Dual versus Single Attending Surgeon Performance of Spinal Deformity Surgery? A Meta-Analysis.

BACKGROUND: The inclusion of two surgeons in spinal deformity surgery is considered beneficial by some. In fact, select studies indicate advantages such as reduced operation time and blood loss. Another observed decreased patient morbidity with a dual-surgeon approach, attributed to shorter operative times and reduced intra-operative blood losses. Therefore, this meta-analysis will assess the benefits of a having two surgeons compared to one surgeon during spine surgeries. METHODS: PubMed, Cochrane, and Google Scholar (page 1-20) were searched till January 2024. The clinical outcomes evaluated were the incidence of adverse events, the rate of transfusion, reoperation, and surgery-related parameters such as operative room time, length of stay (LOS), and estimated blood loss (EBL). RESULTS: Thirteen studies were included. A greater rate of complications was seen in patients operated upon by one surgeon (OR=0.50; 95% CI: 0.25-0.99, p=0.05). Furthermore, operative room time (MD=-82.73; 95% CI: -111.42- -54.03, p<.001), and LOS (MD=-0.91; 95% CI: -1.12- -0.71, p<.001) were reduced in the dual surgeon scenario. No statistically significant difference was shown in the remaining analyzed outcomes. CONCLUSION: The presence of two surgeons in the OR was shown to reduce complications, operative room time, and LOS. More cost-effectiveness studies are needed in order to substantiate the financial advantages associated with the dual-surgeon approach.

Intensive Care Unit Admission After Spine Surgery: A Narrative Review.

INTRODUCTION: Intensive care unit (ICU) admissions constitute a substantial financial challenge for health care systems and patients and are linked to various potentially life-altering complications. A wide range of patient-related, surgical, and medical factors are associated with an increased risk of ICU admission following spine surgery. DISCUSSION: The most notable examples include lung, heart, and kidney disease, as well as estimated blood loss and length of surgery. Various scores that include the most significant patient- and procedure-related factors have been described to assess the risk associated with surgery for individual patients. To date, the fusion risk score and the American Society of Anesthesiologists score have been the most useful in predicting postoperative complications and admission to the ICU. However, other risk factors have also been implicated in ICU admission and length of stay. The current scores must further adapt by using the available evidence to fulfill their intended purpose. Moreover, a handful of measures have shown efficacy in decreasing ICU admission and length of stay, with their benefits still to be demonstrated by future research. CONCLUSION: This review underscores the risk factors predictive of ICU admission following spine surgery and will help surgeons and clinicians in patient stratification. However, future studies are needed to validate the role of protective measures in preventing ICU admissions and the significance of certain risk factors.

Implant density in adolescent idiopathic scoliosis: a meta-analysis of clinical and radiological outcomes.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) affects 1-3% of adolescents, and treatment approaches, including the density of constructs in surgical fusion, vary among orthopedic surgeons. Studies have sought to establish whether high-density or low-density constructs offer superior clinical and radiological outcomes, yet conclusive results are lacking. This meta-analysis aims to provide a definitive answer to the controversial and ambiguous question surrounding the efficacy of different pedicle screw densities in treating AIS. METHODS: PubMed, Cochrane, and Google Scholar (page 1-20) were searched till December 2023. The studied outcomes were Major Cobb angle, major curve correction, lumbar curve, kyphosis (T5-T12), lumbar lordosis, coronal balance, LIV Tilt angle, TAV translation, LAV translation, apical trunk rotation, trunk shift, SRS-22, operative time, blood loss, complications and cost. RESULTS: Twenty-four studies (total of 1985 patients, 1045 in LD group and 940 in HD group) were included in this meta-analysis. A statistically significant better improvement in ATR (p = 0.02) and LIV tilt angle (p = 0.02) was seen in the high-density group. On the other hand, longer operative time (p = 0.002), blood loss (p = 0.0004) and costs (p = 0.02) were seen in the high-density group. No difference was seen in the remaining radiographic and clinical outcomes between both surgeries. CONCLUSION: Both low-density (LD) and high-density (HD) screw constructs show comparable and satisfactory radiographic and QOL for AIS patients. Furthermore, HD constructs had increased costs, operative time, and blood loss associated. However, a definitive conclusion cannot be made and more studies taking into account multiple additional variables are necessary to do so.

Unilateral Versus Bilateral Cages in Lumbar Interbody Fusions: A Meta-Analysis of Clinical and Radiographic Outcomes.

BACKGROUND: Bilateral cages are often used for interbody fusion. However, this procedure may not be possible in some cases making unilateral cages a reasonable alternative. The literature remains divided on the clinical and radiological distinctions when comparing unilateral to bilateral cages in lumbar interbody fusion. Thus, this meta-analysis will analyze the clinical and radiographic outcomes between these 2 groups. METHODS: PubMed, Cochrane, and Google Scholar (page 1-20) were searched till January 2024. The clinical outcomes evaluated were the incidence of adverse events, surgery-related parameters, and patient reported outcomes. RESULTS: Lower rates of pseudoarthrosis, subsidence, were reported in the bilateral cages group (P = 0.01, P = 0.001, respectively) whereas shorter operative time (OR time), and lower estimated blood loss were seen in unilateral cage group (P < 0.001, and P = 0.003). There was no statistically significant difference in the remaining analyzed outcomes. CONCLUSIONS: Unilateral cages were shown to be superior due to their reduced OR time and estimated blood loss. As for the higher rate of pseudoarthrosis, this outcome may not be related to the cage numbers and it did not affect clinical outcomes. Nevertheless, one must consider other factors such as radiographic sagittal parameters before making a surgical decision.

Hybrid vs all pedicle screws constructs in adolescent idiopathic scoliosis: a metaanalysis of clinical and radiological outcomes.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) affects around 1 to 3% of young individuals, leading to spinal deformities typically exceeding a Cobb angle of 10 degrees without congenital or neuromuscular causes. Advances in treatment now include various surgical techniques such as posterior fusion utilizing all-pedicle screw constructs or hybrid constructs. METHODS: PubMed, Cochrane, and Google Scholar (pages 1-20) were searched up until February 2024. Comparative studies in which the cohort was separated into two groups (HC and PSC) were included. Data consisting of, surgery-related outcomes, sagittal radiographic outcomes, coronal radiographic outcomes, and patient-reported outcomes, was extracted and compared. RESULTS: Twenty-eight studies including 3435 patients were included. Higher rates of complications (Odds-Ratio = 1.99, p < 0.00001) and reoperations (Odds-Ratio = 2.82, p < 0.00001) were seen in the hybrid group. Better radiographic coronal correction was seen in the PSC group in both the major curve (Mean Difference = 5.97, p < 0.00001) and the secondary curve (Mean Difference = - 10.73, p < 0.0001). However, restoration of sagittal alignment was better in the HC group when assessing thoracic kyphosis (Mean Difference = 2.97, p = 0.02) and lumbar lordosis (Mean Difference = 3.17, p = 0.005). CONCLUSION: While all-pedicle screw constructs demonstrated greater stability in AIS compared to hybrid constructs, resulting in reduced rates of reoperations and complications, as well as improved correction of major and secondary curves, they were unable to fully restore optimal sagittal alignment.

Will ChatGPT be Able to Replace a Spine Surgeon in the Clinical Setting?

OBJECTIVE: This study evaluates ChatGPT's performance in diagnosing and managing spinal pathologies. METHODS: Patients underwent evaluation by two spine surgeons (and the case was discussed and a consensus was reached) and ChatGPT. Patient data, including demographics, symptoms, and available imaging reports, were collected using a standardized form. This information was then processed by ChatGPT for diagnosis and management recommendations. The study assessed ChatGPT's diagnostic and management accuracy through descriptive statistics, comparing its performance to that of experienced spine specialists. RESULTS: A total of 97 patients with various spinal pathologies participated in the study, with a gender distribution of 40 males and 57 females. ChatGPT achieved a 70% diagnostic accuracy rate and provided suitable management recommendations for 95% of patients. However, it struggled with certain pathologies, misdiagnosing 100% of vertebral trauma and facet joint syndrome, 40% of spondylolisthesis, stenosis, and scoliosis, and 22% of disc-related pathologies. Furthermore, ChatGPT's management recommendations were poor in 53% of cases, often failing to suggest the most appropriate treatment options and occasionally providing incomplete advice. CONCLUSIONS: While helpful in the medical field, ChatGPT falls short in providing reliable management recommendations, with a 30% misdiagnosis rate and 53% mismanagement rate in our study. Its limitations, including reliance on outdated data and the inability to interactively gather patient information, must be acknowledged. Surgeons should use ChatGPT cautiously as a supplementary tool rather than a substitute for their clinical expertise, as the complexities of healthcare demand human judgment and interaction.

Acute unexplained T1-T2 fracture-dislocation following posterior instrumentation and fusion for paralytic scoliosis.

INTRODUCTION AND IMPORTANCE: Upper thoracic fracture-dislocation following posterior instrumentation and fusion is rare, with potentially devastating neurologic consequences. The recommended treatment is an open reduction, spinal cord decompression, and a proximal extension of spinal instrumentation. To report the diagnosis and management of an acute non-traumatic T1-T2 fracture-dislocation, occurring in the early postoperative course of a posterior instrumentation and fusion for neurogenic scoliosis. CASE REPORT: A 12-year-old spastic quadriplegic cerebral palsy (CP) male patient, who underwent an uneventful T2-S1 instrumentation for scoliosis, presented to the emergency department (ED) 2 weeks later, with mild fever, urinary retention, fecaloma and hypotonia of the 4 limbs, of few days duration. His parents reported no history of trauma and denied epileptic seizures. Atypical cervicothoracic spastic movements the night preceding his symptoms were the only relevant events of the patient's history. CT and MRI were both suggestive of a complete T1-T2 fracture-dislocation and spinal cord compromise. CLINICAL DISCUSSION: The patient underwent immediate posterior decompression with wide lamino-arthrectomy, open reduction and proximal extension of his posterior instrumentation to C5. One year following surgery, there was only mild sensorimotor and bladder and bowel function recovery. CONCLUSION: To our knowledge, this is the first report of an acute non-traumatic unexplained T1-T2 fracture-dislocation following posterior instrumentation and fusion. Despite a proper management, only very mild recovery was observed one year following surgery.

Approaches in Anterior Column Support in Adult Spinal Deformity Surgery: A Meta-Analysis of Clinical and Radiologic Outcomes.

OBJECTIVE: This meta-analysis was conducted to compare anterior lumbar interbody fusion (ALIF) with transforaminal lumbar interbody fusion (TLIF) in terms of postoperative complications, improvement in radiographic parameters, and patient-reported outcomes. METHODS: PubMed, Cochrane, and Google Scholar (pages 1-20) databases were searched up to June 2023. The studied outcomes were the rate of rod failures, rod failures requiring revision surgery, all complications, all revision surgeries, the change in pelvic tilt, sacral slope, Cobb angle, lumbar lordosis (LL), sagittal vertical axis, the postoperative pelvic incidence-LL, and LL, and the improvement in back pain and Oswestry Disability Index (ODI). RESULTS: Six studies were included in this meta-analysis. ALIF showed higher postoperative lordosis (P = 0.003) and better improvement in ODI (P = 0.0001). No difference was seen in the remaining outcomes between ALIF and TLIF. CONCLUSIONS: Although ALIF had better improvement in ODI, the mean difference was 6.5 points, which is below the minimal clinically important difference, stripping this result of any clinical value. Furthermore, even though ALIF had better postoperative lordosis, the change in LL postoperatively was not different between ALIF and TLIF. With no difference in complications, sagittal and coronal alignment, and patient-reported outcomes, TLIF was shown in this study to be favored instead of ALIF in adult spinal deformity surgery to avoid all the double approach-related comorbidity.

Exceptional Spinal Mobility Caused by Charcot Disease: Case Description with Several Years of Follow-Up.

A spinal cord injury is now the most common cause of Charcot Spinal Arthropathy (CSA). Paraplegia, loss of pain sensation, laminectomies, and spinal fusions involving more than 5 levels are all risk factors for developing this condition. Low back pain and spinal abnormalities are common symptoms. Circumferential arthrodesis is the chosen treatment. Implant failure and new-onset CSA, which necessitates re-instrumentation, are some of the risks associated with this treatment. This is the case of a patient with a post-traumatic spinal cord injury presenting with spinal Charcot disease with a very long follow-up. We report a unique complication with the replacement of the discal space and portions of the vertebral bodies by fibrotic tissue with an extraordinary spinal movement in the coronal and sagittal planes. Recurrent Charcot disease at the same level or at a caudal level is a devastating complication in spinal surgery. Since this disease naturally exposes the patient to iterative surgeries, it would be wise to limit the extent of the arthrodesis to an optimal number of levels sufficient to ensure perfect stability of the construct and not to be very extensive from the first surge. The risk would increase the fused levels which limit the availability of mobile buffer levels and increase the stress on the remaining levels. Regular follow-ups to the patient should be done to detect recurrence at the same site or distal to the instrumentation.

Transforaminal lumbar interbody fusion using banana-shaped and straight cages: meta-analysis of clinical and radiological outcomes.

PURPOSE: Transforaminal lumbar interbody fusion (TLIF) surgery rate increased over the last decade. There is no consensus about the better shape of cage to use in TLIF. This meta-analysis was conducted to compare the shape focusing on bony union, lordosis restoration as well as perioperative complications. METHODS: PubMed, Cochrane, and Google Scholar (page 1-20) were searched till September 2022. The clinical outcomes consisted of the bony union, segmental and lumbar lordosis restoration, quality of life, and operation-related outcomes. RESULTS: Only 5 studies were included in this meta-analysis. Straight-shaped cages tended to have a lower subsidence rate compared to banana-shaped cages (p = 0.10), had a better restoration of segmental lordosis (p < 0.0001), better disc height restoration (p = 0.01), as well as a higher Oswestry Disability Index decrease (p = 0.0002). CONCLUSION: Straight-shaped cages had a better restoration of lumbar lordosis, disc height, and a lower subsidence rate when compared to banana-shaped cages. This may be explained by the absence of the optimal placement of the curved cages, which is at the most anterior part of the disc space. Better conducted randomized controlled trial could strengthen these findings.

Vertebroplasty versus Kyphoplasty in the Treatment of Osteoporotic Vertebral Compression Fractures: A Meta-Analysis.

BACKGROUND: One of the most frequent consequences of osteoporosis is osteoporotic vertebral compression fractures, which makes it one of the most prevalent health care crises in the world. Two things are needed to manage them: 1) pain management, and 2) fracture stabilization. To take care of both, 2 methods are commonly used: 1) vertebroplasty and 2) kyphoplasty (KP) without a clear consensus on which is the better one. A meta-analysis was done comparing both techniques in the management of osteoporotic vertebral compression fractures. METHODS: PubMed, Cochrane, and Google Scholar (page 1-20) were searched updated to October 2022. Two reviewers determined the eligibility of the studies independently. Only 8 studies were included in the meta-analysis. The clinical outcomes consisted of the complications (cement leakage, adjacent level fractures), the visual analog scale scores, Oswestry disability index, kyphotic wedge angle, and vertebral body height restoration. RESULTS: KP was shown to be superior to vertebroplasty in terms of reducing cement leakage, and increasing postoperative vertebral body height. The comparison of the rest of the outcomes was statistically insignificant between both techniques. CONCLUSIONS: Although KP could significantly increase postoperative vertebral body height and decrease the risk of cement leakage, the fact that it is more costly and has a longer operative time raises the question about the cost effectiveness of the procedure.

Scheuermann's kyphosis: update on pathophysiology and surgical treatment.

Scheuermann's Kyphosis (SK) is a rigid spinal kyphosis. Several theories have been proposed concerning its pathogenesis, but it is, to this day, still unknown. It has a prevalence of 0.4-8.3% in the population with a higher incidence in females. Clinical examination with x-rays is needed to differentiate and confirm this diagnosis. Non-surgical management is reserved for smaller deformities and in skeletally immature patients, whereas surgery is recommended for higher deformities. Combined anterior and posterior approach was considered the gold standard for the surgical treatment of this disease, but there is an increasing trend toward posterior-only approaches especially with use of segmental fixation. This study reviews the pathophysiology of SK while proposing a treatment algorithm for its management.

Clinical predictive model of lumbar curve Cobb angle below selective fusion for thoracic adolescent idiopathic scoliosis: a longitudinal multicenter descriptive study.

PURPOSE: To implement a clinically applicable, predictive model for the lumbar Cobb angle below a selective thoracic fusion in adolescent idiopathic scoliosis. METHODS: A series of 146 adolescents with Lenke 1 or 2 idiopathic scoliosis, surgically treated with posterior selective fusion, and minimum follow-up of 5 years (average 7) was analyzed. The cohort was divided in 2 groups: if lumbar Cobb angle at last follow-up was, respectively, ≥ or < 10°. A logistic regression-based prediction model (PredictMed) was implemented to identify variables associated with the group ≥ 10°. The guidelines of the TRIPOD statement were followed. RESULTS: Mean Cobb angle of thoracic main curve was 56° preoperatively and 25° at last follow-up. Mean lumbar Cobb angle was 33° (20; 59) preoperatively and 11° (0; 35) at last follow-up. 53 patients were in group ≥ 10°. The 2 groups had similar demographics, flexibility of both main and lumbar curves, and magnitude of the preoperative main curve, p > 0.1. From univariate analysis, mean magnitude of preoperative lumbar curves (35° vs. 30°), mean correction of main curve (65% vs. 58%), mean ratio of main curve/distal curve (1.9 vs. 1.6) and distribution of lumbar modifiers were statistically different between groups (p < 0.05). PredictMed identified the following variables significantly associated with the group ≥ 10°: main curve % correction at last follow-up (p = 0.01) and distal curve angle (p = 0.04) with a prediction accuracy of 71%. CONCLUSION: The main modifiable factor influencing uninstrumented lumbar curve was the correction of main curve. The clinical model PredictMed showed an accuracy of 71% in prediction of lumbar Cobb angle ≥ 10° at last follow-up. LEVEL OF EVIDENCE IV: Longitudinal comparative study.

Reliability assessment of cervical spine parameters measured on full-body radiographs in asymptomatic subjects and patients with spinal deformity.

BACKGROUND: Cervical spinal alignment is usually assessed on full-body radiographs allowing for the concomitant evaluation of possible compensatory mechanisms that may occur at any level in the setting of postural malalignment. HYPOTHESIS: Cervical parameters measured on full-body radiographs are reliable. PATIENTS AND METHODS: A total of 70 subjects were included and divided in 3 groups: asymptomatic adults (n=21), adolescents with idiopathic scoliosis (n=20), and adults with spinal deformity (n=29), for whom full-body low-dose biplanar radiographs were obtained. Eighteen cervical parameters including gaze and cervical curvature, upper cervical spine, global cervical alignment, thoraco-cervical and cervico-pelvic parameters were measured by 4 operators, three times each. The intraclass correlation coefficient (ICC) and the 95% confidence interval (95% CI) where calculated for each parameter and compared between the 3 groups. RESULTS: ICC and the 95% CI were similar between the 3 groups. The measured parameters showed a very high repeatability (ICC>0.8) except for C0-C2, which presented an average repeatability (ICC=0.57). The cSVA, CTPA, C2-SPi, cranial offset, T1-SPi, CBVA and cranial tilt had a 95% CI<2 (° or cm). The TIA, T1-CL and C0-C2 had a 95% CI>6°. DISCUSSION: The poor visibility of the foramen magnum, hard palate, C7, T1, and the sternum on radiographs could explain why certain parameters showed a higher measurement error. The assessment of these error margins is essential for an accurate evaluation of cervical spinal deformities and a proper therapeutic approach. LEVEL OF EVIDENCE: III; retrospective analysis of prospectively collected data.

Gait kinematic alterations in subjects with adult spinal deformity and their radiological determinants.

BACKGROUND: Adults with spinal deformity (ASD) are known to have postural malalignment affecting their quality of life. Classical evaluation and follow-up are usually based on full-body static radiographs and health related quality of life questionnaires. Despite being an essential daily life activity, formal gait assessment lacks in clinical practice. RESEARCH QUESTION: What are the main alterations in gait kinematics of ASD and their radiological determinants? METHODS: 52 ASD and 63 control subjects underwent full-body 3D gait analysis with calculation of joint kinematics and full-body biplanar X-rays with calculation of 3D postural parameters. Kinematics and postural parameters were compared between groups. Determinants of gait alterations among postural radiographic parameters were explored. RESULTS: ASD had increased sagittal vertical axis (SVA:34 ±â€¯59 vs -5 ±â€¯20 mm), pelvic tilt (PT:19 ±â€¯13 vs 11 ±â€¯6°) and frontal Cobb (25 ±â€¯21 vs 4 ±â€¯6°) compared to controls (all p < 0.001). ASD displayed decrease walking speed (0.9 ±â€¯0.3 vs 1.2 ±â€¯0.2 m/s), step length (0.58 ±â€¯0.11 vs 0.64 ±â€¯0.07 m) and increased single support (0.45 ±â€¯0.05 vs 0.42 ±â€¯0.04 s). ASD walked with decreased hip extension in stance (-3 ±â€¯10 vs -7 ±â€¯8°), increased knee flexion at initial contact and in stance (10 ±â€¯11 vs 5 ±â€¯10° and 19 ±â€¯7 vs 16 ±â€¯8° respectively), and decreased knee flexion/extension ROM (55 ±â€¯9 vs 59 ±â€¯7°). ASD had increased trunk flexion (12 ±â€¯12 vs 6 ±â€¯11°) and reduced dynamic lumbar lordosis (-11 ±â€¯12 vs -15 ±â€¯7°, all p < 0.001). Sagittal knee ROM, walking speed and step length were negatively determined by SVA; lack of lumbar lordosis during gait was negatively determined by radiological lumbar lordosis. SIGNIFICANCE: Static compensations in ASD persist during gait, where they exhibit a flexed attitude at the trunk, hips and knees, reduced hip and knee mobility and loss of dynamic lordosis. ASD walked at a slower pace with increased single and double support times that might contribute to their gait stability. These dynamic discrepancies were strongly related to static sagittal malalignment.

Toward understanding the underlying mechanisms of pelvic tilt reserve in adult spinal deformity: the role of the 3D hip orientation.

PURPOSE: To explore 3D hip orientation in standing position in subjects with adult spinal deformity (ASD) presenting with different levels of compensatory mechanisms. METHODS: Subjects with ASD (n = 159) and controls (n = 68) underwent full-body biplanar X-rays with the calculation of 3D spinopelvic, postural and hip parameters. ASD subjects were grouped as ASD with knee flexion (ASD-KF) if they compensated by flexing their knees (knee flexion ≥ 5°), and ASD with knee extension (ASD-KE) otherwise (knee flexion < 5°). Spinopelvic, postural and hip parameters were compared between the three groups. Univariate and multivariate analyses were then computed between spinopelvic and hip parameters. RESULTS: ASD-KF had higher SVA (67 ± 66 mm vs. 2 ± 33 mm and 11 ± 21 mm), PT (27 ± 14° vs. 18 ± 9° and 11 ± 7°) and PI-LL mismatch (20 ± 26° vs - 1 ± 18° and - 13 ± 10°) when compared to ASD-KE and controls (all p < 0.05). ASD-KF also had a more tilted (34 ± 11° vs. 28 ± 9° and 26 ± 7°), anteverted (24 ± 6° vs. 20 ± 5° and 18 ± 4°) and abducted (59 ± 6° vs. 57 ± 4° and 56 ± 4°) acetabulum, with a higher posterior coverage (100 ± 6° vs. 97 ± 7° for ASD-KE) when compared to ASD-KE and controls (all p < 0.05). The main determinants of acetabular tilt, acetabular abduction and anterior acetabular coverage were PT, SVA and LL (adjusted R2 [0.12; 0.5]). CONCLUSIONS: ASD subjects compensating with knee flexion have altered hip orientation, characterized by increased posterior coverage (acetabular anteversion, tilt and posterior coverage) and decreased anterior coverage which can together lead to posterior femoro-acetabular impingement, thus limiting pelvic retroversion. This underlying mechanism could be potentially involved in the hip-spine syndrome.

A new classification for coronal malalignment in adult spinal deformity: a validation and the role of lateral bending radiographs.

PURPOSE: Coronal malalignment (CM) causes pain, impairment of function and cosmetic problems for adult spinal deformity (ASD) patients in addition to sagittal malalignment. Certain types of CM are at risk of insufficient re-alignment after correction. However, CM has received minimal attention in the literature compared to sagittal malalignment. The purpose was to establish reliability for our recently published classification system of CM in ASD among spine surgeons. METHODS: Fifteen readers were assigned 28 cases for classification, who represented CM with reference to their full-length standing anteroposterior and lateral radiographs. The assignment was repeated 2 weeks later, then a third assignment was done with reference to additional side bending radiographs (SBRs). Intra-, inter-rater reliability and contribution of SBRs were determined. RESULTS: Intra-rater reliability was calculated as 0.95, 0.86 and 0.73 for main curve types, subtypes with first modifier, and subtypes with two modifiers respectively. Inter-rater reliability averaged 0.91, 0.75 and 0.52. No differences in intra-rater reliability were shown between the four expert elaborators of the classification and other readers. SBRs helped to increase the concordance rate of second modifiers or changed to appropriate grading in cases graded type A in first modifier. CONCLUSIONS: Adequate intra- and inter-rater reliability was shown in the Obeid-CM classification with reference to full spine anteroposterior and lateral radiographs. While side bending radiographs did not improve the classification reliability, they contributed to a better understanding in certain cases. Surgeons should consider both the sagittal and coronal planes, and this system may allow better surgical decision making for CM.

Is There Still a Place for Convex Hemiepiphysiodesis in Congenital Scoliosis in Young Children? A Long-Term Follow-up.

STUDY DESIGN: Retrospective cohort. OBJECTIVES: To evaluate the long-term effect of convex growth arrest (CGA) on coronal deformity correction in congenital scoliosis. METHODS: Twenty-two patients with congenital scoliosis operated by 1-staged double approach hemiephysiodesis by bone grafting of the convex side without instrumentation are included. Eighteen curves had an isolated hemivertebra while 4 curves had congenital bar. Subgroup analysis was performed according to age at surgery (3 years cutoff), type of malformation (hemivertebra vs congenital bar), and severity of curve (35° cutoff). RESULTS: Patients' mean age at surgery was 3 years (range 0.5-8 years), with a mean frontal Cobb angle of 40.59°. Mean follow-up is 10.7 years (range 5.5-25 years). Overall results showed mean frontal Cobb angle reduction of 35.47% (40.59° to 27.41°). Detailed analysis showed that 15 curves had a mean correction of 51.8%, 5 stabilized and 2 had a mean aggravation of 25.11%. Subgroup analysis revealed that patients operated ≤3 years of age had mean cobb angle correction of 43.1% versus 21.49% in patients operated >3 years (P = .140). Mean correction of 44.5% was gained in curves with isolated hemivertebra compared with 1.3% in curves with congenital bar (P = .004). A 58.17% mean correction was reached in curves ≤35° versus 23.68% in curves >35° (P = .032). CONCLUSIONS: A limited convex hemiepiphysiodesis still has a place in congenital scoliosis care when it is performed in patients ≤3 years old, with curves ≤35°, and with isolated hemivertebra. It spares patients the risks of vertebral resection and instrumentation, while fusing the same number of levels.

Influence of spino-pelvic and postural alignment parameters on gait kinematics.

INTRODUCTION: Postural alignment is altered with spine deformities that might occur with age. Alteration of spino-pelvic and postural alignment parameters are known to affect daily life activities such as gait. It is still unknown how spino-pelvic and postural alignment parameters are related to gait kinematics. RESEARCH QUESTION: To assess the relationships between spino-pelvic/postural alignment parameters and gait kinematics in asymptomatic adults. METHODS: 134 asymptomatic subjects (aged 18-59 years) underwent 3D gait analysis, from which kinematics of the pelvis and lower limbs were extracted in the 3 planes. Subjects then underwent full-body biplanar X-rays, from which skeletal 3D reconstructions and spino-pelvic and postural alignment parameters were obtained such as sagittal vertical axis (SVA), center of auditory meatus to hip axis plumbline (CAM-HA), thoracic kyphosis (TK) and radiologic pelvic tilt (rPT). In order to assess the influence of spino-pelvic and postural alignment parameters on gait kinematics a univariate followed by a multivariate analysis were performed. RESULTS: SVA was related to knee flexion during loading response (ß = 0.268); CAM-HA to ROM pelvic obliquity (ß = -0.19); rPT to mean pelvic tilt (ß = -0.185) and ROM pelvic obliquity (ß = -0.297); TK to ROM hip flexion/extension in stance (ß = -0.17), mean foot progression in stance (ß = -0.329), walking speed (ß = -0.19), foot off (ß = 0.223) and step length (ß = -0.181). SIGNIFICANCE: This study showed that increasing SVA, CAM-HA, TK and rPT, which is known to occur in adults with spinal deformities, could alter gait kinematics. Increases in these parameters, even in asymptomatic subjects, were related to a retroverted pelvis during gait, a reduced pelvic obliquity and hip flexion/extension mobility, an increased knee flexion during loading response as well as an increase in external foot progression angle. This was associated with a decrease in the walking pace: reduced speed, step length and longer stance phase.