Assessment of malalignment at early stage in adolescent idiopathic scoliosis: a longitudinal cohort study.

INTRODUCTION: Our objective was to assess abnormalities of the odontoid-hip axis (OD-HA) angle in a mild scoliotic population to determine whether screening for malalignment would help predict the distinction between progressive and stable adolescent idiopathic scoliosis (AIS) at early stage. MATERIALS AND METHODS: All patients (non-scoliotic and AIS) underwent a biplanar X-ray between 2013 and 2020. In AIS, inclusion criteria were Cobb angle between 10° and 25°; Risser sign lower than 3; age higher than 10 years; and no previous treatment. A 3D spine reconstruction was performed, and the OD-HA was computed automatically. A reference corridor for OD-HA values in non-scoliotic subjects was calculated as the range [5th-95th percentiles]. A severity index, helping to distinguish stable and progressive AIS, was calculated and weighted according to the OD-HA value. RESULTS: Eighty-three non-scoliotic and 205 AIS were included. The mean coronal and sagittal OD-HA angles in the non-scoliotic group were 0.2° and -2.5°, whereas in AIS values were 0.3° and -0.8°, respectively. For coronal and sagittal OD-HA, 27.5% and 26.8% of AIS were outside the reference corridor compared with 10.8% in non-scoliotic (OR = 3.1 and 3). Adding to the severity index a weighting factor based on coronal OD-HA, for thoracic scoliosis, improved the positive predictive value by 9% and the specificity by 13%. CONCLUSION: Analysis of OD-HA suggests that AIS patients are almost three times more likely to have malalignment compared with a non-scoliotic population. Furthermore, analysis of coronal OD-HA is promising to help the clinician distinguish between stable and progressive thoracic scoliosis.

Influence of the thoracolumbar junction flexibility on the risk of adding-on after posterior vertebral arthrodesis for thoracic idiopathic adolescent scoliosis.

PURPOSE: The objective was to analyze the role of the thoracolumbar sagittal flexibility on the outcome after posterior spinal fusion of Lenke 1 and 2 adolescent idiopathic scoliosis with last touched vertebra as the lowest instrumented vertebra. METHODS: We included 105 thoracic AIS patients who had a posterior spinal fusion with a 2 years minimum follow-up. Thoracolumbar junction flexibility was assessed on dynamic sagittal X-rays and compared to the standing position. Adding-on was defined according to radiographic Wang criteria. The junction was considered flexible if the variability from the static position to flexion and/or extension was greater than 10°. RESULTS: Mean age of the patients was 14 ± 2 years. The preoperative mean Cobb angle was 61 ± 12.7° and 27.5 ± 7.7° after surgery. Mean follow-up was 3.1 years. Twenty-nine patients (28%) developed an adding-on. Thoracolumbar junction range of motion was higher (p = 0.017) with higher flexibility in flexion (p < 0.001) in the no adding-on group. In no adding-on group, 53 patients (70%) had a flexible thoracolumbar junction, and 23 patients (30%) had a stiff thoracolumbar junction in flexion and flexible in extension. In adding-on group, 27 patients (93%) had a stiff thoracolumbar junction, and 2 patients (7%) had a flexible junction in flexion and stiff in extension. CONCLUSION: The flexibility of the thoracolumbar junction is a determining factor in the surgical outcome after posterior spinal fusion for AIS and should be considered in correlation with the frontal and sagittal alignment of the spine.

Radiographic outcomes and complications after L4 or L5 pedicle subtraction osteotomy for fixed sagittal malalignment in 102 adult spinal deformity patients with a minimum 2-year follow-up.

PURPOSE: The objective of this retrospective study was to provide the radiographic outcomes and complications for pedicle subtraction osteotomy (PSO) performed at the low lumbar spine, i.e., L4 or L5 for ASD patients with fixed sagittal malalignment. METHODS: ASD patients who underwent L4 or L5 PSO with a minimum 2-year follow-up were included. Preoperative and postoperative radiographs, and complications were collected. Radiographic analysis included lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), thoracic kyphosis (TK), sagittal vertical axis (SVA), spinal lordosis (SL) ratio and global tilt (GT) on standing long-cassette radiographs. RESULTS: A total of 102 patients from 2 spinal centers were analyzed. 66 patients underwent PSO at L4 and 36 patients at L5. From preoperatively to the final follow-up, significant improvements occurred in LL (from - 31° to - 52°), SVA (from 13 to 5 cm), and GT (from 44° to 27°) (all, p < 0.05). 12 patients had transient neurological deficits, and 8 patients had persistent neurological deficit. 23 patients underwent revision for PJK (2), pseudarthrosis (10), neurological deficit (2), epidural hematoma (1), or deep surgical site infection (8). No PJK was observed in any of the patients with L5 PSO. CONCLUSIONS: PSO at the level of L4 or L5 remains a challenging technique but with an acceptable rate of complications and revisions. It enables correction of fixed sagittal malalignment in ASD patients with a globally satisfactory outcome. In comparison with L4 PSO, L5 PSO patients did not show PJK as a mechanical complication. Distal lumbar PSO at the level of L5 may represent one of the factors that may help preventing the proximal junctional kyphosis complication.

Effect of curve location on the severity index for adolescent idiopathic scoliosis: a longitudinal cohort study.

OBJECTIVES: Adolescent idiopathic scoliosis (AIS) is the most common spinal disorder in children. A severity index was recently proposed to identify the stable from the progressive scoliosis at the first standardized biplanar radiographic exam. The aim of this work was to extend the validation of the severity index and to determine if curve location influences its predictive capabilities. METHODS: AIS patients with Cobb angle between 10° and 25°, Risser 0-2, and no previous treatment were included. They underwent standing biplanar radiography and 3D reconstruction of the spine and pelvis, which allowed to calculate their severity index. Patients were grouped by curve location (thoracic, thoracolumbar, lumbar). Patients were followed up until skeletal maturity (Risser ≥ 3) or brace prescription. Their outcome was compared to the prediction made by the severity index. RESULTS: In total, 205 AIS patients were included; 82% of them (155/189, 95% confidence interval [74-90%]) were correctly classified by the index, while 16 patients were unclassified. Positive predictive ratio was 78% and negative predictive ratio was 86%. Specificity (78%) was not significantly affected by curve location, while patients with thoracic and lumbar curves showed higher sensitivity (≥ 89%) than those with thoracolumbar curves (74%). CONCLUSIONS: In this multicentric cohort of 205 patients, the severity index was used to predict the risk of progression from mild to moderate scoliosis, with similar results of typical major curve types. This index represents a novel tool to aid the clinician and the patient in the modulation of the follow-up and, for progressive patients, their decision for brace treatment. KEY POINTS: • The severity index of adolescent idiopathic scoliosis has the potential to detect patients with progressive scoliosis as early as the first exam. • Out of 205 patients, 82% were correctly classified as either stable or progressive by the severity index. • The location of the main curve had small effect on the predictive capability of the index.

Specific sagittal alignment patterns are already present in mild adolescent idiopathic scoliosis.

PURPOSE: The complex three-dimensional spinal deformity in AIS consists of rotated, lordotic apical areas and neutral junctional zones that modify the spine's sagittal profile. Recently, three specific patterns of thoracic sagittal 'malalignment' were described for severe AIS. The aim of this study is to define whether specific patterns of pathological sagittal alignment are already present in mild AIS. METHODS: Lateral spinal radiographs of 192 mild (10°-20°) and 253 severe (> 45°) AIS patients and 156 controls were derived from an international consortium. Kyphosis characteristics (T4-T12 thoracic kyphosis, T10-L2 angle, C7 slope, location of the apex of kyphosis and of the inflection point) and sagittal curve types according to Abelin-Genevois were systematically compared between the three cohorts. RESULTS: Even in mild thoracic AIS, already 49% of the curves presented sagittal malalignment, mostly thoracic hypokyphosis, whereas only 13% of the (thoraco) lumbar curves and 6% of the nonscoliosis adolescents were hypokyphotic. In severe AIS, 63% had a sagittal malalignment. Hypokyphosis + thoracolumbar kyphosis occurred more frequently in high-PI and primary lumbar curves, whereas cervicothoracic kyphosis occurred more in double thoracic curves. CONCLUSIONS: Pathological sagittal patterns are often already present in curves 10°-20°, whereas those are rare in non-scoliotic adolescents. This suggests that sagittal 'malalignment' patterns are an integral part of the early pathogenesis of AIS.

Comparison of different strategies on three-dimensional correction of AIS: which plane will suffer?

PURPOSE: There are distinct differences in strategy amongst experienced surgeons from different 'scoliosis schools' around the world. This study aims to test the hypothesis that, due to the 3-D nature of AIS, different strategies can lead to different coronal, axial and sagittal curve correction. METHODS: Consecutive patients who underwent posterior scoliosis surgery for primary thoracic AIS were compared between three major scoliosis centres (n = 193). Patients were treated according to the local surgical expertise: Two centres perform primarily an axial apical derotation manoeuvre (centre 1: high implant density, convex rod first, centre 2: low implant density, concave rod first), whereas centre 3 performs posteromedial apical translation without active derotation. Pre- and postoperative shape of the main thoracic curve was analyzed using coronal curve angle, apical rotation and sagittal alignment parameters (pelvic incidence and tilt, T1-T12, T4-T12 and T10-L2 regional kyphosis angles, C7 slope and the level of the inflection point). In addition, the proximal junctional angle at follow-up was compared. RESULTS: Pre-operative coronal curve magnitudes were similar between the 3 cohorts and improved 75%, 70% and 59%, from pre- to postoperative, respectively (P < 0.001). The strategy of centres 1 and 2 leads to significantly more apical derotation. Despite similar postoperative T4-T12 kyphosis, the strategy in centre 1 led to more thoracolumbar lordosis and in centre 2 to a higher inflection point as compared to centre 3. Proximal junctional angle was higher in centres 1 and 2 (P < 0.001) at final follow-up. CONCLUSION: Curve correction by derotation may lead to thoracolumbar lordosis and therefore higher risk for proximal junctional kyphosis. Focus on sagittal plane by posteromedial translation, however, results in more residual coronal and axial deformity.

New sagittal classification of AIS: validation by 3D characterization.

INTRODUCTION AND AIM: In order to improve surgical planning of sagittal correction in AIS, we proposed a new sagittal classification-Abelin-Genevois et al. Eur Spine J (27(9):2192-2202, 2018. https://doi.org/10.1007/s00586-018-5613-1 ). The main criticism is related to the fact that 2D lateral view results from the projection of the 3D deformity. The aim of this study is to show that the new sagittal classification system is a reliable system to describe the different sagittal scenarios that AIS could create both in 2D and 3D. METHODS: We performed retrospective radiograph analysis of prospectively collected data from 93 consecutive AIS patients who underwent an examination of the whole spine using the EOS® imaging system. 2D (Keops®) and 3D analyses (sterEOS®) provided frontal and sagittal spinal and spinopelvic parameters. In addition, 3D analysis provided apical vertebra rotation (AVR). RESULTS: Comparing 2D and 3D measurements for the general cohort, excellent correlation can be found for all parameters, but only fairly good for T10L2 and L1S1 angles. The highest variability was observed for T10L2, differences between 2D and 3D measurements being greater when the Cobb angle increased. AVR did not influence concordance between 2D and 3D measurements. Eighty-two percent were similarly classified in 2D and 3D according to the new classification. Misclassified patients were all AIS sagittal type 3 in 3D analysis, thoracolumbar junction (TLJ) lordosis being underestimated on 2D view. DISCUSSION: In conclusion, for the majority of cases (82%), 2D analysis may provide enough information for decision making when using a semi-automated 2D measurement system. However, in severe cases, especially when Cobb angle exceeds 55°, 3D analysis should be used to get a more accurate view on the thoracolumbar junction behavior. These slides can be retrieved under Electronic Supplementary Material.

Quasi-automatic early detection of progressive idiopathic scoliosis from biplanar radiography: a preliminary validation.

PURPOSE: To validate the predictive power and reliability of a novel quasi-automatic method to calculate the severity index of adolescent idiopathic scoliosis (AIS). METHODS: Fifty-five AIS patients were prospectively included (age 10-15, Cobb 16° ± 4°). Patients underwent low-dose biplanar X-rays, and a novel fast method for 3D reconstruction of the spine was performed. They were followed until skeletal maturity (stable patients) or brace prescription (progressive patients). The severity index was calculated at the first examination, based on 3D parameters of the scoliotic curve, and it was compared with the patient's final outcome (progressive or stable). Three operators have repeated the 3D reconstruction twice for a subset of 30 patients to assess reproducibility (through Cohen's kappa and intra-class correlation coefficient). RESULTS: Eighty-five percentage of the patients were correctly classified as stable or progressive by the severity index, with a sensitivity of 92% and specificity of 74%. Substantial intra-operator agreement and good inter-operator agreement were observed, with 80% of the progressive patients correctly detected at the first examination. The novel severity index assessment took less than 4 min of operator time. CONCLUSIONS: The fast and semiautomatic method for 3D reconstruction developed in this work allowed for a fast and reliable calculation of the severity index. The method is fast and user friendly. Once extensively validated, this severity index could allow very early initiation of conservative treatment for progressive patients, thus increasing treatment efficacy and therefore reducing the need for corrective surgery. These slides can be retrieved under Electronic Supplementary Material.

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

INTRODUCTION: 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. MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Spino-pelvic alignment influences disc hydration properties after AIS surgery: a prospective MRI-based study.

PURPOSE: To analyze the disc hydration and volumetric changes of the intervertebral disc after scoliosis surgery depending on the sagittal spino-pelvic organization. METHODS: We conducted a prospective MRI study in 45 patients with surgically treated adolescent idiopathic scoliosis (AIS) with a minimum 2-year follow-up. Fusion ended at L1 (n = 13), L2 (n = 14), L3 (n = 11) or L4 (n = 7). Total disc (Vd) and nucleus volumes (Vn) were extrapolated from 3D reconstruction using a custom-made image processing software (Biomechlab, Toulouse, France). Nucleus and external disc contours were semi-automatically detected on turbo spin echo T2-weighted sequence joined 3-mm sagittal cuts. Disc hydration was extrapolated from the nucleus-disc volume ratio (Vn/Vd). Radiographic sagittal parameters were measured pre- and post-operatively on full spine standing views (pelvic incidence, sacral slope, L1S1 lumbar lordosis). Lumbo-pelvic congruity was calculated by the ratio LL/SS according to Stagnara. RESULTS: Mean PI of the cohort was 55° (34°-85°). After surgical correction, lumbar lordosis was slightly increased by 3° (p = 0.02) decreasing lumbo-pelvic congruity from 1.37 to 1.27 (p < 0.01). When pelvic incidence was less than 55° (mean PI 46°), nucleus volumes have increased on average by 30 % compared to the preoperative status in the unfused lumbar discs, while the total disc volumes has remained stable. Five-year follow-up (n = 13) confirmed the constant improvement of the disc hydration ratio. When PI was high (mean PI 64°), volumetric changes were very mild and significant changes in nucleus volumes and disc hydration ratio concerned only the intermediate lumbar levels (L2L3, L3L4 and L4L5). CONCLUSIONS: This prospective MRI study showed a significant and sustainable improvement in T2 hypersignal of the disc, indirectly indicating improvement of disc hydration content after AIS surgery. Analysis of disc volumetric changes according to the pelvic incidence suggests that these changes are under the influence of the sagittal spino-pelvic alignment. PI seems to play a key role in the homeostasis of the discs under fusion and should be taken into account for preoperative planning. The restoration of the lumbo-pelvic congruence may help to limit early degenerative changes in the free-motion segment discs after AIS surgery. Hydration content was less sensitive to surgery when PI was high, suggesting higher shear stress in the lower discs. Longer follow-up is required to confirm this hypothesis.

Surgical management of thoracolumbar kyphosis in mucopolysaccharidosis type 1 in a reference center.

PURPOSE: Mucopolysaccharidosis (MPS) I is a rare autosomal recessive lysosomal storage disease. Thoracolumbar kyphosis is an early characteristic feature of the disease. Ossification failure in the anterosuperior quadrant of the vertebral body results in anterior dislocation. This study describes the surgical management of thoracolumbar kyphosis in MPS IH (Hurler syndrome) in a national reference center. METHODS: Among 72 MPS I patients followed in our institution, we treated surgically 14 MPS IH patients with severe thoracolumbar kyphosis. The decision was made after documented deformity progression. Mean age at surgery was 8 (3.5-15) years. Sagittal imbalance of the trunk was constant. One patient underwent extended fusion for associated scoliosis. We retrospectively reviewed 13 patients who underwent selective circumferential fusion at the thoracolumbar level. RESULTS: Average preoperative kyphosis was +57.5°(+30°; +90°). Surgical correction of the kyphosis was about 66 % and maintained at final follow-up. Fusion was obtained in all patients. Two patients required revision surgery consecutively to a previous posterior-only fusion, as a significant loss of correction occurred. One patient presented delayed neurologic deficit secondarily to cardiac embolism. One patient died postoperatively from cardiorespiratory failure. CONCLUSION: Surgery is necessary when kyphosis is progressive despite orthopedic management, aggravating the multifactorial trunk imbalance. Regarding our experience, circumferential arthrodesis should be recommended to achieve stable correction. Surgical management requires a multidisciplinary approach due to multisystemic failure and neurological risks specific to metabolic disorders.

Tridimensional trunk surface acquisition for brace manufacturing in idiopathic scoliosis.

INTRODUCTION: Brace manufacturing for idiopathic scoliosis requires trunk surface acquisition. Two methods are currently available to design the trunk shape: craft made technique based on a plaster mold and computer-aided design with 3-D reconstruction of the trunk by optical scanning. The objective of the present review was to compare these two methods. METHODOLOGY: We describe the different steps to design and manufacture braces used for spinal deformities. RESULTS: Our prospective evaluation showed good results in terms of the correction achieved and regarding patients' in-brace comfort. DISCUSSION: Optical scanning for computer-aided design and manufacturing (CAD-CAM) of trunk orthoses have proven their effectiveness. These technologies may help in monitoring conservative treatment and may enhance the brace interaction with the spinal deformity when orthopedic treatment is indicated.

Side bending radiographs and lowest instrumented vertebra in adolescent idiopathic scoliosis: A French quality-of-care study.

BACKGROUND: Determining which spinal levels to instrument during surgical treatment of Lenke Type 1 adolescent idiopathic scoliosis (AIS) depends on the reducibility of the primary and secondary curve patterns. This reducibility can be evaluated in several ways, with the most popular being radiographs in bending for moderate thoracic and lumbar curvatures. Hypothesis Side-bending radiographs will alter the choice of the lowest instrumented vertebra (LIV) for the surgical treatment of AIS. METHODS: Thirteen experienced French spine surgeons were invited to perform surgical planning on 23 patients based on stereoradiographs with and without (standing) side-bending views. The surgical planning was repeated a second time to assess the intra- and inter-rater reliability. Variations in the choice of LIV were analyzed for each evaluation. RESULTS: The intra-rater reliability was moderate to substantial. The inter-rater reliability was low to moderate. The study compared 879 surgical plans. Selective fusion was chosen in 0.3% of the plans. The median LIV was L2. The availability of side bending views changed the plan in 39% of cases. However, 36% of the plans were changed in the control (test-retest) condition. No significant difference was found between the variations with side-bending radiographs and "control" variations (p>0.05). CONCLUSION: The use of radiographs in bending has no significant effect on the LIV choice in this study. This result is derived from statistically robust analysis made possible by one of the largest datasets available on this topic. Large inter-rater variability was observed and will be explored further in a future study. LEVEL OF EVIDENCE: II; non-randomized controlled comparative study.

Spine slenderness is not an early sign of progression in adolescent idiopathic scoliosis.

Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spine. Spine slenderness, which represents its potential instability to buckling under compressive loads, was shown to be higher in AIS patients than non-scoliotic subjects, but it is not clear at what stage of the progression this difference appeared, nor if slenderness could be used as an early sign of progression. In this study, we hypothesized that slenderness could be an early sign of progression. One-hundred thirty-eight patients and 93 non-scoliotic subjects were included. They underwent standing biplanar radiography and 3D reconstruction of the spine, which allowed computing vertebra and disc slenderness ratio. Then, patients were followed until progression of the deformity or skeletal maturity (stable patients). Vertebral slenderness ratio in AIS patients varied between 2.9 [2.7; 3.0] (T9) and 3.4 [3.2; 3.6] (T1), while disc slenderness ranged from 0.6 [0.6; 0.7] at T6-T7 to 1.2 [1.1; 1.3] at L4-L5. Slenderness ratio increased with age, while disc slenderness tended to decrease with age and Cobb angle. Slenderness was similar between progressive and stable patients, and also between patients and non-scoliotic subjects. In conclusion, spinal slenderness does not appear to be an early sign of progression. Further studies should analyse the development of slenderness during growth, and how it could be affected by non-operative treatment.

Sagittal balance of the spine.

Spinal balance can be defined as the trade-off between outside forces acting on the spine and the muscle response of the trunk, under sensorineural regulation, to maintain stable upright posture, both static and dynamic. Homo sapiens developed sagittal alignment along with bipedalism. The upright posture was an important step in human evolution, to master the environment, at the price of some instability in postural control in the trunk, and to maintain horizontal gaze. To make upright stance energetically economical and thus sustainable, reciprocal sagittal curvatures developed. Sagittal spinal organization is governed by strict rules under physiological conditions, enabling alignment between the center of mass and the lower limb joint centers. In children and adolescents, morphologic changes related to skeletal growth and postural control centers maturation alter spinal alignment and hence spinal balance, with increases in pelvic incidence, sacral slope and consequently lumbar lordosis and thoracic kyphosis. Global cervical lordosis remains stable, at the cost of an increase of the inferior cervical lordosis angle in correlation with T1 inclination or T1 slope. In pathology, spinal alignment may induce certain spinal pathologies such as growth-related spinal dystrophy or spondylolisthesis. It can also be altered by spinal deformity such as scoliosis, a regional disorder inducing adjacent compensatory mechanisms. The management of spinal pathologies is indissociable from understanding and maintaining or restoring individual sagittal alignment so as to ensure physiological distribution of stresses and limit onset of complications or decompensation in adulthood.

Teleconsultation using multimedia messaging service for management plan in pediatric orthopaedics: a pilot study.

BACKGROUND: Application and assessment of the usefulness of image transfer through a mobile telephone in pediatric orthopaedic practice was investigated. METHODS: Twenty patients with traumatic lesions requiring urgent consultation were included. Relevant x-rays were photographed and transferred using Multimedia Messaging Service to the orthopaedic surgeon at our department. The discussion on the need to transfer the patient for treatment and the final treatment was retrospectively scrutinized by 10 independent orthopaedic surgeons. The agreement on the diagnosis and the management plan proposed after image transfer were assessed. RESULTS: The lesion concerned the lower limb in 6 cases, upper limbs in 13 cases, and the spine in 1 case in patients aged 2 to 16 years. The transmitted images were 160 x 120-pixel jpeg files in 1 case, 240 x 180-pixel jpeg files in 8 cases, 320 x 240-pixel jpeg files in 1 case, and 640 x 480-pixel jpeg files in 10 cases. In all the cases studied, all the investigators agreed that the images were good enough for doing the diagnosis even in cases of minor or nondisplaced fractures. The same decisions of transfer or management were taken in all the cases by all the investigators. Review of the transferred images versus the original full-scale images did not change the final diagnosis and management plan. CONCLUSIONS: In this study, even in case of low-resolution images (160 x 120-pixel jpeg), images were of sufficiently high quality for interpretation. This enables rational management decisions to be made using this costless and widely available technology. In patients requiring surgical treatment, a final operative decision is mandatory after transfer, bedside examination, and review of other data in addition to images. Teleconsultation using Multimedia Messaging Service is especially useful to improve remote management of orthopaedic patients in local hospitals or for decisions of transfer when surgical treatment is needed. CLINICAL RELEVANCE: Level IV (case series).

MRI evaluation of the hydration status of non-pathological lumbar intervertebral discs in a pediatric population.

INTRODUCTION: The intervertebral disc (IVD) is made up of the annulus fibrosus (AF) and the nucleus pulposus (NP) - an inert hydrated complex. The ability of the IVD to deform is correlated to that of the NP and depends on its hydration. As the IVD ages, its hydration decreases along with its ability to deform. In adolescent idiopathic scoliosis, one of the etiological hypotheses pertains to the IVD, thus making its condition relevant for the diagnosis and monitoring of this pathology. HYPOTHESIS: IVD hydration depends on sex, age and spine level in an asymptomatic pediatric population. The corollary is data on a control group of healthy subjects. MATERIAL AND METHODS: A cohort of 98 subjects with normal spine MRI was enrolled; their mean age was 13.3 years. The disc volume and hydration of each IVD was evaluated on T2-weighted MRI sequences, using previously validated image processing software. This evaluation focused on the lumbar spine, from the thoracolumbar junction to the lumbosacral junction. It was assumed that IVD hydration was related to the ratio of NP and AF volumes. A mixed multivariate linear analysis was used to explore the impact of age, sex and spinal level on disc hydration. RESULTS: Disc hydration was higher overall in boys than in girls, but this difference was not significant. Hydration increased with age by +0.005 for each additional year (p=0.0213). Disc hydration appears to be higher at the thoracolumbar junction than the lumbar spine, although this difference was not significant. CONCLUSION: Through this MRI study, we established a database of non-pathological lumbar disc hydration as a function of age, sex and spinal segment along with 95% confidence intervals. LEVEL OF EVIDENCE: IV.

Early Detection of Progressive Adolescent Idiopathic Scoliosis: A Severity Index.

STUDY DESIGN: Early detection of progressive adolescent idiopathic scoliosis (AIS) was assessed based on 3D quantification of the deformity. OBJECTIVE: Based on 3D quantitative description of scoliosis curves, the aim is to assess a specific phenotype that could be an early detectable severity index for progressive AIS. SUMMARY OF BACKGROUND DATA: Early detection of progressive scoliosis is important for adapted treatment to limit progression. However, progression risk assessment is mainly based on the follow up, waiting for signs of rapid progression that generally occur during the growth peak. METHODS: Sixty-five mild scoliosis (16 boys, 49 girls, Cobb Angle between 10 and 20°) with a Risser between 0 and 2 were followed from their first examination until a decision was made by the clinician, either considering the spine as stable at the end of growth (26 patients) or planning to brace because of progression (39 patients). Calibrated biplanar x-rays were performed and 3D reconstructions of the spine allowed calculating six local parameters related to main curve deformity. For progressive curve 3D phenotype assessment, data were compared with those previously assessed for 30 severe scoliosis (Cobb Angle > 35°), 17 scoliosis before brace (Cobb Angle > 29°) and 53 spines of nonscoliosis subjects. A predictive discriminant analysis was performed to assess similarity of mild scoliosis curves either to those of scoliosis or nonscoliosis spines, yielding a severity index (S-index). S-index value at first examination was compared with clinical outcome. RESULTS: At the first exam, 53 out of 65 predictions (82%) were in agreement with actual clinical outcome. Approximately, 89% of the curves that were predicted as progressive proved accurate. CONCLUSION: Although still requiring large scale validation, results are promising for early detection of progressive curves. LEVEL OF EVIDENCE: 2.

Long-term effectiveness of an educational and physical intervention for preventing low-back pain recurrence: a randomized controlled trial.

OBJECTIVE: Low-back pain (LBP) is a common and recurrent condition, but the evidence is scarce about effective strategies to prevent recurrence and disability in the longer term. This study investigated the effect of a light exercise program, initiated in the workplace and continued at home, in reducing recurrence of LBP episodes among healthcare workers. METHODS: A total of 353 healthcare workers from ten hospitals were enrolled in a randomized controlled trial (RCT) and were randomized to the intervention or control groups, the latter of which received usual care. The intervention comprised three steps: (i) a 2-hour education session, (ii) five weekly 90-minutes exercise training sessions in the workplace, and (iii) a home-based self-managed exercise program. The main outcome was recurrence of LBP with sick-leave at 24-months follow-up. RESULTS: At two-year follow-up, 35 workers (24%) in the intervention group and 31 workers (21%) in the control group had at least one LBP recurrence with sick leave. No effect was observed between groups [odds ratio (OR) 1.22, 95% confidence interval (95% CI) 0.67-2.23, P=0.516]. The intervention was effective in reducing fear avoidance with a mean reduction of -3.6 (95% CI -4.8- -2.4) points on the fear-avoidance beliefs questionnaire score for physical activity (FABQ-P) in the intervention group compared with -1.3 (95% CI -2.2- -0.3) points in the control group (P<0.05). It was also effective in improving muscle endurance with a mean increase of 13.9 (95% CI 3.3-24.5) minutes on the Sorensen test in the intervention group compared with -8.3 (95% CI-17.5-0.9) minutes in the control group (P<0.05). Healthcare utilization was reduced in the intervention group for painkillers, medical visits, imaging and outpatient physiotherapy. CONCLUSION: It was not possible to conclude about the effectiveness of a light exercise program to reduce LBP recurrence episodes in the long-term in healthcare workers. However, it was effective to improve muscle endurance, and to reduce fear-avoidance beliefs and healthcare utilization. Further studies are necessary in order to identify effective interventions to reduce LBP recurrence and related sick-leaves.