Change in pelvic incidence due to sacral stress fracture following multilevel instrumented fusion.

Multilevel-instrumented fusion is a common surgical technique used to treat adult spinal deformity (ASD), but it can occasionally lead to rare complications such as sacral insufficiency fractures. The impact of sacral fractures on spinopelvic parameters, particularly pelvic incidence (PI), has not been thoroughly investigated even though they have been documented in the literature. Here, we present a case of a patient who underwent a Th11-sacrum instrumented fusion for ASD. She underwent a revision surgery 18 months after the first procedure to treat proximal junctional pain brought on by a localised kyphosis of the rods. An asymptomatic sacral fracture was discovered during the radiological evaluation: the PI had increased from 71° to 103° between the 2 surgical procedures.

Hybrid kyphoplasty with short-versus intermediate- and long-segment pedicle screw fixations for the management of thoracolumbar burst fractures.

BACKGROUND: This study aimed to determine if the hybrid short-segment (HSS) technique is a good alternative to the intermediate-segment (IS) and long-segment (LS) techniques in pedicle screw fixations for acute thoracolumbar burst fractures (TLBFs). METHODS: In this retrospective evaluation, we examined 43 patients who underwent surgical treatments, including one- or two-level suprajacent (U) and infrajacent (L) pedicle screw fixations, for acute single-level TLBFs with neurological deficits between the T11 and L2 levels from July 2013 to December 2019. Among these patients, 15 individuals underwent HSS (U1L1), 12 received IS (U2L1), and 16 underwent LS (U2L2) fixations. Supplemental kyphoplasty of the fractured vertebral bodies was performed exclusively in the HSS group. Our analysis focused on assessing blood loss and surgical duration. Additionally, we compared postoperative thoracolumbar kyphotic degeneration using the data on Cobb angles on lateral radiographic images acquired at three time points (preoperatively, postoperative day 1, and follow-up). The end of follow-up was defined as the most recent postoperative radiographic image or implant complication occurrence. RESULTS: Blood loss and surgical duration were significantly lower in the HSS group than in the IS and LS groups. Additionally, the HSS group exhibited the lowest implant complication rate (2/15, 13.33%), followed by the LS (6/16, 37.5%) and IS (8/12, 66.7%) group. Implant complications occurred at a mean follow-up of 7.5 (range: 6-9), 9 (range: 5-23), and 7 (range: 1-21) months in the HSS, IS, and LS groups. Among these implant complications, revision surgeries were performed in two patients in the HSS group, two in the IS group, and one in the LS group. One patient treated by HSS with balloon kyphoplasty underwent reoperation because of symptomatic cement leakage. CONCLUSIONS: The HSS technique reduced intraoperative blood loss, surgical duration, and postoperative implant complications, indicating it is a good alternative to the IS and LS techniques for treating acute single-level TLBFs. This technique facilitates immediate kyphosis correction and successful maintenance of the corrected alignment within 1 year. Supplemental kyphoplasty with SpineJack® devices and high-viscosity bone cements for anterior reconstruction can potentially decrease the risk of cement leakage and related issues.

Relationship between spinal structural damage and sagittal balance in axial spondyloarthritis: Is the thoracic spine the starting point?

OBJECTIVES: To assess the relationship between spinal structural damage, sagittal balance parameters and spine curvatures in patients with axial spondyloarthritis (axSpA). MATERIAL AND METHODS: In this cross-sectional study, the pelvic and sagittal balance parameters were obtained through EOS® (Biospace, Paris, France). Patients were divided into three groups according to the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) tertiles (G1 ≤6, n = 36; G2: 6.1-31, n = 36; G3 >31, n = 35) and pelvic and sagittal parameters were compared across them. Multivariable regression analysis was performed to analyze the impact of spinal structural damage and of other factors on sagittal vertical axis (SVA), an important sagittal balance parameter. RESULTS: A total of 107 patients was included. G2 and 3 exhibited higher mean values of thoracic kyphosis T1-T12 when compared to G1 (10.5°(12.3) vs. 22.3°(17.3) vs. 35.2°(14.6), p < 0.001), and G3 demonstrated lumbar L1-S1 straightening compared to the other groups (55.7°(9) and 50.7°(19.8), G1 and G2, respectively, vs. 35.7°(13.2), p < 0.001). Mean SVA values showed an increasing gradient from G1 to G3 (21.6(25.1) vs. 41(44.3) vs. 84.3(47.2)mm, p < 0.001). In the multivariable regression, a one-unit increase in total mSASSS was associated with an average 0.8 mm higher SVA. CONCLUSIONS: Our data showed that more spinal structural damage is associated with a higher SVA, reflecting poorer sagittal balance. Patients with increasing spinal damage have an important increase in thoracic kyphosis suggesting that postural modifications in patients with axSpA might have their origin in the thoracic spine.

Use of global sagittal flexibility to predict proximal junctional kyphosis after spinal deformity surgery.

OBJECTIVE: Sagittal alignment is an important predictor of functional outcomes after surgery for adult spinal deformity (ASD). A rigid spinal column may create a large lever arm that may impact the rate of proximal junctional kyphosis (PJK) after ASD surgery. In this study, the authors sought to determine whether relatively low preoperative global spinal flexibility (i.e., rigid spine) predicts increased incidence of PJK at 1 year after ASD surgery. METHODS: The authors retrospectively reviewed long-segment thoracolumbar fusions with pelvic fixation performed at a single tertiary care center between October 2015 and September 2020 in patients with a minimum of 1-year radiographic and clinical follow-up. Two cohorts were established on the basis of the optimal value for spinal flexibility, as defined by the absolute difference between the preoperative standing and supine C7 sagittal vertical axes, which the authors termed global sagittal flexibility (GSF). Demographic information, radiographs, various associated complications, and patient-reported outcome measures (PROMs) were analyzed. RESULTS: Eighty-five patients met the inclusion criteria. Receiver operating characteristic (ROC) analysis using GSF to predict an increase in the proximal junctional sagittal Cobb angle (PJCA) greater than or equal to 10° at 1-year follow-up provided an area under the curve of 0.64 and identified an optimal GSF threshold value of 3.7 cm. Patients with GSF > 3.7 cm were considered globally flexible (48 patients), and those with GSF ≤ 3.7 cm were classified as rigid (37 patients). Rigid patients were noted to have a significantly higher risk of ΔPJCA ≥ 10° at 1-year follow-up (51.4% vs 29.3%, p = 0.049). No changes in the reoperation rates or PROMs based on GSF were observed in the 1- or 2-year postoperative window. CONCLUSIONS: Based on these retrospective data, preoperative global spinal rigidity portends an independently elevated risk for the development of PJK after ASD surgery. No differences in other complication rates or PROMs data were observed between groups. Data collection was limited to a 2-year postoperative window; therefore, longer follow-up is required to further elucidate the relationship between rigidity and reoperation rates. Based on these retrospective data, flexibility may influence the outcomes of patients with ASD.

Lumbar lordosis restoration by minimally invasive short-segment fusion with anterior column realignment for adult spinal deformity: minimum 2-year follow-up.

OBJECTIVE: The efficacy of anterior column realignment (ACR) remains relatively unclear, possibly because some safety concerns have limited its adoption and extensive evaluation. The authors aimed to study whether a minimally invasive surgery (MIS) triad consisting of ACR, lateral lumbar interbody fusion, and percutaneous pedicle screw fixation in a select group of adult spinal deformity (ASD) patients helps shorten fusion length without compromising clinical and radiographic outcomes over a minimum 2-year follow-up period. METHODS: A series of 61 ASD patients (mean age 72.8 years) with pelvic incidence (PI) - lumbar lordosis (LL) (PI-LL) mismatch > 10° underwent the short-segment MIS triad (mean fusion length 3.0 levels) as a single-stage operation with a mean operative time and estimated blood loss of 157 minutes and 127 mL, respectively. Exclusion criteria were 1) thoracic scoliosis as the main deformity, 2) thoracolumbar junction kyphosis > 25°, 3) ankylosed facet joints, and 4) previous spinal fusion surgery. Seven patients, who needed fusion to be extended to S1, underwent mini-open transforaminal lumbar interbody fusion at L5-S1. RESULTS: The segmental disc angle at the ACR level more than quintupled, averaging from 2.9° preoperatively to 18.9° at the latest follow-up (p < 0.0001). LL, in turn, nearly doubled from 17.0° to 32.8° (p < 0.0001) and PI-LL decreased by nearly half from 28.8° to 13.2° (p < 0.0001). At the same time, other spinopelvic deformity parameters as well as Oswestry Disability Index (ODI) scores significantly improved. Patients were divided into two groups at the latest postoperative evaluation: 36 patients whose PI-LL improved to < 10° and 25 patients who maintained a PI-LL mismatch > 10°. Binary logistic regression revealed preoperative PI-LL mismatch as the only factor that significantly influenced this dichotomous separation postoperatively. Receiver operating characteristic curve analysis identified the critical preoperative mismatch of 26.4° with 68% sensitivity and 84% specificity. Despite this different radiographic consequence, the two groups had an equally successful clinical outcome with no significant difference in ODI scores. CONCLUSIONS: As long as the ASD characteristics are consistent with the authors' exclusion criteria, the short-segment MIS triad served as an excellent surgical option in the patients with preoperative PI-LL mismatch < 26.4°, but the technique also worked well even in those with a mismatch > 26.4°, although ideal spinopelvic alignment targets were not necessarily achieved in these patients.

Risk factors for proximal junctional kyphosis in a multicenter study of Lenke type 5 and 6 adolescent idiopathic scoliosis patients.

PURPOSE: In Lenke type 5 and 6 curves, a major thoracolumbar or lumbar curve, the rates of PJK are reported as high as 50%. The purpose of this study was to confirm the rate of PJK, investigate possible risk factors, and evaluate surgical complications and the long-term effects of PJK on patient outcomes. METHODS: A retrospective review of multicenter data identified 192 with patients with 2 year and 94 with 5-year follow-up. Included patients had a Lenke type 5 or 6 curve and underwent a selective thoracolumbar or lumbar curve fusion. All radiographs preoperatively and postoperatively (1 year, 2 years, and 5 years) were evaluated. Demographic and radiographic data was analyzed as risk factors for PJK using a multi-variate regression. Outcomes scores and complications were compared between groups. RESULTS: 17 patients (8.9%) developed radiographic PJK; 1 at 1 year, 7 at 2 years, and another 9 at 5 years. All 17 patients had an upper instrumented vertebra (UIV) within 3 levels or less caudal of the thoracic kyphosis apex (the most horizontal vertebra on the sagittal); no patient with a UIV 4 or more levels from the thoracic apex (n = 96) developed PJK (X2 = 13.03, p < 0.001). In addition, PJA > 8° was found to significantly increase the risk of PJK (p = 0.039). SRS scores were significantly worse for PJK patients at 5 years in the self-image and function (p < 0.01). CONCLUSION: In Lenke 5/6 curves, no patient with a UIV 4 or more levels caudal to the thoracic kyphosis apex had PJK up to 5 years postoperatively. PJA greater than 8° was identified as a risk factor for PJK. Patients with radiographic PJK had worse SRS scores 5 years postoperatively.

Perioperative complications of symptomatic congenital kyphosis: a retrospective cohort study.

BACKGROUND: Despite the recent improvements in the surgical treatment of congenital kyphosis, this surgery may be associated with high rate of complications "particularly when patients are symptomatic preoperatively". MATERIALS AND METHODS: Medical profiles of 40 patients with symptomatic congenital kyphosis were retrospectively reviewed. Perioperative complications were recorded and divided in two groups including catastrophic complications (neurologic deficit, pulmonary thromboembolic events, and death) and major complications (infection, deep vein thrombosis, device failure, and dural injury). RESULTS: Catastrophic surgical complications occurred in nine (22.5%) patients including seven neurological deficits and two death. A significant association was observed between the incidence of major complications and type III of congenital kyphosis (P = 0.021). Major complications occurred in 14 (30%) patients. CONCLUSION: Surgical treatment significantly improve symptomatic congenital kyphosis deformity; however, surgery of symptomatic patient may be associated with higher rate of complications and even death.

Postoperative quality of life in patients with ankylosing spondylitis and thoracolumbar kyphosis: risk factors and personalized sagittal reconstruction strategy.

OBJECTIVE: The aim of this study was to investigate the factors affecting postoperative quality of life in patients with ankylosing spondylitis (AS) and thoracolumbar kyphosis (TLK), and establish a personalized sagittal reconstruction strategy. METHODS: Patients with AS and TLK who underwent pedicle subtraction osteotomy (PSO) from February 2009 to May 2019 were retrospectively included. Quality of life and spinal sagittal radiographic parameters were collected before surgery and at the last follow-up. Patients were divided into two groups based on the attainment of minimal clinically important difference (MCID) on the Bath Ankylosing Spondylitis Functional Index and Oswestry Disability Index. Comparisons of radiographic parameters and clinical outcomes were conducted between and within groups. Regression analysis was used to identify the risk factors within the missing MCID cohort. Sagittal reconstruction equations were established using the pelvic incidence (PI) and thoracic inlet angle (TIA) in the reached MCID cohort. RESULTS: The study comprised 82 participants. Significant improvements were observed in most radiographic parameters and all quality-of-life indicators during the final follow-up compared with the preoperative measures (p < 0.05). Factors including cervical lordosis (CL) ≥ 18° (OR 9.75, 95% CI 2.26-58.01, p = 0.005), chin-brow vertical angle (CBVA) ≥ 25° (OR 14.7, 95% CI 3.29-91.21, p = 0.001), and pelvic tilt (PT) ≥ 33° (OR 21.77, 95% CI 5.92-103.44, p < 0.001) independently correlated with a failure to attain MCID (p < 0.05). Sagittal realignment targets were constructed as follows: sacral slope (SS) = 0.84 PI - 17.4° (R2 = 0.81, p < 0.001), thoracic kyphosis (TK) = 0.51 PI + 10.8° (R2 = 0.46, p = 0.002), neck tilt (NT) = 0.52 TIA - 5.8° (R2 = 0.49, p < 0.001), and T1 slope (T1S) = 0.48 TIA + 5.8° (R2 = 0.45, p = 0.002). CONCLUSIONS: PSO proved efficacious in treating AS complicated by TLK, yielding favorable outcomes. CBVA ≥ 25°, CL ≥ 18°, and PT ≥ 33° were the primary factors affecting postoperative quality of life in patients with AS. The personalized sagittal reconstruction strategy in this study focused on the subjective sensations and daily needs of patients with AS, which were delineated by the equations SS = 0.84 PI - 17.4°, TK = 0.51 PI + 10.8°, NT = 0.52 TIA - 5.8°, and T1S = 0.48 TIA + 5.8°.

Evaluation of forward head posture and thoracic kyphosis in migraine.

BACKGROUND: The purpose of the current study was to investigate the forward head posture (FHP), thoracic kyphosis and their relationships between individuals with migraine and healthy controls using the DIERS Formetric 4D motion imaging system. METHODS: In this observational case-control study, a total of 39 migraine patients and 44 healthy subjects were enrolled. FHP and thoracic kyphosis were assessed by using the 4D Formetric DIERS system. The visual analogue scale (VAS) and Neck Disability Index (NDI) was used to evaluate neck pain and neck disability. Headache status were evaluated through Migraine Disability Assessment (MIDAS) and Numeric Pain Rating Scale (NPRS) questionnaires. RESULTS: The fleche cervicale (57.72 ± 13.72 mm vs. 40.00 ± 4.75 mm; p < 0.001) and kyphotic angle (57.39 ± 8.76° vs. 38.21 ± 5.67°; p < 0.001) were significantly higher in patients with migraine compared to control group. When NDI categories were compared, the migraine group showed significantly increase in the number of patients with moderate or severe disability (p < 0.001). A positive correlation was found between fleche cervicale and thoracic kyphosis (r = 0.71, p < 0.001). CONCLUSIONS: This study revealed that patients with migraine exhibited a greater FHP and thoracic kyphosis compared to the control group. A 3-dimensional objective measurement may be a reliable diagnostic tool to evaluate posture analysis in clinical practice in the future.

Pain Medication Use Two Years After Adolescent Idiopathic Scoliosis Fusion Surgery.

STUDY DESIGN: Observational case control. OBJECTIVE: The objective of this study was to evaluate the prevalence of opioid use two years after surgical correction of adolescent idiopathic scoliosis (AIS) and its association with preoperative mental health. SUMMARY OF BACKGROUND DATA: Studies of opiate use have reported that up to 80% of users began their addiction with misuse of prescription opioids. Identifying opioid use and those at risk in the AIS population is critical for optimal outcomes. MATERIALS AND METHODS: A query of a multicenter prospective AIS surgical fusion registry was performed to identify patients of all curve types with responses to question 11 on the Scoliosis Research Society-22 questionnaire at two years postoperative. Question 11 asks about pain medication usage for the patient's back with five specific responses: narcotics daily, narcotics weekly or less, non-narcotics daily, non-narcotics weekly/less, or none. Ordinal regression was used to evaluate the association between preoperative Scoliosis Research Society-22 Mental Health (MH) domain scores and two-year postoperative pain medication usage. RESULTS: A total of 2595 patients who underwent surgery from 2002 to 2019 met inclusion. The average primary curve was 56±12°, average age 14.7±3 years, and 81.5% were female. Forty (1.5%) patients reported utilizing opioids two years after surgery, and a significant difference in preoperative MH scores was observed. Patients taking daily opioids postoperatively had the lowest median preoperative MH score (3.75), followed by non-narcotic group (4), and no medication (4.2, P <0.001). Three patients reporting opioid use postoperatively reported preoperative usage. The rate of two-year postoperative medication use based on the year of surgery demonstrated a small linear decrease in opioid use over time, with a slight increase in nonopioid daily use. CONCLUSIONS: Less than 2% of patients reported taking opioids for back pain two years after surgical correction of AIS. A lower MH score before surgery may place a patient at increased risk for opioid use two years after surgery. An analysis of the year of surgery suggests that changes in prescription practices over time may be occurring. LEVEL OF EVIDENCE: 4.

Low BMI, blood calcium and vitamin D, kyphosis time, and outdoor activity time are independent risk factors for osteoporosis in postmenopausal women.

Aim: To explore the risk factors of osteoporosis in postmenopausal women in China. Method: This study collected all patient data from January 2014 to December 2015. Basic information and questionnaires were collected from 524 postmenopausal women in Sanya and Hainan Province. The questionnaire was administered to the enrolled participants by endocrinologists. Biochemical parameters were measured using fasting blood samples, and bone density was measured by dual energy X-ray absorptiometry at the department of radiology of Hainan hospital, PLA General Hospital. Participants with an R-value of ≤-2.5 were diagnosed with osteoporosis. After deleting missing values for each factor, 334 participants were divided into the osteoporosis (n=35) and non-osteoporosis (n=299) groups according to the R-values. Results: The participants had a median age of 60.8 years (range: 44-94 years). Among the 334 postmenopausal women included in this study, 35 (10.5%) were diagnosed with osteoporosis. Univariate analysis showed statistically significant differences in age, BMI, type of work, alkaline phosphatase, years of smoking, blood calcium levels, kyphosis, fracture, and asthma between the two groups (P<0.05). In addition, multivariate logistic analysis showed that age (odds ratio [OR]: 1.185, 95% confidence interval [CI]: 1.085-1.293, P<0.001) and kyphosis times (OR:1.468, 95% CI: 1.076-2.001, P=0.015) were positively correlated with postmenopausal osteoporosis, whereas BMI (OR: 0.717, 95% CI: 0.617-0.832, P<0.001), blood calcium levels (OR: 0.920, 95% CI: 0.854-0.991, P=0.027), vitamin D levels (OR: 0.787, 95% CI: 0.674-0.918, P=0.002), and outdoor activity time (OR: 0.556, 95% CI: 0.338-0.915, P=0.021) were negatively correlated with postmenopausal osteoporosis. Conclusion: Low BMI, blood calcium and vitamin D levels, kyphosis time, and outdoor activity time are independent risk factors for osteoporosis in postmenopausal women.

Percutaneous Functional Spinal Unit Cementoplasty versus Posterior Spinal Fixation with Vertebroplasty for Symptomatic Chronic Osteoporotic Vertebral Fractures: A Retrospective Study with a 2-Year Follow up.

PURPOSE: To compare the clinical efficacy of percutaneous functional spinal unit cementoplasty (PFSUP) and posterior spinal fixation combined with vertebroplasty (PSF + VP) for the treatment of symptomatic chronic osteoporotic vertebral fractures (SCOVFs). METHOD: Thirty-one patients with SCOVFs were included in this retrospective study and divided into PFSUP (n = 14) and PSF + VP (n = 17) groups. Visual analog scores (VAS) and Oswestry Disability Index (ODI) were recorded before and after surgery and at the last follow-up. Besides, the local kyphosis angle (LKA) and sagittal vertical axis (SVA) were measured. The operation duration, number of X-ray exposures, amount of blood loss, bed rest duration, hospitalization duration, and presence of complications were recorded. RESULT: The VAS, ODI, LKA, and SVA after surgery and at the last follow-up were significantly improved in both groups compared to preoperative measurements. The PFSUP group experienced shorter operation duration (78.2 ± 13.1 vs. 124.7 ± 14.7, p < 0.001), less blood loss (31.1 ± 8.1 vs. 334.7 ± 70.9, p < 0.001), more X-ray exposures (92.1 ± 14.3 vs. 29.4 ± 5.5, p < 0.001), shorter bed rest duration (12.4 ± 3.8 vs. 43.4 ± 10.0, p < 0.001), shorter hospitalization (6.6 ± 2.4 vs. 10.9 ± 2.7, p < 0.001), lower complication rate (28.5% vs. 64.7%, p < 0.05), and higher cement leakage rate (42.9% vs. 5.8%, p < 0.05) than the PSF + VP group. CONCLUSION: During the treatment of SCOVFs, the combination of PFSUP and PSF + VP can restore spinal stability, improve kyphosis, and relieve pain. PFSUP can reduce blood loss and complications, early mobilization, and shorten the hospital stay, but it is associated with a higher cement leakage rate and more radiation exposure.

Experimental protocol to investigate cortical, muscular and body representation alterations in adolescents with idiopathic scoliosis.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis. AIS is a three-dimensional morphological spinal deformity that affects approximately 1-3% of adolescents. Not all factors related to the etiology of AIS have yet been identified. OBJECTIVE: The primary aim of this experimental protocol is to quantitatively investigate alterations in body representation in AIS, and to quantitatively and objectively track the changes in body sensorimotor representation due to treatment. METHODS: Adolescent girls with a confirmed diagnosis of mild (Cobb angle: 10°-20°) or moderate (21°-35°) scoliosis as well as age and sex-matched controls will be recruited. Participants will be asked to perform a 6-min upright standing and two tasks-named target reaching and forearm bisection task. Eventually, subjects will fill in a self-report questionnaire and a computer-based test to assess body image. This evaluation will be repeated after 6 and 12 months of treatment (i.e., partial or full-time brace and physiotherapy corrective postural exercises). RESULTS: We expect that theta brain rhythm in the central brain areas, alpha brain rhythm lateralization and body representation will change over time depending on treatment and scoliosis progression as a compensatory strategy to overcome a sensorimotor dysfunction. We also expect asymmetric activation of the trunk muscle during reaching tasks and decreased postural stability in AIS. CONCLUSIONS: Quantitatively assess the body representation at different time points during AIS treatment may provide new insights on the pathophysiology and etiology of scoliosis.

Evaluation of Pulmonary Function After Halo-Pelvic Traction for Severe and Rigid Kyphoscoliosis Utilizing CT with 3D Reconstruction.

BACKGROUND: The purpose of the present study was to evaluate changes in pulmonary function, caused by preoperative halo-pelvic traction (HPT) for the treatment of extremely severe and rigid kyphoscoliosis, with use of 3-dimensional computed tomography (3D-CT) reconstruction and pulmonary function tests (PFTs). METHODS: Twenty-eight patients with severe and rigid scoliosis (Cobb angle, >100°) underwent preoperative HPT and staged posterior spinal fusion. CT, radiographic assessment, and PFT were performed during pre-traction and post-traction visits. The changes in total lung volume were evaluated with use of 3D-CT reconstruction, and the changes in pulmonary function were evaluated with PFTs at each time point. Differences were analyzed with use of 2-tailed paired Student t tests, and correlations were analyzed with use of Spearman rank tests. RESULTS: None of the patients had pulmonary complications during traction, and all radiographic spinal measurements improved significantly after HPT. The main Cobb angle was corrected from 143.30° ± 20.85° to 62.97° ± 10.83° between the pre-traction and post-traction evaluations. Additionally, the C7-S1 distance was lengthened from 280.48 ± 39.99 to 421.26 ± 32.08 mm between the pre-traction and post-traction evaluations. Furthermore, 3D lung reconstruction demonstrated a notable increase in total lung volume (TLV) (from 1.30 ± 0.25 to 1.83 ± 0.37 L) and maximum lung height (from 176.96 ± 27.44 to 202.31 ± 32.45 mm) between the pre-traction and post-traction evaluations. Moreover, PFTs showed that total lung capacity (TLC) improved between the pre-traction and post-traction evaluations (from 2.06 ± 0.32 to 2.98 ± 0.82 L) and that the changes in T1-T12 distance and maximum lung height were correlated with changes in TLV (p = 0.0288 and p = 0.0007, respectively). CONCLUSIONS: The application of HPT is a safe and effective method for improving pulmonary function in patients with extremely severe and rigid scoliosis before fusion surgery. The TLV as measured with CT-based reconstruction was greatly increased after HPT, mainly because of the changes in thoracic height. LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Impact of mental health components on the development of back pain in young adults with adolescent idiopathic scoliosis.

BACKGROUND: Back pain occurs commonly in adults and is multifactorial in nature. This study aimed to assess the prevalence and intensity of back pain during young adulthood in subjects with adolescent idiopathic scoliosis (AIS), as well as factors that may be associated with its prognosis. METHODS: Subjects with AIS aged 20-39 treated conservatively were included in this study. Patient-reported outcome measures in adulthood involved episodes of back pain, and scales of self-image, depression, anxiety, and stress. Additionally, pain, self-image, and mental health scores were retrieved at the first clinic consultation. Occurrence of back pain was defined as a numeric pain rating scale ≥ 6. RESULTS: 101 participants were enrolled. The prevalence of back pain in the lifetime, past 12 months, past 6 months, past 1 month, past 7 days, and past 24 h were 37%, 35%, 31%, 27%, 23%, and 20%, respectively. Male, self-image, and depression were significant associated factors for the development of back pain at all time points. Furthermore, the analyses of the initial presentation of participants have shown that participants with back pain in adulthood were characterised by poor self-image and mental health during their adolescence. CONCLUSION: The present study addressed the natural history of back pain in young adults with conservatively treated AIS. Psychological makeup has been shown to constitute the development of back pain and is strongly hinted as an early sign of having back pain in adulthood among subjects with AIS.

Remission of Dowager's hump by manipulative correction of spinal alignment: a case report.

Dowager's hump is described as excessive kyphotic curvature in the thoracic spine with a Cobb angle of more than 40 degrees. This case report presents a 61 years old female office clerk who experienced headaches and neck pain for 3 years that extended into her right shoulder and upper chest. She consulted her primary care physician two months before seeing the chiropractor when the neck pain worsened. A diagnosis of cervicalgia related to osteoarthritis was made based on cervical and thoracic X-ray findings. The patient received non-steroid anti-inflammatory drugs (celecoxib and etoricoxib) and stretching exercises at home. At the onset of chiropractic care, radiographs showed loss of cervical lordosis, narrowing at the C4-5, C5-C6, and C6-7 intervertebral disc space with marginal osteophytes. Based on these findings, a working diagnosis of cervicogenic headache was established. After treatment for 9 months, the patient showed improvement in symptoms and function from cervical curve radiographic change and dextro-convexity of the thoracic spine. Avoiding forward head flexion and maintaining correct posture in daily activities will be key mechanisms to prevent the reoccurrence of Dowager's hump. The improvement of symptoms following chiropractic therapy has been shown to correlate with radiographic markers of spinal realignment.

Evaluation of cerebellum volume and trunk oscillation velocity in cases with adolescent idiopathic scoliosis: a preliminary report.

PURPOSE: It has been suggested that the cause of the balance disorder seen in adolescent idiopathic scoliosis (AIS) originates from the central nervous system. However, the extent of the balance problem and the dysfunction of which part of the central nervous system has not been investigated in detail. This study aimed to correlate the values obtained by balance analysis and cerebellum volume measurement in female individuals with AIS with healthy individuals. METHODS: Cerebellum volume was calculated via the cloud-based software " https://volbrain.upv.es " using brain magnetic resonance images of 27 healthy and 26 individuals with AIS. The duration of stay in the test positions, the movement strategy used during this time and the amount of postural sway were analyzed by using a computer-assisted force platform and compared statistically. RESULTS: Significant differences were found between the AIS and control groups in cerebellum total volume, vermis cerebelli volume (cm3), and trunk oscillation velocity (mm/s) parameters (p < 0.05). Cerebellum and vermis cerebelli volumes were found to be lower and trunk oscillation velocity was found to be greater in patients with AIS. CONCLUSION: Balance problems in patients with AIS are correlated with decreased cerebellum volume and increased trunk oscillation velocity.

Kyphectomy in myelomeningocele revisited: risk factors for failure.

PURPOSE: Lumbar kyphosis occurs in approximately 8-20% of patients with myelomeningocele (MMC). The purpose of this article is to analyze the risks and benefits of vertebrectomy and spinal stabilization in MMC children with severe lumbar kyphosis and to establish treatment guidelines. METHODS: This is an IRB-approved retrospective analysis of 59 patients with MMC who underwent kyphectomy and posterior instrumentation in three centers. Average age at surgery was 7.9 years (2 weeks-17 years). Sitting trunk position, skin status, kyphosis angle, and thoracic lordosis were analyzed preoperatively, postoperatively, and at an average follow-up of 8.2 years (range 2.5-16). The correction was maintained by applying a short posterior instrumentation in 6 patients, and extending to the pelvis in 53 cases. Pelvic fixation was achieved using the Warner and Fackler technique in 24 patients, the Dunn-McCarthy in 8, Luque-Galveston in 8, sacral screws in 2, and ilio-sacral screws in 11. RESULTS: Sitting position improved postoperatively in 47 of the 53 patients who underwent pelvic fixation and only in one patient with short instrumentation. All 6 patients with long instrumentation and poor postoperative sitting balance were in the Dunn-McCarthy fixation group. Skin sores at the apex of the deformity disappeared postoperatively in all patients but recurred in two patients with short instrumentations. Kyphosis angle improved from 109° (45°-170°) preoperatively to 10° (0°-45°) postoperatively and 21° (0°-55°) at last follow-up. The best results were seen in cases where a cross-k-wire fixation of the kyphectomy site was used, augmented with a long thoraco-pelvic instrumentation consisting of Luque sublaminar wires in the thoracic region and a Warner-Fackler type of pelvic fixation. Good results were also found with the bipolar technique and ilio-sacral screw fixation. Six over 24 patients with the Warner and Fackler technique showed gradual dislodgment or hardware failure, with subsequent nonunion of the kyphectomy site in four. Infection, with or without wound dehiscence and/or hardware exposure, occurred in 17 cases, necessitating hardware removal in 9 patients. CONCLUSION: Lumbar kyphosis in MMC children is best managed by resection of enough vertebrae from the apex to produce a flat lumbar spine, with perfect bone-to-bone contact and long thoraco-pelvic instrumentation using the Warner and Fackler technique through the S1 foramina or the bipolar technique with ilio-sacral screw fixation. Additional local fixation of the osteotomy site using cross-wires with or without cerclage increases the stability of the construct. The majority of complications occurred in patients with short instrumentations or where residual kyphosis persisted postoperatively regardless of the type of pelvic fixation or hardware density. The Dunn-McCarthy technique for pelvic fixation following kyphectomy in MMC was less successful in producing stable pelvic fixation and should not be considered in this patient category.

Effect of C7-T1 Extensional Posterior Transpedicle Osteotomy on Mobility and Quality of Life in Patients with Ankylosing Spondylitis Complicated with Lumbar Kyphosis and Related Factors.

Objective: To analyze the effect of C7-T1 extensional posterior transpedicular vertebral osteotomy (PSO) on mobility and quality of life in patients with ankylosing spondylitis (AS) and lumbar kyphosis. Methods: This study was conducted from February 2019 to February 2021 and a total of 38 patients with AS combined with kyphosis from Tianjin Union Medical Center, Tianjin, China, were selected for the study. After performing all preoperative examinations, all patients were treated with C7-T1 extensional posterior PSO osteotomy. The patients' operation and follow-up, pain degree as a Visual analogue scale (VAS) score and sagittal balance index changes before and after surgery, spinal function measured as; Bath Ankylosing Spondylitis Functional Index (BASFI) score and quality of life by Scoliosis Research Society-22 (SRS-22) score, were observed before and after surgery. Pearson correlation coefficient was used to analyze the correlation between patients' quality of life and BASFI score. Results: After surgery, the pain of the patients' back was significantly relieved, the patients' appearance and trunk balance function were significantly improved, and the symptoms related to nerve function were not significantly aggravated. No complications such as infection, internal fixation failure or spinal decompensation occurred in all patients. VAS score, kyphosis Cobb Angle and Sagittal Vertical Axis (SVA) of all patients showed P < .05 before and 1 year after surgery. BASFI score 1 year after surgery decreased significantly than that before surgery (P < .05). 1 year after surgery, body function, pain symptoms, self-image and psychological state of the patients were significantly improved, and the SRS-22 total score of the patients 1 year after surgery increased significantly than before surgery (P < 0.05). BASFI score was negatively correlated with SRS-22 score by Pearson correlation coefficient analysis (P < .05). Conclusion: C7-T1 extensional posterior PSO osteotomy has a good effect in the treatment of AS patients with lumbar kyphosis. The sagittal balance was well-restored with improvement in patients' quality of life after surgery, which makes C7-T1 osteotomy worthy of clinical application to treat patients suffering from AS combined with lumbar kyphosis.