Does intervertebral disc degeneration in adolescent idiopathic scoliosis correlate with patient-reported pain scores? A review of 968 cases.

PURPOSE: Report the rate and severity of degenerative disc disease (DDD) in non-surgical adolescent idiopathic scoliosis (AIS) patients and correlate these findings with patient-reported symptomatology scores. Additionally, to quantify the rate of concurrent pathological radiological findings in this group. METHODS: This was a retrospective chart review study at a single tertiary centre. AIS patients aged 10-16 who had received a whole spine MRI between September 2007 and January 2019 and who had not received surgical intervention to their spine were included. MRI scan reports were screened to extract those who had evidence of DDD. These were then reviewed by a blinded second reviewer who graded every disc using the Pfirrmann grading system. SRS-22 scores were extracted for patients when available. RESULTS: In total, 968 participants were included in the study. Of these, 93 (9.6%) had evidence of DDD, which was Pfirrmann grade ≥ 3 in 28 (2.9%). The most commonly affected level was L5/S1 (59.1% of DDD cases). A total of 55 patients (5.7%) had evidence of syringomyelia, 41 (3.4%) had evidence of spondylolisthesis (all L5/S1), 14 (1.4%) had bilateral L5 pars defects, and 5 (0.5%) had facet joint degeneration. Spondylolisthesis and bilateral pars defects were more common in patients with DDD identified on MRI scan (p < 0.001 and p = 0.04, respectively). Function (p = 0.048) and pain (p = 0.046) scores were worse in patients with DDD. CONCLUSION: We present a baseline for the rate and severity of DDD in the non-operative AIS cohort. This should assist in decision-making and counselling of patients prior to surgery. LEVEL OF EVIDENCE: III.

Systematic Review and Meta-analysis: Does Anterior-Posterior Spinal Fusion Still have a Role in Severe Thoracic Adolescent Idiopathic Scoliosis?

Background: Debate exists as to whether anterior-posterior spinal fusion (APSF), rather than posterior-only spinal fusion (PSF), provides benefit for treating severe thoracic adolescent idiopathic scoliosis (AIS). This systematic review and meta-analysis compare (1) Cobb angle correction, (2) complication and reoperation rate, (3) pulmonary function, (4) number of fused segments, and 5) patient-reported outcome measures (PROMs) in both groups. Methods: Electronic databases were searched to identify studies that met the following inclusion criteria: comparative studies (level 3 or above), severe thoracic curves (≥ 70°), age ≤ 16, AIS aetiology, Lenke 1-4 curves and follow-up ≥ 1 year for ≥ 95% of patient population. Literature was graded for quality and bias using GRADE and MINORS criteria. Results: Eight studies were included, defined by GRADE as low or moderate level evidence. Three studies showed superior curve correction in the APSF group; however, the meta-analysis showed no significant difference in curve correction between groups (95% CI - 3.45-12.96, P = 0.26). There were more complications in the APSF group, without statistical significance (95% CI 0.53-3.39, P = 0.54; I 2 = 0%, P = 0.78). There were no re-operations in either group. Two studies reported pulmonary function; one showed better function in the APSF group, the other better function in the PSF group. One study showed fewer fused segments in the APSF group, however, no significance was observed in the meta-analysis (95%CI - 1.65-0.31, P = 0.18). Three studies reported PROMs with no differences reported between groups. Conclusions: APSF and PSF have been found to have comparable results. The present evidence cannot support recommendations for guidelines on future practice with regards to effect on curve correction, complications, re-operations, pulmonary function or PROMs. Level of evidence: Level III, Systematic review of Level-III studies.

The Relationship between Sacral Kyphosis and Pelvic Incidence.

STUDY DESIGN: Retrospective cohort study. PURPOSE: Evaluate the fixed anatomical parameter of sacral kyphosis (SK) and its relationship with pelvic incidence (PI). OVERVIEW OF LITERATURE: Pelvic parameters determine pelvic and lumbar spinal position. Studies have defined normative values, and have evaluated the role of these parameters in clinical practice. It has been suggested that a ratio of sacral slope (SS)/PI <0.5 predisposes to spinal pathology. PI=SS+pelvic tilt (PT) and therefore for a given PI, patients with a higher SS due to an elevated SK will potentially predispose to an unfavourable SS/PI ratio. METHODS: CT measurements of SS and PI were made in 100 consecutive patients from our database. Imagings without clear landmarks were excluded. PI and SK were measured using standardised techniques. Pearson's correlation was used to assess association between PI and SK, in addition to the correlation between age and the pelvic parameters. Gender specific values for PI and SK were compared using an unpaired Student t-test. RESULTS: Ninety-five patients (52 females) with a mean age 51.3 years were available for analysis. A strong positive correlation between the PI and the SK was identified (Pearson's coefficient=0.636, R2 value=0.404). Neither PI nor SK had a statistically significant correlation with age (p=0.721 and p=0.572, respectively). The mean values of both the PI and SK were statistically significantly lower in females when compared to males (p=0.0461 and p=0.0031, respectively). CONCLUSIONS: A strong correlation between PI and SK exists and is a reflection of different pelvic morphologies. SK partially determines SS and a relatively high SK compared to PI will result in less ability to change PT and a potentially unfavourable SS/PI ratio, which could theoretically contribute to clinical pathology.

Myelography in the Assessment of Degenerative Lumbar Scoliosis and Its Influence on Surgical Management.

OBJECTIVE: Myelography has been shown to highlight foraminal and lateral recess stenosis more readily than computed tomography (CT) or magnetic resonance imaging (MRI). It also has the advantage of providing dynamic assessment of stenosis in the loaded spine. The advent of weight-bearing MRI may go some way towards improving assessment of the loaded spine and is less invasive, however availability remains limited. This study evaluates the potential role of myelography and its impact upon surgical decision making. METHODS: Of 270 patients undergoing myelography during 2006-2009, a period representing peak utilisation of this imaging modality in our unit, we identified 21 patients with degenerative scoliosis who fulfilled our inclusion criteria. An operative plan was formulated by our senior author based initially on interpretation of an MRI scan. Subsequent myelogram and CT myelogram investigations were scrutinised, with any additional abnormalities noted and whether these impacted upon the operative plan. RESULTS: From our 21 patients, 18 (85.7%) had myelographic findings not identified on MRI. Of note, in 4 patients, supine CT myelography yielded additional information when compared to supine MRI in the same patients. The management of 7 patients (33%) changed as a result of myelographic investigation. There were no complications of myelography of the total 270 analysed. CONCLUSION: MRI scan alone understates the degree of central and lateral recess stenosis. In addition to the additional stenosis displayed by dynamic myelography in the loaded spine, we have also shown that static myelography and CT myelography are also invaluable tools with regards to surgical planning in these patients.

The effect of total knee arthroplasty on lower limb blood flow.

Acute arterial injury at the time of total knee replacement (TKR) is a rare occurrence. We questioned whether TKR could exacerbate preexisting atherosclerotic disease causing chronic limb ischemia. Thirty-three patients undergoing unilateral TKR had the peripheral arterial supply of both legs assessed 2 weeks before and 6 weeks after the operation using various methods. Although a statistically significant reduction in the velocity ratio was measured in the trial leg, 0.92 (0.33) as compared to the control, 1.11 (0.46) (P = .0002) this was not found to be clinically significant when the minimum popliteal artery diameter of the trial limb, 6.23 (1.32), was compared with the control, 6.28 (1.27) (P = .8246). Neither were significant reductions in arterial waveforms or ABPIs measured in the trial legs preoperatively, 0.97 (0.20), and postoperatively, 0.93 (0.27) (P = .2793). TKR does not impair the arterial supply of the limb at 6-week postoperative period.