Sagittal alignment of the cervical spine in adolescent idiopathic scoliosis treated by posteromedial translation

Purpose

To analyze postoperative changes in the cervical sagittal alignment (CSA) of patients with AIS treated by posteromedial translation.

Methods

49 patients with thoracic AIS underwent posterior arthrodesis with hybrid constructs, combining lumbar pedicle screws and thoracic universal clamps. Posteromedial translation was the main correction technique used. 3D radiological parameters were measured from low-dose biplanar radiographs. CSA was assessed using the C2C6 angle, and the central hip vertical axis (CHVA) was used as a reference axis to evaluate patients’ balance.

Results

Preoperatively, 58 % of patients had thoracic hypokyphosis, and 79 % had a kyphotic CSA. Significant correlation was found (r = 0.45, P = 0.01) between thoracic hypokyphosis and cervical kyphosis. Increase in T4–T12 thoracic kyphosis (average 14.5° ± 10°) was associated with significant decrease in cervical kyphosis in the early postoperative period. The CSA further improved spontaneously during follow-up by 7.6° (P < 0.0001). Significant positive correlation (r = 0.32, P = 0.03) was found between thoracic and cervical improvements. At latest follow-up, 94 % of the patients were normokyphotic and 67 % had a CSA in the physiological range. Sagittal balance of the thoracolumbar spine was not significantly modified postoperatively. However, the procedure significantly changed the position of C2 in regard to the CHVA (C2–CHVA), which reflects headposition (P = 0.012). At last follow-up, the patients sagittal imbalance was not significantly different from the preoperative imbalance (P = 0.34).

Conclusions

Thoracic hypokyphosis and cervical hypolordosis, observed in AIS, can be improved postoperatively, when the posteromedial translation technique is used for correction. The cervical spine remains adaptable in most patients, but the proportion of patients with physiological cervical lordosis at final follow-up remained low (24.5 %).     

Adolescent idiopathic scoliosis: Retrospective analysis of 235 surgically treated cases

Background:

The surgical treatment of adolescent idiopathic scoliosis (AIS) has taken great strides in the last two decades. There have been no long term reported studies on AIS from India with documented long term followup. In this study we review a single surgical team''s series of 235 surgically treated cases of AIS with a follow-up from two to six years.

Materials and Methods:

Pre operative charts, radiographs and MRI scans for 235 patients were collected for this study. The patients were grouped into three groups where anterior correction and fusion (n=47), posterior correction and fusion (n=123) and combined anterior release and posterior instrumentation (n=65) was performed. Each group was divided into two subgroups based on the surgical approach and instrumentation strategy (all screw construct or hybrid construct) used. Patients were followed up for coronal and saggital plane corrections, apical vertebral translation (AVT), trunk balance and back pain. The percentage of correction was calculated in each group as well as sub groups.

Results:

The incidence of MRI detected intraspinal anomaly in this series is 5.9% with 3.4% of them requiring neurosurgical procedure along with scoliosis correction. Average coronal major curve correction was 66% in the all screw group and 58.5% in the hybrid group. The coronal plane correction was better when the all screw constructs were employed. Also, the AVT and trunk balance was better with the all screw constructs. The anterior corrections resulted in better correction of the AVT and trunk balance as compared to the posterior correction. There were eight (3.4%) complications in this series. The coronal and saggital plane correction paralleled the published international standards.

Conclusion:

The coronal plane correction was better when all screw constructs were employed. Use of all pedicle screw systems obviated the need for costoplasty in most cases. The increased incidence of intraspinal anomaly may warrant a routine pre operative MR imaging of all adolescent scoliosis needing surgical treatment.     

Posterior scoliosis correction for adolescent idiopathic scoliosis using side-opening pedicle screw-rod system utilizing the axial translation technique

Background:

Though adequate literature is present depicting the results of pedicle screw-rod instrumentation using top loading systems for correction of adolescent idiopathic scoliosis (AIS), using the rod rotation technique, few published data is available regarding side loading systems used for a similar purpose. We report a retrospective study of a cohort of patients with strict inclusion criteria who underwent surgical correction of AIS with side-opening pedicle screw-rod posterior instrumentation using the axial translation technique of curve correction to assess the efficacy of side opening system for scoliosis correction with regards to patient satisfaction, Cobb''s angle correction and spinal balance.

Materials and Methods:

Clinical and radiological outcomes were measured in 14 consecutive patients (3 males, 11 females) with an average age of 14.0 years (range 9 to 23 years). They were followed up for an average period of 13.0 months (range – 2.2 to 28.5). All patients underwent posterior instrumentation only with pedicle screws used as anchor points. Hybrid constructs using hooks/wires or curves requiring anterior release were excluded from the study. All levels were not instrumented – more screws were put on the concavity and in the peri-apical region. Radiological evaluation was done by whole spine standing AP, lateral radiograms preoperatively and 1, 3, 6 and12 months after surgery. Cobb''s angles were measured and the spinal balance was noted. Clinical evaluation was done by SRS questionnaire. The complications were documented.

Results:

The mean preoperative Cobb''s angle was 58.35° (range – 44 to 72°), which came down postoperatively to 23.45° (range – 10 to 38°) signifying a mean correction of 59.57% (range – 26.92 to 76.17%). Clinical outcomes were evaluated using the SRS – 30 questionnaires. The values of mean pre- and postoperative scores are 3.68 and 4.18, showing an improvement of 0.5 points. Other than one patient of superficial wound infection, which healed with antibiotics, there was no major complication. No patient had neurological deterioration.

Conclusion:

Side-opening spinal instrumentation systems, using the axial translation technique, achieved good clinical and radiological outcome for patients of AIS.     

Efficacy and safety of posteromedial translation for correction of thoracic curves in adolescent idiopathic scoliosis using a new connection to the spine: the Universal Clamp

Correction of adolescent idiopathic scoliosis (AIS) has been reported with various systems. All-screw constructs are currently the most popular, but they have been associated with a significant decrease in thoracic kyphosis, with a potential risk of junctional kyphosis, not observed with hybrid constructs in the literature. In addition, it is important to weigh potential advantages of pedicle screw fixation against risks specific to its use. Because hybrid constructs are associated with a lower risk of complications and better sagittal correction than all-screw constructs, at present we use lumbar pedicle screws combined with a new sublaminar connection to the spine (Universal Clamps) at thoracic levels. The purpose of this study was to determine the efficacy and safety of the Universal Clamp (UC) posteromedial translation technique for correction of AIS. Seventy-five consecutive patients underwent posterior spinal fusion and hybrid instrumentation for progressive AIS. Correction was performed at the thoracic level using posteromedial translation. At the lumbar level, correction was performed using in situ contouring and compression/distractions maneuvers. A minimum 2-year follow-up was required. Medical data and radiographs were prospectively analyzed and compared using a paired t test. The average age at surgery was 15 years and 4 months (±19 months). The average number of levels fused was 12 ± 1.6. The mean follow-up was 30 ± 5 months. The average preoperative Cobb angle of the major curve was 60° ± 20°. The immediate postoperative major curve correction averaged 66 ± 13%. The average loss of correction of the major curve between the early postoperative assessment and latest follow-up was 3.5° ± 1.4°. The mean Cincinnati correction index was 1.7 ± 0.8 postoperatively, and 1.57 ± 1 at last follow up. The mean rotation of the apical vertebra was corrected from 23.3° ± 9° preoperatively to 7.3° ± 5° at last follow up (69% improvement, P < 0.0001). In the sagittal plane, the mean thoracic kyphosis improved from 23.8° ± 14.2° preoperatively to 32.3° ± 7.3° at last follow up. For the 68 patients who had a normokyphotic or a hypokyphotic sagittal modifier, thoracic kyphosis increased from 20.5° ± 9.9° to 31.8° ± 7.4°, corresponding to a mean kyphosis correction of 55% at last follow up. No intraoperative complication occurred and none of the patients developed proximal junctional kyphosis during the follow up. The principal limitation of the UC technique was the rate of proximal posterior prominence (14.6%), leading us to recommend the use of conventional claws at the upper extremity of the construct. The technique was safe, and reduced operative time, radiation exposure, and blood loss. While achieving correction of deformity in the coronal and axial planes equivalent to the best reported results of all-screw or previous hybrid constructs, the UC hybrid technique appears to provide superior correction in the sagittal plane. The excellent outcome in all three planes was maintained at 2 year follow up.     

三维矫形手术治疗青少年特发性脊柱侧凸

目的：回顾分析三维矫形内固定手术治疗青少年特发性脊柱侧凸（AIS）的临床效果。探讨手术相关融合区的选择问题。方法：2001年-2006年在我院行三维矫形内固定手术的AIS患者78例。男27例，女51例，年龄10～18岁，平均15．6岁，其中LenkeI型38例，Lenke Ⅱ型6例，LenkeⅢ型11例．LenkeⅣ型1例，LenkeV型14例，LenkeVI型8例。术前冠状面Cobb角平均560，顶椎偏距平均5．9cm。躯干偏移距离平均2．8cm。根据患者畸形类型和柔韧性选择融合范围。术后及随访时在X线片上测量主弯冠状面的Cobb角、顶椎偏距、躯干偏移距离。结果：术后随访1～5年，平均28个月，冠状面Cobb角平均残留230，矫正率为59％；终末随访平均丢失4．5^o，丢失率为8％；顶椎偏距平均残留2．7cm，矫正率为55％，终末随访时平均丢失0．5cm。丢失率为8．5％；终末随访时躯干偏移距离平均1．4cm。结论：三维矫形内固定手术能有效改善AIS畸形。根据畸形特点选择正确的融合区进行适度的矫正是手术成功的关键。     

Selective fusion in adolescent idiopathic scoliosis: a radiographic evaluation of risk factors for imbalance

ObjectivesTo report on the outcome and evaluate possible risk factors for postoperative complications following selective spinal fusion in patients with adolescent idiopathic scoliosis (AIS).ResultsDuring the 11-year study period, 157 patients with AIS underwent surgery for their progressive spinal deformity. Thirty patients (19 %) had a selective spinal fusion, with 16 patients (group A) having a selective thoracic, and 14 patients (group B) having a selective thoracolumbar/lumbar spinal arthrodesis. In both groups the main postoperative complications were adding-on (25 % group A, 36 % group B) and coronal decompensation (25 % group A, 29 % group B). In group A, no statistically significant risk factors for postoperative complications were identified. In group B, global coronal balance was identified as a significant risk factor for adding-on. Patients with adding-on had significantly higher coronal balance scores (mean 3.6) than those who did not experience adding-on (mean 1.9) (p = 0.03). In addition, those with adding-on had a significantly smaller bending lumbar Cobb angle (mean 15) than those without adding-on (mean 31.6) (p = 0.015). None of the patients who underwent selective spinal fusion required revision surgery.ConclusionAlthough the complication rate after performing a selective spinal fusion is high, the revision rate remains low and the debate whether or not to perform a selective spinal fusion will continue.     

Adolescent idiopathic scoliosis: is rising growth rate the triggering factor in progression?

Summary The school scoliosis screening programme at Our Lady's Hospital for Sick Children, Dublin, has provided material for an ongoing prospective natural history study of adolescent idiopathic scoliosis. An examination of the clinical course in 339 girls showed that observation of progression of at least 10°, which occurred in 46 girls (13.6%), depended on the timing of diagnosis and related primarily to the child's position on her growth rate curve and her pubertal status, and much less to skeletal maturity as interpreted by iliac crest ossification or bone age. This has implications for the understanding of results in conservative management, screening programmes and natural history.     

青少年特发性脊柱侧凸患者心脏异常的发生率

目的:研究青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)患者心脏异常的发生率,探讨可能影响AIS患者心脏异常发生的相关因素.方法:2008年6月～2011年6月收治AIS患者719例,其中男113例,女606例,年龄10～18岁,平均15.1±2.2岁.术前均行心脏超声多普勒检查,统计AIS患者心脏异常的发生率.将心脏异常患者分为先天性心脏病及其他心脏异常2组,分别按性别(男组与女组)、弯型(胸弯组与腰弯/胸腰弯组)分组比较先天性心脏病发生率;分别按弯型(胸弯组与腰弯/胸腰弯组)、Cobb角(≤70°组与＞70°组)及胸椎后凸角(＜10°、10°～40°与＞40°组)分组比较其他心脏异常的发生率.利用二分类Logistic回归分析探讨AIS患者弯型(胸弯组与腰弯/胸腰弯组)、Cobb角(连续变量)及胸椎后凸角(连续变量)是否为其他心脏异常发生的显著相关因素.结果:AIS患者心脏异常发生率为6.68％(48/719),其中先天性心脏病发生率为4.59％(33/719),包括房间隔缺损2.50％(21/719)、室间隔缺损0.56％(4/719)、动脉导管未闭0.28％(2/719)、永存左上腔静脉0.28％(2/719)、法洛四联症0.14％(1/719)、二尖瓣狭窄0.14％(1/719)、单心房单心室0.14％(1/719)及房间隔膨出瘤0.14％(1/719);其他心脏异常的发生率为2.09％(15/719),其中二尖瓣脱垂1.11％(8/719)、肺动脉高压0.97％(7/719).48例存在心脏异常的AIS患者中,36例在入院前未获知存在心脏异常,其中3例(8.33％)入院后需先行心脏干预手术(2例行房间隔缺损修补术,1例行动脉导管未闭封堵术),二期行脊柱侧凸矫正手术:12例入院前已获知有心脏异常,其中10例为先天性心脏病,均在脊柱侧凸发现前已行心脏干预手术.AIS患者先天性心脏病的发生率,按性别、弯型分组组间比较均无显著性差异(P＞0.05);二尖瓣脱垂、肺动脉高压的发生率,按弯型、Cobb角以及胸椎后凸角分组组间比较均无显著性差异(P＞0.05).二分类Logistic回归分析显示,二尖瓣脱垂及肺动脉高压的发生与弯型、Cobb角及胸椎后凸角无显著相关性(P＞0.05).结论:AIS患者有较高的心脏异常发生率,部分心脏异常可能严重影响脊柱手术安全性,需要在脊柱矫形术前先行心脏干预手术.AIS患者脊柱矫形术前应常规行心脏超声多普勒检查以评估心脏情况.     

Use of the Universal Clamp in adolescent idiopathic scoliosis for deformity correction and as an adjunct to fusion: 2-year follow-up

Purpose  

Among posterior surgical techniques for treating adolescent idiopathic scoliosis (AIS), hybrid constructs with pedicle-screw fixation in the lumbar spine and other anchors in the thoracic spine have been reported to provide to be of more physiological value in postoperative thoracic kyphosis than all-screw constructs. The Universial Clamp (UC) equipped with a soft sublaminar band is a relatively new thoracic anchor that can be used in hybrid constructs. A dedicated reduction tool that applies traction to the sublaminar band permits gentle translation of the thoracic curve to the precontoured fusion rods, which have been previously anchored distally by pedicle screws and proximally by hooks in a claw configuration. The aim of this study was to evaluate radiographic results of AIS treatment using UC hybrid constructs.     

双胞胎青少年特发性脊柱侧凸的发病特点

目的 :观察青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)双胞胎的共同发病率,比较同卵双胞胎之间的发病特点。方法:2007年1月~2016年12月期间我院收录同时患有AIS的双胞胎患者21对,其中女19对(含三胞胎1例),男2对,记录其初诊年龄、女性月经初潮年龄、BMI、Cobb角、胸椎后凸角、腰椎前凸角、Risser征等资料。通过短串联重复序列检测明确区分同卵双胞胎与异卵双胞胎,比较同卵双胞胎和异卵双胞胎的AIS共同发病率。选取同卵双胞胎中两人Cobb角差值≥10°的病例,将其中度数大者纳入侧凸较大组,度数小者纳入侧凸较小组,采用配对样本t检验比较两组之间初潮年龄、BMI、Risser征临床资料的差异。结果:21对双胞胎平均初诊年龄13.2±2.5岁,女性月经初潮年龄12.2±1.4岁,初诊时平均Cobb角29.2°±14.8°,胸椎后凸角16.8°±9.2°,腰椎前凸角45.5°±7.4°,BMI 17.0±1.6kg/m2,Risser征2.3±1.6。21对双胞胎中同卵双胞胎17对,异卵双胞胎4对。同卵双胞胎中16对(94.1%)共同患有AIS,11对(68.8%)弯型一致,4对(25.0%)Cobb角差值小于10°。异卵双胞胎中3对(75.0%)共同患有AIS,1对(33.3%)弯型一致,1对(33.3%)Cobb角差值小于10°。同卵双胞胎中Cobb角差值≥10°者12对,侧凸较大组的月经初潮年龄和BMI均小于侧凸较小组(P0.05),Risser征两组之间无统计学差异(P0.05)。结论 :同卵双胞胎AIS患者共同发病率较高(94.1%)且弯型一致,但同卵双胞胎两者间畸形严重程度不一,双胞胎中畸形较重者的月经初潮年龄较小、BMI较低。     

Minimal invasive surgery techniques for patients with adolescent idiopathic and early onset scoliosis

ObjectiveProvide an update on minimal invasive surgery (MIS) techniques for surgical management of pediatric spine.MethodsMinimal Invasive surgery for pediatric spine deformity has evolved significantly over the past decade. We include updated information about the surgical management of patients with adolescent idiopathic and Early Onset Scoliosis through MIS techniques. We take into consideration the implementation of this technique in Low-to-Middle Income Countries (LMICs).ResultsAlthough MIS began as a technique in adult and degenerative spine, recent publications on MIS in pediatric spine cases report benefits of decreased blood loss and infection incidence, and cosmetic advantages from fewer incision numbers. Adoption of MIS techniques in pediatric spine can be facilitated with pre- and intraoperative use of pertinent medical systems.ConclusionWith appropriate considerations and training, MIS is a safe procedure for pediatric spine correction surgery and can be applicable in LMICs.     

Current concepts and controversies on adolescent idiopathic scoliosis: Part II

A new era in the surgical treatment of adolescent idiopathic scoliosis (AIS) opened with the introduction of pedicle screw instrumentation, which provides 3-column vertebral fixation and allows major deformity correction on the coronal, sagittal, and axial planes. A steep learning curve can be expected for spinal surgeons to become familiar with pedicle screw placement and correction techniques. Potential complications including injury to adjacent neural, vascular, and visceral structures can occur due to screw misplacement or pull-out during correction maneuvers. These major complications are better recognized as pedicle screw techniques become more popular and may result in serious morbidity and mortality. Extensive laboratory and clinical training is mandatory before pedicle screw techniques in scoliosis surgery are put to practice. Wider application, especially in developing countries, is limited by the high cost of implants. Refined correction techniques are currently developed and these utilize a lesser number of pedicle anchors which are strategically positioned to allow optimum deformity correction while reducing the neurological risk, surgical time, and blood loss, as well as instrumentation cost. Such techniques can be particularly attractive at a time when cost has major implications on provision of health care as they can make scoliosis treatment available to a wider population of patients. Pedicle screw techniques are currently considered the gold standard for scoliosis correction due to their documented superior biomechanical properties and ability to produce improved clinical outcomes as reflected by health-related quality-of-life questionnaires. Ongoing research promises further advances with the future of AIS treatment incorporating genetic counseling and possibly fusionless techniques.     

Volumetric changes in cerebellar regions in adolescent idiopathic scoliosis compared with healthy controls

Background contextAdolescent idiopathic scoliosis (AIS) is a three-dimensional spinal deformation that affects adolescents, especially girls. The etiopathogenesis of this disease remains uncertain, and studies have been carried out to understand its cause and related organs. Previous studies suggest that AIS is probably related to the cerebellum dysfunction, which could also be related to the abnormality in morphology of the cerebellum.PurposeThe purpose of the study is to investigate the relationship between AIS and the volume and morphology of cerebellum.Study design/settingThe study design of the cerebellum segmentation and volume quantification involved the following four steps: whole-brain normalization, cerebellum isolation, mapping with the statistical cerebellum template, and cerebellum regional volume correction.Patient sampleIn particular, high-resolution T1-weighted magnetic resonance images of 50 AIS patients with the right-thoracic curves (ie, Cobb angle ≥20°) and 40 age-matched normal controls were acquired. The exclusion criteria included history of head injury, back injury, severe headache, weakness or numbness in any limbs, urinary incontinence, nocturnal enuresis, and any space-occupying lesion found on magnetic resonance (MR) images.Outcome measuresThe AIS subjects were all with moderate-to-severe curves (ie, Cobb angle ≥20°) (9 moderate and 41 severe; mean Cobb angle 48.7°, range 20°–90°).MethodsThe cerebellum was parcellated to 28 regions by mapping with a well-recognized probabilistic MR cerebellum atlas. Student t test of each cerebellar region and the correction for multiple comparisons were performed.ResultsThe volumes of four regions, namely right VIIIa, right VIIIb, left X, and right X, were significantly increased by approximately 7.43% to 8.25% in the AIS compared with the control group. Statistically, the results suggested that the cerebellar volume in AIS patients was larger compared with normal controls in the cerebellum regions of prepyramidal-prebiventer and intrabiventer fissures, intrabiventer and secondary fissures, and floccular-nodular (X)-posterolateral fissure to the inferior hemispheric margin.ConclusionsThe functions of the affected regions involve motor control, somatosensory, working memory, language, and response to visual stimulation. We conclude that the volume difference could be compensatory consequences in the central nervous system because of the persistent effort in AIS patients to maintain the body balance given the asymmetric spine.     

Spinal penetration index assessment in adolescent idiopathic scoliosis using EOS low-dose biplanar stereoradiography

Purpose

The spinal penetration index (SPI) quantifies the portion of the rib cage occupied by vertebrae. When measured by computed tomography (CT) or magnetic resonance imaging, SPI can only be determined in the reclining position, which modifies spinal and thoracic morphology. CT results in high radiation exposure. The authors studied rib cage and spinal morphology using low-dose biplanar stereoradiography and their impact on respiratory function in adolescent idiopathic scoliosis (AIS).

Methods

In eighty thoracic AIS patients, a slot-scanning radiologic device allowing simultaneous acquisition of orthogonal images and 3D reconstructions with low exposure to radiation (EOS) was used to determine thoracic volume, mean spinal penetration index (SPIm), apical spinal penetration index (SPIa), main thoracic (MT) curve Cobb angle, T4–T12 kyphosis, and apical vertebral rotation (AVR).

Results

Thoracic volume was correlated with thoracic kyphosis (r = 0.31, p = 0.006), but not with SPI, MT Cobb angle, or AVR. SPIm and SPIa were negatively correlated with thoracic kyphosis. Forced vital capacity and forced expiratory volume in 1 s were significantly lower in the hypokyphotic patients (p = 0.04, p = 0.03, respectively) and correlated with thoracic volume and T4–T12 kyphosis. No correlation was found between spinal penetration indices and pulmonary function tests, but SPIm was significantly greater in patients with obstructive syndrome (p = 0.01).

Conclusions

With little radiation exposure, EOS biplanar stereoradiography permits routine imaging is a functional standing position. Hypokyphotic patients had significantly decreased FEV1 and FVC. SPIm was significantly higher in patients with obstructive syndrome.     

Family history and its association to curve size and treatment in 1,463 patients with idiopathic scoliosis

Purpose

To study family history in relation to curve severity, gender, age at diagnosis and treatment in idiopathic scoliosis.

Methods

A self-assessment questionnaire on family history of scoliosis was administered to 1,463 untreated, brace or surgically treated idiopathic scoliosis patients.

Results

Out of the 1,463 patients, 51 % had one or more relatives with scoliosis. There was no significant difference between females and males, nor between juvenile and adolescent study participants in this respect (p = 0.939 and 0.110, respectively). There was a significant difference in maximum curve size between patients with one or more relatives with scoliosis (median 35°, interquartile range 25) and patients without any relative with scoliosis (median 32°, interquartile range 23) (p = 0.022). When stratifying patients according to treatment (observation, brace treatment or surgery), we found that it was more common to have a relative with scoliosis among the treated patients (p = 0.011). The OR for being treated was 1.32 (95 % CI 1.06–1.64) when the patient had a relative with scoliosis, compared to not having.

Conclusions

Larger curve sizes were found in patients with a family history of scoliosis than in the ones without. No relation between family history and gender or between family history and age at onset of idiopathic scoliosis was found. Although the presence of a family history of scoliosis may not be a strong prognostic risk factor, it indicates that these patients are at higher risk of developing a more severe curve.     

Melatonin and adolescent idiopathic scoliosis: The present evidence

IntroductionAdolescent idiopathic scoliosis (AIS) is a multifactorial condition with genetic predisposing factors, and several causes have been put forward for its aetiopathogenesis, including possible hormonal dysfunction. Melatonin seems to play significant role in AIS.MethodsA systematic search in different database, to July 2021, was performed to define the role of melatonin in the pathophysiology of adolescent idiopathic scoliosis. Eight suitable studies were identified.ResultsThe concentration and rhythm of melatonin secretion can play an important role by influencing the pathogenesis of adolescent idiopathic scoliosis.ConclusionsAlthough there are many alterations of melatonin in subjects with adolescent idiopathic scoliosis, the many variables present do not allow to establish a direct cause–effect relationship.Level of evidenceLevel IV.     

Radiographic versus ultrasound evaluation of the Risser Grade in adolescent idiopathic scoliosis: a prospective study of 46 patients

The determination of skeletal age is essential in the management of patients with scoliosis. One of the most frequently used techniques to determine skeletal maturity is the method described by Risser. However, repeated X-ray exposure in the follow-up examinations of scoliosis patients may increase the risk of cancer. We compared conventional radiological evaluation of the Risser grade with ultrasound evaluation. For scoliosis patients routine application of ultrasound in the follow-up examinations may significantly reduce radiation exposure. 46 adolescent idiopathic scoliosis patients (median age, 14.5 years) were investigated. Sonographic and radiographic assessment of Risser sign was carried out by two independent senior staff skeletal radiologists. Agreement of Risser Grade between the two diagnostic methods was determined by Kappa statistics. Coefficients <0.21, 0.21–0.40, 0.41–0.60, 0.61–0.80, and >0.80 were rated as poor, fair, moderate, good, and very good agreement. For Risser Grades I–III 100% agreement was found between the two methods. Disagreement between radiographic and sonographic evaluation was found in Risser Grades IV and V. In five patients, X-ray evaluation yielded Risser Grade V while ultrasound showed Risser Grade IV. In one patient, radiographic examination resulted in Risser Grade IV while Grade V was detected in ultrasound. Overall, the Kappa value showed very good agreement between the two diagnostic methods. Our findings suggest that ultrasound can be applied as an alternative method to X-ray evaluation in Risser Grade determination. It should be routinely used in clinical practice to reduce the patients exposure to radiation.     

Results of brace treatment of adolescent idiopathic scoliosis in boys compared with girls: a retrospective study of 102 patients treated with the Boston brace

The aim of the study was to compare the results of brace treatment of adolescent idiopathic scoliosis (AIS) in male patients with matched female patients and to assess the effectiveness of bracing of boys in AIS and to discuss the results with published data. Between 1987 and 1995, 51 consecutive male patients with AIS were treated with the Boston brace. The patients were advised to wear the brace 23 h/day. The medical records of all patients were reviewed. Cobb angles and Risser signs were measured before bracing, in brace, at brace discontinuation and at final follow-up. Everyone of 51 male patients was compared with a female patient who was treated by the same method and matched by Risser sign, curve pattern, curve magnitude and duration of treatment and follow-up time. Compliance with brace was noted at every visit. Fourteen boys had worn the brace only during nighttime or occasionally and were considered non-compliant. Only compliant patients with treatment period > 1 year and follow-up > 1 year after treatment were accepted for the analyses of effectiveness of brace treatment and its prognostic factors. Thirty-three boys met these inclusion criteria. Bracing was considered to have a failure if > 5° progression occurred or if surgery was performed. At the final follow-up study progression > 5° was found in 16/51 (31.4%) of male patients. Corresponding figures of female patients were 11/51 (21.6%), respectively. In compliant boys progression > 5° occurred in 6/33 boys compared with 9/33 girls. The association between risk of progression and correction% in brace was statistically significant. The overall results of brace treatment of idiopathic scoliosis in male patients were inferior compared with matched females. One reason for inferior overall results in boys was poor compliance with brace wear. However, brace treatment in AIS may be recommended with the same principles in both genders.     

青少年特发性脊柱侧凸交感神经系统活性左右侧对称性的观察

目的:探讨交感神经系统(sympathetic nervous system,SNS)活性在AIS病因学中可能存在的作用.方法:前瞻性研究.纳入68例右胸弯AIS女性患者为观察对象,年龄11～18岁,平均14.2±2.4岁;主弯Cobb角1 1°～64°,平均37.2°±13.5°.选取5例青少年先天性脊柱侧凸(CS)女性患者和28例正常年轻女性作为对照,CS患者年龄12～18岁,平均14.7±3.1岁;正常年轻女性11～22岁,平均17.9±4.0岁.采用交感神经皮肤反应(sympathetic skin response,SSR)评估3组的SNS活性,以上下肢潜伏期和振幅右侧/左侧的比值作为评估指标.组间及组内比较采用独立样本t检验,P＜0.05为差异有统计学意义.结果:正常年轻女性组中,上下肢潜伏期和振幅右/左比值在正常青少年(13.6±2.8岁,11～17岁)和年轻女性(20.7± 1.2岁,19～22岁)间无显著性差异(P＞0.05).女性AIS患者上肢潜伏期右侧/左侧比值(1.01±0.05)显著性大于正常年轻女性(0.98±0.04,P=0.036),上肢振幅、下肢潜伏期和下肢振幅右侧/左侧比值在女性AIS患者与正常年轻女性间无显著性差异(P＞0.05).CS患者上、下肢潜伏期和振幅的右侧/左侧比值与正常年轻女性间无显著性差异(P＞0.05);女性AIS患者上、下肢潜伏期和振幅右侧/左侧比值在小角度(＜40°)和大角度(≥40°)间亦无显著性差异(P＞0.05).结论:女性AIS患者身体两侧SNS活性存在不对称性,其可能与发病有关,但是与侧凸的严重程度无显著相关性.     

Polymorphism in vitamin D receptor is associated with bone mineral density in patients with adolescent idiopathic scoliosis

Low bone mass and osteopenia have been reported in the axial and peripheral skeleton of adolescent idiopathic scoliosis (AIS) patients. Furthermore, several recent studies have shown that gene polymorphisms are related to osteoporosis. However, no study has yet linked polymorphisms in the vitamin D receptor (VDR) gene and bone mass in AIS. Accordingly, the authors examined the association between bone mass and VDR gene polymorphisms in 198 girls diagnosed with AIS. The VDR BsmI (rs1544410), FokI (rs2228670) and Cdx2 (rs11568820) polymorphisms and bone mineral density at the lumbar spine (LSBMD) and femoral neck (FNBMD) were analyzed and compared to their levels in healthy controls. Mean LSBMD and FNBMD in AIS patients were lower than in age- and sex-matched healthy controls (P = 0.0022 and P = 0.0013, respectively). A comparison of genotype frequencies in AIS patients and controls revealed a significant difference for the BsmI polymorphism only (P = 0.0054). Furthermore, a significant association was found between the VDR BsmI polymorphism and LSBMD. In particular, LSBMD in AIS patients with the AA genotype was found to be significantly lower than in patients with the GA (P < 0.05) or GG (P < 0.01) genotypes. However, no significant association was found between LSBMD or FNBMD and the VDR FokI or Cdx2 polymorphisms. These results suggest that the VDR BsmI polymorphism is associated with LSBMD in girls with AIS.