Agreement of repeated motor and sensory scores at individual myotomes and dermatomes in young persons with spinal cord injury.

STUDY DESIGN: A prospective repeated measures multicenter study to determine reliability at individual spinal levels when applied to young persons with spinal cord injury (SCI). OBJECTIVES: To evaluate intra- and inter-rater agreement of repeated motor and sensory scores at individual spinal levels. SETTING: Shriners Hospitals for Children--Philadelphia and Chicago, USA. METHODS: A total 189 youth with complete and incomplete SCI underwent four neurological exams by two different raters. Agreement between and within raters for each myotome and dermatome was evaluated for complete and incomplete SCI separately. Intraclass correlation coefficients and 95% confidence intervals were calculated. RESULTS: Overall, both intra- and inter-rater agreement resulted in moderate-to-high agreement among myotomes. Subjects with complete SCI had moderate agreement for light touch (LT) and pin prick (PP) testing, whereas subjects with incomplete SCI had >60.0% of dermatomes resulting in poor agreement for PP testing. CONCLUSION: Overall, moderate-to-high agreement was found for muscle strength comparisons and moderate-to-poor agreement was found for PP and LT.

Diagnostic accuracy of diffusion tensor imaging for pediatric cervical spinal cord injury.

STUDY DESIGN: Cross-sectional non-experimental study. OBJECTIVES: To examine diagnostic accuracy of diffusion tensor imaging (DTI) for pediatric spinal cord injury (SCI). SETTING: Pediatric Orthopedic Hospital. METHODS: Thirty-five subjects, 10 SCI and 25 controls, mean age 13.38 years underwent two scans with 3.0 T MR scanner. Fractional anisotropy (FA), axial diffusivity (AD) and radial diffusivity (RD) values were calculated. Subjects with SCI underwent examination of muscle strength, sensation and sacral sparing. Mean and s.d. values for FA, AD and RD were compared by group (controls, SCI with sacral sparing, SCI without sacral sparing) using analysis of variance for repeated measures. Comparisons were also made of DTI values at the injury site to values from cervical regions outside of the injury site. Specificity, sensitivity, receiver operating characteristics area under the curve (ROC AUC) and corresponding 95% confidence intervals were calculated. Resampling methods were used to validate the estimates from the final models. RESULTS: FA values differed among SCI subjects with intact sacral sparing, absent sacral sparing and controls, P<0.003 (adjusted). DTI values in combination showed the strongest diagnostic accuracy for predicting the presence of anal contraction (AD, RD; ROC AUC=0.90), deep anal pressure (FA; ROC AUC=0.88), S4-5 sensation (FA, RD; ROC AUC=0.93), motor level (FA, AD, RD; ROC AUC=0.92) and MRI level (FA, AD, RD; ROC AUC=0.92). Bootstrap and Jackknife median values indicated consistency of the parameter estimates. CONCLUSION: The predictive accuracy of DTI for sacral sparing end points and motor and MRI level of injury was good to strong.

Examination and measurement of coping among adolescents with spinal cord injury.

STUDY DESIGN: Cross-sectional survey. OBJECTIVES: To describe coping strategy use in adolescents with spinal cord injury (SCI), to explore the underlying factor structure of a measure of coping among adolescents with SCI and to assess relationships between coping and psychosocial outcomes. SETTING: Multiple pediatric SCI centers in the United States. METHODS: One hundred and eighty-two participants aged 13-17 years who experienced an SCI completed measures including the Kidcope, Children's Depression Inventory, Revised Children's Manifest Anxiety Scale and the Pediatric Quality of Life Inventory. RESULTS: Participants reported that cognitive restructuring and resignation are the most used coping strategies, whereas social support, emotional regulation (calming) and cognitive restructuring are the most effective coping strategies. An exploratory factor analysis revealed that a three-factor solution provided the most parsimonious model for the relationships between the different coping strategies. However, only one of the three factors had acceptable internal consistency. This factor comprised escape-oriented coping strategies or an avoidant approach to coping with the sequelae of SCI. After controlling for demographic/injury-related factors, higher scores on the escape-oriented factor were associated with the lower quality of life and higher levels of depression and anxiety symptomatology. CONCLUSION: Escape-oriented coping is associated with maladaptive psychosocial outcomes in adolescents with SCI. These adolescents report that active coping strategies are most effective in reducing SCI-related distress. Coping strategy use may mediate psychosocial outcomes in adolescents with SCI and represent an intervention target in adolescents who overly rely on escape-oriented coping.

Autologous incubated macrophage therapy in acute, complete spinal cord injury: results of the phase 2 randomized controlled multicenter trial.

STUDY DESIGN: Randomized controlled trial with single-blinded primary outcome assessment. OBJECTIVES: To determine the efficacy and safety of autologous incubated macrophage treatment for improving neurological outcome in patients with acute, complete spinal cord injury (SCI). SETTING: Six SCI treatment centers in the United States and Israel. METHODS: Participants with traumatic complete SCI between C5 motor and T11 neurological levels who could receive macrophage therapy within 14 days of injury were randomly assigned in a 2:1 ratio to the treatment (autologous incubated macrophages) or control (standard of care) groups. Treatment group participants underwent macrophage injection into the caudal boundary of the SCI. The primary outcome measure was American Spinal Injury Association (ASIA) Impairment Scale (AIS) A-B or better at ≥6 months. Safety was assessed by analysis of adverse events (AEs). RESULTS: Of 43 participants (26 treatment, 17 control) having sufficient data for efficacy analysis, AIS A to B or better conversion was experienced by 7 treatment and 10 control participants; AIS A to C conversion was experienced by 2 treatment and 2 control participants. The primary outcome analysis for subjects with at least 6 months follow-up showed a trend favoring the control group that did not achieve statistical significance (P=0.053). The mean number of AEs reported per participant was not significantly different between the groups (P=0.942). CONCLUSION: The analysis failed to show a significant difference in primary outcome between the two groups. The study results do not support treatment of acute complete SCI with autologous incubated macrophage therapy as specified in this protocol.

Effects of cycling and/or electrical stimulation on bone mineral density in children with spinal cord injury.

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To determine the effect of cycling and/or electrical stimulation on hip and knee bone mineral density (BMD) in children with spinal cord injury (SCI). SETTING: Children's hospital specializing in pediatric SCI. METHODS: A total of 30 children, aged 5-13 years, with chronic SCI were randomized to one of three interventions: functional electrical stimulation cycling (FESC), passive cycling (PC), and non-cycling, electrically stimulated exercise (ES). Each group exercised for 1 h, three times per week for 6 months at home. The hip, distal femur and proximal tibia BMD were examined via dual-energy X-ray absorptiometry (DXA) pre- and post-intervention. RESULTS: In all, 28 children completed data collection. The FESC group exhibited increases in hip, distal femur and proximal tibia BMD of 32.4, 6.62 and 10.3%, respectively. The PC group exhibited increases at the hip (29.2%), but no change at the distal femur (1.5%) or proximal tibia (-1.0%). The ES group had no change at the hip (-0.24%) and distal femur (3.3%), but a loss at the proximal tibia (-7.06%). There were no differences between groups or within groups over time. Significant negative correlations were found between baseline BMD and the amount of BMD change. CONCLUSION: Although not achieving statistical significance, hip BMD changes observed were greater than the reported 0.9-10% gains after exercise for children with and without disability. Thus, cycling with and without electrical stimulation may be beneficial for skeletal health in pediatric SCI, but further research is needed with a larger sample size.

The International Standards for Neurological Classification of Spinal Cord Injury: relationship between S4-5 dermatome testing and anorectal testing.

STUDY DESIGN: Prospective cross-sectional multicenter study. OBJECTIVE: To evaluate the correlation, sensitivity, specificity and predictive values of S4-5 dermatome and the anorectal examination for determination of sacral sparing in the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) examination. SETTING: Two tertiary hospitals that specialize in pediatric spinal cord injuries. METHODS: In all, 189 patients who were at minimum 3 month after spinal cord injury participated in complete ISNCSCI examinations. All examiners completed training for the proper completion of the ISNCSCI examination. Correlations and sensitivity/specificity analyses were conducted between S4-5 dermatome testing and the anorectal examination. Results were analyzed by age of patient, examiner, tetraplegia/paraplegia classification and injury level (T10-S3, L1-S3 and S3). RESULTS: The correlation between S4-5 dermatome and anorectal sensation was moderate (0.62, P<0.001). Using the anorectal examination as the gold standard, the sensitivity of S4-5 testing was 0.60 (0.49, 70) and specificity was 0.96 (0.90, 0.99). No single age group, tester, level, or type of injury differed from the overall result. CONCLUSION: In the pediatric population, the correlation between S4-5 and anorectal sensation was lower than anticipated. The sensitivity of 0.62 for S4-5 testing and diminished sensation between T10 and S3 suggests that anorectal testing may either be a more sensitive representation of S4-5 function or activate an alternative neuronal pathway that is perceived by the patient. Further investigation into the validity of the sacral sparing components of the ISNCSCI examination is warranted.

An inertial sensor-based protocol for spinal range of motion measurements.

To develop a protocol for assessing spinal range of motion using an inertial sensor device. The baseline error of an inertial sensor was assessed using a bicycle wheel. Nineteen healthy subjects (12 females and 7 males, average age 18.2 ± 0.6 years) were then prospectively enrolled in a study to assess the reliability of an inertial sensor-based method for assessing spinal motion. Three raters each took three measurements of subjects' flexion/extension, right and left bending, and right and left rotation. Afterwards, one trial from each set of measurements was excluded. Correlations and the ICC (3,1) were used to assess intra-rater reliability, and ICC (3,2) was used to assess inter-rater reliability of the protocol. The baseline error of the sensor was 1.45°. Correlation and ICC (3,1) values for the protocol all exceeded 0.888, indicating high intra-rater reliability. ICC (3,2) values for the protocol exceed 0.87, indicating high inter-rater reliability. Our study presents both a paradigm for assessing the baseline error of inertial sensors and a protocol for assessing motion of the spine using an inertial sensing device.

A phase 2 autologous cellular therapy trial in patients with acute, complete spinal cord injury: pragmatics, recruitment, and demographics.

STUDY DESIGN: Post hoc analysis from a randomized controlled cellular therapy trial in acute, complete spinal cord injury (SCI). OBJECTIVES: Description and quantitative review of study logistics, referral patterns, current practice patterns and subject demographics. SETTING: Subjects were recruited to one of six international study centers. METHODS: Data are presented from 1816 patients pre-screened, 75 participants screened and 50 randomized. RESULTS: Of the 1816 patients pre-screened, 53.7% did not meet initial study criteria, primarily due to an injury outside the time window (14 days) or failure to meet neurological criteria (complete SCI between C5 motor/C4 sensory and T11). MRIs were obtained on 339 patients; 51.0% were ineligible based on imaging criteria. Of the 75 participants enrolled, 25 failed screening (SF), leaving 50 randomized. The primary reason for SF was based on the neurological exam (51.9%), followed by failure to meet MRI criteria (22.2%). Of the 50 randomized subjects, there were no significant differences in demographics in the active versus control arms. In those participants for whom data was available, 93.8% (45 of 48) of randomized participants received steroids before study entry, whereas 94.0% (47 of 50) had spine surgery before study enrollment. CONCLUSION: The 'funnel effect' (large numbers of potentially eligible participants with a small number enrolled) impacts all trials, but was particularly challenging in this trial due to eligibility criteria and logistics. Data collected may provide information on current practice patterns and the issues encountered and addressed may facilitate design of future trials.

Preclinical Bench Testing on a Novel Posterior Dynamic Deformity Correction Device for Scoliosis.

STUDY DESIGN: Biomechanical test. OBJECTIVE: To summarize the preclinical tests performed to assess the durability of a novel fusionless dynamic device for the treatment of adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The minimal invasive deformity correction (MID-C) system is a distractible posterior dynamic deformity correction device designed to reduce scoliosis for AIS patients, to maintain curve correction, and to preserve spinal motion. To overcome the challenges of wear and fatigue of this procedure, the system has two unique features: polyaxial joints at the rod-screw interface and a ceramic coating of the moving parts. METHODS: Five biomechanical tests were performed: Static compression to failure, fatigue loading per ASTM F 1717 with 5.5-mm screws for 10 million cycles (MC) at 5 Hz, wear assessment, wear test of the polyaxial joint under 100 N load for 10 MC, and wear particle implantation in rabbits. RESULTS: The system failed through buckling of the rod with loads over 3000 N (400% of human body weight). Dynamically, the system maintained 700 N for 10 MC with 5.5 mm screws. The maximum total steady-state wear rate was 0.074 mg/MC (0.03 per polyaxial joint and 0.014 mg/MC for the ratchet mechanism). Histologic evaluation of the particle injection sites indicated no difference in the local tissue response between the control and test articles. At 3 and 6 months postinjection, there were neither adverse local effects nor systemic effects observed. CONCLUSIONS: The unique design features of the MID-C system, based on polyaxial joints and ceramic coating, resulted in favorable static, fatigue, and wear resistance properties. Wear properties were superior to those published for artificial spinal discs. Long-term outcomes from clinical use will be required to correlate these bench tests to the in vivo reality of clinical use. LEVEL OF EVIDENCE: Level V.

A syndrome of dislocated hips and radial heads, carpal coalition, and short stature in Puerto Rican children.

An orthopaedic syndrome that apparently had not been reported previously was identified in twenty-three children. Characteristics shared by all twenty-three children included Hispanic descent, residence in Puerto Rico, bilateral dislocation of the hip, dislocated radial heads, short stature, and other osseous anomalies. Twelve dislocated hips in six patients were not treated. All of these hips were functioning satisfactorily at the time of the review, but only four of the children had reached skeletal maturity. Sixteen hips in eight patients remained reduced after closed reduction. Of these eight patients, the four who were skeletally immature at the time of the review had a satisfactory result, and the four who were skeletally mature had an unsatisfactory result because of discomfort or fibrous ankylosis. Eighteen hips in nine patients were treated with a reduction augmented by some form of operation. All of these hips redislocated. Of the forty-six elbows in the twenty-three children, thirty-three were dislocated, as seen clinically and radiographically; eight were normal, both clinically and radiographically; and there was dysplasia at the radiocapitellar articulation of the remaining five. Twenty of the twenty-three children were found to have carpal coalitions. Fourteen children had scoliosis, and five of them were managed with spinal arthrodesis and correction. Three patients had an anomaly of the cervical spine, with one deformity causing symptoms and signs that were treated with decompression. Eight patients had talipes cavus bilaterally, which was not treated.

Iliofemoral fusion for proximal femoral focal deficiency.

Iliofemoral fusion, as performed for proximal femoral focal deficiency, is designed so that the knee, acting at the level of the triradiate cartilage, will act as the hip. This procedure was indicated in four of our patients to promote fitting of a prosthesis. The results after follow-up of more than five years are reported. Two of the patients also had a Van Nes rotationplasty and two had a Syme amputation. The Syme amputation produced better results. Distal epiphyseodesis of the ipsilateral femur also was performed in three of the four patients to minimize the anterior prominence of the knee. Two patients required a closing wedge osteotomy of the distal part of the femur to improve the alignment. All four patients walked well as functional above-the-knee amputees.

Chiari pelvic osteotomy in children and young adults.

We conducted a follow-up study of twenty-four patients who had been treated with a Chiari osteotomy at the Alfred I. duPont Institute between 1966 and 1981. The length of follow-up ranged from three to twenty years, and the age at operation ranged from ten to twenty-three years. The indication for the operation was either painful dysplasia or gross instability of the hip. Twelve patients had had congenital dislocation of the hip; six, poliomyelitis; three, cerebral palsy; and three had had another disorder. A good or excellent result was obtained in twenty-one of the twenty-four patients. Preoperative pain and antalgic gait were consistently improved. In twenty-one patients, the osteotomy had to be displaced more than 50 per cent to provide adequate coverage of the femoral head, and bone-grafting was necessary at the site of the osteotomy to prevent problems with healing.

Scoliosis and pregnancy.

The effects of pregnancy on patients who have idiopathic scoliosis were investigated in terms of increased risk of progression of the curve. The charts, radiographs, and other pertinent data on 355 affected women who had reached skeletal maturity (Risser Grade 4) before 1975 were reviewed and analyzed. One hundred and seventy-five patients had had at least one pregnancy each (Group A) and 180 patients had never been pregnant (Group B). The groups were comparable with regard to the treatments that they had received. After skeletal maturity was reached, the curve progressed more than 5 degrees in 25 per cent and more than 10 degrees in 10 per cent of the patients in each group. The age of the patient at the time of the first pregnancy did not influence the risk of progression, and the stability of the curve before pregnancy did not decrease the risk of its progression during pregnancy. In patients who had had a spinal fusion, progression in the unfused portion of the spine was negligible in both Group A and Group B. The presence of a pseudarthrosis did not result in progression of the curve during pregnancy. The effects of scoliosis on pregnancy and delivery were evaluated in the 175 women in Group A. No specific problems that were directly related to the scoliosis were noted except for four patients, in whom delivery posed difficulties. The incidence of cesarean section was one-half of the national average, and no sections were directly related to the mother's scoliosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of slipped capital femoral epiphysis. Spica-cast immobilization.

Thirty-two patients (thirty-seven hips) who had a so-called acute-on-chronic or chronic slipped capital femoral epiphysis were treated with traction for relief of symptoms and then with immobilization in a spica cast for eight to sixteen weeks. The disappearance on radiographs of a metaphyseal juxtaphyseal radiolucency, rather than closure of the physis, was used as the criterion for removing the cast. In one (3 per cent) of the thirty-seven hips, the slip progressed; possibly this could have been prevented by keeping the cast on for a longer period of time. Narrowing of the cartilage space was seen after treatment in a cast in seven (19 per cent) of the thirty-seven hips. In five of these seven hips, this was true chondrolysis; in one, the diagnosis of chondrolysis had been apparent before treatment. Avascular necrosis did not develop as a result of treatment in any patient. Treatment in a spica cast should be considered as an alternative for patients who have an acute-on-chronic or chronic slipped capital femoral epiphysis.

Intraobserver and interobserver reliability of the classification of thoracic adolescent idiopathic scoliosis.

The system described by King et al. is the standard method for the classification of thoracic adolescent idiopathic scoliosis. Although it is widely used and referenced, its reliability and reproducibility among scoliosis surgeons are unknown. We used a scoliosis case-presentation format to examine the interobserver and intraobserver reliability of the classification of thoracic adolescent idiopathic scoliosis with the system of King et al. Eight active, current members of the Scoliosis Research Society reviewed twenty-seven full-length radiographs that had been made before operative correction of the scoliotic deformity. On the basis of these images, which included posteroanterior and lateral radiographs made with the patient standing as well as right and left forced-side-bending radiographs made with the patient supine, the reviewers assigned a type to each curve according to the classification system of King et al. Kappa coefficients were used to test statistical reliability. The mean interobserver reliability of the classification was only 64 per cent (range, 54 to 77 per cent) when the responses of seven of the reviewers were compared with those of one of the originators of the classification. The mean kappa coefficient was 0.49 (range, 0.27 to 0.73), which indicates poor reliability. When each reviewer's responses were compared with those of the other reviewers, the reliability was similarly poor (interobserver reliability, 55 per cent [range, 33 to 81 per cent] and mean kappa coefficient, 0.40 [range, 0.21 to 0.63]). Intraobserver reliability was evaluated in a trial in which five reviewers in a group setting were shown the same radiographs in a different order at two different viewings. Comparison of the results at the two viewings revealed a mean intraobserver reliability of 69 per cent (range, 56 to 85 per cent) and a mean kappa coefficient of 0.62 (range, 0.34 to 0.95), which indicates fair reliability. The current method of classification of adolescent idiopathic scoliosis does not appear to have sufficient intraobserver or interobserver reliability among scoliosis surgeons to portray curve types accurately. Thus, it may not help to guide treatment with use of modern spinal fixation methods.

Slipped capital femoral epiphysis. The prevalence of late contralateral slip.

We evaluated the prevalence of slipped capital femoral epiphysis in the contralateral hip of 169 children who had been managed with pinning in situ and thirty who had been managed with immobilization in a spica cast. Only children who had initially been seen with a unilateral slip and had been followed for a minimum of two years or until skeletal maturity were included in the study. The average duration of follow-up was 3.6 years (range, 0.5 to 9.5 years) for the group that had been managed with a cast and 2.8 years (range, 1.0 to 8.3 years) for the group that had been managed operatively. In sixty-one (36 per cent) of the 169 patients who had had operative treatment and two (7 per cent) of the thirty who had been managed with a spica cast, a slip subsequently developed in the contralateral hip; this difference was significant (p = 0.001). On the basis of these findings, we recommend that closer attention be paid to the potential development of a slip in the contralateral hip after pinning.

Adolescent idiopathic scoliosis: a new classification to determine extent of spinal arthrodesis.

BACKGROUND: The lack of a reliable, universally acceptable system for classification of adolescent idiopathic scoliosis has made comparisons between various types of operative treatment an impossible task. Furthermore, long-term outcomes cannot be determined because of the great variations in the description of study groups. METHODS: We developed a new classification system with three components: curve type (1 through 6), a lumbar spine modifier (A, B, or C), and a sagittal thoracic modifier (-, N, or +). The six curve types have specific characteristics, on coronal and sagittal radiographs, that differentiate structural and nonstructural curves in the proximal thoracic, main thoracic, and thoracolumbar/lumbar regions. The lumbar spine modifier is based on the relationship of the center sacral vertical line to the apex of the lumbar curve, and the sagittal thoracic modifier is based on the sagittal curve measurement from the fifth to the twelfth thoracic level. A minus sign represents a curve of less than +10 degrees, N represents a curve of 10 degrees to 40 degrees, and a plus sign represents a curve of more than +40 degrees. Five surgeons, members of the Scoliosis Research Society who had developed the new system and who had previously tested the reliability of the King classification on radiographs of twenty-seven patients, measured the same radiographs (standing coronal and lateral as well as supine side-bending views) to test the reliability of the new classification. A randomly chosen independent group of seven surgeons, also members of the Scoliosis Research Society, tested the reliability and validity of the classification as well. RESULTS: The interobserver and intraobserver kappa values for the curve type were, respectively, 0.92 and 0.83 for the five developers of the system and 0.740 and 0.893 for the independent group of seven scoliosis surgeons. In the independent group, the mean interobserver and intraobserver kappa values were 0.800 and 0.840 for the lumbar modifier and 0.938 and 0.970 for the sagittal thoracic modifier. These kappa values were all in the good-to-excellent range (>0.75), except for the interobserver reliability of the independent group for the curve type (kappa = 0.74), which fell just below this level. CONCLUSIONS: This new two-dimensional classification of adolescent idiopathic scoliosis, as tested by two groups of surgeons, was shown to be much more reliable than the King system. Additional studies are necessary to determine the versatility, reliability, and accuracy of the classification for defining the vertebrae to be included in an arthrodesis.

The relationship between tight hamstrings and lumbar hypolordosis in children with cerebral palsy.

STUDY DESIGN: Retrospective clinical and radiographic review. OBJECTIVE: To assess the influence of tight hamstrings on the sagittal alignment of the thoracic and lumbar spine in children with cerebral palsy. SUMMARY OF BACKGROUND DATA: It is postulated that tight hamstrings may produce a hypolordosis of the lumbar spine. The abnormal sagittal contour of the spine may lead to increased stresses in the lumbar spine and subsequent pain and disability. This is of special concern in children with cerebral palsy who often have shortened spastic hamstring muscles. METHODS: Twenty-one patients were evaluated, with a mean age of 9.4 years. Standing and sitting lateral spine films were obtained and the lumbar lordosis and thoracic kyphosis were measured using the Cobb method. The popliteal angle was measured to assess hamstring tightness, such that a large popliteal angle indicates tight hamstrings. RESULTS: We found a statistically significant correlation between the sitting lumbar curve and popliteal angle (Pearson correlation value -0.77, P < 0.01). As the popliteal angle increased, the amount of lumbar lordosis decreased. This correlation was less significant when the patient was standing (Pearson correlation value -0.59). CONCLUSION: This study demonstrates that there is a correlation between tight hamstrings, as measured by the popliteal angle, and decreasing lumbar lordosis, especially when sitting.

Anterior versus posterior instrumentation for the correction of thoracic idiopathic scoliosis.

Traditionally, thoracic idiopathic scoliosis has been treated by posterior instrumentation and fusion, which is still the gold standard. However, anterior instrumentation and fusion became a viable option for these patients during the 1990s and are gaining acceptance. Currently, controversy still exists regarding the indications for the anterior approach, and the benefits of the anterior versus posterior approach remain unsettled. Therefore, this topic was considered ideal for noted experts on both sides to present their opinions, with Dr. Harry Shufflebarger promoting posterior instrumentation and Dr. Randy Betz encouraging anterior instrumentation. The efforts of these two outstanding and dedicated scoliosis specialists to educate the readers of Spine regarding their viewpoints are appreciated.