Core planar cell polarity genes VANGL1 and VANGL2 in predisposition to congenital vertebral malformations.

Congenital scoliosis (CS), affecting approximately 0.5 to 1 in 1,000 live births, is commonly caused by congenital vertebral malformations (CVMs) arising from aberrant somitogenesis or somite differentiation. While Wnt/ß-catenin signaling has been implicated in somite development, the function of Wnt/planar cell polarity (Wnt/PCP) signaling in this process remains unclear. Here, we investigated the role of Vangl1 and Vangl2 in vertebral development and found that their deletion causes vertebral anomalies resembling human CVMs. Analysis of exome sequencing data from multiethnic CS patients revealed a number of rare and deleterious variants in VANGL1 and VANGL2, many of which exhibited loss-of-function and dominant-negative effects. Zebrafish models confirmed the pathogenicity of these variants. Furthermore, we found that Vangl1 knock-in (p.R258H) mice exhibited vertebral malformations in a Vangl gene dose- and environment-dependent manner. Our findings highlight critical roles for PCP signaling in vertebral development and predisposition to CVMs in CS patients, providing insights into the molecular mechanisms underlying this disorder.

Can the proximal humeral ossification system (PHOS) effectively guide brace weaning in patients with adolescent idiopathic scoliosis?

PURPOSE: The proximal humeral epiphyses can be conveniently viewed in routine spine radiographs. This study aimed to investigate whether the proximal humeral epiphyseal ossification system (PHOS) can be used to determine the timing of brace weaning in adolescent idiopathic scoliosis (AIS), as assessed by the rate of curve progression after brace weaning. METHODS: A total of 107 patients with AIS who had weaned brace-wear at Risser Stage ≥  4, no bodily growth and post-menarche ≥  2 years between 7/2014 and 2/2016 were studied. Increase in major curve Cobb angle > 5° between weaning and 2-year follow-up was considered curve progression. Skeletal maturity was assessed using the PHOS, distal radius and ulna (DRU) classification, Risser and Sanders staging. Curve progression rate per maturity grading at weaning was examined. RESULTS: After brace-wear weaning, 12.1% of the patients experienced curve progression. Curve progression rate for weaning at PHOS Stage 5 was 0% for curves < 40°, and 20.0% for curves ≥ 40°. No curve progression occurred when weaning at PHOS Stage 5 with radius grade of 10 for curves ≥ 40°. Factors associated with curve progression were: Months post-menarche (p = 0.021), weaning Cobb angle (p = 0.002), curves < 40° versus ≥ 40° (p = 0.009), radius (p = 0.006) and ulna (p = 0.025) grades, and Sanders stages (p = 0.025), but not PHOS stages (p = 0.454). CONCLUSION: PHOS can be a useful maturity indicator for brace-wear weaning in AIS, with PHOS Stage 5 having no post-weaning curve progression in curves < 40°. For large curves ≥ 40°, PHOS Stage 5 is also effective in indicating the timing of weaning together with radius grade ≥ 10.

Predictive factors for successful non-operative treatment and achieving MCID improvement in health-related quality of life in adult spinal deformity.

BACKGROUND: Adult spinal deformity is a spectrum of degenerative spinal diseases with increasing prevalence and healthcare burden worldwide. Identification of patients who are more likely to improve through conservative management may reduce cost and potentially prevent surgery and its associated costs and complications. This study aims to identify predictive factors for MCID in improvement of ODI and SRS-22r questionnaires in patients with adult spinal deformity treated with conservative treatment. METHODS: A prospective, observational cohort study of 46 patients was conducted at a spine specialist clinic. Inclusion criteria were 30-80 years of age, diagnosis of neglected adolescent idiopathic scoliosis, de-novo scoliosis, degenerative spondylolisthesis, and sagittal plane deformities (thoracic hypokyphosis, lumbar hypolordosis), presenting with mechanical back pain with or without radicular leg pain. All patients received conservative management including medication and physiotherapy. Radiological and clinical parameters were measured at baseline and at 1-year follow-up. Primary outcomes were ODI and SRS-22r scores. Secondary outcomes were EQ-5D-5L scores and requiring spine surgery during conservative treatment. Predictors for MCID improvement in ODI and SRS-22r were identified using multivariate regressions and receiver operating characteristic (ROC) analyses. RESULTS: At baseline, patients who reached MCID in ODI and/or SRS-22r showed less comorbidities (diabetes mellitus, hypertension, ischemic heart disease, osteoarthritis, cancer), smaller range of lateral spinal flexion, larger trunk shift, larger pelvic incidence, a higher EQ-5D-5L anxiety/depression dimension score, a lower SRS-22r total score, and presence of spondylolisthesis. Lateral flexion range < 25 degrees, trunk shift > 14 mm, pelvic incidence > 50 degrees, EQ-5D-5L anxiety/depression dimension score > 1, and SRS-22r total score < 3.5 were the cut-off values generated by ROC analysis. CONCLUSIONS: Both radiological and clinical predictive factors for MCID improvement in health-related quality of life were identified. Future research should identify subgroups of patients who are responsive to specific conservative treatment modalities, so as to provide information for personalized medicine. LEVEL OF EVIDENCE: II.

Longitudinal comparison of direct medical cost, radiological and health-related quality of life treatment outcomes between traditional growing rods and magnetically controlled growing rods from preoperative to maturity.

BACKGROUND: Magnetically controlled growing rods (MCGR) have replaced traditional growing rods (TGR) in the past decade, however, a comparison of their direct costs and treatment outcomes based on real longitudinal data is lacking. This study aims to compare the direct cost and treatment outcomes between TGR and MCGR, whilst incorporating complications, reoperations and changes in health-related quality of life (HRQoL) throughout the entire treatment course. METHODS: Patients with early onset scoliosis (EOS) who underwent initial growing rod surgery between 2003 and 2016 at a tertiary scoliosis clinic were studied with longitudinal data. Accumulated direct medical costs were calculated based on the unit cost of surgeries of each TGR and MCGR, costs incurred for any rod exchange or remedial surgery for post-operative complication. Treatment outcomes were evaluated via: Patient's HRQoL using SRS-22r questionnaire, and radiological parameters (including major curve correction, spine length gains, spinal balance) throughout the treatment until maturity. RESULTS: A total of 27 EOS patients (16 MCGR, 11 TGR) were studied. Total direct cost of index surgery for MCGR was HKD$223,108 versus lower cost of HKD$135,184 for TGR (p < 0.001). At 2-3 years post-index surgery, accumulative total direct medical cost of MCGR and TGR became most comparable (TGR:MCGR ratio = 1.010) and had reached neutrality between the two groups since. Radiological parameters had no intergroup differences at maturity. For HRQoL, TGR group had shown the trend of less pain (domain score mean difference: 0.53, p = 0.024) post-index surgery and better self-appearance (domain score mean difference: 1.08, p = 0.017) before fusion. Higher satisfaction with treatment (domain score mean difference: 0.76, p = 0.029) was demonstrated by TGR patients at fusion/maturity. MCGR had negative (rs = -0.693) versus TGR's positive (rs = 0.989) correlations (p < 0.05) of cost and SRS-22r total scores at 2-3 years post-index surgery. CONCLUSIONS: From index surgery to maturity, TGR demonstrated better satisfaction with treatment by patients and comparable overall HRQoL with MCGR during the treatment course, as MCGR did not show apparent benefit despite less surgeries and cost neutrality between the two groups at 2-3 years post-index surgery.

What determines immediate postoperative coronal balance and delayed global coronal balance after anterior spinal fusion for Lenke 5C curves?

PURPOSE: To determine the factors associated with 6-week postoperative global coronal balance and delayed global coronal balance at 2-year follow-up after anterior spinal fusion for Lenke 5C curves. METHODS: A total of 124 consecutive Lenke 5C curves with minimum 2-year follow-up was studied. Radiographic parameters were studied preoperatively, 6 weeks postoperatively, and 2 years postoperatively. Coronal balance was measured by C7-CSVL and trunk shift < 20 mm. The study outcomes were patients with early coronal balance and those who had immediate imbalance but developed delayed balance. Multivariate regression analyses of associated factors were performed with cutoffs determined by receiver operating characteristic curve. RESULTS: 31.5% patients attained global coronal balance immediate postoperatively and 89.4% of the early imbalance cases showed spontaneous coronal balance at 2-year follow-up. Increased preoperative UIV tilt (OR 1.093; p = 0.026; 95% CI: 1.011-1.182) and reduced immediate postoperative RSH difference (OR 0.963; p = 0.015; 95% CI: 0.935-0.993) were associated with immediate postoperative balance. For those with immediate imbalance, larger preoperative major Cobb angle (OR 1.226; p = 0.047; 95% CI: 1.003-1.499), less preoperative C7-CSVL (OR 0.829; p = 0.016; 95% CI: 0.712-0.966), and less immediate postoperative LIV tilt (OR 0.728; p = 0.013; 95% CI: 0.567-0.934) were associated with 2-year coronal balance. There was significant improvement in function (p = 0.006), self-image (p = 0.039) and total score domains (p = 0.014) in immediate imbalance to 2-year balance and imbalance groups. CONCLUSION: Successful balance is achieved with a parallel fusion mass when performing anterior spinal fusion for Lenke 5C curves. Patients should be reassured that most attain eventual coronal balance despite the early imbalance. Level of evidence Therapeutic III.

Does the Use of Sanders Staging and Distal Radius and Ulna Classification Avoid Mismatches in Growth Assessment with Risser Staging Alone?

BACKGROUND: Although Risser stages are visible on the same radiograph of the spine, Risser staging is criticized for its insensitivity in estimating the remaining growth potential and its weak correlation with curve progression in patients with adolescent idiopathic scoliosis. Risser staging is frequently accompanied by other skeletal maturity indices to increase its precision for assessing pubertal growth. However, it remains unknown whether there is any discrepancy between various maturity parameters and the extent of this discrepancy when these indices are used concurrently to assess pubertal growth landmarks, which are important for the timing of brace initiation and weaning. QUESTIONS/PURPOSES: (1) What is the chronologic order of skeletal maturity grades based on the growth rate and curve progression rate in patients with adolescent idiopathic scoliosis? (2) What are the discrepancies among the grades of each maturity index for indicating the peak growth and start of the growth plateau, and how do these indices correspond to each other? (3) What is the effectiveness of Risser staging, Sanders staging, and the distal radius and ulna classification in assessing peak growth and the beginning of the growth plateau? METHODS: Between 2014 and 2017, a total of 13,536 patients diagnosed with adolescent idiopathic scoliosis were treated at our tertiary clinic. Of those, 3864 patients with a radiograph of the left hand and wrist and a posteroanterior radiograph of the spine at the same visits including initial presentation were considered potentially eligible for this study. Minimum follow-up was defined as 6 months from the first visit, and the follow-up duration was defined as 2 years since initial consultation. In all, 48% (1867 of 3864) of patients were eligible, of which 26% (485 of 1867) were excluded because they were prescribed bracing at the first consultation. These patients visited the subsequent clinics wearing the brace, which might have affected body height measurement. Six percent (117 of 1867) of eligible patients were also excluded as their major coronal Cobb angle reached the surgical threshold of 50° and had undergone surgery before skeletal maturity. Another 21% (387 of 1867) of patients were lost before minimum follow-up or had incomplete data, leaving 47% (878) for analysis. These 878 patients with 1139 skeletal maturity assessments were studied; 74% (648 of 878) were girls. Standing body height was measured in a standardized manner by a wall-mounted stadiometer. Several surgeons measured curve magnitude as per routine clinical consultation, skeletal maturity was measured according to the distal radius and ulna classification, and two raters measured Risser and Sanders stages. Reliability tests were performed with satisfaction. Data were collected for the included patients at multiple points when skeletal maturity was assessed, and only up to when brace wear started for those who eventually had bracing. The growth rate and curve progression rate were calculated by the change of body height and major coronal Cobb angle over the number of months elapsed between the initial visit and next follow-up. At each skeletal maturity grading, we examined the growth rate (in centimeters per month) and curve progression rate (in degrees per month) since the skeletal maturity assessment, as well as the mean age at which this maturity grading occurred. Each patient was then individually assessed for whether he or she was experiencing peak growth and the beginning of growth plateau at each timepoint by comparing the calculated growth rate with the previously defined peak growth rate of ≥ 0.7 cm per month and the beginning of growth plateau rate of ≤ 0.15 cm per month in this adolescent idiopathic scoliosis population. Among the timepoints at which the peak growth and the beginning of growth plateau occurred, the median maturity grade of each maturity index was identified as the benchmark grade for comparison between indices. We used the McNemar test to investigate whether pubertal growth landmarks were identified by specific maturity grades concurrently. We assessed the effectiveness of these skeletal maturity indices by the difference in proportions (%) between two benchmark grades in indicating peak growth and the growth plateau. RESULTS: For girls, the chronological order of maturity grades that indicated peak growth was the radius grade, ulna grade, Sanders stage, and Risser stage. Curve progression peaked between the age of 11.6 and 12.1 years at a similar timing by all maturity indices for girls but was inconsistent for boys. For both sexes, radius (R) grade 6, ulna (U) grade 5, Sanders stage (SS) 3, and Risser stage 0+ were the median grades for peak growth, whereas Risser stage 4, R8/9, U7/8, and SS6/7 indicated the beginning of the growth plateau. The largest discrepancy between maturity indices was represented by Risser stage 0+, which corresponded to six grades of the Sanders staging system (SS2 to SS7) and to R6 in only 41% (62 of 152) of girls in the whole cohort. Despite Risser stage 0+ corresponding to the wide range of Sanders and distal radius and ulna grades, none of the R6, U5, SS3, and Risser stage 0+ was found more effective than another grade in indicating the peak growth in girls. R6 most effectively indicated the peak growth in boys, and Risser stage 0+ was the least effective. For the beginning of the growth plateau in girls, SS6/7 was the most effective indicator, followed by U7/8. Risser stage 4 was the least effective because it indicated 29% (95% CI 21% to 36%; p < 0.001) fewer patients who reached the beginning of the growth plateau than did those with R8/9. Risser stage 4 also indicated 36% (95% CI 28% to 43%; p < 0.001) fewer patients who reached the beginning of the growth plateau than those indicated by U7/8, and it identified 39% fewer patients than SS6/7 (95% CI 32% to 47%; p < 0.001). For boys, similarly, R8/9, U7/8, and SS6/7 were all more effective than Risser stage 4 in identifying when the growth plateau began. CONCLUSION: Risser stage 0+ corresponds to a wide range of Sanders and distal radius and ulna grades. Risser stage 0+ is least effective in indicating the peak growth in boys, and Risser stage 4 is the least effective maturity grade for indicating when the growth plateau starts in both sexes. The concurrent use of R6 and SS3 can be useful for detecting the peak growth, and SS6/7 in conjunction with U7/8 is most effective in indicating the beginning of the growth plateau. Using a combination of specific grades of Sanders staging and the distal radius and ulna classification can indicate pubertal growth landmarks with reduced risk of underestimating or overestimating skeletal maturity. These findings may aid in refining clinical decision-making of brace initiation and weaning at a more precise timing. Among Risser stage 0, the appearance of R6, U5, and SS3 provide the most effective assessment of peak growth that can indicate the most effective bracing period within which curve progression occurs. For initiation of the growth plateau, Risser 4 is not useful, and SS6/7, R8/9 and U7/8 should be used instead. LEVEL OF EVIDENCE: Level III, diagnostic study.

Patterns of coronal and sagittal deformities in adolescent idiopathic scoliosis.

BACKGROUND: Thoracic scoliosis has been shown to be associated with hypokyphosis in adolescent idiopathic scoliosis (AIS). However, the relationship of sagittal spino-pelvic parameters with different coronal curve patterns and their influence on patient-perceived quality of life is unknown. This study aims to determine the association between coronal and sagittal malalignment in patients with AIS and to determine their effects on SRS-22r scores. METHODS: A cross-sectional study was conducted on 1054 consecutive patients with AIS. The coronal Cobb angle, thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), PI-LL mismatch (PI-LL), pelvic tilt (PT), and sacral slope (SS) were measured on standing radiographs. The coronal Cobb angle (mild: 10-20°; moderate: > 20-40°; severe: > 40°) and PI (low: < 35°; average: 35-50°; high: > 50°) were divided into 3 sub-groups for comparison. Relationship between coronal curve magnitudes and sagittal parameters was studied as was their association with SRS-22r scores. RESULTS: Low PI had smaller SS (30.1 ± 8.3° vs 44.8 ± 7.7°; p < 0.001), PT (- 0.3 ± 8.1° vs 14.4 ± 7.5°; p < 0.001), and LL (42.0 ± 13.2° vs 55.1 ± 10.6°; p < 0.001), negative PI-LL mismatch (- 12.1 ± 13.1° vs 4.1 ± 10.5°; p < 0.001) as compared to large PI. There were no significant relationships with PI and TK (p = 0.905) or curve magnitude (p = 0.431). No differences in sagittal parameters were observed for mild, moderate or severe coronal Cobb angles. SRS-22r scores only correlated with coronal Cobb angle and larger Cobb angles were negatively correlated with the function, appearance and pain domains. CONCLUSIONS: The sagittal profile for AIS is associated with the pelvic parameters especially PI but not with the coronal curve pattern. All patients have a similar TK regardless of coronal curve type. However, it appears that the coronal deformity is a greater influence on quality of life outcomes especially those > 40°.

Predictive factors for intraoperative blood loss in surgery for adolescent idiopathic scoliosis.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is a common spinal deformity. Posterior spinal fusion remains an important surgical treatment for AIS. This study aims to determine the predictive factors for intraoperative blood loss in AIS surgery. METHODS: Patients who had undergone posterior spinal fusion for adolescent idiopathic scoliosis in a single university hospital were reviewed over a 7-year period. Predictive factors for intra-operative blood loss were studied by multivariate analysis to derive a regression model. Receiver operating characteristic analysis was performed to determine the cut-off values of factors contributing to significant intraoperative blood loss (≥500 ml). RESULTS: Two hundred and twelve patients were included. Intraoperative blood loss was found to be correlated with gender (rs = 0.30 (0.17-0.43)), preoperative hemoglobin level (rs = 0.20 (0.04-0.31)), preoperative Cobb angle (rs = 0.20 (0.02-0.29)), number of fused levels (rs = 0.46 (0.34-0.58)), operation duration (rs = 0.65 (0.54-0.75)), number of anchors (rs = 0.47 (0.35-0.59)), and p-value ranged from < 0.001 to < 0.05. Significant intraoperative blood loss was influenced by the male gender, operation duration greater than 257.5 min and more than 10 anchors used. CONCLUSIONS: Male gender, increased operation duration and higher number of anchors predicted higher intra-operative blood loss.

Responsiveness of the EuroQoL 5-Dimension (EQ-5D) questionnaire in patients with spondyloarthritis.

BACKGROUND: Spondyloarthritis (SpA) has a significant impact on patients' quality of life due to functional impairments. Generic health instruments like the EuroQoL 5-dimension (EQ-5D) is important for cost-utility analysis of health care interventions and calculation of quality-adjusted life-years. It has been validated in patients with SpA. However, its responsiveness property is unclear. Hence, the aim of study is to test the responsiveness properties of the EQ-5D health measure for Chinese patients with SpA. METHODS: Prospective and consecutive recruitment of 151 Chinese patients with SpA was conducted with follow-up assessments 6 months later. Demographic data including smoking and drinking habits, education level, income and occupation was collected. Disease-associated data including disease duration, presence of back pain, peripheral arthritis, dactylitis, enthesitis, uveitis, psoriasis, and inflammatory bowel disease was also recorded. Questionnaires regarding disease activity and functional disability (BASDAI, BASFI, BASGI, BASMI, ASDAS), mental health (HADS) and the EQ-5D scores were recorded. Responsiveness was tested against the global rating of change scale (GRC) and changes in disease activity using BASDAI and ASDAS-CRP. RESULTS: A total of 113 (74.8%) patients completed the follow-up assessments. Most patients (61.6%) had low disease activity level with BASDAI <4 and 39.7% of patients had inactive disease by ASDAS-CRP. EQ-5D scores was well discriminated along with BASDAI and BASFI scores. EQ-5D scores also correlated well with HADS. The GRC was not able to discriminate adequately. No significant ceiling or floor effect was observed. CONCLUSIONS: EQ-5D demonstrates satisfactory responsiveness property for assessment of changes in SpA disease activity. LEVEL OF EVIDENCE: II.

Multidisciplinary programme for rehabilitation of chronic low back pain - factors predicting successful return to work.

BACKGROUND: There are no clear indicators for predicting return to work for patients with chronic low back pain (LBP). We aim to report the outcomes of a 14-week multidisciplinary programme targeting patients with chronic LBP who failed conventional physiotherapy to provide functional rehabilitation. Also, this study will identify factors predicting successful return to work (RTW). METHODS: A collected cohort of patients with chronic LBP was consecutively enrolled into the programme from 1996 to 2014. All recruited patients failed to RTW despite at least 3 months of conservative treatment. Patient underwent weekly multidisciplinary sessions with physiotherapists, occupational therapists and clinical psychologists. Patient perceived function was considered the primary outcome of the programme. Patients were assessed for their sitting, standing and walking tolerance. Oswestry Disability Index (ODI) and Spinal Function Sort Score (SFSS) were used to assess patient perceived disability. RESULTS: One hundred and fifty-eight patients were recruited. After the programme, statistically significant improvement was found in ODI (47.5 to 45.0, p = 0.01) and SFSS (98.0 to 109.5, p <  0.001). There was statistically significant improvement (p <  0.01) in sitting, standing, walking tolerance and straight leg raise tests. 47.4% of the patients were able to meet their work demand. Multivariate logistic regression model (R2 = 59.5%, χ2 (9) = 85.640, p <  0.001) demonstrated that lower initial job demand level and higher patient-perceived back function correlated with greater likelihood of returning to work. CONCLUSION: The results of this study may support the use of this multidisciplinary programme to improve patient function and return to work.

A systematic review of developmental lumbar spinal stenosis.

PURPOSE: To systematically evaluate any consensus for the etiology, definition, presentation and outcomes of developmental lumbar spinal stenosis (DLSS). METHODS: A comprehensive literature search was undertaken by 2 independent reviewers with PubMed, Ovid, and Web of Science to identify all published knowledge on DLSS. Search terms included "developmental spinal stenosis" or "congenital spinal stenosis" and "lumbar". The inclusion criteria were English clinical studies with sample size larger than 8, articles examining the etiology, diagnostic criteria, surgical outcomes of DLSS, and its association with other spinal pathologies. Articles that did not specify a developmental component were excluded. The GRADE approach was used to assess their quality of evidence. RESULTS: The initial database review found 404 articles. Twenty articles with moderate to very low quality met the inclusion criteria for analysis. The bony canal diameter was significantly shorter in patients with DLSS than normal subjects. In addition, the risk of re-operation on adjacent levels (21.7%) was high which could be explained by multi-level stenosis. However, there was a lack of consensus on the methodology of diagnosing DLSS and on its specific surgical techniques. CONCLUSION: Multi-level stenosis and re-operation at adjacent levels are especially common with DLSS. Identification of these individuals provides better prognostication after surgery. However, current literature provides few consensus on its definition and the required surgical approach. Besides, there are limited reports of its etiology and association with other spinal pathologies. Due to these limitations, standardizing the definition of DLSS and investigating its etiology and expected clinical course are necessary.

How do we follow-up patients with adolescent idiopathic scoliosis? Recommendations based on a multicenter study on the distal radius and ulna classification.

PURPOSE: To determine the capability of the distal radius and ulna (DRU) classification for predicting the scoliosis progression risk within 1 year in patients with adolescent idiopathic scoliosis (AIS) and to develop simple recommendations for follow-up durations. METHODS: Medical records of patients with AIS at two tertiary scoliosis referral centers were retrospectively reviewed for their DRU classification and major curve Cobb angles. Baseline DRU grades and Cobb angles with subsequent 1-year follow-up curve magnitudes were studied for scoliosis progression, which was defined as exacerbation of the Cobb angle by ≥ 6°. The relationship between DRU classification and scoliosis progression risk within 1 year was investigated. Patients were divided into three groups according to the Cobb angle (10°-19°, 20°-29°, ≥ 30°). RESULTS: Of the 205 patients with 283 follow-up visits, scoliosis progression occurred in 86 patients (90 follow-up visits). Radius and ulna grades were significantly related to scoliosis progression (p < 0.001). R6, R7, and U5 grades were significantly related to scoliosis progression risk. The curve progression probability increased as the Cobb angle increased. Cobb angles ≥ 30°, with these grades, led to progression in > 80% of patients within 1 year. Curve progression was less likely for grades R9 and U7. Most patients with more mature DRU grades did not experience progression, even with Cobb angles ≥ 30°. CONCLUSION: With R6, R7, and U5, scoliosis may progress within a short period; therefore, careful follow-up with short intervals within 6 months is necessary. R9 and U7 may allow longer 1-year follow-up intervals due to the lower progression risk.

Does Curve Regression Occur During Underarm Bracing in Patients with Adolescent Idiopathic Scoliosis?

BACKGROUND: Successful brace treatment entails good control of scoliosis with avoidance of surgery. However, achieving curve regression may be an even better radiological result than prevention of curve progression for patients with adolescent idiopathic scoliosis. Vertebral remodeling may occur with well-fitted braces. Better in-brace curve correction may influence the likelihood of vertebral remodeling and the chance of curve regression. Only a few reports have evaluated curve regression with brace treatment, and the factors associated with these events are unknown. QUESTIONS/PURPOSES: (1) What changes in curvature are observed with brace treatment for adolescent idiopathic scoliosis? (2) What factors are associated with curve improvement? (3) What factors are associated with curve deterioration? (4) Is curve regression associated with improvements in patient-reported objective outcome scores? METHODS: Between September 2008 and December 2013, 666 patients with adolescent idiopathic scoliosis underwent underarm brace treatment and were followed until skeletal maturity at 18 years old. Among these patients, 80 were excluded because of early discontinuation of brace treatment (n = 66) and loss to follow-up (n = 14). Hence, 586 patients were included in this study, with a mean brace-wear duration of 3.8 ± 1.5 years and post-weaning follow-up duration of 2.0 ± 1.1 years. The mean age at baseline was 12.6 ± 1.2 years. Most patients were female (87%, 507 of 586) and up to 53% (267 of 507) of females were post-menarche. Bracing outcomes were based on changes in the Cobb angle measured out of brace. These included curve regression, as indicated by at least a 5° reduction in the Cobb angle, curve progression, as indicated by at least a 5° increase in the Cobb angle, and unchanged, as indicated by a change in the Cobb angle of less than 5°. We studied the pre-brace and supine Cobb angles, curve flexibility (pre-brace Cobb angle - supine Cobb angle / pre-brace Cobb angle x 100%), correction rate (pre-brace Cobb angle - in-brace Cobb angle / pre-brace Cobb angle x 100%), location of apical vertebrae, apical ratio (convex vertebral height/concave vertebral height), change in the major curve Cobb angle, and apical ratio post-bracing. The refined 22-item Scoliosis Research Society questionnaire was used for patient-reported outcomes and is composed of five domains (function, pain, appearance, mental health and satisfaction with treatment). Its minimum clinically important difference, based on a scale from 0 to 5, has been quoted as 0.2 for pain, 0.08 for activity and 0.98 for appearance domains. Mental health has no quoted minimum clinically important difference for the adolescent idiopathic scoliosis population. Satisfaction with treatment is described based on improvement or deterioration in domain scores. Intergroup differences between bracing outcomes were evaluated with the Kruskal Wallis test. Univariate analyses of bracing outcomes were performed with a point-biserial correlation coefficient for continuous variables and Pearson's chi-square test for categorical variables. Multivariate logistic regression models were created for improved and deteriorated outcomes. P values < 0.05 were considered significant. RESULTS: In all, 17% of patients (98 of 586) had an improved angle and 40% of patients (234 of 586) had curve deterioration. In patients who improved, the mean reduction in the Cobb angle was 9 ± 4°, while in patients who deteriorated, the mean increase in the Cobb angle was 15 ± 9°, and this was maintained at the latest post-brace weaning follow-up. Despite a trend for patients with curve regression to have higher baseline flexibility and correction rate, after controlling for age, Risser staging, radius and ulnar grading, and Sanders staging, we found no clinically important differences with increased correction rate or flexibility. We did find that improvement in the Cobb angle after bracing was associated with reduced apical ratio (odds ratio [OR] 0.84 [95% CI 0.80 to 0.87]; p < 0.001). Curve progression was associated with younger age (OR 0.71 [95% CI 0.55 to 0.91]; p = 0.008), pre-menarche status (OR 2.46 [95% CI 1.31 to 4.62]; p = 0.005), and increased apical ratio (OR 1.24 [95% CI 1.19 to 1.30]; p < 0.001) but no clinically important differences were observed with less flexible curves and reduced correction rate. Improvements in scores of the refined 22-item Scoliosis Research Society domains of function (mean difference on a scale from 0 to 5: 0.2; p = 0.001 versus 0.1; p < 0.001) and pain (mean difference on a scale from 0 to 5: 0.2; p = 0.020 versus 0.0; p = 0.853) were greater in the post-brace improvement group than in the deterioration group and fulfilled the minimum clinically important difference threshold. The appearance domain did not fulfill the minimum clinically important difference. Satisfaction with treatment domain score minimally improved with the curve regression group (mean difference on a scale from 0 to 5: 0.2) but deteriorated in the curve progression group (mean difference on a scale from 0 to 5: -0.4). CONCLUSIONS: Curve regression occurs after underarm bracing and is associated with superior patient-reported outcome scores. This possible change in Cobb angle should be explained to patients before and during bracing. Whether this may help improve patients' duration of brace-wear should be addressed in future studies. Patients with well-fitting braces may experience curve improvement and possible vertebral remodeling. Those braced at a younger age and with increased vertebral wedging are more likely to have curve progression. LEVEL OF EVIDENCE: Level III, therapeutic study.

When Should We Wean Bracing for Adolescent Idiopathic Scoliosis?

BACKGROUND: Current brace weaning criteria for adolescents with idiopathic scoliosis (AIS) are not well defined. Risser Stage 4, ≥ 2 years since the onset of menarche, and no further increase in body height over 6 months are considered justifications for stopping bracing. However, despite adherence to such standards, curve progression still occurs in some patients, and so better criteria for brace discontinuation are needed. QUESTIONS/PURPOSES: (1) Is no change in height measurements over 6 months and Risser Stage 4 sufficient for initiating brace weaning? (2) What is the association between larger curves (45°) at brace weaning and the progression risk? (3) Are a more advanced Risser stage, Sanders stage, or distal radius and ulna classification associated with a decreased risk of curve progression? (4) When should we wean patients with AIS off bracing to reduce the time for brace wear while limiting the risk of postweaning curve progression? METHODS: All AIS patients who were weaned off their braces from June 2014 to March 2016 were prospectively recruited and followed up for at least 2 years after weaning. A total of 144 patients were recruited with mean followup of 36 ± 21 months. No patients were lost to followup. Patients were referred for brace weaning based on the following criteria: they were Risser Stage 4, did not grow in height in the past 6 months of followup, and were at least 2 years postmenarche. Skeletal maturity was assessed with Risser staging, Sanders staging, and the distal radius and ulna classification. Curve progression was determined as any > 5° increase in the Cobb angle between two measurements from any subsequent six monthly followup visits. All radiographic measurements were performed by spine surgeons independently as part of their routine consultations and without knowledge of this study. Statistical analyses included an intergroup comparison of patients with and without curve progression, binomial stepwise logistic regression analysis, odds ratios (ORs) with their 95% confidence intervals (CIs), and a risk-ratio calculation. A reasonable protective maturity stage would generate an OR < 1. RESULTS: Among patients braced until they had no change in height for 6 months, were 2 years postmenarche for girls, and Risser Stage 4, 29% experienced curve progression after brace weaning. Large curves (≥ 45°) were associated with greater curve progression (OR, 5.0; 95% CI, 1.7-14.8; p = 0.002) as an independent risk factor. Patients weaned at Sanders Stage 7 (OR, 4.7; 95% CI, 2.1-10.7; p < 0.001), radius Grade 9 (OR, 3.9; 95% CI, 1.75-8.51; p = 0.001), and ulna Grade 7 (OR, 3.1; 95% CI, 1.27-7.38; p = 0.013) were more likely to experience curve progression. The earliest maturity indices with a reasonable protective association were Sanders Stage 8 (OR, 0.21; 95% CI, 0.09-0.48; p < 0.001), and radius Grade 10 (OR, 0.42; 95% CI, 0.19-0.97; p = 0.042) with ulna Grade 9 (no patients with curve progression). CONCLUSION: Brace weaning indications using Risser staging are inadequate. Curve progression is expected in patients with large curves, irrespective of maturity status. Bone age measurement by either Sanders staging or the distal radius and ulna classification provides clearer guidelines for brace weaning, resulting in the least postweaning curve progression. Weaning in patients with Sanders Stage 8 and radius Grade 10/ulna Grade 9 provides the earliest and most protective timepoints for initiating brace weaning. LEVEL OF EVIDENCE: Level II, prognostic study.

Validation of the LOCOMO-25 and its minimum clinically important differences in domain scores for Chinese patients with low back pain and neck pain.

BACKGROUND: The 25-question Geriatric Locomotive Function Scale (LOCOMO-25) was developed to assess any decline in mobility functions. This study aims to validate the LOCOMO-25 in Chinese patients with chronic low back pain and/or neck pain. METHODS: Adult patients with chronic low back pain and/or neck pain completed the LOCOMO-25, SF-36, EQ-5D-5L, ODI, VAS and/or NDI. Internal consistency was assessed by Cronbach's alpha coefficient (α). Test-retest reliability was assessed by intra-class correlation coefficients. Construct validity was assessed by Spearman correlation tests against other outcome measures. Sensitivity to detect differences between groups was assessed by Mann-Whitney U or Kruskal-Wallis H test, where appropriate. Intergroup comparison was performed further in terms of domain scores and their changes at test-retest. RESULTS: A total of 111 patients were consecutively recruited. LOCOMO-25 demonstrated excellent internal consistency (α = 0.915) and test-retest reliability (Intraclass correlation: 0.705 to 0.826). LOCOMO-25 was significantly correlated with all domains of SF-36, EQ-5D, ODI, NDI, and VAS (p < 0.01). It was found to be sensitive in differentiating between patients with neural compression (32.8 ± 16.9) and without (21.2 ± 12.7), with history of fall(s) within the previous one year (30.8 ± 16.0) and without (24.2 ± 15.1), requires assistive devices for ambulation (40.6 ± 21.6) or independent (23.6 ± 13.1) and various pain levels (mild: 17.2 ± 10.6; moderate: 23.5 ± 11.7; severe: 38.5 ± 16.5). Patients with neural compression scored significantly higher in the domain of pain and patients requiring assistive devices for ambulation scored significantly higher in the domains of ADL and social functions. The minimum detectable differences for various domains of the LOCOMO-25 score included pain (2.76), activities of daily living (6.07), social function (1.59), and mental health status (2.06). CONCLUSIONS: LOCOMO-25 has been validated in Chinese patients with chronic low back and neck pain with satisfactory psychometric properties, and with individual domain minimum clinically important differences. There is adequate internal consistency, test-retest reliability, construct validity and sensitivity to detect differences between patients with/without neural compression, different ambulatory statuses and pain severity.

Psychometric validation of the cross-culturally adapted traditional Chinese version of the Back Beliefs Questionnaire (BBQ) and Fear-Avoidance Beliefs Questionnaire (FABQ).

PURPOSE: To translate and cross-culturally adapt the Back Beliefs Questionnaire (BBQ) and Fear-Avoidance Beliefs Questionnaire (FABQ) into traditional Chinese for their use in patients experiencing low back pain (LBP). METHODS: This was a prospective questionnaire translation and psychometric validation of the BBQ and FABQ in Chinese patients with back pain. Patients also completed the Traditional Chinese (Hong Kong) versions of the Oswestry Disability Index (ODI), the Short Form-12 version 2 (SF-12v2) questionnaires and the visual analogue scale (VAS) for LBP. Construct validity was assessed using Spearman's correlation test against the subscales and domains with similar constructs. Internal consistency was assessed by Cronbach's alpha (α). Sensitivity was determined by known-group comparisons. RESULTS: A total of 100 patients were recruited. Both BBQ (α = 0.810) and FABQ (α = 0.859) demonstrated excellent overall internal consistency. BBQ scores significantly correlated with ODI scores, VAS-LBP and all domains of SF-12v2 (p < 0.01-0.05), whereas only FABQ Work subscale correlated with ODI scores (p < 0.01) and VAS-LBP (p < 0.05). Both FABQ subscales correlated with only specific domains of SF-12v2 (p < 0.01-0.05). FABQ-W was sensitive to difference between patients with acute versus chronic back pain. CONCLUSIONS: Both the adapted BBQ and FABQ (Traditional Chinese-Hong Kong) were demonstrated to have satisfactory psychometric properties, with adequate internal consistencies, construct validity and sensitivity to certain clinical parameters. Our findings were based on a clinically relevant patient group and provides insight into patients' own perception of back pain which may often be different from that of surgeons. This is a platform for future cross-cultural comparisons. LEVEL OF EVIDENCE: 2. These slides can be retrieved under Electronic Supplementary Material.

Comparable clinical and radiological outcomes between skipped-level and all-level plating for open-door laminoplasty.

PURPOSE: To compare the clinical and radiological outcomes between skipped-level and all-level plating for cervical laminoplasty. METHODS: Patients with cervical spondylotic myelopathy (CSM) treated by open-door laminoplasty with minimum 2-year postoperative follow-up were included. All patients had opening from C3-6 or C3-7 and were divided into skipped-level or all-level plating groups. Japanese Orthopaedic Association (JOA) scores and canal measurements were obtained preoperatively, immediate (within 1 week) postoperatively, and at 2, 6 weeks, 3, 6 and 12 months postoperatively. Paired t test was used for comparative analysis. Receiver operating characteristic analysis was used to determine the canal expansion cutoff for spring-back closure. RESULTS: A total of 74 subjects were included with mean age of 66.1 ± 11.3 years at surgery. Of these, 32 underwent skipped-level plating and 42 underwent all-level plating. No significant differences were noted between the two groups at baseline and follow-up. Spring-back closure was observed in up to 50% of the non-plated levels within 3 months postoperatively. The cutoff for developing spring-back closure was 7 mm canal expansion for C3-6. No differences were observed in JOA scores and recovery rates between the two groups. None of the patients with spring-back required reoperation. CONCLUSIONS: There were no significant differences between skipped-level and all-level plating in terms of JOA or recovery rate, and canal diameter differences. This has tremendous impact on saving costs in CSM management as up to two plates per patient undergoing a standard C3-6 laminoplasty may be omitted instead of four plates to every level to achieve similar clinical and radiological outcomes. LEVEL OF EVIDENCE: III. These slides can be retrieved under Electronic Supplementary Material.

Responsiveness of the EuroQoL 5-dimension (EQ-5D) in adolescent idiopathic scoliosis.

PURPOSE: To test the responsiveness of the EuroQoL 5-dimension (EQ-5D) utility scores for adolescent idiopathic scoliosis (AIS). METHODS: A baseline sample of 227 AIS patients was recruited between August and October 2015, and was surveyed prospectively to 9-12 months follow-up. EQ-5D-5L utility scores were derived using a two-step approach: (1) cross-walking from five-level responses to three-level responses and (2) applying the EQ-5D-3L Chinese population value set. An anchor approach was adopted to assess the responsiveness of EQ-5D. Effect size statistics (standardized effect size and standardized response mean) and independent t test were used to assess the responsiveness, as well as to analyze the ability of measures to detect score changes with global health condition changes or discriminate between the worsened and unchanged/improved groups. RESULTS: Approximately two-thirds of follow-up patients (64.2%) reported no change in global health condition based on the self-reported health anchor, whilst 4.6 and 31.3% of patients rated worse and better in current health condition compared to baseline, respectively. In the subgroup where health worsened, EQ-5D utility scores were responsive to detect negative changes. EQ-5D utility scores had slight improvement in the group where health improved, despite a high mean score of 0.92 at baseline. Neither statistical significance nor moderate-large effect size was observed in mean changes among unchanged group. Responsiveness property of the EQ-5D utility score was generally satisfactory with respect to each health condition group. CONCLUSIONS: EQ-5D is found to be able to capture positive changes, and responsive in detecting important clinical changes in the improved group of this AIS population.

Curve Progression in Adolescent Idiopathic Scoliosis Does Not Match Skeletal Growth.

BACKGROUND: Determining the peak growth velocity of a patient with adolescent idiopathic scoliosis (AIS) is important for timely treatment to prevent curve progression. It is important to be able to predict when the curve-progression risk is greatest to maximize the benefits of any intervention for AIS. The distal radius and ulna (DRU) classification has been shown to accurately predict skeletal growth. However, its utility in predicting curve progression and the rate of progression in AIS is unknown. QUESTIONS/PURPOSES: (1) What is the relationship between radius and ulna grades to growth rate (body height and arm span) and curve progression rate? (2) When does peak curve progression occur in relation to peak growth rate as measured by months and by DRU grades? (3) How many months and how many DRU grades elapse between peak curve progression and plateau? METHODS: This was a retrospective analysis of a longitudinally maintained dataset of growth and Cobb angle data of patients with AIS who presented with Risser Stages 0 to 3 and were followed to maturity at Risser Stage 5 at a single institute with territory-wide school screening service. From June 2014 to March 2016, a total of 513 patients with AIS fulfilled study inclusion criteria. Of these, 195 were treated with bracing at the initial presentation and were excluded. A total of 318 patients with AIS (74% girls) with a mean age of 12 ± 1.5 years were studied. For analysis, only data from initial presentation to commencement of intervention were recorded. Data for patients during the period of bracing or after surgery were not used for analysis to eliminate potential interventional confounders. Of these 318 patients, 192 were observed, 119 were braced, and seven underwent surgery. Therefore 192 patients (60.4%) who were observed were followed up until skeletal maturity at Risser Stage 5; no patients were lost to followup. The mean curve magnitude at baseline was 21.6 ± 4.8. Mean followup before commencing intervention or skeletal maturity was 4.3 ± 2.3 years. Standing body height, arm span, curve magnitude, Risser stage, and DRU classification were studied. A subgroup analysis of 83 patients inclusive of acceleration, peak, and deceleration progression phases for growth and curve progression was studied to determine any time lag between growth and curve progression. Results were described in mean ± SD. RESULTS: There was positive correlation between growth rate and curve progression rate for body height (r = 0.26; p < 0.001) and arm span (r = 0.26; p < 0.001). Peak growth for body height occurred at radius grade (R) 6 (0.56 ± 0.29 cm/month) and ulna grade (U) 4 (0.65 ± 0.31 cm/month); peak change in arm span occurred at R5 (0.67 ± 0.33 cm/month) and U3 (0.67 ± 0.22 cm/month); and peak curve progression matched with R7 (0.80 ± 0.89 cm/month) and U5 (0.84 ± 0.78 cm/month). Subgroup analysis confirmed that peak curve progression lagged behind peak growth rate by approximately 7 months or one DRU grade. The mean time elapsed between the peak curve progression rate and the plateau phase at R9 U7 was approximately 16 months, corresponding to two DRU grades. CONCLUSIONS: By using a standard skeletal maturity parameter in the DRU classification, this study showed that the maximal curve progression occurs after the peak growth spurt, suggesting that the curve should be monitored closely even after peak growth. In addition, the period of potential curve continuing progression extends nearly 1.5 years beyond the peak growth phase until skeletal maturity. Future studies may evaluate whether by observing the trend of growth and curve progression rates, we can improve the outcomes of interventions like bracing for AIS. LEVEL OF EVIDENCE: Level II, prognostic study.

Psychometric validation of the adapted Traditional Chinese version of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ).

BACKGROUND: Low back pain is a common health problem encountered by various populations among different countries. This prospective study aimed to translate and cross-culturally adapt the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) into Traditional Chinese and to assess its validity, reliability and sensitivity in Chinese patients experiencing low back pain. METHODS: Double forward and single back translation of the JOABPEQ was performed with cross-cultural adaptation. By convenience sampling, the final version of the translated JOABPEQ was administered to Chinese patients attending a specialty outpatient clinic with a history of back pain, followed by the traditional Chinese versions of Oswestry Disability Index (ODI) and Short Form-12 version 2 (SF-12v2). Construct validity of the domains were assessed using Spearman's correlation test. Internal consistency was assessed by Cronbach's alpha (α). Sensitivity of the adapted JOABPEQ was determined by known group comparisons. RESULTS: A total of 100 patients were recruited. The translated JOABPEQ demonstrated excellent overall internal consistency (α: 0.912); and good internal consistency for the domains of Lumbar Function, Walking Ability, Social Life Function and Mental Health (α: 0.811, 0.808, 0.788, and 0.827 respectively). Scores of all domains of the translated JOABPEQ had significant correlations (p < 0.01) with ODI at all domains, as well as with almost all domains of SF-12v2 (p < 0.01-0.05). The translated JOABPEQ was sensitive in detecting differences in patients with/without a history of previous spine surgery, and also between patients with acute/acute on chronic versus chronic pain in specific domains. CONCLUSIONS: The Traditional Chinese version of JOABPEQ has satisfactory psychometric properties in general, including adequate clinical and construct validity, and internal consistency in assessing Southern-Chinese patients with low back pain. It is demonstrated as a sensitive outcome measure. The translated JOABPEQ is verified for its use in the local clinical setting for patient assessment and future research.