Lateral Cobb Angle Research Articles

Manual Reduction for Subacute Osteoporotic Burst and Severe Compression Thoracolumbar Fractures

The objective of this study was to retrospectively assess the impact of manual reduction (MR) on patients with subacute osteoporotic thoracolumbar burst fractures and severe compression fractures (OTLBFSCFs). From January 2016 to May 2020, 101 cases of OTLBFSCFs were reviewed, comprising 73 women and 28 men, with an average age of 77.4 ± 8.5 years. Preoperative radiographs, CT or MRI scans, intraoperative C-arm fluoroscopic images, and postoperative X-ray films were utilized to evaluate spinal radiographic parameters. Initially, all patients underwent 3 min of prone positioning as posture reduction (PR), followed by 1–3 sessions of six-member MR to approximate anatomical reduction of the fracture. The average preoperative anterior body height ratio (ABH%) and lateral Cobb angle (LCA) were 38.8% ± 6.2% and 22.6° ± 4.2°, respectively. Post-PR, the average ABH% and LCA were 50.5% ± 8.0% and 14.7° ± 2.7°, respectively. Following MR, the average ABH% and LCA were 99.6% ± 2.4% and 0.4° ± 2.4°, respectively. PR achieved an ABH% correction of 11.7%, while MR achieved 49.1%. LCA restoration was 7.9° with PR and 14.3° with MR. It was deduced that MR proved to be safe and efficacious for subacute OTLBFSCFs and could potentially alter the approach to subsequent surgeries.

Association Between Incorrect Posture and Adolescent Idiopathic Scoliosis Among Chinese Adolescents: Findings From a Large-Scale Population-Based Study.

Objectives: Adolescent idiopathic scoliosis (AIS) affects between 1 and 4% of adolescents, and severe curvature may be related to their adverse long-term outcomes. However, whether the change in body appearance is related to AIS remains largely unclear. We aimed to explore the association between incorrect posture and AIS among Chinese adolescents.Methods: Data were collected from a population-based (595,057) school scoliosis screening program in China. A sample of 3,871 adolescents was classified as cases with a diagnosed radiological lateral Cobb angle ≥10°, and 3,987 control subjects with a Cobb angle <10° were randomly selected from the screening system. Adolescents were accessed with demographic information and incorrect posture measured by visual inspection of physical signs, Adam's forward bending test (FBT), and the angle of trunk rotation (ATR). Logistic regression (LR) models were used to examine the associations.Results: Multivariate LR showed that shoulder-height difference, scapula tilt, lumbar concave, and pelvic tilt were associated with AIS. Adolescents with angle of thoracic rotation ≥5° [adjusted odds ratio (AOR) = 5.33–14.67, P < 0.001], thoracolumbar rotation ≥5° (AOR = 4.61–5.79, P < 0.001), or lumbar rotation ≥5° (AOR = 7.49–7.85, P < 0.001) were at especially higher risk for AIS than those with ATR <5°.Conclusions: Incorrect posture may be the potential risk factor for developing AIS, and ATR ≥5° was an important indicator for predicting the occurrence of scoliosis. Early monitoring of incorrect posture for school adolescents should be considered as a routine intervention to effectively identify the progress of scoliosis.

From genetics to epigenetics to unravel the etiology of adolescent idiopathic scoliosis.

Scoliosis is defined as the three-dimensional (3D) structural deformity of the spine with a radiological lateral Cobb angle (a measure of spinal curvature) of ≥10° that can be caused by congenital, developmental or degenerative problems. However, those cases whose etiology is still unknown, and affect healthy children and adolescents during growth, are the commonest form of spinal deformity, known as adolescent idiopathic scoliosis (AIS). In AIS management, early diagnosis and the accurate prediction of curve progression are most important because they can decrease negative long-term effects of AIS treatment, such as unnecessary bracing, frequent exposure to radiation, as well as saving the high costs of AIS treatment. Despite efforts made to identify a method or technique capable of predicting AIS progression, this challenge still remains unresolved. Genetics and epigenetics, and the application of machine learning and artificial intelligence technologies, open up new avenues to not only clarify AIS etiology, but to also identify potential biomarkers that can substantially improve the clinical management of these patients. This review presents the most relevant biomarkers to help explain the etiopathogenesis of AIS and provide new potential biomarkers to be validated in large clinical trials so they can be finally implemented into clinical settings.

Predicting Adolescent Idiopathic Scoliosis among Chinese Children and Adolescents.

Objective Adolescent idiopathic scoliosis (AIS) affects 1%-4% of adolescents in the early stages of puberty, but there is still no effective prediction method. This study aimed to establish a prediction model and validated the accuracy and efficacy of this model in predicting the occurrence of AIS. Methods Data was collected from a population-based school scoliosis screening program for AIS in China. A sample of 884 children and adolescents with the radiological lateral Cobb angle ≥ 10° was classified as an AIS case, and 895 non-AIS subjects with a Cobb angle < 10° were randomly selected from the screening system. All selected subjects were screened by visual inspection of clinical signs, the Adam's forward-bending test (FBT), and the measurement of angle of trunk rotation (ATR). LR and receiver operating characteristic (ROC) curves were used to preliminarily screen the influential factors, and LR models with different adjusted weights were established to predict the occurrence of AIS. Results Multivariate LR and ROC curves indicated that angle of thoracic rotation (adjusted odds ratios (AOR) = 5.18 − 10.06), angle of thoracolumbar rotation (AOR = 4.67 − 7.22), angle of lumbar rotation (AOR = 6.97 − 8.09), scapular tilt (area under the curve (AUC) = 0.77, 95% CI: 0.75-0.80), shoulder-height difference, lumbar concave, and pelvic tilt were the risk predictors for AIS. LR models with different adjusted weights (by AOR, AUC, and AOR+AUC) performed similarly in predicting the occurrence of AIS compared with multivariate LR. The sensitivity (82.55%-83.27%), specificity (82.59%-83.33%), Youden's index (0.65-0.67), positive predictive value (82.85%-83.58%), negative predictive value (82.29%-83.03%), and total accuracy (82.57%-83.30%) manifested that LR could accurately identify patients with AIS. Conclusions LR model is a relatively high accurate and feasible method for predicting AIS. Increased performance of LR models using clinically relevant variables offers the potential to early identify high-risk groups of AIS.

China urgently needs a nationwide scoliosis screening system.

Scoliosis is the most common spine deformity and is defined as a radiological lateral Cobb angle of at least 10 degrees (1). Adolescent idiopathic scoliosis (AIS), occurs in individuals aged 10-18 years and disproportionately affects females (2,3). Severe spinal curvature may be related to adverse long-term health outcomes. Early identification and effective intervention could stop or slow the curve progression of mild scoliosis before skeletal maturity. A meta-analysis showed that the pooled prevalence of scoliosis among primary and middle school students in China was 1.02% (95% confidence interval 0.85%-1.18%) (4). There are more than 300 million Chinese adolescents aged 10-18 years, so there could be millions with AIS. Early detection, diagnosis and treatments are urgently needed to improve long-term outcomes.

The Choice of Lower Instrumented Vertebra in AIS Comparison of Lenke, Suk and Dubousset Criteria

Background Distal extension of the selective fusion in AIS is currently among the most explored topics in literature especially for Lenke type 1 and 2 curves and a lot of variability in the distal extension of the fusion is noted among different specialized centers around the world. Methods This is a retrospective descriptive study examining 41 Adolescent Idiopathic Scoliosis (AIS) cases (Lenke type I or II curves) undergoing posterior selective fusion with a minimum follow up of 2 years. We assessed the concordance between Dubousset's, Lenke's and Suk's criteria in the choice of the Lower Instrumented Vertebra (LIV). Baseline and post-operative X-rays of 41 AIS patients presenting with Lenke type I or II curves treated with selective fusion were studied. For each patient, the LIV is determined according to Dubousset's, Suk's and Lenke's criteria. Based on these results, patients are divided into two groups. “Group 1” includes patients where LIV designated by Dubousset's criteria is identical to the LIV designated by Lenke's or Suk's criteria. “Group 2” includes patients where the LIV dictated by Dubousset's criteria is more distal when compared with the LIV dictated by Lenke's and Suk's criteria. The charts of those 41 patients are reviewed at their last post-operative follow-up. The primary outcome measure used to compare those different groups is the frontal balance. The secondary endpoints are the (1) AP Cobb angle of the thoracic curve, (2) the AP Cobb angle of the lumbar curve, (3) the improvement of the Cobb angle of the thoracic curve (% ACT), (4) the improvement of the Cobb angle of the lumbar curve (% ACL), (5) the AP and lateral inclination of the LIV, (6) the AP lumbar Apical Vertebral Translation (AVT-L) and (7) the lateral Cobb angle of D5-D12. Results The LIV recommended by Lenke and the one recommended by Suk's criteria are identical in 70% of cases. The match between the choice based on Dubousset's criteria and the choice accounted by Lenke's or Suk's criteria is obtained for 70% of patients also. In 20% of cases, the LIV recommended by Dubousset's criteria is more distal than the one recommended by Lenke and Suk. Groups' comparison. Preoperatively, the comparison between groups 1 and 2 for the frontal balance and for the secondary endpoints shows no difference. Similarly, non-statistically significant difference was found between both groups for the primary and the secondary endpoints in the immediate post-operative setting and on the last follow-up. Conclusions The 70% accordance rate between Dubousset's criteria and those of Lenke and Suk attributes some validity to Dubousset's criteria. Thus, the statistical study showing no evolution toward a postoperative coronal imbalance or toward a worsening of other structural criteria of the spine curvatures in group 2, which is discordant with the recommendations of Lenke and Suk, prove the validity of the selection criteria of the LIV according to Dubousset. These same results also show that a more extensive distal correction-fusion does nothing for the frontal balance in the immediate postoperative setting, and even after several months of follow-up.

Adolescent idiopathic scoliosis.

Adolescent idiopathic scoliosis (AIS) is the most common form of structural spinal deformities that have a radiological lateral Cobb angle - a measure of spinal curvature - of ≥10(°). AIS affects between 1% and 4% of adolescents in the early stages of puberty and is more common in young women than in young men. The condition occurs in otherwise healthy individuals and currently has no recognizable cause. In the past few decades, considerable progress has been made towards understanding the clinical patterns and the three-dimensional pathoanatomy of AIS. Advances in biomechanics and technology and their clinical application, supported by limited evidence-based research, have led to improvements in the safety and outcomes of surgical and non-surgical treatments. However, the definite aetiology and aetiopathogenetic mechanisms that underlie AIS are still unclear. Thus, at present, both the prevention of AIS and the treatment of its direct underlying cause are not possible.

Factors affecting postural reduction in posterior surgery for thoracolumbar burst fracture.

Retrospective analysis of a prospectively collected patient database. To investigate the significance and relevant factors of postural kyphosis reduction during posterior surgical treatment of thoracolumbar burst fracture. Optimal reduction of kyphosis is a goal in the surgical treatment of thoracolumbar burst fracture. Several factors are known to limit the amount of posterior surgical reduction. However, few comprehensive assessments of intraoperative postural reduction have been reported. Seventy-two consecutive patients who underwent posterior surgical treatment for thoracolumbar (T11-L2) burst fracture were included. Postural reduction was evaluated using C-arm fluoroscopic images and regarded as insufficient when the lateral Cobb angle was ≥20 degrees or AP Cobb angle ≥10 degrees. Clinical characteristics including sex, age, body mass index, time to operation, injury level, and neurological injury, as well as radiologic characteristics including fracture morphology, fracture deformity, canal stenosis, and ligament injuries were investigated to determine the relevant factors. The mean lateral Cobb angle was 22.2±11.0 degrees preoperatively, 16.4±7.7 degrees after postural reduction (P<0.001), and 13.4±6.9 degrees after instrumental reduction (P<0.001). Insufficient postural reduction was found in 25 (34.7%) patients, all of which were lateral. The relevant factors for insufficient reduction, as identified by multivariate analysis, were time to operation >72 hours (OR, 6.453; 95% CI, 1.283-32.553), burst-split type injury (OR, 4.689; 95% CI, 1.314-25.225), and anterior compression ratio >0.5 (OR, 2.284; 95% CI, 1.151-19.811). Postural reduction plays an important role in the reduction of kyphosis and compression deformity after thoracolumbar burst fracture. However, it was affected by delayed operation time, burst-split type injury, and severe anterior vertebral compression.

Subpedicle Decompression and Vertebral Reconstruction for Thoracolumbar Magerl Incomplete Burst Fractures via a Minimally Invasive Method

Retrospective. To evaluate the clinical and radiographical results. The evolution of posterior approach for burst fractures was from long-segment to short-segment and then to monosegmental fixation. Decompression of the spinal cord is performed by anterior or posterior approaches. The technique attempts to decompress the spinal cord by a paramedian subpedicle approach, and simultaneous vertebral reconstruction with pile-up titanium spacers (subpedicle decompression and body augmentation [SpBA]) was developed. Eighty patients with symptomatic single thoracolumbar Magerl incomplete burst fractures were included. After manual reduction, transpedicle body augmentation and shortsegment fixation (TpBA group) were performed in 38 patients and SpBA in 42 cases. The mean follow-up was 52.6 ± 18.7 (TpBA) and 42.1 ± 7.8 (SpBA) months, and the age was 57.9 ± 7.2 and 59.1 ± 8.3 years. Clinical and radiographical outcomes were analyzed. The operation time was 66 ± 11 (TpBA) versus 34.5 ± 5.5 (SpBA) minutes. The initial anterior vertebral correction was 46.8 ± 12.2% (TpBA) versus 53.2 ± 15.0% (SpBA) (P = 0.03) and the final correction was 44.0 ± 10.8% versus 51.5 ± 15.3% (P = 0.01). Initial corrections of the lateral Cobb angle were 22.3° ± 2.6° versus 22.8° ± 2.7° and the final corrections were 19.1° ± 3.4° versus 20.5° ± 2.9°. The VAS score was 7.7 ± 1.2 versus 7.9 ± 1.2 preoperatively and 2.2 ± 0.7 versus 1.8 ± 0.6 (P = 0.02) at the final visit. Seventy-five patients maintained or recovered to Frankel grade E. Three patients in the TpBA group and 2 in the SpBA group improved from grade C to D. Technical complications included 1 root overstretch in the SpBA group and one incomplete decompression in the TpBA group. SpBA is a safe and fast technique to treat Magerl incomplete burst fractures and leads to good clinical results. N/A.

Ponte Osteotomies With Pedicle Screw Instrumentation in the Treatment of Adolescent Idiopathic Scoliosis

Study designReview of prospective database. ObjectivesTo report the results of Ponte osteotomy with pedicle screw instrumentation for major thoracic adolescent idiopathic (AIS) curves. Summary of background dataPonte osteotomy for achieving coronal and sagittal correction of major thoracic curves in AIS with pedicle screw instrumentation is a widespread technique, but results have not been well described. MethodsReview of 87 consecutive AIS patients with Lenke 1–4 curves who underwent Ponte osteotomies and pedicle screw instrumentation by 2 surgeons at a single institution. Surgical details, blood loss, and complications were recorded. We evaluated coronal and sagittal radiological measurements and Scoliosis Research Society–22 (SRS-22) questionnaire scores over 2-year follow-up. ResultsThe mean preoperative thoracic coronal Cobb angle was 57° ± 9.7°, fulcrum flexibility was 47.2%, and lateral Cobb angle was 17.8° ± 4°. The mean estimated blood loss (EBL), expressed as percent estimated blood volume, was 35.8 ± 20.5 mL. There was significant improvement in coronal thoracic Cobb angle, percent correction, and apical vertebral translation over 2-year follow-up (p < .05). In hypokyphotic curves, there was a significant increase in lateral thoracic T5–T12 kyphosis from 8.1° to 18.3° (p < .001). In hyperkyphotic curves, mean lateral thoracic T5–T12 kyphosis improved from 45° to 26° (p < .001). Median SRS-22 domains were higher after treatment (p < .05). Complications included significant hypotension (1), EBL greater than 75% estimated blood volume (2), and wound infection needing drainage (2). There were neuromonitoring signal changes in 7 patients but no significant neurological complications. ConclusionsIn this case series of major thoracic AIS curves treated with segmental pedicle screw instrumentation and Ponte osteotomies, there was an improvement in the coronal and sagittal radiological parameters. A prospective controlled study is needed to determine whether pedicle screw instrumentation and Ponte osteotomies influence outcomes and complications.

Is the surface topography a helpful tool for the management of scoliosis?

Material and methods We have used the Formetric 4D-Dicom II system, which is supplied also with lateral Cobb angle measurement. We have examined 616 patients (432 females and 184 males), age 5 y to 21 y. The patients have been visited clinically by inspection, Adams forward bending test and Perdriolle scoliometer. We have fit, to every patient, 4-8 reflectors on the apex of T1 through L4 spinal process and 2 shoulder reflectors to get the possibility for lateral Cobb angle measurement with the Formetric 4D.

Spinal shortening and monosegmental posterior spondylodesis in the management of dorsal and lumbar unstable injuries

Introduction:Patients with spinal injuries have been treated in the past by laminectomy in an attempt to decompress the spinal cord. The results have shown insignificant improvement or even a worsening of neurologic function and decreased stability without effectively removing the anterior bone and disc fragments compressing the spinal cord. The primary indication for anterior decompression and grafting is narrowing of the spinal canal with neurologic deficits that cannot be resolved by any other approach. One must think of subsequent surgical intervention for increased stability and compressive posterior fusion with short-armed internal fixators.Aim:To analyze the results and efficacy of spinal shortening combined with interbody fusion technique for the management of dorsal and lumbar unstable injuries.Materials and Methods:Twenty-three patients with traumatic fractures and or fracture-dislocation of dorsolumbar spine with neurologic deficit are presented. All had radiologic evidence of spinal cord or cauda equina compression, with either paraplegia or paraparesis. Patients underwent recapping laminoplasty in the thoracic or lumbar spine for decompression of spinal cord. The T-saw was used for division of the posterior elements. After decompression of the cord and removal of the extruded bone fragments and disc material, the excised laminae were replaced exactly in situ to their original anatomic position. Then application of a compression force via monosegmental transpedicular fixation was done, allowing vertebral end-plate compression and interbody fusion.Results:Lateral Cobb angle (T10–L2) was reduced from 26 to 4 degrees after surgery. The shortened vertebral body united and no or minimal loss of correction was seen. The preoperative vertebral kyphosis averaged +17 degrees and was corrected to +7 degrees at follow-up with the sagittal index improving from 0.59 to 0.86. The segmental local kyphosis was reduced from +15 degrees to −3 degrees. Radiography demonstrated anatomically correct reconstruction in all patients, as well as solid fusion.Conclusion:This technique permits circumferential decompression of the spinal cord through a posterior approach and posterior interbody fusion.

Influence of selective posterior rhizotomy via different operation-sites on lumbar spine stability in children with spastic cerebral palsy

Objective To investigate variation of lumbar spine stability in children with spastic cerebral palsy (SCP) after two types selective posterior rhizotomy (SPR) at lumbosacral and conical sites.Methods Forty-five cases of SCP have undergone with lumbosacral SPR and 38 with conical SPR. Posteroanterior, lateral, 40°-double-oblique, and dynamic (hyperextension and hyperflexion) position lumbar Xray films were taken for all of them before and three months to seven years ( 19 months in average) after operation to observe postoperative lumbar deformity, lumbosacral angle, lateral Cobb' s angle, arch-vertex distance, lordotic index, Posner's definition, and other stability indicators pre- and post-operation of the two groups. Results ① There was statistically significant difference in lumbosacral angle, lateral Cobb's angle, arch-vertex distance, lordotic index and Posner's definition at the 1 st to 2nd lumbar vertebrae (L1-L2 ), the 4th to 5th lumbar vertebrae ( L4 - L5 ), and the 5th lumbar to the 1st sacral vertebrae ( L5 - S1 ) among those with lumbosacral SPR before and after operation (P ＜0. 05). But, only Posner's definition at the 12th thoracic vertebra to the 2nd lumbar vertebra ( T12 - L2 ) varied significantly ( P ＜ 0. 05 ) among those with conical SPR ② Various lumbar deformity was observed in six cases ( 13% ) with lumbosacral SPR, three of them with instable neurological symptoms; while two cases (5%) did so after conical SPR,one with neurological symptoms, with statistical significance ( P ＜ 0. 05). Conclusions Little variation of lumbar spine stability is found among children with spastic cerebral palsy in mid-short term after SPR, while influence of conical SPR is much less on lumbar stability. Their long-term postoperative influence has to be followed-up further. Key words: Cerebral palsy ; Rhizotomy ; Lumbar vertebrae ;

Flexion myelopathy of the thoracic spine

The authors report a rare case of surgically treated symptomatic thoracic kyphosis caused by dynamic compression in an elderly man. Myelopathy due to thoracic kyphosis has been reported in patients with congenital kyphosis, Scheuermann dorsal kyphosis, and Cushing disease, but to the authors' knowledge this is the first report of dynamic kyphosis in an elderly person. This otherwise healthy 84-year-old man presented with a 2-year history of progressive difficulty in walking and bilateral leg dysesthesia. Despite several cervical and lumbar surgeries, his symptoms gradually worsened. A radiological examination revealed severe thoracic kyphosis, with a lateral Cobb angle of 59 degrees from T-2 to T-12. On a dynamic computed tomography (CT) myelogram, severe thoracic spinal cord draping and stretching on flexion was demonstrated. On extension, however, imaging studies failed to show draping or stretching. Posterior corrective fusion was performed with instrumentation from T-2 to T-9. Postoperative CT myelography demonstrated no significant spinal cord compression with restoration of the cerebrospinal fluid space anterior to the spinal cord, and the successful correction of the kyphosis to 44 degrees. The patient's neurological sequelae gradually resolved throughout 6 months of follow up.