Does the coronal deformity angular ratio affect bracing outcome in adolescent idiopathic scoliosis?

PURPOSE: To examine if coronal deformity angular ratio (C-DAR) serves as a predictor for progression to surgical magnitude in patients with Adolescent Idiopathic Scoliosis (AIS) treated with thoracolumbar sacral orthosis (TLSO). METHODS: Patients with AIS, prescribed a full-time TLSO, Cobb angle 20-40°, Risser 0-2, who wore the brace ≥ 12.9 h and reached skeletal maturity/surgery were included retrospectively. C-DAR was defined as the Cobb angle divided by the number of vertebrae in the curve, yielding a larger value in short curves. The association between C-DAR and the risk of progression to surgical magnitude (> 45°) was assessed. Secondly, we evaluated the association between pre-treatment Cobb angle and in-brace correction on the risk of progression to > 45°. RESULTS: We included 165 patients with a mean Cobb angle of 30 ± 6°. Of these, 46/165 (28%) progressed ≥ 6° and 26/165 (16%) reached surgical magnitude at the end of treatment. C-DAR was a significant predictor for risk of progression to surgical magnitude with an OR of 1.9 (CI 1.2-2.9) per unit increase in C-DAR. A threshold value of 5.15 was established and demonstrated an OR 5.9 (CI 2.1-17.9) for curve progression to a surgical magnitude. Likewise, pre-treatment Cobb angle showed a significant OR 1.3(CI 1.2-1.4) per degree increase in Cobb, whereas in-brace % correction showed OR 0.96 (CI 0.93-0.98). CONCLUSION: C-DAR is an independent predictor for progression to a surgical magnitude in AIS patients treated with bracing. Patients with a higher C-DAR should be counseled to help set realistic expectations regarding the likelihood of curve progression despite compliance with brace wear.

Association between meeting 24-hour movement behavior guidelines and quality of life in adolescents with idiopathic scoliosis.

BACKGROUND: Meeting the 24-hour movement behavior (24-HMB) guideline helps enhance quality of life (QOL) of adolescents. This study aimed to assess the associations between the 24-HMB (physical activity, screen time, sleep) and QOL among adolescents with idiopathic scoliosis. METHODS: A cross-sectional study was conducted between September 2021 and September 2023. 24-HMB, QOL and demographic variables were collected through a self-reported questionnaire. Linear regression models and stratified analyses were used to explore statistical associations between the 24-HMB and QOL. RESULTS: A total of 1073 participants aged 10-18 years with a spinal Cobb angle between 10° and 40° were included. Overall, 20 participants (1.9%) met all three behavioral guidelines, and 272 participants (25.3%) met none. Compared to those who did not meet any of the guidelines, adolescents meeting both screen time and sleep duration (ß = 4.10, 95% CI: 2.02-6.18, P < 0.001) and all 3 guidelines (ß = 4.39, 95% CI: 0.27-8.51, P = 0.037) had higher QOL scores. Stratified analyses showed that the above associations were more pronounced in adolescents without back pain or with good self-image. CONCLUSIONS: These findings highlight the importance of adopting and maintaining healthy behavioral habits in order to improve QOL among adolescents with idiopathic scoliosis, especially in those without back pain or with good self-image.

Conditional generative adversarial network-assisted system for radiation-free evaluation of scoliosis using a single smartphone photograph: a model development and validation study.

Background: Adolescent idiopathic scoliosis (AIS) is the most common spinal disorder in children, characterized by insidious onset and rapid progression, which can lead to severe consequences if not detected in a timely manner. Currently, the diagnosis of AIS primarily relies on X-ray imaging. However, due to limitations in healthcare access and concerns over radiation exposure, this diagnostic method cannot be widely adopted. Therefore, we have developed and validated a screening system using deep learning technology, capable of generating virtual X-ray images (VXI) from two-dimensional Red Green Blue (2D-RGB) images captured by a smartphone or camera to assist spine surgeons in the rapid, accurate, and non-invasive assessment of AIS. Methods: We included 2397 patients with AIS and 48 potential patients with AIS who visited four medical institutions in mainland China from June 11th 2014 to November 28th 2023. Participants data included standing full-spine X-ray images captured by radiology technicians and 2D-RGB images taken by spine surgeons using a camera. We developed a deep learning model based on conditional generative adversarial networks (cGAN) called Swin-pix2pix to generate VXI on retrospective training (n = 1842) and validation (n = 100) dataset, then validated the performance of VXI in quantifying the curve type and severity of AIS on retrospective internal (n = 100), external (n = 135), and prospective test datasets (n = 268). The prospective test dataset included 268 participants treated in Nanjing, China, from April 19th, 2023, to November 28th, 2023, comprising 220 patients with AIS and 48 potential patients with AIS. Their data underwent strict quality control to ensure optimal data quality and consistency. Findings: Our Swin-pix2pix model generated realistic VXI, with the mean absolute error (MAE) for predicting the main and secondary Cobb angles of AIS significantly lower than other baseline cGAN models, at 3.2° and 3.1° on prospective test dataset. The diagnostic accuracy for scoliosis severity grading exceeded that of two spine surgery experts, with accuracy of 0.93 (95% CI [0.91, 0.95]) in main curve and 0.89 (95% CI [0.87, 0.91]) in secondary curve. For main curve position and curve classification, the predictive accuracy of the Swin-pix2pix model also surpassed that of the baseline cGAN models, with accuracy of 0.93 (95% CI [0.90, 0.95]) for thoracic curve and 0.97 (95% CI [0.96, 0.98]), achieving satisfactory results on three external datasets as well. Interpretation: Our developed Swin-pix2pix model holds promise for using a single photo taken with a smartphone or camera to rapidly assess AIS curve type and severity without radiation, enabling large-scale screening. However, limited data quality and quantity, a homogeneous participant population, and rotational errors during imaging may affect the applicability and accuracy of the system, requiring further improvement in the future. Funding: National Key R&D Program of China, Natural Science Foundation of Jiangsu Province, China Postdoctoral Science Foundation, Nanjing Medical Science and Technology Development Foundation, Jiangsu Provincial Key Research and Development Program, and Jiangsu Provincial Medical Innovation Centre of Orthopedic Surgery.

Analysis of odontoid parameters in adolescent idiopathic scoliosis patients with different curve types.

Introduction: Odontoid incidence (OI) is an important parameter that has recently been developed. However, there are currently no studies on OI in adolescent idiopathic scoliosis (AIS) patients. We aimed to examine the significance of OI in describing cervical sagittal alignment in AIS patients, explore the differences in cervical sagittal parameters among these patients with different curve types, and investigate the correlations between coronal deformity and cervical sagittal parameters in AIS patients. Methods: The whole-spine anteroposterior and lateral plain radiographs of AIS patients were retrospectively analyzed. The parameters, including OI, odontoid tilt (OT), C2 slope, cervical lordosis (CL), T1 slope (T1S), and others, were measured. The AIS patients were grouped based on different curve types. Measurement parameters were compared between different groups. Pearson correlation analysis was performed for cervical sagittal parameters and Cobb angle. Results: Ninety AIS patients were included, consisting of 14 males and 76 females. The main thoracic curve group exhibited a smaller OI compared to the main thoracolumbar/lumbar curve group (P < 0.05). In the AIS patients with a main thoracic curve, there was a significant correlation between Cobb angle and OI (r = -0.371, p < 0.01). The odontoid parameters exhibited significant correlations with several classic cervical sagittal parameters in AIS patients with different curve types. The validation of the formula CL = 0.36 × OI-0.67 × OT-0.69 × T1S showed a significant correlation (correlation coefficient = 0.917) between the actual measurements and the predicted values, with a determination coefficient of 0.842. Conclusion: There may be a difference in OI between AIS patients with a main thoracic curve and those with a main thoracolumbar/lumbar curve. Odontoid parameters could be used to describe cervical sagittal alignment in AIS patients with different curve types.

Postoperative adding-on phenomenon in Lenke 1A/B and 2A/B adolescent idiopathic scoliosis: risk factors and predictive index.

PURPOSE: The aim of this study was to identify associated risk factors of distal adding-on phenomenon in Lenke 1A/B and 2A/B adolescent idiopathic scoliosis (AIS) patients and establish the corresponding prediction model. METHODS: The clinical data of 119 Lenke 1A/B and 2A/B AIS patients were retrospectively analyzed. Preoperative, first erect (FE) radiographic parameters and radiographic parameters at the last follow-up were measured. Patients were divided into the adding-on group and the no adding-on group according to whether the adding-on phenomenon was observed at the last follow-up. Univariate analysis and multivariate logistic regression analysis were used to establish the corresponding prediction model. RESULTS: Adding-on affected 39 (32.8%) patients at the last follow-up. Risser sign and 19 radiographic parameters showed significant differences between the two groups by univariate analysis. Stepwise logistic regression analysis found that the Risser sign and so on five predictor variable, and the nomogram was drawn. The calibration curve showed that the model fitted well. The area under the receiver operating characteristic (ROC) curve is 0.949. And the decision curve analysis curve model within the threshold range for interventions to improve clinical outcomes. There was no significant difference in SRS-22 scores between the two groups. CONCLUSIONS: This study established a prediction model with adding-on in Lenke 1A/B and 2A/B AIS patients. The nomogram contains five predictive variables, which can effectively predict the probability of adding-on phenomenon during follow-up, and may have greater clinical value for the treatment and prevention of adding-on phenomenon.

Spinal deformity surgery in Scheuermann's kyphosis versus adolescent idiopathic scoliosis: meta-analysis of complications and clinical outcomes.

BACKGROUND: Surgical management of adolescent idiopathic scoliosis (AIS) and Scheuermann's kyphosis (SK) may be associated with several complications including extended length of stay and unplanned reoperations. Several studies have previously compared postoperative complications and functional outcomes for AIS and SK patients with mixed results. However, a meta-analysis compiling the literature on this topic is lacking. METHODS: Following the PRISMA guidelines, PubMed, Cochrane, and Google Scholar (pages 1-20) were accessed and explored until April 2024. The extracted data consisted of complications (overall and surgical-site infections [SSI]), readmissions, reoperations, and Scoliosis Research Society-22 (SRS-22) score. Mean differences (MD) with 95% CI were used for continuous data and odds ratio (OR) was utilized for dichotomous data were calculated across studies. RESULTS: Seven retrospective articles were included in the meta-analysis, including 4866 patients, with 399 in the SK group and 4467 in the AIS group. SK patients were found to have statistically significantly higher rates of overall complications (OR = 5.41; 95% CI 3.69-7.93, p < .001), SSI (OR = 11.30; 95% CI 6.14-20.82, p < .001), readmissions (OR = 2.81; 95% CI 1.21-6.53, p = 0.02), and reoperations (OR = 7.40; 95% CI 4.76-11.51, p < .001) than AIS patients. However, they had similar SRS-22 scores postoperatively (MD = -0.06; 95% CI -0.16 to 0.04, p = 0.26) despite the SK group having lower SRS-22 scores preoperatively (MD = -0.30; 95% CI -0.42 to -0.18, p < .001). CONCLUSION: In this meta-analysis of studies comparing spinal deformity surgery outcomes in AIS and SK patients, SK was associated with more complications, readmissions, and reoperations. SK did have equivalent SRS-22 scores postoperatively to AIS patients, highlighting the benefit of surgical treatment despite higher complication rates. This data may help inform healthcare institutions, payors, and quality monitoring organizations who examine outcomes of pediatric and adult spinal deformity surgery.

Five days of inpatient scoliosis-specific exercises improve preoperative spinal flexibility and facilitate curve correction of patients with rigid idiopathic scoliosis.

Preoperative spine flexibility plays a key role in the intraoperative treatment course of severe scoliosis. In this cohort study, we examined the effects of 5 day inpatient scoliosis-specific exercise (SSE) on the spinal flexibility of patients with adolescent idiopathic scoliosis before surgery. A total of 65 patients were analyzed. These patients were divided into a prospective cohort (n = 43, age: 15 ± 1.6 years, 36 girls and 7 boys, Lenke class 1 and 2, Cobb angle: 64 ± 11°) who underwent spinal fusion in 2020, and a retrospective cohort (n = 22, age: 15 ± 1.5 years, 17 girls and 5 boys, Lenke class 1 or 2, Cobb angle: 63 ± 10°), who underwent surgery between 2018 and 2019 and did not receive preoperative SSE. Rigid scoliosis was defined as a reduction of less than 50% in Cobb angle between the preoperative fulcrum bending and initial standing curve magnitude. In the prospective cohort, 21 patients (Cobb angle: 65 ± 11°) presented with rigid thoracic scoliosis (pre-SSE fulcrum bending: 40 ± 9°, 39% reduction), and therefore received 5-day SSE to improve their preoperative spinal flexibility (SSE group), whereas 22 patients (Cobb angle: 63 ± 12°) presented with flexible thoracic scoliosis (pre-SSE fulcrum bending: 27 ± 8°, 58% reduction), and therefore underwent surgery without preoperative SSE (non-SSE group). For patients who received 5-day preoperative SSE for 4 h every day, the International Schroth Three-Dimensional Scoliosis Therapy technique was implemented with an inpatient model. After 5 days of SSE, improvements in Cobb angle with post-SSE fulcrum-bending radiography (23 ± 7°, 66% reduction) and pulmonary function (forced expiratory volume in 1 s/forced expiratory volume: 87% before SSE and 92% after SSE, p < 0.01) were observed. At the postoperative day 5, the degree of scoliosis had reduced from 44 ± 6.6° to 22 ± 6° in the SSE group, which is 1° less than the Cobb angle obtained on post-SSE fulcrum-bending radiography. In the non-SSE group, the degree of scoliosis decreased to 26 ± 5.7°. In the retrospective cohort, the degree of scoliosis decreased to 35 ± 5°, with the group also having higher postoperative pain (Visual Analog Scale score = 7, range = 5-10) and an extended hospitalization duration (11 ± 3 days). At 2-year follow-up, curve correction was found to be maintained without adding-on or proximal junctional kyphosis. Compared with the non-SSE group, the SSE group exhibited a greater curve correction (66%) with a shorter hospitalization duration (5 ± 1 days) and a lower degree of postoperative pain (Visual Analog Scale score = 4, range = 3-8). Taken together, our findings indicate that 5 day SSE improves preoperative spinal flexibility and facilitates curve correction.

Magnetic resonance imaging evaluation of the cerebellar tonsil position before and after posterior spinal fusion in adolescent idiopathic scoliosis.

BACKGROUND: Chiari malformation type I(CM-I) is one of the most common neurological malformations observed in patients with adolescent idiopathic scoliosis (AIS). It remains uncertain whether AIS patients without neurological symptoms require CM-I decompression before undergoing spinal corrective surgery to prevent cerebellar tonsil herniation and potential neurological complications. This study aims to assess variations in the position of the cerebellar tonsil after posterior spinal fusion (PSF) in neurologically intact patients with AIS. METHODS: We retrospectively evaluated 40 patients with AIS who underwent posterior spinal fusion (PSF) without neurological symptoms. Sagittal hindbrain MRIs were performed before and after spinal surgery. The cerebellar tonsil's position relative to the foramen magnum was measured using the method described by Aboulezz (J Comput Assist Tomogr 1985). We assessed variations in the cerebellar tonsil position concerning spinal correction and elongation after PSF. RESULTS: The average preoperative magnitude of the scoliotic curve was 53.15 degrees (SD 10.46 degrees), and that of thoracic kyphosis was 35.42 degrees (SD 12.38 degrees). In the immediate postoperative period, the average magnitudes were 7.45 degrees (SD 7.33 degrees) and 27.87 degrees (SD 9.03 degrees), respectively. The average correction achieved with PSF was 86% in the coronal plane (p < 0.00001). The average length of the spine in the coronal plane was 44.5 cm (SD 5.25 cm) preoperatively and 48.27 cm (SD 4.40 cm) postoperatively (p < 0.00001). The average length of the vertebral column in the sagittal plane was 50.87 cm (SD 4.47 cm) preoperatively and 55.13 cm (SD 3.27 cm) postoperatively (p < 0.00001). No significant difference was observed in the position of the cerebellar tonsil in the measurements taken before and after spinal deformity correction (p = 0.6042). In 10 out of 40 patients, caudal displacement of the cerebellar tonsil was observed after PSF. In 28 patients, no variation in the position of the cerebellar tonsil was observed, and in 2, cephalic displacement was noted. CONCLUSION: In AIS patients with a normal position of the cerebellar tonsil undergoing posterior spinal fusion, there is no significant change in their position after surgery. Our analysis did not reveal any correlation between curve correction, spine elongation, and variations in the cerebellar tonsil position. SIGNIFICANCE: The position of the cerebellar tonsil remained largely unchanged after PSF in AIS patients without neurological symptoms. Further studies would be necessary to determine whether surgical decompression is required in asymptomatic patients with CM-I before undergoing surgery to correct spinal deformity.

Do teams of strangers create health care dangers? The effect of OR team consistency on operative times in adolescent idiopathic scoliosis.

PURPOSE: Teamwork and communication are important components of any surgical team. This study uses a simple, reproducible, and quantitative "team consistency score" and a nodal-based model for examining prior interactions amongst team members to represent and quantify the regularity of an OR team for a specific surgical case. METHODS: The electronic medical record (EMR) at our institution was queried for pediatric patients undergoing spinal surgery from January 2021 through December 2023. The number of prior interactions between individuals filling distinct roles in the OR for each case was recorded. A metric coined the consistency score was developed representing the sum total of these prior interactions standardized to a reference case. Spearman's Correlation as well as the Mann-Whitney comparison test were used to analyze the associations between case team consistency score and efficiency measures. RESULTS: 154 cases were included for analysis. There was a statistically significant negative correlation between case consistency score and both anesthesia time (rho = -0.159; p < 0.05) and patient preparation time (rho = -0.218; p < 0.01). When looking at the consistent (above median consistency score of 0.46) vs. inconsistent cohorts, the inconsistent cohort had a higher mean patient preparation time (53.3 ± 14.0 min vs. 49.0 ± 9.3 min; p < 0.05), as well as a higher overall mean case length (336.6 ± 47.4 min vs. 321.9 ± 42.4 min; p < 0.05). CONCLUSION: The findings suggest that increased team consistency, as measured by a "team consistency score" metric, is related to heightened efficiency and reduced intraoperative times.

Psychometric analysis and the implications for the use of the scoliosis research society questionnaire (SRS-22r English) for individuals with adolescent idiopathic scoliosis.

Background: Despite widespread usage of the SRS-22r questionnaire (Scoliosis Research Society Questionnaire-22r), the English version has only sparingly been subjected to analysis using modern psychometric techniques for patients with adolescent idiopathic scoliosis (AIS). The study purpose was to improve interpretation and clinical utility of the SRS-22r for adolescents with AIS by generating additional robust evidence, using modern statistical techniques. Questions about (1) Structure and (2) Item and Scale Functioning are addressed and interpreted for clinicians and researchers. Methods: This retrospective case review analyzed SRS-22r data collected from 1823 patients (mean age 14.9±2.2years) with a primary diagnosis of AIS who clinically completed an SRS-22r questionnaire.Individual SRS-22r questions and domain scores were retrieved through data queries. Patient information collected through chart review included diagnosis, age at assessment, sex, race and radiographic parameters. From 6044 SRS-22r assessments, 1 assessment per patient was randomly selected. Exploratory structural equation modeling (ESEM) and item response theory (IRT) techniques were used for data modeling, item calibration, and reliability assessment. Results: ESEM demonstrated acceptable fit to the data: χ2 (130)=343.73, p<.001; RMSEA=0.035; CFI=0.98; TLI=0.96; SRMR=0.02. Several items failed to adequately load onto their assigned factor. Item fit was adequate for all items except SRSq10 (Self-Image), SRSq16 (Mental Health), and SRSq20 (Mental Health). IRT models found item discriminations are within normal levels for items in psychological measures, except items SRSq1 (pain), SRSq2 (pain), and SRSq16 (mental health). Estimated reliability of the Function domain (ρ=0.69) was low, however, Pain, Self-Image and Mental Health domains exhibited high (ρ>0.80) reliability. Conclusions: Modern psychometric assessment of the SRS-22r, in adolescent patients with AIS, are presented and interpreted to assist clinicians and researchers in understanding its strengths and limitations. Overall, the SRS-22r demonstrated good psychometric properties in all domains except function. Cautious interpretation of the total score is suggested, as it does not reflect a single HRQoL construct.

Rule breakers achieve successful shoulder balance: unraveling the myth of upper instrumented vertebrae selection criteria.

PURPOSE: This study compared shoulder balance outcomes in "rule breakers" (RB) vs. "rule followers" (RF) based on commonly utilized upper instrumented vertebrae (UIV) selection guidelines. METHODS: Adolescent idiopathic scoliosis (AIS) patients (Lenke 1-4) who underwent posterior spine fusion (PSF) with minimum 2-year follow-up had radiographic measurement of shoulder balance including first rib angle (FRA), T1 tilt, coracoid process height difference (CPHD), and clavicle angle (CA) at preop, postop, 6-month, 1-year, and 2-year timepoints. Postoperative outcomes were compared between RB and RF groups defined based on the UIV selection guidelines of Rose and Lenke. RESULTS: Among 88 patients (43 RF, 45 RB), age, gender, preoperative T1 tilt, FRA, CA, and CPHD were not significantly different between groups (p > 0.05). Immediately post-surgery, the RF group had more balanced shoulders (CPHD: 11.6 mm vs. 15.7 mm, p = 0.033; CA: 2.8° vs. 3.6°, p = 0.045; FRA: 3.4° vs. 5.1°, p = 0.009; T1 tilt: 4.7° vs. 6.1°, p = 0.045). At 2 years, no difference was observed between RF vs. RB in CA (2.3 vs. 2.2°, p = 0.857) and CPHD (8.5 vs. 8.1 mm, p = 0.791). FRA and T1 tilt were higher in RB vs. RF (FRA: 4.6 vs. 2.9°, p = 0.002; T1 tilt: 5.6 vs. 3.9, p = 0.008). Shoulder balance (CPHD < 1 cm) was achieved in 73.1% of RB and 69.9% of RF at 2-year follow-up (p = 0.216). CONCLUSION: Adherence to commonly accepted UIV selection guidelines did not predict better shoulder balance. The RB group had worse shoulder balance immediately post-surgery, but also improved more over time. These results suggest the need to refine current UIV selection and management. LEVEL OF EVIDENCE: III.

Pediatric spinal alignment and spinal development.

Background: Knowledge of the growth spurt and remaining growth is essential for managing musculoskeletal diseases in children. Accurate prediction of curve progression and timely interventions are crucial, particularly for conditions like adolescent idiopathic scoliosis (AIS). Methods: This study conducted a comprehensive review and synthesis of existing literature on spinal growth, skeletal maturity classifications, and the evolution of sagittal alignment parameters during childhood and adolescence. Key anatomical elements involved in spinal development, natural history of spinal growth, and skeletal maturity assessment systems were analyzed. Results: The analysis highlighted that key parameters such as Pelvic incidence (PI), Pelvic tilt (PT), and Lumbar lordosis (LL) increase significantly with growth, especially during the pubertal growth spurt. In contrast, Sacral slope (SS) remains relatively constant, and Thoracic kyphosis (TK) shows a slight increase. Additionally, there is a posterior shift in the center of gravity as children grow, reflecting progressive postural maturation. The study also reviewed and compared various maturity classification systems, noting the reliability and clinical implications of systems like the Sanders Maturity Stage (SMS) and Tanner-Whitehouse III. Conclusions: Reliable maturity classification systems, such as the Sanders Maturity Stage (SMS) and Tanner-Whitehouse III, allow for tailored treatments to individual growth patterns. Integrating these classification systems into clinical practice enables precise prediction of curve progression and timely therapeutic interventions. This includes options from bracing to surgical techniques like growing rods or vertebral body tethering (VBT), with growth modulation being a key factor in achieving successful outcomes.

No effects of four weeks of combined brace and Schroth therapy in moderate adolescent idiopathic scoliosis on plantar pressure distribution.

BACKGROUND: Positive effects of brace treatments in adolescent idiopathic scoliosis patients on gait were proven. AIM: Therefore, this study examined whether the influence of brace therapy in combination with Schroth therapy influencing the plantar pressure distribution, pre and post intensive rehabilitative inpatient treatment. DESIGN: Prospective cohort study, longitudinal. SETTING: Scoliosis rehabilitation clinic "Asklepios Katharina-Schroth-Klinik" (Bad Sobernheim, Germany). POPULATION: Twenty (14f/6m) patients (12-16 years) had a medically diagnosed moderate idiopathic scoliosis (Cobb angle 20-50°, Median 30°) and an indication for combined brace and Schroth therapy with an inpatient stay (4 weeks) at the Asklepios Katharina Schroth Clinic (Germany). METHODS: At the beginning (T1) and at the end of the stay (T2), the plantar pressure distribution with (A) and without wearing a brace (B) was recorded (walking distance 10 m). RESULTS: No significant differences between the left and right foot were found at baseline (T1). The T1 - T2 comparison of one foot revealed significant differences (p ≤ 0.05 - 0.001, respectively) for (A): mean pressure right midfoot, loaded area total left foot, left midfoot, left inner ball of foot, right midfoot, impulse total right foot, right midfoot and for (B): mean pressure right midfoot, right outer ball of foot, loaded area total right foot, right heel, right midfoot, impulse right heel, right midfoot, right outer ball of foot. CONCLUSIONS: A combined brace and Schroth therapy maintains the initial symmetrical plantar pressure distribution over the duration of four weeks since the significant differences fall within the range of measurement error. CLINICAL REHABILITATION IMPACT: The insole measuring system can be used to objectively support therapeutic gait training as part of rehabilitation and to assess insole fitting based on foot shape. Due to its convenient handling and rapid data acquisition, it may be a suitable method for interim or follow-up diagnostics in the treatment of idiopathic scoliosis.

Asymmetric Osteopenia in Adolescent Idiopathic Scoliosis Based on Hounsfield Unit of Computed Tomography.

Purpose: To characterize the asymmetrical loss of bone mass and identify the association between scoliosis and osteopenia in patients with adolescent idiopathic scoliosis (AIS). Methods: Demographic information, Cobb angle, and Hounsfield unit (HU) of the neutral vertebra (NV) and apical vertebra (apex) of the major curve were collected retrospectively in 54 AIS patients. For 84 control subjects, HU values were measured at T12 and L5. Propensity score matching was performed to balance the interference of age and BMI. Results: In the AIS group, the concave and convex lateral HU of the NV and the convex lateral HU of the apex were negatively correlated with the Cobb angle. The AIS patients had lower bilateral HU. The mean HU and the apex-convex HU were also lower in the AIS group, while the apex-concave HU was slightly higher. After matching, the apex-convex HU of the AIS group remained lower, while the apex-concave HU was higher. Conclusion: Patients with AIS exhibit osteopenia, particularly on the convex side. The severity of scoliosis was found to be directly proportional to the severity of bone loss and the degree of bilateral osteopenia asymmetry. Appropriate intervention for bone loss may be able to curb the progression of scoliosis.

Biomechanical study of spinal cord and nerve root in idiopathic scoliosis: based on finite element analysis.

BACKGROUND: Current research lacks comprehensive investigation into the biomechanical changes in the spinal cord and nerve roots during scoliosis correction. This study employs finite element analysis to extensively explore these biomechanical variations across different Cobb angles, providing valuable insights for clinical treatment. METHODS: A personalized finite element model, incorporating vertebrae, ligaments, spinal cord, and nerve roots, was constructed using engineering software. Forces and displacements were applied to achieve Cobb angle improvements, designating T1/2-T4/5 as the upper segment, T5/6-T8/9 as the middle segment, and T9/10-L1/2 as the lower segment. Simulations under traction, pushing, and traction + torsion conditions were conducted, and biomechanical changes in each spinal cord segment and nerve roots were analyzed. RESULTS: Throughout the scoliosis correction process, the middle spinal cord segment consistently exhibited a risk of injury under various conditions and displacements. The lower spinal cord segment showed no significant injury changes under traction + torsion conditions. In the early correction phase, the upper spinal cord segment demonstrated a risk of injury under all conditions, and the lower spinal cord segment presented a risk of injury under pushing conditions. Traction conditions posed a risk of nerve injury on both sides in the middle and lower segments. Under pushing conditions, there was a risk of nerve injury on both sides in all segments. Traction + torsion conditions implicated a risk of injury to the right nerves in the upper segment, both sides in the middle segment, and the left side in the lower segment. In the later correction stage, there was a risk of injury to the upper spinal cord segment under traction + torsion conditions, the left nerves in the middle segment under traction conditions, and the right nerves in the upper segment under pushing conditions. CONCLUSION: When the correction rate reaches 61-68%, particular attention should be given to the upper-mid spinal cord. Pushing conditions also warrant attention to the lower spinal cord and the nerve roots on both sides of the main thoracic curve. Traction conditions require attention to nerve roots bilaterally in the middle and lower segments, while traction combined with torsion conditions necessitate focus on the right-side nerve roots in the upper segment, both sides in the middle segment, and the left-side nerve roots in the lower segment.

Goldenhar syndrome associated with increased risk of respiratory failure and reoperations following spinal deformity surgery.

BACKGROUND: Goldenhar syndrome is a rare congenital disease that presents with a spectrum of clinical sequelae related to the vertebrae and other organs. The spinal manifestations of the syndrome are associated with scoliosis for which fusion may be considered. The current study aimed to evaluate the risks of adverse events and reoperations following posterior spinal fusion for those with Goldenhar syndrome relative to those with adolescent idiopathic scoliosis (AIS). METHODS: Patients with Goldenhar syndrome and AIS between the ages of 10 and 17 who underwent posterior spinal fusion were abstracted from the 2010 to 2022 PearlDiver Database. The Goldenhar syndrome patients were matched 1:4 to patients with AIS based on age, sex, and Elixhauser Comorbidity Index. All 90 day postoperative adverse events, readmissions, and 5 year reoperations were identified using administrative coding. Incidence of adverse events between the cohorts were compared using multivariate logistic regression. RESULTS: A total of 11,742 patients with AIS and 72 (0.61%) Goldenhar syndrome undergoing deformity surgery were identified. On matched comparison, patients with Goldenhar syndromes had higher odds ratio (OR) of respiratory failure (OR: 2.99, p = 0.009), severe adverse events (p = 2.29, p = 0.01), and readmissions (p = 2.26, p = 0.02). Over 5 years, they had a significantly higher incidence of reoperation compared to those with AIS (18.1% versus 5.5%, p = 0.005). CONCLUSIONS: In this national sample of patients with Goldenhar syndrome undergoing posterior spinal fusion, patients with Goldenhar had increased odds of respiratory failure, readmissions, and reoperations. Targeted risk mitigation strategies may be appropriately considered for those with Goldenhar syndrome undergoing such surgeries. LEVEL OF EVIDENCE: Level III; Case-control study or retrospective cohort study.

Transitional and spectrum-based care for idiopathic scoliosis.

OBJECTIVE: The goal of this study is to discuss the transitional nature of idiopathic scoliosis and the variation in treatment and management across the spectrum of age presentation. METHODS: This is a review article that discusses the evaluation, management, and classification of idiopathic scoliosis. The authors searched PubMed/MEDLINE, Google Scholar, and the Cochrane database for articles published up to April 2024. Keywords and MeSH terms relevant to the topic were used, including adolescent idiopathic scoliosis (AIS), adult idiopathic scoliosis (AdIS), adult degenerative scoliosis, young adult idiopathic scoliosis, early-onset scoliosis (EOS), classification, management, follow-up, outcomes, natural history, Cobb angle, and transitional care. Reference lists of selected articles were also searched to identify further articles. Inclusion criteria included English language articles that summarized any type of study design, including randomized controlled trials, observational studies, case-control/series, or metaanalysis, with study populations ranging from infants to > 50-year-old patients. Inter-reviewer disagreement on inclusion of particular articles was resolved through discussion. Related information was analyzed, and relevant concepts related to the transitional period dilemma have been discussed. RESULTS: Each idiopathic scoliosis case needs independent assessment with regard to the age, degree of the curve, and patient-specific presentation. An accurate prediction of the curve progression by considering the patient's remaining growth potential is paramount to the treatment strategy. The classification system for EOS, AIS Lenke classification, AdIS classification, and the Scoliosis Research Society-Schwab classification are important for reliable communication between surgeons treating deformities. Untreated progressive idiopathic scoliosis warrants multidisciplinary management during the transition from EOS stage to AIS and then to AdIS. Also, surgical treatment of untreated AIS transitioning to AdIS is specific and nuanced. AdIS needs to be differentiated from adult degenerative scoliosis because the latter is associated with multiple comorbidities and anatomical differences. CONCLUSIONS: Idiopathic scoliosis presents across the age spectrum with specific age-related decisions that transition into adulthood. Integrated models of both surgical and nonsurgical treatment of idiopathic scoliosis are warranted.

Effectiveness and Safety of High-Dose Tranexamic Acid in Adolescent Idiopathic Scoliosis Surgery: A Meta-Analysis and Systematic Review.

OBJECTIVE: This systematic review and meta-analysis of randomized controlled trials and retrospective controlled studies aims to evaluate the efficacy and safety of high-dose tranexamic acid (TXA) in spinal correction surgery for adolescent idiopathic scoliosis patients. METHODS: In March 2024, a comprehensive search was conducted in PubMed, Web of Science, Embase, and Cochrane databases to identify randomized controlled trials and retrospective controlled studies comparing the effects of high-dose TXA on blood loss and transfusion requirements during spinal correction surgery. RESULTS: This meta-analysis included 10 studies encompassing a total of 741 patients. The pooled results indicated that the use of high-dose TXA significantly reduced intraoperative blood loss [weighted mean difference (WMD) = -519.83, 95% CI (-724.74, -314.92), P < 0.00001], transfusion rate [RR = 0.28, 95% CI (0.17, 0.45), P < 0.00001], total blood loss [WMD = -891.09, 95% CI (-1623.92, -158.26), P = 0.02], and postoperative blood loss [WMD = -105.91, 95% CI (-141.29, -70.52), P < 0.00001]. There was no significant difference in operative time [WMD = -18.96, 95% CI (-40.20, 2.28), P = 0.08] and blood loss per segment [WMD = -50.51, 95% CI (-102.19, 1.17), P = 0.06]. Both groups had a comparable incidence of thromboembolic events. CONCLUSIONS: Our meta-analysis suggests that the use of high-dose TXA reduces intraoperative blood loss, transfusion rate, total blood loss, and postoperative blood loss in spinal correction surgery for adolescent idiopathic scoliosis patients. However, there were no significant differences in operative time and blood loss per segment.

Surgical Treatment Strategies for Severe and Neglected Spinal Deformities in Children and Adolescents without the Use of Radical Three-Column Osteotomies.

Background: Severe spinal deformity manifests as a pronounced deviation from the normal curvature of the spine in the frontal, sagittal, and horizontal planes, where the coronal plane curvature exceeds 90 degrees and may coincide with hyperkyphotic deformity. The most severe deformities exhibit rigidity, with flexibility below 30%. If left untreated or improperly treated, these deformities can result in serious complications associated with progression of the curvature. A combination of surgical techniques is frequently employed to attain optimal outcomes and minimize the risk of complications. The overall medical condition of the patient, their capacity to endure extensive procedures, the expertise of the surgeon, and the resources available all play significant roles in determining the course of management. A systematic and thorough review of the relevant literature was conducted utilizing a variety of electronic databases. The primary objective of this study was to scrutinize the surgical techniques commonly employed in complex spine surgeries for the management of severe scoliosis without resection vertebral body techniques, with higher potential risk of major complications, including permanent neurological deficit. Conclusions: Halo-gravity traction, halo femoral traction, and all techniques for releases of the spine (anterior, posterior, or combine), as well as thoracoplasty, have demonstrated significant effectiveness in managing severe and rigid idiopathic scoliosis. The combination of several of these methods can lead to optimal alignment correction without the need to perform high-risk techniques involving three-column osteotomies. Surgeons must customize the indications based on factors such as available resources, characteristics of the deformity, and the patient's individual profile. Surgical correction of severe scoliosis without vertebral body resection surgeries decreases the potential risks related to neurological and pulmonary complications while providing significant clinical improvement outcomes. The powerful Ponte osteotomy is indicated for severe scoliosis, curves with poor flexibility, for better restoration of hypokyphosis, and decrease of hyperkyphosis. These corrective techniques combined with HGT or temporary internal distraction rods are recommended as viable options for managing individuals with severe rigid spine deformity characteristics. Therefore, they also should be considered and performed by a proficient surgical team. The presence of neuromonitoring is crucial throughout these procedures.