Impact of FDG PET/CT on detection of synchronous and metachronous malignancies and clinical management in patients with multiple primary cancers.

Multiple primary cancers are usually defined as primary malignant tumors of different histological origins in one person. Recently, there has been an increase in the number of patients diagnosed with multiple primary cancers. The study aims to evaluate the role of PET/CT in detecting second primary and subsequent tumors as well as to demonstrate the influence on the treatment management in patients with histologically proven synchronous or metachronous tumors. Fifty patients with clinically proven at least one malignancy have been evaluated and followed up for a year. Another inclusion criterion was a biopsy-proven additional primary synchronous (within 2-6 months after the first one) or metachronous (more than 6 months after the diagnosis of the first one) malignant tumor in a different organ. All patients were scanned on GE Discovery PET/CT 16 slices scanner from the top of the head to mid-thigh. The study was performed one hour after injection, using the weight-adjusted activity, hydration of patients with diuretic stimulation, and oral/i.v. contrast intake. Thirty out of 50 patients were females. The youngest patient was 25 years old, while the highest age was 84 years. Ten of the patients had third primary tumors and one patient had four different malignancies. Metachronous tumors were 2.4-fold higher than synchronous ones. The minimum time to detect a second tumor was 1 month, while the maximum was 15 years. As second malignancies we detected fourteen gastrointestinal cancers (28%), ten urogenital ones (20%), ten pulmonary tumors (20%), five breast cancers (10%), four lymphoma patients (8%), four head and neck squamous cell carcinomas (8%), two NET (4%), and one sarcoma (2%). As a result of the 18F-FDG PET/CT scan, the therapy plans of all 50 patients required modification at the minimum for the second tumor. 64% of the patients had multimodality therapy for their first cancer, which suggests that this approach could play an important role in the development of MPM. 81% of the additional malignancies in the female group, detected by PET/CT were in stages I or II, which provides a higher probability of cure. On the other hand, we detected advanced stage second primary disease in 70% of the patients in the male group. PET/CT can identify a significant number of additional primary neoplasms in patients with known primary cancer, acquiring combined metabolic and morphologic information, as well as its whole-body protocol. Integrated PET/CT can significantly modify the assessment of the tumor's dissemination and often change patient management substantially. Subsequent primary lesions identified after PET/CT scan are mainly in the early stage and thus have an excellent likelihood of being cured if treated promptly and aggressively.

Vertebral column growth in children with early onset scoliosis treated with magnetically controlled growing rods - Effects of distraction on vertebral and disc morphology.

OBJECTIVES: To report changes in vertebral and disc morphology following treatment of early onset scoliosis (EOS) with magnetically controlled growing rods (MCGR). METHODS: 30 Patients, 21 girls and 9 boys, treated with MCGR for EOS were compared to a matched control group of 19 patients (12 girls, 7 boys) treated with bracing or observation. Age at surgery in the MCGR group was 8.75 (range: 4.6-11) years compared to 7.75 (range: 3.5-10.3) years in the control group at the time of onset of treatment. Mean follow-up was 45 (range: 24-65) months in the MCGR group vs 42 (range: 24-65) months in the control group. Calibrated radiographs were used to digitally measure disc height, vertebral body height, depth and width after surgery and at latest follow-up. Height, width and depth of lumbar and thoracic vertebrae and discs under distraction were compared to the control group and to vertebrae below instrumentation. T1-T12, T1-S1 length and Cobb angles were also measured. RESULTS: (1) There is a significant increase of lumbar vertebral height under distraction. (2) Lumbar disc height as well as lumbar vertebral width within distraction is significantly reduced. (3) Depth of lumbar vertebrae is not significantly affected by distraction. (4) Morphology of thoracic vertebrae and adjacent discs is not significantly changed with distraction. (5) T1-T12 distance did not show any significant changes between surgical and control group, while T1-S1 growth was significantly reduced compared to the control group. CONCLUSIONS: Significant changes of morphology of lumbar vertebra and discs are observed under distraction with MCGR compared to segments below instrumentation and the control group. LEVEL OF EVIDENCE: Level III - retrospective comparative series.

The impact of 18F-FDG PET/CT in the clinical management of patients with lymph node metastasis of unknown primary origin.

The aim of this study was to evaluate the diagnostic performance and the utility of F-18-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET/CT) in the clinical management of patients presenting with lymph node metastasis of undefined primary origin (CUP). A total of 53 patients (34 males, 19 females) with a diagnosis of lymph node metastasis according to the histopathology and/or conventional imaging were enrolled in this retrospective study. Patients were divided into four groups according to the initial location of their metastasis - group 1, cervical lymph nodes (n=39), group 2, axillary lymph nodes (n=6), group 3, mediastinal lymph nodes (n=2) and group 4, abdominal and pelvic lymph nodes (n=6). The site of a probable primary malignancy suggested by PET/CT was confirmed by biopsy/further investigations or follow-up. 18F-FDG PET/CT accurately detected the primary carcinoma in 19 of 53 patients (36%), with head and neck cancer and lung carcinoma being the most common primary locations. The PET-CT scan results were negative for primary site localization in 13% of patients (false-negative), while 45% had true negative results, and 6% displayed false-positive results. Additional distant metastatic foci were identified in 21 of all patients (40%). The overall sensitivity, specificity, and accuracy rates of the study were identified as 73%, 89%, and 81%, respectively; in the group with cervical lymph node metastasis sensitivity 70% and specificity 84%. To conclude, 18F-FDG PET/CT is a sensitive and selective procedure for detecting unknown primary tumors, especially in the clinical setting of cervical lymph node metastasis and its use should be encouraged earlier in the pre-treatment phase of CUP-patients, leading to higher detection of probable primary sites, guiding subsequent biopsy, and more accurate detection of distant metastases in a single examination.

[Spinal deformity in Duchenne muscular dystrophy]. / Wirbelsäulendeformität bei Muskeldystrophie Typ Duchenne.

Boys with Duchenne muscular dystrophy develop scoliosis in 95% of cases. Conservative management to avoid progression of the deformity is not successful. However, treatment with corticosteroids may avoid the onset of scoliosis in some patients. Early surgical treatment and spine fusion is usually recommended before severe cardiopulmonary symptoms have developed. With modern surgical techniques, the sitting ability and quality of life can be preserved with a moderate complication rate. An interdisciplinary approach is mandatory to achieve these goals.

Management of spinal deformities and tibial pseudarthrosis in children with neurofibromatosis type 1 (NF-1).

The skeletal system is affected in up to 60% of patients with neurofibromatosis type 1. The most commonly observed entities are spinal deformities and tibial dysplasia. Early recognition of radiologic osseous dystrophy signs is of utmost importance because worsening of the deformities without treatment is commonly observed and surgical intervention is often necessary. Due to the relative rarity and the heterogenic presentation of the disease, evidence regarding the best surgical strategy is still lacking. PURPOSE: To report our experience with the treatment of skeletal manifestations in pediatric patients with (neurofibromatosis type 1) NF-1 and to present the results with our treatment protocols. MATERIALS AND METHODS: This is a retrospective, single expert center study on children with spinal deformities and tibial dysplasia associated with NF-1 treated between 2006 and 2020 in a tertiary referral institution. RESULTS: Spinal deformity: Thirty-three patients (n = 33) were included. Mean age at index surgery was 9.8 years. In 30 patients (91%), the deformity was localized in the thoracic and/or lumbar spine, and in 3 patients (9%), there was isolated involvement of the cervical spine. Eleven patients (33%) received definitive spinal fusion as an index procedure and 22 (67%) were treated by means of "growth-preserving" spinal surgery. Halo-gravity traction before index surgery was applied in 11 patients (33%). Progression of deformity was stopped in all patients and a mean curve correction of 60% (range 23-98%) was achieved. Mechanical problems with instrumentation requiring revision surgery were observed in 55% of the patients treated by growth-preserving techniques and in none of the patients treated by definitive fusion. One patient (3%) developed a late incomplete paraplegia due to a progressive kyphotic deformity. Tibial dysplasia: The study group comprised of 14 patients. In 5 of them (36%) pathological fractures were present on initial presentation. In the remaining 9 patients (64%), anterior tibial bowing without fracture was observed initially. Four of them (n = 4, 28%) subsequently developed a pathologic fracture despite brace treatment. Surgical treatment was indicated in 89% of the children with pathological fractures. This involved resection of the pseudarthrosis, autologous bone grafting, and intramedullary nailing combined with external fixation in some of the cases. In 50% of the patients, bone morphogenic protein was used "off-label" in order to promote union. Healing of the pseudarthrosis was achieved in all of the cases and occurred between 5 to 13 months after the index surgical intervention. Four of the patients treated surgically needed more than one surgical intervention in order to achieve union; one patient had a re-fracture. All patients had a good functional result at last follow-up. CONCLUSION: Early surgical intervention is recommended for the treatment dystrophic spinal deformity in children with NF-1. Good and sustainable curve correction without relevant thoracic growth inhibition can be achieved with growth-preserving techniques alone or in combination with short spinal fusion at the apex of the curve. Preoperative halo-gravity traction is a safe and very effective tool for the correction of severe and rigid deformity in order to avoid neurologic injury. Fracture union in tibial dysplasia with satisfactory functional results can be obtained in over 80% of the children by means of surgical resection of the pseudarthrosis, intramedullary nailing, and bone grafting. Wearing a brace until skeletal maturity is achieved is mandatory in order to minimize the risk of re-fracture.

Pedicle screw instrumentation with or without pelvic fixation in neuromuscular scoliosis: Outcome and complications in a series of 37 patients with a minimum 2-year follow-up.

OBJECTIVE: Neuromuscular scoliosis (NMS) is often associated with rapid progressive spinal deformities. Indications, when to extend the instrumentation to the pelvis for pelvic obliquity are not generally accepted at this time. This study reports on the indications, surgical technique and results using pedicle screw instrumentation exclusively with or without pelvic fixation for spine fusion in patients with NMS. PATIENTS AND METHODS: Thirty-seven NMS patients were treated with pedicle screw instrumentation (PSI) between 2007 and 2013 with a minimum follow-up of 24 months. The mean age at the time of operation was 14.91 ± 2.03 years (range, 11.17-18.58). Posterior spine fusion (PSF) was conducted in 33 patients; 4 patients underwent a combined anterior spinal release followed by PSF during one-stage surgery. Pelvic fixation was achieved by ilium screws combined with S-1 screws in 4 cases and by sacral-alar-iliac (SAI) technique by Sponseller in 9 cases, respectively. RESULTS: The mean primary Cobb angle was 65.5° (range, 14-103°) and improved significantly to 19.8° (range, 1-50°, p < 0.001) after surgery and 20.5° (range, 3-57, p = 0.47) at 2 years FU, respectively. Besides, an improvement of pelvic obliquity and T1 tilt angle could be detected. Major complications occurred in 19% and minor complications in 32%. CONCLUSION: Pedicle screw fixation only for spine fusion in patients with NMS can be applied safely with reasonable complication rates. An excellent correction in all planes, a significant improvement of the pelvic obliquity and almost no loss of correction at 2 years FU were observed.

Serial casting in early onset scoliosis: syndromic scoliosis is no contraindication.

BACKGROUND: Serial casting is a treatment for early onset scoliosis (EOS) in young children to achieve curve correction before bracing or to postpone initial surgical treatment until the patient is older. Good results have been reported for patients with idiopathic early onset scoliosis (IS). However, there are few reports of results in non-idiopathic cases, and the benefits of non-surgical methods in the syndromic-associated early onset scoliosis subgroup are unknown. METHODS: Retrospective single-institution study of patient charts and X-rays of all cases of sustained serial casting for EOS. Staged correction was obtained by applying three consecutive casts under general anaesthesia. These were changed every 4 weeks, followed by the implementation of a custom-made full-time Chêneau brace. Correction was measured by Cobb angle (CA) and rib-vertebra angle difference (RVAD) on whole spine anterior-posterior radiographs. Statistical analysis was performed via ANOVA. RESULTS: The study group consisted of 6 patiens with IS and 10 with non-idiopathic scoliosis (NIS) - exclusively syndromic-associated. The mean age at onset of treatment was 35 months (±15). The mean follow up was 21 months (±15). In IS patients average CA/RVAD before treatment was 46°(±8)/20°(±12). In NIS patients average CA/RVAD before treatment was 55°(±15)/24°(±14). After application of the third cast, the CA/RVAD was reduced to 20°(±11)/11°(±10) in IS patients. Whereas in NIS patients average CA/RVAD after the thrid cast was 28°(±12)/18°(±13). At latest follow-up the CA/RVAD was 16°(±7)/9°(±8) in IS patients and 31°(±11)/17° (±15) in NIS patients. CONCLUSION: Syndromic etiology is not a contraindication for serial casting in EOS. Our results show a curve correction, measured in CA, of 65% in IS patients and 44% in NIS patients. Significant reduction in the morphologic deformity, measured in RVAD, was achieved in the IS cohort, but not in the NIS cohort. In all cases surgical treatment could be delayed.

Health-related quality of life in early-onset-scoliosis patients treated with growth-friendly implants is influenced by etiology, complication rate and ambulatory ability.

BACKGROUND: Progressive Early-Onset Scoliosis (EOS) in children may lead to surgical interventions with growth-friendly implants, which require repeated lengthening procedures in order to allow adequate growth. Quality of life was studied using the validated German version of the EOS-Questionnaire (EOSQ-24-G) in surgically treated EOS children with different lengthening modalities. METHODS: EOSQ-24-G and the KINDLR questionnaire were given to families with EOS children who had been treated by either vertical expandable prosthetic titanium rib implants and repetitive lengthening surgeries every 6 months or children who had received a magnetically expansion controlled implant, which was externally lengthened every 3 months. Results were compared according to differences between the two tests, and with possible influencing factors such as surgical method, severity of scoliosis, relative improvement of curvature, etiology, weight, age, travelling distance, complications, ambulatory ability and others. RESULTS: 56 children with an average curve angle of 69° corrected to 33° (52%; average age 5.6 yrs) answered the EOSQ-24-G and the KINDLR after an average follow-up of 3.9 years. Health-related quality of life (HRQoL) was not affected by the initial scoliosis correction, the number of surgeries or the implant type. However, there was a negative correlation with non-ambulatory status, complications during treatment and for children with a neuromuscular scoliosis. CONCLUSION: Using the validated EOSQ-24-G, no statistically significant differences were found between the group of children receiving repetitive surgeries and children with external lengthening procedures without surgery. However, results were influenced by the etiology, complication rate or ambulatory ability. LEVEL OF EVIDENCE/CLINICAL RELEVANCE: Therapeutic Level IV.

[The painful knee in children]. / Das schmerzhafte kindliche Kniegelenk.

Knee pain is one of the most common reasons for medical consultation for musculoskeletal problems in the paediatric population. The aetiology is of very variable origin and necessitates a precise assessment. In addition to a thorough anamnesis, clinical and imaging examination methods, as well as laboratory diagnostics are of utmost importance to establish a proper diagnosis and an adequate treatment regimen. This chapter summarises the current diagnostic algorithm for dealing with knee pain in children and adolescents.

[Growth-preserving instrumentation for early onset scoliosis]. / Mitwachsende Korrektursysteme bei Early-Onset-Skoliosen.

OBJECTIVE: Early onset scoliosis is defined as a spinal deformity originating in the first 10 years of life. Growth-preserving spinal instrumentation has therefore been designed to preserve growth of spine and chest wall and lungs to avoid serious pulmonary complications after early spine fusion. Indications, surgical technique and results of the vertical expandable prosthetic titanium rib (VEPTR) technique, traditional growing rods (TGR), and magnetically controlled growing rods (MCGR) will be described. INDICATIONS: Indications for VEPTR are so-called mixed congenital deformities (type 3) associated with vertebral malformations in association with chest wall deformities, especially fused ribs. There are also indications for neuromuscular or syndromic early onset scoliosis with bilateral rib-to-ilium constructs. However, most of those deformities are currently treated with either GR or MCGR in most centers. GR and MCGR are currently the treatment of choice for the majority of early onset scoliosis. CONTRAINDICATIONS: There is no indication for growth-preserving strategies if the patients are mature or there is only little growth remaining. In these cases, final fusion should be performed. SURGICAL TECHNIQUE: While the VEPTR technique involves an extensive approach with muscular dissections to the thoracic cage including rib osteotomies and thoracotomies, treatment with TGR or MCGR is minimally invasive, only exposing proximal and distal anchor points, leaving most of the spine including the apex undisturbed. POSTOPERATIVE MANAGEMENT: Early mobilization is usually possible after 24-48 h. Braces may have to be prescribed for patients with osteopenia, noncompliance, or a risk to fall. RESULTS: Since 2005, more than 200 patients were treated with the VEPTR technique, more than 200 patients with the MCGR technique, and about 30 patients with the TGR technique in our department. Complication rates are high with all techniques including the law of diminishing returns, autofusion, bone anchor-related complications like loosening or migration of implants, failure to distract and proximal junctional kyphosis. In our own series of 13 patients below age 3 years, VEPTR proved to be effective for mixed deformities. In other studies, we were able to show that physiological growth with MCGR can be maintained for 2-3 years but spinal growth declines after that period with acceptable complications. Complication rates in most studies are lower with MCGR compared to TGR and VEPTR. Therefore, it is currently the treatment of choice for most early onset scoliosis patients.

Pelvic Fixation for Non-Ambulatory Patients with Neuromuscular Scoliosis Treated with Magnetically Controlled Growing Rods-A 4-Year Comparison of Two Different Fixation Methods.

Background/Objectives: This study aims to analyze the efficacy and safety of the two pelvic fixation systems, S-hooks (SH) and lumbar-sacral-alar-iliac (SAI) screws, when used in association with magnetically controlled growing rods (MCGRs) in non-ambulatory children with severe neuromuscular scoliosis (NMS). Methods: Forty-one patients were retrospectively examined and subdivided corresponding to ilium hook fixation or SAI screws. The major curve correction (%) and pelvic obliquity (PO) correction (%) were assessed utilizing scoliosis plain film radiographs over time. Complications and unplanned return to the operating room (UPROR) were recorded. Patient-specific pre- and postoperative values were included in a backward stepwise regression model to assess UPROR. Results: Mean age at index intervention was 9.4 years. Preoperative main curve was 81° and PO was 22°. 21 and 20 patients were categorized into the SH and SAI subgroups, respectively. Initial curve correction was significantly better in the SAI subgroup (63 vs. 42% in the SH, p = 0.045), while PO correction was equally good. Curve and PO correction were maintained throughout the follow-up period of 55 months. UPROR rate was 38% in the SH subgroup, and 5% in the SAI subgroup (p = 0.010). Regression analysis identified postoperative curve correction as predictive value for UPROR (p = 0.006). Conclusions: SAI screw fixation has a low UPROR rate and achieves superior curve correction. S-hooks are a viable option to correct PO and NMS in children with high operative risk to reduce operative time, but revision surgery is not uncommon.

Safety and efficacy of growth-friendly instrumentation for early-onset scoliosis in patients with spinal muscular atrophy type 1 in the disease-modifying treatment era.

Purpose: To evaluate the safety of growth-friendly instrumentation for early-onset scoliosis (EOS) in patients with spinal muscular atrophy (SMA) type 1 who received disease-modifying treatment (DMT) and analyze short-term efficacy. Methods: Retrospective search was conducted between 2017 and 2023. Patients with genetically confirmed SMA type 1 who were surgically treated for spinal deformity and receiving DMTs (nusinersen, risdiplam, or onasemnogene abeparvovec) were included. SMA types 2 and 3 and patients who do not receive DMTs were excluded. Clinical and radiographic data were collected at preoperative, postoperative, and latest follow-up visits. Results: Twenty-eight patients (mean follow-up: 16 months (range 2-41)) were included. The mean age at surgery was 60 months (range 29-96). Fifteen were treated with dual magnetically controlled growing rods (MCGR), four with unilateral MCGR and a contralateral guided growth system, three with Vertical Expandable Prosthetic Titanium Rib (VEPTR®) implants, five with self-distracting systems, and one with traditional dual growing rods. The mean amount of correction was 57% (44°± 17) for scoliosis and 83% (13°± 11) for pelvic obliquity. The mean T1-12 height gain during surgery was 31 mm (±16 mm), while the mean T1 S1 height gain was 51 mm (±24 mm), and instrumented growth was observed during follow-up. Five patients (18%) developed six serious adverse events: three surgical site infections, two anchor failures, and one rod fracture, and all required unplanned reoperations. No neurologic complication, difficulty during nusinersen injections, or respiratory decline was recorded. Conclusion: We report that spinal deformity in this population can be safely treated with growth-friendly instrumentation, with similar complication rates when compared with SMA type 2.

Anterior Vertebral Body Tethering for Skeletally Immature Patients with AIS: Indication for Spinal Fusion at Skeletal Maturity Is Not Obviated in 60% of Cases.

The role of anterior vertebral body tethering (aVBT) in obviating the need for spinal fusion in patients with AIS remains unclear, and a large amount of variation exists in the data among different studies. The present study aims to investigate and analyze what factors have a potential influence on aVBT outcome. Skeletally immature patients with AIS who underwent aVBT for scoliosis correction were followed up until skeletal maturity. The mean age at the time of surgery was 13.4 ± 1.1, and the mean follow-up time was 2.5 ± 0.5 years. The Cobb angle of the main curve was 46.6 ± 9° at the time of surgery and was significantly corrected to 17.7 ± 10.4° (p < 0.001) immediately postoperatively. A significant loss of correction was observed during the latest follow-up (Cobb angle 33.8 ± 18.7°; p < 0.001). An indication for spinal fusion at skeletal maturity was not obviated in 60% of the patients. The factors identified as having an influence on the outcome were preoperative bone age and the magnitude of the major curve. Patients with advanced bone age and larger curves were more likely to reach an indication for spinal fusion at skeletal maturity. In conclusion, no general recommendation for aVBT can be made for AIS patients. The method can be discussed as a treatment option in skeletally very immature preadolescent patients (Sanders Stadium ≤ 2) with a moderate Cobb angle (≤50°) who failed previous brace therapy.

Hemivertebra resection in children, results after single posterior approach and after combined anterior and posterior approach: a comparative study.

PURPOSE: To compare the results after hemivertebra resection through a single posterior approach and through a combined anterior and posterior approach. METHODS: This is a retrospective study on patients treated by hemivertebra resection with monosegmental instrumentation for congenital scoliosis at a single institution. The patients were divided into two groups according to the surgical approach. Both groups were compared for curve correction, complication rate and perioperative data. Paired samples T test was used for statistical evaluation. RESULTS: Twenty-five consecutive patients were included. In 12 cases the hemivertebra resection was performed through a single posterior approach (SPA) and in 13 via a combined anterior and posterior approach (CAPA). Curve correction was similar in both groups (59 vs. 55%, p>0.05). Duration of surgery (272 vs. 319 min) and postoperative mechanical ventilation were shorter in the SPA group (5 vs. 30 h), but did not reach statistical significance (p>0.05). Significant blood loss necessitating blood transfusion was observed in six patients operated through an SPA and in 8 patients operated through a CAPA. The duration of the ICU management (1 vs. 3 days) and the hospital stay (12 vs. 19 days) were significantly shorter in the SPA group (p<0.05). Less surgery related general complications were observed in the SPA group (0 vs. 38%). CONCLUSIONS: Similar correction of the main and the compensatory curves can be achieved with single posterior and combined anterior and posterior hemivertebra resection. Benefits of the SPA are lower complication rate and shorter recovery period.

Etiology, Risk Factors, and Diagnosis of Back Pain in Children and Adolescents: Evidence- and Consensus-Based Interdisciplinary Recommendations.

Using a structured approach and expert consensus, we developed an evidence-based guideline on the diagnosis of back pain and the treatment of non-specific back pain in children and adolescents. The first part comprises etiology, risk factors, and diagnosis. The second part, published in the same issue, includes treatment and prevention. A comprehensive and systematic literature search was conducted to identify relevant guidelines and studies. Based on the findings of this literature search, recommendations on risk factors and diagnosis were formulated and voted on by experts in a structured consensus-building process. Notable red flags for specific back pain and evidence-based risk factors for non-specific back pain in children and adolescents were identified. Only three evidence-based recommendations could be formulated for causes, red flags, and risk factors for back pain, while two recommendations are based on expert consensus. Regarding diagnostics, eight expert consensus recommendations and one evidence-based recommendation could be provided. Despite the importance of adequate diagnosis for the treatment of back pain in children and adolescents, results of this work confirm the deficit in research investment in this area.

Treatment of Unspecific Back Pain in Children and Adolescents: Results of an Evidence-Based Interdisciplinary Guideline.

Using a structured approach and expert consensus, we developed an evidence-based guideline on the treatment and prevention of non-specific back pain in children and adolescents. A comprehensive and systematic literature search identified relevant guidelines and studies. Based on the findings of this literature search, recommendations on treatment and prevention were formulated and voted on by experts in a structured consensus-building process. Physical therapy (particularly physical activity) and psychotherapy (particularly cognitive behavioral therapy) are recommended for treating pediatric non-specific back pain. Intensive interdisciplinary treatment programs should be provided for chronic and severe pain. Drug therapy should not be applied in children and adolescents. Further research on non-specific back pain in childhood and adolescence is strongly needed to reduce the imbalance between the high burden of non-specific back pain in childhood and adolescence and the low research activity in this field.

Selective posterior thoracic fusion by means of direct vertebral derotation in adolescent idiopathic scoliosis: effects on the sagittal alignment.

The objectives of this retrospective study were to evaluate the effect of direct vertebral derotation on the sagittal alignment of the spine after selective posterior thoracic fusion for Lenke Type I adolescent idiopathic scoliosis (AIS). Preservation of the sagittal alignment has become critical in the management of spinal deformity. Better coronal and rotational corrections in posterior selective thoracic fusion for AIS have been reported with direct vertebral derotation as compared with the simple rod rotation technique. A greater lordogenic effect has been anticipated with direct vertebral derotation; however, data comparing those two techniques in terms of correction in the sagittal plane are still lacking. Standing full-spine PA and standard lateral serial X-rays of a total of 30 consecutive patients with adolescent idiopathic scoliosis treated between 2002 and 2008 at a single institution were evaluated. All the patients had Lenke Type I curves and underwent selective posterior thoracic fusion with pedicle screw instrumentation. Patients who were treated with additional osteotomies and concave or convex thoracoplasty or concomitant anterior releases were excluded. Minimum follow-up period was 24 months. Preoperative and postoperative coronal and sagittal spinal alignments in both the groups were compared. In 13 patients, the correction was achieved by means of a simple rod rotation (SRR). In 17 patients, the technique of direct vertebral derotation (DVD) was used. Scoliosis correction averaged 67 and 69%, respectively, and was similar in both groups (p > 0.05). Thoracic kyphosis and lumbar lordosis remained unchanged in the SRR group (p > 0.1). In the direct vertebral derotation group, a significant decrease of both thoracic kyphosis and lumbar lordosis of 8.1° and 11.8°, respectively, was observed (p < 0.0001). Global sagittal balance remained within normal limits in all the patients at the latest follow-up. Decrease in thoracic kyphosis and lumbar lordosis should be taken into account when using direct vertebral derotation for selective posterior thoracic fusion in AIS. In order to preserve sagittal alignment in these patients, ultra hard rods or maneuvers that pull posteriorly the concave side of the spine, thus avoiding the application of additional flattening forces should be considered.

Detection of Ureteral Stump Transitional Cell Carcinoma, Presenting as Bone Metastases from Unknown Primary by 18F-FDG PET/CT: A Case Report with Review of Literature.

A case of occult carcinoma of the ureteral stump is reported. A 67-year-old man presented with pain syndrome due to multiple bone metastases from unknown primary origin detected by previous imaging studies as magnetic resonance imaging, whole body contrast-enhanced computed tomography (CT), and technetium-99m methyldiphosphonate bone scan. He had undergone a right nephrectomy for a benign disease previously. He was referred to our department for an 18F-fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) to help localize possible primary tumor. Our observations in this case show that the use of 18F-FDG PET/CT successfully and more accurately evaluated the overall tumor burden and led to a rapid decision of an adequate therapeutic approach.

The use of recombinant human BMP-2 as a salvage procedure in the pediatric spine: a report on 3 cases.

The study is a retrospective case series. The objective is to review the results after off-label recombinant human BMP-2 (rhBMP-2) use in the pediatric spine after previously failed spinal fusion. Non-union in the pediatric spine is a challenging condition associated with increased morbidity due to instability, neurological impairment or multiple revision surgeries. BMP has been used with good results in the adult spine; however, information on its use in the pediatric population is still lacking. rhBMP-2 was used at our institution at revision posterior spinal surgery in three patients. Solid spinal fusion was achieved in all three cases despite underlying bone dysplasia (Hurler's disease), instability or bony substance loss. No adverse reactions due to rhBMP-2 use were observed. rhBMP-2 should be considered as potential option to achieve spinal fusion in children with compromised bone healing due to congenital, local or systemic conditions.