Management Of Adolescent Idiopathic Scoliosis Research Articles

Surgical management of adolescent idiopathic scoliosis

Without a complete understanding of the natural history of adolescent idiopathic scoliosis (AIS), the treating spine surgeon will be unable to effectively appreciate the indications for surgery nor will the long-term management plan be appropriate. Basic evaluation of the patient with AIS should center on a thorough history and physical examination. It is crucial that applicable radiographic imaging is obtained as well, which must be tailored to each individual patient given the findings on history and physical examination. For patients in whom surgical correction is indicated, many factors comprise the ultimate treatment plan. The goals of surgery center on prevention of curve progression, adequate coronal and sagittal realignment, and the preservation of as much motion as possible. Vertebral-level selection, curve-reduction techniques, fixation strategies, postoperative protocols, and potential complications each play a vital role in the successful surgical treatment of AIS. With an in-depth understanding of all of these variables, the spine surgeon can achieve excellent outcomes for his or her AIS patients.

Perceived level of knowledge and skills about clinical management of adolescent idiopathic scoliosis among undergraduate chiropractic students and clinical faculty at a Canadian chiropractic program: cross–sectional study

Perceived level of knowledge and skills about clinical management of adolescent idiopathic scoliosis among undergraduate chiropractic students and clinical faculty at a Canadian chiropractic program: cross–sectional study

Preoperative Variables Predicting Massive Blood Loss During Surgical Management of Adolescent Idiopathic Scoliosis

Background: Massive blood loss is one of the most important concerns in scoliosis surgery. There are some factors suggested to predict the massive blood loss in patients with adolescent idiopathic scoliosis (AIS), however, their predictive value remained unclear. Objectives: The current study aimed to investigate whether preoperative variables can predict perioperative massive blood loss in patients with AIS. Patients and Methods: There were 60 patients with AIS who underwent surgical treatment in the current retrospective study. Posterior spinal fusion (PSF) was performed on 36 patients and PSF and anterior spinal fusion (ASF) for the other 24. Estimated blood loss (EBL) was calculated intraoperative. The correlation between preoperative radiographic and demographic variables with EBL was investigated. Results: Among the variables, only AVB-R ratio positively correlated with the amount of intraoperative blood transfusion (r = 0.28; P = 0.03). Also, preoperative lateral rib hump positively correlated with blood loss in the PSF group (r = 0.39; P < 0.05). Also, the classification of the scoliosis did not affect the amount of blood loss and the number of transfused units. Conclusions: The preoperative lateral rib hump is an important factor positively correlated with the EBL.

Effects of novel corrective spinal technique on adolescent idiopathic scoliosis as assessed by radiographic imaging

To compare the therapeutic effects of a 3-dimensional corrective spinal technique (CST) and a conventional exercise program (CE) on altered spinal curvature and health related quality-of-life in patients with adolescent idiopathic scoliosis (AIS). Adolescents with idiopathic scoliosis (N=32, 6 males and 26 females) between 10 and 19 years of age (14.34 ± 2.60 years) were recruited and underwent the CST or CE for 60 minutes/day, 2-3 times a week, and an average of total 30 sessions. Diagnostic X-ray imaging technique was used to determine intervention-related changes in the Cobb angle, thoracic kyphosis angle, lumbar lordosis angle, sacral slope, pelvic tilt, pelvic incidence, and vertebral rotation (Nash-Moe method). The Scoliosis Research Society-22 (SRS-22) health related quality-of-life questionnaire was used. Data were analysed using independent t-test, paired t-test, and non-parametric Mann-Whitney U-test at p < 0.05. CST showed greater improvements in Cobb angle (p=0.003), vertebral rotation (p=0.000), and SRS-22 scores (self-image and treatment satisfaction subscale scores and total score, p=0.026, p=0.039, and p=0.041, respectively) as compared to the controls. There were no significant changes in the other measures between the two groups. This is the first clinical trial to investigate the effects of the 3-dimensional CST on spinal curvatures and health related quality-of-life in AIS, providing the important clinical rationale and compelling evidence for the effective management of AIS.

Choosing Fusion Levels in Adolescent Idiopathic Scoliosis

Correct identification of fusion levels in surgical planning for the management of adolescent idiopathic scoliosis is a complex task. Several classification systems and algorithms exist to assist surgeons in determining the appropriate levels to be instrumented. The Lenke classification is the benchmark system. Among the many factors and measurements that are taken into account when selecting the proper upper instrumented vertebra and lower instrumented vertebra are planning for selective fusion; preserving motion segments; preventing proximal and/or distal junctional kyphosis, shoulder imbalance, and neck pain; and maintaining short fusion lengths. Existing treatment algorithms do not account for every exception, and further research is required to improve long-term surgical outcomes.

Recent Trends in Surgical Management of Adolescent Idiopathic Scoliosis: A Review of 17,412 Cases from the Scoliosis Research Society Database 2001-2008

Recent Trends in Surgical Management of Adolescent Idiopathic Scoliosis: A Review of 17,412 Cases from the Scoliosis Research Society Database 2001-2008

Is There a Global Consensus on Optimal Surgical Care for Adolescent Idiopathic Scoliosis? A Delphi Study

The surgical management of adolescent idiopathic scoliosis (AIS) has seen many developments in the last two decades including use of pedicle screws, bone substitutes, and so on. Little high-level evidence is available to support these changes and guide treatment. Therefore, the AOSpine Knowledge Forum Deformity identified a need to explore what is currently practiced and what constitutes optimal operative care for these patients.

Choosing Fusion Levels in Adolescent Idiopathic Scoliosis

Correct identification of fusion levels in surgical planning for the management of adolescent idiopathic scoliosis is a complex task. Several classification systems and algorithms exist to assist surgeons in determining the appropriate levels to be instrumented. The Lenke classification is the benchmark system. Among the many factors and measurements that are taken into account when selecting the proper upper instrumented vertebra and lower instrumented vertebra are planning for selective fusion; preserving motion segments; preventing proximal and/or distal junctional kyphosis, shoulder imbalance, and neck pain; and maintaining short fusion lengths. Existing treatment algorithms do not account for every exception, and further research is required to improve long-term surgical outcomes.

Arachnoiditis Ossificans After Revision Adolescent Idiopathic Scoliosis Surgery

Case report. To report the clinical and imaging findings of a patient with arachnoiditis ossificans (AO) 22 years after revision surgery for adolescent idiopathic scoliosis (AIS). To our knowledge, there are no reports in the literature that describe AO developing after primary or revision surgery for AIS. Ararchnoiditis ossificans is a rare finding and we provide a review of its presentation and management. We report the patient's history, physical examination, radiographical findings, and management in addition to providing a literature review. A 43 year-old-male who underwent revision surgery for AIS due to intradural migration of a laminar hook presented 22 years after surgery with subjective leg weakness. On physical examination, no weakness was elicited and radiographs demonstrated the instrumentation to be intact. Computed tomographic imaging was performed to assess for adjacent segment disease and diffuse ossification or AO of the thecal sac from L3 to S1 was noted. We recommended observation and nonoperative management because the patient's symptoms were relatively mild. To our knowledge, this is the first report of AO after surgical management of primary or revision AIS. A discussion on the management of AO and a literature review is presented.

Clavicle Chest Cage Angle Difference (CCAD)

Retrospective case series of surgically treated patients with adolescent scoliosis. To establish a new radiographical measurement method to determine the best preoperative predictor of postoperative shoulder balance. Shoulder balance is an important aspect of the overall cosmetic balance in patients with adolescent idiopathic scoliosis. Despite recent reports, it is still difficult to estimate the postoperative shoulder balance accurately. A retrospective review of 89 consecutive patients who had thoracic fusion with a minimum 2-year follow-up (mean, 3.1 yr) was conducted to investigate the radiographical measurements and patient demographics. The shoulder height difference (SHD) was measured as the graded height difference of the soft tissue shadows. SHD more than 2 cm indicated an unbalanced shoulder. The clavicle chest cage angle difference (CCAD) was established and evaluated. The CCAD was graded as grade A: no imbalance (<0°), grade B: mild imbalance (0°-10°), and grade C: significant imbalance (>10°). Of the 89 patients, 22 patients had a moderate or significant SHD at 2 years postoperatively and were categorized as the unbalanced shoulder group (unbalanced SD). A significant difference was observed in preoperative CCAD between the balanced and unbalanced SD groups (P = 0.01). The intraclass correlation coefficient for CCAD was 0.94 among the observers. CCAD was consistent from the preoperative to the final postoperative follow-ups in both groups. The classification of the CCAD preoperatively indicated that 12 of 22 (54.4%) patients who were classified into the postoperative unbalanced SD group showed grade 3 CCAD preoperatively, whereas only 9 of 67 (13.4%) patients who were classified in the postoperative balanced SD group had grade 3 CCAD preoperatively. The developed method to predict postoperative shoulder balance was demonstrated to be easy to perform, reliable, and practical. Additionally, we classified the estimation of postoperative shoulder imbalance by preoperation CCAD. The results of this comprehensive review will guide spinal surgeons in their preoperative planning and in the surgical management of adolescent idiopathic scoliosis to reduce postoperative shoulder imbalance. 4.

A multicenter analysis of factors associated with change in height after adolescent idiopathic scoliosis deformity surgery in 447 patients

In the surgical management of adolescent idiopathic scoliosis (AIS), patients are often preoperatively informed that they will gain height as a result of their surgery. However, current estimations conflict significantly and do not have any clinical correlation. The authors developed a formula that would predict postoperative gains in height after deformity correction in AIS. A large, multicenter, prospective database was retrospectively queried for AIS patients with Lenke Type 1, 2, or 3 curves having undergone posterior spinal fusion alone. A univariate and multivariate analysis was performed to identify which factors contributed significantly to changes in height. Four hundred forty-seven patients were included in the series. Factors correlating with changes in postoperative height included: upper thoracic curve magnitude, main thoracic curve magnitude, lumbar curve magnitude, T2-12 kyphosis, T5-12 kyphosis, curve flexibility, number of levels fused, presence of Ponte osteotomies, total preoperative coronal Cobb angle, change in coronal curve magnitude, total preoperative sagittal curvature, change in sagittal curvature, and thoracic curve correction. When combined in a multivariate regression analysis the following variables remained significant: thoracic curve magnitude (p < 0.01), number of levels fused (p < 0.01), change in total sagittal curvature (p < 0.01), and the presence of osteotomies (p = 0.03). The contribution from the thoracic curve magnitude was significantly greater than any of the other parameters identified (R2 = 0.140). Change in height (in cm) = ([thoracic curve magnitude × 0.039] + [number of levels fused × 0.193] - [change in sagittal curvature × 0.033] + [x × 0.375]) - 1.858, where x = 1 if 1 or more osteotomies were performed and x = 0 if no osteotomy was performed. The authors' results suggest that changes in the coronal plane contribute more significantly to height changes than those in the sagittal plane and approximately 0.39 cm of height gain can be expected for each 10° of coronal curve preoperatively. Unfortunately, a significant fraction of the postoperative height changes cannot be predicted by currently measured parameters.

The impact of direct vertebral body derotation on the lumbar prominence in Lenke Type 5C curves

The thoracic rib hump, caused by axial rotation of the spine, is one of the most dissatisfying cosmetic features associated with adolescent idiopathic scoliosis (AIS). However, advances in instrumentation and surgical techniques, such as direct vertebral body derotation (DVBD), have allowed improved correction in the axial plane and the rib hump. In cases of thoracolumbar/lumbar curves (Lenke Type 5), the lumbar prominence can be equally disfiguring and is often associated with waist asymmetry, another cosmetic concern. Although DVBD has been evaluated in the thoracic spine, little is known about its impact on the lumbar spine. The authors investigated the outcomes of DVBD on the lumbar prominence. A prospectively collected multicenter database was queried for pediatric patients with AIS and Lenke Type 5 curves. All patients who underwent thoracoplasty procedures were excluded. A total of 34 patients underwent surgical correction via a posterior-only approach using pedicle screw constructs. Nineteen patients underwent concurrent DVBD, and the remaining 15 patients served as a control group and did not undergo DVBD. All patients had a minimum of 2 years of follow-up. The mean age of the entire cohort was 14.9 ± 2.3 years, and the majority of patients were female (88%). All patients had Lenke Type 5C curves with a mean major curve of 46.0° ± 8.7°, which corrected to 13.7° ± 7.2° (70% correction). A mean of 10.7 ± 3.0 levels were fused. Only thoracic kyphosis was significantly different between the groups preoperatively. Similarly, postoperative radiographic parameters were comparable between the groups, with equivalent percentages of correction. Although improvement in the thoracic rib hump was comparable between the groups, the DVBD group had 56.2% correction of the lumbar prominence, and the control group had 76% improvement (p = 0.05). Although DVBD has been a valuable tool in the management of AIS, the authors' results suggest that its application for thoracolumbar curves may be limited. Further analysis with a larger cohort is required to better ascertain the impact of DVBD on thoracolumbar curves.

Patient Self-Assessment of Appearance Is Improved More by All Pedicle Screw Than by Hybrid Constructs in Surgical Treatment of Adolescent Idiopathic Scoliosis

A multicenter prospective cohort study. To compare the effect of all pedicle screw versus hybrid constructs on patient self-assessment of appearance after posterior spinal fusion with instrumentation for adolescent idiopathic scoliosis (AIS). This will contribute to future cost-effective analyses on surgical management of AIS. For surgical management of AIS, the Spinal Appearance Questionnaire (SAQ) and the Scoliosis Research Society outcomes instrument (SRS-30) are reliable surveys of patient satisfaction, but neither tool has been used to assess outcome by implant type. Patients received either all pedicle screws or hybrid instrumentation. Self-assessment of appearance pre- and after surgery was measured by SAQ and SRS-30. Statistical significance was evaluated through P values (P < 0.01 in the SAQ, P < 0.05 in the SRS-30) and effect sizes. There were 93 patients in the all pedicle screw cohort and 61 in the hybrid cohort. There were no significant preoperative differences between the cohorts in the SAQ or SRS-30. All pedicle screw patients tended to see more improvement in shoulder level than hybrid patients in 2 separate SAQ questions (P = 0.025, Cohen's D = 0.20; P = 0.013, D = 0.24). The screw patients also tended to have better scores than hybrid patients in the category, "looking better in clothes" (P = 0.017, V = 0.24) at 2 years postoperative. All pedicle screw patients self-reported significant greater improvement than hybrid patients in the SRS-30 Appearance and Mental domains (P = 0.016, ES = 0.038; P = 0.005, ES = 0.051). There were no significant differences between cohorts in age, gender, baseline curve, or major curve magnitude. All pedicle screw constructs lead to better self-assessment of appearance in operative treatment of AIS, as determined by SAQ and SRS-30.

Top Theories for the Etiopathogenesis of Adolescent Idiopathic Scoliosis

Despite considerable advances in the past few decades, there is no generally accepted "top theory or theories" of the etiology of adolescent idiopathic scoliosis (AIS). This article aims to provide an overview of the current main hypothetical "concepts" on the etiopathogenesis of AIS. An extensive literature review on hypothetical concepts on the etiology and etiopathogenesis of AIS. Concepts of etiopathogenesis in AIS were summarized and highlighted under 6 subgroups: genetics factors, abnormalities in nervous system, abnormal skeletal growth, hormones and metabolic dysfunction, biomechanical factors, and environmental and life style factors. An integrative model on the etiopathogenesis of AIS is proposed. The current knowledge is still fragmented and many fundamental questions have remained to be answered. In moving forward in the perusal of further advancement of our understanding of the etiopathogenetic mechanisms and future evidence-based prevention and management of AIS, multidisciplinary and multicenter innovative research collaboration is imminently important and necessary. With a relatively comprehensive review on the current understanding on the etiology and etiopathogenesis of AIS, the article would help to stimulate further innovative thoughts, research, and especially collaborative research in this area of great interest.

Use of All-pedicle-screw Constructs in the Treatment of Adolescent Idiopathic Scoliosis

All-pedicle-screw constructs are safe and biomechanically advantageous in the management of adolescent idiopathic scoliosis. Safe and reproducible placement of thoracic pedicle screws is dependent on a thorough understanding of normal and abnormal anatomy, meticulous technique, and the use of neuromonitoring and fluoroscopy. Improvement in the biomechanical properties secondary to the use of pedicle screw fixation has led to shorter fusions with improved deformity correction. Coronal, sagittal, and rotational correction is superior to that obtained with hook instrumentation. Improved derotation may decrease the need for thoracoplasty, thus eliminating the risk of associated morbidity. Superior control of the deformity with all-pedicle-screw fixation, as well as the use of adjunctive posterior releases, often obviates the need for an anterior approach, even in severe curves measuring 70 degrees to 100 degrees . Improved correction, shorter fusion, and the lower morbidity associated with posterior-only approaches may compensate for higher implant costs.

Improvement in Quality of Life Following Surgery for Adolescent Idiopathic Scoliosis

We used the Climent Quality of Life for Spinal Deformities Scale prospectively in a nonrandomized prospective comparative cohort of operative versus observational management of adolescent idiopathic scoliosis. To compare the change in disease-specific quality of life associated with operating on adolescents with idiopathic scoliosis, to the change in disease-specific quality of life among observed scoliosis patients with a similar 2-year follow-up period. The immediate effect of scoliosis surgery on quality of life from a patient perspective has not been properly documented but should play a role in the patient's decision to operate. At a single tertiary referral children's hospital spinal clinic, 119 patients undergoing scoliosis surgery and 42 patients undergoing observation only for scoliosis were enrolled in a prospective study, including preoperative and postoperative spine-specific quality of life. Change in quality of life after 2 years of follow-up among operated versus observed patients (adjusted for baseline quality of life) was used to estimate the short-term benefit of scoliosis surgery. The operated group experienced an increase in quality of life of 4.3 points (95% confidence interval, 0.69-7.88) on the 115-point Climent scale. Although statistically significant, this increase was lower than the 5.5-point cutoff we had defined a priori as clinically significant. Scoliosis surgery results in a small increase in spine-related quality of life at 2 years. This increase is of questionable clinical significance. Decisions to operate on adolescents with scoliosis should acknowledge modest expectations about short-term gains in quality of life.

The Use of Thoracoscopy in the Management of Adolescent Idiopathic Scoliosis

Retrospective case cohort series. To analyze the outcomes of thoracoscopy in the surgical treatment of adolescent idiopathic scoliosis. Traditionally, progressive idiopathic scoliosis has been treated surgically with either an open posterior, anterior, or combined surgical approach. Surgical methods are being explored to minimize the extent of soft tissue disruption such as thoracoscopy followed spinal release, bone grafting, and instrumentation. Several authors have reported good results using thoracoscopy in the treatment of spinal deformity following a requisite learning curve. A consecutive case cohort series of 45 adolescent patients with idiopathic scoliosis evaluated and treated at a single institution. Patients with a progressive deformity underwent a thoracoscopically assisted curve correction, fusion, and instrumentation procedure. After surgery, patients were assessed at 1, 3, 6, and 12 months and then annually. All patients underwent successful thoracoscopic instrumentation and fusion without the need for an open conversion. The average preoperative thoracolumbar Cobb measurement of the major curve was 51.6 degrees . The thoracolumbar levels instrumented anteriorly ranged from T7 to L3 and had an average postoperative Cobb angle of 6.58 degrees , with an overall improvement of 87.3%. To date, at a mean follow up of 4.6 years, all curves have maintained correction. Sagittal balance was recreated or maintained through the application of interbody femoral ring allografts. Operative times averaged 5 hours and 46 minutes, with a range of 3 hours, 48 minutes to 6 hours, 55 minutes. Hospital stays averaged 2.9 days, with a range of 2 to 7 days. All patients were completely off pain medication before their first postoperative visit at 4 weeks. Children were back to school between 2 and 4 weeks on average. There were a total of 3 complications. One patient experienced transient chest wall numbness, which resolved by 3 months. Two patients developed postoperative mucus plugging in the ventilated lung. Endoscopic thoracoscopic spinal deformity correction, fusion, and instrumentation is a safe and feasible method of surgical management of an adolescent patient with progressive scoliosis. The key to successful fusion is a total discectomy and complete endplate removal. This method appears to be comparable to open procedures in terms of curve correction with significantly shorter hospitalization and rehabilitation due to less surgical discomfort. The thoracoscopic correction of adolescent scoliosis warrants continued development and evaluation as a surgical method of scoliosis correction.

Twelve DNA markers accurately assess risk of progression in adolescent idiopathic scoliosis

Objective Optimization of AIS management necessitates early and accurate identification of progressive deformities. As standard radiographic evaluation relies on variables that change over time, these methods are often inaccurate in assessing risk of progression. Most data suggest that adolescent idiopathic scoliosis (AIS) has a polygenic inheritance. The exact gene(s) involved, however, have not been identified. Using our unique genealogy resources and a large patient population from across the United States, we hope to discover the molecular basis of AIS. As an interim result in our efforts to understand the genetic basis of AIS, we report on twelve DNA markers potentially useful in accurately predicting curve progression.

Orthotic Management in Adolescent Idiopathic Scoliosis

In this issue, we are publishing 2 articles that have used the new Scoliosis Research Society (SRS) guidelines for inclusion and assessment of brace studies in adolescent idiopathic scoliosis. The guidelines are a product of the SRS Committee on Bracing and Nonoperative Management and are designed to establish standardized reporting parameters for subjects and measures for use in determining effective treatment. Such guides will allow for meaningful comparisons in future studies. The SRS inclusion criteria for bracing studies are diagnosis of adolescent idiopathic scoliosis, age of 10 years or older when the orthosis was fabricated, skeletal immaturity (Risser sign 0, 1, or 2), primary curve between 25 and 40 degrees, absence of previous treatment, and, if female, either premenarcheal or less than 1 year past menarche. All patients are to be included regardless of whether or not they were found to be compliant with their treatment regimen (intent to treat). The new SRS assessment of effectiveness criteria includes (1) the percentage of patients who had 5 degrees or less of curve progression, (2) the percentage of patients who had 6 degrees or more of curve progression at maturity, (3) the percentage of patients whose curve progressed beyond 45 degrees, and (4) the percentage of patients who had surgery recommended or performed. A minimum of 2 years of follow-up beyond skeletal maturity was required to complete a successful brace treatment. It is also recommended that all studies be stratified according to curve magnitude and type. We have embraced these guidelines and expect them to be used in future submissions to the Journal of Pediatric Orthopaedics of studies on brace management of adolescent idiopathic scoliosis. The lack of standardized inclusion and assessment criteria has recently led the US Preventive Health Task Force to recommend against school screening for early diagnosis for scoliosis. The rationale is a documented lack of evidence that there is an effective nonoperative treatment option to prevent curve progression in patients with mild curves. We think that this is a grievous error and may lead to a greater number of patients presenting late with more severe curves. Abandoning early diagnosis will limit any chance of nonoperative treatment and will result in greater risk associated with a larger number of children requiring complex surgical procedures for correction. However, it is also a challenge for pediatric orthopaedic surgeons to seek evidence-based proof that orthotic management is a statistically significant effective treatment for mild but progressive curves. These 2 articles share similar inclusion criteria and comparable results in curves of 25 to 35 degrees at the time of initiation of brace management. The thoracolumbar sacral orthosis and Providence orthosis were less successful in preventing progression in the larger curves and in reducing the need for surgery. However, the SpineCor orthosis demonstrated better results in this group. The exact reasons remain unclear. These 2 articles should serve as encouragement to future investigators to perform level 1 evidencebased research on this important question.

The effect of rigid versus flexible spinal orthosis on the gait pattern of patients with adolescent idiopathic scoliosis

The conventional rigid spinal orthosis and the flexible spinal orthosis, SpineCor, have different treatment principles in the management of adolescent idiopathic scoliosis (AIS). These may influence the patients’ gait pattern and clinical outcome. In this study, gait analysis on patients with AIS undergoing these two orthotic interventions were conducted. The patients’ lower limb kinematic and kinetic data during level walking were collected using a motion analysis system and two force platforms in four test conditions: pre-intervention, having used the orthosis for 1 month and 1 year (in and out of the orthosis). Twenty-one subjects were randomly assigned to the rigid spinal orthosis group (10 subjects) and the SpineCor group (11 subjects). Neither group showed gait asymmetry when comparing the convex and concave sides in the four test conditions. However, significant reduction in the range of motion of the pelvis and hip joints in the coronal plane were found. Although patients with AIS undergoing these two orthotic interventions showed significant changes in walking pattern within the study period, their long-term effect on gait and function requires further investigation through long-term prospective studies.