Cobb Method Research Articles

291. Influence of lumbar lordosis on posterior rod strain in long-segment pedicle screw and rod instrumentation with anterior column realignment: cadaveric study

BACKGROUND CONTEXT Lumbar lordosis (LL) has a close geometric relationship with pelvic parameters and sagittal profile. The association between the alignment of the pelvis (sacral slope) and the lumbar spine is an important determinant of sagittal balance, with the lower arc of lordosis being the most important determinant of the global lordosis. Posterior rod strain (RS) monitoring during biomechanics tests is an effective method to infer the stress on spinal implants. Yet it remains unknown whether lumbar lordosis and final construct geometry have a significant impact on instrumentation loading. An improved understanding of key factors that influence stress and strain in spinal instrumentation may serve to maximize construct longevity and avoid implant failure. PURPOSE Investigate the relationship between lordosis angle in different levels and different conditions with rod strain during loading. METHODS Seven fresh-frozen specimens underwent standard dynamic nondestructive bending tests in flexion (FL), extension (EX) (7.5 Nm) as well as compression (C) (400N) in a 6DOF robotic apparatus. Conditions tested were: 1) intact; 2) pedicle screws and rods only (PSR); 3) Anterior column realignment at L3-L4 (ACR). The posterior right rod at L3-L4 and at L5-S1 was instrumented with strain gauges. Lateral x-rays of all conditions were taken before testing. Lumbar lordosis spanning different levels were measured in all different conditions (unloaded) using the Cobb method (L5-S1, L4-S1, L3-S1, L2-S1 and L1-S1) and correlated with rod strain (RS) (during loading) using a Pearson correlation analysis (p RESULTS L3-S1 intact (P=0.028) and PSR (p=0.007) lordotic angle demonstrated strong correlation with L3-4 RS in PSR condition during FL. The L3-S1 intact angle also correlated with RS with PSR in EX (p=0.018). L3-S1 intact angle demonstrated a relationship with L5-S1 RS with ACR during C (p=0.008). L2-S1 intact angle also demonstrated a correlation with L3-4 RS with PSR during FL (p=0.007) and EX (p=0.002). The L2-S1 intact lordosis was linked with L5-S RS with PSR during FL (p=0.03) and with ACR during compression (p=0.03). All correlations were positive (i.e. strains increased in magnitude with increasing Cobb angles). CONCLUSIONS Different lumbar lordotic measures taken in intact and PSR conditions demonstrated strong correlations with in vitro posterior RS. Both native lumbar curvature and after placement of pedicle screw and rod instrumentation have a significant influence on in vitro posterior hardware strain changes during loading. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Surgical treatment of severe congenital cervical kyphosis

Objective: To investigate the surgical treatment of severe congenital cervical kyphosis. Methods: The clinical data of patients with severe congenital cervical kyphosis (Cobb>40°) treated in Peking University Third Hospital from March 2004 to March 2018 were retrospectively summarized. In this series, 8 cases were enrolled, included 4 males and 4 females; the patients were 5-45 years old. According to the etiology, 4 patients were diagnosed with vertebral body underdevelopment, 2 with vertebral insufficiency, 1 with cervical spine congenital fusion and 1 with C(2) spinous process mecism. Five cases were treated with traction before final surgical correction. The surgical strategy was anterior correction or posterior correction or combined procedure in regards to different situation. The curvature of cervical angle was measured by two-line Cobb method, and the cervical kyphosis angle was measured on lateral radiographs in the neutral and extended position at the pre-operation and post-operation in each patient. The correction rate and evaluated Japanese Orthopedic Association (JOA) scoring for the function of spinal cord were also measured. The data before and after the operation were compared with t test. Results: In this series, the average kyphotic Cobb angle was 67°±18° and 8°±8° before and after surgical correction, respectively (t=8.471,P<0.05).The final correction rate was 87%±13%.The JOA score improved from 11.1±2.7 to 14.0±1.5 (t=-2.656, P<0.05) at the end of follow up. Conclusions: The pre-correction by cervical spine traction and final surgical correction by anterior, posterior or combined approaches of internal fixation and fusion can achieve good results and reduce risk and difficulty in operation for severe congenital cervical spine kyphosis with vertebral body underdevelopment without vertebral insufficiency and cervical spine congenital fusion. The final surgical correction by one-stage anterior, posterior or combined approaches of internal fixation and fusion can achieve good results for severe congenital cervical spine kyphosis with vertebral insufficiency and/or cervical spine congenital fusion.

A semi-automatic 3D ultrasound reconstruction method to assess the true severity of adolescent idiopathic scoliosis.

Adolescent idiopathic scoliosis (AIS) is a three-dimensional (3D) spinal deformity. Current practice uses the Cobb method to measure spinal severity on postero-anterior (PA) radiographs. This method may underestimate spinal deformity and exposes patients to ionizing radiation, increasing the risk of cancer. This paper reports a new 3D ultrasound method using the voxel-based reconstruction technique with bilinear interpolation to reconstruct a 3D spinal image and measure true spinal curvature on the plane of maximal curvature (PMC). Axial vertebral rotation (AVR) was measured on the 3D image and utilized to estimate the PMC. In vitro phantom experiments and in vivo clinical study were conducted to evaluate reconstruction accuracy and measurement reliability. The in vitro study showed a high accuracy of the reconstruction of vertebrae with the mean absolute difference (MAD) < 3mm. The in vitro and in vivo measurements of AVR were reliable (> 0.90). The in vivo study also showed high intra- and inter-rater reliabilities of the PA and PMC Cobb angle measurements with ICC values > 0.90 and MADs within the clinical accepted tolerances. The PMC Cobb angles were up to 7° greater than their corresponding PA Cobb angles. This method demonstrated a non-ionizing radiation method to assess the actual severity of AIS. Graphical abstract Adolescent idiopathic scoliosis (AIS) is a lateral curvature of spine with vertebral rotation. Using the Cobb method to measure spinal severity on postero-anterior (PA) radiographs may under estimate its severity.

The role of the angle of the ascending aortic curvature on the development of type A aortic dissection: ascending aortic angulation and dissection.

Type A aortic dissection (TAD), which consists of an intimal tear in the aorta, necessitates emergency surgery. Various risk factors related to aortic dissection have been defined in the literature. According to our hypothesis, a narrower angle of ascending aortic curvature (AAAC) may be an additional risk factor in relation to aortic dissection due to the increased force applied to the aortic wall. Patients undergoing ascending aortic surgery due to an ascending aortic aneurysm (AsAA) (n = 105) and patients undergoing such surgery because of the occurrence of TAD (n = 101) were enrolled in this study. The AAAC was measured using Cobb's method; the measurements were made on all patients by just 1 cardiovascular radiologist using 3-dimensional computerized tomographic imaging. This measurement was made indirectly by using the aortic valve and brachiocephalic artery to avoid obtaining misleading data as a result of distortions due to dissection. A statistical comparison was also performed relating the traditional risk factors for TAD to other clinical and echocardiographic parameters: the diameter of the ascending aorta and the AAAC. The AAAC was found to be narrower statistically in the TAD group (α = 76.2° ± 17.5°) than it was in the AsAA group (α = 92.9° ± 13°) (P < 0.001). Furthermore, mean ascending aortic diameter (P = 0.019), the presence of a bicuspid aorta (P = 0.007) and aortic valve stenosis (P = 0.005) were higher in the AsAA group. According to multivariable analyses, a narrower AAAC is a significant predictor for the development of TAD (odds ratio 0.93, 95% confidence interval 0.91-0.95; P < 0.001). Overall hospital mortality from various causes including stroke, myocardial infarction, bleeding or renal failure was 13% in the TAD group and 7% in the AsAA group. According to this study, the AAAC was significantly smaller in aortic dissection patients than in aortic aneurysm patients. This may be related to higher shear stress and elevated pressure on the ascending aorta in patients with a narrower AAAC. Thus, a narrower AAAC may be an additional risk factor in the development of TAD. Therefore, we may need to be more careful in terms of looking for the development of aortic dissection in patients with narrower AAAC.

Lumbar Retrolisthesis Compensates Spinal Kyphosis

Study DesignLarge cohort study. ObjectiveTo investigate the role of lumbar retrolisthesis in spinopelvic alignment and health-related quality of life (HRQOL) among volunteers aged >50 years. Summary of Background DataLumbar retrolisthesis pathology has not been sufficiently elucidated. MethodsWe included 639 volunteers (257 men, average age 73 [50-92] years). Sagittal vertical axis (SVA), maximum thoracic kyphosis (maxTK), lumbar lordosis (LL), pelvic incidence (PI), and pelvic tilt (PT) were measured using whole-spine and pelvic radiographs taken in standing position. MaxTK was measured from the upper to the lower end vertebrae of spinal kyphosis in the sagittal plane using Cobb's method. HRQOL was evaluated using the Oswestry Disability Index (ODI). Subjects with ≥3 mm posterior lumbar vertebral slip and those with multiple retrolisthesis were included in R(+) and multiple groups, respectively. In single lumbar retrolisthesis subjects, those above L3–L4 were defined as the superior group and below L4–L5 as the inferior group. ResultsThe R(+) group had 259 (41%) subjects. Of the posterior slipped vertebrae, 235 (91%) were consistent with the lower end vertebra of the maxTK or its adjacent one. The R(+) group had significantly more males; subjects were older than those in the R(–) group. They also had significantly greater SVA, TK, maxTK, and PI-LL and smaller LL and PI. Multivariate analysis revealed that sex, maxTK, and LL were independent predictors of lumbar retrolisthesis. The inferior group had a significantly greater SVA, PT and PI-LL, and smaller LL and PI than the R(–), superior, and multiple groups. The inferior group also had significantly worse ODI than the R(–) group. ConclusionsSubjects with lumbar retrolisthesis showed greater spinal kyphosis and worse spinopelvic alignments. Subjects with lower-generated lumbar retrolisthesis showed worse spinopelvic alignment and HRQOL than subjects with upper-generated lumbar retrolisthesis and multiple ones and those without it. Level of EvidenceLevel IV.

Reprodutibilidade do método Cobb na medição da lordose lombar de crianças utilizando diferentes níveis vertebrais

Introdução: A radiografia é o padrão ouro para avaliação da coluna vertebral. Contudo, apresenta uma variabilidade inerente ao exame e ao avaliador. Objetivos: (1) comparar os ângulos de lordose lombar utilizando diferentes níveis vertebrais de referência e (2) verificar a repetibilidade e a reprodutibilidade do método Cobb na avaliação da lordose lombar de crianças. Métodos: Participaram do estudo 50 crianças, idade de 11,5 ± 2,6 anos. Os exames foram avaliados de forma independente por três avaliadores utilizando os níveis vertebrais L1-L5 e L1-S1. Os dados foram analisados com ICC, SEM e MDC (a0,05). Resultados: Os ângulos Cobb, usando L1-L5, são de 11° a 13° menores que aqueles utilizando L1-S1. Os ICCs foram excelentes para repetibilidade e reprodutibilidade intra-avaliador, e de excelentes (L1-L5) a moderados (L1-S1), para a reprodutibilidade interavaliador. Conclusão: Ambas as metodologias são passíveis de serem utilizadas na avaliação da lordose lombar, pelo mesmo avaliador, de crianças e adolescentes. Ainda, é de fundamental importância que o avaliador saiba das diferenças entre os níveis de referência disponíveis.

ROTATION ASSESSMENT IN ADOLESCENT IDIOPATHIC SCOLIOSIS WITH ROD DEROTATION.

ABSTRACTObjective:Adolescent idiopathic scoliosis (AIS) is characterized by rotational and lateral deformity of the spine. The measurement of vertebral rotation is important for prognosis and treatment. Our objective was to evaluate whether the Nash-Moe method can be used to measure axial deformity correction with surgical treatment using the rod derotation maneuver at both the apex and extremities of the deformity in patients with AIS.Methods:Rotation was assessed using the Nash and Moe criteria, on preoperative and postoperative radiographs. We also evaluated the severity on the coronal plane using the Cobb method, ratio of correction achieved, screw density, and number of vertebrae involved in the instrumentation.Results:The Cobb method correction average was 54.8%. When we disregarded vertebrae that presented preoperative Nash-Moe grade 0, the average measurable correction was 54.5% in the first non-instrumented vertebra above, 69.2% in the first instrumented vertebra, 32.2% in the apical vertebra, 36.8% in the last instrumented vertebra, and 30% in the first non-instrumented vertebra below. In our study, 32.14% of the patients presented a measurable correction in the apical vertebra.Conclusion:On the axial plane, correction can be satisfactorily evaluated using the Nash-Moe method. Level of Evidence VI. Case Series.

Skip laminectomy versus cervical laminectomy, an analysis of patient reported outcomes, spinal alignment and re-operation rates: The Leeds spinal unit experience (2008–2016)

Abstract The two leading techniques in the UK utilised in the posterior decompression of the cervical spinal cord for cervical spondylotic myelopathy (CSM) are skip laminectomy (Skip LAMT) and open cervical laminectomy (LAMT). To the authors' knowledge no studies have directly compared effectiveness of skip laminectomy versus cervical laminectomy. This study assessed for differences in neck disability index, sagittal alignment and re-operation rates between both treatment options. A retrospective single institution cohort study was performed. Subjects underwent skip- or cervical laminectomy between 2008 and 2016. Patients whom had undergone previous cervical spinal surgery were excluded. Statistical analysis compared radiological differences in sagittal alignment of the vertebral bodies between C2-7 pre- and post-operatively in static lateral cervical spine radiographs using the Cobb method. A description of the surgical technique of skip laminectomy is also provided. In total 42 patients and 29 patients had skip and cervical laminectomy respectively. Both groups were matched pre-operatively in terms of cervical sagittal alignment (p = 0.17), age and gender. Median follow up time was 32 ± 23.1 (Range: 1–325) weeks. Post-operatively there was no difference in patient reported outcomes namely Visual Analogue Scale and Neck Disability Index between treatment groups compared to pre-operatively (p = 0.64 and p = 0.75). There was suggestion of difference in median length of hospital stay between treatment groups, however this was not statistically significant. There was no difference in sagittal alignment between groups following surgery (p = 0.65). Three patients (7.1%) in the skip laminectomy group and two patients (6.9%) in the cervical laminectomy group required revision surgery. No patients needed instrumentation. Skip laminectomy and cervical laminectomy deliver similar patient reported outcomes, sagittal alignment preservation and re-operation rates over this follow-up period.

The Superiority of Plain Radiography to Magnetic Resonance Imaging in Determining Lumbar Lordosis Angles in Patients with Disc Herniation

Objective: It is estimated that about 80% of general population experience low back pain lifetime. Decreased lumbar lordosis is one of the important findings of disc disease and degenerative process is the result. In this retrospective study, Magnetic Resonance Imaging (MRI) and direct radiographs were used to measure lordosis in patients with disc herniation and compared to patients with low back pain without disc herniation. Materials and Methods: Patients admitted to outpatient clinics of our institution with low back pain and sciatalgia between 2014 and 2017 were enrolled in the study. In present retrospective study, MRI and plain radiographic images were obtained and evaluated. Patients with disc hernia in L4–5 or L5–S1 level were determined. Control group were consisted of healthy subjects whom low back pain was not caused by disk herniation. Lumbar lordotic angle was measured by an experienced radiologist by Cobb method. Results: The lumbar spinal angles measured by plain radiography were 45.41±11.53 mm in the patient groups with disc hernia, and 54.87±8.80 mm in the control group (Fig. 2). The difference between the study groups was significant (p &lt; 0.001). The lumbar lordosis angles measured by MRI were 41.65±8.50 mm in the patient groups with disc hernia, and 44.85±7.58 mm in control group. The difference between the study groups did not reach a significant level (p = 0 428) (Fig. 3). Conclusion: Lumbar disc herniation decreases lumbar lordosis and we suggest that lumbar lordotic angles should be measured by direct plain radiographies in standing position in these patients. Nevertheless, beside a detailed medical history and physical examination, the diagnosis and treatment should be decided by a combination of MRI and standing plain radiograph in subjects with herniated lumbar discs.

Evaluation of posture in sports performance

Abstract The aim of this paper was to study a number of 34 athletes practicing different kinds of sports activities, in order to determine whether they have developed a certain spine deficiency and if there is any association between the type of sports they practice and the postural changes they develop. Methods: In this study we have enrolled 12 members of the men’s volleyball team of the “West University of Timisoara”, 9 members of the men’s football team ASU Politehnica Timișoara, and 13 members of the men’s basketball team BC SCM Timișoara. Postural analysis was carried out with the Zebris CMS-10 from the mechatronics department of the Politehinca University Timisoara, a device that determines the spatial coordinates of the spinous processes. From the obtained data we have established the angle of the spinal deviation both sagittal and frontal, in a similar manner as with the Cobb method. Results: We have observed a reduction in the spinal curvature in volleyball players; 8 out of 12 had values under the normal range that can in time lead to a rigid spine. 7 players from the basketball team presented values out of the normal range for kyphosis and 8 of them for lordosis, while all except two of the team players present with a front plane deviation of the spine. From the evaluation of the football players from ASU Politehnica Timișoara we cannot generalize a deviation in the sagittal plane, but all of them present deviations in the frontal plane. Conclusion: Professional athletes can also present postural changes determined by the positions they most frequently adopt depending on the type of sports they practice.

Reference values for Cobb angles when evaluating the spine in the sagittal plane: a systematic review with meta-analysis

The present systematic review of observational studies with meta-analysis aim to identify the reference values of the spinal curvatures in the sagittal plane, as evaluated using the Cobb angle in X-rays, in healthy individuals. Electronic searches were undertaken in MEDLINE, Scopus, ScienceDirect and LILACS. Studies that evaluated the spinal curvature of healthy children, adolescents, adults, and elderly using Cobb method and presented reference values for those curvatures were incluced. Thirty-one studies were eligible for inclusion. The reference values found (confidence interval 95%) were: for children, thoracic (28.7°-37.9°), lumbar L1-L5 (34.5o-44.8º), and lumbar L1-S1 (41.7o-54.1o); for adolescents: thoracic (31.5o-39.2o), lumbar L1-L5 (39.8o-45.6o), and lumbar L1-S1 (51.9o-59.1o); for adults: thoracic (33.7o-40.3o), lumbar L1-L5 (38.1o-45.6o), and lumbar L1-S1 (54.2o-61.7o); and for the elderly: thoracic (37.7º-50.4o), and lumbar L1-S1 (56.6º-65.9o). For the cervical region, it was impossible to establish consistent reference values. The present study supports that precise reference intervals were identified for the sagittal curvatures of the thoracic and lumbar spine in healthy children, adolescents, adults and elderly, as evaluated by means of the Cobb Method.

Is the occiput-wall distance valid and reliable to determine the presence of thoracic hyperkyphosis?

BackgroundHyperkyphosis may be frequently found nowadays due to the change in current lifestyles of sustained flexion postures and age-related system decline. The occiput-wall distance (OWD) is a practical measure that is commonly used to screen and monitor thoracic hyperkyphosis in epidemiologic studies. However, there was no clear evidence to support the clinical utility of the tool as compared to the data from direct standard measures. ObjectivesTo investigate psychometric properties—including validity, reliability, and appropriate cut-off point—of the OWD to determine the presence of thoracic hyperkyphosis, as compared to a standard Cobb's method. DesignObservational study. MethodsThis study was conducted in ninety-nine participants, aged 10 years and above who had different degrees of thoracic hyperkyphosis from several communities. All participants were assessed for their severity of thoracic hyperkyphosis using the OWD, and 14 participants were involved in a reliability study. Within 7 days later, all participants were at a hospital to complete a radiographic examination. ResultsOutcomes from OWD had good concurrent validity with the Cobb angles (r = 0.683, P < 0.001) and excellent rater reliability when assessed by well-trained health professionals (ICCs > 0.9, P < 0.001). The OWD of at least 6.5 cm had the best diagnostic properties to determine the presence of thoracic hyperkyphosis (sensitivity = 71.4%, specificity = 76.6%, and area under the curve = 0.846). ConclusionThe findings support validity and reliability of OWD, and offer a clear cut-off point to determine the presence of thoracic hyperkyphosis for clinical utility in various settings.

Validation of a Generally Applicable Method for the Characterization of Scoliotic Deformities and Sagittal Spinal Curvatures

The oldest and most precise way to determine the curvatures of the spine is two directional X-ray measurement from the sagittal and coronal planes. By using X-ray, patients are exposed to radiation, which limits the repeatability of the measurements even in serious deformities, thus X-ray is not applicable for frequent monitoring. Therefore new alternative non-invasive radiation-free measurement systems appeared, which measure the external shape of the spine on the back surface. The goal of the present study is to validate the new tangential calculation method by Cobb method based radiographic analysis and by two other alternative calculation methods. In the study 22 young patients suffering from scoliotic deformities are examined. Thoracic kyphosis, lumbar lordosis and scoliotic deformity, as the three characterizing angles of spinal curvatures, are calculated by four different methods. The results show that the newly developed tangent line method could be applicable for the evaluation of spinal curvatures.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P61. Clinical outcomes of microendoscopic decompression for lumbar canal stenosis: a comparison between patients with and without degenerative lumbar scoliosis

BACKGROUND CONTEXT The operative management of degenerative lumbar scoliosis includes decompression or decompression with fusion. However, there is currently no consensus on the criteria for the role of adjunctive fusion. We have performed microendoscopic decompression in patients with the chief complaint of radicular and/or cauda equina symptoms due to degenerative lumbar scoliosis. Although the surgical procedure almost improved leg symptoms, it seemed that the patients had severe low back pain postoperatively as compared with patients without degenerative lumbar scoliosis. PURPOSE To compare the clinical outcomes of microendoscopic decompression for lumbar canal stenosis between patients with and without degenerative lumbar scoliosis. METHODS A total of 75 patients with lumbar canal stenosis between March 2006 and December 2014 were included in this study. The patients who had disc herniation and foraminal stenosis were excluded. The patients were treated with microendoscopic decompression and followed more than two years after the surgery. Of those, 34 were males and 41 were females. The mean age at the time of the surgery was 73.1years (range, 61–86 year). The mean follow-up period was 48.1 months (range, 24–102 months). Twenty-seven patients had degenerative lumbar scoliosis with coronal curvature of more than 10° measured by Cobb's method (DLS group). The other 48 patients had neither degenerative lumbar scoliosis nor degenerative lumbar spondylolisthesis (nonDLS group). Clinical outcomes were assessed using the Japanese Orthopedic Association (JOA) score and Short-Form 36 (SF-36) preoperatively and at the final follow-up. Recovery rate of the JOA score was calculated as (postoperative score − preoperative score)/(29 − preoperative score)×100%. The visual analogue scale (VAS) for low back pain was also measured at the final follow-up. RESULTS In the DLS group, the JOA score significantly improved from 13.7 preoperatively to 23.4 postoperatively. Also in the nonDLS group, the preoperative JOA score of 15.7 significantly improved to 25.0 postoperatively. Recovery rate in the DLS and nonDLS group were 62.5% and 69.0%, respectively. There were no significant differences in preoperative and postoperative JOA scores between the two groups. At the final follow-up, VAS for low back pain in the DLS group (45.4 mm) was significantly higher than that in the nonDLS group (25.4 mm). As for the preoperative SF-36 score, there were no significant differences in all 8 subscales between the two groups. In the DLS group, a significant improvement was observed only in bodily pain scores after surgery. In the nonDLS group, all subscales except general health perception significantly improved after surgery. All postoperative subscales except social role function and mental health in the DLS group were significantly lower than in the nonDLS group. CONCLUSIONS This study showed that the patients with lumbar degenerative scoliosis had higher VAS for low back pain and lower QOL scores after microendoscopic decompression as compared with the patients without lumbar degenerative scoliosis. We might consider other surgical options in patients with lumbar canal stenosis due to degenerative lumbar scoliosis.

Accuracy of photogrammetry for detecting adolescent idiopathic scoliosis progression

BACKGROUNDThe gold standard method of monitoring the evolution of scoliosis has been serial standing, posteroanterior, full-length spine radiographs with curvature measurements using the Cobb method. However, over the course of follow-up, patients can receive high radiation doses. Various studies have shown that repeated exposure to radiation in children and adolescents can be harmful to their health. PURPOSETo determine the accuracy of photogrammetry in evaluating the progression of adolescent idiopathic scoliosis in comparison with radiography. STUDY DESIGNDiagnostic study. PATIENT SAMPLENinety adolescents subjected to radiographic follow-up of idiopathic scoliosis. OUTCOME MEASURESThe angle of scoliotic curvature was measured using the Cobb radiographic method and photogrammetry. An increase of 5° or more between two radiographic exams was considered a progression of the curvature and was defined as the standard for calculations of sensitivity, specificity, predictive value, and accuracy of the photogrammetric method for measuring scoliosis progression. METHODSPatients were subjected to radiographic and photogrammetric exams concomitantly and were reevaluated after an average of 8.6 months. The exams were analyzed separately and independently by two examiners for progression of scoliosis. RESULTSThe measurements of the curves at the beginning of the study were 39.5±16.7° and 39.5±14.3° for radiographic and photogrammetric exams, respectively (p=1.0). At the end of the study, the measurements of the curves were 40.2±16.2° and 41.3±15.1° for the radiographic and photogrammetric exams, respectively (p=.310). The photogrammetric method had an accuracy of 89% (Confidence interval [CI] 95%=82.5–95.5) for the detection of scoliosis progression, with a sensitivity of 94.4% (CI 95%=89.6–99.2), a specificity of 86.7% (CI 95%=79.7–93.7), a positive predictive value of 75.5% (CI 95%=66.6–84.4), a negative predictive value of 97.2% (CI 95%=93.8–100), and a Kappa index of 0.75 (CI 95%=66.1–83.9). The interclass correlation coefficient between the two methods was 0.74 (CI 95%=0.65–0.81; p=0). CONCLUSIONSThe photogrammetric method showed good performance for detecting the progression of adolescent idiopathic scoliosis in comparison with the radiographic exam method.

Effect of upper thoracic mobilization on cervical alignment in stroke patients with forward head posture: A case study

The purpose of this study was to identify the effect of upper thoracic mobilization on cervical alignment in stroke patients with forward head posture. The subject's of this study were two stroke patients with forward head posture and a cervical curve angle (four-line Cobb's method; FLCM) less than 40°. The intervention, central posterior-anterior (PA) mobilization, was applied to the T1-T4 vertebrae (upper thoracic spine) following the Maitland concept. This mobilization was applied three times per week for four weeks. In the results, the cervical curve angle (FLCM) increased for both subject 1 and 2. However, Jochumsen method score was decreased in subject 1, while it was increased in subject 2. These results demonstrate that upper thoracic mobilization had the positive effect on the cervical curve angle but not on Jochumsen method score. These findings suggest that PA mobilization on the upper thoracic spine could correct cervical curve angle measured by FLMC in stroke patients with FHP.

Correction in a severe post-tuberculosis kyphosis using modified posterior vertebral column resection

Introduction: Kyphotic Deformity is one of the complications that affect the quality of life in patients post-tuberculosis. Patients with significant kyphosis typically present cosmetic and functional problems related to the biomechanical changes. There are many types of kyphotic deformity corrections, the posterior approach allows bigger degree of correction, but its main problem is neurological deficit during or post-surgery. Therefore, we correct the deformity by performing gradual cantilever bending after vertebral resection. Methods: We present a case: a 31 year-old female diagnosed with severe kyphosis in healed spondylitis tuberculosis. The patient was diagnosed with lung and spine tuberculosis 20 years ago and she was treated with anti-TB drugs for 12 months. Physical examination showed severe kyphotic deformity of 91 degrees. Although the patient did not have any neurological deficit or pain, the patient had difficulty when lying on bed and she also complained about getting easily fatigue, hence she agreed on the correction procedure. The procedure took place at Cipto Mangunkusumo Hospital dated January 24th 2017. The Surgery was performed by an attending spine surgeon, one spine fellow surgeon and two orthopedic residents. The technique used was a modification of posterior approach of vertebral column resection with gradual bending. The length of surgery was 7 hours, with 2100 ml blood loss during the surgery. Results: Pre- and post-operative X-rays was compared with Cobb method, pre-operative X-ray was 91.47o compared to post-operative X ray which was 51.35o. There was no major event observed. The patient was discharged 7 days postoperative without any neurological deficit. Discussion: A single stage posterior approach with posterior column resection could be one choice of treatment in patients with post-tuberculosis kyphosis. The advantages of this single stage approach is reduced possibility of what could occur in a two-stage surgery: extensive blood loss and longer duration of surgery. Conclusion: We conclude that this procedure is an effective and a save method in correcting severe post-tuberculosis kyphosys.

Hyperkyphotic measures using distance from the wall: validity, reliability, and distance from the wall to indicate the risk for thoracic hyperkyphosis and vertebral fracture

To investigate psychometric properties of the 7th cervical vertebra wall distance (C7WD) to determine the risk of thoracic hyperkyphosis and spinal fracture, as compared to a standard radiologic Cobb's method. Community-dwelling elderly (n = 104), aged at least 60years with occiput-wall distance > 0cm, were assessed for their C7WD using rulers and a specially developed tool for an accurate perpendicular distance from C7 to the wall: infrared-gun kyphosis wall distance tool (IG-KypDisT). The first 15 participants were also involved in the reliability tests by a healthcare professional, village health volunteer, and caregiver. Within 7days, all participants were at a hospital to complete a lateral plain radiograph (Cobb's method). Outcomes of C7WD had excellent correlation to the Cobb angles (r = 0.87 for rulers and r = 0.92 for IG-KypDisT), with excellent reliability when used by all three raters (ICC3,3 = 0.85-0.99). The C7WD of at least 7.5 and 9.5cm had the best diagnostic properties to determine the risk of thoracic hyperkyphosis and vertebral fracture, respectively. C7WD is valid and reliable with good diagnostic properties for thoracic hyperkyphosis and vertebral fracture. The findings confirm the use of C7WD using traditional ruler-based method as a practical tool to screen and monitor severity of thoracic hyperkyphosis in clinics and communities. In addition, the measurement using the IG-KypDisT provided accurate data that can be saved for further analysis; it is therefore suggested for research settings. The findings would promote the standardization of hyperkyphosis measurements in various settings.

COSTAL MALFORMATION RELATED TO THORACOLUMBAR SCOLIOSIS IN ADOLESCENTS - CASE REPORT

ABSTRACT Congenital scoliosis associated with costal malformation is well known. However, there are no reports of idiopathic scoliosis associated with the fusion of the costal arcs in the literature. This report describes a case of idiopathic scoliosis with fusion of the 1st and 2nd costal arches in a female patient and reports changes in the deformity due to scoliosis because of the treatment. The analysis was performed from a morphological and clinical point of view, and by complementary tests. Radiographs and CT scans were obtained and evaluated from the first consultation in 2012 and during the period in which the patient was followed in a private clinic, until the stabilization of the condition, in 2014. The evolution was favorable with the use of a Milwaukee vest and there was improvement of the clinical picture after the skeletal maturity, and the angle of lateral curvature, measured by the Cobb method, initially of 20 degrees, was reduced and stabilized in nine degrees, measure which is currently maintained. The analysis showed concomitant pathologies, and the fusion of costal arches did not influence the spine deformity, since there was regression with the clinical treatment. This evolution leads us to conclude that adolescent idiopathic scoliosis should be imputed as the sole responsible for the clinical picture of the patient, and that the fusion of the costal arches does not interfere with the biomechanics of the spine. Level of Evidence: IV. Type of study: Case series.

ERECTOR SPINAE AND SCOLIOSIS IN A POPULATION WITH CEREBRAL PALSY: A PRELIMINARY STUDY

ABSTRACT Objective: To verify the relation of muscular response to the vestibular stimulation of the erector spinae, specifically longissimus thoracis and iliocostalis lumborum, with the origin of scoliosis in a population of individuals with level V cerebral palsy of the Gross Motor Function Classification System (GMFCS). Methods: Cross-sectional study of 12 individuals aged between four and 14 years. The muscular activity of the longissimus thoracis and iliocostalis lumborum was recorded by electromyography in the presence of anteroposterior and lateral imbalances, comparing it with that obtained in sitting position without imbalances. Scoliosis was assessed by radiological study following Cobb method. Results: Statistically significant differences were found between correct responses of both muscles to anteroposterior imbalances and absence of right thoracolumbar scoliosis (p=0.005; p=0.028), left thoracic scoliosis (p=0.005; p=0.046) and right lumbar scoliosis (p=0.005; p=0.046). Conclusions: The symmetry of muscular responses to anteroposterior imbalances, both of longissimus thoracis and iliocostalis lumborum, seems to be one of the factors that prevent the development of spine deviations in this population. Level of evidence: IV. Type of Study: Case series