Coronal Curve Research Articles

A novel classification of congenital cervicothoracic scoliosis: identification of coronal subtypes and their prognostic significance.

To propose a novel classification system for stratifying coronal curve patterns in congenital cervicothoracic scoliosis with hemivertebrae (CTS-HV). Type A: regional cervicothoracic deformity only disturbing the balance of head-neck-shoulder complex; Type B: cervicothoracic deformity with significant trunk tilt to the convex side; Type C: cervicothoracic deformity with a significant compensatory thoracic curve. The reliability and reproducibility were assessed via the Kappa test. The differences among different subtypes in deformity parameters and bony structures were compared to identify the causative factors predisposing to different subtypes. 98 patients were classified into Type A (47 cases), Type B (31 cases), and Type C (20 cases). The Kappa test showed excellent reliability (Kappa value = 0.847) and reproducibility (Kappa value = 0.881). The proportions of Klippel-Feil syndrome in Types B (71.0%) and C (85.0%) were significantly higher than in Type A (46.8%; all P < 0.05). Type A (66.0%) and Type B (71.0%) predominantly had their hemivertebra (HV) at T3 or T4, while Type C (75%) mostly had HV at T1 or T2. Type B exhibited the most severe trunk tilt, head shift, neck tilt, head tilt, and coronal balance distance (all P < 0.05). Type C had the lowest T1 tilt and first rib angle despite the greatest cervicothoracic Cobb angle (all P < 0.05). This novel reliable classification allows a better understanding of structural diversity and different coronal compensatory mechanisms for the natural progression of CTS-HV. It can contribute to determining the individualized treatment strategy and standardizing academic communication for this rare clinical entity.

Defining modern iatrogenic flatback syndrome: examination of segmental lordosis in short lumbar fusion patients undergoing thoracolumbar deformity correction.

Understanding the mechanism and extent of preoperative deformity in revision procedures may provide data to prevent future failures in lumbar spinal fusion patients. ASD patients without prior spine surgery (PRIMARY) and with prior short (SHORT) and long (LONG) fusions were included. SHORT patients were stratified into modes of failure: implant, junctional, malalignment, and neurologic. Baseline demographics, spinopelvic alignment, offset from alignment targets, and patient-reported outcome measures (PROMs) were compared across PRIMARY and SHORT cohorts. Segmental lordosis analyses, assessing under-, match, or over-correction to segmental and global lordosis targets, were performed by SRS-Schwab coronal curve type and construct length. Among 785 patients, 430 (55%) were PRIMARY and 355 (45%) were revisions. Revision procedures included 181 (23%) LONG and 174 (22%) SHORT corrections. SHORT modes of failure included 27% implant, 40% junctional, 73% malalignment, and/or 28% neurologic. SHORT patients were older, frailer, and had worse baseline deformity (PT, PI-LL, SVA) and PROMs (NRS, ODI, VR-12, SRS-22) compared to primary patients (p < 0.001). Segmental lordosis analysis identified 93%, 88%, and 62% undercorrected patients at LL, L1-L4, and L4-S1, respectively. SHORT patients more often underwent 3-column osteotomies (30% vs. 12%, p < 0.001) and had higher ISSG Surgical Invasiveness Score (87.8 vs. 78.3, p = 0.006). Nearly half of adult spinal deformity surgeries were revision fusions. Revision short fusions were associated with sagittal malalignment, often due to undercorrection of segmental lordosis goals, and frequently required more invasive procedures. Further initiatives to optimize alignment in lumbar fusions are needed to avoid costly and invasive deformity corrections. IV: Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

Apical stress redistribution during anterior vertebral body tethering for thoracic adolescent idiopathic scoliosis: a finite element analysis of a novel surgical technique.

Apical stress redistribution (ASR) is proposed to mitigate failure risks after anterior vertebral body tethering for adolescent idiopathic scoliosis. It consists in releasing set-screws at peri-apical levels following curve tensioning to redistribute stresses within the construct. This study determines the biomechanical impact and curve correction obtained with ASR. Finite element models of anterior vertebral body tethering were constructed for three typical scoliotic patients with Lenke 1 curves. ASR was simulated by releasing tension on the cable at the level of the three apical set screws (i.e. untightening three consecutive periapical set screws), followed by retightening of the set screws without further tensioning. Cable tension, implant forces and spine geometry were compared before and after performing ASR. Periapical cable tension decreased post-ASR, and ASR alsoreduced the maximum tensions proximally and distally. Postoperative disc height was similar between conventional and ASR approaches. Apical intervertebral disc stresses were shifted from concave to convex compression intra and postoperatively, with a similar pattern between the conventional and ASR techniques. The ASR technique achieved scoliotic curve corrections of 54%, 68%, and 79%, while the conventional technique resulted in corresponding corrections (54%, 68%, and 80%) for subjects 1, 2, and 3. The periapical coronal curves exhibited similar patterns. ASR demonstrated promising apical cable and implant forces re-equilibrium compared to the conventional approach. This novel technique did not impair immediate and postoperative curve correction, while maintaining similar apical intervertebral stress distribution. ASR shows potential to modulate growth while reducing maximum cable tension infra- and supra-apical.

The impact of halo-pelvic traction on sagittal kyphosis in the treatment of severe scoliosis and kyphoscoliosis

BackgroundHalo-pelvic traction (HPT) is acknowledged for enhancing pulmonary function and reducing neurological complications in severe and rigid scoliosis and kyphoscoliosis. While its role in improving coronal balance is established, its impact on sagittal kyphosis remains under-researched. This study aims to assess HPT’s effects on sagittal alignment in these conditions.MethodsA retrospective review of 37 patients with severe and rigid scoliosis or kyphoscoliosis was conducted to evaluate HPT’s efficacy. The analysis focused on the impact of HPT on coronal and sagittal parameters, pulmonary function tests (PFTs) and complications. Radiographic assessments included main cobb angle in coronal, sagittal major kyphosis.ResultsHPT was applied for an average of 2.9 months, significantly reducing the primary coronal curve from 127.7°±30.3° to 74.9°±28.3° (P < 0.05), achieving a 41.3% correction rate. Sagittal kyphosis correction was more pronounced, with angles decreasing from 80.4°±26.4° to 41.3°±24.4° (P < 0.05), resulting in a 48.6% correction rate. Pulmonary function tests showed improvements in forced vital capacity (FVC) (from 1.32 ± 0.91 to 1.55 ± 0.83) and forced expiratory volume in 1 s (FEV1) (from 1.03 ± 0.76 to 1.28 ± 0.72), with percentage predicted values also increasing (FVC%: 40.4%±24.3–51.4%±23.1%; FEV1%: 37.8%±25.2–48.1%±22.7%; all P < 0.05).ConclusionHPT effectively reduces spinal deformity severity and improves pulmonary function in patients with severe and rigid scoliosis and kyphoscoliosis. Sagittal kyphosis correction was notably greater than coronal scoliosis correction. The correlation between PFT improvements and coronal curve adjustments suggests that correcting the coronal Cobb angle is pivotal for pulmonary function enhancement.

Outcome of distraction-based growing rods at graduation: a comparison of traditional growing rods and magnetically controlled growing rods.

Distraction-based growing rods have been considered as an alternative surgical option for the operative treatment of EOS. TGR has been challenged by MCGR, which is reported to have the advantage of non-invasive lengthening with fewer planned returns to theatre. This study explores the radiographic outcomes, Unplanned Returns to the Operating Room (UPROR) and complication profile of both the procedures at the end of the planned growing rod treatment with either TGR or MCGR. We included all the EOS cases from the PSSG database that underwent either TGR or MCGR with spine-based proximal anchors, followed up to the time of graduation. Any crossover or hybrid procedures were excluded. 549 patients (409 TGR and 140 MCGR) were eligible for review. We measured the coronal curve magnitude, Kyphosis, T1-T12, T1-S1 and L1-S1 lengths at 4 time points (before and after the index surgery and before and after the definitive surgery). The TGR group were slightly younger at the time of the index procedure (7years for TGR vs. 8.5years for MCGR, p < 0.001). We noted an improvement in all radiological parameters after the growing rod implantation. The spinal lengths increased through the lengthening period, while the coronal curve magnitude and the kyphosis increased. The kyphosis normalized following the final fusion, the coronal curve magnitude reduced further with a further increase in spinal lengths. The final follow-up from the time of the index implantation to the definitive surgery was 5.1years (IQR 3.8) in TGR and 3.5years (IQR 1.65) in the MCGR groups. The total number of complications was fewer in the MCGR group. The overall risk of UPROR was lower in the MCGR group and implant breakage was less in the MCGR group by 4.7 times. This study confirms the equivalence of both the distraction-based growing rods systems from the radiological stand-point, during the lengthening phase and at the time of the definitive surgery. The TGR was more kyphogenic during the lengthening period. The complications and UPROR were fewer in the MCGR groups.

In-office Maximal Voluntary Ventilation Testing Demonstrates Pulmonary Improvement Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

Pulmonary function can be impaired in patients with adolescent idiopathic scoliosis (AIS). Maximal voluntary ventilation (MVV) has been shown to be more strongly correlated with major coronal curve, and a more easily obtained measurement of pulmonary function, than forced vital capacity (FVC). We evaluated changes in pulmonary function using these 2 measures in patients with AIS in relation to changes in major coronal curves over time. Forty-seven patients with AIS with thoracic curves ≥10 degrees performed pulmonary function tests using the Carefusion MicroLoop Spirometer at enrollment and 1 year later. Major coronal curve worsening >5 degrees was considered curve progression. At enrollment, 47 patients had a mean major coronal curve of 38 degrees (range: 10 to 76 degrees). One year later, 17 patients had undergone posterior spinal fusion, 9 had curve progression >5 degrees, and 21 had no progression. MVV and major coronal curve were negatively correlated (r = -0.36, P = 0.01) at enrollment. After fusion, the major coronal curve improved by a mean of 41 degrees, and MVV improved by 23% (P < 0.01), but FVC did not improve significantly (6%, P = 0.29). In stable curves, MVV improved 12% (P = 0.01) and FVC improved 9% (P = 0.007). In patients without surgery whose curves progressed an average of 11 degrees, there was no significant change in MVV or FVC (P > 0.44). This is the first study using office-based spirometry in an orthopaedic clinic showing improved pulmonary function with posterior spinal fusion and growth in patients with AIS. It is notable that MVV improved after spinal fusion, but FVC did not, as MVV appears to be a more sensitive measurement for the assessment of pulmonary function in these patients. Level II.

Presence of compensatory curve predicts postoperative curve progression in congenital scoliosis after thoracolumbar hemivertebra resection and short fusion.

To investigate the impact of preoperative compensatory curve on the postoperative curve progression in congenital scoliosis (CS) patients following thoracolumbar hemivertebra (HV) resection and short fusion. This study retrospectively reviewed a consecutive cohort of patients with CS who underwent thoracolumbar HV resection and short fusion with a minimum of 2 years follow-up. According to the preoperative curve pattern, patients were divided into compensatory curve group non-compensatory curve group. Based on the postoperative coronal curve evolution, patients were further divided into the progressed group (Group P, with curve decompensation ≥ 20°) and the non-progressed group (Group NP, characterized by well-compensated curves). A total of 127 patients were included in this study, with 31 patients in the compensatory curve group and 96 patients in the non-compensatory curve group. The incidence of postoperative coronal curve progression was significantly higher in the compensatory curve group than that in non-compensatory curve group (35.5% vs. 13.5%, p = 0.007). In the compensatory curve group, patients who experienced postoperative curve progression showed fewer fusion segments (p = 0.001), greater preoperative UIV translation (p = 0.006), greater preoperative LIV tilt (p = 0.017), and larger postoperative UIV tilt (p < 0.001) compared with patients in group NP. Multiple logistic regression demonstrated that the shorter fusion segments and greater postoperative UIV tilt were two independent risk factors for postoperative curve progression. The presence of the compensatory curve was associated with a higher incidence of postoperative curve progression in patients with CS who underwent thoracolumbar HV resection and short fusion. Shorter fusion segments and greater postoperative UIV tilt were found to be the risk factors for postoperative curve progression.

Validity and accuracy of automatic cobb angle measurement on 3D spinal ultrasonographs for children with adolescent idiopathic scoliosis: SOSORT 2024 award winner.

Ultrasonography for scoliosis is a novel imaging method that does not expose children with adolescent idiopathic scoliosis (AIS) to radiation. A single ultrasound scan provides 3D spinal views directly. However, measuring ultrasonograph parameters is challenging, time-consuming, and requires considerable training. This study aimed to validate a machine learning method to measure the coronal curve angle on ultrasonographs automatically. A total of 144 3D spinal ultrasonographs were extracted to train and validate a machine learning model. Among the 144 images, 70 were used for training, and 74 consisted of 144 curves for testing. Automatic coronal curve angle measurements were validated by comparing them with manual measurements performed by an experienced rater. The inter-method intraclass correlation coefficient (ICC2,1), standard error of measurement (SEM), and percentage of measurements within clinical acceptance (≤ 5°) were analyzed. The automatic method detected 125/144 manually measured curves. The averages of the 125 manual and automatic coronal curve angle measurements were 22.4 ± 8.0° and 22.9 ± 8.7°, respectively. Good reliability was achieved with ICC2,1 = 0.81 and SEM = 1.4°. A total of 75% (94/125) of the measurements were within clinical acceptance. The average measurement time per ultrasonograph was 36 ± 7s. Additionally, the algorithm displayed the predicted centers of laminae to illustrate the measurement. The automatic algorithm measured the coronal curve angle with moderate accuracy but good reliability. The algorithm's quick measurement time and interpretability can make ultrasound a more accessible imaging method for children with AIS. However, further improvements are needed to bring the method to clinical use.

Direct Vertebral Rotation versus Simple Rod Derotation Techniques in Correction of Adolescent Idiopathic Scoliosis

Abstract Background One method for treating adolescent idiopathic scoliosis (AIS), which is characterised by abnormal spinal alignment in the coronal, sagittal, and rotational planes, is surgical correction. The two surgical techniques most typically used to correct spine alignment are simple rod derotation (SRD) and direct vertebral rotation (DVR). Aim The study's goal was to assess the effectiveness of two treatment methods for adolescent idiopathic scoliosis: simple rod derotation and direct vertebral rotation. Subjects and Methods A randomised controlled research involving 36 adolescents with idiopathic scoliosis was done. patients were randomly split into one of two groups: 18 patients in group A had DVR treatment, while 18 patients in group B received SRD with a 2-year follow-up. Results Apical Vertebral Rotation measured from CT scans in DVR group was 24.4° ±8.38° preoperatively and it decreased significantly postoperatively to 14.4°±4.61 °with (42.22%) correction rate while in SRD group it was 25.03°±7.99° preoperatively and it also decreased significantly postoperatively to a mean value of 21.41°±7.01° with (14.65%) correction rate. There were statistically significant differences between both groups postoperative (P &amp;lt; 0.001) Conclusion The most noticeable difference between DVR and SRD was clinical rib hump correction, which was explained by apical vertebral rotation correction determined on an axial CT scan. It also demonstrates that there is no significant difference in coronal curve correction, shoulder height difference, or patient satisfaction between the two techniques.

Back pain in adolescent idiopathic scoliosis: frequency and risk factors

PurposeAlthough back pain is commonly reported in patients with adolescent idiopathic scoliosis (AIS), factors that influence the presence and severity of back pain in AIS, including curve-specific variables, have not been well studied. This study aims to describe the prevalence and severity of back pain in AIS patients and determine the extent to which patient characteristics, including curve-specific factors, are associated with a higher risk of back pain in AIS.MethodsThe study was a retrospective medical records review of adolescents (aged 10–17 years) diagnosed with AIS between 01/01/2018 and 12/31/2021 at an academic tertiary children’s hospital. Patients with previous spine surgery were excluded. Variables collected included demographics (age, sex, race, insurance), Lenke classification, major coronal curve, back pain-related information, Risser stage, vitamin D levels, post-diagnosis brace utilization, physical therapy or chiropractic treatment, and surgery.ResultsA total of 891 AIS patients were included in the analysis. The sample was predominantly female (73.3%) and insured by Medicaid (57.8) with a mean age of 12.8 years. The mean major coronal curve was 26.3 degrees. Most patients had Lenke type 1 (47%) and type 5 (41%) curves. Nearly half of patients reported back pain (48.5%) with average pain severity in the low-to-moderate range (4.7) on FACES pain scale (0–10). Among those who reported back pain, 63.2% specified a location with the majority reporting pain in the lumbar region (56%) and, less commonly, in the thoracic (39%) and scapular (8%) regions. Lumbar pain was associated with significantly higher pain intensity (p = 0.033). Additionally, the location of pain reported was associated with location of major coronal curve (p < 0.0001). No association was observed between pain presence and vitamin D deficiency (p = 0.571, n = 175), major coronal curve magnitude (p = 0.999), Lenke curve type (p = 0.577), and sex (p = 0.069). Older patients, those insured by Medicaid, and those with higher Risser scores were more likely to report pain scores (p = 0.001 for all).ConclusionNearly half (48%) of newly diagnosed AIS patients experience back pain which is higher than the prevalence of 33% seen in the general adolescent population. Pain was more prevalent among patients over the age of 13, with heavier body weight, and those insured by Medicaid. Pain was most commonly reported in the lumbar region, especially among patients with lumbar curves. This information can be helpful in counseling AIS patients, though further investigations are needed, especially to determine the underlying causes of back pain in AIS and to elucidate the discrepancy in pain between patients with Medicaid and commercial insurance.Level of evidence.Prognostic Study Level II.

Two AIS Cases, 2 Surgeons, 1 Operating Room, 1 Day: Faster and Safer Than 1 Case in a Day.

To lessen surgical times for patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal instrumentation and fusion (PSIF), our department developed a quality improvement initiative where 2 AIS cases were completed in 1 day by the same 2 surgeons operating together in 1 operating room (OR). We describe the results of this initiative, comparing operative times and outcomes to cases of these surgeons operating individually. From 2017 to 2023, patients aged 10 to 18 years with AIS undergoing PSIF were prospectively enrolled for "Two Spine Tuesday." Patients were matched by age, sex, curve severity, and number of levels fused to historical AIS controls. Outcomes included surgery time, total OR time, estimated blood loss (EBL), volume of cell saver transfused, allogenic blood transfusion, length of stay, 90-day readmissions, Clavien-Dindo-Sink Complication Classification System complication rates, and percentage who achieved the minimal clinically important difference (MCID) for SRS-22. Fifty-five patients composing the 2-spine group (group 2) were compared with 55 historical sex-matched and age-matched controls (group 1). Major coronal curve and average number of levels fused were similar between groups. Overall surgery time (203 vs. 296min, P <0.001), total OR time ( P <0.001), and EBL (400 vs. 550mL, P <0.001) were lower for group 2. Group 2 had fewer complications [n=17 (31%) vs. n=28 (51%), P =0.03]. Performing 2 AIS cases in 1 OR by 2 surgeons the same day resulted in shorter surgery times, less total time in the operating room, lower complication rates, and less blood loss compared with single-surgeon matched controls. Level III-retrospective comparative study.

Pre-contoured patient-specific rods result in superior immediate sagittal plane alignment than surgeon contoured rods in adolescent idiopathic scoliosis.

Adolescent idiopathic scoliosis (AIS) surgery typically involves posterior spinal fusion (PSF) using rods contoured by the surgeon, which may be time-consuming and may not reliably restore optimal sagittal alignment. However, pre-contoured patient-specific rods may more optimally restore sagittal spinal alignment. This study evaluates the radiographic outcomes of AIS patients who underwent PSF utilizing surgeon contoured vs. pre-contoured rods. This is a retrospective cohort study of AIS patients who underwent PSF with either surgeon contoured or pre-contoured rods. Demographics, Lenke classification, fused levels, osteotomies, estimated blood loss (EBL), and surgical time were also obtained via chart review. Coronal curve magnitude, T5-T12 thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), PI-LL mismatch, and T1 pelvic angle (TPA) were obtained pre-operatively, postoperatively and at last follow up. Outcome measures included rate of achievement of postoperative radiographic alignment goals (TK between 20 and 40 degrees, PI-LL mismatch within 10 degrees, and TPA <14 degrees). Predicted post-operative sagittal alignment was also compared with observed measurements. Student's and paired t-tests were performed to determine significant mean differences for continuous variables, and chi-square for categorical variables. No differences were found in demographics, Lenke classification, preop radiographic measurements, fused levels, osteotomies, EBL, and surgical time in the surgeon contoured cohort (n=36; average follow up 11.3 months) and pre-contoured cohort (n=22; average follow up 9.7 months). At last follow up, 95.5% of patients with pre-contoured rods vs. 61.1% of patients with surgeon contoured rods (P=0.004) met TK goal. During assessment of first standing postoperative X-ray, 72.7% of patients with pre-contoured rods vs. 33.3% of patients with surgeon contoured rods met PI-LL mismatch goal (P=0.004). Other radiographic measurements were similar. Artificial intelligence (AI) predicted and observed differences for the pre-contoured group were 3.7 for TK (P=0.005), -7.6 for PI-LL mismatch (P=0.002), and -2.6 for TPA (P=0.11). AI and pre-contoured rods help achieve global sagittal balance with high accuracy and improved kyphosis restoration and PI-LL mismatch than surgeon contoured rods in AIS patients.

Safety of Traditional Growing Rods in Patients with Early-Onset Congenital Scoliosis Associated with Type-I Split Cord Malformation.

Literature regarding the application of traditional growing rod (TGR) instrumentation in patients with early-onset congenital scoliosis with type-I split cord malformation is scarce. The purpose of the present study was to assess the safety and effectiveness of TGR surgery and repeated lengthening procedures in patients with congenital scoliosis with type-I split cord malformation not treated with prophylactic osseous spur excision. Thirteen patients with early-onset congenital scoliosis associated with type-I split cord malformation and a stable neurologic status between March 2009 and July 2020 were recruited. All patients underwent primary TGR surgery and subsequent repeated lengthening procedures without osseous spur excision by the same surgical team. Clinical information and radiographic data from the preoperative, postoperative, and latest follow-up periods were collected. The mean preoperative Cobb angle of the major coronal curve was 74.62° ± 25.59°, the mean early postoperative angle was 40.23° ± 17.89°, and the mean latest follow-up angle was 40.62° ± 16.60°. The scoliotic deformity correction percentage was 46.81% ± 12.26% after the initial operation and 45.08% ± 15.53% at the latest follow-up. Compared with the preoperative values, significant improvements were observed in the coronal and sagittal balance early postoperatively and at the latest follow-up (p < 0.05 for all). The average annual amounts of spinal height gained were 15.73 ± 5.95 mm at T1-S1, 8.94 ± 3.94 mm at T1-T12, and 12.02 ± 6.70 mm between the instrumented segments. The total height gained at T1-S1 and T1-T12 was 72.18 ± 28.74 mm and 37.62 ± 12.53 mm, respectively. No intraoperative neurophysiological monitoring events were observed, and no case of neurological deficit was observed postoperatively or during follow-up. Patients without neurologic deficit and having a stable neurologic exam who have early-onset congenital scoliosis associated with type-I split cord malformation can safely and effectively undergo TGR surgery, followed by repeated lengthening procedures, without prophylactic osseous spur excision. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Progression of Cervical Congenital Scoliosis and Associated Compensatory Curve Behavior.

Background: This study investigated risk factors for progression of deformity in pediatric congenital cervical scoliosis (CCS) and evaluated the correlation between congenital cervical curves and compensatory thoracic and lumbar curves. Methods: Medical records were retrospectively reviewed for 38 pediatric patients with CCS with a minimum 2-year follow-up. Curve progression was defined as >10° increase in cervical coronal curve angle between presentation and last follow-up. Results: A total of 38 patients (16 girls, 22 boys) with a mean age at presentation of 5.6 ± 4.1 years met the inclusion criteria. Sixteen patients (42%) had curve progression with a mean follow-up of 3.1 ± 3.0 years. At presentation, T1 slope was significantly larger among children with progressive deformities (p = 0.041). A total of 18 of the 38 patients with strictly cervical spine deformity were then selected for subanalysis to evaluate the progression of compensatory curves. Cervical major coronal curves were found to significantly correlate with lumbar major coronal curves (r = 0.409), C2 central sacral vertical line (CSVL) (r = 0.407), and C7-CSVL (r = 0.403) (p < 0.05). Thoracic major coronal curves did not significantly correlate with cervical major coronal curves (r = 0.218) (p > 0.05). Conclusion: In conclusion, 42% of osseous CCS curves progressed over time in the overall cohort, and high initial T1 slope was found to be most highly correlated with progression of cervical deformity. Cervical major coronal curves significantly correlated with lumbar curve magnitude but not with thoracic curve size in isolated CCS, possibly due to the increased flexibility of the lumbar spine which may allow greater compensatory balance and thus have a greater correlation with cervical curve magnitude and possibly progression.

The Longitudinal Effects of Posterior Spinal Fusion with Derotation on Axial Deformity in Adolescent Idiopathic Scoliosis.

Retrospective case series. To characterize the change in angle of trunk rotation (ATR), axial vertebral rotation (AVR), and body surface rotation (BSR) in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF) with en-bloc derotation across multiple postoperative visits. Previous research has documented ATR, AVR, and BSR correction for AIS patients after surgery. However, there is a lack of evidence on the sustainability of this correction over time. This was a retrospective study from a single-center prospective surface topographic registry of patients with AIS, age 11-20 at time of surgery, who underwent PSF with en-bloc derotation. Patients with previous spine surgery were excluded. ATR was measured with a scoliometer, AVR through EOS radiographic imaging, and BSR via surface topographic scanning, Data collection occurred at: preoperative, six-week, three-month, six-month, one-year, and two-year postoperative visits. BSR and AVR were tracked at the preoperative apical vertebral level, and the level with maximum deformity, at each respective timepoint. Generalized estimating equations models were used for statistical analysis. Covariates included age, sex, and body mass index. 49 patients (73.4% female, mean age 14.6±2.2 years, mean preoperative coronal curve angle 57.9°±8.5, and 67% major thoracic) were evaluated. ATR correction was significantly improved at all postoperative timepoints and there was no significant loss of correction. AVR Max and AVR Apex were significantly improved at all timepoints but there was a significant loss of correction for AVR Apex between the six-week and one-year visit (P=0.032). BSR Max achieved significant improvement at the three-month visit. BSR Apex was significantly improved at the three-month and one-year visit. ATR and AVR demonstrated significant axial plane correction at two-years postoperative in patients undergoing PSF for AIS. BSR did not maintain significant improvement by the two-year visit.

Improvement in axial rotation with bracing reduces the risk of curve progression in patients with adolescent idiopathic scoliosis.

New evidence highlights the significance of 3D in-brace correction for Adolescent Idiopathic Scoliosis (AIS) patients. This study explores how axial parameters relate to treatment failure in braced AIS patients. AIS patients (Sanders 1-5) undergoing Rigo-Chêneau bracing at a single institution were included. Axial vertebral rotation (AVR) was determined by utilizing pre-brace and in-brace 3D reconstructions from EOS® radiographs. The primary outcome was treatment failure: surgery or coronal curve progression > 5°. Minimum follow-up was two years. 75 patients (81% female) were included. Mean age at bracing initiation was 12.8 ± 1.3years and patients had a pre-brace major curve of 31.0° ± 6.5°. 25 patients (76% female) experienced curve progression > 5°, and 18/25 required surgical intervention. The treatment failure group had larger in-brace AVR than the success group (5.8° ± 4.1° vs. 9.9° ± 7.6°, p = 0.003), but also larger initial coronal curve measures. In-brace AVR did not appear to be associated with treatment failure after adjusting for the pre-brace major curve (Hazard Ratio (HR):0.99, 95% Confidence Interval (CI):0.94-1.05, p = 0.833). Adjusting for pre-brace major curve, patients with AVR improvement with bracing had an 85% risk reduction in treatment failure versus those without (HR:0.15, 95% CI:0.02-1.13, p = 0.066). At the final follow-up, 42/50 (84%) patients without progression had Sanders ≥ 7. While in-brace rotation was not an independent predictor of curve progression (due to its correlation with curve magnitude), improved AVR with bracing was a significant predictor of curve progression. This study is the first step toward investigating the interplay between 3D parameters, skeletal maturity, compliance, and brace efficacy, allowing a future prospective multicenter study. Retrospective study; Level III.

Three-dimensional vertebral shape changes confirm growth modulation after anterior vertebral body tethering for idiopathic scoliosis.

To evaluate three-dimensional (3D) vertebra and disk shape changes over 2years following anterior vertebral body tether (AVBT) placement in patients with idiopathic scoliosis (IS). Patients with right thoracic IS treated with AVBT were retrospectively evaluated. 3D reconstructions were created from biplanar radiographs. Vertebral body and disk height (anterior, posterior, left and right) and shape (wedging angle) were recorded over the three apical segments in the local vertebral reference planes. Changes in height and wedging were measured through 2years postoperatively. Change in patient height was correlated with changes in the spine dimensions. Forty-nine patients (Risser 0-3, Sanders 2-4) were included. The mean age was 12.2 ± 1.4years (range 8-14). The mean coronal curve was 51 ± 10° preoperatively, 31 ± 9° at first postoperative time point and 27 ± 11° at 2-year follow-up (p < 0.001). The mean patient height increased 8cm by 2years (p < 0.001). The left side of the spine (vertebra + disc) grew in height by 2.2mm/level versus 0.7mm/level on the right side (p < 0.001). This differential growth was composed of 0.5mm/vertebral level and 1.0mm/disk level. Evaluation of the change in disk heights showed significantly decreased height anteriorly (- 0.4mm), posteriorly (- 0.3mm) and on the right (- 0.5mm) from FE to 2years. Coronal wedging reduced 2.3°/level with 1.1°/vertebral level change and 1.2°/disk level. There was no differential growth in the sagittal plane (anterior/posterior height). Patient height change moderately correlated with 3D measures of vertebra + disk shape changes. Three-dimensional analysis confirms AVBT in skeletally immature patients results in asymmetric growth of the apical spine segments. The left (untethered) side length increased more than 3 × than the right (tethered) side length with differential effects observed within the vertebral bodies and disks, each correlating with overall patient height change.

Preoperative Echocardiogram Does Not Contribute to Surgical Risk Assessment in Patients With Large Curve Scoliosis and No Cardiac Risk Factors.

Severe scoliosis can affect thoracic organs, potentially leading to cardiovascular abnormalities. Thus, echocardiograms have been suggested for use in preoperative screening in patients with significant scoliosis. However, the utility of preoperative heart screenings in patients without known or suspected heart problems is not well understood. This study aims to find the incidence of cardiac findings in patients with severe scoliosis ≥90° without cardiac history. A single-institution retrospective chart review was performed. Inclusion criteria were scoliosis patients with curves ≥90 degrees and a screening echocardiogram performed within 6 months of spine surgery. Patients with a previous cardiac history, diagnosis associated with cardiac comorbidities (eg, connective tissue disease), or major coronal curves <90 degrees were excluded. Echocardiogram reports and perioperative clinical notes from involved services (including orthopaedics, cardiology, and anesthesia) were reviewed. Any postoperative use of vasopressors and reasons for their use were recorded. Overall, 50 patients met the inclusion criteria. The mean age at surgery was 14.0 ± 4.9 years old (range: 2 to 33). The mean major curve was 108 ± 19 degrees (range: 90 to 160 degrees). A normal echocardiogram was seen in 38 (76%), whereas 6 patients (12%) had mild dilation of the aortic sinus or root, 4 (8%) had mild valvular regurgitation, 1 patient had a small atrial septal defect, and 1 had a trace pericardial effusion. No patient had any changes made to their perioperative plan and one patient was advised to see a cardiologist postoperatively. Postoperatively, 8 patients (16%) received vasopressors to raise blood pressure to meet preset goal MAP, but only one of these 8 had a positive echocardiogram (mild valvular insufficiency), which was not seen as a contributing factor to the use of pressors. This study suggests that screening echocardiograms for patients without a cardiac history or related symptoms does not contribute to the evaluation of perioperative risk or anesthetic management. Creating clear, evidence-based guidelines for the utilization of perioperative testing, like echocardiograms, can reduce the social, time, and financial burdens on families. Such guidelines are vital for appropriate risk assessment and proper utilization of health care resources. Level III.

Is the Child Opportunity Index a Factor in Surgical Outcomes for Adolescent Idiopathic Scoliosis?

Low socioeconomic status (SES) has been previously associated with delays in orthopaedic care. However, it is unclear how SES impacts patients with adolescent idiopathic scoliosis (AIS), particularly regarding preoperative major coronal curve angle or surgical outcomes. Utilizing the Child Opportunity Index (COI)-an address-driven measure of pediatric education, health/environment, and SES-we investigated whether COI is associated with differences in preoperative scoliosis magnitude, age at surgery, and AIS surgical outcomes. Consecutive patients with AIS surgically treated at a single center from 2011 to 2017 were reviewed. COI was calculated by inserting a patient's home address into the nationally available COI database to derive a COI value. COI is scored from 0.0 to 100.0 (0.0 is lowest, 100.0 is highest). Specifically, COI is categorized as very low (<20.0), low (20 to 39.9), moderate (40 to 59.9), high (60 to 79.9), and very high (≥80). Those without addresses were excluded. Patients without proper radiographs to assess curve correction were also excluded. A COI threshold of 60.0 was used to separate patients into a low (<60.0) or high COI ( ) group based on published COI guidelines. Outcomes, including preoperative curve magnitude, age at surgery, percentage curve correction, operative time (OT), intraoperative estimated blood loss per level fused, length of stay, and complications, were compared across groups. Pearson correlation analysis was used to assess correlations between COI and preoperative curve magnitude, as well as age. Four hundred four patients were included in the study, and 263 had 2-year follow-up data. Patients were an average age of 14.9 years old (range: 11.2 to 19.8), had a median COI of 76 (range: 4 to 100), and had a mean preoperative major curve angle of 59 degrees (range: 36 to 93). COI was significantly higher for white patients compared with non-white (80.0 vs 40.0, P < 0.001), and higher for non-Hispanic individuals (79.0 vs 15.0, P < 0.001). Patients with Low COI were associated with a lower OT per level fused ( P = 0.003) and decreased postoperative complication risk ( P = 0.02). COI was not associated with preoperative major coronal curve angle, age at surgery, or any other surgical outcomes. COI was significantly lower for non-white patients and those of Hispanic ethnicity. Patients from low COI backgrounds achieved similar surgical results as those from high COI addresses and had a decreased OT per level fused and complication incidence, though the clinical significance of these differences is unknown. Future prospective studies are needed to determine whether these findings are reproducible across other states and health systems. Level III-prognostic study.

Scoliosis Research Society-22r and Ceiling Effects: Limited Capabilities for Precision-Medicine with Adolescent Idiopathic Scoliosis.

Retrospective registry analysis. To examine predictions of individual Scoliosis Research Society-22r (SRS-22r) questions one year after surgery for adolescent idiopathic scoliosis (AIS). A precision-medicine approach to AIS surgery will inform patients of the likelihood of achieving particular results from surgery, specifically individual responses to the SRS-22r questionnaire. A multi-center AIS registry was queried for surgical AIS patients treated between 2002-2020. Preoperative data collected included standard demographic data, deformity descriptive data, and SRS-22r scores. Postoperative 1yr SRS-22r scores were modeled using ordinal logistic regression. . The highest probability was the most likely response. Model performance was examined by c-statistics, where c>.8 was considered excellent. Ceiling effects were measured by the proportion of patients reporting "5" to each question. 3251 patients contributed data to the study; mean age 14.4 (±2.2) yrs, female 2631 (81%), major thoracic coronal curve 53°, mean lumbar 41°. C-statistic values ranged from .6 (poor) to .8 (excellent) evidence of varied predictive capabilities. Q17 ("days off work/school", c = .84, ceiling achieved 75%) and Q15 ("financial difficulties", c = .86, ceiling achieved 82%) had the greatest predictive capabilities while Q11 ("pain medication", c=.73, ceiling achieved 67%), Q10 ("appearance", c=.72, ceiling achieved 35%), and Q19 ("attractive", c=.69, ceiling achieved 37%) performed poorly. Prediction of individual SRS-22r item responses perhaps most germane to AIS treatment was poor. Prediction of less relevant outcomes, where ceiling effects are present, was greater as the models chose "5" for all responses. These ceiling effects may limit discrimination and hamper efforts at personalized outcome predictions. 3.