Radiographic study of peak velocity of pelvic incidence in adolescent idiopathic scoliosis.

BACKGROUND: Pelvic incidence (PI), a parameter related to the ideal spinopelvic alignment, is a morphological parameter that is usually considered fixed, but the PI's growth during adolescence has been reported. We investigated the peak PI velocity during adolescence and describe the relationship between increasing PI and changes in the morphology of the pelvis and sacrum. METHODS: We measured standing height (SH) and radiological anatomical parameters including pelvic height (PH), pelvic width (PW), sacral width (SW), femoral head-sacrum (FH-S), sacrum-coccyx (S-C) length, and S-C distance at each follow-up of 76 adolescent idiopathic scoliosis (AIS) patients. ΔParameter was the difference between the next measurement and the previous one. Growth velocity was ΔParameter divided by time interval. All ΔParameters were compared between different Risser stages using repeated-measures analysis of variance (ANOVA). The Pearson coefficients of correlation were calculated to assess the relationships between PI and ΔParameters. RESULTS: PI reached peak growth with a 1.6°/year growth in females and 1.8°/year in males at Risser stage 1. PI tended to grow rapidly with Risser 0 and closed triradiate cartilage (female: 1.3°/year and male: 1.4°/year) and to slow down at Risser 2 (female: 1.2°/year and male: 1.3°/year). ΔPI strongly correlated with ΔFH-S (R>0.508, P<0.05) and also correlated with ΔSH, ΔPH, ΔPW, ΔSW, and ΔS-C length (R>0.192, P<0.05) but not correlated with ΔS-C distance and ΔS-C ratio. CONCLUSIONS: In patients with AIS, the peak PI velocity is at Risser 1, and it is still increasing at Risser 5. Our result suggested that the growth of the PI may be associated with SH and changing pelvic morphology during skeletal growth of adolescence.

Sacral Agenesis: A Neglected Deformity That Increases the Incidence of Postoperative Coronal Imbalance in Congenital Lumbosacral Deformities.

STUDY DESIGN: A retrospective study. OBJECTIVES: To identify if there is a link between sacral agenesis (SA) and post-operative coronal imbalance in patients with congenital lumbosacral deformities. METHODS: This study reviewed a consecutive series of patients with congenital lumbosacral deformities. They had a minimum follow-up of 2 years. According to different diagnosis, they were divided into SA and non-SA group. Comparison analysis was performed between patients with and without post-operative coronal imbalance and risk factors were identified. RESULTS: A total of 45 patients (18 in SA group and 27 in non-SA group) were recruited into this study, among whom 33 patients maintained coronal balance while 12 demonstrated postoperative coronal imbalance at last follow-up (14.32 ± 7.67 mm vs 35.53 ± 3.91 mm, P < 0.001). Univariate analysis showed that preoperative lumbar Cobb angle, immediate postoperative coronal balance distance and diagnosis of SA were significantly different between patients with and without post-operative coronal imbalance (P < 0.05). Binary logistic regression analysis showed that SA was an independent risk factor for postoperative coronal imbalance. CONCLUSIONS: As an independent risk factor for postoperative coronal imbalance, high level of suspicion of SA should be aware in children with congenital lumbosacral deformities. Sufficient bone grafts at sacroiliac joint are recommended for SA patients to prevent postoperative coronal imbalance.

Risk factors for postoperative coronal decompensation in adult lumbar scoliosis after posterior correction with osteotomy.

INTRODUCTION: To determine potential risk factors for postoperative coronal imbalance following posterior osteotomy for adult scoliosis. MATERIALS AND METHODS: A total of 74 patients underwent osteotomy for rigid adult lumbar scoliosis. A group of 20 patients with postoperative coronal imbalance was identified. Clinical data and surgical strategies were compared to determine the risk factors, including age, gender, etiology, Cobb angle, preoperative coronal balance distance, direction of preoperative imbalance, T1 tilt, tilt of upper instrumented vertebra (UIV), UIV translation, location of UIV (T6 above or below), fusion to L5 or S1, lower instrumented vertebra (LIV) tilt, LIV rotation, screw density, osteotomy procedure (PSO or SPOs) and use of iliac screws. RESULTS: Comparison between patients with and without postoperative coronal imbalance showed that postoperative coronal imbalance occurred in older patients and those with degenerative scoliosis as the etiology, UIV above T6, preoperative LIV rotation, preoperative LIV tilt and preoperative coronal imbalance towards the convex side and who underwent Smith-Petersen osteotomy. All seven parameters were included in the logistic regression analysis. UIV above T6 (P = 0.010), LIV rotation (P = 0.012) and preoperative coronal imbalance towards the convex side (P = 0.005) were identified as risk factors for postoperative coronal imbalance after osteotomy. CONCLUSIONS: Patients with preoperative coronal imbalance towards the convex side (UIV above T6) and LIV rotation were more likely to develop coronal imbalance than those without risk factors. Older patients and those with degenerative scoliosis were also at a relatively higher risk of postoperative coronal imbalance.

Optimizing the fusion level for lenke 5C adolescent idiopathic scoliosis: is the S-line a validated and reproducible tool to predict coronal decompensation?

PURPOSE: To validate the predictability of S-line in Lenke 5C patients. METHODS: Lenke 5C patients with a minimum 2-year follow-up and with the lowest instrumented vertebra (LIV) at lower end vertebra were included. The S-line was defined as a line connecting the centers of concave-side pedicles of upper instrumented vertebra (UIV) and LIV on baseline films. The S-line tilt to right was defined as positive S-line status (S-line +) and tilt to left as S-line - status. Statistical analysis was performed between different subgroups. RESULTS: Among the 92 patients, 69 patients had a left lumbar curve and 23 patients had a right lumbar curve. For left curves, the S-line + status had a significantly higher incidence of both proximal and distal decompensation. However, for right curves, the S-line - status was the risk factor. Thus, we modified the definition of S-line: The value of S-line tilt for right curves was opposite to that for left curves. Patients with modified S-line + showed a significantly higher incidence of both proximal and distal decompensation in Lenke 5C patients with both left and right curves (p < 0.001 and p = 0.010). In UEV group, patients with modified S-line + showed significantly higher incidence of proximal decompensation (P = 0.001). However, in UEV-1 group, the incidence of proximal decompensation was not statistically affected by modified S-line + (P = 0.281). CONCLUSION: Modified S-line + is a validated risk factor that predisposed to post-operative coronal decompensation in Lenke 5C AIS patients. Selecting UIV at one level caudal to UEV could be a possible solution if the modified S-line was positive.

Position-related Change of Pelvic Incidence Depends on the Nonfused Sacroiliac Joint in Patients with Degenerative Spinal Diseases.

STUDY DESIGN: A retrospective cross-sectional study. OBJECTIVE: This study aims to determine whether the sacroiliac (SI) joint motion correlated to pelvic incidence (PI) change from standing to supine position in patients with degenerative spinal diseases. SUMMARY OF BACKGROUND DATA: PI was found an unstable parameter after adolescence as the fixed nature of PI was challenged by several studies. The SI joint has been shown to have some motion, age-related degenerative changes of cartilage and SI ligaments contribute to SI joint instability. METHODS: The study contains both specimen study and radiographic study. One human specimen was acquired, on which PI was measured with different sacrum-ilium positions. In radiographic study, patients with old thoracolumbar fracture, lumbar disc herniation, stenosis, and spondylolisthesis were included. Ankylosing spondylitis (AS) patients were also included as control group. PI was measured on standing x-rays and scanogram of computed tomography images in supine position. RESULTS: Specimen study result revealed that SI motion would lead to the change of PI with fixed pelvic thickness. In radiographic study, 101 patients with different etiology and 30 AS patients were included. After stratifying into different age groups, standing PI was significantly larger than supine PI in each age groups (P = 0.002, <0.001, and <0.001, respectively). In patients with degenerative diseases, PI was significantly larger on standing position than that on supine position. ΔPI showed no significant difference across etiologies. However, in AS patients, standing PI and supine PI revealed no significant difference (P = 0.528). CONCLUSION: Mobile SI joint may be the cause of increased PI in the aging spine. The dynamic change of PI is etiology-independent if the SI joint was not fused. Older patients have greater position-related change of PI.Level of Evidence: 4.

Comparison of Long-Term Outcomes of Endoscopic and Minimally Invasive Catheter Evacuation for the Treatment of Spontaneous Cerebellar Hemorrhage.

Recently, minimally invasive techniques, including endoscopic evacuation and minimally invasive catheter (MIC) evacuation, have been used for the treatment of patients with spontaneous cerebellar hemorrhage (SCH). However, credible evidence is still needed to validate the effects of these techniques. To explore the long-term outcomes of both surgical techniques in the treatment of SCH. Fifty-two patients with SCH who received endoscopic evacuation or MIC evacuation were retrospectively reviewed. Six-month mortality and the modified Rankin Scale (mRS) score were the primary and secondary outcomes, respectively. A multivariate logistic regression model was used to assess the effects of the different surgical techniques on patient outcomes. In the present study, the mortality rate for the entire cohort was 34.6%. Univariate analysis showed that the surgical technique and preoperative Glasgow Coma Scale (GCS) score affected 6-month mortality. However, no variables were found to be correlated with 6-month mRS scores. Further multivariate analysis demonstrated that 6-month mortality in the endoscopic evacuation group was significantly lower than that in the MIC evacuation group (OR = 4.346, 95% CI 1.056 to 17.886). The 6-month mortality rate in the preoperative GCS 9-14 group was significantly lower than that in the GCS 3-8 group (OR = 7.328, 95% CI 1.723 to 31.170). Compared with MIC evacuation, endoscopic evacuation significantly decreased 6-month mortality in SCH patients. These preliminary results warrant further large, prospective, randomized studies.

Quality of Life During Pregnancy, Caesarean Section Rate, and Anesthesia in Women with a History of Anterior Correction Surgery for Lumbar Scoliosis: A Case-Control Study.

BACKGROUND This study investigated the prevalence and severity of low back pain (LBP), caesarean section (C-section) rate, and the anesthesia approaches among lumbar scoliosis patients undergoing anterior correction surgery, and compared them with a healthy control cohort. MATERIAL AND METHODS The inclusion criteria for adolescent idiopathic scoliosis (AIS) patients were: presence of lumbar scoliosis, history of 1 or more pregnancies after surgery, and underwent anterior-only surgery. Healthy women with a history of 1 pregnancy were included as the control group. We recorded the type of delivery, neonatal birth weight, and perinatal complications. The quality of life was also evaluated. RESULTS New-onset LBP was reported in 65.6% of AIS patients, significantly higher than in the control group (p<0.001). C-section was performed in 11 scoliosis patients (34.4%) and 25 healthy controls (31.25%), and the rates were not significantly different between groups (P=0.75). No serious perinatal complications were reported in either group. General anesthesia was used for all C-section AIS patients. The rate of successful neuraxial anesthesia in the control group was significantly higher (P<0.001). CONCLUSIONS Compared with the healthy control group, lumbar AIS patients did not experience a higher risk of perinatal complications or C-section rate after anterior surgical correction, but general anesthesia was more commonly used than neuraxial regional anesthesia. LBP was more frequently observed in the post-operative AIS patients.

Long-Term Effect of Endoscopic Evacuation for Large Basal Ganglia Hemorrhage With GCS Scores ≦ 8.

Aims: The surgical evacuation, including stereotactic aspiration, endoscopic evacuation, and craniotomy, is the most effective way to reduce the volume of intracerebral hemorrhage. However, credible evidence for the effects of these techniques is still insufficient. The present study explored the long-term outcomes of these techniques in the treatment of basal ganglia hematoma with low Glasgow Coma Scale (GCS) scores (≤8) and large-volume (≥40 ml), which were predictors of high mortality. Methods: Two hundred and fifty-eight consecutive patients were reviewed retrospectively. The primary and secondary outcomes were 6-months mortality and 6-months modified Rankin Scale score, which were assessed by a multivariate logistic regression model. Results: Compared with the endoscopic evacuation group, the mortality was significantly higher in the stereotactic aspiration group (OR 6.858, 95% CI 3.146-14.953) and open craniotomy group (OR 3.315, 95% CI 1.497-7.341). Age (OR = 2.237, 95% CI 1.290-3.877) and herniation (OR = 2.257, 95% CI 1.172-4.348) were independent predictors for mortality. No significant difference in the neurological functional outcome was found in the stereotactic aspiration group (OR 0.501, 95% CI 0.192-1.308) and the craniotomy group (OR 0.774, 95% CI 0.257-2.335) compared with the endoscopic evacuation group. Conclusion: Endoscopic evacuation significantly decreased the 6-months mortality in patients with hemorrhage ≥40 ml and GCS ≤ 8.

Hyper-Selective Posterior Fusion in Lenke 5C Adolescent Idiopathic Scoliosis: When Can We Stop Below the Upper End Vertebra?

STUDY DESIGN: A prospective analysis. OBJECTIVE: To investigate whether the hyper-selective posterior fusion (upper instrumented vertebra [UIV] as the vertebra one level below the upper end vertebra [UEV], lower instrumented vertebra [LIV] as the lower end vertebra [LEV]) was applicable in posterior fusion of Lenke 5C adolescent idiopathic scoliosis (AIS) patients and what could be the indication of hyper-selective fusion. SUMMARY OF BACKGROUND DATA: The improper UIV selection in selective fusion could lead to progressive thoracic compensatory curve, shoulder imbalance, and even coronal imbalance. However, few studies analyzed the clinical outcome of hyper-selective fusion. METHODS: A prospective analysis of 80 patients with Lenke 5C AIS who underwent selective fusion was performed. According to the relationship between UEV and UIV, the patients were divided into UEV group (UIV = UEV) and UEV-1 group (UIV = UEV-1). Radiographic parameters and the incidence of postoperative proximal decompensation were compared. The Scoliosis Research Society (SRS)-22 scores were used to evaluate clinical outcomes between two groups. RESULTS: Thirteen patients (27%) in UEV group and six (18.75%) in UEV-1 group showed proximal decompensation during follow-up, and the incidence was equivalent (P = 0.280). Within the UEV-1 group, the patients with proximal decompensation showed similar Risser grade, baseline thoracic Cobb angle, and main Cobb angle (P = 0.611, 0.435, 0.708, respectively). However, the baseline L-T apical vertebral translation (AVT) ratio was significantly larger in patients with proximal decompensation (P = 0.028). Meanwhile, patients with proximal decompensation in UEV group showed significantly smaller preoperative UIV translation and lumbar AVT but similar postoperative UIV tilt. CONCLUSION: Hyper-selective posterior fusion strategy could be performed in Lenke 5C patients with Risser more than grade 2 and with thoracic compensatory curve over 15°. The UIV in patients with small baseline thoracic curve, represented by larger baseline lumbar-thoracic AVT ratio, should be selected as UEV to prevent proximal decompensation. LEVEL OF EVIDENCE: 4.

Selection of Distal Fusion Level for Lenke 5 Curve: Does the Rotation of the Presumed Lower Instrumented Vertebra Matter?

STUDY DESIGN: A retrospective analysis. OBJECTIVE: To evaluate whether the rotation of the presumed lower instrumented vertebra (LIV) on baseline convex side-bending (SB) radiographs leads to distal adding-on in Lenke 5C adolescent idiopathic scoliosis (AIS) patients. SUMMARY OF BACKGROUND DATA: In Lenke 1A patients, derotation of the presumed LIV on baseline bending films is important owing to the association between LIV rotation and postoperative distal adding-on. However, the relationship between distal adding-on and derotation of the presumed LIV in Lenke 5C patients remains unknown. METHODS: Eighty-five Lenke 5C patients with a minimum of 2-year follow-up for posterior fusion were enrolled. L3 was selected as the LIV in all patients. Patients were divided into the presumed LIV derotation (DR group) and nonderotation (NDR group) groups according to derotation of the presumed LIV on SB films. Radiographic parameters, including Cobb angle, coronal balance, lower disc angle of LIV, LIV tilt, and LIV translation, were measured pre- and postoperatively. RESULTS: Distal adding-on occurred in 16 patients (18.8%) at the final follow-up: 2 patients (10%) in the DR group and 14 patients (21.5%) in the NDR group (P = 0.248). Distal adding-on incidence was not greatly reduced with derotation of the presumed LIV on SB films at baseline. In the NDR group, the immediately postoperative lower disc angle of the LIV, LIV tilt, and LIV translation were significantly smaller in patients without than in those with distal adding-on (all P < 0.05). Logistic regression analysis revealed that the immediately postoperative LIV tilt and LIV translation were significant predictors of distal adding-on. CONCLUSION: Derotation of the presumed LIV on SB films may hint less risk of distal adding-on in Lenke 5C patients. Nevertheless, horizontalization of the LIV and minimizing LIV translation during correction could reduce the risk of distal adding-on despite the presence of LIV rotation at baseline. LEVEL OF EVIDENCE: 4.

The natural course of unruptured intracranial aneurysms in a Chinese cohort: protocol of a multi-center registration study in CIAP.

BACKGROUND: Subarachnoid hemorrhage (SAH) accounts for 4.4% of cerebral vascular disease, which is one of the leading causes of death in China. Rupture of intracranial aneurysms (IAs) is the most common cause of SAH. The natural history of unruptured IAs (UIAs) and the risk factors for rupture are among the key issues regarding the pathogenesis of IA and SAH that remain unclear in the Chinese population. METHODS: The China Intracranial Aneurysm Project (CIAP) is a prospective, observational, multicenter registry study of the natural courses, risk factors for the onset and rupture, treatment methods, comorbidity management and other aspects of intracranial aneurysms. To date, there are five studies in the CIAP. CIAP-1 is a prospective observational cohort study of UIAs. More than 5000 patients who will be followed for at least 1 year are expected to be enrolled in this cohort. These participants come from more than 20 centers that represent different regions in China. Enrollment began on May 1, 2017, and will take approximately 5 years. A nationwide online database of UIAs will be built. Participants' basic, lifestyle, clinical and follow-up information will be collected. The blood samples will be stored in the Central Biological Specimen Bank. Strict standards have been established and will be followed in this study to ensure efficient implementation. DISCUSSION: The natural course of UIAs in the Chinese population will be explored in this registry study. In addition, the risk factors for the rupture of the UIAs and the joint effect of those factors will be analyzed. The present study aims to create a nationwide database of UIAs and investigate the natural course of UIAs in China. Trial registration The Natural Course of Unruptured Intracranial Aneurysms in a Chinese Cohort (ClinicalTrials.gov Identifier: NCT03117803). Registered: July 5, 2017.