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Concept: Scoliosis


BACKGROUND: This study investigated the incidence, imaging characteristics and mechanical factors in scoliotic patients with pectus excavatum. METHODS: A total of 142 scoliostic patients with pectus excavatum were evaluated prior to operation. The evaluation included a complete physical exam, phenotype and severity of the pectus excavatum, incidence and severity of scoliosis, and analysis of radiological images, including calculation of the Haller index. RESULTS: Twenty five out of 142 patients (17.61%) with pectus excavatum had scoliosis with a Cobb angle >10 degrees, and in 80.00% of the cases the spinal column was bent to the right. Seventeen patients had bent-to-the-right spines that involved the 6th to 10 th thoracic vertebrae. We found that 23 out of 25 patients with a Cobb angle more than 10 [degree sign] were teenagers and adults. The incidence of scoliosis was only 6.06% in the children under 11 years whereas it was 21.79% in the teenage group. CONCLUSIONS: Mechanical forces appear to play a role in the coexistence of pectus excavatum and scoliosis. There is a relationship between age, severity (Haller index), asymmetry and scoliosis. The heart and mediastinum play a role in providing an outward force to the left of the sternum which may be an important reason for the coexistence of pectus excavatum and scoliosis, but the correlation needs further proof.

Concepts: Vertebral column, Pectus excavatum, Haller index, Chest, Degree, Sternum, Scoliosis


Background The role of bracing in patients with adolescent idiopathic scoliosis who are at risk for curve progression and eventual surgery is controversial. Methods We conducted a multicenter study that included patients with typical indications for bracing due to their age, skeletal immaturity, and degree of scoliosis. Both a randomized cohort and a preference cohort were enrolled. Of 242 patients included in the analysis, 116 were randomly assigned to bracing or observation, and 126 chose between bracing and observation. Patients in the bracing group were instructed to wear the brace at least 18 hours per day. The primary outcomes were curve progression to 50 degrees or more (treatment failure) and skeletal maturity without this degree of curve progression (treatment success). Results The trial was stopped early owing to the efficacy of bracing. In an analysis that included both the randomized and preference cohorts, the rate of treatment success was 72% after bracing, as compared with 48% after observation (propensity-score-adjusted odds ratio for treatment success, 1.93; 95% confidence interval [CI], 1.08 to 3.46). In the intention-to-treat analysis, the rate of treatment success was 75% among patients randomly assigned to bracing, as compared with 42% among those randomly assigned to observation (odds ratio, 4.11; 95% CI, 1.85 to 9.16). There was a significant positive association between hours of brace wear and rate of treatment success (P<0.001). Conclusions Bracing significantly decreased the progression of high-risk curves to the threshold for surgery in patients with adolescent idiopathic scoliosis. The benefit increased with longer hours of brace wear. (Funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and others; BRAIST number, NCT00448448 .).

Concepts: Epidemiology, Randomized controlled trial, Scoliosis, Randomness, Arthritis, The Adolescents, Statistical terminology, Odds


The purpose of this study is to review our operative experience of congenital kyphosis or kyphoscoliosis undergoing either pedicle subtraction osteotomy (PSO) or posterior vertebral column resection (pVCR) according to certain criteria we have established.

Concepts: Vertebral column, Scoliosis, According to Jim, Vertebra, Skeletal disorders, Lordosis, Kyphosis, Kyphoscoliosis


STUDY DESIGN.: Meta-analysis on mid- to long-term outcomes in adolescent idiopathic scoliosis after instrumented posterior spinal fusion. OBJECTIVE.: To compare mid- to long-term outcomes and complications of the most commonly used instrumentation systems in adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA.: A meta-analysis of mid- to long-term results of different methods of instrumentation, including the most currently used all-pedicle screw construct, is lacking. METHODS.: A structured literature review was conducted for studies concerning management of patients with adolescent idiopathic scoliosis with instrumented posterior fusion. Pooled means, standard deviations, and sample sizes were either identified or calculated on the basis of the results of each study. RESULTS.: Meta-analyses were performed on outcomes from 27 studies. Overall, 1613 patients who had been treated with Harrington rods, 361 patients who had undergone Cotrel-Dubousset instrumentation, and 298 patients who managed with all-pedicle screw constructs were reviewed. The mean follow-up was 14.9 years. Cotrel-Dubousset and pedicle screw instrumentations achieved a significantly greater degree of correction of the thoracic curve than Harrington rods (40.3° vs. 14.7°; P < 0.001 and 21.9° vs. 14.7°; P = 0.005, respectively). Cotrel-Dubousset technique achieved a significantly higher degree of correction than all-pedicle screw construct in both the thoracic (40.3° vs. 21.9°, respectively; P < 0.001) and lumbar curves (37.2° vs. 16°, respectively; P < 0.001). Similarly, Cotrel-Dubousset construct achieved a greater correction of both thoracic kyphosis (33.5° vs. 23°, respectively; P < 0.001) and lumbar lordosis (46° vs. 50.7°, respectively; P = 0.002) than pedicle screws. All-pedicle screw fixation was associated with the lower risk of pseudarthrosis, infection, neurological deficit, and reoperation. CONCLUSION.: This study confirms the negative effect of Harrington rods on sagittal alignment. We further found that the degree of correction in the coronal and sagittal planes was higher after Cotrel-Dubousset instrumentation than all-pedicle screw fixation. All-pedicle screw constructs offered the lower risk of mid- to long-term complications and revision surgery.

Concepts: Vertebral column, Scoliosis, Lordosis, Spinal fusion, Kyphosis, Scheuermann's disease, Kyphoscoliosis, Harrington implant


STUDY DESIGN.: Prospective case series study. OBJECTIVE.: To study the effect of percutaneous thoracoplasty-only procedure on curve pattern in mature adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA.: The rib hump prominence on the convex side is the major cosmetic concern among patients with AIS. Thoracoplasty combined with spinal fusion is a commonly used procedure in scoliosis. However, there are no studies regarding the effect of isolated thoracoplasty procedure on curve pattern in skeletally matured patients with AIS. METHODS.: The study involved 7 skeletally matured female patients with AIS. The convex rib hump deformity was measured preoperatively using hump height and hump angle. We performed thoracoplasty without spinal fusion in patients with the Cobb angle less than 40° but with prominent hump deformity. Thoracoplasty was performed percutaneously using 1 or 2 transverse incisions along the rib hump, and apex portions of the deformed ribs were resected. The Cobb angle was measured before surgery, immediately after surgery, and at final follow-up visit. In all cases, clinical satisfaction was assessed using the Scoliosis Research Society Instrument (SRS-22 questionnaires) and trunk appearance perception scale before surgery and at final follow-up visit. RESULTS.: The mean patient age was 20.24 years and an average of 4 ribs were resected. The mean preoperative hump height and hump angle of 38.14 mm and 14.14° improved to 11.70 mm and 11.42° respectively, after surgery (P = 0.018 and 0.042). Preoperative and the final follow-up mean Cobb angles were 35.43° and 45.00°, respectively (P = 0.028). On average, the mean thoracic curve progressed by 9.57°. Preoperative Scoliosis Research Society Instrument SRS-22 questionnaires and trunk appearance perception scale scores of 4.09 and 2.57 respectively improved to and 4.26 and 3.66 after surgery (P = 0.126 and 0.014). CONCLUSION.: Percutaneous thoracoplasty-only procedure gives significant rib humps correction and satisfactory clinical outcome. However, progression of the curve was observed after surgery. This suggests that the convex ribs function as a buttress for curve progression.

Concepts: Vertebral column, Scoliosis, Arithmetic mean, Paul Randall Harrington, Scoliosis Research Society, Thorax, Spinal fusion, Case series


STUDY DESIGN.: This is a case report. OBJECTIVE.: To report a case of soft-tissue reaction to wear debris and osteolysis around a pedicle screw after posterior spine fusion in a pediatric patient. SUMMARY OF BACKGROUND DATA.: Posterior spine fusion with instrumentation is a standard procedure for stabilization and curve correction in patients with scoliosis. Late operative site pain accounts for the highest frequency of reoperation. Debris accumulation for steel and titanium constructs occurs at the pedicle screw-rod junction. Cellular reaction to metal wear may be responsible for osteolysis and aseptic loosening around spinal implants. METHODS.: A 14-year-old male patient with neurofibromatosis and right thoracic scoliosis of 50° underwent posterior spine fusion from T2 to T10. The postoperative course was complicated by continuous pain, and imaging studies demonstrated hardware failure, requiring a revision and subsequent development of a perihilar opacity of unknown origin. Further studies demonstrated hypermobility with adjacent soft-tissue reactivity and inflammation surrounding the right T5 transpedicle screw. RESULTS.: After hardware removal, the patient’s recovery was uneventful. Six months later, a repeated computed tomographic scan demonstrated resolution of the previously described soft-tissue mass and a satisfactory fusion of the thoracic spine. CONCLUSION.: Metal wear debris can form in pediatric patients during the healing process after spinal fusions or when pseudarthrosis is present. Clinically, this manifests as back pain with a possible aseptic inflammatory abscess. Hardware removal can achieve resolution of symptoms and regression of inflammation.

Concepts: Patient, Vertebral column, Scoliosis, Right-wing politics, Thoracic vertebrae, Conservatism, Spinal fusion, Reactionary


Study Design. Retrospective case control study.Objective. To evaluate the effectiveness of bracing in patients with Chiari malformation-associated scoliosis (CMS) following posterior fossa decompression (PFD).Summary of Background Data. The effectiveness of bracing has been poorly studied in CMS patients who have received PFD.Methods. A retrospective study was conducted on 22 CMS patients who received brace treatment for their scoliosis following PFD. Forty-four age- and gender-matched IS patients who received bracing served as the control group. The bracing outcome was considered a failure if the curve worsened ≥ 6°; otherwise, the treatment was considered to be successful.Results. The age and Risser grade were similar between the CMS and IS patients at brace initiation. The initial curve magnitude of CMS patients (mean, 32.9° ± 6.3°; range, 20°-45°) was marginally significantly larger than that of the IS patients (mean, 29.6° ± 6.4°; range, 20°-45°). Until the final follow-up, a ≥ 6° worsening of the major curve occurred in 8 CMS patients (36%) and in 15 IS patients (34%). Overall, 7 CMS patients (32%) and 13 IS patients (30%) underwent spinal fusion surgery. No significant differences were observed between the two groups in the surgery rates or the bracing success rates (P>0.05). In the CMS patients, neither the performance of syringosubarachnoid shunting nor the extent of tonsillar descent correlated with the bracing outcomes, whereas a double major curve pattern was found to be predictive for the failure of bracing.Conclusion. Brace treatment subsequent to PFD is effective in preventing curve progression for 64% of CMS patients, which is comparable to the rate that is observed in IS patients. Double major curve pattern may be a risk factor in predicting treatment failure in CMS patients.

Concepts: Scientific method, Vertebral column, Scoliosis, The Age, Retrospective, Major, Spinal fusion, Scheuermann's disease


Spinal arthrodesis was the first successful treatment for scoliosis, performed by Dr. Russell A. Hibbs in 1911 and later by Dr. Fred H. Albee for tuberculosis. In 1914, Dr. H.P.H. Galloway and Dr. Hibbs began using the method to treat neuromuscular scoliosis in patients with poliomyelitis. However, this treatment approach was plagued by loss of deformity correction over time and high pseudarthrosis rates. The turning point in the operative management of spinal deformities began in 1947 with Dr. Paul Randall Harrington when he started a decade-long process to revolutionize surgical treatment of spinal deformities culminating in the advent of the Harrington Rod, the first successful implantable spinal instrumentation system. During the epoch that he was in practice, Dr. Harrington’s achievement influenced the technology and art of spine surgery for his contemporaries and the coming generations of spine surgeons. The purpose of this article is to review the life of Dr. Harrington, and how he has arguably come to be known as “Father of the Modern Treatment of Scoliosis.”

Concepts: Medicine, Surgery, Vertebral column, Scoliosis, Physician, Orthopedic surgery, Paul Randall Harrington, Harrington implant


Study Design. Review and statistical analysis of studies evaluating health-related quality of life (HRQOL) in adolescents with untreated adolescent idiopathic scoliosis (AIS) using Scoliosis Research Society (SRS) outcomes.Objective. Apply normative values and minimum clinical important differences (MCID) for the SRS22r to the literature. Identify whether the HRQOL of adolescents with untreated AIS differs from unaffected peers and if any differences are clinically relevant.Summary of Background Data. The effect of untreated AIS on adolescent HRQOL is uncertain. The lack of published normative values and MCID for the SRS22r has so far hindered our interpretation of previous studies. The publication of this background data allows these studies to be re-examined.Methods. Using suitable inclusion criteria a literature search identified studies examining HRQOL in untreated adolescents with AIS. Each cohort was analysed individually. 95% confidence intervals for the difference in SRS22r domain mean scores between the cohorts with AIS and the published data for unaffected adolescents were used to identify statistically significant differences. If the lower bound of the confidence interval was greater than the MCID the difference was considered clinically significant.Results. Of 21 included patient cohorts 81% reported statistically worse pain than those unaffected. Yet in only 5% of cohorts was this difference clinically important. Of the 11 cohorts included examining patient self image 91% reported statistically worse scores than those unaffected. In 73% of cohorts this difference was clinically significant. Affected cohorts tended to score well in function/activity and mental health domains and differences from those unaffected rarely reached clinically significant values.Conclusions. Pain and self image tend to be statistically lower amongst cohorts with AIS than those unaffected. The literature to date suggests it is only self image which consistently differs clinically. This should be considered when assessing the possible benefits of surgery.

Concepts: Statistics, Statistical significance, Scoliosis, Confidence interval, Statistical hypothesis testing, Paul Randall Harrington, Normal distribution, Scoliosis Research Society


Adolescent idiopathic scoliosis (AIS) affects up to 3% of the population. It can be stratified by curve type according to the Lenke classification. This classification system incorporates curve magnitude, flexibility, the lumbar modifier, and the sagittal plane. The Lenke classification serves as a guide for selection of levels for surgical treatment of AIS. Surgical treatment of AIS includes anterior and posterior approaches; most AIS is treated through a posterior approach. Surgical goals include maximizing correction in the coronal, sagittal, and axial planes.

Concepts: Scoliosis, Anatomy, Anatomical terms of location, Coronal plane, Sagittal plane