The effect of Providence night-time bracing on the sagittal profile in adolescent idiopathic scoliosis.

PURPOSE: Adolescent idiopathic scoliosis (AIS) is characterized by coronal scoliosis and often a sagittal hypokyphosis. The effect of bracing on the sagittal profile is not well understood. The aim of this study is to assess the effect of night-time bracing on the sagittal profile in patients with AIS. METHODS: We retrospectively included AIS patients with a main curve of 25-45° treated with a night-time brace in our institution between 2005 and 2018. Patients with estimated growth potential based on either Risser stage, hand X-rays, or menarchal status were included. Coronal and sagittal radiographic parameters were recorded at both brace- initiation and -termination. Patients were followed until surgery or one year after brace termination. Results were compared to a published cohort of full-time braced patients. RESULTS: One hundred forty-six patients were included. Maximum thoracic kyphosis (TK) increased 2.5° (± 9.7) (p = 0.003), corresponding to a 3.5-fold relative risk increase post bracing in TK compared to a full-time brace cohort. Twenty-seven percent (n = 36) of the patients were hypokyphotic (T4/T12 < 20°) at brace initiation compared with 19% (n = 26) at brace termination (p = 0.134). All other sagittal parameters remained the same at follow-up. We found no association between progression in the coronal plane and change in sagittal parameters. CONCLUSION: This is the first study to indicate that night-time bracing of AIS does not induce hypokyphosis. We found a small increase in TK, with a substantially lower risk of developing flat back deformity compared to full-time bracing. The coronal curve progression was not coupled to a change in TK.

The influence of night-time bracing on curve progression is not affected by curve magnitude in adolescent idiopathic scoliosis: a study of 299 patients.

BACKGROUND AND PURPOSE: The efficacy of bracing larger curves in adolescent idiopathic scoliosis (AIS) patients is uncertain. We aimed to assess the influence of night-time bracing in AIS patients with main curves exceeding 40° Cobb angle at brace initiation. METHODS: We reviewed AIS patients treated with nighttime braces between 2005 and 2018. Patients with curves ≥ 25° and estimated growth potential were included. Patients were monitored with radiographs from brace initiation until brace weaning at skeletal maturity. Patients were grouped based on curve magnitude at initial evaluation: a control group (25-39°) and a large-curves group (≥ 40°). Progression was defined as > 5° increase. RESULTS: We included 299 patients (control group, n = 125; large-curves group, n = 174). In the control group, 65 (52%) patients progressed compared with 101 (58%) in the large-curves group (P = 0.3). The lower-end vertebra (LEV) shifted distally post-bracing in 41 (23%) patients in the largecurves group. Patients with progressive large curves were younger (age 13.2 [SD 1.5] vs. 13.9 [SD 1.1], P = 0.009) and more premenarchal (n = 36 [42%] vs. n = 6 [9%], P < 0.001) compared with non-progressive large curves. CONCLUSION: Progression risk in patients with curves exceeding 40° treated with night-time bracing is similar to smaller curves. The LEV moved distally in almost one-fourth of the larger curves, possibly affecting fusion levels in cases of surgery.

Does Risser stage accurately predict the risk of curve progression in patients with adolescent idiopathic scoliosis treated with night-time bracing?

PURPOSE: Risser stage is widely used as a marker for skeletal maturity (SM) and thereby an indirect measure for the risk of progression of adolescent idiopathic scoliosis (AIS). The Scoliosis Research Society recommends bracing for Risser stages 0-2 as Risser stage 3 or above is considered low risk. Very few studies have assessed the risk of progression during bracing in Risser stages 3-4. The objective of the current study is to determine if Risser stages 3-4 provide a meaningful cutoff in terms of progression risk in patients with AIS treated with night-time bracing. METHODS: AIS patients treated with night-time brace from 2005 to 2018 with a Cobb angle between 25 and 40 degrees and Risser stages 0-4 were retrospectively included. Curve progression (> 5 degrees increase) was monitored until surgery or SM. Skeletal maturity was defined as either 2 years postmenarchal, no height development or closed ulnar epiphyseal plates on radiographs. RESULTS: One hundred and thirty-five patients were included (Risser stages 0-2: n = 86 and 3-4: n = 49). Overall, radiographic curve progression occurred in 52% while progression beyond 45 degrees was seen in 35%. The progression rate in the Risser 0-2 group was 60% and 37% in the Risser 3-4 group (p = 0.012). In multivariate logistic regression analysis, adjusted for Risser stages and age, only premenarchal status showed a statistically significant association with progression (OR: 2.68, 95%CI 1.08-6.67). CONCLUSION: Risser stage does not provide a clinically meaningful differentiation of progression risk in AIS patients treated with a night-time brace. Risk assessment should include other more reliable measures of skeletal growth potential.

The Collateral Effect of Enhanced Recovery After Surgery Protocols on Spine Patients With Neuromuscular Scoliosis.

INTRODUCTION: Enhanced recovery after surgery (ERAS) protocols are often specific to a specific type of surgery without assessing the overall effect on the ward. Previous studies have demonstrated reduced length of stay (LOS) with ERAS protocols in patients with adolescent idiopathic scoliosis (AIS), although the patients are often healthy and with few or no comorbidities. In 2018, we used ERAS principles for patients undergoing AIS surgery with a subsequent 40% reduced LOS. The current study aims to assess the potential collateral effect of LOS in patients surgically treated for neuromuscular scoliosis admitted to the same ward and treated by the same staff but without a standardized ERAS protocol. METHODS: All patients undergoing neuromuscular surgery 2 years before and after ERAS introduction (AIS patients) with a gross motor function classification score of 4 to 5 were included. LOS, intensive care stay, and postoperative complications were recorded. After discharge, all complications leading to readmission and mortality were noted with a minimum of 2 years of follow-up using a nationwide registry. RESULTS: Forty-six patients were included; 20 pre-ERAS and 26 post-ERAS. Cross groups, there were no differences in diagnosis, preoperative curve size, pulmonary or cardiac comorbidities, weight, sex, or age. Postoperative care in the intensive care unit was unchanged between the two groups (1.2 vs 1.1; P = 0.298). When comparing LOS, we found a 41% reduction in the post-ERAS group (11 vs 6.5; P < 0.001) whereas the 90-day readmission rates were without any significant difference (45% vs 34% P = 0.22) We found no difference in the 2-year mortality in either group. CONCLUSION: The employment of ERAS principles in a relatively uncomplicated patient group had a positive, collateral effect on more complex patients treated in the same ward. We believe that training involving the caregiving staff is equally important as pharmacological protocols.

Rapid Discharge Protocol Reduces Length of Stay and Eliminates Postoperative Nausea and Vomiting After Surgery for Adolescent Idiopathic Scoliosis.

BACKGROUND: Implementing standardized pathways following adolescent idiopathic scoliosis surgery have been shown to reduce length of stay (LOS). However, controversies still exist. This applies especially to the transition to solid foods, postoperative pruritus, and postoperative nausea and vomiting (PONV). The aim of this proposed protocol is to present an option to reduce these factors while reducing the LOS. METHODS: The protocol was designed with reduction of morphine. One-hundred and eight patients were included in this study, including 66 controls before intervention. All patients underwent posterior scoliosis surgery. All patients were scored daily using a numeric rating scale, and they noted if any nausea, vomiting, or pruritus was present. All medications were recorded. For every 20 patients included, the steering committee met to identify any implementation issues. RESULTS: LOS was reduced from 6.3 to 3.6 days (43% reduction, P = 0.003). PONV was reduced from affecting 82% to 9% of patients (P < 0.0001). The number of patients experiencing postoperative pruritus was reduced from 40% to 2% (P < 0.001). Time spent in postoperative recovery was reduced from 278 (117 - 470) minutes to 199 (128 - 643), P < 0.001. Patients' pain scores remained unchanged compared with controls (mean 4 [3 - 8]). We found no adverse effects of solid food intake from postoperative day 0. CONCLUSIONS: We found a significant reduction in length of stay, PONV, and pruritus after implementation of the protocol. This allowed for no restrictions in regards to solid food intake postoperatively.

Intraoperative traction in neuromuscular scoliosis surgery improves major curve correction when fusing to L5.

BACKGROUND: Intraoperative traction has shown improved curve correction in neuromuscular scoliosis surgery. It is found to be superior to anterior release in terms of correction of both main curve and pelvic obliquity. No previous study has examined the effect of intraoperative traction in patients without pelvic fixation. METHOD: This retrospective study included 40 non-ambulatory (GMFCS 4 or above) patients with neuromuscular scoliosis undergoing surgery with bilateral segmental pedicle screw instrumentation to L5. Twenty-two consecutive patients had intraoperative Gardner-Wells tongs and skin traction (traction group), while the remaining did not (non-traction group). Inclusion criteria were minimum 2-year follow-up, complete medical records and radiographs. Main curve (MC), pelvic obliquity (POB), T1 tilt, kyphosis, rotation, coronal and sagittal balance and preoperative bending radiographs were measured and analyzed in all patients. RESULTS: Both groups demonstrated roughly 60% MC correction. Preoperative MC was larger in the traction group [97° (49-126) vs. 83° (40-134); P = 0.03]. The measured correction index was almost twice as large in the traction group (1.9 vs. 1.1; P = 0.001). Mean [IQR] 2-year POB was 14° [7-40] in the traction group compared to 16° [4-60] in the non-traction group (P = 0.59). Eleven patients (50%) in the traction group compared to only four (22%) in the non-traction group had a POB within 10° at 2-year follow up (RR: 2.1; 95% CI 0.8-5.2). We found no difference in kyphosis or remaining radiographic parameters. No traction-related complications were recorded. CONCLUSION: In patients with neuromuscular scoliosis undergoing instrumented fusion to the L5, we found that intraoperative traction increased the degree of MC correction and patients were more likely to achieve POB below 10° without any effects on sagittal parameters or without any detectable significant reduction on rotation.

[Spinefractures - diagnosis and treatment].

Acute onset back pain is a common reason for referral to primary health care or emergency departments. In this review, the different spine fracture types are highlighted, and a treatment algorithm is proposed. CT is the modality of choice when a spine fracture is suspected. MRI should be performed when disc or ligamentous lesions are suspected or in patients with known ankylosis or diffuse idiopathic skeletal hyperostosis. Treatment is mainly conservative with bracing, but unstable fractures and patients with neurological deficits should be treated surgically.

Should instrumented spinal fusion in nonambulatory children with neuromuscular scoliosis be extended to L5 or the pelvis?

AIMS: It is uncertain whether instrumented spinal fixation in nonambulatory children with neuromuscular scoliosis should finish at L5 or be extended to the pelvis. Pelvic fixation has been shown to be associated with up to 30% complication rates, but is regarded by some as the standard for correction of deformity in these conditions. The incidence of failure when comparing the most caudal level of instrumentation, either L5 or the pelvis, using all-pedicle screw instrumentation has not previously been reported. In this retrospective study, we compared nonambulatory patients undergoing surgery at two centres: one that routinely instrumented to L5 and the other to the pelvis. METHODS: In all, 91 nonambulatory patients with neuromuscular scoliosis were included. All underwent surgery using bilateral, segmental, pedicle screw instrumentation. A total of 40 patients underwent fusion to L5 and 51 had their fixation extended to the pelvis. The two groups were assessed for differences in terms of clinical and radiological findings, as well as complications. RESULTS: The main curve (MC) was a mean of 90° (40° to 141°) preoperatively and 46° (15° to 82°) at two-year follow-up in the L5 group, and 82° (33° to 116°) and 19° (1° to 60°) in the pelvic group (p < 0.001 at follow-up). Correction of MC and pelvic obliquity (POB) were statistically greater in the pelvic group (p < 0.001). There was no statistically significant difference in the operating time, blood loss, or complications. Loss of MC correction (> 10°) was more common in patients fixated to the pelvis (23% vs 3%; p = 0.032), while loss of pelvic obliquity correction was more frequent in the L5 group (25% vs 0%; p = 0.007). Risk factors for loss of correction (either POB or MC) included preoperative coronal imbalance (> 50 mm, odds ratio (OR) 11.5, 95%confidence interval (CI) 2.0 to 65; p = 0.006) and postoperative sagittal imbalance (> 25 mm, OR 11.0, 95% CI1.9 to 65; p = 0.008). CONCLUSION: We found that patients undergoing pelvic fixation had a greater correction of MC and POB. The rate of complications was not different. Preoperative coronal and postoperative sagittal imbalance were associated with increased risks of loss of correction, regardless of extent of fixation. Therefore, we recommend pelvic fixation in all nonambulatory children with neuromuscular scoliosis where coronal or sagittal imbalance are present preoperatively. Cite this article: Bone Joint J 2020;102-B(2):261-267.

Reproducibility of the classification of early onset scoliosis (C-EOS).

STUDY DESIGN: Reproducibility study. OBJECTIVES: Assess the agreement and reliability of the classification of early onset scoliosis (C-EOS). C-EOS is a promising tool for patients with early onset scoliosis (EOS). However, the reliability has only been examined without measuring radiographs and not including the annual progression rate (APR) modifier. METHODS: We included a single-center consecutive cohort of patients diagnosed with EOS seen in our outpatient clinic. Patients had no previous spine surgery. Four raters rated 60 cases. Two anterior-posterior full-spine radiographs, taken minimum 6 months apart, and one sagittal radiograph were measured twice by all raters in a blinded test-retest setup. Results were assessed using crude frequency of overall agreement (OA), intra- and inter-rater Fleiss kappa (κ) statistics, and intraclass correlation coefficient (ICC). We calculated the 95% limits of agreement (LOA) for major curve angle (MCA), kyphosis, and APR using a linear mixed-effects model. Inter- and intra-rater LOA were analyzed for each etiology separately. RESULTS: Mean age was 8.7 ± 3.4 years and the etiology were congenital/structural (n = 20), idiopathic (n = 19), neuromuscular (n = 13), or syndromic (n = 8). For etiology, OA was 75.8% and κ = 0.80. For major curve angle, OA was 84.2%, κ = 0.86, ICC = 0.97, and LOA = 12.8°. For kyphosis, OA was 55.8%, κ = 0.52, ICC = 0.87, and LOA = 20.6°. For APR, OA was 76.7%, κ = 0.61, ICC = 0.77, and LOA = 17.4°/year. Inter- and intra-rater LOA were generally largest for neuromuscular and smallest for idiopathic patients. CONCLUSIONS: We found substantial agreement for etiology, however, with disagreement in certain cases. The reliability of MCA was excellent; however, somewhat lower for kyphosis and APR with less accuracy. The measurement errors of MCA, kyphosis, and APR depended largely on the etiology. Regarding APR, LOA exceeded the 10°/year increments proposed in the C-EOS, suggesting a revision of this optional modifier. LEVEL OF EVIDENCE: Diagnostic study level 1.

Moderate Interrater and Substantial Intrarater Reproducibility of the Roussouly Classification System in Patients With Adult Spinal Deformity.

STUDY DESIGN: Reproducibility study of a classification system. OBJECTIVES: To provide the inter- and intrarater reproducibility of the Roussouly Classification System in a single-center prospective cohort of patients referred for Adult Spinal Deformity. SUMMARY OF BACKGROUND DATA: The Roussouly Classification System was developed to describe the variation in sagittal spine shape in normal individuals. A recent study suggests that patients' spine types could influence the outcome following spinal surgery. The utility of a classification system depends largely on its reproducibility. METHODS: Sixty-four consecutive patients were included in a blinded test-retest setting using digital radiographs. All ratings were performed by four spine surgeons with different levels of experience. There was a 14-day interval between the two reading sessions. Inter- and intrarater reproducibility was calculated using Fleiss Kappa and crude agreement percentages. RESULTS: We found moderate interrater (κ = 0.60) and substantial intrarater (κ = 0.68) reproducibility. All 4 raters agreed on the Roussouly type in 47% of the cases. The most experienced rater had significantly higher intrarater reliability compared to the least experienced rater (κ = 0.57 vs 0.78). The two most experienced raters also had the highest crude agreement percentage (75%); however, they also had a significant difference in distribution of spine types. CONCLUSION: The current study presents moderate interrater and substantial intrarater reliability of the Roussouly Classification System. These findings are acceptable and comparable to previous results of reproducibility for a classification system in patients with Adult Spinal Deformity. Additional studies are requested to validate these findings as well as to further investigate the impact of the classification system on outcome following surgery.

Spinopelvic Parameters Depending on the Angulation of the Sacral End Plate Are Less Reproducible Than Other Spinopelvic Parameters in Adult Spinal Deformity Patients.

STUDY DESIGN: Reproducibility study. OBJECTIVES: To report the agreement and reliability for commonly used sagittal plane measurements. SUMMARY OF BACKGROUND DATA: Spinopelvic parameters and sagittal vertical axis (SVA) are commonly used parameters for preoperative planning and postoperative evaluation of patients with adult spinal deformity (ASD). Previous reproducibility studies have focused on describing the reliability using intraclass correlation coefficients (ICCs), thus quantifying the methods' ability to distinguish between individuals. To our knowledge, no previous study in patients with ASD has reported the measurement error in terms of limits of agreement. The current study aimed to report the agreement and reliability for measurements of pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and SVA in ASD patients. METHODS: In a consecutive, one-center cohort of 64 patients referred for ASD evaluation, a blinded test-retest study was performed. Reliability was assessed using ICCs, whereas 95% limits of agreement (LOAs) were used to quantify agreement. RESULTS: We found "excellent" (ICC > 0.9) results in all analyses of reliability except for interrater PI, which was classified as "good" (ICC = 0.89). However, considerable interrater measurement error was observed for parameters depending on the angulation of the sacral end plate (95% LOA of ±11° and ±14° for SS and PI, respectively) compared with ±5° for PT and ±7 mm for SVA, which depends on the location of the sacral end plate. Intrarater agreement was only slightly better. CONCLUSION: These are to our knowledge the first estimates of measurement error for sagittal spinopelvic parameters in ASD patients. Despite near excellent ICCs, we found considerable measurement error for parameters depending on the angulation rather than the location of the sacral end plate. LEVEL OF EVIDENCE: Level II.

A suggestion of reference data for flow distribution at ankle and foot level using quantitative 99Tc-HDP three-phase bone scintigraphy.

AIM: To determine reference intervals for quantitative 99mTc-hydroxymethylene diphosphonate (99mTc-HDP) three-phase bone scintigraphy regarding flow distribution at ankle and mid-foot level. MATERIALS AND METHODS: Fifty patients referred to bone scintigraphy without known or suspected pathology in the legs or hips were included. Quantitative three-phase bone scintigraphy was performed in all patients. A processing protocol with standardized size regions of interests (ROIs) was used to quantify the distribution of flow and blood pool at ankle and level mid-foot levels. Patients were divided into three groups: <60 years (n = 20), 60 years or older (n = 17) and finally a group (n = 13) with pedal foci (PF). RESULTS: Blood pool distribution varied between the two age groups, with younger having the narrowest confidence interval at mid-foot level but the widest at ankle level. Blood flow distribution confidence intervals were wider in the presence of PF, whereas blood pool distribution intervals were independent of PF. Both blood flow distribution and blood pool at ankle and mid-foot level were independent of gender and referral status being either cancer or skeletal complaints. CONCLUSION: As there was no evident increase in blood flow distribution at ankle and mid-foot level with age, we suggest the use of pooled data from both age groups. Subsequently, the confidence interval for the relative distribution of blood flow at ankle level is 37/63 and 33/67 at mid-foot level. For blood pool, the corresponding intervals are 43/57 and 40/60, respectively. Blood flow distribution appears to be influenced by the presence of PF, whereas blood pool distribution is not.