Curve progression to surgical range in patients with adolescent idiopathic scoliosis (AIS) is strongly associated with the initial major curve angle and the degree of skeletal maturity as staged by the modified Proximal Humerus Ossification System (PHOS) and other systems. Our purpose was to (1) develop a prognostic model and risk score to estimate the probability of progression to surgical indications in untreated patients using the PHOS and (2) compare its performance to a model using the Risser stage. Patients from the BrAIST study and 2 other institutions were followed to either skeletal maturity (Risser 4+), a major curve angle of ≥45°, or spinal fusion. Candidate variables for the predictive models included age, sex, major curve angle, Scoliosis Research Society (SRS) curve classification, status of triradiate cartilage, Risser stage, and PHOS. Model calibration and discrimination were evaluated. A probability threshold was set, creating low- and high-risk groups to aid in clinical decision-making. Overall, 164 patients (77% female) were included. The mean age at presentation was 12.2±1.4 years (range: 10 to 16 years), and the mean maximum major curve angle was 24±9° (range: 10° to 43°). Fifty-six (34%) patients progressed to a surgical range or had a spinal fusion. The PHOS model included the major curve angle and the presence/absence of a thoracic apex. The model demonstrated strong discrimination (c-statistic = 0.89) and calibration (ICI = 0.02), performing similarly to one developed in this sample using the Risser stage. The sensitivity was 0.91, the specificity was 0.71, the PPV was 0.62, and the NPV was 0.94 at the probability cut-point of 0.22. This study derived a prognostic model estimating the baseline risk of progression to surgical indications in AIS patients using the PHOS. Estimates from this model can inform the shared decision-making process and motivate compliant bracing. Further validation in larger independent samples and exploration of the PHOS to predict bracing outcomes should be performed. Level II.

Adherence to treatment protocol is important prognostic factor for successful result in adolescent idiopathic scoliosis treatment with bracing and/or physiotherapeutic scoliosis specific exercises. However, patients living away from specialized centers, have travelling and financial obstacles to receive proper care. Our clinic developed a specific protocol for online evaluation and treatment sessions. To evaluate the effectiveness of a hybrid in-person and online treatment protocol for scoliosis treatment. Retrospective matched case-control study. Our online evaluation required patient digital radiographs and eight standardized clinical photos, in standing and forward bending positions. An intensive in-person program was prescribed, to allow adequate teaching of physiotherapeutic scoliosis specific exercises or brace manufacturing when needed. Then, the patients followed a home-program of exercises, having regular online supervised sessions. They were asked to re-visit our clinic every 3-6 months. Our online intervention group (OIG) (combined in-person and online treatment) was consisted of 118 patients (103 females-15 males, mean Cobb angle 29.4°, Risser 0.8, age 12.6 years). Our inclusion criteria were Cobb angle 10°-40°, Risser 0-2, less 1-year post-menarche for girls, and permanent residence outside of our region. We used a retrospective matched-control group (MCG) with similar characteristics that received only in-person treatment (106 patients, 92 females-14 males, mean Cobb angle 27.1°, Risser 1.1, age 12.9 years). In the last 3 years totally 3092 online sessions were done for the OIG. Compliance was self-reported in both groups. Independent sample t-test were used for statistical analysis. Mean follow-up was 29.7 months. Compliance with exercises was significantly better (P = 0.006) in OIG (78.3% > 3 days/week) compared to MCG (52.8% > 3 days/week). In OIG 35% improved, 54% remained stable, and 11% progressed, while in MCG 23.6% improved, 56.6% stable, and 19.8% progressed (P = 0.04). The loss to follow-up was also significantly lower (P = 0.03) in the OIG (6 subjects, 5.1%) compared to MCG (10 subjects, 10.9%). Our tele-scoliosis-screening and treat protocol significantly improved compliance, monitoring, and final treatment result in adolescent idiopathic scoliosis patients at high risk of progression. Online supervision can keep patient's motivation, allowing proper follow-up and can be used for patients with transportation barriers.

Congenital scoliosis encompasses a highly variable, heterogenous group of vertebral anomalies, the mere presence of which is not an indication for intervention; documentation of curve progression is a prerequisite for treatment. Initial evaluation should include investigations to diagnose concomitant genitourinary and cardiac anomalies primarily, and the morphology of the vertebral anomaly should be classified for prognostic purposes. Although sometimes considered only a delaying tactic, bracing treatment and casting can have definite value in controlling flexible congenital curves. Surgical options include prophylactic in situ fusion for the child with mixed vertebral anomalies involving ≤5 segments and a small curve. For young patients without coronal imbalance and ≤5 anomalous segments, a convex growth arrest/hemiepiphysiodesis can be effective for growth modulation, and it can be augmented with a concave growing rod, either traditional or magnetically controlled to improve balance and correction. Although traditional growing rod methods have been used for congenital scoliosis, crankshafting and adding-on may occur due to lack of apical fixation. Thus, apical control techniques have been recently added to traditional growing rod to minimize this cause of curve progression. Finally, an isolated hemivertebra excision with short segment fusion is a mainstay of treatment for progressive curves <50° in young children. In the more mature patient, generally at least 8 to 10 years old, a single definitive correction and fusion gives the most reliable outcomes.

Adolescent idiopathic scoliosis (AIS) is the most common spinal deformity of adolescence and disproportionately affects females, with outcomes strongly dependent on curve magnitude and timing of detection. Increasing evidence demonstrates that structural and systemic factors influence multiple stages of the AIS care continuum and may be the primary drivers of disparities in care amongst this population. This narrative review synthesizes contemporary evidence on sex- and race-based inequities in AIS, emphasizing structural drivers rather than biologic explanations for these disparities and highlighting priorities for future research. Studies examining presentation severity show heterogeneous results, but intersectional analyses consistently identify compounded disadvantage among Black adolescents with public insurance. Delayed detection and loss to follow-up emerge as central mechanisms linking social context to higher surgical rates and greater economic burden. In contrast, disparities in short-term postoperative complications appear attenuated after adjustment in many cohorts. However, differences in length of stay, hospital charges, and the geographic distribution of care persist, primarily related to patient race and insurance coverage. Most variation in findings across settings reflects differences in screening policies, insurance structures, and the socioeconomic indices used to characterize disadvantage, as well as limitations inherent to administrative databases and registry attrition. The available evidence indicates that structural and systemic factors, rather than biological factors, have a direct impact on disparate care in AIS. This impact is most noticeable at the initial stages of care, such as screening and diagnosis, where sociocultural and socioeconomic differences can affect patients' access to timely non-operative care. However, it seems once the decision to treat with surgery has been made, the previously existing disparities do not affect surgical outcomes but can affect long-term follow-up.

Purpose To explore how adolescents with congenital scoliosis receiving tertiary corrective care describe daily life, social relationships, emotional adaptation, and treatment. Materials/Methods Qualitative phenomenological interviews were conducted face-to-face in a Chinese tertiary referral hospital (Oct 2023 to Jan 2024). Adolescents aged 12–18 years were purposively sampled. Recordings were transcribed verbatim and analyzed using Colaizzi’s seven-step method with team coding and member checking. Results Eleven adolescents (mean age 14.6 years; 45.5% female) participated; nine had undergone corrective surgery. Four themes emerged: (1) surgery as restoration of participation (schooling, mobility, breathing comfort) despite perioperative fear, pain, and recovery burden; (2) function and quality of life prioritized over scarring, although some voiced appearance-related worries; (3) peer and family life described as largely ordinary, with overt stigmatization infrequently reported and often framed as minor; (4) emotional resilience and rejection of a tragedy framing, including contrasts between adolescent self-appraisal and adult worry. Conclusion In this tertiary-care cohort, adolescents centered participation and ordinariness more than stigma or sadness. Care and research should prioritize adolescent-defined outcomes and avoid presuming psychosocial distress as a default.

"Perioperative Vitamin D Repletion Is Associated With Improvement in SRS-22r Function Scores in Pediatric Patients With Idiopathic Scoliosis Undergoing Posterior Spinal Fusion and Instrumentation" by Umesh et al.

Adolescent idiopathic scoliosis (AIS) affects physical and psychosocial health, with treatments including surgery, bracing, and observation. However, the long-term effects on health-related quality of life (HRQoL) are still uncertain. The aim of the present study was to evaluate the long-term HRQoL outcomes in untreated AIS patients compared to those undergoing surgical or brace interventions through systematic review and meta-analysis. A systematic search was conducted across multiple databases (PubMed, Scopus, WoS, and Medline). Study quality was assessed using the Methodological Index for Non-randomized Studies (MINORS) tool, and evidence certainty was evaluated using the GRADE system. The primary outcomes of the meta-analysis were measured using SRS-22r and SF-12 scales for the assessment of HRQoL, evaluating domains including function, mental health, pain, self-image, and satisfaction after a minimum ten-year follow-up period. Eight studies published between 2010 and 2023 that assessed HRQoL after a follow-up period of ten years or more were included in the systematic review. Six studies were included in the meta-analysis. The observation group showed better outcomes in functional (MD 0.43, 95% CI 0.01-0.84) and mental health domains (MD 0.12, 95% CI 0.03-0.20) compared to the surgical group. No significant differences were found in pain, self-image, and satisfaction domains. Comparison between observation and brace groups showed equivalence across all domains. Evidence certainty ranged from moderate to low. Long-term HRQoL in AIS shows no clear benefit of surgery or bracing over observation, which may offer equal or better mental and functional outcomes. This supports personalized care. Further high-quality research is needed to strengthen the evidence base.

Letter to the Editor: The Effect of night-time Versus full-time Bracing on the Sagittal Profile in Adolescent Idiopathic Scoliosis: A Propensity score-matched Study.

Limited fusion strategy for congenital scoliosis: is it truly one and done?

Is multimodal monitoring effective in detecting neurological changes in cases of severe idiopathic scoliosis after halo gravity traction?: a series of 70 patients.

Evaluation of the relationship between unilateral condylar hyperplasia and idiopathic scoliosis.

An effective active self-correction in standing without external aids is possible in adolescents with idiopathic scoliosis: a cross-sectional study.

Bleeding management in adolescent idiopathic scoliosis: the role of low-dose tranexamic acid.

Instrumented scoliosis correction to T12/L1 can be a full correction (FC) of a single thoracic curve or a selective thoracic fusion (STF) where there is a significant lumbar curve. This study aims to evaluate the utility and feasibility of 3-dimensional (3D) EOS modelling to quantify pre- and post-operative axial plane changes in the uninstrumented lumbar spine. This study included patients undergoing primary surgery (2018-2021) for AIS Lenke 1 or 3, with the lowest instrumented level at T12-L1 and reconstructable EOS bi-planar images available pre-op, post-op, and at 1-year follow-up. EOS 3D modelling gives the apical rotation and mean rotation form T1-L5 from a neutral pelvis. Twenty patients (age 14.3; 7 Lenke 1A (FC), 13 Lenke 1B-3C (STF)) were included. Lumbar Cobb correction averaged 54% (1A), 41% (1B), and 21% (1C/3C). Neither the STF nor FC achieved notable correction of apical lumbar rotation (1A: -5%, p > 0.05, 1B; +0°, p > 0.05, 1C/3C; +2.5°, p > 0.05). Uninstrumented average L1-L5 rotation showed no significant change at 1 year for any curves. A significant correlation was observed between lateral bending Cobb angles and L1-L5 average rotation at one year (p < 0.05). Notably, EOS imaging measured greater axial rotation than PA x-rays, with differences normalising after accounting for pelvic parameters. EOS 3D modelling is valuable for visualising the mobile lumbar spine. Our models showed no significant correction of lumbar rotation, and a large impact from pelvic rotation on radiographic measurements. Increased curve flexibility may improve axial correction. The apparent reduction in lumbar rotation on plain radiographs is more likely attributable to pelvic rotation.

Robotic-assisted navigation (RAN) during posterior spinal fusion and instrumentation (PSFI) for pediatric patients with idiopathic scoliosis has been increasingly adopted over the traditional freehand (FH) technique due to enhanced accuracy. RAN requires either intraoperative or preoperative three-dimensional imaging or computed tomography (CT). Safety concerns, therefore, exist with regard to radiation exposure for the patient and surgeon, who have been shown to experience higher cancer rates than the general population. The objective of this study was to compare the mean intraoperative fluoroscopy radiation dosage and total perioperative radiation dosage between RAN and FH. One hundred and twenty-one patients with idiopathic scoliosis who underwent PSFI were included (41 FH, 80 RAN). Patients underwent FH pedicle screw placement with fluoroscopy assistance, or RAN (Mazor, Medtronic), using a preoperative CT and fluoroscopy-to-CT registration intraoperatively. The mean intraoperative fluoroscopy radiation dose in millisieverts (mSv) and total perioperative radiation dose (preoperative CT + intraoperative fluoroscopy) in mSv were compared by one-way analysis of covariance, controlling for preoperative curve magnitude, body mass index, and number of levels fused. Significance was set at P≤0.05. The mean intraoperative fluoroscopy dose was 0.5±0.2 and 0.4±0.1 mSv for FH and RAN, respectively. Mean cumulative radiation doses for FH and RAN were 0.5±0.2 and 12.5±4.7mSv, respectively. RAN had lower intraoperative radiation than FH (P<0.001), but FH had a significantly lower cumulative perioperative dosage than RAN (P<0.001). RAN had a 1.5-fold decrease in intraoperative radiation but a 25-fold greater total radiation compared with FH, representing lower radiation exposure to the surgeon but a much higher exposure to the patient. Literature demonstrates the potential efficacy of low-dose CT and, paired with our findings, suggests that there is room for improvement in radiation exposure in the robotic field. Surgeons must try to reduce radiation exposure for patients when feasible and reassess surgical practice and imaging protocols. Level III.

Scoliosis is a three-dimensional spinal deformity exceeding 10 degrees. Left untreated, it can lead to comorbidities, as well as surface deformity. Brace treatment is common in smaller curves (20-40 degrees), with strong evidence in adolescent idiopathic scoliosis (AIS), but overall effectiveness and impact on quality of life is controversial. This scoping review sought to map existing reviews on all aspects of bracing in scoliosis of any aetiology, to identify future research priorities. Searches were conducted in MEDLINE and EMBASE, excluding abstracts, narrative reviews and guidelines. Included articles reported on scoliosis patients of any age and aetiology and examined the use of spinal bracing. Four independent reviewers screened articles for inclusion and completed data extraction. Data were summarised narratively in themes, looking at effectiveness of bracing in AIS, patient factors influencing outcomes of AIS brace treatment, interventions to improve bracing success in AIS, patient and family experiences with bracing in AIS and bracing in adult and neuromuscular scoliosis. AMSTAR2 was used to assess confidence in the results in the reviews. Searches yielded 59 eligible studies which were included. Whilst bracing is recommended for curves 20°-40° in AIS, it may be successful in those over 40° with good compliance. Bracing is effective in lowering rates of curve progression in AIS and therefore reducing surgery rates. There is no strong evidence that one brace type produces superior outcomes over another, compared to other treatments. Brace adherence is associated with significantly lower rates of curve progression; this is affected by appearance, comfort and psychology. Evidence shows adherence improves with sensor monitoring and psychosocial interventions. Some evidence suggests in-brace correction can be predicted by curve flexibility. More remaining growth potential and associated factors (younger age, lower Risser stage, pre-menarchial, open triradiate cartilage) can increase the risk of curve progression during bracing. Scoliosis-specific exercises may be beneficial alongside brace treatment. Long-term QoL does not appear to be affected by brace treatment. Some low-quality evidence suggests reduced QoL during bracing compared to observation. Function may be impacted by brace treatment, but pain is not increased. In degenerative spinal deformity, there may be some shorter term benefit for pain and function. Little evidence on bracing in neuromuscular scoliosis exists. There is a large research base of evidence to support bracing for AIS; however, this base is limited due to the substantial amount of low-quality research it includes. The aim of this scoping review was to identify gaps in the literature to guide future research. This comprehensive review captured the breadth of existing review evidence on all aspects of bracing in scoliosis. Evidence supports bracing as an effective treatment in scoliosis, controlling curve progression, and often increasing patient satisfaction. Compliance is key, and measures such as compliance sensors can be effective. This scoping review has summarised the existing literature; however, the evidence base is limited. Further research could explore objective measures for compliance monitoring, optimal treatment protocols around brace cessation and effects of bracing on patient quality of life.

Bracing is the primary non-operative treatment for adolescent idiopathic scoliosis (AIS), with in-brace correction (IBC) being a key predictor of long-term success. Although BMI has been linked to bracing outcomes, it fails to capture important aspects of body habitus, such as fat distribution and torso shape, that influence brace fit and force transmission. This study aims to evaluate a novel radiographic measure, the lateral waist-to-height (WH) ratio, as a more accurate predictor of IBC in AIS patients. A retrospective review of AIS patients treated with Rigo-style braces between 2014 and 2024 at a single institution was conducted. Thoracolumbar (TL) height and waist width at the iliac crest were measured on AP and lateral radiographs to calculate WH ratios. Linear regression evaluated associations between IBC and BMI, WH ratios, and TL height change. Multivariate regression adjusted for major curve angle and curve apex. The study included 209 females (mean age 11.4±2.1y, BMI 17.7±2.8). Mean pre-brace major curve angle was 28.2±7.3 degrees, with average IBC of 64.8%±31.6%. Lateral WH ratio correlated positively with IBC (R=0.21, P=0.014), representing a weak but statistically significant correlation. By contrast, BMI and AP ratio did not demonstrate significant associations with IBC. In multivariate analysis, both major curve angle (P<0.001) and lateral WH ratio (P=0.009) were independent predictors of IBC. Lateral WH ratio offers a more holistic representation of body habitus than BMI and is independently associated with in-brace correction. These findings suggest that the lateral WH ratio may provide additional insight into brace fit and initial correction, warranting further study to determine its potential role in predicting long-term bracing outcomes in AIS. Level III.

Orthopedic device-related infection (ODRI) is a major postoperative complication encompassing a broad spectrum of clinical situations depending on the anatomical site, type of implanted material, and patient-specific factors. Despite their clinical significance, data on ODRIs in children are scarce and standardized management guidelines are lacking. Our aim was to characterize the clinical presentation, laboratory findings, microbiological characteristics, therapeutic management and outcomes of ODRIs in children. We conducted a retrospective, observational study at Montpellier University Hospital from January 2015 to June 2023. All children under 16 years with an ODRI diagnosis, defined as the presence of clinical signs requiring surgical revision, were included. Sixty-nine ODRI cases were analyzed. Initial surgical indications were: 25 fractures, 16 cases of nonidiopathic scoliosis (NIS), 12 of idiopathic scoliosis (IS) and 16 other orthopedic anomalies. Infections were polymicrobial in 35% of cases. Staphylococcus aureus (SA) was isolated in 39/69 cases, Gram-negative bacteria (GNB) in 13/69 cases and anaerobic bacteria in 9/69 cases (none on fracture cases). SA was involved in 72% of fracture-related ODRI. 50% of NIS were affected by GNB and 58% of IS by anaerobic bacteria. Empirical antibiotic treatment was mainly piperacillin/tazobactam and vancomycin (n = 38). Median duration of intravenously antibiotic therapy was 15 days [interquartile range (IQR) 10-18.5]. Median duration of total antibiotic therapy was 60 days (IQR 44.5-92), 46.5 days (IQR 42-61.75) with implant removal and 63.5 days (IQR 42.25-96.5) with implant retention. The cure rate in our cohort was 85%. SA is the first cause of ODRIs in children. GNB predominates in the case of NIS and anaerobic bacteria in the case of IS. Surgical indications and comorbidities are essential to determine antibiotic prophylaxis, antibiotic therapy and optimize their duration.

Demonstration of the importance of MRI in preoperative evaluation of adolescent idiopathic scoliosis.

The etiology of adolescent idiopathic scoliosis (AIS) remains unresolved. The human upright posture results in vertebral posterior inclination. It has been hypothesized that this can lead to increased posterior shear in the thoracolumbar spine depending on the actual inclination angle and facet joint orientation which in turn could lead to unlocking of facet joints. This would result in increased axial rotation and thereby the likelihood of overstraining the fibers of the anterior annulus fibrosus (AF). Potentially, these aspects may enhance the risk of AIS development and progression. In this population-based in silico study, we use novel computational techniques to examine how posterior vertebral inclination and facet joint orientation affect range of motion and AF fiber strain in a cohort of children with increased AIS risk. Finite element subject-specific models of the T11-T12 motion segment were created from MR images of 18 prepubescent girls. An axial compressive force representing the combined action of gravity and muscle forces together with axial rotation moment was applied at three posterior inclination angles (5°, 15°, 25°). Facet joint orientation was modelled as subject-specific, lumbar, or thoracic. Posterior inclination had little impact on the stiffness of the neutral zone. However, the fraction of fibers exceeding 15% strain increased from 14.5±9.3% at 5° to 18.7±12.4% at 25°. Transverse facet joint orientation angle highly correlated with the range of motion, but poorly correlated with fiber overstraining. Comparing the lumbar-oriented to the thoracic-oriented facet joints, fiber overstraining increased across all inclination degrees. This study showed that posterior inclination and increasing thoracic-like facet joint orientation increases AF fiber strains, providing further biomechanical evidence that helps understanding AIS development.