Improvement In Cobb Angle Research Articles

Preoperative LIV Tilt Affects Post Operative Coronal Imbalance in Patients with Lenke 5C Scoliosis

Introduction Lenke 5C curves are increasingly being treated through posterior pedicle screw based correction techniques. We evaluated different preoperative radiological parameters which could affect post operative coronal imbalance (POCI) in patients with Lenke 5C scoliosis treated with posterior instrumented correction. Methods We retrospectively evaluaed twenty-three cases with Lenke 5C scoliosis who underwent selective posterior pedicle screw based deformity correction. Fusion was performed from proximal neutral to distal stable vertebra. Preoperative, immediate post operative and final whole spine standing radiographs were analyzed. The pre-operavtive radiological parameters were assessed including lower instrumented vertebra(LIV) tilt and translation, Cobb angle,C7 offset from CSVL, lumbar lordosis and upper instrumented vertebra(UIV) tilt and translation. Post-operatively we assessed the correction in cobb angle and post-operative coronal imbalance. Results Twenty -three patients had a mean age: 11.8 ± 4.6 years, with 4 males and 19 females. There was a significant improvement in Cobb angle from mean of 55 ± 13.3° to mean of 14.7 ± 8.8°. Nineteen patients had lower instrumented vertebra at L4, 3 at L3 and one at L5. Correction was maintained with no significant loss in the late post op period (15.2 ±8.9 degrees). The mean pre op C7-CSVL distance was 24.7 mm While eight patients had immediate post operative coronal imbalance (POCI), six of them balanced at a mean 8.2 months. Four patients had POCI at the time of final follow-up including two, who developed late imbalance. POCI correlated with pre operative LIV tilt only > 25° ( p < 0.05) and not with LIV translation, UIV tilt or translation. Five of the eight patients with immediate POCI and all four patients with late POCI had preoperative LIV tilt > 25°. Conclusion In Lenke 5C scoliosis treated by posterior pedicle screw instrumentation, patients with a preoperative LIV tilt (>25°) have a risk of developing POCI.

Growing Rods Versus Shilla Growth Guidance: Better Cobb Angle Correction and T1–S1 Length Increase But More Surgeries

Study DesignRetrospective comparison. ObjectivesTo compare treatment of early-onset scoliosis (EOS) with Shilla growth guidance versus distraction-based dual growing rods (GR). Summary of Background DataWe are not aware of any prior studies comparing the Shilla procedure with other surgical procedures in the treatment of EOS. MethodsThe authors performed a multicenter case-matched comparison of patients with EOS treated with Shilla versus dual spine–spine GR from 1995 to 2009. A total of 36 Shilla patients from 3 centers were matched with 36 GR patients from the database by age at index surgery (±1 year), preoperative Cobb angle (±15°), and diagnosis (neuromuscular, congenital, idiopathic, or syndromic). Average follow-up was similar between groups (GR, 4.3 years; Shilla, 4.6 years; p = .353). ResultsAverage Cobb angle improvement preoperatively to latest follow-up was 36° (range, 72° to 36°) in the GR group versus 23° (range, 69° to 45°) in the Shilla group (p = .0124). T1–S1 length increased 8.8 cm in patients treated with GR, compared with 6.4 cm in Shilla patients (p = .0170). Shilla patients had fewer surgeries (2.8) than patients in the GR group (7.4) (p < .001) but had a higher rate of unplanned surgeries for implant complications (Shilla, 1.3; GR, 0.5; p = .0151). When revisions for implant complications done at the time of scheduled lengthenings and revisions for construct maintenance were included, the groups did not differ significantly in the number of procedures for implant complications (Shilla, 1.4; GR, 1.5; p = .9451). The overall complication rate did not differ significantly between groups (Shilla, 1.9 [range, 0–7]; GR, 1.3 [range, 0–9]; p = .2085). ConclusionsThe GR group had a greater improvement in Cobb angle and a greater increase in T1–S1 length than Shilla. The GR patients had more surgeries but Shilla patients had more unplanned procedures. The rate of complications overall did not differ significantly between groups.

Serial Derotational Casting in Idiopathic and Non-Idiopathic Progressive Early-Onset Scoliosis

IntroductionSerial derotational casting has been used as a definitive treatment or as delaying strategy in progressive idiopathic (IS) and non-idiopathic (NIS) early-onset scoliosis (EOS). MethodsRetrospective chart and radiographic review of patients who underwent serial casting for progressive EOS between 2005 and 2012 at a single institution. ResultsA total of 74 consecutive patients entered serial cast treatment. Twenty-eight were currently being casted, 30 completed cast treatment and were converted to thoracolumbosacral orthosis (TLSO), 9 were treated surgically, 6 were lost to follow-up, and 1 had no further treatment. The researchers diagnosed IS in 41 patients; 33 had NIS. At presentation the IS group had an average Cobb angle (CA) of 49° and a rib vertebral angle difference (RVAD) of 37°. The NIS group had a CA of 51° (p = .69) and RVAD of 37° (p = .94). In patients currently being casted, 19 IS patients had a decreased CA, from 47° to 27°. The 9 NIS patients had a decreased CA, from 62° to 57° (p = .0002). Cobb angle improvement was significantly better in IS (p = .0005). In the TLSO group the 17 IS patients had a decreased average CA, from 46° to 18°, after serial casting and the 13 NIS patients decreased CA from 42° to 32°. Patients with IS had better improvement in CA than the NIS group (p < .001). At last follow-up, this was reduced to 11° in the IS group and maintained at 32° in the NIS. In the IS group, 5 of 41 patients were converted to growth constructs, and 4 of 26 in the NIS group. Casting initiated before age 2 years yielded better curve correction for IS (p < .01) compared with NIS. ConclusionsProgressive idiopathic scoliosis patients had better curve correction with casting than NIS patients. Casting in IS patients before age 24 months yielded better curve correction. Patients who required surgery had a higher age and Cobb angle at presentation than those who transitioned to a TLSO. The surgical group was observed for a similar duration of time and there was no significant statistical difference. Although RVAD is a predictor of progression in infantile IS, it did not show a predictive value in the response to casting of either the IS or NIS groups.

Chronic Painful Osteoporotic Vertebral Compression Fractures of Thoracolumbar Spine: Percutaneous Vertebroplasty versus Conservative Management among Egyptian Patients

Background Data: Vertebral augmentation procedures are widely used today in treating acute and subacute osteoporotic vertebral compression fractures (OVCFs). However, percutaneous vertebroplasty for patients with chronic painful OVCFs has been less well studied. Study Design: A prospective cohort study. Purpose: to compare the efficacy and safety of percutaneous vertebroplasty with conservative treatment for management of chronic painful OVCFs in thethoracolumbar spine among Egyptian patients. Patients and Methods: Ninety-eight patients presented with acute OVCFs during the period from October 2009 to December 2013. They were treated conservatively and followed for at least 3 months. Thereafter, 38 patients were excluded from this study as significant pain improvement was noticed in 32 patients and 6 didn't fulfill the inclusion criteria of this study. The remaining 60 patients (38 females and 22 males, mean age: 65.42±8.63) with chronic painful OVCFs were included in this prospective cohort study. Twenty-eight patients were treated with percutaneous vertebroplasty (Vertebroplasty group). Thirty two patients refused surgical treatment and constituted the control group (Conservative group). All patients were evaluated with X-rays and CT scan, where Cobb angle and the anteroposterior height comparison (APHC) were measured. Overall pain and quality of life were assessed with the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) respectively.Results: All patients were followed for at least 12 months. Statistical analysis of the demographic data of the two groups could not reveal any significant differences. At latest follow up, there was significant improvement in Cobb angle and APHC in Vertebroplasty group when compared with Conservative group (P=0.001). Three patients in the Conservative group (9.37%) went into nonunion, while all patients in the Vertebroplasty group showed radiological evidence of good stability at latest follow up. A significant improvement of VAS Scores (P=0.001) and ODI (P=0.001) was observed in theVertebroplasty group when compared to the Conservative group at the latest follow up. Conclusion: Percutaneous vertebroplasty is safe and effective in treatment of chronic painful osteoporotic vertebral compression fractures with significantly better radiological and clinical outcomes when compared with conservative management. (2015ESJ086)

Clinical Evaluation of the Ability of a Proprietary Scoliosis Traction Chair to De-Rotate the Spine: 6-month Results of Cobb Angle and Rotational Measurements

The aim of this study was to investigate the immediate and 6-month effects of a scoliosis traction chair on scoliosis rotation and Cobb angle. The scoliosis traction chair has been used clinically for 10 years and has been part of previous studies, but has not been the focus of any previous study. Our goal was to test the scoliosis traction chair’s ability to de-rotate the spine to create scoliosis correction. Fifteen patient files were retrospectively selected for study. Patients were radiographically studied in a proprietary traction chair to evaluate impact on Cobb angle and apical vertebral rotation. Six-month follow-up results were recorded. Six-month results showed an average overall Cobb angle increase of about 7°. Patients with in-chair apical de-rotation showed 9° of Cobb angle improvement, while those with increased in-chair apical rotation showed an average 16° progression. Scoliotic curves whose apical rotation worsened on stress radiography showed deterioration of the curve at 6 months. Those with improved apical rotation showed Cobb angle corrections at 6 months. Since progression of scoliotic curvatures was observed in our cohort of patients after 6 months of home and clinical use, it is imperative that further studies attempt to qualify which patients and scoliosis curve patterns are best suited for the scoliosis traction chair.

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.

The management of malignant spinal cord compression: a modified technique of spinal reconstruction

Objectives:This study aims to assess the results of a single-stage posterolateral transpedicular corpectomy and fusion in malignant spinal cord compression of the thoracolumbar spine.Methods:Sixteen cases of thoracolumbar metastases were treated with single-stage posterolateral transpedicular corpectomy and fusion. A modified technique of nerve preserving bilateral cage placement was described. Pain, American Spinal Injury Association (ASIA) scores, spinal deformity, primary pathologies, and survival were recorded.Results:The most common primary pathology was lung, followed by renal and colorectal cancer. Significant pain reduction was achieved in all patients, regardless of previous nonsurgical treatment. No patient suffered neurological deterioration after surgery. For the 10 patients who presented with neurological deficits, 90% improved after surgery. Significant improvement in Cobb angle and vertebral height were observed postoperatively. A mean survival of 5·6 months was recorded at the completion of this manuscript.Discussion:Single-stage posterolateral transpedicular corpectomy and fusion appeared to be a safe and an effective approach in malignant spinal cord compression. The current modified technique extends its application to lumbar spine by preserving all nerve roots. The significant improvement of pain and neurological deficits leads to better quality of life. The benefits of surgery in the overall survival remain to be investigated.

Pedicle-sparing transforaminal thoracic spine wedge osteotomy for kyphosis correction.

Background:Correction of a focal kyphotic deformity at times requires performing a pedicle subtraction osteotomy, which is accompanied by loss of pedicles as anchor points at the affected level in addition to significant blood loss. To help alleviate these two issues, a novel osteotomy technique for correction of kyphosis using a transforaminal approach to the thoracic vertebral body is described.Methods:We describe a bilateral pedicle-sparing approach and demonstrate it in a patient with proximal junctional kyphosis.Results:The proposed osteotomy resulted in a 28-degree Cobb angle improvement in the sagittal plane.Conclusion:The operation resulted in a similar degree of correction as a pedicle subtraction osteotomy, with the added benefit of maintaining the pedicles closest to the kyphotic deformity.

VEPTR to Treat Nonsyndromic Congenital Scoliosis

Traditional surgical management of multiple congenital vertebral anomalies in young children, including fusion in situ and hemiepiphyseodesis, do not promote spinal growth nor address the associated thoracic insufficiency syndrome. We hypothesize that vertical expandable prosthetic titanium rib (VEPTR) with expansion thoracoplasty may control spinal deformity, allow spinal growth, and address thoracic insufficiency syndrome in children with nonsyndromic complex congenital spinal deformities. Eight pediatric spine centers prospectively entered clinical and radiographic data into a database on every congenital spinal deformity treated with VEPTR as part of an Food and Drug Administration study. We retrospectively reviewed these data and excluded patients with spina bifida, Jarcho-Levin, or other syndromes. Data analysis focused on surgical technique and expansion frequency, change in Cobb angle and thoracic heights, and adverse events for a consecutive series of patients with at least 2 years of follow-up. Twenty-four children with an average age at surgery of 3.3 years (range, 1.0 to 12.5 y) were treated with VEPTR insertion and expansion thoracostomy and were followed for an average of 40.7 months (range, 25 to 78 mo). Twenty-three (95.8%) had associated rib fusions. All patients had subsequent expansion surgery; 50% had 5 or more expansions. Twenty patients (83.3%) had an improvement in Cobb angle during treatment with an average improvement of 8.9 degrees. All had an increase in thoracic height, with a mean increase of 3.41 cm. The most common adverse events were device migration in 7 patients and infection or skin problems in 6 patients. VEPTR insertion with expansion thoracoplasty represents a successful treatment paradigm for nonsyndromic congenital spinal deformities. We report multicenter data with midterm follow-up of children without syndromic diagnoses, in which the vast majority had an improvement in Cobb angle and thoracic height over the treatment period. Challenges include the demands of multiple procedures, skin problems, and device migration. Level IV-prognostic study.

Factors influencing the residual rib hump after posterior spinal fusion for adolescent idiopathic scoliosis with Lenke 1 and 2 curves

BackgroundDespite remarkable improvement in Cobb angle after surgery for scoliosis, many patients have a residual rib hump. We studied the factors responsible for this hump and their influence on patient satisfaction. MethodsWe recruited 2 men and 38 women (mean age 14.9years) who underwent skip pedicle screw fixation combined with direct vertebral body derotation for adolescent idiopathic scoliosis with Lenke type 1 and 2 curves. Hump size was evaluated by measuring apical trunk rotation (ATR). Patients with postoperative ATR ≤10° were categorized as group A and those with postoperative ATR >10° as group B. We analyzed postoperative self-image and satisfaction subscores of the SRS-22 questionnaire. We also compared the rate of postoperative improvement in ATR between patients who underwent additional Ponte osteotomy and those who did not. ResultsPreoperative ATR, preoperative apical translation, and preoperative and postoperative apical rotation significantly differed between groups A and B. In contrast, Cobb angles before and after surgery, Cobb angle correction rates, apical translation after correction, and postoperative self-image and satisfaction scores did not differ significantly between the groups. However, the rate of improvement in ATR showed a strong correlation with self-image (correlation coefficient 0.64) and satisfaction (correlation coefficient 0.52). This improvement rate did not differ significantly between subjects who underwent additional Ponte osteotomy and those who did not. ConclusionsPreoperative apical rotation and ATR were clearly related to postoperative residual hump. For decreasing the postoperative rib hump, removal of the deformation by apical rotation was considered more important than correction of Cobb angle. Patient satisfaction and self-image scores were not significantly related to postoperative residual hump size, but they were influenced by improvement in ATR.

Adult Degenerative Scoliosis Surgical Outcomes: A Systematic Review and Meta-analysis

IntroductionThere is increasing awareness of adult degenerative or de novo scoliosis, and its surgical treatment when indicated can be challenging and resource intense. Surgical randomized controlled trials are rare, and observational studies pose limitations because of the heterogeneity of surgical practices, techniques, and patient populations. Pooled analysis of current literature may identify effective treatment strategies and guide future efforts at prospective clinical research. This study aimed to synthesize existing data on the outcomes of surgical intervention for adult degenerative scoliosis. MethodsPubMed, Medline, Cochrane, and Web of Science databases were searched using key words and were limited to the English language. Spine surgeons reviewed abstracts and evaluated whether they contained surgically treated cohorts of adults (more than 18 years of age) with degenerative scoliosis. Full-text articles were reviewed in detail and data were abstracted. All meta-analyses were conducted using random effects models and heterogeneity was estimated with I2. Random-effects meta-regression models were used to investigate the association of treatment effects with baseline levels of each outcome. ResultsOf 482 articles, 24 (n = 805) met inclusion criteria Available outcomes included Cobb angle correction, coronal and sagittal balance, visual analog scale for pain (VAS), and Oswestry Disability Index. Despite significant heterogeneity among studies, random-effects meta-analysis showed significant improvements in Cobb angle (−11.1°; 95% confidence interval [CI], −13.86° to −8.40°), coronal balance (7.674 mm; 95% CI, −10.5 to −4.9), VAS (−3.24; 95% CI, −4.5 to −1.98), and Oswestry Disability Index (−27.18%; 95% CI, −34.22 to −20.15) postoperative treatment (p < .001). Meta-regression models showed that preoperative values for Cobb angle, coronal balance, and VAS were significantly associated with surgical treatment effect (p < .05). Changes in sagittal balance did not reach statistical significance although only 6 articles were included. ConclusionsExhaustive literature review yielded 24 studies reporting preoperative and postoperative data regarding the surgical treatment of adult degenerative scoliosis. No randomized clinical trials (RCTs) were identified. Despite heterogeneity, a limited meta-analysis showed significant improvement in Cobb angle, coronal balance, and VAS after surgical treatment of adult degenerative scoliosis.

Comparing results of posterior spine fusion in patients with AIS: Are two surgeons better than one?

AimsSpinal deformity surgery is one of the most complicated procedures performed in pediatric orthopedics. These surgeries can account for long operative times and blood losses. Finding ways to limit patient morbidity undergoing these procedures may benefit many. We hypothesized that utilizing two fellowship trained pediatric spinal deformity surgeons would lead to decreased operative time and blood loss when compared with single surgeon. We felt very little difference would be found in terms of curve correction. MethodsA retrospective review of spinal deformity surgeries performed at two institutions was performed. At one institution, the standard of care was to have two fellowship deformity trained surgeons perform all deformity surgeries simultaneously, while at the second institution posterior spinal fusions performed by individual surgeons were performed. The single surgeon cohort was further divided based on instrumentation type (pedicle screw vs hybrid constructs). Cases for this review were limited to posterior spinal fusions without osteotomies in patients with idiopathic or idiopathic like curves. Cohorts were compared pre-operatively for age at surgery, sex, BMI, largest Cobb angle. Intra-operative comparisons included total EBL, instrumentation type screws vs hybrid, levels fused, and operative time. Comparisons between largest remaining Cobb, EBL/level, time/level, lowest recorded Hb, allogenic transfusion requirements, length of PICU stay, and total length of hospital stay were then made. Pair-wise student t-tests was performed between cohorts with significance defined as a p-value of 0.05 or less. ConclusionsTwenty-four patients were found in the (BMP) cohort, where as eighty-two were found in the control group. No significant difference in age, sex, starting hemoglobin, BMI*, or maximum pre-operative Cobb between cohorts was found. A significantly lower number of levels were fused in the BMP cohort than the control (9 ± 2 vs 11 ± 2) p < 0.001, and likewise a significantly shorter operative time (average >2 h) was seen in the BMP cohort. Interestingly, no difference in estimated blood loss, blood loss/level fused, operative time/level fused was observed, yet a significantly greater drop in hemoglobin (average 1 g) p = 0.001 and allogenic transfusion rate was seen in the control group (4% (1/24) vs 29% (24/82)) p = 0.01. A greater improvement in Cobb angle was seen in the BMP group 46 ± 8 vs 35 ± 10° p < 0.001. No differences were seen in nights in the PICU and peri-operative complications, however patients in the BMP averaged nearly 1day less in the hospital than in the control group.Utilizing a blood management program including two surgeons in spinal deformity surgery appears to decrease operative time, blood loss, and improve curve correction. Confounding factors such as differences in number of fusion levels, curve types, instrumentation type, and institutional practices prevents drawing definitive conclusions. This is the first study to show potential benefits of utilizing a blood management program with dual surgeons in spinal deformity cases.

Apical Wiring Technique in Surgical Treatment of Adolescent Idiopathic Scoliosis

Retrospective cohort study of apical wiring technique for surgical treatment of adolescent idiopathic scoliosis patients. To evaluate the intermediate outcome of adolescent idiopathic scoliosis patients treated with apical wiring technique. Regarding surgical treatment for adolescent idiopathic scoliosis, there are reports of the superiority of coronal plane correction using all-screw constructs compared with all-hook or hybrid constructs. Major limitations of all-screw constructs are thoracic hypokyphosis and increased proximal junctional kyphosis. There are few reports about apical wiring technique outcomes and no reports of this surgical technique comparing Lenke types. Consecutive adolescent idiopathic scoliosis patients treated with apical wiring technique were analyzed. Inclusion criteria were patient 21 years old or younger, who underwent a posterior only surgical correction with a follow-up of at least 2 years. Radiographic data were analyzed according to the criteria given by Lenke and colleagues. The radiographic parameters included global balance, Cobb angle, curve flexibility, apical vertebral translation, tilt angle of lower instrumented vertebra, angle of caudal disk to the lower instrumented vertebra, thoracic kyphosis, lumbar lordosis, and proximal junctional angle preoperatively and postoperatively. There was a significant improvement of Cobb angle in every Lenke type with an average correction of 74.6%. At latest follow-up, the average loss of correction was 3.5% (1.9 degrees). The greatest loss of correction for the minor curve of Lenke 2 was 14.1% (5.8 degrees). There was an improvement of thoracic kyphosis in hypokyphosis group (1.9-21.1 degrees; P<0.001) and hyperkyphosis group (49.8-33.2 degrees; P=0.001). Thoracic normokyphosis alignment was also preserved. No cases of abnormal proximal junctional kyphosis were noted in this cohort. Apical wiring technique for surgical treatment of adolescent idiopathic scoliosis provides an average correction of 71.1% at 3.4 years of average follow-up with harmonious sagittal plane correction even with preexisting abnormal thoracic kyphosis.

The Role of Serial Casting in Early-onset Scoliosis (EOS)

Serial casting has demonstrated efficacy for idiopathic early-onset scoliosis (EOS). Results of casting in nonidiopathic (syndromic and congenital) EOS patients have not previously been well described. A total of 53 patients underwent serial casting for EOS from 2005 to 2010 at a single institution. Deformity was classified as idiopathic or nonidiopathic. Diagnosis, time in cast, number of casts, use of bracing, complications, and outcomes were recorded. Radiographic measures included Cobb angle and thoracic height (T1-T12). Thoracic height velocity was calculated and compared with established norms. A total of 36 patients, 19 idiopathic and 17 nonidiopathic (14 syndromic, 3 congenital), completed cast treatment and had >6-month follow-up and were therefore included. Of those, 17% (6/36) experienced resolution of their deformity, 53% (19/26) are currently in braces, and 31% (11/36) had undergone surgery. Surgery occurred on average at age 5.6 years and was delayed by an average of 2.1 years from time of first cast. A 19% complication was observed. There was no statistical difference in the rate of resolution of deformity between idiopathic (5/19) and nonidiopathic (1/17) patients (P=0.182), although there exists a trend toward greater curve correction in idiopathic patients. Surgery occurred in fewer patients (2/19) in the idiopathic group compared with the nonidiopathic group (9/17) (P=0.006). Significant improvements in Cobb angle was observed in the idiopathic group (12.2 degrees) during casting (P=0.003). Nonidiopathic patients did not maintain the correction gained during casting at the time of final follow-up. T1-T12 height increased across all study patients regardless of etiology during the period of casting at similar velocity to established norms of 1.4 cm/y for this age group. Serial casting offers modest deformity correction in idiopathic deformities compared with nonidiopathic deformities. Thoracic height growth continued throughout the casting period at normal velocity. Serial casting maintained normal longitudinal thoracic growth in all patients with EOS in this cohort. Although many required surgery, the increased thoracic height may have positive implications on ultimate pulmonary function. Therapeutic level III.

Surgical Correction of Paralytic Neuromuscular Scoliosis With Poor Pulmonary Functions

A retrospective study. To evaluate clinical and functional success by all pedicle screw construct in paralytic neuromuscular scoliosis (NMS) with poor pulmonary functions (PFT). Duchene muscular dystrophy and spinal muscular atrophy are often associated with poor PFT and the development of scoliosis simultaneously. Poor PFT often make surgeons reluctant to operate. Eighteen paralytic NMS patients who had preoperative forced vital capacity (FVC) < 30% were operated with all pedicle screw construct. Average preoperative, postoperative, and final follow-up Cobb angle, pelvic obliquity, thoracic kyphosis and lumbar lordosis, PFT (FVC% and forced expiratory volume 1%), and preoperative and follow-up functional status were analyzed. Perioperative and postoperative complications were also noted. The average follow-up was 31.6 ± 7.7 months. There was significant improvement in Cobb angle (61.7%) and pelvic obliquity (56.7%), postoperatively (P < 0.001). All corrections were maintained at final follow-up. FVC was decreased from 25.2 ± 4.7% preoperatively to 24.2 ± 5.0%, 6 weeks postoperatively (P = 0.067); and on follow-up it further decreased to 20.6 ± 3.9% (P < 0.0001) (1.8%/y). Forced Expiratory Volume 1 also decreased from 22.7 ± 4.5% preoperatively to 21.8 ± 4.2% postoperatively (P = 0.037) and was 19.8 ± 3.8% at final follow-up (P < 0.0001) (1.1%/y). However, none of the patients had any respiratory complications postoperatively. Functional status was improved in 6 patients and they were able to sit without support (P = 0.027). Eight (44.4%) perioperative complications (5 pulmonary, 1 intraoperative death, and 2 others) were noticed. Postoperatively, 4 patients (23.5%) had complications; coccygodynia, back sore because of screw prominence, impingement of iliac screw, and loosening of the rod from L5 screw. All the patients were satisfied with the treatment. There were no major pulmonary complications requiring admission postoperatively. Although complications are associated with the treatment of paralytic NMS, a good clinical and function outcome suggests that poor PFT should not be considered as a contraindication of scoliosis surgery.

Thoracoscopy in Children Less than 20 kg fortheManagement of Spinal Disorders

Thoracoscopy is now considered a safe and feasible method for surgical management of spinal disorders in both adults and children. Nevertheless, a weight less than 20 kg has been reported as a relative contraindication because of the small volume of the thoracic cage and the anticipated difficulties of single-lung ventilation. The aim of this study was to evaluate the feasibility, as well as the safety and efficacy, of thoracoscopic procedures in such patients. This study was a retrospective analysis of a consecutive group of patients less than 20 kg weight, who underwent a thoracoscopy between 1998 and 2005. Results were evaluated radiologically, and intraoperative and postoperative complications were reported. A minimum 2-year follow-up was required. Seventeen patients were included. Age at surgery averaged 3 years and 4 months (±1.25). The mean weight was 13.3 kg (±2.8). Fourteen of the patients had congenital scoliosis, 9 due to hemivertebrae and 5 due to segmentation failures. The other 3 suffered from evolutive kyphosis, 2 caused by Pott disease, and 1 caused by congenital anterior failure of segmentation. The mean follow-up was 6 years and 9 months (±1.5). Lung exclusion time averaged 114 minutes (±20). The intended procedure was possible in all cases and no conversion to open thoracotomy was required. The mean operating time was 139 minutes (±10). A posterior arthrodesis was associated and performed during the same anesthesia in 15 cases. The selective breathing was efficient and well tolerated in all cases. No intraoperative respiratory complication was observed. For patients with congenital scoliosis, the average improvement of the main curve between preoperative and latest follow-up was 55%, with an average Cobb angle improvement of 19.1 degrees (±10.5). For the 3 cases of kyphosis, the curve progression stopped, with a mean reduction of the regional kyphosis of 6 degrees (±11.5). Fusion was obtained radiologically in all cases. This study confirms the feasibility, safety, and efficacy of thoracoscopy for the management of spinal disorders in children less than 20 kg weight. Thoracoscopy can still be considered as an option in very young children, even though the small chest cavity creates additional technical challenges and the diminutive bronchial tree necessitates a dedicated method of single-lung ventilation. IV.

Reversal of curvature magnitude in response to physical methods: a 15-year followup in an adult female diagnosed with moderately severe scoliosis at age eleven years

Results Stable, progressive improvement in Cobb angle occurred over a fifteen-year period in response to physical methods. The improved curvature occurred in correlation with progressive improvement of chest wall morphology and excursion. Conclusion The forty percent (thoracic curve) and fifty percent (lumbar curve) reduction in curvature magnitude compares favorably with results from surgical intervention [1].

Evaluation of Postoperative Residual Spinal Deformity and Patient Outcome in Idiopathic Scoliosis Patients in Japan Using the Scoliosis Research Society Outcomes Instrument

This study clarifies the correlation between the components of the Scoliosis Research Society Outcomes Instrument (SRS-24) and the radiographic parameters after surgery in Japanese idiopathic scoliosis patients. To investigate the correlation between the magnitude of back deformity after scoliosis surgery and the components of the SRS-24. Patient outcomes for Japanese scoliosis patients using the SRS-24 have not been fully investigated. Idiopathic scoliosis patients (n = 81) who were treated with surgery and followed up for more than 2 years were evaluated. Radiographic examination included Cobb angle, rotation angle of apical vertebrae, and translation of the C7 vertebra from the center sacral line on the coronal plane. In addition, the score of one new question regarding postoperative scar was investigated and compared with that of the individual SRS-24 domains. A comparison of the SRS-24 and radiographic results revealed a significant inverse correlation between total pain and the postoperative correction of the rotation angle in the thoracic curve (rs = 0.27; P < 0.05). General self-image was inversely correlated with the Cobb angle (rs = -0.23; P < 0.05) and the rotation angle (rs = -0.30; P < 0.01) in the thoracic curve. Self-image after surgery was positively correlated with the correction degree of the thoracic Cobb angle (rs = 0.27; P < 0.05); 60% of patients had some concerns regarding postoperative scar, and the concerned patients demonstrated significantly lower scores in the pain and general self-image domains (P < 0.05) than the unconcerned patients did. Patients with a greater Cobb angle or rotation angle in the thoracic curve had a negative self-image. Self-image improved after surgery by greater correction of the thoracic Cobb angle. Thoracic scoliotic deformity with prominence should be substantially reduced by the surgical treatment to improve satisfaction rates and self-image regarding back appearance. Additionally, physicians should pay more attention to patients' concern regarding their postoperative scars to obtain better outcomes.

Clinical improvement and radiological progression in a girl with early onset scoliosis (EOS) treated conservatively--a case report.

BackgroundChêneau-Brace treatment of a certain standard reduces the rate of surgery, prevents progression and in a certain patient population leads to marked improvement of Cobb angle and cosmetic appearance. During the last two years a patient refusing surgery with a double major curvature of initially 60° showed a clear cosmetic improvement and a clear radiological progression at the same time. The findings of this patient have been reviewed in order to find out how cosmetic appearance and Cobb angle can develop differently.MethodsThe patient entered conservative treatment at the age of 13 years, premenarchial with Tanner II and a Cobb angle of 60° thoracic and 59° lumbar. The angle of trunk rotation (ATR; Scoliometer) was 13° thoracic and 13° lumbar. We have documented the findings of this patient (Surface topography, ATR, Cobb angles and angles of vertebral rotation (according to Raimondi) during the treatment period (27 Month) until 2 years after the onset of menarche.ResultsAfter a treatment time of 27 Month the Cobb angle increased to 74° thoracic and 65° lumbar. The angles of vertebral rotation according to Raimondi increased slightly from 26° thoracic and 28° lumbar to 30° thoracic and 28° lumbar. The ATR improved to 12° thoracic and 5° lumbar while Lateral deviation improved from 22,4 mm to 4,6 mm and average surface rotation improved from 10,6° to 6°. In the X-rays a reduction of decompensation was visible. The patient felt comfortable with the cosmetic result.ConclusionConservative treatment may improve cosmetic appearance while the curve progresses radiologically. This could be explained by assuming that (1) the Rigo Chêneau brace is able to improve cosmetic appearance by changing the shape of the thorax when the curve itself is too stiff to be corrected by a brace, that (2) reduction of decompensation leads to significant cosmetical improvements or (3) that the patient gained weight and therefore the deformation is masked. However, the weight the patient gained cannot explain the cosmetical improvement in this case.Conservative treatment with a certain standard of quality seems a viable alternative for patients with Cobb angles of > 60° when surgical treatment is refused.Specialists in scoliosis management should be aware of the fact that curve progression can occur even if the clinical measurements show an improvement.

Surgical correction of lumbar scoliosis: a comparison of different techniques. Results

Vertebral rotation is at the basis of structural scoliosis. Its measurement gives the possibility to evaluate the surgical correction. Three groups of five lumbar scolioses (means angle 45°) were treated with rotation of the convex rod (group 1), bending in situ (group 2) and bending associated with rotation of the convex screws (group 3). Cobb angle improvement was the same with the three techniques. The Vertebral Rotational Angle (VRA) and the most suitable Intervertebral Rotational Angle (IRA) were used for this study. IRA (difference of rotation between two consecutive vertebrae) stays the same whatever the reference axis and VRA depends on conditions of measurement. IRA is improved of 15% in group 1, 35% in group 2 and 54% in group 3.In situ bending associated with the rotation of the convex screws is a good method for correcting the torsion of the scoliotic lumbar spine.