Risser Grade Research Articles

Does Risser Casting for Adolescent Idiopathic Scoliosis Still Have a Role in the Treatment of Curves Larger Than 40°? A Case Control Study with Bracing.

Background: The most common conservative treatment for Adolescent Idiopathic Scoliosis (AIS) is bracing. However, several papers questioned the effectiveness of bracing for curves between 40° and 50° Cobb: the effectiveness in preventing curve progression could be as low as 35%. Seriate casting is considered a standard approach in early onset scoliosis; however, in the setting of AIS, cast treatment is seldom utilized, with only few studies reporting on its effectiveness. Aim of the study: The main aim of the study is to determine whether a seriate casting with Risser casts associated with bracing is more effective in preventing curve progression than bracing alone in curves larger than 40°. Furthermore, the secondary endpoints were: (1) is there a difference in effectiveness of casting between Thoracic (T) and Thoracolumbar/Lumbar (TL/L) curves? (2) Does the ‘in cast’ correction predicts the treatment outcome? (3) What is the effect on thoracic kyphosis of casting? Methods: This is a retrospective monocentric case–control study; through an Institutional Database search we identified all the patients treated at our institution between 1 January 2017 and 31 December 2020, with a diagnosis of AIS, Risser grade between 0 and 4 at the beginning of the treatment, at least one curve above 40° Cobb and treatment with either seriate Risser casting and bracing (Study Group, SG) or bracing alone (Control Group, CG). Standing full spine X-rays in AP and LL are obtained before and after the cast treatment; only AP standing full spine X-rays ‘in-cast’ are obtained for each cast made. Patients were stratified according to the curve behavior at the end of treatment (Risser 5): progression was defined as ≥6° increase in the curve magnitude or fusion needed; stabilization is defined as a change in curve by ±5°; and improvement was defined as ≥6° reduction in the curve. Results: For the final analysis, 55 compliant patients (12 M, 43 F, mean age 13.5 ± 1.6) were included in the SG and 27 (4 M, 23 F, mean age 13.6 ± 1.6) in the CG. Eight (14.5%) patients in the SG failed the conservative treatment while 14 (51.3%) failed in the CG. Consequently, the Relative Risk for progression in the Efficacy Analysis was 1.8 (95% CI 1, 3–2.6, p = 0.001), and the Number Needed to Treat was 2,4. No significant difference was found between the T and TL/L curves concerning the ‘progressive’ endpoint (z-score 0.263, p = 0.79). The mean percentage of ‘in cast’ curve reduction was 40.1 ± 15.2%; no significant correlation was found between the percentage of correction and the outcome (Spearman Correlation Coefficient 0.18). Finally, no significant differences between baseline and end of FU TK were found (32° ± 16.2 vs. 29.6 ± 15.8, p = ns). Discussion: Seriate Risser casting for AIS with larger curves (>40° Cobb) is effective in reducing curve progression when compared with full time bracing alone in treatment compliant patients. The treatment is equally effective in controlling T and TL/L curves; furthermore, a slight but non-significant decrease in TK was observed in patients treated with casting. This type of treatment should be considered for AIS patients who present with large curves to potentially reduce the percentage of surgical cases. Short : The aim of the study is to determine whether seriate Risser casting associated with bracing is more effective in preventing curve progression than bracing alone in curves larger than 40°. This is a retrospective monocentric case–control study; we identified all the patients treated at our institution with a diagnosis of AIS, Risser grade 0–4 at the beginning of the treatment, at least one curve above 40° Cobb (35° if treated with bracing alone) and treatment with either seriate Risser casting and bracing (Study Group, SG) or bracing alone (Control Group, CG). Fifty-five patients (12 M, 43 F, mean age 13.5 ± 1.6) were included in the SG and 30 (5 M, 25 F, mean age 13.9 ± 1.7) in the CG. Eight (14,5%) patients in the SG failed the conservative treatment while fifteen (50%) failed in the CG. Consequently, the Relative Risk for progression in the Efficacy Analysis was 1.8 (95% CI 1.3–2.6, p = 0.001), and the Number Needed to Treat was 2,4. Seriate Risser casting for AIS with larger curves (>40°) is effective in reducing curve progression when compared with full time bracing alone. This type of treatment should be considered for AIS patients who present with large curves.

Postoperative improvement in leg length discrepancy in adolescent idiopathic scoliosis differs between right and left legs

BackgroundIn adolescent idiopathic scoliosis (AIS) patients, leg length discrepancies (LLDs) often occur to compensate for scoliosis. However, there have been no reports on the LLD changes after corrective surgery for AIS. This study aimed to clarify the difference of LLD changes after corrective surgery for AIS by classifying LLD based on the shortened side. MethodsWe analyzed preoperative and postoperative radiographs of 94 consecutive AIS patients who underwent posterior corrective surgery between 2012 and 2018. The patients enrolled were divided into three groups according to the presence of preoperative LLD of more than 5 mm and the LLD side: the left leg shortened group (L group), the non-LLD group (N group), and the right leg shortened group (R group). The three groups were compared with regard to age, sex, Lenke classification, Risser grade, fused levels, and radiographic parameters before surgery and at 6-month follow-up (thoracic Cobb angle, lumbar Cobb angle, L4 tilt, coronal balance, T1 tilt, and LLD). ResultsThe L, N, and R groups included 23 (24%), 60 (64%), and 11 patients (12%), respectively. The demographics and radiographic parameters were not significantly different among the groups except for preoperative L4 tilt. In the L group only, the LLD decreased from 7.9 ± 2.2 mm to 5.7 ± 3.7 mm (p = 0.002) after surgery. In contrast, the LLD in the N and R groups did not change significantly. ConclusionsThe postoperative improvement of LLD in AIS patients differed between the left and right sides. Different pathologies may contribute to the LLD on the left and right sides.

Prognostic factors to predict the progression of adolescent idiopathic scoliosis: A narrative review

Scoliosis has always presented a challenge to the clinicians both at the stage of decision-making and at the stage of correcting the same. Predicting curve progression is important as it helps in selecting the patients who may benefit from an earlier intervention. Patients can be treated either by brace application or by operative intervention depending on the magnitude of curve and potential of curve progression. In this review, we have summarized the past and present parameters used to predict scoliosis progression with a brief introduction about the future trend in this respect. We identified and reviewed a total of 46 relevant papers written in English language utilizing PubMed, Google Scholar, and Scopus search engines. Many clinicians had come up with various radiological methods such as Risser grading, Tanner–Whitehouse staging (TW2-RUS and TW3) methods, Greulich–Pyle method, Sauvegrain method using only olecranon process radiographs and various clinical methods such as age of menarche and Tanner staging for sexual maturity. Apart from these, recently, various genetic factors such as single-nucleotide polymorphism of various genes, platelet calmodulin, peripheral blood mononuclear cell, impairment in melatonin signaling, DNA-based test called “ScoliScore” and hormones such as serum ghrelin and leptin have been investigated. Changes in brainstem vestibular function and alteration in electrical activities of paraspinal muscles are also studied to predict the curve progression. The two most important dilemmas faced by clinicians while approaching patients with scoliosis are the identification of patients requiring intervention and the right time to intervene in the selected patients. The goal of scoliosis treatment is to halt the progression. Predicting the growth spurt in an individual patient will guide the appropriate timing of intervention which can prevent complications associated with adolescent idiopathic scoliosis so that they can lead a better quality of life.

The L-type Amino Acid Transporter (LAT1) Expression in Patients with Scoliosis.

Introduction Amino acid transporters are transmembrane proteins that are known to mediate the transfer of amino acids. As one of the amino acid transporters, LAT1, which is encoded by Slc7a5, mediates the cellular uptake of the essential amino acids. Recently, most studies have focused on examining the relationship between LAT1 and skeletal formation in terms of development. However, little is known regarding the clinical features of LAT1 in the cartilage, which might result in the development of skeletal deformities such as scoliosis. Thus, the aim of this study was to investigate the expression of L-type amino acid transporter 1 (LAT1) and its solute carrier transporter 7a5 (Slc7a5) in patients with pediatric scoliosis and to compare with the relationship between LAT1 and Slc7a5 expression and their clinical features. Methods We have prospectively recruited 56 patients who underwent corrective spinal fusion for scoliosis. The patients comprised 40 girls and 16 boys, with a mean age of 13.1 years at the time of surgery. There were 34 idiopathic scoliosis (IS) patients, whereas 22 were congenital scoliosis (CS) patients. During the surgery, an epiphyseal part of the spinous process at apical vertebra was harvested; then, LAT1 and Slc7a5 expressions in the cartilage were evaluated. Results As per our findings, LAT1 expression was observed in the cartilage in 60.7% (34 out of 56) of the patients. LAT1 expression in IS patients was 76%, which were statistically higher compared to 36% in CS patients. When compared with LAT1 expression, no statistical difference was noted in terms of age, gender, body mass index (BMI), Cobb angle, and Risser grade. Meanwhile, the mean Slc7a5 expression in IS patients was determined to be significantly higher than that in CS patients. No significant correlation was observed between Slc7a5 expression and age, BMI, and Cobb angle. Conclusions LAT1 and Slc7a5 expression in IS and CS patients showed significant differences. These expressions were found to be not correlated with age, stature, and severity of the deformity.

Contribution of postoperative vertebral remodeling to reversal of vertebral wedging and prevention of correction loss in patients with adolescent Scheuermann's kyphosis.

This study aimed to investigate reversal of vertebral wedging and to evaluate the contribution of vertebral remodeling to correction maintenance in patients with adolescent Scheuermann's kyphosis (SK) after posterior-only instrumented correction. A retrospective cohort study of patients with SK was performed. In total, 45 SK patients aged 10-20 years at surgery were included. All patients received at least 24 months of follow-up and had Risser sign greater than grade 4 at latest follow-up. Patients with Risser grade 3 or less at surgery were assigned to the low-Risser group, whereas those with Risser grade 4 or 5 were assigned to the high-Risser group. Radiographic data and patient-reported outcomes were collected preoperatively, immediately postoperatively, and at latest follow-up and compared between the two groups. Remarkable postoperative correction of global kyphosis was observed, with similar correction rates between the two groups (p = 0.380). However, correction loss was slightly but significantly less in the low-Risser group during follow-up (p < 0.001). The ratio between anterior vertebral body height (AVBH) and posterior vertebral body height (PVBH) of deformed vertebrae notably increased in SK patients from postoperation to latest follow-up (p < 0.05). Loss of correction of global kyphosis was significantly and negatively correlated with increased AVBH/PVBH ratio. Compared with the high-Risser group, the low-Risser group had significantly greater increase in AVBH/PVBH ratio during follow-up (p < 0.05). The two groups had similar preoperative and postoperative Scoliosis Research Society-22 questionnaire scores for all domains. Obvious reversal in wedge deformation of vertebrae was observed in adolescent SK patients. Patients with substantial growth potential had greater vertebral remodeling and less correction loss. Structural remodeling of vertebral bodies has a positive effect and protects against correction loss. These results could be help guide treatment decision-making.

Clinical study of selection of the upper instrumented vertebra at one level caudal to upper end vertebra in patients with Lenke 5C adolescent idiopathic scoliosis

Objective: To investigate whether the upper instrumented vertebra (UIV) can be selected at one level caudal to upper end vertebra (UEV) in Lenke type 5C adolescent idiopathic scoliosis (AIS) patients. Methods: Total of 28 Lenke 5C AIS patients who underwent selective posterior fusion in Drum Tower Hospital of Nanjing University Medical School from September 2013 to September 2015 were included. There were 4 males and 24 females, with an age of (15.0±2.0) years, the Risser sign was graded 2-5. The following imaging parameters were measured on standing full spine X-ray before, immediately after the surgery and at the last follow-up: thoracolumbar/lumbar (TL/L) Cobb angle, coronal balance, UIV translation, lower instrumented vertebra (LIV) translation, UIV tilt, LIV tilt, and thoracic apical vertebral translation (T-AVT), lumbar apical vertebral translation (L-AVT). The patients were divided into two groups: decompensation group (n=6) and non-decompensation group (n=22). Radiographic parameters and Scoliosis Research Society (SRS)-22 scores were compared between the two groups. Results: Six cases (21.4%) had proximal decompensation at the last follow-up. There were no significant differences in Risser grade(3.8±1.0 vs 3.6±1.6), baseline thoracic Cobb angle(25.8°±2.2° vs 26.3°±6.4°) and TL/L Cobb angle(43.7°±3.4° vs 45.2°±6.5°) between the two groups (all P>0.05). However, the baseline lumbar/thoracic apical vertebra translation (L-T AVT ratio) was significantly higher in patients with proximal decompensation (6.3±1.3 vs 4.0±2.0, P=0.048). Conclusion: Selecting UIV at one level caudal to UEV, would not increase the incidence of proximal decompensation in Lenke 5C AIS patients with Risser higher than grade 2, the smaller baseline L-T AVT ratio, and with thoracic compensatory curve over 15°, and can obtain satisfactory clinical results.

Automatic bone maturity grading from EOS radiographs in Adolescent Idiopathic Scoliosis.

Adolescent Idiopathic Scoliosis (AIS) is a deformation of the spine and it is routinely diagnosed using posteroanterior and lateral radiographs. The Risser sign used in skeletal maturity assessment is commonly accepted in AIS patient's management. However, the Risser sign is subject to inter-observer variability and it relies mainly on the observation of ossification on the iliac crests. This study proposes a new machine-learning-based approach for Risser sign skeletal maturity assessment using EOS radiographs. Regions of interest including right and left humeral heads; left and right femoral heads; and pelvis are extracted from the radiographs. First, a total of 24 image features is extracted from EOS radiographs using a ResNet101-type convolutional neural network (CNN), pre-trained from the ImageNet database. Then, a support vector machine (SVM) algorithm is used for the final Risser sign classification. The experimental results demonstrate an overall accuracy of 84%, 78%, and 80% respectively for iliac crests, humeral heads, and femoral heads. Class activation maps using Grad-CAM were also investigated to understand the features of our model. In conclusion, our machine learning approach is promising to incorporate a large number of image features for different regions of interest to improve Risser grading for skeletal maturity. Automatic classification could contribute to the management of AIS patients.

Lack of in-brace x-rays in compliant AIS patients wearing full-time TLSO braces associates with failure

BackgroundIn-brace correction and brace compliance with thoraco-lumbo-sacral orthotic (TLSO) braces are associated with successful treatment of adolescent idiopathic scoliosis (AIS). This paper compares patients who had consistent radiographic documentation of in-brace correction to those who did not.MethodsAll skeletally immature (Risser 0-2) patients were treated for AIS (25-45°) with full-time TLSO braces that had compliance temperature monitors. All patients wore their braces at least 12 h a day. Brace failure was defined as curve progression to a surgical magnitude (≥ 50°). All patients were followed until brace discontinuation.ResultsNinety patients (F 82, M 8) with an average age of 12.1 (10.1-15.0) years, Risser grade 0 (0-2), BMI percentile 48.5 (0.0-98.8), and daily brace wear of 16.5 (12.1-21.6) h/day were treated for 24.3 (8.0-66.6) months. Patients went through 1.7 (1-4) braces on average. Forty-two out of 90 (46.7%) patients had some amount of brace time with an unknown in-brace correction, which, on average, was 66.1% of their total treatment course (11.5-100). On univariate analysis, patients that did not have a repeat in-brace x-ray with major brace adjustments or new brace fabrication tended to be more skeletally immature (Risser 0 and tri-radiate open, p = 0.028), wear more braces throughout their treatment (2.0 vs 1.4, p < 0.001), were treated for a longer period of time (27 vs 22 months, p = 0.022), and failed bracing more often (47.6% vs 22.9%, p = 0.014).ConclusionsPatients who did not have new in-brace x-rays with major brace adjustments and/or new brace fabrication were 3.1 (95% CI 1.2-7.6) times more likely to fail bracing than patients who were re-checked with new in-brace x-rays.Trial registrationClinicalTrials.gov—NCT02412137, initial registration date April 2015Level of evidenceIII

Adolescent Idiopathic Scoliosis Treated by Posterior Spinal Segmental Instrumented Fusion : When Is Fusion to L3 Stable?

ObjectiveThe purpose of this study was to identify risk factors for distal adding on (AO) or distal junctional kyphosis (DJK) in adolescent idiopathic scoliosis (AIS) treated by posterior spinal fusion (PSF) to L3 with a minimum 2-year follow-up. MethodsAIS patients undergoing PSF to L3 by two senior surgeons from 2000–2010 were analyzed. Distal AO and DJK were deemed poor radiographic results and defined as >3 cm of deviation from L3 to the center sacral vertical line (CSVL), or >10° angle at L3–4 on the posterior anterior- or lateral X-ray at ultimate follow-up. New stable vertebra (SV) and neutral vertebra (NV) scores were defined for this study. The total stability (TS) score was the sum of the SV and NV scores. ResultsTen of 76 patients (13.1%) were included in the poor radiographic outcome group. The other 66 patients were included in the good radiographic outcome group. Lower Risser grade, more SV-3 (CSVL doesn’t touch the lowest instrumented vertebra [LIV]) on standing and side bending films, lesser NV and TS score, rigid L3–4 disc, more rotation and deviation of L3 were identified risk factors for AO or DJK. Age, number of fused vertebrae, curve correction, preoperative coronal/sagittal L3–4 disc angle did not differ significantly between the two groups. Multiple logistic regression results indicated that preoperative Risser grade 0, 1 (odds ratio [OR], 1.8), SV-3 at L3 in standing and side benders (OR, 2.1 and 2.8, respectively), TS score -5, -6 at L3 (OR, 4.4), rigid disc at L3–4 (OR, 3.1), LIV rotation >15° (OR, 2.9), and LIV deviation >2 cm from CSVL (OR, 2.2) were independent predictive factors. Although there was significant improvement of the of Scoliosis Research Society-22 average scores only in the good radiographic outcome group, there was no significant difference in the scores between the groups. ConclusionThe prevalence of AO or DJK at ultimate follow-up for AIS with LIV at L3 was 13.1%. To prevent AO or DJK following fusion to L3, we recommend that the CSVL touch L3 in both standing and side bending, TS score is -4 or less, the L3/4 disc is flexible, L3 is neutral (<15°) and ≤2 cm from the midline and the patient is ≥ Risser 2.

Prospective Follow-up Report on Anterior Vertebral Body Tethering for Idiopathic Scoliosis: Interim Results from an FDA IDE Study.

Anterior vertebral body tethering (aVBT) has emerged as a novel treatment option for patients with idiopathic scoliosis. We present the results from the first U.S. Food and Drug Administration (FDA) Investigational Device Exemption (IDE) study on aVBT. In this prospective review of a retrospective data set, eligible patients underwent aVBT at a single center from August 2011 to July 2015. Inclusion criteria included skeletally immature patients with Lenke type-1A or 1B curves between 30° and 65°. Clinical and radiographic parameters were collected, with the latter measured by an independent reviewer. Fifty-seven patients (49 girls and 8 boys), with a mean age (and standard deviation) of 12.4 ± 1.3 years (range, 10.1 to 15.0 years), were enrolled in the study. The patients had a mean of 7.5 ± 0.6 levels tethered, the mean operative time was 223 ± 79 minutes, and the mean estimated blood loss was 106 ± 86 mL. The patients were followed for an average of 55.2 ± 12.5 months and had a mean Risser grade of 4.2 ± 0.9 at the time of the latest follow-up. The main thoracic Cobb angle was a mean of 40.4° ± 6.8° preoperatively and was corrected to 18.7° ± 13.4° at the most recent follow-up. In the sagittal plane, T5-T12 kyphosis measured 15.5° ± 10.0° preoperatively, 17.0° ± 10.1° postoperatively, and 19.6° ± 12.7° at the most recent follow-up. Eighty percent of patients had curves of <30° at the most recent follow-up. The most recent Scoliosis Research Society (SRS) scores averaged 4.5 ± 0.4, and scores on the self-image questionnaire averaged 4.4 ± 0.7. No major neurologic or pulmonary complications occurred. Seven (12.3%) of 57 patients had a revision: 5 were done for overcorrection and 2, for adding-on. Anterior VBT is a promising technique that has emerged as a treatment option for patients with immature idiopathic scoliosis. We present the results from the first FDA-approved IDE study on aVBT, which formed the basis for the eventual Humanitarian Device Exemption approval. The findings affirm the safety and efficacy of this technique and suggest opportunities for improvement, particularly with respect to reoperation rates. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Upper End Vertebra of Proximal Thoracic Curve At T1 is a Novel Risk Factor of Postoperative Shoulder Imbalance in Lenke Type 2 Adolescent Idiopathic Scoliosis.

Retrospective single-center study. We investigated the risk factors of postoperative shoulder imbalance (PSI) in patients with Lenke type 2 adolescent idiopathic scoliosis (AIS) including the position of preoperative upper end vertebra (UEV). Seventy-five patients with Lenke type 2 AIS who underwent posterior correction and fusion surgeries from 2008 to 2018 were included. We included only patients whose upper instrumented vertebrae were at T2. The patients were divided into 2 groups based on radiographic shoulder height (RSH) at final follow-up, namely PSI group and non-PSI group, and PSI was defined as RSH > 10 mm. UEV, RSH, Cobb angle, curve flexibility, T1 and T2 tilt, correction rate, Risser grade, Scoliosis Research Society-22 scores, and demographic data were compared between the groups using independent t-tests or chi-square tests. Variables with P value < 0.20 in univariate analysis were assessed in logistic regression analysis. Thirty-four patients in the PSI group and 37 patients in the non-PSI group were analyzed. Univariate analysis revealed that there were more patients with UEV at T1 (PSI: 85%, non-PSI: 54%, P < 0.01) and Risser grade ≥ 3 (PSI: 88%, non-PSI: 62%; P < 0.05) in the PSI group than in the non-PSI group. Logistic regression analysis revealed that UEV at T1 (odds ratio [OR] = 4.1 [1.2-14.4], P < 0.05) and Risser grade ≥ 3 (OR = 3.9 [1.1-14.5], P < 0.05) are significantly associated with PSI. UEV at T1 and Risser grade ≥ 3 at the time of surgery are significant risk factors of PSI.

Factors Affecting Operation Duration in Posterior Spinal Fusion (PSF) Using Dual Attending Surgeon Strategy Among Lenke 1 and 2 Adolescent Idiopathic Scoliosis (AIS) Patients.

This was a retrospective study. Prolonged operation duration in adolescent idiopathic scoliosis (AIS) surgery was associated with increased perioperative complications. However, the factors affecting operation duration in AIS surgery were unknown. The aim of the study was to investigate the factors affecting operation duration in posterior spinal fusion (PSF) surgery using a dual attending surgeon strategy among Lenke 1 and 2 AIS patients. In all, 260 AIS patients with Lenke 1 and 2 curves who underwent PSF were retrospectively reviewed. Preoperative and intraoperative factors affecting operation duration such as age, sex, height, weight, body mass index, Risser grade, Lenke subtypes, number of fusion level, number of screws, screw density, wound length, upper and lowest instrumented vertebrae level, preoperative Cobb angle, and flexibility of the major curve were assessed using univariate and multivariate linear regression analyses. Independent factors were determined when P-value <0.05. The mean operation duration was 122.2±28.6 minutes. Significant independent factors affecting operation duration in PSF among Lenke 1 and 2 AIS patients were Lenke 2 subtypes (β=8.86, P=0.008), number of screws (β=7.01, P<0.001), wound length (β=1.14, P=0.009), and flexibility of the major curve (β=-0.25, P=0.005). The overall model fit was R2=0.525. Operation duration can be predicted using the formula: (8.86×Lenke subtypes)+(7.01×number of screws)+(1.14×wound length)-(0.25×flexibility)-0.54, where Lenke 2=1 and Lenke 1=0. The factors affecting operation duration in PSF among Lenke 1 and 2 AIS patients were Lenke 2 curves, number of screws, wound length, and curve flexibility. The knowledge of these factors enables the spinal deformity surgeons to plan and estimate the operation duration before AIS surgery.

Novel questionnaire to enhance brace wear adherence in patients with adolescent idiopathic scoliosis and the relationship of the quality of life.

Bracing is an effective non-operative treatment, in patients with adolescent idiopathic scoliosis (AIS). The relationship between patients’ quality of life (QOL) and brace wear adherence has been reported. This study aims to determine brace wear adherence for AIS patients with novel questionnaire. A nested case-control study was conducted, included patient age 10-18 years, coronal Cobb angle 20-50°, and Risser grade 0-3. Correlation between patients’ QOL and the average hours of daily brace-wear were determined. Patients were divided into 3 groups based on brace wear adherence and were compared. QOL domains associated with the incompleteness of brace-wearing were determined by Cox proportional-hazards regression. Mean age of patients was 13.3 years (range 11-17.3 years) with initial Cobb angle of 33.5° (range 20-48°). There were significant negative correlations between total QOL scores and brace wearing time. Increased social domain scores was significantly associated with less brace wearing time (HR 1.5, 95% CI 1.12-2.04). Significant correlations between patients’ QOL and the average hours per day of brace wear. Poor social QOL have a significant impact on brace wear adherence.

Preoperative "Cervical Axis" Deviation Increases the Risk of Distal Adding-On Following Surgery in Lenke 1 and 2 Adolescent Idiopathic Scoliosis Patients.

Retrospective. To evaluate the relationship between shoulder/ neck imbalance with distal adding-on phenomenon and to identify other risk factors in Lenke 1 and 2 (non-AR curves) adolescent idiopathic scoliosis (AIS) patients. 100 Lenke 1 and 2 AIS patients with lowest instrumented vertebra (LIV) cephalad to or at L1 were recruited. Medial shoulder/ neck balance was represented by T1-tilt and cervical axis (CA). Lateral shoulder balance was represented by clavicle angle (Cla-A) and radiographic shoulder height (RSH). Distal adding-on phenomenon was diagnosed when there was disc wedging below LIV of >5o at final follow-up. Predictive factors and odds ratio were derived using univariate and multivariate logistic regression analysis. Mean age of this cohort was 15.9 ± 4.4 years. Mean follow-up duration was 30.9 ± 9.6 months. Distal adding-on phenomenon occurred in 19 patients (19.0%). Only Risser grade, preoperative CA and final follow-up lumbar Cobb angle were the independent factors. A positive preoperative CA deviation increased the odds of distal adding-on by 5.4 times (95% CI 1.34-21.51, P = 0.018). The mean immediate postoperative T1-tilt, CA, RSH and Cla-A were comparable between the group with distal adding-on and the group without. Distal adding-on phenomenon occurred in 19.0% of patients. Preoperative "Cervical Axis" was an important factor and it increased the risk of distal adding-on by 5.4 times. Other significant predictive factors were Risser grade and lumbar Cobb angle at final follow-up. Immediate postoperative shoulder or neck imbalance was not a significant factor for postoperative distal adding-on phenomenon.

Safety and efficacy of anterior vertebral body tethering in the treatment of idiopathic scoliosis.

AimsSpinal fusion remains the gold standard in the treatment of idiopathic scoliosis. However, anterior vertebral body tethering (AVBT) is gaining widespread interest, despite the limited data on its efficacy. The aim of our study was to determine the clinical efficacy of AVBT in skeletally immature patients with idiopathic scoliosis.MethodsAll consecutive skeletally immature patients with idiopathic scoliosis treated with AVBT enrolled in a longitudinal, multicentre, prospective database between 2013 and 2016 were analyzed. All patients were treated by one of two surgeons working at two independent centres. Data were collected prospectively in a multicentre database and supplemented retrospectively where necessary. Patients with a minimum follow-up of two years were included in the analysis. Clinical success was set a priori as a major coronal Cobb angle of < 35° at the most recent follow-up.ResultsA total of 57 patients were included in the study. Their mean age was 12.7 years (SD 1.5; 8.2 to 16.7), with 95% being female. The mean preoperative Sanders score and Risser grade was 3.3 (SD 1.2), and 0.05 (0 to 3), respectively. The majority were thoracic tethers (96.5%) and the mean follow-up was 40.4 months (SD 9.3). The mean preoperative major curve of 51° (SD 10.9°; 31° to 81°) was significantly improved to a mean of 24.6° (SD 11.8°; 0° to 57°) at the first postoperative visit (45.6% (SD 17.6%; 7% to 107%); p < 0.001)) with further significant correction to a mean of 16.3° (SD 12.8°; -12 to 55; p < 0.001) at one year and a significant correction to a mean of 23° (SD 15.4°; -18° to 57°) at the final follow-up (42.9% (-16% to 147%); p < 0.001). Clinical success was achieved in 44 patients (77%). Most patients reached skeletal maturity, with a mean Risser score of 4.3 (SD 1.02), at final follow-up. The complication rate was 28.1% with a 15.8% rate of unplanned revision procedures.ConclusionAVBT is associated with satisfactory correction of deformity and an acceptable complication rate when used in skeletally immature patients with idiopathic scoliosis. Improved patient selection and better implant technology may improve the 15.8% rate of revision surgery in these patients. Further scrutiny of the true effectiveness and long-term risks of this technique remains critical.Cite this article: Bone Joint J 2020;102-B(12):1703–1708.

Loss of Correction After Removal of Spinal Implants in Congenital Scoliosis

Previous studies have reported the progression of deformity in patients with adolescent idiopathic scoliosis after implant removal. However, for patients with congenital scoliosis, few studies have investigated the prognosis after implant removal. We observed 24 patients with congenital scoliosis, who underwent implant removal, for at least 3 years. Radiographic parameters and demographic data were compared to evaluate whether implant removal would lead to deformity progression. Four of the 24 patients (16.7%) suffered correction loss and underwent revision surgery (RS). All correction losses occurred within 12 months of implant removal. The average curve of fixed segments (9.84° ± 7.22° to 16.42° ± 16.79°; P= 0.017) and kyphosis of fixed segments (10.46° ± 13.42° to 18.98° ± 25.99°; P= 0.03) increased significantly throughout the follow-up. After excluding patients who underwent RS, the changes in curve of fixed segments (9.10°-11.58°) and kyphosis of fixed segments (8.50°-9.24°) were all within the measurement error. The coronal and sagittal balance maintained during the follow-up. Through comparison, we thought that the younger age and lower Risser's grade with larger scoliosis might be risk factors for correction loss. Implant removal after fusion surgery for congenital scoliosis may present loss of correction and require RS, thus preserving implants is recommended. When removal of instrumentation is inevitable, parents and patients should be counseled for potential loss of correction and RS, and patients should be monitored for the progression of deformity.

The rate of intraspinal problems and clinical evaluation of scoliosis: A cross-sectional, descriptive study.

Objectives This study aims to define the chronological, angular, and topographic classes in presumed idiopathic scoliosis and to investigate the frequency of generalized joint hypermobility, pain, neurological deficit, ankle deformity, Risser grade, and magnetic resonance imaging (MRI) findings in these patients.Patients and methods This cross-sectional, descriptive study included a total of 36 patients (11 males, 25 females; mean age 13.4±4.6 years; range, 6 to 24 years) with idiopathic scoliosis between January 2015 and January 2019. Data including age, sex, complaint of pain, generalized joint hypermobility (based on Beighton score), neurological deficit, ankle deformity, and definition of scoliosis were recorded. Chronological, angular, and topographic classification were carried out. The Risser grade and MRI findings were noted.Results Of all patients, 30 (83.3%) were idiopathic, five (13.9%) were neuromuscular, and one (2.8%) was congenital scoliosis based on MRI findings. Of 13 (36.1%) spine MRI scans, six (46.2%) were intraspinal anomalies, four were syringomyelia (30.8%), one was Chiari type 1 malformation (7.7%), and one was hemivertebrae with diastematomyelia (7.7%). The highest rates of classes according to chronological, angular, and topographical classifications of idiopathic scoliosis were adolescent (17/30, 56.7%), low angular (24/30, 80.0%), and lumbar scoliosis (15/30, 50.0%), respectively. Ten patients (33.3%) complained of pain, while 23 patients (76.7%) had no neurological deficit and seven (23.3%) had hypoesthesia. Seventeen patients (56.7%) had generalized joint hypermobility.ConclusionIdiopathic scoliosis with non-severe spinal deformity may present with intraspinal neural axis abnormalities, even when it is neurologically intact. Based on our study results, it seems to be useful to consider whole spine MRI for the evaluation of thoracic and lumbar scoliosis.

How to select the lowest instrumented vertebra in Lenke type 5 adolescent idiopathic scoliosis patients?

BACKGROUND CONTEXTThe lowest instrumented vertebra (LIV) determination in Lenke type 5 Adolescent Idiopathic Scoliosis (AIS) requires a thorough understanding and prediction of the correction force on the LIV from coronal, sagittal, and axial plane. Although many LIV selection criteria have been reported, none of them comprehensively evaluated the multidimensional characteristics of the LIV till now. PURPOSETo develop and evaluate our LIV selection criteria in Lenke type 5 AIS patients using pedicle screw system via posterior approach. STUDY DESIGNA retrospective study. PATIENT SAMPLEAll consecutive patients with Lenke 5 curves who were treated with one-stage selective lumbar fusion using complete pedicle screw system in our center from January 2006 to December 2017, with minimum 2-year follow-up. OUTCOME MEASURESAge, gender and Risser grade, fused levels, operating time, intraoperative blood loss, complications, and Scoliosis Research Society (SRS)-22 questionnaires outcome were recorded. Coronal, sagittal, and axial parameters were measured from plain radiographs. METHODSA total of 138 consecutive patients with Lenke 5 curves treated with selective lumbar fusion were retrospectively analyzed, with minimum 2-year follow-up. Our LIV selection criteria include: (1) the most cephalad vertebrae touched by central sacrum vertical line (CSVL); (2) Nash-Moe rotation being equal or less than grade I on the standing AP radiograph; (3) CSVL cross between the two pedicles of LIV on concave bending film; (4) not at the apex of kyphosis. Radiographic data, operative data, perioperative complications and SRS-22 outcomes were collected and analyzed. RESULTSThe mean follow-up period was 50.9±24.7 months. The thoracolumbar/lumbar curve was corrected from 46.9°±8.9° before surgery to 5.5°±2.6° at the final follow-up. The C7-CSVL was 19.7±6.2 mm before surgery and 5.2±3.4 mm at the final follow-up. The LIV translation was corrected from 22.3 ±5.4 mm before surgery to 4.8 ± 2.6 mm at the final follow-up, with the correction rate of 78.4%. The LIV tilt was corrected from 21.6 ± 4.4° before surgery to 2.6 ± 2.3° at the final follow up, with the correction rate of 87.9%. Our LIV saved 0.3 level than SRS-last barely touching vertebra, 0.6 level than SRS-last substantially touching vertebra, 0.9 level than neutral vertebra, and 1.4 level than stable vertebra. CONCLUSIONThe present study indicates using our LIV criteria, our study achieved the correction rate of thoracolumbar/lumbar curve as 88.9%, with the rate of adding on or coronal imbalance as 8.7% (12/138). The criteria may provide important guidance for preoperative decision-making in Lenke 5 AIS patients, and more multicenter prospective studies with larger samples are needed to further validate the findings of this study.

Hyper-Selective Posterior Fusion in Lenke 5C Adolescent Idiopathic Scoliosis: When Can We Stop Below the Upper End Vertebra?

A prospective analysis. To investigate whether the hyper-selective posterior fusion (upper instrumented vertebra [UIV] as the vertebra one level below the upper end vertebra [UEV], lower instrumented vertebra [LIV] as the lower end vertebra [LEV]) was applicable in posterior fusion of Lenke 5C adolescent idiopathic scoliosis (AIS) patients and what could be the indication of hyper-selective fusion. The improper UIV selection in selective fusion could lead to progressive thoracic compensatory curve, shoulder imbalance, and even coronal imbalance. However, few studies analyzed the clinical outcome of hyper-selective fusion. A prospective analysis of 80 patients with Lenke 5C AIS who underwent selective fusion was performed. According to the relationship between UEV and UIV, the patients were divided into UEV group (UIV = UEV) and UEV-1 group (UIV = UEV-1). Radiographic parameters and the incidence of postoperative proximal decompensation were compared. The Scoliosis Research Society (SRS)-22 scores were used to evaluate clinical outcomes between two groups. Thirteen patients (27%) in UEV group and six (18.75%) in UEV-1 group showed proximal decompensation during follow-up, and the incidence was equivalent (P = 0.280). Within the UEV-1 group, the patients with proximal decompensation showed similar Risser grade, baseline thoracic Cobb angle, and main Cobb angle (P = 0.611, 0.435, 0.708, respectively). However, the baseline L-T apical vertebral translation (AVT) ratio was significantly larger in patients with proximal decompensation (P = 0.028). Meanwhile, patients with proximal decompensation in UEV group showed significantly smaller preoperative UIV translation and lumbar AVT but similar postoperative UIV tilt. Hyper-selective posterior fusion strategy could be performed in Lenke 5C patients with Risser more than grade 2 and with thoracic compensatory curve over 15°. The UIV in patients with small baseline thoracic curve, represented by larger baseline lumbar-thoracic AVT ratio, should be selected as UEV to prevent proximal decompensation. 4.

Convolutional Neural Networks for Automatic Risser Stage Assessment.

To develop an automatic method for the assessment of the Risser stage using deep learning that could be used in the management panel of adolescent idiopathic scoliosis (AIS). In this institutional review board approved-study, a total of 1830 posteroanterior radiographs of patients with AIS (age range, 10-18 years, 70% female) were collected retrospectively and graded manually by six trained readers using the United States Risser staging system. Each radiograph was preprocessed and cropped to include the entire pelvic region. A convolutional neural network was trained to automatically grade conventional radiographs according to the Risser classification. The network was then validated by comparing its accuracy against the interobserver variability of six trained graders from the authors' institution using the Fleiss κ statistical measure. Overall agreement between the six observers was fair, with a κ coefficient of 0.65 for the experienced graders and agreement of 74.5%. The automatic grading method obtained a κ coefficient of 0.72, which is a substantial agreement with the ground truth, and an overall accuracy of 78.0%. The high accuracy of the model presented here compared with human readers suggests that this work may provide a new method for standardization of Risser grading. The model could assist physicians with the task, as well as provide additional insights in the assessment of bone maturity based on radiographs.© RSNA, 2020.