditional open-door laminoplasty (bilateral elevation group). Preoperative and postoperative cervical sagittal parameters, including C2–C7 sagittal vertical axis (SVA), C0–2 Cobb angle and T1 slope, were compared. The cervical curvature, range of motion (ROM) and JOA score were also compared. The average follow-up time was 16.7 months (range 3–40 months). C2–C7 SVA significantly increased in the bilateral elevation group (+4.9 mm, P = 0.005) but remained unchanged in the unilateral elevation group (−0.2 mm, P = 0.414). The C0–2 Cobb angle increased in both groups (+4.1°, P < 0.001; +2.5°, P = 0.002). The T1 slope also increased in both groups (+1.1°, P = 0.015; +0.7°, P = 0.042). The postoperative C3–C7 curvature significantly decreased in the bilateral elevation group (−4.1°, P < 0.001). The C3–C7 ROM decreased in both groups (−17.9°, P < 0.001; −15.1°, P < 0.001). C2–C7 SVA was positively correlated with the T1 slope (Pearson = 0.468, P < 0.001) and negatively correlated with the C3–C7 curvature (Pearson = −0.322, P = 0.001). The C0–2 Cobb angle was positively correlated with C2–C7 SVA (Pearson = 0.303, P = 0.004) and negatively correlated with the C3–C7 curvature (Pearson = −0.362, P < 0.001). There was no significant between-group difference in the JOA improvement rate. Open-door laminoplasty significantly affected postoperative cervical sagittal balance, with the cervical vertebra appearing to tilt forward. As the severity of surgical invasion to the posterior muscular-ligament complex increased, the loss of cervical sagittal balance also increased.

58 citations


Journal ArticleDOI
13 Aug 2015-PLOS ONE
TL;DR: It is suggested that spinal curvature measurements are included in marker-based clinical gait analysis protocols in order to enable a deeper understanding of the biomechanical behavior of the healthy and pathological spine in dynamic situations as well as to comprehensively evaluate treatment effects.
Abstract: Background and Purpose Although the relevance of understanding spinal kinematics during functional activities in patients with complex spinal deformities is undisputed among researchers and clinicians, evidence using skin marker-based motion capture systems is still limited to a handful of studies, mostly conducted on healthy subjects and using non-validated marker configurations. The current study therefore aimed to explore the validity of a previously developed enhanced trunk marker set for the static measurement of spinal curvature angles in patients with main thoracic adolescent idiopathic scoliosis. In addition, the impact of inaccurate marker placement on curvature angle calculation was investigated. Methods Ten patients (Cobb angle: 44.4±17.7 degrees) were equipped with radio-opaque markers on selected spinous processes and underwent a standard biplanar radiographic examination. Subsequently, radio-opaque markers were replaced with retro-reflective markers and the patients were measured statically using a Vicon motion capture system. Thoracolumbar / lumbar and thoracic curvature angles in the sagittal and frontal planes were calculated based on the centers of area of the vertebral bodies and radio-opaque markers as well as the three-dimensional position of the retro-reflective markers. To investigate curvature angle estimation accuracy, linear regression analyses among the respective parameters were used. The impact of inaccurate marker placement was explored using linear regression analyses among the radio-opaque marker- and spinous process-derived curvature angles. Results and Discussion The results demonstrate that curvatures angles in the sagittal plane can be measured with reasonable accuracy, whereas in the frontal plane, angles were systematically underestimated, mainly due to the positional and structural deformities of the scoliotic vertebrae. Inaccuracy of marker placement had a greater impact on thoracolumbar / lumbar than thoracic curvature angles. It is suggested that spinal curvature measurements are included in marker-based clinical gait analysis protocols in order to enable a deeper understanding of the biomechanical behavior of the healthy and pathological spine in dynamic situations as well as to comprehensively evaluate treatment effects.

Journal ArticleDOI
TL;DR: For flexible main thoracic curve AIS, both rods with high stiffness and those with low stiffness combined with high or low screw density could provide effective correction in the coronal plane.
Abstract: OBJECT The aim of this study was to evaluate the effects of rod stiffness and implant density on coronal and sagittal plane correction in patients with main thoracic curve adolescent idiopathic scoliosis (AIS). METHODS The authors conducted a retrospective study of 77 consecutive cases involving 56 female and 21 male patients with Lenke Type 1 main thoracic curve AIS who underwent single-stage posterior correction and instrumented spinal fusion with pedicle screw fixation between July 2009 and July 2012. The patients' mean age at surgery was 15.79 ± 3.21 years. All patients had at least 1 year of follow-up. Radiological parameters in the coronal and sagittal planes, including Cobb angle of the major curve, side-bending Cobb angle of the major curve, thoracic kyphosis (TK), correction rates, and screw density, were measured and analyzed. Screw densities (calculated as number of screws per fusion segment × 2) of < 0.60 and ≥ 0.60 were defined as low and high density, respectively. Titanium rods of 5.5 mm an...

Journal ArticleDOI
TL;DR: This report describes the first large population-based study with a long-term follow-up indicating that a scoliosis screening program can have sustained clinical effectiveness in identifying patients with adolescent idiopathic scolia needing clinical observation.

Journal ArticleDOI
TL;DR: The reported 3-D ultrasound imaging system can potentially be used for scoliosis mass screening and frequent monitoring of progress and treatment outcome because of its radiation-free and easy accessibility feature.
Abstract: Summary Background/Objective Standing radiograph with Cobb's method is routinely used to diagnose scoliosis, a medical condition defined as a lateral spine curvature > 10° with concordant vertebral rotation. However, radiation hazard and two-dimensional (2-D) viewing of 3-D anatomy restrict the application of radiograph in scoliosis examination. Methods In this study, a freehand 3-D ultrasound system was developed for the radiation-free assessment of scoliosis. Bony landmarks of the spine were manually extracted from a series of ultrasound images with their spatial information recorded to form a 3-D spine model for measuring its curvature. To validate its feasibility, in vivo measurements were conducted in 28 volunteers (age: 28.0 ± 13.0 years, 9 males and 19 females). A significant linear correlation ( R 2 = 0.86; p Results The 3-D ultrasound method using bony landmarks tended to underestimate the deformity, and a proper scaling is required. Nevertheless, this study demonstrated the feasibility of the freehand 3-D ultrasound system to assess scoliosis in the standing posture with the proposed methods and 3-D spine profile. Conclusion Further studies are required to understand the variations that exist between the ultrasound and radiograph results with a larger number of volunteers, and to demonstrate its potential clinical applications for monitoring of scoliosis patients. Through further clinical trials and development, the reported 3-D ultrasound imaging system can potentially be used for scoliosis mass screening and frequent monitoring of progress and treatment outcome because of its radiation-free and easy accessibility feature.

Journal ArticleDOI
TL;DR: A supervised exercise program was superior to controls in reducing spinal deformities and improving the quality of life in patients with AIS.
Abstract: Objectives. This systematic review was conducted to examine the effects of exercise on spinal deformities and quality of life in patients with adolescent idiopathic scoliosis (AIS). Data Sources. Electronic databases, including PubMed, CINAHL, Embase, Scopus, Cochrane Register of Controlled Trials, PEDro, and Web of Science, were searched for research articles published from the earliest available dates up to May 31, 2015, using the key words “exercise,” “postural correction,” “posture,” “postural curve,” “Cobb's angle,” “quality of life,” and “spinal deformities,” combined with the Medical Subject Heading “scoliosis.” Study Selection. This systematic review was restricted to randomized and nonrandomized controlled trials on AIS published in English language. The quality of selected studies was assessed by the PEDro scale, the Cochrane Collaboration's tool, and the Grading of Recommendations Assessment, Development, and Evaluation System (GRADE). Data Extraction. Descriptive data were collected from each study. The outcome measures of interest were Cobb angle, trunk rotation, thoracic kyphosis, lumbar kyphosis, vertebral rotation, and quality of life. Data Synthesis. A total of 30 studies were assessed for eligibility. Six of the 9 selected studies reached high methodological quality on the PEDro scale. Meta-analysis revealed moderate-quality evidence that exercise interventions reduce the Cobb angle, angle of trunk rotation, thoracic kyphosis, and lumbar lordosis and low-quality evidence that exercise interventions reduce average lateral deviation. Meta-analysis revealed moderate-quality evidence that exercise interventions improve the quality of life. Conclusions. A supervised exercise program was superior to controls in reducing spinal deformities and improving the quality of life in patients with AIS.

Journal ArticleDOI
TL;DR: The developed classification tree technique was implemented using the local deformity of the torso in the thoracic-thoracolumbar and lumbar regions to categorize curves into progression and nonprogression groups, and showed promise to monitor the progression of T-TL scoliosis curves.

Journal ArticleDOI
TL;DR: The US method may be considered a radiation-free alternative to assess children with scoliosis of mild to moderate severity and illustrated substantial intra- and inter-rater reliability.
Abstract: Study Design Retrospective reliability study of the coronal curvature measurement on ultrasound (US) imaging in adolescent idiopathic scoliosis (AIS). Objectives To determine the intra- and inter-rater reliability and validity of the coronal curvature measurements obtained from US images. Summary of Background Data Cobb angle measurements on radiographs are the usual method to diagnose and monitor the progression of scoliosis. Repeated ionizing radiation exposure is a frequent concern of patients and their families. Use of US imaging method to measure coronal curvature in children who have idiopathic scoliosis has not been clinically validated. Methods The researchers scanned 26 subjects using a medical 3-dimensional US system. Spinal radiographs were obtained on the same day from the local scoliosis clinic. Three raters used the center of lamina method to measure the coronal curvature on the US images twice 1 week apart. The raters also measured the Cobb angle on the radiographs twice. Intra- and inter-rater reliability of the coronal curvature measurement from the US images was analyzed using intra-class correlation coefficients. The correlation coefficient of the US coronal curvature measurements was compared with the Cobb angles. Results The intra-class correlation coefficient (2,1) values of intra- and inter-rater reliability on the US method were greater than 0.80. Standard error of measurement on both of the intra- and inter-rater US methods was less than 2.8°. The correlation coefficient between the US and radiographic methods ranged between 0.78 and 0.84 among 3 raters. Conclusions The US method illustrated substantial intra- and inter-rater reliability. The measurement difference between radiography and the US method was within the range of clinically acceptable error (5°). The US method may be considered a radiation-free alternative to assess children with scoliosis of mild to moderate severity.

Journal ArticleDOI
TL;DR: A multicenter case-matched comparison of patients with EOS treated with Shilla versus dual spine-spine GR from 1995 to 2009 found the GR group had a greater improvement in Cobb angle and a greater increase in T1-S1 length than Shilla.
Abstract: Study Design Retrospective comparison. Objectives To compare treatment of early-onset scoliosis (EOS) with Shilla growth guidance versus distraction-based dual growing rods (GR). Summary of Background Data We are not aware of any prior studies comparing the Shilla procedure with other surgical procedures in the treatment of EOS. Methods The authors performed a multicenter case-matched comparison of patients with EOS treated with Shilla versus dual spine–spine GR from 1995 to 2009. A total of 36 Shilla patients from 3 centers were matched with 36 GR patients from the database by age at index surgery (±1 year), preoperative Cobb angle (±15°), and diagnosis (neuromuscular, congenital, idiopathic, or syndromic). Average follow-up was similar between groups (GR, 4.3 years; Shilla, 4.6 years; p = .353). Results Average Cobb angle improvement preoperatively to latest follow-up was 36° (range, 72° to 36°) in the GR group versus 23° (range, 69° to 45°) in the Shilla group (p = .0124). T1–S1 length increased 8.8 cm in patients treated with GR, compared with 6.4 cm in Shilla patients (p = .0170). Shilla patients had fewer surgeries (2.8) than patients in the GR group (7.4) (p Conclusions The GR group had a greater improvement in Cobb angle and a greater increase in T1–S1 length than Shilla. The GR patients had more surgeries but Shilla patients had more unplanned procedures. The rate of complications overall did not differ significantly between groups.

Journal ArticleDOI
01 Jan 2015-Spine
TL;DR: Global sagittal alignment and SVA interactively associate with quantitative MRI spinal cord signal abnormalities and worse CSM-related disability and may reflect an optimal spinal alignment to achieve during surgical management.
Abstract: Study design This is an ambispective analysis of a prospectively followed cohort of patients with cervical spondylotic myelopathy (CSM). Objective The goal of this study was to evaluate the impact of sagittal alignment on magnetic resonance imaging (MRI) abnormalities in the cervical spinal cord as well as myelopathy severity in a prospective series of surgical patients. Summary of background data There is emerging evidence that sagittal alignment of the cervical spine in patients with CSM may be associated with disease severity. The impact on actual spinal cord pathology is unclear, with suspected mechanisms including focal static ventral compression, repeated dynamic injury, and increased cord intramedullary tension. The relationship between sagittal imbalance and disease severity remains undefined. Methods An ambispective analysis of prospectively collected data was performed of surgical patients with CSM at a single tertiary-care neurosurgical center. Demographic data and measures of neurological disability were collected and analyzed for dependency on cervical spine alignment parameters including qualitative (kyphotic vs. lordotic) and quantitative (sagittal Cobb angle (C2-C7) and sagittal vertical axis (SVA, C2-C7)). MRI cord signal hyperintensity at the most pathological level was also evaluated for dependency on the same alignment metrics. Multiple logistic regression analysis was used at the 0.05 level of significance with correction for multiple comparisons. Results Among 124 patients with CSM, kyphotic alignment was seen in 34% of patients and hyperintense T2 MRI signal was observed in 55% of patients. No difference in MRI signal or myelopathy severity was observed in univariate analysis on global alignment. Among patients with kyphosis, quantitative MRI parameters and myelopathy severity were both correlated with increasing SVA, an observation not seen among patients with lordosis. Conclusion Global sagittal alignment and SVA interactively associate with quantitative MRI spinal cord signal abnormalities and worse CSM-related disability. The reciprocal relationships of SVA effect in patients with kyphosis and those with lordosis may reflect an optimal spinal alignment to achieve during surgical management.

Journal ArticleDOI
TL;DR: MIPS combined with PVP is a good choice for the treatment of acute thoracolumbar osteoporotic VCF, which can prevent secondary VCF after PVP.
Abstract: Percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) could give rise to excellent outcomes and significant improvements in pain, analgesic requirements, function, cost, and incidence of serious complications for thoracolumbar osteoporotic vertebral compression fractures (VCFs). But some studies showed the recurrent fracture of a previously operated vertebra or adjacent vertebral fracture after PVP or PKP. The purpose of this study was to compare minimally invasive pedicle screw fixation (MIPS) and PVP with PVP to evaluate its feasibility and safety for treating acute thoracolumbar osteoporotic VCF and preventing the secondary VCF after PVP. Sixty-eight patients with a mean age of 74.5 years (ranging 65 ~ 87 years), who sustained thoracic or lumbar fresh osteoporotic VCFs without neurologic deficits underwent the procedure of PVP (group 1, n = 37) or MIPS combined with PVP (group 2, n = 31). Visual analog scale pain scores (VAS) were recorded and Cobb angles, central and anterior vertebral body height were measured on the lateral radiographs before surgery and immediately, 1 month, 2 months, 3 months, 6 months, 1 year, and 2 years after surgery. The patients were followed for an average of 27 months (ranging 24–32 months). The VAS significantly decreased after surgery in both groups (P < 0.005). The central and anterior vertebral body height significantly increased (P < 0.005), and the Cobb angle significantly decreased (P < 0.05) immediately after surgery in both groups. No significant changes in both the Cobb angle correction and the vertebral body height gains obtained were observed at the end of the follow-up period in group 2. But the Cobb angle significantly increased (P < 0.005), and the central and anterior vertebral body height significantly decreased (P < 0.005) 2 years after surgery compared with those immediately after surgery in group 1, and there were five patients with new fracture of operated vertebrae and nine cases with fracture of adjacent vertebrae. MIPS combined with PVP is a good choice for the treatment of acute thoracolumbar osteoporotic VCF, which can prevent secondary VCF after PVP.

Journal ArticleDOI
01 Jan 2015-Spine
TL;DR: A short fusion strategy, in which the upper instrumented vertebra is 1-level caudal to the upper EV, is applicable to posterior correction and fusion surgery with pedicle-screw constructs for Lenke type 5C curves.
Abstract: Study Design. A retrospective case series. Objective. To assess whether a short fusion strategy is applicable when treating adolescent idiopathic scoliosis with Lenke type 5C curve by posterior correction and fusion surgery using pedicle-screw constructs. Summary of Background Data. Previous studies have discussed the selection of the lower instrumented vertebra to best preserve motion segments and obtain coronal balance. However, reports evaluating the selection of the upper instrumented vertebra when treating Lenke type 5C curves are not available. Methods. We evaluated 29 patients who were treated surgically for adolescent idiopathic scoliosis with Lenke type 5C curve (mean age, 16.8 ± 4.7 yr; range, 10–29 yr). The mean follow-up period was 28.0 ± 6.3 months (range, 24–48 mo). We compared radiographical parameters and clinical outcomes between patients with an upper instrumented vertebra at the end vertebra (EV) (n = 10) and those treated by short fusion (S group), with a upper instrumented vertebra 1-level caudal to the EV (n = 19 patients). Results. In the EV group, a preoperative mean Cobb angle of 50°± 15° was corrected to 8°± 7°, which was maintained at the final follow-up (7°± 1°). In the S group, a mean preoperative Cobb angle of 47°± 4° was corrected to 8°± 5°, but this increased significantly to 12°± 7° at final follow-up (P = 0.033). The mean correction rate at final follow-up was significantly lower in the S group (72%) than in the EV group (86%) (P = 0.027). Coronal and sagittal balance, thoracic kyphosis, lumbar lordosis, L4 tilt, and clinical outcomes evaluated by Scoliosis Research Society patient questionnaire-22 were equivalent between the 2 groups. Conclusion. Scoliosis Research Society patient questionnaire-22 scores and radiographical parameters other than the correction rate were equivalent between the 2 groups. A short fusion strategy, in which the upper instrumented vertebra is 1-level caudal to the upper EV, is applicable to posterior correction and fusion surgery with pedicle-screw constructs for Lenke type 5C curves. Conclusion. Level of Evidence: 4

Journal ArticleDOI
01 Apr 2015-Spine
TL;DR: This retrospective review of prospective multicenter database of patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion suggests that for a low implant density construct, the best regions for planned screw dropout may be in the periapical convexity.
Abstract: STUDY DESIGN Retrospective review of prospective multicenter database of patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion. OBJECTIVE To analyze implant distribution in surgically instrumented Lenke 1 patients and evaluate how it impacts curve correction. SUMMARY OF BACKGROUND DATA Although pedicle screw constructs have demonstrated successful surgical results, the optimal pedicle screw density and configuration remain unclear. METHODS A total of 279 patients with adolescent idiopathic scoliosis treated with pedicle screws were reviewed. Implant density was computed for each side of the instrumented segment, which was divided into 5 regions: distal and proximal ends (upper/lower instrumented vertebra +1 adjacent vertebra), apical region (apex ± 1 vertebra), and the 2 regions in between (upper/lower periapical). Centralized measurement of Cobb angle and thoracic kyphosis was performed on preoperative and at 1-year postoperative radiographs as well as percent curve flexibility. RESULTS The mean implant density was 1.66 implants per level fused (1.08 to 2) with greater available pedicles filled on the concavity (92%, 53%-100%) compared with the convex side (73%, 23%-100%, P 0.05). Other convex regions of the construct had less instrumentation, with only 54% to 78% of pedicles instrumented (P < 0.01). Implant density in the concave apical region (69%, 23%-100%) had a positive effect on curve correction (P = 0.002, R = 0.19). CONCLUSION Significant variability exists in implant distribution with the greatest variation on the convex side and lowest implant density used in the periapical convex regions. Only instrumentation at the concave side, particularly at the apical region, was associated with curve correction. This suggests that for a low implant density construct, the best regions for planned screw dropout may be in the periapical convexity. LEVEL OF EVIDENCE 3.

Journal ArticleDOI
TL;DR: Patients operated on in adolescence showed little radiological progression, demonstrating the efficacy of surgical treatment for curvature greater than 50°, and lumbar scoliosis showed greater potential progression than thoracic scolia in adulthood, requiring fusion as of 35° angulation.
Abstract: Introduction To date there is no consensus on therapeutic indications in adolescent idiopathic scoliosis (AIS) with curvature between 30° and 60° at the end of growth. Objective The objective of this study was to assess outcome in patients with moderate AIS. Material and methods A multicenter retrospective study was conducted. Inclusion criteria were: Cobb angle, 30–60° at end of growth; and follow-up > 20 years. The data collected were angular values in adolescence and at last follow-up, and quality of life scores at follow-up. Results A total of 258 patients were enrolled: 100 operated on in adolescence, 116 never operated on, and 42 operated on in adulthood. Mean follow-up was 27.8 years. Cobb angle progression significantly differed between the 3 groups: 3.2° versus 8.8° versus 23.6°, respectively; P 35° (OR = 4.278, P = 0.002). There were no significant differences in quality of life scores. Discussion Patients operated on in adolescence showed little radiological progression, demonstrating the efficacy of surgical treatment for curvature greater than 50°. Curvature greater than 40° was progressive and may require surgery in adulthood. Lumbar scoliosis showed greater potential progression than thoracic scoliosis in adulthood, requiring fusion as of 35° angulation. Level of evidence IV, retrospective study.

Journal ArticleDOI
TL;DR: Degenerative lumbar scoliosis is a progressive coronal plane deformity that includes sagittal malalignment and usually occurs in patients older than forty years of age and is more commonly seen in the thoracic spine.
Abstract: Degenerative lumbar scoliosis is a progressive coronal plane deformity that includes sagittal malalignment and usually occurs in patients older than forty years of age1. This is in contrast to adult idiopathic scoliosis, which is a result of untreated adolescent idiopathic scoliosis and is more commonly seen in the thoracic spine. Degenerative lumbar scoliosis involves fewer segments and less severe curves than adult idiopathic scoliosis; however, both diagnoses can present with similar symptoms of back pain, lower-limb pain, and functional impairment. The prevalence is difficult to determine, possibly because of the diverse patient populations studied; it has ranged from 1% to 68% in the literature1-8, but most studies have demonstrated prevalences of about 7.5% to 15%6. There are radiographic findings that may predict which patients will develop scoliosis (defined as a coronal Cobb angle of >10°), as one community cohort demonstrated that asymmetric disc degeneration and unilateral osteophyte formation led to an increased prevalence of scoliosis5,9. The pathogenesis of degenerative lumbar scoliosis is unknown. However, recently researchers have investigated markers that could help establish an etiology or risk for progression of this condition10. Biomarkers that signify type-II-collagen synthesis and degradation have been …

Journal ArticleDOI
TL;DR: A systematic review of the effectiveness of the anterior and posterior approaches in the treatment of thoracolumbar fractures found the posterior approach is more effective for canal decompression, operative times, and perioperative blood loss.
Abstract: Despite extensive research on thoracolumbar fractures, controversy still exists about which approach is the most appropriate. Lack of evidence-based practice may result in patients being treated inappropriately. The objective of study was to perform a systematic review of the effectiveness of the anterior and posterior approaches in the treatment of thoracolumbar fractures. We conducted searches of PubMed and the Cochrane Library, searching for relevant trials up to August 2013 that compared anterior and posterior for the treatment of thoracolumbar fractures. The key words "anterior," "posterior," "thoracolumbar fracture," "CCT," and "RCT" were used. We assessed all included literature by using the Cochrane handbook (version 5.1). The results were expressed as the mean difference for continuous outcomes and risk difference for dichotomous outcomes, with a 95% confidence interval, using RevMan version 5.2. There were 3 randomized controlled trials and 11 clinical controlled trials included. The meta-analysis showed no significant difference between groups regarding Cobb angle, the Frankel scale, ASIA/JOA motor score, complications, and number of patients returning to work. Compared with the anterior approach, the posterior approach demonstrated superior canal decompression. In the burst fracture subgroup, operative times were significantly shorter and perioperative blood loss was less in the posterior approach group. The posterior approach is more effective for canal decompression, operative times, and perioperative blood loss. However, because of the lack of randomized controlled trials, and because of large sample size studies, heterogeneity was significant between reports. The optimal treatment for thoracolumbar fractures requires further study.

Journal ArticleDOI
TL;DR: Clavicle position during whole-spine radiograph caused a substantial decrease in the T1-slope; head position posteriorly translated followed by the cervical sagittal alignment became more hypo-lordotic, with slight downward gazing in comparison with the cervical radiograph.
Abstract: To evaluate the differences of cervical alignment between standing cervical lateral radiograph and whole-spine lateral radiograph with clavicle position. We prospectively evaluated 101 asymptomatic adults from whom standing cervical lateral radiograph with hands on both side followed by whole-spine lateral radiographs with clavicle position were obtained from April 2012 to December 2013. On two radiographs, cervical sagittal alignment from C2 to C7 was analyzed by Gore angle (GA) and Cobb angle (CA); head position was evaluated using the translation distance (TD, distance of the anterior tubercle of C1 compared with the vertical line through the posterior-inferior body of C7) and McGregor angle (MA, angle between the McGregor and horizontal lines). T1-slope was also evaluated. Cervical alignment on the cervical radiograph (GA −13.59° [−15.58 to −11.60], CA −9.76° [−11.65 to −7.86]) was significantly more lordotic than that on whole-spine radiographs (GA −6.28° [−8.65 to −3.91] and −4.14° [−6.40 to −1.89]). TD and MA on cervical radiographs (TD 34.98 mm [33.22–36.75]; MA 7.20° [6.35–8.35]) were meaningfully higher than those on whole-spine radiographs (TD 31.31 mm [29.47–33.16]; MA 6.32° [5.25–7.39]), but the MA values were not significant (p = 0.064). T1-slope was significantly lower in whole-spine radiographs (20.11° [18.88–21.35]) than in cervical radiographs (24.37° [23.14–25.6]). Values are expressed as mean (95 % confidence interval). Clavicle position during whole-spine radiograph caused a substantial decrease in the T1-slope; head position posteriorly translated followed by the cervical sagittal alignment became more hypo-lordotic, with slight downward gazing in comparison with the cervical radiograph.

Journal ArticleDOI
TL;DR: The results of this study reveal high variability in the effect of brace treatment on sagittal and pelvic alignment, and treatment with the Chêneau brace may also influence sagittal global balance.
Abstract: OBJECT The aim of the present study was to retrospectively evaluate progressive correction of coronal and sagittal alignment and pelvic parameters in patients treated with a Cheneau brace METHODS Thirty-two patients with adolescent idiopathic scoliosis (AIS) were assessed before initiation of bracing treatment and at the final follow-up Each patient underwent radiological examinations, and coronal, sagittal, and pelvic parameters were measured RESULTS No statistically significant modification of the Cobb angle was noted The pelvic incidence remained unchanged in 59% of the cases and increased in 28% of the cases The sacral slope decreased in 34% of the cases but remained unchanged in 50% Thoracic kyphosis and lumbar lordosis were significantly decreased, whereas the sagittal vertical axis was significantly increased from a mean of -440 to -302 mm (p = 002) The mean pelvic tilt increased significantly from 45° to 83° (p = 0002) CONCLUSIONS The Cheneau brace can be useful for preventing curvat

Journal ArticleDOI
TL;DR: Greater severity of PD was significantly associated with greater magnitude of scoliosis Cobb angle, even after adjusting for the effects of patient age and gender, and coronal parameters related to spine alignment, and disease severity were not significantly correlated with the dominant laterality of PD symptoms.

Journal ArticleDOI
TL;DR: Wearing a spinal brace improved postural stability in terms of increased proprioception, equilibrium performance, and rhythmic movement ability in patients with AIS.

Journal ArticleDOI
TL;DR: In different angles of lamina open-door, the improvement rate of neurological function after surgery had no statistically significant difference between 2 groups, and no significant differences in the Japanese Orthopedic Association scores, C2–C7 Cobb angle, cervical CI, and ROM showed.
Abstract: Study design A retrospective study. Objective To evaluate and compare the relation of the efficacy and clinical results of expansion open-door laminoplasty (EOLP) with different angles in lamina open-door. Summary of background data EOLP is currently the most widely adopted surgical treatment for cervical spondylotic myelopathy. Although many long-term clinical follow-up studies have reported that most patients recover satisfactorily after EOLP, there have been numerous reports regarding postoperative complications, such as stubborn axial symptoms (AS) and C5 palsy. The lamina open-door angles in EOLP play a decisive role in determining the openness of the door that affects clinical outcomes. Nonetheless, no thorough studies on different angles in EOLP have been published. Method A total of 198 cervical spondylotic myelopathy patients who underwent posterior cervical EOLP and at least 24 months follow-up treatment between July 2006 and January 2009 were selected as case studies. Among the 198 cases used, there were 39 double-segment cases with the location being C3-C5 in 11 cases and C4-C6 in 28 cases, 97 three-segments (C4-C7) and 62 four segments (C3-C7). All of the patients underwent x-ray, computed tomography, and magnetic resonance imaging images for evaluation of the cervical spine. According to different opening angles, measured by computed tomography scan after operation 1 week, the patients were divided into 2 groups, group A (>30 degrees, 76 patients including 44 males and 32 females) and group B (15-30 degrees, 122 patients including 71 males and 51 females). All patients were followed up for over 24 months, clinical results including operative duration, intraoperative bleeding volume, postoperative complications, C2-C7 Cobb angle, cervical curvature index (CI), range of motion (ROM), and values after the spinal cord backward shift were analyzed statistically, evaluating the neurological function at final follow-up and calculating the improvement rate of nerve function recovery. Results There was no statistically significant difference (P>0.05) between the 2 groups in the following areas: the Japanese Orthopedic Association scores, C2-C7 Cobb angle, cervical CI, and ROM. In addition, operative duration and intraoperative bleeding volume between A group and B group showed no significant differences (P>0.05). After surgery, 51 patients (67.1%) in group A had AS, 8 patients (10.4%) had C5 palsy, and 1 patient had mild cervical kyphosis. Whereas postoperatively group B contained 37 cases (10.5%) with AS, 3 (2.4%) with C5 palsy, and in 4 cases (3.28%) the lamina open-door had reclosed. The rate of patients with AS and C5 palsy in group A was higher than group B. The incidence of postoperative complications between the 2 groups have a significant difference (P 0.05). At the 1-month follow-up the range of the value of spinal cord backward shift was 0-7.95 mm with the average being 2.41±0.46 mm. C2-C7 Cobb angle, CI, and ROM between the 2 groups revealed no statistical significance (P>0.05). ROM comparisons preoperatively and postoperatively between the 2 groups were significantly different (P Conclusions In different angles of lamina open-door, the improvement rate of neurological function after surgery had no statistically significant difference between 2 groups. When the open-door angle is maintained between 15 and 30 degrees, it can reduce the incidence of C5 palsy in the hinge side and AS, but we should prevent reclosure of the lamina open-door.