An All-in-One Array of Pressure Sensors and sEMG Electrodes for Scoliosis Monitoring.

Scoliosis often occurs in adolescents and seriously affects physical development and health. Traditionally, medical imaging is the most common means of evaluating the corrective effect of bracing during treatment. However, the imaging approach falls short in providing real-time feedback, and the optimal corrective force remains unclear, potentially slowing the patient's recovery progress. To tackle these challenges, an all-in-one integrated array of pressure sensors and sEMG electrodes based on hierarchical MXene/chitosan/polydimethylsiloxane (PDMS)/polyurethane sponge and MXene/polyimide (PI) is developed. Benefiting from the microstructured electrodes and the modulus enhancement of PDMS, the sensor demonstrates a high sensitivity of 444.3 kPa-1 and a broad linear detection range (up to 81.6 kPa). With the help of electrostatic attraction of chitosan and interface locking of PDMS, the pressure sensor achieves remarkable stability of over 100 000 cycles. Simultaneously, the sEMG electrodes offer exceptional stretchability and flexibility, functioning effectively at 60% strain, which ensures precise signal capture for various human motions. After integrating the developed all-in-one arrays into a commercial scoliosis brace, the system can accurately categorize human motion and predict Cobb angles aided by deep learning. This study provides real-time insights into brace effectiveness and patient progress, offering new ideas for improving the efficiency of scoliosis treatment.

Development and validation of AI-based automatic measurement of coronal Cobb angles in degenerative scoliosis using sagittal lumbar MRI.

OBJECTIVES: Severity of degenerative scoliosis (DS) is assessed by measuring the Cobb angle on anteroposterior radiographs. However, MRI images are often available to study the degenerative spine. This retrospective study aims to develop and evaluate the reliability of a novel automatic method that measures coronal Cobb angles on lumbar MRI in DS patients. MATERIALS AND METHODS: Vertebrae and intervertebral discs were automatically segmented using a 3D AI algorithm, trained on 447 lumbar MRI series. The segmentations were used to calculate all possible angles between the vertebral endplates, with the largest being the Cobb angle. The results were validated with 50 high-resolution sagittal lumbar MRI scans of DS patients, in which three experienced readers measured the Cobb angle. Reliability was determined using the intraclass correlation coefficient (ICC). RESULTS: The ICCs between the readers ranged from 0.90 (95% CI 0.83-0.94) to 0.93 (95% CI 0.88-0.96). The ICC between the maximum angle found by the algorithm and the average manually measured Cobb angles was 0.83 (95% CI 0.71-0.90). In 9 out of the 50 cases (18%), all readers agreed on both vertebral levels for Cobb angle measurement. When using the algorithm to extract the angles at the vertebral levels chosen by the readers, the ICCs ranged from 0.92 (95% CI 0.87-0.96) to 0.97 (95% CI 0.94-0.98). CONCLUSION: The Cobb angle can be accurately measured on MRI using the newly developed algorithm in patients with DS. The readers failed to consistently choose the same vertebral level for Cobb angle measurement, whereas the automatic approach ensures the maximum angle is consistently measured. CLINICAL RELEVANCE STATEMENT: Our AI-based algorithm offers reliable Cobb angle measurement on routine MRI for degenerative scoliosis patients, potentially reducing the reliance on conventional radiographs, ensuring consistent assessments, and therefore improving patient care. KEY POINTS: • While often available, MRI images are rarely utilized to determine the severity of degenerative scoliosis. • The presented MRI Cobb angle algorithm is more reliable than humans in patients with degenerative scoliosis. • Radiographic imaging for Cobb angle measurements is mitigated when lumbar MRI images are available.

Association Between Two Methods of Spinal and Pelvic Analysis Among Children With Cerebral Palsy.

OBJECTIVES: Children with cerebral palsy have weak muscles, which may impair postural adjustments. These postural adjustments are required for gait and dynamic balance during the daily living activities. The aim of this study was to investigate the association between Cobb's angle and Formetric 4D surface topography system in evaluating spinal and pelvic deformity in children with cerebral palsy. METHODS: One hundred children with spastic diplegia (6 to 8 years old) diagnosed as cerebral palsy participated in this study and selected from the Outpatient Clinic of Faculty of Physical Therapy. Digital x- ray and formetric analysis were used to measure spinal deformities and pelvic deviation in children with cerebral palsy. RESULTS: There were positive correlations between Cobb's angle and formetric parameters, including trunk imbalance, lateral deviation, and pelvic tilt. Also, Formetric parameters were significant predictors of Cobb's angle, including trunk imbalance (for a one-degree increase, Cobb's angle increases by 0.227, lateral deviation (for a one-degree increase, Cobb's angle increases by 0.665), and pelvic tilt (for a one-degree increase, Cobb's angle increases by 0.252). CONCLUSION: Formetric 4D surface topography system was effective in evaluating spinal and pelvic deformity in children with cerebral palsy when compared with Digital x-ray.

Deep learning algorithm for automatically measuring Cobb angle in patients with idiopathic scoliosis.

PURPOSE: The Cobb angle is a standard measurement to qualify and track the progression of scoliosis. However, the Cobb angle has high inter- and intra-observer variability. Consequently, its measurement varies with vertebrae and may even differ when the same vertebra is measured. Therefore, it is not constant and differs with measurements. This study aimed to develop a deep learning model that automatically measures the Cobb angle. The deep learning model for identifying vertebrae on spine radiographs was developed. METHODS: The dataset consisted of 297 images that were divided into two subsets for training and validation. Two hundred and twenty-seven images (76.4%) were used to train the model, while 70 images (23.6%) were used as the validation dataset. Absolut error between the measurements by the observer and developed deep learning model and intraclass correlation coefficient (ICC). RESULTS: The average absolute error between the measurements was 1.97° with a standard deviation of 1.57°. In addition, 95.9% of the angles had an absolute error of less than 5°. The ICC was calculated to assess the model's reliability further. The ICC was 0.981, indicating excellent reliability. CONCLUSIONS: The authors believe the model will be useful in clinical practice by relieving clinicians of the burden of having to manually compute the Cobb angle. Further studies are needed to enhance the accuracy and versatility of this deep learning model.

The diagnostic accuracy of community spine radiology for adolescent idiopathic scoliosis brace candidates.

PURPOSE: The study aims to establish the diagnostic accuracy of community spine x-rays for brace candidates. METHODS: A review of adolescent idiopathic scoliosis patients seen for initial visit at a tertiary care pediatric hospital was conducted (n = 170). The index test was the pre-referral community spine x-ray interpreted by a community radiologist. Measures of diagnostic accuracy for the index test were determined against the reference standard if images were obtained within 90 days (n = 111). The reference standard was the 3-foot standing EOS spine x-ray evaluated by spine specialists. Diagnostic criterion for a brace candidate was dichotomized by Cobb angle range (25-40°) according to Scoliosis Research Society criteria. Risser stage was not included given significant missing data in index reports. To mitigate the uncertainty around true progression, sensitivity analyses were conducted on a sub-sample of data when index test was within 60 days of the reference standard (n = 67). RESULTS: Accuracy of the community spine x-ray to detect a brace candidate was 65.8% (95% CI 56.2-74.5). Sensitivity of the index test was 65.4% with a false negative rate of 34.6%. Specificity was 66.1% with a false positive rate of 33.9%. Positive and negative predictive values were 63.0% and 68.4%, respectively. Of the total number of brace candidates (n = 52), 32.7% were missed because of underestimation in Cobb angle (95% CI 21.5-46.2). The proportion of missed brace candidates because of underestimation was unchanged with 60-day data (p = 0.37). CONCLUSIONS: Inaccuracies in community spine radiology may lead to missed opportunities for non-operative treatment.

Impact of postoperative spinal malalignment on postoperative health-related quality of life after long-level fixation for degenerative lumbar scoliosis: does residual coronal angularity matter?

PURPOSE: This study evaluates the influence of spinal malalignment on health-related quality of life (HRQOL) in a long-level fusion spine. METHODS: This was a retrospective analysis of 121 consecutive patients with DLS after long-segment fusion. HRQOL and radiographic parameters were collected at final follow-up. For postoperative residual Cobb angle (CA), patients were divided as follows: group (0) (CA < 10°), group (+) (CA 10°âˆ¼20 °), and group (++) (CA > 20°). For postoperative coronal vertical axis (CVA), patients were separated as follows: group (0) (CVA < 2 cm), group (+) (CVA 2 ∼ 3 cm), and group (++) (CVA > 3 cm). Patients were also grouped by the sagittal modifiers as group (0), group (+), and group (++) according to the Scoliosis Research Society (SRS)-Schwab classification, respectively. RESULTS: Visual analog scale (VAS) for back was significantly lower in CA 10°âˆ¼20° group compared to other groups. Patients with remnant CA > 20° showed worse Oswestry Disability Index (ODI), SRS-22 and the 36-item Short Form Health Survey (SF-36) - physical component scores (PCS). Sagittal vertical axis (SVA) showed significant correlation with HRQOLs after surgery, and the statistical significance of ODI, SRS-22 and SF-36 scores was observed among subgroups. CONCLUSIONS: In long-level fused spine, residual CA > 20° resulted in worse clinical outcomes and was recommended to avoid during surgery. And 10° to 20° residual CA was acceptable in DLS patients and even better than Cobb angle < 10° in several HRQOLs, therefore strictly pursing upright alignment seems unnecessary. SVA also showed effectiveness in assessing HRQOL in the fixed spine.

Adult versus adolescent idiopathic scoliosis surgery: a meta-analysis of clinical and radiographic outcomes.

INTRODUCTION: While the natural history of adolescent idiopathic scoliosis (AIS) and adult idiopathic scoliosis (AdIS) is well documented in the literature, the impact of age on postoperative outcomes remains an active area of research. We performed a systematic review and meta-analysis to compare patients undergoing surgery for AIS and AdIS with respect to: (1) postoperative Cobb correction, (2) perioperative variables, and (3) postoperative complications. METHODS: A systematic literature search was performed in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. INCLUSION CRITERIA: studies published between 2002 and 2022, retrospective, and comparing AIS vs. AdIS patients undergoing deformity surgery. The primary outcome was postoperative Cobb correction. Secondary outcomes included estimated blood loss (EBL), operative time, total instrumented levels, length of stay (LOS), and postoperative complications. Random-effects models were performed according to the method of DerSimonian and Laird. RESULTS: Of 190 identified articles, 14 fit the inclusion criteria. A total of 1788 patients were included, 1275(71.3%) with AIS, and 513(28.7%) with AdIS. There was a significant age difference between AIS and AdIS (15.3 vs. 36.7 years, mean difference (MD) = 21.3 years, 95%CI = 14.3-28.4,p < 0.001). Mean postoperative Cobb percentage correction was reported in 5 articles and was significantly higher in AIS (68.4%) vs. AdIS (61.4%) (MD = -7.2, 95%CI = -11.6,-2.7,p = 0.001). EBL was not significantly different between AIS and AdIS (695.6 mL vs 817.7 mL,p = 0.204). Furthermore, no difference was found in operative time (MD = 37.9 min,95%CI = -10.7;86.6,p = 0.127), total instrumented level (MD = 0.88,95%CI = -0.7,2.4,p = 0.273), and LOS (MD = 0.5, 95%CI = -0.2;1.2, p = 0.188). Four articles reported postoperative complications in AIS vs AdIS, with no difference in neurological deficit, instrumentation-related complications, and medical complications. CONCLUSION: AIS patients had better radiographic correction compared to AdIS. Though no difference was found in perioperative outcomes and complications, these findings emphasize the importance of counseling patients regarding the optimal timing of surgical correction.

Validity and accuracy of automatic cobb angle measurement on 3D spinal ultrasonographs for children with adolescent idiopathic scoliosis: SOSORT 2024 award winner.

PURPOSE: Ultrasonography for scoliosis is a novel imaging method that does not expose children with adolescent idiopathic scoliosis (AIS) to radiation. A single ultrasound scan provides 3D spinal views directly. However, measuring ultrasonograph parameters is challenging, time-consuming, and requires considerable training. This study aimed to validate a machine learning method to measure the coronal curve angle on ultrasonographs automatically. METHODS: A total of 144 3D spinal ultrasonographs were extracted to train and validate a machine learning model. Among the 144 images, 70 were used for training, and 74 consisted of 144 curves for testing. Automatic coronal curve angle measurements were validated by comparing them with manual measurements performed by an experienced rater. The inter-method intraclass correlation coefficient (ICC2,1), standard error of measurement (SEM), and percentage of measurements within clinical acceptance (≤ 5°) were analyzed. RESULTS: The automatic method detected 125/144 manually measured curves. The averages of the 125 manual and automatic coronal curve angle measurements were 22.4 ± 8.0° and 22.9 ± 8.7°, respectively. Good reliability was achieved with ICC2,1 = 0.81 and SEM = 1.4°. A total of 75% (94/125) of the measurements were within clinical acceptance. The average measurement time per ultrasonograph was 36 ± 7 s. Additionally, the algorithm displayed the predicted centers of laminae to illustrate the measurement. CONCLUSION: The automatic algorithm measured the coronal curve angle with moderate accuracy but good reliability. The algorithm's quick measurement time and interpretability can make ultrasound a more accessible imaging method for children with AIS. However, further improvements are needed to bring the method to clinical use.

The role of the paraspinal muscles in the development of adolescent idiopathic scoliosis based on surface electromyography and radiographic analysis.

BACKGROUND: Patients with idiopathic scoliosis commonly present with an imbalance of the paraspinal muscles. However, it is unclear whether this muscle imbalance is an underlying cause or a result of idiopathic scoliosis. This study aimed to investigate the role of paraspinal muscles in the development of idiopathic scoliosis based on surface electromyography (sEMG) and radiographic analyses. METHODS: This was a single-center prospective study of 27 patients with single-curve idiopathic scoliosis. Posteroanterior whole-spine radiographs and sEMG activity of the erector spinae muscles were obtained for all patients in the habitual standing position (HSP), relaxed prone position (RPP), and prone extension position (PEP). The Cobb angle, symmetrical index (SI) of the sEMG activity (convex/concave), and correlation between the two factors were analyzed. RESULTS: In the total cohort, the mean Cobb angle in the HSP was significantly greater than the mean Cobb angle in the RPP (RPP-Cobb) (p < 0.001), whereas the mean Cobb angle in the PEP (PEP-Cobb) did not differ from the RPP-Cobb. Thirteen patients had a PEP-Cobb that was significantly smaller than their RPP-Cobb (p = 0.007), while 14 patients had a PEP-Cobb that was significantly larger than their RPP-Cobb (p < 0.001). In the total cohort and two subgroups, the SI of sEMG activity at the apex vertebra (AVSI) in the PEP was significantly greater than 1, revealing significant asymmetry, and was also significantly larger than the AVSI in the RPP. In the RPP, the AVSI was close to 1 in the total cohort and two subgroups, revealing no significant asymmetry. CONCLUSION: The coronal Cobb angle and the SI of paraspinal muscle activity in AIS patients vary with posture changes. Asymmetrical sEMG activity of the paraspinal muscles may be not an inherent feature of AIS patients, but is evident in the challenging tasks. The potential significance of asymmetric paraspinal muscle activity need to be explored in further research.

Can conservative treatment be effective for thoracolumbar injuries patients with TLICS scores of 4 or 5? An analysis of initial radiological findings and clinical risk factors for treatment failure.

BACKGROUND: This study aimed to assess the outcomes of conservative management in patients with thoracolumbar fractures classified with a Thoracolumbar Injury Classification and Severity (TLICS) score of 4 or 5, and to analyze initial imaging findings and clinical risk factors associated with treatment failure. METHODS: In this retrospective analysis, patients with thoracolumbar fractures and a TLICS score of 4 or 5, determined through MRI from January 2017 to December 2020, were included. Patients undergoing conservative treatment were categorized into two groups: Group 1 (treatment success) and Group 2 (treatment failure), based on initial and 6-month follow-up outcomes. Clinical data were compared between the two groups. Initial radiological assessments included three kyphosis measurements (Cobb angle, Gardner angle, and sagittal index [SI]), anterior and posterior wall height, and central canal compromise (CC). Additionally, risk factors contributing to treatment failure were analyzed. RESULTS: The conservative treatment group comprised 84 patients (mean age, 60.25 ± 15.53; range 22-85; 42 men), with 57 in Group 1 and 27 in Group 2. Group 2 exhibited a higher proportion of women, older age, and lower bone mass density (p = 0.001-0.005). Initial imaging findings in Group 2 revealed significantly greater values for Cobb angle, SI, and CC (p = 0.001-0.045 or < 0.001; with cutoff values of 18.2, 12.8, and 7.8%, respectively), and lower anterior wall height (p = 0.001), demonstrating good to excellent interobserver agreement (0.72-0.99, p < 0.001). Furthermore, osteoporosis was identified as a significant risk factor (odds ratio = 5.64, p = 0.008). CONCLUSION: Among patients with TLICS scores of 4 or 5, those experiencing conservative treatment failure exhibited unfavorable initial radiological findings, a higher proportion of women, advanced age, and osteoporosis. Additionally, osteoporosis emerged as a significant risk factor for treatment failure.

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.

Automatic Assessment of Ultrasound Curvature Angle for Scoliosis Detection Using 3-D Ultrasound Volume Projection Imaging.

OBJECTIVE: Scoliosis is a spinal deformation in which the spine takes a lateral curvature, generating an angle in the coronal plane. The conventional method for detecting scoliosis is measurement of the Cobb angle in spine images obtained by anterior X-ray scanning. Ultrasound imaging of the spine is found to be less ionising than traditional radiographic modalities. For posterior ultrasound scanning, alternate indices of the spinous process angle (SPA) and ultrasound curve angle (UCA) were developed and have proven comparable to those of the traditional Cobb angle. In SPA, the measurements are made using the spinous processes as an anatomical reference, leading to an underestimation of the traditionally used Cobb angles. Alternatively, in UCA, more lateral features of the spine are employed for measurement of the main thoracic and thoracolumbar angles; however, clear identification of bony features is required. The current practice of UCA angle measurement is manual. This research attempts to automate the process so that the errors related to human intervention can be avoided and the scalability of ultrasound scoliosis diagnosis can be improved. The key objective is to develop an automatic scoliosis diagnosis system using 3-D ultrasound imaging. METHODS: The novel diagnosis system is a three-step process: (i) finding the ultrasound spine image with the most visible lateral features using the convolutional RankNet algorithm; (ii) segmenting the bony features from the noisy ultrasound images using joint spine segmentation and noise removal; and (iii) calculating the UCA automatically using a newly developed centroid pairing and inscribed rectangle slope method. RESULTS: The proposed method was evaluated on 109 patients with scoliosis of different severity. The results obtained had a good correlation with manually measured UCAs (R2=0.9784 for the main thoracic angle andR2=0.9671 for the thoracolumbar angle) and a clinically acceptable mean absolute difference of the main thoracic angle (2.82 ± 2.67°) and thoracolumbar angle (3.34 ± 2.83°). CONCLUSION: The proposed method establishes a very promising approach for enabling the applications of economic 3-D ultrasound volume projection imaging for mass screening of scoliosis.

Outcomes of 12 Weeks of Schroth and Asymmetric Spinal Stabilization Exercises on Cobb Angle, Angle of Trunk Rotation, and Quality of Life in Adolescent Boys with Idiopathic Scoliosis: A Randomized-controlled Trial.

Objectives: The available evidence on the efficiency of well-known Schroth's exercises (SE) for correcting adolescent idiopathic scoliosis (AIS) is limited, especially in combination with the asymmetric spinal stabilization exercises (ASSE) method. Therefore, we hypothesized that, first, there is no difference in the efficiency of the combined exercises (SE+ASSE) and SE alone in improving Cobb angle, angle of trunk rotation (ATR), and quality of life (QoL) in AIS. Second, there is no difference in the efficiency of SE and no intervention on corresponding variables in treating AIS. Methods: This randomized controlled trial (RCT) consisted of 40 patients with mild AIS (10-18-year-old boys) divided into three groups: SE (n=15), SE+ASSE (n=15), and a waitlist control group (n=10). For 12 weeks (three days a week), both experimental groups performed SE, the combined group additionally received ASSE, and the control group received no intervention. The assessment included Cobb angle (photogrammetry), ATR (Adam's test), and QoL (Scoliosis Research Society-22 questionnaire). Results: It was found that Cobb angle, ATR, and QoL improved significantly in the combined SE+ASSE group (Cobb=16.45° to 9.01°; ATR=4.93° to 1.33°) compared to the SE group (P<.001). In addition, the SE group showed significant amelioration in the mentioned variables (Cobb=15.09° to 9.77°; ATR=4.23° to 2.17°) compared to the control group (P<.001), whereas the control group remained almost unchanged. Conclusion: Based on the obtained results, the combination of SE and ASSE provided more benefits than SE alone, and the SE results were efficient compared to the no-intervention group regarding the correction of scoliosis and related problems. However, patients with moderate to severe scoliosis should also be investigated in longer treatment periods in future.

Automated 3D Cobb Angle Measurement Using U-Net in CT Images of Preoperative Scoliosis Patients.

To propose a deep learning framework "SpineCurve-net" for automated measuring the 3D Cobb angles from computed tomography (CT) images of presurgical scoliosis patients. A total of 116 scoliosis patients were analyzed, divided into a training set of 89 patients (average age 32.4 ± 24.5 years) and a validation set of 27 patients (average age 17.3 ± 5.8 years). Vertebral identification and curve fitting were achieved through U-net and NURBS-net and resulted in a Non-Uniform Rational B-Spline (NURBS) curve of the spine. The 3D Cobb angles were measured in two ways: the predicted 3D Cobb angle (PRED-3D-CA), which is the maximum value in the smoothed angle map derived from the NURBS curve, and the 2D mapping Cobb angle (MAP-2D-CA), which is the maximal angle formed by the tangent vectors along the projected 2D spinal curve. The model segmented spinal masks effectively, capturing easily missed vertebral bodies. Spoke kernel filtering distinguished vertebral regions, centralizing spinal curves. The SpineCurve Network method's Cobb angle (PRED-3D-CA and MAP-2D-CA) measurements correlated strongly with the surgeons' annotated Cobb angle (ground truth, GT) based on 2D radiographs, revealing high Pearson correlation coefficients of 0.983 and 0.934, respectively. This paper proposed an automated technique for calculating the 3D Cobb angle in preoperative scoliosis patients, yielding results that are highly correlated with traditional 2D Cobb angle measurements. Given its capacity to accurately represent the three-dimensional nature of spinal deformities, this method shows potential in aiding physicians to develop more precise surgical strategies in upcoming cases.

Clinical Application of Automatic Assessment of Scoliosis Cobb Angle Based on Deep Learning.

INTRODUCTION: A recently developed deep-learning-based automatic evaluation model provides reliable and efficient Cobb angle measurements for scoliosis diagnosis. However, few studies have explored its clinical application, and external validation is lacking. Therefore, this study aimed to explore the value of automated assessment models in clinical practice by comparing deep-learning models with manual measurement methods. METHODS: The 481 spine radiographs from an open-source dataset were divided into training and validation sets, and 119 spine radiographs from a private dataset were used as the test set. The mean Cobb angle values assessed by three physicians in the hospital's PACS system served as the reference standard. The results of Seg4Reg, VFLDN, and manual measurement were statistically analyzed. The intra-class correlation coefficients (ICC) and the Pearson correlation coefficient (PCC) were used to compare their reliability and correlation. The Bland-Altman method was used to compare their agreement. The Kappa statistic was used to compare the consistency of Cobb angles at different severity levels. RESULTS: The mean Cobb angle values measured were 35.89° ± 9.33° with Seg4Reg, 31.54° ± 9.78° with VFLDN, and 32.23° ± 9.28° with manual measurement. The ICCs for the reliability of Seg4Reg and VFLDN were 0.809 and 0.974, respectively. The PCC and MAD between Seg4Reg and manual measurements were 0.731 (p<0.001) and 6.51°, while those between VFLDN and manual measurements were 0.952 (p<0.001) and 2.36°. The Kappa statistic indicated VFLDN (k= 0.686, p< 0.001) was superior to Seg4Reg and manual measurements for Cobb angle severity classification. CONCLUSION: The deep-learning-based automatic scoliosis Cobb angle assessment model is feasible in clinical practice. Specifically, the keypoint-based VFLDN is more valuable in actual clinical work with higher accuracy, transparency, and interpretability.

Using Electric Stimulation of the Spinal Muscles and Electromyography during Motor Tasks for Evaluation of the Role in Development and Progression of Adolescent Idiopathic Scoliosis.

Introduction: The role of the spinal muscles in scoliogenesis is not fully substantiated. Do they act scoliogenic (inducing scoliosis) or counteract scoliosis in adolescent idiopathic scoliosis (AIS)? In this study, we will examine this by using selectively placed Transcutaneous Electric Stimulation (TES) combined with a cinematic radiographic technique and by performing electromyographic (EMG) evaluations during various motor tasks. Method: This is a cross-sectional study of subjects with small-curve AIS. Using cinematic radiography, they were evaluated dynamically either under electrical stimulation or when performing motor tasks of left and right lateral bending and rotation whilst measuring the muscle activity by EMG. Results: Forty-five patients with AIS were included as subjects. Five subjects volunteered for TES and six subjects performed the motor tasks with EMG. At the initial visual evaluation, and when stimulated with TES, the frontal plane spatial positions of the vertebral bodies showed discrete changes without an apparent pattern. However, analyzing the spatial positions when calibrated, we found that the spinal muscles exert a compressive 'response' with a minor change in the Cobb angle (CA) in small-curve AIS (CA = 10-20°). In larger curves (CA > 20°), TES induced a 'larger deformity' with a relative four-fold change in the CA compared to small-curve AIS with a ratio of 0.6. When evaluating local amplitude (peak) or cumulative (mean) EMG signals, we were unable to find consistent asymmetries. However, one subject had rapid progression and one regressed to a straight spine. When adding the absolute EMG ratios for all four motor tasks, the subject with progression had almost 10-fold less summed EMG ratios, and the subject with regression had more than 3-fold higher summed EMG ratios. Discussion: Based on these findings, we suggest that the spinal muscles in small-curve AIS have a stabilizing function maintaining a straight spine and keeping it in the midline. When deformities are larger (CA > 20°), the spine muscle curve exerts a scoliogenic 'response'. This suggests that the role of the muscles converts from counteracting AIS and stabilizing the spine to being scoliogenic for a CA of more than 20°. Moreover, we interpret higher EMG ratios as heightened asymmetric spinal muscle activity when the spinal muscles try to balance the spine to maintain or correct the deformity. When progression occurs, this is preceded or accompanied by decreased EMG ratios. These findings must be substantiated by larger studies.

Application of Multi-Rod Constructs for the Revision of Thoracolumbar Fractures.

OBJECTIVE: The revision procedure for failure of internal fixation after thoracolumbar fracture is controversial. Combined anterior and posterior surgery is associated with higher risk more intraoperative bleeding and tissue damage. The success rate of simple anterior surgery needs further confirmation, and posterior surgery lacks stability of internal fixation. This study evaluates the feasibility and surgical effect of multi-rod constructs in the revision of thoracolumbar fractures. METHODS: Eleven patients with thoracolumbar fractures who underwent previous construct failure and were treated with revision and internal fixation with the multi-rod technique from March 2017 to September 2018 were analyzed. The original internal fixation was removed and replaced in the medial insertion of satellite rods and bone graft. The average follow-up time was 15.97 months. The intraoperation blood loss, the time of the operation, activation and discharge and the rate of rod fracture were calculated. The sagittal Cobb angle before revision, after revision and at the last follow-up were compared. The clinical effect was evaluated by visual analogue scale (VAS) and Oswestry Disability Index questionnaire (ODI). RESULTS: The average operation time was 107 min, the intraoperative blood loss was 131.81 mL, the active time was 1.59 days, and the discharge time was 10.89 days. No rod fractured again during the follow-up period. The paired t-test was used to compare the Cobb angle, VAS score, and ODI before and after surgery. There was significant difference in the sagittal Cobb angle between the pre-revision and the posterior sagittal position (p = 0.000), and no significant difference was found between post-revision and last follow-up (p = 0.551). VAS and ODI were greatly improved at the last follow-up. CONCLUSION: The literature on revision of thoracolumbar fractures is insufficient and comprises varying opinions. This paper proposes a new treatment option. The application of the multi-rod constructs in the revision of thoracolumbar fractures is safe, simple, and effective and might provide guidance for future clinical work.

The impact of patient scoliosis-specific exercises for adolescent idiopathic scoliosis: a systematic review and meta-analysis of randomized controlled trials with subgroup analysis using observational studies.

PURPOSE: Adolescent idiopathic scoliosis (AIS) is a common pediatric spinal deformity frequently treated with patient scoliosis-specific exercises (PSSE). The purpose of this study is to perform a systematic review and meta-analysis of randomized controlled trials and sensitivity analysis of observational studies to determine the impact of PSSE on outcomes for AIS. METHODS: A systematic review and meta-analysis on impact of PSSE for patients with AIS was performed. Databases used included PubMed, CINAHL, MEDLINE, Cochrane, and ScienceDirect database inception to October 2022. Inclusion criteria included use of PSSE, patient population of AIS, and full text. RESULTS: A total of 26 articles out of 628 initial retrieved met final inclusion criteria (10 randomized controlled trials (RCTs), 16 observational studies). Total included patients (n = 2083) had a frequency weighted mean age of 13.2 ± 0.9 years and a frequency weighted mean follow-up of 14.5 ± 20.0 months. Based on only data from RCTs with direct comparison groups (n = 7 articles), there was a statistically significant but clinically insignificant improvement in Cobb angle of 2.5 degrees in the PSSE group (n = 152) as compared to the control group (n = 148; p = 0.017). There was no statistically significant improvement in Cobb angle when stratified by small curve (< 30 degrees) or large curve (> 30 degrees) with PSSE (p = 0.140 and p = 0.142, respectively). There was no statistically significant improvement in ATR (p = 0.326) or SRS-22 score (p = 0.370). CONCLUSION: PSSE may not provide any clinically significant improvements in Cobb angle, ATR, or SRS-22 scores in patients with AIS. PSSE did not significantly improve Cobb angle when stratified by curve size. LEVEL OF EVIDENCE: Level I.

Relationship between inflammatory laboratory parameters and severity of adolescent idiopathic scoliosis: A pilot study.

BACKGROUND: Adolescent idiopathic scoliosis is a complex condition whose pathogenesis may include inflammation and signs of joint and bone degeneration. OBJECTIVE: The main objective of this study is to evaluate the relationship between the severity of adolescent idiopathic scoliosis and inflammatory blood parameters. METHODS: The study recruited patients with adolescent idiopathic scoliosis who attended the Rehabilitation Center of the Apostolo Foundation in Merate (LC). The scoliosis curve (Cobb's angle) was used as a severity index to compare with inflammatory blood parameters (white blood cells subpopulations, immunoglobulins, protein electrophoresis). In addition, the study used an overall severity grading called "Scoliosis Score" which includes all spine angles and Risser's score (bone development index). RESULTS: Thirty-four subjects were recruited (mean age 14 years, 2 months), 30 females and 2 males. A significant correlation was found between Cobb's angle and the percentage values of beta-2 globulins in a directly proportional manner (r= 0.42, p= 0.01), and gamma globulins in an inversely proportional manner (r=-0.366, p= 0.04). However, no significant correlation between Cobb's angle and the absolute values of white blood cells and percentage subpopulations was found (r= 0.0821 p= 0.655). A moderate, inverse correlation was found between the Scoliosis Score and the percentage of neutrophils (r=-0.385, p= 0.02), a direct correlation was found between the Scoliosis Score and the percentage of lymphocytes (r= 0.404, p= 0.02). In addition, there was a strong correlation of the Scoliosis Score with alpha-2 globulin (r= 0.564, p= 0.0012), beta-1 globulin (r= 0.478, p= 0.0074), and beta-2 globulin (r= 0.370, p= 0.044) and an inverse relationship with gamma globulin (r=-0.625, p= 0.0002). The main correlations were confirmed by regression analysis. CONCLUSION: The correlation between beta-2 globulins and gamma globulins with Cobb's angle and the Scoliosis Score suggests a link between spinal curvature and inflammation in scoliosis patients, This link may indicate the significance of these parameters for diagnosing, staging the disease, and monitoring therapies.

Representation and Race in Adolescent Idiopathic Scoliosis Research: Disparities in Curve Magnitude and Follow-Up.

STUDY DESIGN: Prospective Cohort Study. OBJECTIVE: The present study aims to determine if the racial representation of patients enrolled in a large prospective scoliosis registry is reflective of the general United States population. Further, we studied whether there was an association between race, pre-operative parameters, outcomes and loss to follow-up. METHODS: Prospectively collected data for patients who underwent spinal fusion for adolescent idiopathic scoliosis (AIS) was reviewed, including self-reported race/ethnicity. The U.S. pediatric population and U.S. patients enrolled in the prospective registry were compared. The data obtained was analyzed for variations between races, for pre-operative variables and follow-up. RESULTS: Of the 2210 included patients in the registry 66% of patients reported as White, while 52% of the 2018 U.S. pediatric population reported as White. 15% of the registry reported as Hispanic/Latino compared to 22% of the U.S. pediatric population, 13% Black compared to 14% of the U.S. pediatric population, and 4% Asian compared to 5% of the U.S. pediatric population. Asian and White patients had statistically significant higher 2-year follow-up in all but one of six enrollment sites (P < 0.001). Native American, Other, and Hispanic/Latino patients had the highest BMIs. Native American and Black patients had the highest pre-op thoracic Cobb angles. Pre-op ages of Black, Hispanic, and Native American patients were statistically lower (P < 0.01). CONCLUSION: This study demonstrates the association between race and patient follow-up and pre-operative factors in patients who underwent surgery for AIS. Black, Native American, and Hispanic populations were underrepresented both at pre-op and follow-up when compared to their relative proportion in the U.S. pediatric population.