Effect of the type of brace on head to pelvis sagittal alignment of adolescents with Scheuermann's kyphosis.

The aim of this study was to determine the effects of the Milwaukee brace and thoracolumbosacral orthosis (TLSO) on head to pelvis sagittal alignment in adolescents with Scheuermann's kyphosis (SK). A total of 52 adolescents with SK who were under brace treatment were studied. They underwent biplanar radiography of the head to pelvis (EOS Imaging, Paris, France) before and 6 months after the beginning of bracing. We measured T1 slope, neck tilt (NT), cervical sagittal vertical axis (cSVA), thoracic inlet angle (TIA), C0-C2 lordosis, C2-C7 lordosis, thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), sagittal vertical axis (SVA) and T1 spinopelvic inclination (T1SPi). There were no significant differences in baseline values of TIA, PT, SS, PI, SVA, TK, cSVA, NT and T1 slope between the two groups (p > 0.05). There were significant differences between the baseline and final measurements of T1 slope, cSVA, TK, LL, T1SPi and TIA in both groups (p < 0.05). The results imply that brace treatment can significantly affect head to pelvis sagittal parameters of adolescents with SK. However, there are no significant differences in the values of head to pelvis sagittal parameters when comparing short-term effect of TLSO and the Milwaukee brace.

Cross-Cultural Adaptation and Validation of the Persian Version of the 24-Item Early-Onset Scoliosis Questionnaire.

STUDY DESIGN: Cross-sectional study. PURPOSE: To translate and culturally adapt the original English version of the 24-item Early-Onset Scoliosis Questionnaire (EOSQ-24) to the Persian language as well as assess its reliability and validity. OVERVIEW OF LITERATURE: Early-onset scoliosis (EOS) patients with progressive curves require active treatments, such as serial elongation- derotation-flexion casting, bracing, and surgery, which are stressful and expensive. In order to evaluate the impact of EOS and its treatment strategies, it is important to consider the patients and their parents' quality of life as the clinical and radiological parameters. The EOSQ-24 is a parent-based measure that evaluates the health-related quality of life of patients with EOS and their caregivers/parents. Similar to other widely used questionnaires, EOSQ-24 needs to be translated into other languages to make it usable in populations from different cultures and societies. METHODS: We evaluated the translation and back translation of the EOSQ-24 and made the required revisions as per the analysis performed by the expert committee and an international guideline to adapt it for use in this study. Thereafter, we recruited 100 EOS patients in order to evaluate its reliability and validity. The reliability was assessed with internal consistency. Convergent validity was assessed by comparing the scores of the EOSQ-24 and the 22-item Scoliosis Research Society Questionnaire (SRS-22r). Finally, the known groups validity was assessed as per patient's sex, curve magnitude, and treatment type. RESULTS: The Persian EOSQ-24 demonstrated very good internal consistency (Cronbach's α=0.88). All the items had an acceptable corrected item-total correlation (>0.3). Further, the EOSQ-24 and the SRS-22r scores (p <0.001) were significantly correlated. The EOSQ-24 could discriminate patients with different curve magnitudes. CONCLUSIONS: The Persian EOSQ-24 can serve as a disease-specific instrument with strong validity and reliability in the evaluation of EOS patients. Its applicability in other Persian-speaking countries and regions of the world needs to be investigated further.

Efficacy of Computer-Aided Design and Manufacturing Versus Computer-Aided Design and Finite Element Modeling Technologies in Brace Management of Idiopathic Scoliosis: A Narrative Review.

The efficiency and design quality of scoliosis braces produced by the conventional casting method depends highly on the orthotist's experience. Recently, advanced engineering techniques have been used with the aim of improving the quality of brace design and associated clinical outcomes. Numerically controlled machine tools have provided enormous opportunities for reducing the manufacturing time and saving material. However, the effectiveness of computer-aided brace manufacturing for scoliosis curve improvement is controversial. This narrative review is aimed at comparing the efficacy of braces made by the conventional method with those made by two computer-aided methods: computer-aided design and manufacturing (CAD-CAM), and computer-aided design and finite element modeling (CAD-FEM). The comparison was performed on scoliosis parameters in coronal, sagittal, and transverse planes. Scientific databases were searched, and 11 studies were selected for this review. Because of the diversity of study designs, it was not possible to decisively conclude which brace-manufacturing method is most effective. Similar effectiveness in curve correction was found in the coronal plane for braces made by using advanced manufacturing and conventional methods. In the sagittal plane, modern braces seem to be more effective than traditional braces, but there is an ongoing debate among clinicians, about which CAD-CAM and CAD-FEM brace provides a better treatment outcome. The relative effectiveness of modern and conventional methods in correcting deformities in the transverse plane is also a controversial subject. Overall, advanced engineering design and production methods can be proposed as time- and cost-efficient approaches for scoliosis management. However, there is insufficient evidence yet to conclude that CAD-CAM, and CAD-FEM methods provide significantly better clinical outcomes than those of conventional methods in the treatment of scoliosis curve. Moreover, for some factors, such as molding and the patient's posture during the data acquisition, in brace curve-correction plan, the orthotist's experience and scoliosis curve flexibility should be explored to confidently compare the outcomes of conventional, CAD-CAM, and CAD-FEM methods.

Effects of calcitonin addition on epidural injection in patients with degenerative spinal canal stenosis: a randomized double blind clinical trial.

OBJECTIVE: Back pain is reported to be the fifth most common reason for referral a patient to a physician and the most common disability in modern society. The present study aimed to evaluate the effects of calcitonin addition on epidural injection in patients with degenerative spinal canal stenosis in comparison with epidural triamcinolone injection. MATERIALS AND METHODS: The clinical trial study was performed on 40 patients with degenerative spinal stenosis, referred to pain clinic of RasoulAkram Hospital in 2018, who were randomly divided into two intervention and control groups, including 20 individuals in each group. In the intervention group, 50 units of calcitonin were injected with 8 cc of ropivacaine 0.2% while 80 mg of triamcinolone with 8 cc of ropivacaine 0.2% was injected in the control group. Functional disability was evaluated based on the Oswestry Disability Index (ODI) and pain ratings were assessed using the Visual Analogue Scale (VAS). RESULTS: Pain at 4 and 8 weeks after the procedure was significantly different between the two groups. A significant difference in the patient disability index was observed between two groups at 8 and 12 weeks after the procedure. On the other hand, the rate of analgesic consumption at 4, 8 and 12 weeks after the procedure was significantly decreased in the calcitonin group (P <0.001). CONCLUSIONS: Based on our results, injection of calcitonin into the epidural space can reduce the pain of the patients and their analgesic consumption compared to the group receiving steroids through the epidural space.

The Effect of Bracing on Spinopelvic Rotation and Psychosocial Parameters in Adolescents with Idiopathic Scoliosis.

STUDY DESIGN: Retrospective study. PURPOSE: To evaluate the effect of bracing on spinopelvic rotation and psychosocial parameters in adolescents with idiopathic scoliosis (AIS). OVERVIEW OF LITERATURE: Complex three-dimensional deformity in AIS is proposed to influence the spinopelvic parameters and psychosocial condition in adolescents; however, few studies have quantitatively evaluated these parameters. METHODS: Thirty AIS who were prescribed a brace were included in the study. The patients' standing postero-anterior and total spine radiographs were used to measure the primary curve Cobb angle, vertebral rotation, and pelvic rotation. Apical vertebral rotation (AVR), upper AVR, and lower AVR were measured using the Nash-Moe method. Pelvic rotation was determined using the left-to-right hemipelvic width ratio. The curve pattern was classified as per the Lenke classification system. In all, 14 patients had a type I curve, five had type II, six had type III, one had type IV, and four had type V curves. Brace compliance was subjectively evaluated by interviewing the patients and their parents. The health-related quality of life (HRQOL) and stress level of the recruited patients were assessed using the Brace Questionnaire and Bad Sobernheim Stress Questionnaire, respectively. RESULTS: The Cobb angle significantly decreased with at least 6 months of brace use. AVR correction changed significantly; however, no such results were observed for upper and lower AVR. Pelvic rotation and psychosocial parameters were not significantly affected by brace use. No statistically significant correlation was observed between brace compliance and curve correction. CONCLUSIONS: The Cobb angle and AVR are crucial measurements that help evaluate the treatment efficacy in AIS with small curves who undergo brace treatment. HRQOL and pelvic axial rotation are not influenced by the brace treatment.

The effect of Cobb angle correction on spinal length gain in patients with adolescent idiopathic scoliosis.

The relationship between curve correction and spinal length gain in adolescent idiopathic scoliosis was examined. A total of 102 patients who underwent posterior spinal correction and fusion alone or in combination with anterior spinal correction and fusion (ASF) were studied. The Cobb angle correction, increase in the main thoracic length, T1-L5 spinal length gain, and T1-L5 spinal length gain/Cobb angle correction were reported. The length gain/Cobb angle correction value was not significantly associated with sex, fusion approach, and the number of fused levels. Surgical T1-L5 spinal length gain (mm) equaled (70.20)-(3.51)×(degrees of Cobb angle correction)+(0.08)×(degrees of Cobb angle correction).

Osteoid Osteoma of Odontoid: Case Report and Literature Review.

Osteoid osteoma (OO) is a small tumor of bone that affects the spine in 10% of the cases. The tumor has a tendency to neural arc, and the lumbar spine is the most common site of presentation. Lesions of the odontoid process are very rare. We presented the case of a 20-year-old man who had cervical pain for 8 months. The pain responded to medical therapy. After investigation, there was a lytic lesion at the odontoid process with the characteristic features of OO in computed tomography scan and magnetic resonance imaging. Firstly, medical treatment was initiated with the administration of nonsteroidal anti-inflammatory drugs; however, due to adverse effects and worsening of his pain, the patient underwent surgical treatment with intralesional curettage from the transoral approach. In addition, the posterior fusion of the first and second cervical vertebrae was performed. The pain disappeared, and the patient was symptom-free after one year of follow-up.

The Role of Spinopelvic Parameters in Clinical Outcomes of Spinal Osteotomies in Patients with Sagittal Imbalance.

BACKGROUND: Sagittal imbalance is known as the main radiographic driver of disability in adult spinal deformity (ASD). In this study, the association of radiological spinopelvic parameters and clinical outcomes was evaluated following the corrective surgery of sagittal imbalance, in order to explore the predictive ability of each parameter. METHODS: A total of 23 patients, who underwent corrective osteotomy for restoration of sagittal balance, were included in this study. The mean follow-up period of the patients was 15.5±2.1, ranging from 12 to 18 months. Pre- and postoperative radiological parameters including pelvic tilt (PT), sagittal vertical axis (SVA) and pelvic incidence minus lumbar lordosis (PI-LL) were assessed for each patient. Clinical outcomes were evaluated using Oswestry disability Index (ODI). RESULTS: The mean ODI improved 32% following the corrective osteotomy of sagittal imbalance. Postoperative ODI was significantly correlated with all preoperative radiological parameters (r=0.608, P=0.002 for PI-LL; r=0.483, P=0.01 for PT; and r=0.464, P=0.02 for SVA). ODI improvement was significantly correlated with PI-LL and SVA change (r=536, P=0.008 and r=416, P=0.04, respectively), but not with PT change (r=247, P=0.25). The outcome was better in pedicle subtraction osteotomy (PSO) compared to Smith-Petersen Osteotomy (SPO). CONCLUSION: Surgical correction of sagittal imbalance could limit the amount of disability caused by this misalignment. According to our results, while all the spinopelvic parameters could be used in the prediction of the outcomes of corrective surgery of sagittal imbalance, PI-LL was the most informative parameter and more attention should be devoted to this parameter.

Is Facet Tropism Associated with Increased Risk of Disc Herniation in the Lumbar Spine?

STUDY DESIGN: Retrospective case control study. PURPOSE: In current study, we compared the incidence of facet tropism (FT) in patients with lumbar disc herniation and normal controls. OVERVIEW OF LITERATURE: It has been suggested that FT can be associated with increased risk of lumbar disc herniation. METHODS: A total of 66 and 63 patients with L4/L5 and L5/S1 disc herniation, respectively, were evaluated in the present study. The control group comprised 61 normal subjects. Facet joint angle was measured using axial magnetic resonance images. The FT was defined as a difference of >10° between the right and left facet joints. The incidence of FT was compared between patients and controls. We also investigated the relationship between facet orientation (sagittal or coronal) and side of disc herniation. RESULTS: The incidence of FT at the L4/L5 level was significantly higher in patients with disc herniation (48.5% vs. 26.2%, p =0.01), while it was found to be the same at the L5/S1 level in patients and controls (50.8% vs. 36%, p =0.098). Among the 64 patients with FT, intervertebral disc herniation occurred significantly toward the more sagittally oriented facet joint in 41 patients (p <0.05). CONCLUSIONS: FT is associated with increased risk of L4/L5 intervertebral disc herniation, but not at the L5/S1 level. In addition, disc herniation occurred toward the more sagittally oriented facet joint.

The Effect of Concomitant Rib Deformity in Congenital Scoliosis on Spinal Curve Correction After Segmental Pedicle Screw Instrumentation.

STUDY DESIGN: A single-center, prospective study. OBJECTIVE: To investigate the effect of rib anomaly on surgical curve correction outcome in congenital scoliosis. SUMMARY OF BACKGROUND DATA: The presence of rib anomalies may complicate surgical correction of congenital scoliosis. The outcome of surgical correction, however, has not been documented in scoliotic patients with and without rib deformity. METHODS: Percent Cobb angle decrease (CAD) after operation was calculated in 94 patients with congenital scoliosis. Posterior segmental pedicle screw instrumentation (posterior approach) with or without previous anterior spinal release and fusion (anterior approach) was the method of correction. The impact of vertebral anomaly and rib deformity on CAD was examined. RESULTS: Although the type of vertebral anomaly had no significant effect on the mean CAD, it was significantly lower in 56 patients with rib deformity compared with that in the remaining patients without rib deformity (35.14%±15.83% vs. 51.54%±17.82%, P<0.001); particularly in those with complex, unilateral rib abnormalities, and in those with same-level vertebral and rib deformities. Patients' sex and age at the time of operation, rib number abnormality, and the type of operation (ie, posterior-only approach vs. anterior and posterior approach) did not contribute significantly to Cobb angle change after operation. CONCLUSIONS: Concomitant rib deformities, particularly of complex and unilateral types, significantly compromise operative curve correction outcome in congenital scoliosis.

Autograft versus allograft reconstruction of acute tibial plateau fractures: a comparative study of complications and outcome.

BACKGROUND: There is no consensus regarding the use of filling agent in the re-elevation of depressed tibial plateau fracture (TPF). Although autograft is considered as the gold standard approach of such reconstructions, its limitation has led to a recent attraction toward allograft substitution. In this study, we compare the complications and outcome of autograft and allograft in TPF reconstruction, in order to address the existing controversy. MATERIALS AND METHODS: A total of 81 patients with acute TPF were included in this study. Allograft and autograft were applied in 58 and 23 cases, respectively. The mean age of the patients was 40.26 years, and the mean follow-up period of patients was 19.1 months. Clinical and radiological assessment of the outcome was conducted, employing the modified Rasmussen clinical criteria. RESULTS: A total of three infections were observed in our patients, from which two infections occurred in allograft received patients. Articular surface collapse was seen in two cases, including one allograft and one autograft receiving patient. The mean clinical score was 18.65 and 18.55 in autograft and allograft received patients, respectively (p = 0.09). The mean radiological score was 15.65 and 15.68 in autograft and allograft received patients (p = 0.3). CONCLUSION: With respect to the comparable complication rate, clinical and radiological outcome of allogenic versus autologous reconstruction of TPF, freeze-dried allograft could be recommended as an appropriate substitute of autograft in this treatment. Nevertheless, the longer follow-up period of the patients could further extend our understanding of the clinical outcome of each component.

Correlation between pelvic tilt and the sacro-femoral-pubic angle in patients with adolescent idiopathic scoliosis, patients with congenital scoliosis, and healthy individuals.

PURPOSE: To examine whether the sacro-femoral-pubic (SFP) angle could estimate pelvic tilt (PT) in scoliotic and normal subjects. METHODS: One hundred nine subjects including 38 patients with adolescent idiopathic scoliosis (AIS), 35 patients with congenital scoliosis (CS), and 36 healthy individuals were studied. PT, as the angle between the lines connecting the midpoint of the sacral plate to the centroid of one acetabulum and the vertical plane, and the SFP angle, as the angle between the midpoint of the upper sacral endplate, the centroid of one acetabulum, and the upper midpoint of the pubic symphysis, were calculated on full-length lateral and anteroposterior radiographs, respectively. Correlations between PT and the SFP angle were investigated in each group. RESULTS: The three groups were comparable in terms of age, sex, and the mean SFP angle. The mean PT, however, was significantly lower in healthy subjects compared to that in patients with AIS and CS. Significant and reverse correlations were present between PT and the SFP angle in all three groups (AIS: r = -0.32, p = 0.04, PT = 82.5 - average SFP angle; CS: r = -0.48, p = 0.003, PT = 95.41 - average SFP angle; healthy: r = -0.33, p = 0.04, PT = 88.95 - average SFP angle). CONCLUSIONS: Unlike two previous reports, the SFP angle correlated poorly to PT in this study, limiting its use as a suitable surrogate for PT in scoliotic and healthy subjects.

Vertebral, rib, and intraspinal anomalies in congenital scoliosis: a study on 202 Caucasians.

PURPOSE: To investigate vertebral, rib and intraspinal anomalies in patients with congenital scoliosis and their association with each other METHODS: Clinical data and preoperative imaging studies of 202 Caucasians with congenital scoliosis operated on at an educational hospital within 6 years were reviewed for vertebral, rib, and intraspinal anomalies. RESULTS: Rib and intraspinal anomalies were present in 57.4 and 21.8 % of patients, respectively. Most vertebral anomalies were located in the middle-lower thorax. Being the most common vertebral defect (53.5 %), failure of segmentation was significantly more common in males, whereas mixed defects were more frequent in females. Formation and mixed defects were associated with rib changes. Vertebral anomalies were more extensive in males than in females. The presence of multiple hemivertebrae was associated with rib deformity and intraspinal anomaly. Location of the vertebral anomalies varied with gender and rib involvement. Majority of rib changes were of simple type (70.7 %), significantly more common in males. Conversely, females had significantly more fused and bifid ribs. Two most common intraspinal anomalies were diastematomyelia (36.4 %) and syringomyelia (18.2 %). Intraspinal anomalies were located most frequently in the upper and lower thoracic regions. Syringomyelia and low conus were associated with female gender, and patients with rib changes suffered from intraspinal anomalies more frequently. No significant association was found between vertebral and intraspinal anomalies. CONCLUSIONS: The incidences of rib and intraspinal anomalies were 57.4 and 21.8 % in surgical Caucasians with congenital scoliosis, respectively. Unlike vertebral and intraspinal anomalies, rib and intraspinal anomalies were significantly associated. Male gender and intraspinal anomaly were associated with some previously suggested risk factors of curve progression.

Preservation of thoracic kyphosis is critical to maintain lumbar lordosis in the surgical treatment of adolescent idiopathic scoliosis.

Restoration of the sagittal alignment is one of the fundamental goals in scoliosis correction surgery. Having an increase in popularity of segmental spinal instrumentation, thoracic kyphosis (TK) is often sacrificed to achieve frontal and axial plane correction. Patients with a Lenke type 1 deformity underwent selective thoracic fusion (lowest instrumented vertebra of T12 or L1) using corrective segmental spinal instrumentation (Hook-Rod) and were followed up for 2 years. They were evaluated before and after operation for coronal and sagittal alignments using standing anteroposterior and lateral radiographs. There were 63 patients (21 male, 42 female) with a mean age of 15.8 ± 2.1 years included to this study. TK reduction had significant correlation (P≤0.001) with lumbar lordosis (LL) decrease at preoperative (r=0.47), immediately postoperative (r=0.37) and at 2-year follow-up (r=0.5). The decrease in LL after 2-years was less than decrease in TK (4.5 ± 8.5 vs 6 ± 10, respectively).

The prevalence of distal junctional kyphosis following posterior instrumentation and arthrodesis for adolescent idiopathic scoliosis.

Distal junctional kyphosis (DJK) is a radiographic finding in patients that undergo spinal instrumentation and fusion, since there is an abrupt transition between fixed and mobile spinal segments.The true incidence of DJK is variable in literature and seems that has a multifactorial etiology. A consecutive series of 130 patients (mean age 15.6 years) with adolescent idiopathic scoliosis who underwent posterior spinal fusion and instrumentation were evaluated by analyzing coronal and sagittal angulation and balance measurements from standing radiographs obtained pre-operatively, within 6 weeks post-operation, at two years postoperative and at the latest follow-up. There was 35 male and 95 female. The mean time of follow-up was 36 months. The incidence of DJK at latest follow-up was 6.9% (9 patients). In DJK group, distal junctional angle from pre-operative of -12.5° lordosis (-30 to 0) reached to -5.5° (P=0.015) at 6 weeks postoperation and to -1.4° (-20 to 12°) (P=0.000) at 2 years follow-up,with mean of 12.1° kyphotic change (10-20°). In non DJK group, distal junctional angle from pre-operative angle of -7.5° reached -8.1° at 2 years follow-up (P=0.43). The mean age of DJK group at surgery was 17 years and for non-DJK group was 15.4 years (P=0.022). Distal junctional kyphosis was less common in this study than previous reports and stabilized after two years. The magnitude of coronal cobb angles or multiplicity of coronal curves had no effect in developing DJK that may be prevented by incorporation of the first lordotic disc into the fusion construct.