Treatment Of Adolescent Idiopathic Scoliosis Research Articles

A neglected point in surgical treatment of adolescent idiopathic scoliosis: Variations in the number of vertebrae.

Inaccurate identification of vertebral levels is the main cause of wrong-site spine surgery which is performed by nearly half of the spine surgeons. Unusual anatomy and failure to verify the surgical level on radiographs have been commonly reported. We aimed at investigating the variations in vertebral number in adolescent idiopathic scoliosis (AIS) patients and thus to raise awareness of the possibility for wrong-level spinal surgery and to make a comparison with normal adolescents. A cohort of 657 AIS patients and 248 normal adolescents, presented to our center from June 2008 to February 2013, who met the inclusion criteria, were recruited. Radiographs were reviewed to identify the number of thoracic or lumbar vertebrae and the presence of a lumbosacral transitional vertebra. In the AIS group, 70 (10.6%) patients had variations in the number of thoracic and/or lumbar vertebrae. Remarkably, the prevalence of variations in male subjects was significantly higher than that in female subjects (P < 0.05). Thirty-seven patients (5.6%) had an atypical number of thoracic vertebrae, with 33 having 11 thoracic vertebrae and 4 patients having 13. Forty-eight patients (7.3%) had an atypical number of lumbar vertebrae, with 14 having 4 lumbar vertebrae and 34 patients having 6. Multilevel vertebral anomalies were present in 2.3% of the patients (15 of 657). A variation in the number of vertebrae had been identified in 1.7% (11) of the reports by the radiologist. In the normal group, 27 (10.9%) subjects showed variations in the vertebral number. There was no significant difference in the prevalence of atypical numbers of vertebral number between the AIS and normal groups (P > 0.05). Therefore, we concluded that variations in the number of thoracic–lumbar vertebrae were found in up to10.6% of AIS patients. Identification of variations in the number of vertebrae is crucial to serve to decrease the risk of wrong-level surgery.

A Uniquely Shaped Rod Improves Curve Correction in Surgical Treatment of Adolescent Idiopathic Scoliosis.

A retrospective cohort study. The aim of this study is to determine the initial curve correction in patients surgically treated for adolescent idiopathic scoliosis (AIS) using either beam-like rods (BRs) or traditional circular rods (CRs). Posterior fusion using all pedicle screw instrumentation has become the standard for the surgical treatment of AIS. Traditionally, the rod is circular in the cross-sectional plane. Recent biomechanical studies suggest that a beam-like structure of the rod may enhance the stiffness of the construct and thereby possibly improve curve correction. Two consecutive series of patients surgically treated for AIS between May 2011 and May 2015 were included in the study. Patients were all treated with an ultralow profile all-pedicle screw implant system. In the first series, conventional 5.5 mm CoCr CR were used, and in the second series, 5.5 mm CoCr BR were used. Antero-posterior and lateral radiographs preoperatively and within seven days after surgery were used to measure the correction obtained. The first 60 patients were operated with CR and the subsequent 69 with BR. There was no statistical difference in age, gender, preoperative curve magnitude, Lenke type, or number of levels instrumented (P = 0.451). Major curve correction was significantly better in the BR group than in the CR group (66 vs. 57%) (P < 0.001). We found no difference in preoperative flexibility, secondary curve correction, sagittal balance, or coronal balance (P > 0.058). A postoperative decrease in thoracic kyphosis was seen with no significant difference between groups. Median T5-T12 change was -7° versus -3° for BR and CR, respectively (P = 0.051). A BR design results in a significantly better curve correction than conventional rods, but the difference is moderate and the clinical value is uncertain. 3.

Biomechanical Assessment of Providence Nighttime Brace for the Treatment of Adolescent Idiopathic Scoliosis

Study DesignBiomechanical study of the Providence brace for the treatment of adolescent idiopathic scoliosis (AIS). ObjectivesTo model and assess the effectiveness of Providence nighttime brace. Summary of Background DataProvidence nighttime brace is an alternative to traditional daytime thoracolumbosacral orthosis for the treatment of moderate scoliotic deformities. It applies three-point pressure to reduce scoliotic curves. The biomechanics of the supine position and Providence brace is still poorly understood. MethodsEighteen patients with AIS were recruited at our institution. For each patient, a personalized finite element model (FEM) of the trunk was created. The spine, rib cage, and pelvis geometry was acquired using simultaneous biplanar low-dose radiographs (EOS). The trunk surface was acquired using a three-dimensional surface topography scanner. The interior surface of each patient's Providence brace was digitized and used to generate an FEM of the brace. Pressures at the brace/skin interface were measured using pressure sensors, and the average pressure distribution was computed. The standing to supine transition and brace installation were computationally simulated. ResultsSimulated standing to supine position induced an average curve correction of 45% and 48% for thoracic and lumbar curves, while adding the brace resulted in an average correction of 62% and 64% (vs. real in-brace correction of 65% and 70%). Simulated pressures had the same distribution as measured ones. Bending moments on apical vertebrae were mostly annulled by the positioning in the supine position, and further overcorrected on average by 10% to 13%, but in the opposite direction. ConclusionsThe supine position is responsible for the major part of coronal curve correction, while the brace itself plays a complementary role. Bending moments induced by the brace generated a rebalancing of pressure on the growth plates, which could help reduce the asymmetric growth of the vertebrae. Level of EvidenceLevel II.

Adolescent Idiopathic Scoliosis

The effective treatment of adolescent idiopathic scoliosis (AIS) is predicted on timely detection and appropriate intervention. School screening programs have resulted in a reduced incidence of advanced curvature upon referral. Studies of the natural history of AIS demonstrate that a number of factors are of predictive value in assigning risk for progressive curvature and subsequent deformity and/or morbidity. These are age at time of diagnosis, stage of skeletal maturity, and magnitude and pattern of curvature. The options in treating AIS are observation, orthosis, and operation. Spinal orthoses are designed to arrest the progression of curvature during skeletal maturation. Newer brace designs and protocols facilitate compliance with long-term bracing and may reduce the incidence of curves requiring operative intervention. The goal in scoliosis surgery is to reduce curvature and to create a stable framework on which vertebral fusion can occur. Technical advances have yielded a number of instrumentation options for achieving this goal. Basic technical comparisons are made among of prototypes of posterior spinal instrumentation. The newest of these, Cotrel-Dubousset, may supplant Harrington rod instrumentation as the preferred standard in the operative treatment of AIS.

Three-dimensional correction for idiopathic scoliosis with posterior spinal fusion and the risk of neurological complications

Abstract Introduction The correction of adolescent idiopathic scoliosis (AIS) using the posterior approach is the most common and well-documented technique in medical literature. As with any invasive procedure, it carries the risk of potential neurological complications (NCs). Aim Evaluation of NCs after surgical treatment of AIS and patient satisfaction after surgery. Material and methods A retrospective evaluation of 195 patients operated in 2007–2013 with posterior approach and direct vertebral derotation. We evaluated the age of the patients during the surgery, the angle of the main curvature, the thoracic kyphosis, sex, BMI, the average length of stay in the hospital after surgery, the average percent curve correction, postoperative NCs, and SRS-22 at the final follow-up (FFU). Results The operated patients were 71% female. The average age was 16.5 years. The mean duration of surgery was 330 min. The average amount of blood loss was 820 mL. The average length of stay was 5.5 days. NCs were recorded as follows: numbness of the lateral femoral cutaneous nerve (6), muscle weakness of the lower limbs (5), paraesthesia of the foot (5), lower limb paraesthesia (5), radiculopathy (4), paraparesis (2), and neurogenic bladder (2). All NCs were eliminated in the postoperative period and at FFU, and there were no neurological deficits. SRS-22 scores at FFU were good. Conclusions (1) The rate of NCs is insignificant and left no lasting musculoskeletal dysfunction. (2) Number of complications was higher when we did not use neuromonitoring. (3) Total satisfaction after surgery at FFU was good.

Assessment of Intraoperative Blood Loss at Different Surgical Stages During Posterior Spinal Fusion Surgery in the Treatment of Adolescent Idiopathic Scoliosis.

Prospective clinical study. To analyze the amount of blood loss at different stages of Posterior Instrumented Spinal Fusion (PSF) surgery in adolescent idiopathic scoliosis (AIS) patients. Knowing the pattern of blood loss at different surgical stages may enable the surgical team to formulate a management strategy to reduce intraoperative blood loss. One hundred AIS patients who underwent PSF from January 2013 to December 2014 were recruited. The operation was divided into six stages; stage 1-exposure, stage 2-screw insertion, stage 3-release, stage 4-correction, stage 5-corticotomies and bone grafting, and stage 6-closure. The duration and blood loss at each stage was documented. The following values were calculated: total blood loss, blood loss per estimated blood volume, blood loss per minute, blood loss per vertebral level fused, and blood loss per minute per vertebral level fused. There were 89 females and 11 males. The mean age was 17.0 ± 5.8 years old. Majority (50.0%) were Lenke 1 curve type. The mean preoperative major Cobb angle was 64.9 ± 15.0°. The mean number of levels fused was 9.5 ± 2.3 levels. The mean operating time was 188.5 ± 53.4 minutes with a mean total blood loss 951.0 ± 454.0 mLs. The highest mean blood loss occurred at stage 2 (301.0 ± 196.7 mL), followed by stage 4 (226.8 ± 171.2 mL) and stage 5 (161.5 ± 146.6 mL). The highest mean blood loss per minute was at stage 5 (17.1 ± 18.3 mL/min), followed by stage 3 (12.0 ± 10.8 mL/min). The highest mean blood loss per vertebral levels fused was at stage 2 (31.0 ± 17.7 mL/level), followed by stage 4 (23.9 ± 18.1 mL/level) and stage 5 (16.6 ± 13.3 mL/level). All stages were significant contributors to the total blood loss except exposure (stage 1) and closure (stage 6). Blood loss per minute and blood loss per minute per level was highest during corticotomies (stage 5), followed by release (stage 3). However, the largest amount of total blood loss occurred during screw insertion (stage 2). 2.

Supine Lateral Bending Radiographs Predict the Initial In-brace Correction of the Providence Brace in Patients With Adolescent Idiopathic Scoliosis.

Retrospective, cross-sectional. To determine the initial curve correction of the providence brace (PB) and to determine to what extend the in-brace Cobb angle corresponds to the curve seen on supine lateral bending radiographs (SLBR). SLBR are used to assess curve flexibility in patients undergoing surgical treatment for adolescent idiopathic scoliosis (AIS). A low rate of in-brace correction (IBC) has been associated with a higher risk of curve progression, but to what extent SLBR can be used to predict IBC before initiating bracing treatment is unknown. All patients with AIS treated with the PB from January 1, 2006 to December 31, 2013 with a major curve of 25 to 45 degrees° were included. Cobb angle on SLBR before treatment and on initial standing, in-brace radiograph (IBR) were measured twice for each patient by one observer 30 days apart. Using a repeated measure mixed effect model, mean difference and 95% limits of agreement (LOA) between Cobb angles on each type of radiograph were estimated. Correction index (CI) was calculated as: curve flexibility (%)/curve correction (%). A total of 127 patients were included. Mean long-standing Cobb angle was 35° (SD: 6°), which was reduced to mean 13° (SD: 8) on IBR (P < 0.05). No difference in curve correction between curve types was found when adjusting for flexibility using correction index (P = 0.77). Overall mean difference between SLBR and IBR was 0.2° (LOA ± 10°). Mean difference for thoracic curves was 0.2° (LOA ± 8°), for thoracolumbar/lumbar curves 0.9° (LOA ± 10°) and for double major curves 0.4° (LOA ± 16). SLBR provide a close estimation to the expected in-brace correction with a mean difference of less than one degree. SLRB could potentially serve as prognostic parameter for curve progression before initiating brace treatment. 3.

Video-Assisted Thoracoscopic Surgery (VATS) for Anterior Release of Rigid Thoracic Scoliosis

Introduction Standard anterior approach to the dorsal spine using thoracotomy carries a great morbidity; video-assisted thoracic surgery (VATS) has been used as a less invasive approach for many intrathoracic disease processes; among which anterior releases in rigid dorsal scoliosis. The authors performed (VATS) in patients with Adolescent Idiopathic Scoliosis (AIS), attempting to reduce the morbidity attributable to standard open thoracotomy surgery for anterior curve release; reporting their experience with thoracoscopy as part of the treatment for adolescent idiopathic scoliosis with rigid thoracic curves. Material and Method: A prospective randomized study of 34 cases of AIS with rigid thoracic curves underwent VATS for anterior release surgery between March 2008 and April 2013 was performed. The ages of the patients ranged from 11 to 27 years with a mean of 16.3 +/− 4.2 SD years. Spinal flexibility was assessed by the fulcrum bending technique. Cobb angle before and after the anterior release was compared. All patients had an anterior spinal release and posterior spinal fusion at two separate surgeries to evaluate the flexibility after anterior release without posterior instrumentation. Results The average follow up ranged from 22.3 to 39.2 months (mean 30.33 +/− 4.64 SD months). The mean preoperative Cobb angle was 78.4° +/− 8.87° SD on standing radiographs and 70.3° +/− 8.48° SD with the fulcrum-bending radiograph. After anterior release, the fulcrum bending radiograph showed reduction of mean Cobb angle to mean angle of 41.6° +/− 6.98°. The mean fulcrum bending flexibility index was improved from 10.41% +/− 3.97 SD (prior to VATS release) to 46.97% +/− 5.23 SD after release. VATS was successfully completed in all patients without major morbidities. The mean operative time for the anterior procedure was 123.96 minutes +/− 28.77 SD. The average number of excised discs was four. Conclusion Anterior spinal release using VATS may reduce postoperative morbidity and produces satisfactory degree of flexibility for rigid thoracic curves. It can be considered as a good and safe alternate to open thoracotomy for anterior release.

The Convex Manipulation: An Alternative Technique in Surgical Treatment of Adolescent Idiopathic Scoliosis

Introduction Concave derotation is the traditional correction maneuver in adolescent idiopathic scoliosis surgery. However, the positioning of thoracic pedicle screws at concave side of the curve can be quite challenging, because of the small pedicle size and the wide variation in its morphological characteristics, due to the vertebral dystrophy observed in scoliotic patients. Then, to reduce risks of neural damages, and ensure the same strenght of derotation maneuver, a convex manipulation through an all-level pedicle screws convex instrumentation can be performed. We report perioperative and 2-year results in a consecutive series of patients treated by convex manipulation through an all-level pedicle screws convex instrumentation. Material and Methods From January 2013 to January 2015 we surgical treated 36 consecutive patients (28 F, 8 M, mean age 13 years) affected by thoracic adolescent idiopathic scoliosis (Lenke type 1, 27 patients, and Lenke type 2, 9 patients). Mean pre-operative Cobb angle was 56°±6° in Lenke type 1 group and 51°±4° plus 32°±3° in Lenke type 2 group. We performed a posterior access only in all patients using polyaxial pedicle screws at each level on the convex side of the curve. Derotation and manipulation maneuvers were performed on the convex prebent rod. In all cases motor-evoked potentials monitoring was used. Mean follow-up time was 27 months. Results The average percentage of coronal correction was 76 ± 5% (mean post-operative Cobb angle 15°±4°), with no neurological complications. Concerning the post-operative kyphosis, we observed a slight decrease of mean values compared with pre-operative measurements (mean reduction of thoracic kyphosis 5°±2°). At 2-year follow-up no changes in coronal nor in sagittal plane were observed. The mean operative time was 210 ± 30 minutes, with a mean blood loss of 500 ± 100 ml. Using the free-hand technique, the mean time of pedicle screws positioning in the thoracic area on the convex side was 2 ± 1 minutes from T6 to T12, and 4 ± 1 minutes from T3 to T5. Whenever included in the area of arthrodesis, T2 was usually instrumented with the Universal Clamps, to reduce the stiffness of the construct. Instead, T1 has never been included in the arthrodesis area. Conclusion This case-series study shows the effectiveness and the safety of convex manipulation in Lenke type 1 and type 2 scoliosis. The coronal correction obtained with this technique is comparable to that obtained with the traditional concave derotation. Other advantages are the short operative time, the low intra-operative blood loss and, mostly, a lower risk of neurological complications.

Selection of Lowest Instrumented Vertebra in the Management of Thoracolumbar and Lumbar Adolescent Idiopathic Scoliosis using Pedicle Screw Instrumentation

Introduction The aim of surgical treatment for adolescent idiopathic scoliosis (AIS) is correction of the three dimensional deformity, achievement of stability and preservation of as many distal motion segments as possible. In Thoracolumbar/ Lumbar adolescent idiopathic scoliosis (TL/L AIS) correction of C-shaped coronal curve into S-shaped saggital curve is a considerable challenge to a spine surgeon. In this regard, selection of Lowest Instrumented Vertebra (LIV) is of particular importance and remains controversial in literature. We conducted a retrospective study involving Lenke V patients to determine the exact distal fusion level (LIV) in the management of thoracolumbar/lumbar adolescent idiopathic scoliosis (TL/L AIS) using pedicle screw instrumentation. Material and Methods Analysis of radiographic parameters of 32 TL/L AIS was done. The patients were grouped according to the Lowest Instrumented Vertebra; Group I (fusion to L3, n = 25) and Group II (fusion to L4, n = 7). The Group I was subdivided into Group IA (L3 crosses the mid-sacral line with rotation of less than grade II on bending films, n = 14) and Group IB (L3 does not cross the mid-sacral line or rotation is grade II or more on bending films, n = 11). All of the patients in the Group II had the same location and rotation of L3 in bending films as that of patients in the Group IB. Patients with lowest instrumented vertebral tilt (LIVT) of more than 10° or coronal balance of more than 15 mm were considered to have unsatisfactory results. Results In these 3 groups, there was a significantly lesser correction in the TL/L curve and LIVT in the Group IB. Unsatisfactory results were obtained in 1 patients (7.1%) of the Group IA, in 7 patients (63.3%) of the Group IB, and in 1 patient (12.5%) of the Group II, which was found to be statistically significant. Conclusion In TL/L AIS patients undergoing treatment with pedicular screw instrumentation, the curve can be fused to L3 with good radiographic outcomes when L3 crosses the mid-sacral line with rotation of less than grade II on bending films. Otherwise, L4 should be selected as the Lowest Instrumented Vertebra.

The Apifix Automatic Self-Correction Technique for Adolescent Idiopathic Scoliosis at 1 ½ Years Follow-Up: A Preliminary Report

Introduction To present a new system for the treatment of adolescent idiopathic scoliosis and the first outcomes. Material-Methods: The new system (Apifix) is an automatic self-correction system, which is fixed by two transpendicular screws on the convex side of the apex of the curve. This system has been used in 4 adolescents with progressive scoliosis of 32°-42°. No blood transfusion was needed. The surgical time was ~1 hour, and the hospital stay was one day. After three weeks, a special program of physiotherapy was started to expand further the system. The Cobb angle, the parameters of sagittal balance and the vertebra rotation (using Nash-Moe technique), has been evaluated during a follow-up of 1 ½ years. Results The Cobb angle average improved from 37° to 18,2°. Immediately postoperatively a scoliosis improvement of 13,7° (range: 17°-12°) was noted, and after the physiotherapy other 5° (range: 1°-8°) of improvement was achieved. The sagittal balance parameters remained unchanged. A spontaneous vertebra derotation average from 39,1% to 28,6% was noted using Nash-Moe evaluation. Conclusions The first outcomes of the use of this system are encouraging but further research in more patients, and in longer follow-up is needed. This system offers an option between conservative treatment and spinal posterior fusion to be used as an internal brace.

Is There a Difference in Outcome between Top and Side Loading Instrumentation System Used for the Surgical Treatment of Adolescent Idiopathic Scoliosis (AIS)

Introduction Different Instrumentation systems has been developed for the surgical correction of Adolescent idiopathic Scoliosis (AIS) with different deformity correction techniques. Material and Method: The purpose of this retrospective study was to compare top loading to side-loading instrumentation systems used in the surgical treatment of AIS looking at the clinical, functional and radiological outcomes as well as the cost difference between different systems. Thirty matched surgically treated female patients were assigned to 2 groups, group one were treated using a top loading system and in group 2 a side-loading spinal instrumentation system was used. The groups were evaluated for curve magnitude, percent correction, functional outcome using the scoliosis research society questionnaire-30. Results both groups were similar in their demographic data, preoperative clinical and functional variables. The cost of instrumentation was significantly higher in group 2. At 2 years follow up: both groups have significant improvement in all domaines of Scoliosis Research Society score-30. Group 1 had a better (not significant) correction of the rib hump and both groups had similar percent correction of the main curve. Conclusion The surgical treatment of AIS with side loading systems was significantly more expensive but had statstically similar functional and radiographic results to the top loading system. The top loading system achieved better correction of the rib hump.

Prevalence and Significance of Vitamin D deficiency in Patients with Idiopathic Scoliosis Requiring Corrective Surgery

Introduction Vitamin D deficiency may affect children in terms of growth disturbance, deformity and metabolic disease. The senior authors have felt significant difference in bone quality intra operatively and wondered if vitamin D status was relevant in this. The aim was to assess the prevalence of vitamin D deficiency in a cohort of patients undergoing scoliosis correction surgery for adolescent idiopathic scoliosis (AIS) and to assess if Vitamin D deficiency had any significance/correlation to the pre-operative cobb angle or pain scores. Material and Methods Any patient undergoing corrective surgery for AIS who had pre-operative Vitamin D sample taken. From January to December 2014 a total of 69 records were assessed yielding a cohort of 41 patients undergoing surgery for Adolescent Idiopathic Scoliosis (AIS) with a recorded pre-operative total 25-OH vitamin D level. Three tiers of Vitamin D level were assessed including normal &gt; 50nmol/L, insufficiency &lt; 50 but &gt; 25nmol/L and deficiency &lt; 25nmol/L as per local guidelines for Vitamin D deficiency in children. Patients' age, sex, pre-operative vitamin D levels, Cobb angles at time of surgery, pre-operative back pain scores were recorded. Results 41 Children with a recorded Vitamin D level pre-operatively were analyzed. There were 4 male and 37 females. The average age at surgery was 15 years,(range 12 – 17). Of the 41 patients 9 (22%) were Vitamin D Deficient (range 10–25), 14 (34%) were insufficient (range 29.3–49.8) and 18 (44%) were above the treatment level (range 54.8 – 139.1). The average pre-operative Cobb angle for the deficient patients was 68 (range 50–89) compared with 64 (range 48 – 85) for the insufficient patients and 62 (range 44–76) for the patients with normal Vitamin D levels. The pain scores for each of the 3 groups revealed that the patients in each group complained of a similar (moderate) amount of back and rest pain pre-operatively. Conclusion Vitamin D deficiency in children leads to reduced calcium absorption from the bowel and may lead to skeletal deformity and rickets. The effect on bone healing of Vitamin D deficiency may have an affect on the quality of spinal fusion required as part of the surgical treatment for AIS and it is not known whether those patients undergoing surgery have adequate levels. This study reveals that 56% of patients had Vitamin D levels requiring supplementation. Further work is being undertaken to evaluate pain values, fusion time and deformity correction in those children with insufficient or deficient levels of vitamin D.post-op complications and hospitalisation

A Genetic Test Predicts Providence Brace Success for Adolescent Idiopathic Scoliosis When Failure Is Defined as Progression to >45 Degrees.

Retrospective cohort. To determine whether a genetic test is associated with successful Providence bracing for adolescent idiopathic scoliosis (AIS). Genetic factors have been defined that predict the risk of progression of AIS in a polygenic fashion. From these data, a commercially available genetic test, ScoliScore, was developed. It is now used in clinical practice for counseling and to guide clinical management. Bracing is a mainstay of treatment for AIS. Large efforts have been made recently to reduce potential confounding across studies of different braces; however, none of these have considered genetics as a potential confounder. In particular, ScoliScore has not been evaluated in a population undergoing bracing. We conducted a retrospective cohort study in which we identified a population of AIS patients who were initiated with Providence bracing and followed over time. Although these patients did not necessarily fit the commercial indications for ScoliScore, we contacted the patients and obtained a saliva sample from each for genetic analysis. We then tested whether ScoliScore correlated with the outcome of their bracing therapy. We were able to contact and invite 25 eligible subjects, of whom 16 (64.0%) returned samples for laboratory analysis. Patients were followed for an average of 2.3 years (range, 1.1-4 y) after initiation of the Providence brace. Eight patients (50.0%) progressed to >45 degrees, whereas the other 8 patients (50.0%) did not. The mean ScoliScore among those who progressed to >45 degrees was higher than that among those who did not (176 vs. 112, P=0.030). We demonstrate that a genetic test correlates with bracing outcome. It may be appropriate for future bracing studies to include analysis of genetic predisposition to limit potential confounding.

Characteristics of patients with more than 20° of improvement or worsening during conservative treatment of adolescent idiopathic scoliosis.

Since the beginning of history of Medicine, it has been possible to learn from the worst and best results of treatments. Our aim was to verify which patients can reach the best and worst results during conservative treatment. All AIS patients with more than 2 visits included in a prospective clinical database started in September 2003 were reviewed on August 31st 2010. A cut-off of 20 degrees (improvement or worsening) from the first observation was used to select patients. Patients were analysed for diagnosis, morphology, Cobb degrees at start, curve improved/worsened, treatment, gender, Body Mass Index, clinical parameters. Out of 1886 consecutive patients, 62 (3.3%) changed 20° or more: 26 (1.4%) improved (range 20-34°), 36 (1.9%) progressed (20-60°). Relative Risk of progression of 20° or more was increased more than 10 times in cases of thoracic curve or secondary scoliosis, 5 times for Moe scoliosis and BMI <15 kg/mq, 3 times for age <12 years, and congenital or juvenile scoliosis. Relative Risk of improvement of 20° statistically was increased more than 3 times in cases of previous exercises, female gender, thoracolumbar curve or scoliosis, ISICO treatment, and age <12 years. Not all our results correspond to the usually reported prognostic factors in ample case series, but it must be taken into account that only wide variations (20° or more) have been considered here. In this population we had 1.9% of patients who improved at least 20° with conservative treatment, and this is notable as well. Finally, since these results are not similar to what would be expected according to the known natural history, conservative treatment appears able to change it.

Thoracoplasty in the surgical treatment of adolescent idiopathic scoliosis.

A consecutive series of 40 adolescents surgically treated between 1998-2001, by posterior spinal fusion and thoracoplasty were compared with a similar group of 40 adolescents treated in the same period by posterior only segmental fusion. Clinical and radiographic analysis was performed, including the SRS-30 questionnaire and Pulmonary Function Tests (PFT). Minimum five years follow-up was requested. No statistical differences were found between the two groups in PFT's both pre-operatively and at latest follow up. Our findings suggest that thoracoplasty did not adversely affected long-term PFT's in AIS patients treated by posterior spinal fusion alone.

Progress of gait analysis in adolescent idiopathic scoliosis

Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spine, which not only affects spinal anatomy, mobility and trunk symmetry, but also leads to the changes of human locomotion through pelvic. During the past 30 years, though great progress has been made in the treatment of AIS, the pathogeny of AIS is still uncertain. Most scholars believe that many factors contribute to the pathogeny of AIS, however, some studies have shown that poor posture during walking and poor manage of balance could lead to the progress of scoliosis. Gait is a behaviour characteristic during walking, and normal gait is the result of nervous system, musculoskeletal system, proprioception and vision. Any disease of the system above may cause abnormal gait. Gait analysis can spot the key links and impact factors of abnormal gait by observing and measuring the testers' walking, reflect the abnormal gait objectively and quantitatively, and provide reference opinions for the recovery and treatment of patients. At present, gait analysis has been mostly applied in hemiplegia, cerebral palsy and knee osteoarthritis. In recent years, gait analysis has been increasingly used in AIS patients. There have been many researches about the kinematics and kinetics of gait analysis in adolsecent idiopathic scoliosis abroad and some positive results have been reported. But in China, it's still in the initial stage. We reviewed the published papers about gait analysis in AIS patients, and summarized the kinematics, kinetics and different means of intervention on gait in AIS patients. We hope it will provide references for our researches.

Role of Intraoperative Radiographs in the Surgical Treatment of Adolescent Idiopathic Scoliosis.

One of the main goals of scoliosis surgery is to obtain a balanced fused spine. Although preoperative planning remains essential, intraoperative posteroanterior radiographs are the only available tool during the procedure to verify shoulder and coronal spinal balance and, if necessary, adjust the construct. The aim of this study was to quantify the direct influence of intraoperative radiographs on the surgical procedure itself during correction of adolescent idiopathic scoliosis. Retrospective analysis of prospectively collected data on a monocentric cohort of adolescent idiopathic scoliosis patients undergoing corrective surgery. A total 148 consecutive patients operated in the same department following the same validated preoperative planning method were included in this prospective radiologic study. The mean follow-up averaged 33 months. Frontal Cobb angles, T1 tilt, shoulder tilt, iliolumbar angle, and frontal balance were measured and compared on intraoperative, early postoperative, and latest follow-up radiographs. Any intraoperative modification of the correction performed after analysis of the intraoperative radiograph were recorded. The analysis of all radiologic parameters was possible in 90.5% of the cases. In 9.5% of the cases, shoulders could not be properly distinguished. Significant modifications on the upper thoracic curve to correct T1 tilt or shoulder balance were performed in 29% of the patients, and changes at the distal levels were recorded in 19%, underlining planification imperfections. On postoperative standing radiographs, the average coronal parameters were neutral, without loss of correction at follow-up. Intraoperative radiographs remain necessary to ensure compensation of the shortcomings of the modern preoperative planification method.

Effectiveness of braces designed using computer-aided design and manufacturing (CAD/CAM) and finite element simulation compared to CAD/CAM only for the conservative treatment of adolescent idiopathic scoliosis: a prospective randomized controlled trial.

Clinical assessment of immediate in-brace effect of braces designed using CAD/CAM and FEM vs. only CAD/CAM for conservative treatment of AIS, using a randomized blinded and controlled study design. Forty AIS patients were prospectively recruited and randomized into two groups. For 19 patients (control group), the brace was designed using a scan of patient's torso and a conventional CAD/CAM approach (CtrlBrace). For the 21 other patients (test group), the brace was additionally designed using finite element modeling (FEM) and 3D reconstructions of spine, rib cage and pelvis (NewBrace). The NewBrace design was simulated and iteratively optimized to maximize the correction and minimize the contact surface and material. Both groups had comparable age, sex, weight, height, curve type and severity. Scoliosis Research Society standardized criteria for bracing were followed. Average Cobb angle prior to bracing was 27° and 28° for main thoracic (MT) and lumbar (L) curves, respectively, for the control group, while it was 33° and 28° for the test group. CtrlBraces reduced MT and L curves by 8° (29%) and 10° (40%), respectively, compared to 14° (43%) and 13° (46%) for NewBraces, which were simulated with a difference inferior to 5°. NewBraces were 50% thinner and had 20% less covering surface than CtrlBraces. Braces designed with CAD/CAM and 3D FEM simulation were more efficient and lighter than standard CAD/CAM TLSO's at first immediate in-brace evaluation. These results suggest that long-term effect of bracing in AIS may be improved using this new platform for brace fabrication. NCT02285621.

The effectiveness of the SpineCor brace for the conservative treatment of adolescent idiopathic scoliosis. Comparison with the Boston brace

Background ContextThe Boston brace (Bb) is the most widely used brace design to treat adolescent idiopathic scoliosis (AIS). The dynamic SpineCor (SC) brace is prescribed in several scoliosis clinics worldwide, but its effectiveness remains controversial. PurposeThe study aimed to compare the treatment effectiveness of SC in patients with AIS treated by the developers of the brace with that of the Bb at a single institution. Study Design/SettingThis is a retrospective comparison between a cohort of AIS patients treated using the SC brace and a cohort treated using the Bb. Patient SampleWe assessed 243 patients treated with either Bb or SC brace to prevent the progression of AIS. Outcome MeasuresThe primary outcome was the progression in main Cobb angle when reaching one of the following end point criteria: (1) progression in Cobb angle of ≥6°, (2) main Cobb angle of ≥45°, (3) surgery undertaken, or (4) reaching skeletal maturity (Risser sign of 5 or growth of <1 cm in the previous 6 months). MethodsPatients were identified at a single institution between 2000 and 2012 following the Scoliosis Research Society criteria for brace treatment: (1) diagnosis of AIS, (2) Risser sign of ≤2, (3) curve magnitude between 25° and 40°, and (4) age ≥10 years. A total of 97 patients treated with SC by the developers of the brace and 146 patients treated with Bb were identified. Data collection and radiograph measurements were performed by a single experienced nurse not involved in the decision-making for brace treatment or in the data analysis. Age and Risser sign at onset of treatment, initialmain Cobb angle, curve type, and duration of follow-up were similar in both cohorts. Statistical analysis was done using chi-square and logistic regression models, with a level of significance of .05. ResultsThe average progression was 14.7°±11.9° in the SC cohort compared with 9.6°±13.7° in the Bb cohort (p=.003). The average Cobb angle at the end point of the study reached 47°±13° in the SC cohort and 41.7°±14.2° in the Bb cohort (p=.005), whereas at the onset of bracing it was 32.2°±4.9° and 32.2°±4.4°, respectively, for the SC and Bb cohorts. The percentage of patients with a progression of ≥6° was 76% in the SC cohort and 55% in the Bb cohort (p=.001). The proportion of patients reaching 45° in the SC and Bb cohorts was, respectively, 51% and 37% (p=.03), whereas the proportion of patients referred to surgery was 39% and 30%, respectively, for the SC and Bb cohorts (p=.2). The odds of progressing ≥6° and of reaching ≥45° were 2.67 and 2.07 times greater, respectively, when using the SC brace. ConclusionsThe SC brace did not prevent curve progression as effectively as the Bb. Although it has the potential benefit of increasing mobility during brace wear, the SC brace was associated with increased curve progression in comparison with the Bb. There is also a trend for increased risk of requiring surgery when the SC brace is worn.