Functional recovery priorities and community rehabilitation service preferences of spinal cord injury individuals and caregivers of Chinese ethnicity and cultural background.

Introduction: Spinal cord injury (SCI) causes significant and permanent disability affecting motor, sensory and autonomic functions. We conducted a survey on the priorities of functional recovery and preferences for community rehabilitation services in a cohort of Chinese individuals with SCI as well as the primary caregivers. The study also investigated their views on advanced technology and research. Methods: An online platform with a self-administered questionnaire was used to collect the opinions of clients that received services from an SCI follow-up clinic, a self-help association, or a non-government organization from 1 September-31 December 2021. Results: Eighty-seven subjects (74 individuals with SCI-48 tetraplegic, 26 paraplegic, and 13 caregivers) responded to the survey. Recovery of arm/hand function was given the highest priority among tetraplegics, followed by upper trunk/body strength and balance, and bladder/bowel function. Sexual function had a significant lower ranking than all priority areas except normal sensation (p < 0.05). Paraplegics viewed bladder/bowel function as the most important area of functional recovery, followed by walking movement, upper trunk/body strength and balance, elimination of chronic pain, and regaining normal sensation. There was no statistically significant difference among the top priority areas (p > 0.05). In contrast to previous studies done in Western populations, the study revealed that sexual function was ranked as the lowest by all 3 groups of respondents (tetraplegics, paraplegics, and caregivers). The majority of participants thought community rehabilitation services were inadequate. Most of the respondents were interested to try advanced technology which would facilitate their daily life and rehabilitation. About half of the individuals with SCI thought advance in technology and research could bring significant improvement in their quality of life in the coming 10 years. Conclusion: This survey is the first study specifically looking into the recovery and rehabilitation priorities of a Chinese population of individuals with SCI. This is also the first study to investigate the priorities of the primary caregivers of SCI individuals. The findings are useful as a reference for planning of future research and provision of rehabilitation services for the SCI community locally and in other parts of China.

Knowledge Gaps in Biophysical Changes After Powered Robotic Exoskeleton Walking by Individuals With Spinal Cord Injury-A Scoping Review.

In addition to helping individuals with spinal cord injury (SCI) regain the ability to ambulate, the rapidly evolving capabilities of robotic exoskeletons provide an array of secondary biophysical benefits which can reduce the complications resulting from prolonged immobilization. The proposed benefits of increased life-long over-ground walking capacity include improved upper body muscular fitness, improved circulatory response, improved bowel movement regularity, and reduced pain and spasticity. Beyond the positive changes related to physical and biological function, exoskeletons have been suggested to improve SCI individuals' quality of life (QOL) by allowing increased participation in day-to-day activities. Most of the currently available studies that have reported on the impact of exoskeletons on the QOL and prevention of secondary health complications on individuals with SCI, are of small scale and are heterogeneous in nature. Moreover, few meta-analyses and reviews have attempted to consolidate the dispersed data to reach more definitive conclusions of the effects of exoskeleton use. This scoping review seeks to provide an overview on the known effects of overground exoskeleton use, on the prevention of secondary health complications, changes to the QOL, and their effect on the independence of SCI individuals in the community settings. Moreover, the intent of the review is to identify gaps in the literature currently available, and to make recommendations on focus study areas and methods for future investigations.

Outcomes of a Multicenter Safety and Efficacy Study of the SuitX Phoenix Powered Exoskeleton for Ambulation by Patients With Spinal Cord Injury.

Objective: To examine the safety and efficacy of ambulation utilizing a semi-passive and lightweight powered exoskeleton by spinal cord injury (SCI) patients. Methods: This is a multi-center, open-label, prospective cohort study across three facilities. A cohort of 40 individuals with SCI from T4-L5 was recruited into a 20-session training and assessment protocol, utilizing the SuitX Phoenix. All patients were tested using a 10-m-walk test (10 MWT), 6-min-walk test (6 MWT), and Timed up & Go test (TUG). Patient satisfaction, pain, exertion, changes in affect, as well as overall comfort and confidence were reported using a satisfaction survey, Rated Perceived Exertion (RPE) scale, and Positive and Negative Affect Schedule (PANAS). Safety outcomes, adverse events, and device malfunctions were reported. Results: Forty participants completed the study. There were no serious adverse events. All participants reported moderate to high levels of comfort and confidence using the device. All patients were able to achieve FIM of >4 on transitional movements and walking. The neurological level of injury had a statistically significant association with walking speed, WISCI-II, and FIM. Participants with an incomplete spinal cord injury had a higher FIM, faster speed, and higher WISCI-II in all outcome measures. Conclusion: This is the first study to examine the safety and efficacy of SuitX Phoenix for ambulation by SCI patients. We have shown that Phoenix is efficacious in allowing adults with SCI T4 to L5 perform walking and transitional movements. This study also reports the safety-profile of the device, user satisfaction, and psychological trends during training.

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.

Intrathecal Baclofen Pump Infection With Meningitis: Effective Treatment by Radical Debridement and Intrareservoir Baclofen-Vancomycin Co-Infusion.

OBJECTIVES: Intrathecal baclofen pump associated central nervous system (CNS) infection and meningitis is a rare but serious complication and may have dire consequences. Due to bacterial biofilm formation, the optimal treatment strategy is usually for removal of the pump, followed by systemic antibiotics for treatment of local and CNS infection. We describe this case of a patient with recurrent Staphylococcus aureus pump site empyema and meningitis leading to status dystonicus, who was successfully managed with radical debridement and intrareservoir baclofen-vancomycin co-infusion. MATERIALS AND METHODS: We retrospectively report a case of infected intrathecal baclofen pump with meningitis and provide a full review of literature. CONCLUSIONS: To the best of our knowledge, this is the first reported case of intrathecal baclofen (ITB)-associated pump site empyema and meningitis successfully treated with this technique. In selected cases where surgical explantation is deemed not feasible, this method can provide clinicians with an additional option for pump salvage and retention, while eradicating CNS infection and maintaining optimal control of spasticity and dystonia.

Surgical repair of a large intrathoracic meningocele associated with neurofibromatosis type 1 after failed cystoperitoneal shunts: illustrative case.

BACKGROUND: Surgical treatment of intrathoracic meningoceles, commonly associated with neurofibromatosis type 1 (NF1), aims to reduce sac size for symptomatic relief. The procedures can be divided into cerebrospinal fluid diversion and definitive repair. The authors describe the management of an intrathoracic meningocele in a 56-year-old female with preexisting NF1. OBSERVATIONS: The patient presented with progressive dyspnea. Magnetic resonance imaging revealed a left hemithoracic meningocele arising from the thecal sac at C7-T2. Two attempts at diversion by cystoperitoneal shunts resulted in recurrence. For definitive repair, T2-3 costotransversectomy was performed, and intradural closure of the meningocele opening was performed utilizing spinal dura and autologous fascia lata graft. Trapezius muscle regional flap was turned for reinforcement. Persistent leak warranted reoperation 7 days later. A transthoracic approach was undertaken using video-assisted thoracoscopic resection of the sac at aortic arch level, with reinforcement by latissimus dorsi flap and synthetic materials. Mechanical pleurodesis was performed. Intradural repair of the meningocele opening was revised. LESSONS: Inherent dural abnormality makes repair difficult for meningoceles associated with NF1. A combined intradural and thoracoscopic approach with regional muscle flap and synthetic material reinforcement is a unique method for definitive treatment. Some essential points of perioperative management are highlighted.

What every orthopaedic surgeon should know about COVID-19: A review of the current literature.

The coronavirus (COVID-19) pandemic has severely affected the medical community and stopped the world in its tracks. This review aims to provide the basic information necessary for us, orthopaedic surgeons to prepare ourselves to face this pandemic together. Herein, we cover the background of COVID-19, presentation, investigations, transmission, infection control and touch upon emerging treatments. It is of paramount importance that we should stay vigilant for our patients, our families and ourselves. Adequate infection control measures are necessary during day-to-day clinical work.

Predictive factors for neurological deterioration after surgical decompression for thoracic ossified yellow ligament.

PURPOSE: To investigate the rate and predictive factors of post-operative neurological deterioration in ossified yellow ligament (OYL) surgery. METHODS: A retrospective review was conducted for all patients with thoracic OYL causing myelopathy requiring surgical decompression from January 1998 to December 2012. Clinical parameters under study included clinical presentation, distribution of OYL, pre-operative walking score, pre- and post-operative neurological status, status of intra-operative neurophysiological monitoring, and modified Japanese Orthopaedic Association (mJOA) score. Any complications were also recorded. All outcomes were measured at post-operative 1 week and at 2 years. RESULTS: A total of 26 patients were included in this study. Most patients (92.3%) had Frankel grade D pre-operatively. The rate of neurological deterioration was 15.4% and was correlated with the presence of dural tear, extra-dural hematoma and spinal cord injury. Pre-operative walking score was prognostic of patients' walking ability in the post-operative period. Intra-operative monitoring of Somatosensory Evoked Potentials (SSEP) was found to be useful for monitoring spinal cord injury in OYL surgery, with a positive predictive value of 100% and a negative predictive value of 92.3%. The false negative rate of a SSEP signal drop was only 7.7% CONCLUSIONS: This is the first study exploring risk factors for post-operative neurological deterioration after surgery for thoracic OYL. The rate of neurological deficit is not small and prognostic factors for poor outcome include poor pre-operative walking score, presence of intra-operative dural tear, extra-dural hematoma and spinal cord injury, and intra-operative drop of SSEP signal.

A rare postoperative complication of anterior lower thoracic instrumentation: diaphragmatic laceration with hemothorax.

PURPOSE: To highlight the importance of preventing visceral injury due to prominent anterior implants at the spinal column. METHODS: A 52-year-old man with cord compression was treated with a T9/10 discectomy and instrumented fusion via a right thoracotomy and trans-pleural approach. Postoperatively, he had improved lower limb numbness. However, after a bout of coughing, there was sudden increase in chest drain output, hemodynamic instability and massive fluid collection in the right chest cavity. RESULTS: Emergency re-exploration of the thoracotomy was performed and a 6 cm laceration of the right postero-medial diaphragm was identified as the bleeding source and was found to be in close proximity with the locking nut of the anterior implants. The laceration was repaired and a soft synthetic patch was used to cover the implants. Postoperatively, the hemothorax resolved and the patient recovered from the neurological deficit. CONCLUSIONS: Prevention of diaphragmatic injury can be performed using lower profile and less sharp-edged implants. Implant coverage with a soft synthetic material is necessary if unable to perform direct repair of the parietal pleura over the implants.

Efficacy of Postoperative Pain Management Using Continuous Local Anesthetic Infusion at the Iliac Crest Bone Graft Site in Patients with Adolescent Idiopathic Scoliosis: A Parallel, Double-Blinded, Randomized Controlled Pilot Trial.

Study Design Randomized controlled trial. Objective Adolescent idiopathic scoliosis (AIS) is a common spinal deformity that affects every population. In severe deformity, surgical intervention is performed. Autogenous iliac crest bone graft (ICBG) harvesting remains a common procedure worldwide for scoliosis surgery. Postoperative pain at the ICBG donor site is a major concern in patients undergoing spine surgery that affects postoperative functional outcome and consumes health care resources. Previous studies have noted a decrease in pain and postoperative analgesic use with the application of continuous infusion of anesthetic at the ICBG site in comparison with placebo. However, there is lack of evidence addressing the efficacy of continuous anesthetic infusion at the ICBG site in young patients and in particular those with spinal deformity, such as AIS. As such, this parallel, double-blinded, randomized controlled trial addressed the pain management efficacy of continuous anesthetic infusion versus saline at the ICBG site in patients with AIS during the immediate postoperative period. Methods Participants were randomized into two groups. Group A (control subjects) received 3 mL per hour of saline locally at the ICBG site, and group B (treatment subjects) received a constant rate of infusion of 3 mL per hour of 0.25% levobupivacaine. Both groups received their postoperative intervention for 47 hours. All subjects and outcome assessors were blinded to the type of intervention. Utilizing the visual analog pain scale, pain was assessed at the primary spine surgical site, ICBG site, and contralateral ICBG site. Overall physical pain was assessed by the McGill Pain Questionnaire. The degree of analgesic use and complications were also evaluated. All outcomes were assessed up until the fourth day of the patients' hospitalization following surgery. Results Twelve subjects were recruited (five in group A; seven in group B). No difference was noted at baseline regarding age, weight, height, arm span, sex, curve type, instrumented and fused levels, length of hospitalization, and pain scores between groups. Postoperatively, no difference was noted in surgical site pain between groups (p > 0.05). However, decreased ICBG and contralateral ICBG pain decreased twofold in group B patients in comparison with group A. Similarly, group B subjects had notably decreased postoperative overall pain scores (group A, mean 15.3; group B, mean 3.8). No significant differences were noted for the pain scores due to the small sample size. Conclusions This study is the first with a robust level I study design to assess the efficacy of continuous infusion of analgesia into the ICBG site in young patients with AIS. This pilot study noted a trend that continuous anesthetic infusion reduces pain at the ICBG site and may further decrease overall physical bodily pain. This study further established a sample size calculation to facilitate large-scale studies addressing these parameters. This study provides further support of postoperative pain management options for children with spinal deformities.

Antimicrobial prophylaxis to prevent surgical site infection in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion: 2 doses versus antibiotics till drain removal.

PURPOSE: There is much variation in the choice, timing and duration of antimicrobial prophylaxis for preventing surgical site infections (SSI) but no guideline exists for scoliosis surgery. The aim of study was to compare the efficacy of two antimicrobial prophylaxis (AMP) protocols with cephazolin in preventing SSI in adolescent idiopathic scoliosis (AIS). METHODS: A retrospective comparative analysis of two post-operative AMP protocols (two postoperative doses versus continued antibiotics till drain removal) was performed. Patient characteristics, pre-operative, intra- and post-operative risk factors for infection, drain use, generic drug name and number of doses administered were recorded from 226 patients with AIS who had undergone posterior spinal fusion. Details of superficial or deep SSI and wound healing aberrations, and serious adverse events were recorded. Analysis was performed to evaluate differences in the pre-, intra- and post-operative variables between the two groups. RESULTS: 155 patients received 2 postoperative doses of AMP and 71 patients had antibiotics till drain removal. The average follow-up was 43 months. The overall rate of SSI was 1.7 % for the spine wound and 1.3 % for the iliac crest wound. 1.9 % of patients with 2 doses of AMP and 1.4 % of patients with antibiotics till drain removal had SSI. No adverse reactions attributable to cephazolin were observed. CONCLUSIONS: This is the first study on the AMP protocol in scoliosis surgery for SSI prevention. Results suggest that two doses of AMP are as effective as continued antimicrobial use until drain removal. Cephazolin appears to be effective and safe for prophylaxis.

Disappearing bone disease of the humerus and the cervico-thoracic spine: a case report with 42-year follow-up.

BACKGROUND CONTEXT: Disappearing bone disease (DBD) is a rare idiopathic musculoskeletal disorder that is distinguished by bone resorption without bone formation, vascular or lymphatic vessel proliferation, and soft-tissue swelling. Long-term follow-up of a patient with DBD has rarely been reported in the literature. PURPOSE: The following is a case report of a female patient with DBD of the humerus and the spine who was followed for 42 years, documenting the progression of the disease and outcomes. STUDY DESIGN: Case report. METHODS: A review of the medical records since the time of initial hospital admission throughout follow-up was performed. RESULTS: A female patient was first seen at our institution at the age of 14. She later developed DBD of the humerus and the spine. The initial difficulty encountered was reaching the diagnosis, and later on with management of the patient as the disease progressed. The case was complicated by syrinx and arachnoid cyst formation, which caused neurologic changes leading to tetraplegia and shunt infection. The patient's inability to form a solid fusion mass led to repeated implant loosening and progressive deformity despite efforts made to stabilize both the humerus and the spine. The treatment modalities used were oral bisphosphonates, rhBMP, repeated surgeries, and instrumentation with adjunct bone graft and substitutes. At the age of 56 years, the patient died because of septicemia secondary to urinary tract infection from tetraplegia. CONCLUSIONS: To our knowledge, this is the first report documenting a 42-year follow-up of a patient with DBD of the humerus and the spine. Our report showed that DBD greatly affects the quality of life of the patient. Close follow-up, a multidisciplinary approach, and supportive care are stressed when managing patients with DBD.

A population-based cohort study of 394,401 children followed for 10 years exhibits sustained effectiveness of scoliosis screening.

BACKGROUND CONTEXT: The value of scoliosis screening has been recently shown in a multicenter randomized controlled trial. However, the long-term sustainability of the clinical effectiveness of scoliosis screening as a routine health service remains unknown. PURPOSE: The aim of this study was to assess the sustainability of the clinical effectiveness of school scoliosis screening. STUDY DESIGN/SETTING: A large population-based cohort study with a 10-year follow-up was conducted. PATIENT SAMPLE: A total of 394,401 students who were in the fifth grade during the five academic years from 1995/1996 to 1999/2000 formed five consecutive annual cohorts. The students were eligible for the Hong Kong scoliosis screening program, with their screening history and medical records until their nineteenth birthdays being assessed. OUTCOME MEASURES: The outcome measures considered in the study were development of adolescent idiopathic scoliosis by the 19 years of age and the Cobb angle. METHODS: The clinical effectiveness of scoliosis screening was assessed by referral rate for radiographic diagnosis, sensitivity, specificity, and predictive values. RESULTS: A total of 306,144 students (78%) participated in scoliosis screening, which used a two-tier system. The prevalence of curves of 20° or greater was 1.8% (95% confidence interval [CI], 1.7-1.8%), whereas the referral rate for radiography, the sensitivity, and the positive predictive value (PPV) for curves of 20° or greater were 4.1% (95% CI, 4.0-4.2%), 91% (95% CI, 90-92%), and 40% (95% CI, 39-41%), respectively. Across the five consecutive annual cohorts, the prevalence and sensitivity for curves of 20° or greater increased by 0.23% (95% CI, 0.21-0.25%; p<.001) and 0.76% (95% CI, 0.43-1.04%; p<.001) per year, respectively; however, the PPV was reduced by 1.71% (95% CI, 1.09-2.33%; p<.001) per year. CONCLUSIONS: This report describes the first large population-based study with a long-term follow-up indicating that a scoliosis screening program can have sustained clinical effectiveness in identifying patients with adolescent idiopathic scoliosis needing clinical observation. As the prevalence of adolescent idiopathic scoliosis increases, scoliosis screening should be continued as a routine health service in schools or by general practitioners if there is no scoliosis screening policy.

Acute spinal subdural hematoma complicating lumbar decompressive surgery.

STUDY DESIGN: A case report. OBJECTIVE: To report a rare case of acute spinal subdural hematoma (SSH) complicating lumbar spine surgery, its characteristic presenting symptoms, diagnostic imaging, possible cause, and pitfall in management. METHODS: A 59-year-old woman with lumbar spinal instability and stenosis underwent laminectomy and decompression at L3-L5 with instrumentation and fusion from L3-S1. RESULTS: Immediately following surgery, the patient presented with incapacitating pain of both lower extremities from the mid-thigh downward, which was not relieved by narcotic analgesia and was disproportional to surgical trauma. Left ankle and great toes weakness was detected at postoperative day 2 and deteriorated on day 6. Magnetic resonance imaging was performed urgently and revealed a characteristic SSH with thecal sac compression at the level of L2, proximal to the laminectomy. Emergency decompression and evacuation of the hematoma was performed. The patient had partial recovery 6 weeks postoperatively. CONCLUSION: Acute SSH is a rare complication of lumbar spine surgery. This diagnosis must be considered when severe leg pain, unresolved with analgesia and disproportional to surgical trauma, with neurological deterioration occurring after lumbar spine surgery. Magnetic resonance imaging is the imaging modality of choice to assist in the differential diagnosis of an SSH. Early surgical decompression is necessary for optimal neurological recovery.

The predictive value of the fulcrum bending radiograph in spontaneous apical vertebral derotation in adolescent idiopathic scoliosis.

STUDY DESIGN: A prospective cohort study of Cobb angles (CA) and apical vertebral rotations (AVR) in 25 patients who had adolescent idiopathic scoliosis. OBJECTIVE: To assess in vivo the concomitant vertebral derotation occurring with correction of scoliosis deformity as a result of coupling effect by using the fulcrum bending radiograph and to assess whether the fulcrum bending radiograph can predict the amount of postoperative apical derotation when no additional intraoperative apical derotation maneuver is used. SUMMARY OF BACKGROUND DATA: Adolescent idiopathic scoliosis (AIS) is a 3-dimensional coupling deformity. Various studies have reported vertebral derotational effects, using different implant constructs and surgical techniques for AIS. However, none of them have considered the spontaneous coupling effect on vertebral derotation produced by correction of the coronal deformity, in particular, using the predictive capacity of the preoperative fulcrum bending radiograph. METHOD: Twenty-five patients with flexible Lenke type 1 AIS with CA greater than 45° who underwent posterior spinal fusion with instrumentation, without direct apical derotation were prospectively assessed. CA and AVR in standing, supine, and fulcrum bending positions preoperatively and in supine position postoperatively were assessed on radiographs and computed tomographic scans. RESULTS.: The study entailed 80% adolescent girls and 20% adolescent boys (mean age, 15.5 years). The mean AVR values on preoperative standing, supine, and fulcrum bending positions and postoperation were 24.2°, 17.7°, 9.8°, and 8.1° respectively. The preoperative AVR highly correlated with the preoperative CA (R = 0.75). The postoperative AVR was correlated with the postoperative CA (r = 0.82) and the change in curve magnitude (r = -0.49), correction rate (r = -0.83), and fulcrum bending correction index (r = -0.45) (P < 0.05). There was no significant difference in AVR between preoperative fulcrum bending and postoperative assessment. CONCLUSION: Correction of scoliosis deformity produces spontaneous reduction of rotational deformity through coupling. The amount of spontaneous apical vertebral derotation with fulcrum bending can be used to assess the flexibility of the rotational deformity. In flexible curves, it also predicts the amount of apical derotation achievable with surgery. These should be considered when assessing the derotational effect of different implants and surgical strategies.

Magnetically controlled growing rods for severe spinal curvature in young children: a prospective case series.

BACKGROUND: Scoliosis in skeletally immature children is often treated by implantation of a rod to straighten the spine. Rods can be distracted (lengthened) as the spine grows, but patients need many invasive operations under general anaesthesia. Such operations are costly and associated with negative psychosocial outcomes. We assessed the effectiveness and safety of a new magnetically controlled growing rod (MCGR) for non-invasive outpatient distractions. METHODS: We implanted the MCGR in five patients, two of whom have now reached 24 months' follow-up. Each patient underwent monthly outpatient distractions. We used radiography to measure the magnitude of the spinal curvature, rod distraction length, and spinal length. We assessed clinical outcome by measuring the degree of pain, function, mental health, satisfaction with treatment, and procedure-related complications. FINDINGS: In the two patients with 24 months' follow-up, the mean degree of scoliosis, measured by Cobb angle, was 67° (SD 10°) before implantation and 29° (4°) at 24 months. Length of the instrumented segment of the spine increased by a mean of 1·9 mm (0·4 mm) with each distraction. Mean predicted versus actual rod distraction lengths were 2·3 mm (1·2 mm) versus 1·4 mm (0·7 mm) for patient 1, and 2·0 mm (0·2 mm) and 2·1 mm (0·7 mm) versus 1·9 mm (0·6 mm) and 1·7 mm (0·8 mm) for patient 2's right and left rods, respectively. Throughout follow-up, both patients had no pain, had good functional outcome, and were satisfied with the procedure. No MCGR-related complications were noted. INTERPRETATION: The MCGR procedure can be safely and effectively used in outpatient settings, and minimises surgical scarring and psychological distress, improves quality of life, and is more cost-effective than is the traditional growing rod procedure. The technique could be used for non-invasive correction of abnormalities in other disorders. FUNDING: Ellipse Technologies.

Natural history of spinal deformity in a patient with Ehlers-Danlos syndrome: case report with 20-year follow-up.

BACKGROUND CONTEXT: Scoliosis can present in patients with Ehlers-Danlos syndrome (EDS) and can be surgically treated despite possible complications. The long-term natural history of the progression of spinal deformity, particularly scoliosis, and associated complications in EDS patients remains relatively unknown. PURPOSE: To assess the progression of spinal deformity and associated complications in a patient with EDS, who was not surgically treated for her spine condition and was followed up for 20 years. STUDY DESIGN: A case report. METHODS: A 9-year-old female with EDS presented to the orthopedic clinic with scoliosis and mild thoracic hyperkyphosis. The patient was followed up for a 20-year period. Progression of her spinal deformity and associated complications were noted. RESULTS: The patient's curve progressed rapidly in the initial follow-up period an 83° worsening from the age of 9 to 10 years. Because she refused surgical intervention, her spinal deformity continued to progress. As such, by the age of 29 years, she presented with 115° from T9 to L4 with severe hyperkyphosis. The patient eventually developed respiratory compromise and diminished functional capacity. CONCLUSIONS: In patients with EDS, scoliosis may progress rapidly and unrelentingly, and if not treated early may lead to respiratory compromise. Close follow-up of such patients is imperative, and appropriate management should be sought to prevent potentially fatal morbidities.

The "X-Factor" index: a new parameter for the assessment of adolescent idiopathic scoliosis correction.

The correction rate (CR) and fulcrum bending correction index (FBCI) based on the fulcrum bending radiograph (FBR) were parameters introduced to measure the curve correcting ability; however, such parameters do not account for contributions by various, potential extraneous "X-Factors" (e.g. surgical technique, type and power of the instrumentation, anesthetic technique, etc.) involved in curve correction. As such, the purpose of the following study was to propose the concept of the "X-Factor Index" (XFI) as a new parameter for the assessment of the correcting ability of adolescent idiopathic scoliosis (AIS). A historical cohort radiographic analysis of the FBR in the setting of hook systems in AIS patients (Luk et al. in Spine 23:2303-2307, 1998) was performed to illustrate the concept of XFI. Thirty-five patients with AIS of the thoracic spine undergoing surgical correction were involved in the analysis. Plain posteroanterior (PA) plain radiographs were utilized and Cobb angles were obtained for each patient. Pre- and postoperative PA angles on standing radiograph and preoperative fulcrum bending angles were obtained for each patient. The fulcrum flexibility, curve CR, and FBCI were determined for all patients. The difference between the preoperative fulcrum bending angle and postoperative PA angle was defined as Angle(XF), which accounted for the correction contributed by "X-Factors". The XFI, designed to measure the curve correcting ability, was calculated by dividing Angle(XF) by the fulcrum flexibility. The XFI was compared with the curve CR and FBCI by re-evaluating the original data in the original paper (Luk et al. in Spine 23:2303-2307, 1998). The mean standing PA and FBR alignments of the main thoracic curve were 58.3° and 24.5°, respectively. The mean fulcrum flexibility was 58.8%. The mean postoperative standing PA alignment was 24.7°. The mean curve CR was 58.0% and the mean FBCI was 101.1%. The mean XFI was noted as 1.03%. The CR was significantly positively correlated to curve flexibility (r = 0.66; p < 0.01).The FBCI (r = -0.47; p = 0.005) and the XFI (r = -0.45; p = 0.007) were significantly negatively correlated to curve flexibility. The CR was not correlated to Angle(XF) (r = 0.29; p = 0.089).The FBCI (r = 0.97; p < 0.01) and the XFI (r = 0.961; p < 0.01) were significantly positively correlated to Angle(XF). Variation in XFI was noted in some cases originally presenting with same FBCI values. The XFI attempts to quantify the curve correcting ability as contributed by "X-Factors" in the treatment of thoracic AIS. This index may be a valued added parameter to accompany the FBCI for comparing curve correction ability among different series of patients, instrumentation, and surgeons. It is recommended that the XFI should be used to document curve correction, compare between different techniques, and used to improve curve correction for the patient.

The proximal thoracic curve in adolescent idiopathic scoliosis: surgical strategy and management outcomes.

There is no consensus on the definition of a structural proximal thoracic curve (PTC) and the indications for fusion. As such, we assessed a single institute's experience in the management of large PTCs (>35 degrees) in patients with adolescent idiopathic scoliosis (AIS) who were either fused or not fused. A retrospective radiographic analyses of 30 consecutive AIS patients with double thoracic curves who underwent PSF with a minimum of 2 years' follow-up were included for review. The patients were divided into two groups: group 1 (n = 15 patients) with fusion extended up to T2 or T3 and group 2 (n = 15) with fusion limited to T5 or below. Shoulder balance was assessed according to clavicular angle, first-rib difference, and radiographic shoulder height difference (SHD). PTCs were defined based on a Cobb angle of >35, the presence of apical rotation, and a positive T1 tilt. The decision to fuse the PTC was based on curve magnitude only, with those between 35 and 45 degrees undergoing a selective fusion of the main thoracic curve (MTC), with both curves fused if the PTC was more than 45 degrees. In group 1, there were eight females and seven males. Their ages ranged between 12 and 33 years, with a mean of 16.2 ± 5.5 years. Postoperatively, the mean PTC correction was 45.6%, which statistically differed from preoperative status (p = 0.001). No statistical difference was noted in T1 tilt and the first-rib difference from preoperative to postoperative follow-up (p > 0.05). However, the clavicular angle and SHD were increased significantly at the immediate postoperative interval (p < 0.05) but demonstrated no significant changes between the initial and the last follow-up values (p > 0.05). Group 2 consisted of one male and 14 females. The mean age was 16.4 ± 4 years (range: 11 to 28 years). The mean spontaneous PTC correction was 28.3% and remained essentially unchanged at the end of the follow-up. The improvement in the curve from preoperative status was highly statistically significant (p = 0.001). All radiographic shoulder parameters exhibited a significant increase in the immediate postoperative period and at last follow-up, and shoulder balance improvement was not noted on follow-up. Although both groups were not statistically similar with regards to the preoperative PTC, AVR, apical vertebral translation, and shoulder parameters, no significant difference could be found in PTC or shoulder parameters between both groups at last follow-up (p > 0.05). Our study illustrates important observations that should be considered in defining the PTC for fusion consideration. Spontaneous correction of the PTC occurs in structural curves greater than 35 degrees and less than 45 degrees, and this correction is maintained over time. Despite that correction, radiographic shoulder parameters are expected to slightly increase. Nonfusion strategy may be appropriate for PTCs between 35 and 45 degrees. After fusion of both the MTC and the PTC, the radiographic shoulder parameters did not significantly differ. Preoperative radiographic shoulder parameters are not predictive of postoperative shoulder imbalance.