Showing papers on "Cobb angle published in 2018"

Screening for Adolescent Idiopathic Scoliosis: US Preventive Services Task Force Recommendation Statement.

Abstract: Importance Adolescent idiopathic scoliosis, a lateral curvature of the spine of unknown cause with a Cobb angle of at least 10°, occurs in children and adolescents aged 10 to 18 years. Idiopathic scoliosis is the most common form and usually worsens during adolescence before skeletal maturity. Severe spinal curvature may be associated with adverse long-term health outcomes (eg, pulmonary disorders, disability, back pain, psychological effects, cosmetic issues, and reduced quality of life). Early identification and effective treatment of mild scoliosis could slow or stop curvature progression before skeletal maturity, thereby improving long-term outcomes in adulthood. Objective To update the 2004 US Preventive Services Task Force (USPSTF) recommendation on screening for idiopathic scoliosis in asymptomatic adolescents. Evidence Review The USPSTF reviewed the evidence on the benefits and harms of screening for and treatment of adolescent idiopathic scoliosis. Findings The USPSTF found no direct evidence on screening for adolescent idiopathic scoliosis and health outcomes and no evidence on the harms of screening. The USPSTF found inadequate evidence on treatment with exercise and surgery. It found adequate evidence that treatment with bracing may slow curvature progression in adolescents with mild or moderate curvature severity (Cobb angle Conclusions and Recommendation The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for adolescent idiopathic scoliosis in children and adolescents aged 10 to 18 years. (I statement)

Incidence of scoliosis in cerebral palsy.

Abstract: Background and purpose - Surveillance of scoliosis in individuals with cerebral palsy (CP) is important for ensuring timely diagnosis and identification of curve progression. We analyzed the incidence of scoliosis in relation to age, sex, and gross motor function in a population-based cohort of individuals with CP. Patients and methods - This was a prospective register study of all 1,025 individuals born 1990-2012 in southern Sweden (1.4 million inhabitants) in the Swedish surveillance program for CP, which included >95% of the total population of people with CP in the area. Annual clinical examinations and radiographic measurement of the Cobb angle of those with a moderate or severe scoliosis were registered. We determined the incidence of scoliosis related to age, sex, and the Gross Motor Function Classification System (GMFCS) level. Results - The inclusion criteria were fulfilled by 962 individuals. The number of people (140/962) with scoliosis increased up to 20-25 years of age. The incidence of scoliosis was related to age and GMFCS level. In individuals at the lowest level of gross motor function (GMFCS V) scoliosis was seen in 10/131 before 5 years of age and at the age of 20 years 75% of these individuals had a Cobb angle ≥40°. No one in the highest level of motor function (GMFCS I) developed a Cobb angle ≥40° Interpretation - Surveillance programs for scoliosis in CP should be based on age and GMFCS level and should be initiated at a young age and continued into adulthood.

Comparative analysis of 3 surgical strategies for adult spinal deformity with mild to moderate sagittal imbalance.

Abstract: OBJECTIVE Surgical treatment of adult spinal deformity (ASD) is an effective endeavor that can be accomplished using a variety of surgical strategies. Here, the authors assess and compare radiographic data, complications, and health-related quality-of-life (HRQoL) outcome scores among patients with ASD who underwent a posterior spinal fixation (PSF)-only approach, a posterior approach combined with lateral lumbar interbody fusion (LLIF+PSF), or a posterior approach combined with anterior lumbar interbody fusion (ALIF+PSF). METHODS The medical records of consecutive adults who underwent thoracolumbar fusion for ASD between 2003 and 2013 at a single institution were reviewed. Included were patients who underwent instrumentation from the pelvis to L-1 or above, had a sagittal vertical axis (SVA) of 10°, a pelvic tilt of > 20°, a lumbar Cobb angle of > 20°, and a thoracic Cobb angle of > 15°. Preoperative SVA, LL, pelvic incidence-LL mismatch, and lumbar and thoracic Cobb angles were similar among the groups. Patients in the PSF-only group had more comorbidities, those in the ALIF+PSF group were, on average, younger and had a lower body mass index than those in the LLIF+PSF group, and patients in the LLIF+PSF group had a significantly higher mean number of interbody fusion levels than those in the ALIF+PSF and PSF-only groups. At final follow-up, all radiographic parameters and the mean numbers of complications were similar among the groups. Patients in the LLIF+PSF group had proximal junctional kyphosis that required revision surgery significantly less often and fewer proximal junctional fractures and vertebral slips. All preoperative HRQoL scores were similar among the groups. After surgery, the LLIF+PSF group had a significantly lower ODI score, higher SRS-22 self-image/total scores, and greater achievement of the minimal clinically important difference for the SRS-22 pain score. CONCLUSIONS Satisfactory radiographic outcomes can be achieved similarly and adequately with these 3 surgical approaches for patients with ASD with mild to moderate sagittal deformity. Compared with patients treated with an ALIF+PSF or PSF-only surgical strategy, patients who underwent LLIF+PSF had lower rates of proximal junctional kyphosis and mechanical failure at the upper instrumented vertebra and less back pain, less disability, and better SRS-22 scores.

Global Spinal Alignment in Cervical Kyphotic Deformity: The Importance of Head Position and Thoracolumbar Alignment in the Compensatory Mechanism.

Abstract: BACKGROUND Previous studies have evaluated cervical kyphosis (C-kypho) using cervical curvature or chin-brow vertical angle, but the relationship between C-kypho and global spinal alignment is currently unknown. OBJECTIVE To elucidate global spinal alignment and compensatory mechanisms in primary symptomatic C-kypho using full-spine radiography. METHODS In this retrospective multicenter study, symptomatic primary C-kypho patients (Cerv group; n = 103) and adult thoracolumbar deformity patients (TL group; n = 119) were compared. We subanalyzed Cerv subgroups according to sagittal vertical axis (SVA) values of C7 (SVAC7 positive or negative [C7P or C7N]). Various Cobb angles (°) and SVAs (mm) were evaluated. RESULTS SVAC7 values were -20.2 and 63.6 mm in the Cerv group and TL group, respectively (P < .0001). Various statistically significant compensatory curvatures were observed in the Cerv group, namely larger lumbar lordosis (LL) and thoracic kyphosis. The C7N group had significantly lower SVACOG (center of gravity of the head) and SVAC7 (32.9 and -49.5 mm) values than the C7P group (115.9 and 45.1 mm). Sagittal curvatures were also different in T4-12, T10-L2, LL4-S, and LL. The value of pelvic incidence (PI)-LL was different (C7N vs C7P; -2.2° vs 9.9°; P < .0003). Compensatory sagittal curvatures were associated with potential for shifting of SVAC7 posteriorly to adjust head position. PI-LL affected these compensatory mechanisms. CONCLUSION Compensation in symptomatic primary C-kypho was via posterior shifting of SVAC7, small T1 slope, and large LL. However, even in C-kypho patients, lumbar degeneration might affect global spinal alignment. Thus, global spinal alignment with cervical kyphosis is characterized as head balanced or trunk balanced.

Proximal junctional kyphosis in thoracic adolescent idiopathic scoliosis: risk factors and compensatory mechanisms in a multicenter national cohort.

Abstract: Proximal junctional kyphosis (PJK) is a frequent complication, up to 46%, in adolescent idiopathic scoliosis surgical treatment (AIS). Several risk factors have been evoked but remain controversial. The purpose of this study was to analyze the incidence of PJK in a multicenter cohort of AIS patient and to determine risk factor for PJK. Lenke I and II AIS patients operated between 2011 and 2015 (minimum of 2-years follow-up) were included. On fullspine X-rays, coronal and sagittal radiographic parameters were measured preoperatively, postoperatively and at final follow-up. Occurrence of radiological PJK corresponding to a 10° increase in the sagittal Cobb angle, measured between the upper instrumented vertebra (UIV) and UIV + 2, between postoperative and 2-years follow-up X-rays, was reported. Among the 365 patients included, 15.6% (n = 57) developed a PJK and only 10 patients required a revision surgery. Preoperatively, PJK patients had significantly larger pelvic incidence (57° ± 13° vs. 51° ± 12°), larger lumbar lordosis (LL) (63° ± 12° vs. 57° ± 11°) and bigger C7 slope. Postoperatively (3 months), in the non-PJK group, thoracic kyphosis (TK) was increased and LL was not significantly different. However, postoperatively, in the PJK group, no significant change was observed in TK, whereas C7 slope decreased and LL significantly increased. There was also a postoperative change in inflection point which was located at a more proximal level in the PJK group. Between postoperative time and final follow-up, TK and LL significantly increased in the PJK group. PJK is a frequent complication in thoracic AIS, occurring 16%, but remains often asymptomatic (less than 3% of revisions in the entire cohort). An interesting finding is that patients with high pelvic incidence and consequently large LL and TK were more at risk of PJK. As demonstrated in ASD, one of the causes of PJK might be postoperative posterior imbalance that can be due to increased LL, insufficient TK or inflection point shift during surgery. These slides can be retrieved under Electronic Supplementary Material.

Minimally Invasive Surgery for Neuromuscular Scoliosis: Results and Complications in a Series of One Hundred Patients.

Abstract: Study design A retrospective review. Objective To report the results of an alternative technique using a minimally invasive fusionless surgery. The originality is based on the progressive correction of the deformities with proximal and distal fixation and on the reliability of the pelvic fixation using iliosacral screws on osteoporotic bones. Summary of background data Spinal deformities are common in neuromuscular diseases. Conventional treatment involves bracing, followed by spinal instrumented fusion. Growing rod techniques are increasingly advocated but have a high rate of complications. Methods The technique relies on a bilateral double rod sliding construct anchored proximally by four hooks claws and distally to the pelvis by iliosacral screws through a minimally invasive approach. Hundred patients with neuromuscular scoliosis underwent the same fusionless surgery extended from T1 to the pelvis. The average age at initial surgery was 11 + 6 years. Diagnoses included cerebral palsy (61), spinal muscular atrophy (22), muscular dystrophy (10), and other neurological etiologies (7). Cobb angle and pelvic obliquity were measured before and after initial surgery, and at final follow-up. Complications were reviewed. Results At latest follow-up 3 + 9 years (range 2 yr-6 + 3 yr), the mean Cobb angle improved from 89° to 35° which corresponds to 61% correction. Mean pelvic obliquity improved from 29° to 5°, which corresponds to 83% correction. Mean T1-S1 length increased from 30.02 to 37.28 cm. Mean preoperative hyper kyphosis was reduced from 68.44° to 33.29°. Complications occurred in 26 patients including mechanical complications (12) and wound infections (16). No arthrodesis was required at last follow-up. Conclusion This original fusionless technique is safe and effective, preserving spinal and thoracic growth. It provides a significant correction of spinal deformities and pelvic obliquity with a reduced complications rate. The strength and stability of this modular construct over time allow the avoidance of final arthrodesis. Level of evidence 4.

Difference in whole spinal alignment between supine and standing positions in patients with adult spinal deformity using a new comparison method with slot-scanning three-dimensional X-ray imager and computed tomography through digital reconstructed radiography.

Abstract: A precise comparison of supine and standing whole spine alignment in both the coronal and sagittal planes, including the pelvic parameters, has not been reported. Furthermore, previous studies investigated positional differences in the Cobb angle only in young patients with idiopathic scoliosis. The difference in alignment has never been investigated in a population of patients with adult spinal deformity (ASD). In most cases, ASD patients are aware of the symptoms when standing and tend to stoop with back pain, whereas the symptoms disappear when lying on a bed. Therefore, it is important to elucidate the positional differences in the deformity in older adults. The purposes of this study are to establish a method for comparing whole spine alignment between supine and standing, and to clarify the positional difference of the alignment in the patients with ASD. Twenty-four patients with ASD (mean age: 60.1 years, range 20–80 years; 24 women) were evaluated. A slot-scanning three-dimensional X-ray imager (EOS) was used to assess the whole spine in the standing position. Computed tomography was used to assess the whole spine in the supine position. The computed tomography DICOM dataset of the whole spine in the supine position was transformed to two-dimensional (coronal and sagittal) digital reconstructed radiography images. The digital reconstructed radiography images were input for three-dimensional measurement by the EOS software and compared with the standing whole spine alignment measured by EOS. The mean intraclass correlation coefficients (supine, standing) of intra-rater / inter-rater reliabilities for the measured parameters were 0.981, 0.984 / 0.970, 0.986, respectively. The Cobb and rotation angles of the major curve, mostly the thoracolumbar area, were significantly greater in the standing position than in the supine position. Lumbar lordosis during standing was significantly kyphotic. With respect to the pelvic parameters, the sacral slope was significantly smaller in the standing position than in the supine position. Pelvic tilt and pelvic incidence were significantly greater in the standing position than in the supine position. The lumbar to pelvic parameters and the major curve in standing position significantly deteriorate compared with the supine position in patients with ASD.

Measurement of scoliosis Cobb angle by end vertebra tilt angle method

Abstract: Scoliosis is a common deformity, and its severity is usually assessed by measuring the Cobb angle on the spinal X-ray film. The measurement of the Cobb angle is an important basis for selecting therapeutic methods and evaluating therapeutic effects. To measure and calculate the scoliosis Cobb angle by end vertebra tilt angle method (tilt angle method) and assess its accuracy and usability. It is deduced that the Cobb angle is the sum of upper and lower end vertebra tilt angles through the law of plane geometry. The project included 32 patients with scoliosis who have received treatment in our hospital from June 2011 to July 2016, whose Cobb angles were measured at various segments (total 50). The measuring results of the tilt angle method and the classical method were compared, and the time spent for the measurement of the two groups was respectively recorded with an electronic stopwatch for comparison. The interference of line marking in imaging data pixel in the two groups was compared using Beyond Compare software. The measuring results through PACS (picture archiving and communication systems) were regarded as the reference standard. There was no statistical difference for measuring the Cobb angle between the PACS method, end vertebra tilt angle method, and classical method. The end vertebra tilt angle method takes less measuring time than the classical method. The measuring error between the classical method and the tilt angle method showed no statistical significance for the difference. The scoliosis Cobb angle can be measured accurately and rapidly using the principle of the Cobb angle being equal to the sum of tilt angles of the upper and lower end vertebra, where in the film data of imaging will not be easily contaminated. Under special conditions, the average measuring error is ± 3°.

Clinical Outcomes of Posterolateral Fusion vs. Posterior Lumbar Interbody Fusion in Patients with Lumbar Spinal Stenosis and Degenerative Instability.

Abstract: Background Degenerative lumbar spine disease can lead to lumbar spine instability. Lumbar spine instability is defined as an abnormal response to applied loads characterized kinematically by abnormal movement in the motion segment beyond normal constraints. Patients with lumbar spinal stenosis (LSS) typically present with low back pain (LBP), cramping, cauda equine syndrome, and signs of nerve root compression associated by weakness, numbness and tingling in their legs that are worsened with standing and walking. This degenerative condition severely restricts function, walking ability, and quality of life (QOL). Objectives This study aims to compare clinical and radiological outcomes of posterolateral fusion (PLF) with posterior lumbar interbody fusion (PLIF) with posterior instrumentation in the treatment of LSS and degenerative instability. Study design A randomized prospective controlled clinical study. Methods In this prospective study, 88 patients with LSS and degenerative instability were randomly allocated to one of 2 groups: PLF (Group I) or PLIF (Group II). Primary outcomes were the control of LBP and radicular pain, evaluated with visual analog scale (VAS), the improvement of QOL assessed by the Oswestry disability index (ODI) scale, and measurement of fusion rate, Cobb angle, spinal sagittal balance, and modic changes in the 2 groups. Results At 24 months postoperatively, the mean reduction in VAS scores in Group I was more than in Group II (5.67 vs. 5.48, respectively) and the patients in Group I had more improvement in the ODI score than the patients in Group II (42.75 vs. 40.94, respectively). There was a statistically significant difference between the preoperative and postoperative sagittal balance in the 2 groups. The mean Cobb angle changed significantly in the 2 groups. Limitations There are few prospective studies of PLIF or PLF in patients with LSS and degenerative lumbar spine instability, and a limited number of studies which exists have examined the safety and outcome of each procedure without comparing it with other fusion techniques. Because most of the studies in the literature have been conducted in the patients with IS, we could not compare and contrast our findings with studies in patients with LSS and degenerative lumbar spine instability. In addition, although in our study the findings at a 24-month follow-up period showed that PLF was better than PLIF in these patients, there were some studies in which the authors reported that PLIF showed better clinical results than PLF at a 48-month follow-up period. So we suggest that rigorous controlled trials at longer follow-up periods should be undertaken in groups of patients with LSS and degenerative lumbar spine instability who undergo posterior decompression and instrumented fusion to help to determine the ultimate best fusion technique for these patients. Conclusion PLF with posterior instrumentation provides better clinical outcomes and improvement in the LBP, radicular pain, and functional QOL, more correction of the Cobb angle, more restoration of sagittal alignment, more decrease in Modic type 1, and more increase in Modic type 0, despite the low fusion rate compared to PLIF. Key words Lumbar spinal stenosis, degenerative instability, posterolateral fusion, posterior lumbar interbody fusion, low back pain, quality of life, cobb angle, fusion rate, modic changes, sagittal balance.

Bone cement distribution is a potential predictor to the reconstructive effects of unilateral percutaneous kyphoplasty in OVCFs: a retrospective study

Abstract: Osteoporotic vertebral compression fracture (OVCF) is a common type of fracture, and percutaneous kyphoplasty (PKP) is an eligible solution to it. Previous studies have revealed that both the volume and filling pattern of bone cement correlate with the clinical outcomes after PKP procedure. However, the role of bone cement distribution remains to be illustrated. To retrospectively evaluate the relationship between the bone cement distribution and the clinical outcomes of unilateral PKP, we enrolled 73 OVCF patients receiving unilateral PKP treatment. All the intervened vertebrae were classified into three groups based on the bone cement distribution observed on postoperative X-ray films. Preoperative and postoperative radiographic parameters including the vertebral height and kyphotic Cobb angle were recorded, and anterior vertebral height restoration rate (AVHRR) and Cobb angle correction (CR) were then calculated to assess the vertebral height reconstruction. Preoperative and postoperative Oswestry Disability Index (ODI) and visual analogue scale (VAS) were adopted by interviewing patients to assess the mobility improvement and pain relief. Demographic data, body mass index (BMI), lumbar bone mineral density (evaluated by BMD T-score) of each patient, bone cement volume (BV), and bone cement extravasation (BE) were also recorded. Between- and within-group comparisons and multivariable correlation analysis were carried out to analyze the data. VAS and ODI scores were both significantly improved in all of the enrolled cases with no significant differences between groups. Among the three groups, the average age, AVHRR, and BV were significantly different. Occurrence of BE was significantly different between two of the three groups. AVHRR was demonstrated to correlate negatively with preoperative anterior vertebral height ratio and positively with preoperative Cobb angle, CR, diffusion score, and ODI changes. Bone cement distribution is a potential predictor to the reconstructive effects in unilateral PKP for OVCFs. Bone cement distribution is associated with AVHRR and BV, as well as the risk of BE occurrence. Greater bone cement distribution may indicate better vertebral restoration along with a higher BE risk.

Sagittal radiographic parameters demonstrate weak correlations with pretreatment patient-reported health-related quality of life measures in symptomatic de novo degenerative lumbar scoliosis: a European multicenter analysis

Abstract: OBJECTIVE Previous studies have demonstrated that among patients with adult spinal deformity (ASD), sagittal plane malalignment is poorly tolerated and correlates with suboptimal patient-reported health-related quality of life (HRQOL). These studies included a broad range of radiographic abnormalities and various types of ASD. However, the clinical and radiographic characteristics of de novo degenerative lumbar scoliosis (DNDLS), a subtype of ASD, may influence previously reported correlation strengths. The aim of this study was to correlate sagittal radiographic parameters with pretreatment HRQOL in patients with symptomatic DNDLS. METHODS In this multicenter retrospective study of prospectively collected data, 74 patients with symptomatic DNDLS were enrolled based on anteroposterior and lateral 36-inch standing radiographs. Measurements included Cobb angle, coronal imbalance, pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL), sagittal vertical axis (SVA), thoracic kyphosis, pelvic incidence minus lumbar lordosis (PI-LL), T1-pelvic angle, and global tilt. HRQOL questionnaires included the Oswestry Disability Index (ODI), Scoliosis Research Society (SRS-22r), 36-item Short-Form Health Survey, and numeric rating scale (NRS) for back and leg pain. Correlations between radiographic parameters and HRQOL were assessed. Finally, HRQOL and increasing severity of sagittal modifiers (SVA, PI-LL, and PT) were evaluated. RESULTS Weak correlations were found between SVA and ODI (r = 0.296, p < 0.05) and PT with NRS back pain and the SRS pain domain (r = -0.260, p < 0.05, and r = 0.282, p < 0.05, respectively). Other sagittal radiographic parameters did not show any significant correlation with HRQOL. No significant differences in HRQOL were found concerning the increasing severity of PT, PI-LL, and SVA. CONCLUSIONS While DNDLS is a severe disabling condition, no noteworthy association between clinical and sagittal radiographic parameters was found through this study, demonstrating that sagittal radiographic parameters should not be considered the unique predictor of pretreatment suboptimal health status in this specific group of patients. Future studies addressing classification and treatment algorithms will have to take into account the existing subgroups of ASD.

Oblique retroperitoneal approach for lumbar interbody fusion from L1 to S1 in adult spinal deformity.

Abstract: In recent years, with advancements in surgical techniques and instrumentation, the lateral lumbar interbody fusion is being used increasingly as an alternative procedure to anterior approach. In this study, we illustrated a oblique retroperitoneal approach for lumbar interbody fusion with one incision site and tilting of the operation table in adult spinal deformity and evaluate the radiographical findings and clinical outcomes of patients treated using this technique. This study included 32 patients scheduled to undergo anterior and posterior long-level fusions for lumbar degenerative kyphosis or degenerative lumbar scoliosis. Data collected included blood loss, operative time, incision size, and perioperative complications. Pre- and postoperative radiographic parameters and clinical outcome measures were assessed. Mean follow-up time was 26.1 months. The mean blood losses were 107.4 and 102.4 ml, and the mean operative times were 116, 97, and 82 min for the patients within five levels (4 cases), four levels (18 cases), and three levels (10 cases). The mean incision sizes were 14.63, 13.82, and 12.5 cm in the patients with five, four, and three levels. The mean pelvic incidence was 50.3°. The mean preoperative sagittal vertical axis (SVA) was + 13.66 cm, and the last follow-up SVA was + 2.94 cm. The preoperative lumbar lordosis (LL) was 5.79°, and the last follow-up LL was 46.54°. The mean correction angle was 41°. The mean Cobb angle decreased from a preoperative value of 21.55° to 9.6°at the last follow-up. An oblique retroperitoneal approach is very safe, allowing reproducible access from L1 to S1 for lumbar interbody fusion in adult spinal deformity.

Diagnosing Pseudoarthrosis After Anterior Cervical Discectomy and Fusion

Abstract: Radiographic confirmation of fusion after anterior cervical discectomy and fusion (ACDF) surgery is a critical aspect of determining surgical success. However, there is a lack of established diagnostic radiographic parameters for pseudoarthrosis. The purpose of this study is to summarize the findings of previous studies, review the advantages and disadvantages of frequently employed diagnostic criteria, and present our recommended protocol of fusion assessment. This study identified randomized controlled trials, case-control studies, and prospective and retrospective cohort studies reporting on spinal fusion and how successful fusion after ACDF. Among the 39 articles reviewed, bridging bone across the operated levels on static radiographs was the most commonly used criteria to confirm fusion (31 of 39, 79%). Dynamic flexion-extension radiographs were used to assess for interspinous movement (ISM) (22 of 39, 56.4%) and change in Cobb angle (12 of 39, 30.8%). Computed tomography (CT) based findings (21 of 39, 53.8%) were employed in ambiguous cases with improved sensitivity and specificity. Reconstructed CT scans were used to assess for intragraft bridging bone and extragraft bridging bone (ExGBB). ExGBB were proved to have the highest diagnostic sensitivity and specificity for pseudoarthrosis detection when compared to all other radiographic criteria. The ISM <1 mm on dynamic flexion-extension radiographs had high diagnostic sensitivity and specificity as well. After our reviewing, we recommend using dynamic lateral flexion-extension cervical spine radiographs at 150% magnificationin which the interspinous motion <1 mm and superjacent interspinous motion ≥4 mm confirms fusion. In ambiguous cases, we recommend using reconstructed CT scans to evaluate for ExGBB.

Whether Orthotic Management and Exercise are Equally Effective to the Patients With Adolescent Idiopathic Scoliosis in Mainland China?: A Randomized Controlled Trial Study.

Abstract: STUDY DESIGN A prospective randomized controlled trial. OBJECTIVE The aim of this study was to investigate the effectiveness of orthotic management versus exercise on spinal curvature, body symmetry, and quality of life. SUMMARY OF BACKGROUND DATA A number of well-designed studies comparing conservative treatment of adolescent idiopathic scoliosis (AIS) have been conducted and the evidence becomes stronger. However, there is a lack of the information on the effectiveness of orthotic management versus exercise. METHODS The inclusion criteria recommended by the Scoliosis Research Society (SRS) and the international Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) were used during enrollment. Eligible patients were randomly assigned to either bracing group or exercise group. Patients in the bracing group were prescribed with a rigid thoracolumbosacral orthosis and requested to wear 23 h/day, while patients in the exercise group were treated with the protocol of the Scientific Exercise Approach to Scoliosis. Data regarding angle of trunk inclination, Cobb angle, shoulder balance, body image, and quality of life (QoL) were collected every 6 months. RESULTS Twenty-four patients in the bracing group and 29 patients in the exercise group participated in this study. For the intergroup comparison, the bracing group showed better results about the correction of spinal curvature (Cobb angle at the first 12 months of intervention, P = 0.039), scores concerning QoL, especially function (P < 0.001), mental health (P < 0.001), and total score (P < 0.001), were higher than that of the exercise group. The results of body symmetry evaluation did not differ significantly between the two groups. For the intragroup comparison, parameters of spinal curvature (baseline vs. 12-month, P < 0.03 in the exercise group and P < 0.001 in the bracing group), QoL (baseline vs. 12-month, P < 0.001), and TAPS (baseline vs. 12-month, P < 0.033) significantly improved over the studied period. Shoulder balance (baseline vs. 12-month, P < 0.005) showed significant improvement only in the bracing group. CONCLUSION Both interventions of bracing and exercise showed significant treatment effectiveness on the patients with AIS. Bracing was superior to capture corrections in parameters of spinal curvature and body symmetry, while the QoL, especially in aspect of the functional and psychological status, was significantly better in the exercise group. LEVEL OF EVIDENCE 1.

The Conservative Treatment of Traumatic Thoracolumbar Vertebral Fractures.

Abstract: Background The conservative treatment of traumatic thoracolumbar vertebral fractures is often not clearly defined. Methods This review is based on articles retrieved by a systematic search in the PubMed and Web of Science databases for publications up to February 2018 dealing with the conservative treatment of traumatic thoracolumbar vertebral fractures. The search initially yielded 3345 hits, of which 35 were suitable for use in this review. Results It can be concluded from the available original clinical research on the subject, including three randomized controlled trials (RCTs), that the primary diagnostic evaluation should be with plain x-rays, in the standing position if possible. If a fracture is suspected on the plain films, computed tomography (CT) is indicated. Magnetic resonance imaging (MRI) is additionally advisable if there is a burst fracture. The spinal deformity resulting from the fracture should be quantified in terms of the Cobb angle. The choice of a conservative or operative treatment strategy is based on the primary stability of the fracture, the degree of deformity, the presence or absence of disc injury, and the patient's clinical state. Our analysis of the three RCTs implies that early functional therapy without a corset should be performed, although treatment in a corset may be appropriate to control pain. Follow-up x-rays should be obtained after mobilization and at one week, three weeks, six weeks, and twelve weeks. Conclusion Further comparative studies of the indications for surgery and specific conservative treatment modalities would be desirable.

Effectiveness of basic body awareness therapy in adolescents with idiopathic scoliosis: A randomized controlled study1.

Abstract: Background In scoliosis, curve progresses due to muscle imbalance and poor posture. Basic body awareness therapy (BBAT) aims to improve posture, coordination, and balance by increasing body awareness, which may help decrease deformities. Objective This study aimed to investigate effects of Basic body awareness therapy (BBAT) on curve magnitude, trunk asymmetry, cosmetic deformity, and quality of life in adolescent idiopathic scoliosis (AIS) patients. Methods Twenty female AIS patients were randomly assigned to BBAT and traditional exercises (TEs) groups. The BBAT group received BBAT and traditional exercises (TEs), while the TEs group received only TEs. The following assessments were included: Cobb angles using X-ray, angle of trunk rotation (ATR) using scoliometer, trunk asymmetry using the Posterior Trunk Symmetry Index (POTSI), cosmetic deformity using the Walter Reed Visual Assessment Scale (WRVAS), and quality of life using the SRS-22 test. Measurements were conducted at baseline examination and ten weeks later. Patients were instructed to wear their brace 23 h daily. Results were analyzed using the Wilcoxon rank-sum test to compare repeated measurements and Mann-Whitney U test to compare the groups. Results The BBAT group had greater improvement in the thoracic Cobb angle than the TEs group. Cosmetic deformity improved in both groups, whereas body asymmetry improved in only the BBAT group. SRS-22 scores were unchanged in both groups. Conclusions BBAT as an additive to bracing and TEs improve curve magnitude, body symmetry and trunk deformity.

Preventing Distal Junctional Kyphosis by Applying the Stable Sagittal Vertebra Concept to Selective Thoracic Fusion in Adolescent Idiopathic Scoliosis

Abstract: Study Design Multicenter retrospective review. Objective To assess the effectiveness of using the stable sagittal vertebra (SSV) for selecting the lowest instrumented vertebrae (LIV) to prevent distal junctional kyphosis (DJK) in selective thoracic fusions. Summary of Background Data Cho et al. reported that including the SSV in a fusion decreased the rate of DJK in thoracic hyperkyphosis. Methods A retrospective review was performed of patients from two pediatric hospitals with adolescent idiopathic scoliosis who underwent selective posterior thoracic fusion with the LIV at L2 or above from 2000 to 2012. Patients with less than 2 years' follow-up were excluded. The primary outcome measure was DJK, defined radiographically as ≥10° between the superior end plate of the LIV and the inferior end plate of the vertebra below on a standing lateral radiograph. We investigated the SSV, which was defined as the vertebral level at which 50% of the vertebral body was in front of the posterior sacral vertical line (PSVL) on a standing lateral radiograph. This particular definition was referred to as SSV. Results A total of 113 patients met the inclusion criteria. Mean age was 14.4 years. Mean Cobb angle was 58°. The overall rate of DJK was 7% (8/113). When the LIV was superior to SSV, the rate of DJK was 17% (8/46) versus 0% (0/67) when the LIV was at or inferior to SSV (p=.01). The rates of DJK for patients with the LIV one, two, and three levels above SSV were 17% (4/24), 7% (1/14), and 43% (3/7), respectively. There was no significant association between preoperative or postoperative maximum kyphosis, thoracic kyphosis, thoracolumbar kyphosis, pelvic incidence, sagittal balance or coronal balance, and development of DJK. Conclusion Although LIV selection is complex, choosing the LIV at or below the SSV is a simple rule that minimizes the risk of DJK. Level of Evidence Level IV.

The expandable transforaminal lumbar interbody fusion - Two years follow-up.

Abstract: Study Design: This was a retrospective, observational study. Objectives: We hypothesize that the expandable transforaminal lumbar interbody fusion (TLIF) cage achieves satisfactory clinical outcomes while allowing for safe placement, improvement, and maintenance of foraminal and disc dimensions at 24 months postsurgery with low risk of cage migration, subsidence, and nerve injury. Methods: TLIF with expandable cages was performed in 54 patients (62 levels) over a 24-month-period using open midline or minimally invasive surgery techniques with placement of Globus Caliber, Rise, or Altera expandable cages. All patients underwent clinical and radiological assessment at 6 weeks, 6 months, 1, and 2 years postoperatively. Clinical outcome was measured by Oswestry disability index (ODI), visual analog pain score for both back and leg (visual analog scores [VASs]). Radiological assessment was done by X-ray standing lateral position. Results: There were significant clinical improvements in ODI, VAS leg, and VAS back at all postoperative time points. Disc height, foraminal height, focal Cobb angle, and global Cobb angle were significantly increased and maintained at all time points for 24 months (P Conclusions: These preliminary results indicate that the use of an expandable interbody cage achieves good clinical outcomes by improving and maintaining foraminal dimensions and disc height with minimal complication rate.

Clinical and Radiographic Outcomes After Posterior Vertebral Column Resection for Severe Spinal Deformity with Five-Year Follow-up.

Abstract: Background Short-term studies have shown improved outcomes and alignment after posterior vertebral column resection for severe spinal deformity. Our goal was to report long-term changes in radiographic and health-related quality-of-life measures in a consecutive series of pediatric and adult patients undergoing posterior vertebral column resection with a minimum follow-up of 5 years. Methods We reviewed all patients undergoing posterior vertebral column resection by a single surgeon prior to January 1, 2010, at a single institution. Standard preoperative and perioperative data were collected, including the Scoliosis Research Society (SRS)-22/24 instrument. Radiographic and health-related quality-of-life measures changes were evaluated at a minimum follow-up of 5 years. Results One hundred and nine patients underwent posterior vertebral column resection prior to January 2010, and 54 patients (49.5%) were available for analysis: 31 (57.4%) were pediatric patients, and 23 (42.6%) were adult patients. The mean age (and standard deviation) was 12.5 ± 3 years for the pediatric cohort and 39.3 ± 20 years for the adult cohort. Improvements in the mean major Cobb angle at a minimum follow-up of 5 years were seen: 61.6% correction for the pediatric cohort and 53.9% correction for the adult cohort. The rates of proximal junctional kyphosis, defined as proximal junctional kyphosis of >10°, were 16.1% for the pediatric cohort and 34.8% for the adult cohort, but none underwent a revision surgical procedure for symptomatic proximal junctional kyphosis. Of the 54 patients, 30 (55.6%) sustained complications, 5 (9.3%) experienced postoperative neurological deficits, and 7 (13.0%) required a revision by 5 years postoperatively. Significant improvements were observed in the SRS-Self Image with regard to the pediatric cohort at 0.9 (p = 0.017) and the adult cohort at 1.3 (p = 0.002) and in the SRS-Satisfaction with regard to the pediatric cohort at 1.8 (p = 0.008) and the adult cohort at 1.3 (p = 0.005). Conclusions Posterior vertebral column resection offers substantial, sustained improvements in global radiographic alignment and patient outcome scores at 5 years. The major radiographic deformity was reduced by 61.6% in the pediatric cohort and by 53.9% in the adult cohort. Despite the high rate of complications, patients experienced significant improvement in the SRS-Self Image and SRS-Satisfaction domains. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bone Cement-Augmented Short-Segment Pedicle Screw Fixation for Kümmell Disease with Spinal Canal Stenosis.

Abstract: BACKGROUND This study aimed to explore the feasibility and efficacy of bone cement-augmented short-segmental pedicle screw fixation in treating Kummell disease. MATERIAL AND METHODS From June 2012 to June 2015, 18 patients with Kummell disease with spinal canal stenosis were enrolled in this study. Each patient was treated with bone cement-augmented short-segment fixation and posterolateral bone grafting, and posterior decompression was performed when needed. All patients were followed up for 12-36 months. We retrospectively reviewed outcomes, including the Oswestry disability index (ODI), visual analog scale (VAS) score, anterior and posterior heights of fractured vertebrae, kyphotic Cobb angle, and neurological function by Frankel classification. RESULTS The VAS grades, ODI scores, anterior heights of affected vertebrae, and kyphotic Cobb angles showed statistically significant differences between pre- and postoperative and between preoperative and final follow-up values (P 0.05). The differences between posterior vertebral heights at each time point were not statistically significant (P>0.05). Improved neurological function was observed in 12 cases at final follow-up. Three cases had complications, including asymptomatic cement leakage in 2 patients and delayed wound infection in 1 patient. CONCLUSIONS Bone cement-augmented short-segment pedicle screw fixation is safe and effective for treating Kummell disease, and can achieve satisfactory correction of kyphosis and vertebral height, with pain relief and improvement in neurological function, with few complications.

A comparative study of single-stage transpedicular debridement, fusion, and posterior long-segment versus short-segment fixation for the treatment of thoracolumbar spinal tuberculosis in adults: minimum five year follow-up outcomes

Abstract: This a retrospective study in single centre. The objective of this retrospective clinical study is to compare the long-term clinical efficacy of posterior long-segment and short-segment fixation with single-stage transpedicular debridement and fusion for the treatment of thoracolumbar spinal tuberculosis in adults. Sixty-six cases of thoracolumbar tuberculosis were treated by single-stage transpedicular debridement, bone graft fusion, and pedicle screw fixation. Thirty-five cases were under long-segment fixation (group A) and 31 cases were under short-segment fixation (group B). These patients were followed up for a minimum of five years. The clinical and radiographic results for these patients were analyzed and compared. All 66 patients were completely cured during the follow-up. All patients had significant improvement of neurological condition and visual analogue scale pain scores at the final follow-up. The average operation duration and blood loss in group A were more than that in group B. Kyphosis Cobb angle of both groups was significantly corrected after surgical management. The correction rate of Cobb angle in group A was significantly higher than that in group B at the time of immediate post-operative period or the last follow-up (P < 0.05). The correction loss of group A was significantly less than that in group B (P < 0.05). Both posterior long-segment and short-segment pedicle screw fixations for the treatment of thoracolumbar spinal tuberculosis have significant effects in the correction of kyphosis and the improvement of neurological function. Although the blood loss and operation time of long-segment fixation were more than that of short-segment fixation, long-segment fixation was superior to the short-segment fixation in the correction of kyphosis and the maintenance of spinal stability, especially in the prevention of long-term correction loss.

Correlation Between Hump Dimensions and Curve Severity in Idiopathic Scoliosis Before and After Conservative Treatment.

Abstract: Study design. Prospective study in 150 consecutive outpatients affected by adolescent idiopathic scoliosis (AIS) Objectives. The purposes were to (1) identify a correlation between hump dimensions and the severity of scoliotic curve, and (2) evaluate how the treatment influenced the main parameters of scoliosis. Summary of Background Data. The existence of a relationship between clinical deformities and curve severity in AIS is still debated. Furthemore, only a few studies have investigated the effectiveness of conservative treatment for idiopathic scoliosis taking into account both clinical and radiological factors. Materials and Methods. 150 consecutive outpatients (mean age 12.8 ± 1.9 years) affected by AIS were subjected to conservative brace-based treatment. 134 participants completed the treatment protocol. Two parameters were considered to evaluate the treatment progress: the hump and the Cobb angle. Measurements were determined at the beginning and the end of treatment. Statistical analyses were performed in the whole sample and after dividing the study participants into 4 sub-groups: patients with lumbar (n=66) or thoracic curves (n=68), patients ranging in age between 6 and 13 years (n=89) and patients ≥ 14 years of age (n=45). Results. A positive correlation was detected between the hump dimension and curve severity at the beginning and the end of treatment, except for lumbar curves at baseline. The deformity was effectively corrected by the orthotic treatment (Cobb angle: 29.4 ± 8.5° at baseline and 19.3 ± 9.8° at the end of treatment; hump severity: 11.6 ± 5.6 mm at baseline and 6.2 ± 4.6 mm at the end). In addition, our data indicate that the hump correction is more evident than that of the curve registered in Cobb degrees. Conclusions. A significant correlation exists between the hump dimension and curve severity both at the beginning and the end of treatment, except for lumbar curves at baseline. The brace treatment confirmed its effectiveness in arresting the deformity progression and inducing a remodeling both of the scoliotic curve and the hump.