The effectiveness of a protocol without routine radiographs for follow-up of adolescent idiopathic scoliosis patients (CURVE): a study protocol.

BACKGROUND AND PURPOSE: Current follow-up protocols for adolescent idiopathic scoliosis (AIS) are based on consensus and consist of regular full-spine radiographs to monitor curve progression and surgical complications. Consensus exists to avoid inappropriate use of radiographs in children. It is unknown whether a standard radiologic follow-up (S-FU) approach is necessary or if a patient-empowered follow-up (PE-FU) approach can reduce the number of radiographs without treatment consequences. METHODS AND ANALYSES: A nationwide multicenter pragmatic randomized preference trial was designed for 3 follow-up subgroups (pre-treatment, post-brace, post-surgery) to compare PE-FU and S-FU. 812 patients with AIS (age 10-18 years) will be included in the randomized trial or preference cohorts. Primary outcome is the proportion of radiographs with a treatment consequence for each subgroup. Secondary outcomes consist of the proportion of patients with delayed initiation of treatment due to non-routine radiographic follow-up, radiation exposure, societal costs, positive predictive value, and interrelation of clinical assessment, quality of life, and parameters for initiation of treatment during follow-up. Outcomes will be analyzed using linear mixed-effects models, adjusted for relevant baseline covariates, and are based on intention-to-treat principle. Study summary: (i) a national, multicenter pragmatic randomized trial addressing the optimal frequency of radiographic follow-up in patients with AIS; (ii) first study that includes patient-empowered follow-up; (iii) an inclusive study with 3 follow-up subgroups and few exclusion criteria representative for clinical reality; (iv) preference cohorts alongside to amplify generalizability; (v) first study conducting an economic evaluation comparing both follow-up approaches.

Remineralization Rate of Lytic Lesions of the Spine in Multiple Myeloma Patients Undergoing Radiation Therapy.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: In general, Multiple Myeloma (MM) patients are treated with systemic therapy including chemotherapy. Radiation therapy can have an important supportive role in the palliative management of MM-related osteolytic lesions. Our study aims to investigate the degree of radiation-induced remineralization in MM patients to gain a better understanding of its potential impact on bone mineral density and, consequently, fracture prevention. Our primary outcome measure was percent change in bone mineral density measured in Hounsfield Units (Δ% HU) between pre- and post-radiation measurements, compared to non-targeted vertebrae. METHODS: We included 119 patients with MM who underwent radiotherapy of the spine between January 2010 and June 2021 and who had a CT scan of the spine at baseline and between 3-24 months after radiation. A linear mixed effect model tested any differences in remineralization rate per month (ßdifference) between targeted and non-targeted vertebrae. RESULTS: Analyses of CT scans yielded 565 unique vertebrae (366 targeted and 199 non-targeted vertebrae). In both targeted and non-targeted vertebrae, there was an increase in bone density per month (ßoverall = .04; P = .002) with the largest effect being between 9-18 months post-radiation. Radiation did not cause a greater increase in bone density per month compared to non-targeted vertebrae (ßdifference = .67; P = .118). CONCLUSION: Our results demonstrate that following radiation, bone density increased over time for both targeted and non-targeted vertebrae. However, no conclusive evidence was found that targeted vertebrae have a higher remineralization rate than non-targeted vertebrae in patients with MM.

Efficacy of Biphasic Calcium Phosphate Ceramic With a Needle-shaped Surface Topography Versus Autograft in Instrumented Posterolateral Spinal Fusion: A Randomized Trial.

STUDY DESIGN: A multicenter randomized controlled noninferiority trial with intrapatient comparisons. OBJECTIVE: The aim of this study was to determine noninferiority of a slowly resorbable Biphasic Calcium Phosphate with submicron microporosity (BCP<µm, MagnetOs™ Granules) as an alternative for autograft in instrumented posterolateral fusion (PLF). SUMMARY OF BACKGROUND DATA: Successful spinal fusion with a solid bone bridge between the vertebrae is traditionally achieved by grafting with autologous iliac bone. However, the disadvantages of autograft and unsatisfactory fusion rates have prompted the exploration of alternatives, including ceramics. Nevertheless, clinical evidence for the standalone use of these materials is limited. METHODS: Adults indicated for instrumented PLF (one to six levels) were enrolled at five participating centers. After bilateral instrumentation and fusion-bed preparation, the randomized allocation side (left or right) was disclosed. Per segment 10cc of BCP<µm granules (1-2 mm) was placed in the posterolateral gutter on one side and 10cc autograft on the contralateral side. Fusion was systematically scored on 1-year follow-up CT scans. The study was powered to detect >15% inferiority with binomial paired comparisons of the fusion performance score per treatment side. RESULTS: Of the 100 patients (57 ± 12.9 years, 62% female), 91 subjects and 128 segments were analyzed. The overall posterolateral fusion rate per segment (left and/or right) was 83%. For the BCP<µm side only the fusion rate was 79% vs. 47% for the autograft side (difference 32 percentage points, 95% CI = 23-41). Analysis of the primary outcome confirmed the noninferiority of BCP<µm with an absolute difference in paired proportions of 39.6% (95% CI = 26.8-51.2, < 0.001). CONCLUSION: This clinical trial demonstrates noninferiority and even indicates superiority of MagnetOs™ Granules as a standalone ceramic compared to autograft for posterolateral spinal fusion. These results challenge the belief that autologous bone is the most optimal graft material.

The Prevalence of Cancer in Dutch Female Patients with Idiopathic Scoliosis Compared with the General Population.

Background and Objectives: Epidemiological studies have demonstrated the potential oncogenic effects of cumulative radiation exposure, particularly during childhood. One group experiencing repeated exposure to radiation at an early age for multiple years is patients treated for idiopathic scoliosis (IS). This study aimed to determine the relationship between childhood radiological exposure and adult cancer prevalence in children treated for IS. Materials and Methods: Data from 337 predominantly female patients treated at our hospital between January 1981 and January 1995 were gathered and compared to the Dutch national cancer rates. The standardized prevalence ratios for cancer in IS patients were compared with the cancer prevalence rates from the general Dutch population. Results: The overall cancer prevalence in women was 5.0%, with no significant difference compared to the general population (p = 0.425). The results of this study do not suggest that female patients treated for idiopathic scoliosis during childhood have an increased risk of cancer later in life. Conclusion: Despite being the largest recent study in its field, the modest participant number limits its ability to draw conclusions. However, the detailed data collected over a long observation period, alongside data from a period with comparable radiation rates, contributes to refining clinical practice and laying the groundwork for future systematic reviews.

Clinical Utility of An Intervertebral Motion Metric for Deciding on the Addition of Instrumented Fusion in Degenerative Spondylolisthesis.

STUDY DESIGN: A prospective single-arm clinical study. OBJECTIVE: To explore the clinical utility of an intervertebral motion metric by determining the proportion of patients for whom it changed their surgical treatment plan from decompression only to decompression with fusion or vice versa. SUMMARY OF BACKGROUND DATA: Lumbar spinal stenosis (LSS) from degenerative spondylolisthesis is commonly treated with decompression only or decompression with additional instrumented fusion. An objective diagnostic tool capable of establishing abnormal motion between lumbar vertebrae to guide decision-making between surgical procedures is needed. To this end a metric, based on the vertebral sagittal plane translation-per-degree-of-rotation (TPDR) calculated from flexion-extension radiographs, was developed. METHODS: First, spine surgeons documented their intended surgical plan. Subsequently, the participants' flexion-extension radiographs were taken. From these the TPDR was calculated and reported as a Sagittal Plane Shear Index (SPSI). The SPSI metric of the spinal level intended to treat was used to decide if the intended surgical plan needed to be changed or not. RESULTS: SPSI was determined for 75 participants. Of these, 51 (68%) had an intended surgical plan of decompression only and 24 (32%) decompression with fusion. In 63% of participants the SPSI was in support of their intended surgical plan. For 29% of participants the surgeon changed the surgical plan after the SPSI metric became available to them. A suggested change in surgical plan was overruled in 8% of participants. The final surgical plan was decompression only for 59 (79%) and decompression with fusion for 16 (21%) participants. CONCLUSION: The 29% change in intended surgical plans suggested that SPSI was considered by spine surgeons as an adjunct metric in deciding whether to perform decompression only or or to add instrumented fusion. This change exceeded the a priori defined 15% considered necessary to show potential clinical utility of SPSI.

Fracture rate after conventional external beam radiation therapy to the spine in multiple myeloma patients.

BACKGROUND CONTEXT: Conventional external beam radiation therapy (cEBRT) is used in multiple myeloma (MM) to treat severe pain, spinal cord compression, and disease-related bone disease. However, radiation may be associated with an increased risk of vertebral compression fractures (VCFs), which could substantially impair survival and quality of life. Additionally, the use of the Spinal Instability Neoplastic Score (SINS) in MM is debated in MM. PURPOSE: To determine the incidence of VCFs after cEBRT in patients with MM and to assess the applicability of the SINS score in the prediction of VCFs in MM. STUDY DESIGN: Retrospective multicenter cohort study. PATIENT SAMPLE: MM patients with spinal myeloma lesions who underwent cEBRT between January 2010 and December 2021. OUTCOME MEASURES: Frequency of new or progressed VCFs and subdistribution hazard ratios for potentially associated factors. METHODS: Patient and treatment characteristics were manually collected from the patients' electronic medical records. Computed tomography (CT) scans from before and up to 3 years after the start of radiation were used to score radiographic variables at baseline and at follow-up. Multivariable Fine and Gray competing risk analyses were performed to evaluate the diagnostic value of the SINS score to predict the postradiation VCF rate. RESULTS: A total of 127 patients with 427 eligible radiated vertebrae were included in this study. The mean age at radiation was 64 years, and 66.1% of them were male. At the start of radiation, 57 patients (44.9%) had at least one VCF. There were 89 preexisting VCFs (18.4% of 483 vertebrae). Overall, 39 of 127 patients (30.7%) reported new fractures (number of vertebrae (n)=12) or showed progression of existing fractures (n=36). This number represented 11.2% of all radiated vertebrae. Five of the 39 (12.8%) patients with new or worsened VCFs received an unplanned secondary treatment (augmentation [n=2] or open surgery [n=3]) within 3 years. Both the total SINS score (SHR 1.77; 95% confidence interval (CI) 1.54-2.03; p<.001) and categorical SINS score (SHR 10.83; 95% CI 4.20-27.94; p<.001) showed an independent association with higher rates of new or progressed VCFs in adjusted analyses. The use of bisphosphonates was independently associated with a lower rate of new or progressed VCFs (SHR 0.47 [95% CI 0.24-0.92; p=.027]). CONCLUSIONS: This study demonstrated that new or progressed VCFs occurred in 30.7% of patients within 3 years, in a total of 11.2% of vertebrae. The SINS score was found to be independently associated with the development or progression of VCFs and could thus be applied in MM for fracture prediction and possibly prevention.

Heath-related quality of life and functional outcomes in patients with congenital or juvenile idiopathic scoliosis after an average follow-up of 25 years: a cohort study.

BACKGROUND CONTEXT: Congenital and juvenile scoliosis are both early-onset deformities that develop before the age of 10. Children are treated to prevent curve progression and problems in adulthood such as back pain and a decreased quality of life but literature on long-term outcomes remains scarce. PURPOSE: To evaluate the health-related quality of life (HRQoL) and potential disability of children with congenital scoliosis (CS) or juvenile idiopathic scoliosis (JIS) after a minimum of 20 years follow-up. STUDY DESIGN: Comparative cohort study. PATIENT SAMPLE: A consecutive cohort of CS and JIS patients were retrospectively identified from a single-center scoliosis database. Patients born between 1968 and 1981 and treated during skeletal growth were eligible for participation. OUTCOME MEASURES: HRQoL (SF-36, SRS-22r, ODI). METHODS: The primary aim was to evaluate the HRQoL of CS and JIS patients using the general SF-36 questionnaire. Both patient cohorts were compared with age-matched national norms. The secondary aim was to analyze the differences between conservatively and surgically treated patients using the scoliosis-specific Scoliosis Research Society-22r questionnaire (SRS-22r) and the Oswestry Disability Index (ODI). T-tests were used for statistical comparison. RESULTS: In total, 114 patients (67% of the eligible patients) completed the questionnaire, with a mean follow-up of 25.5±5.5 years after their final clinical follow-up. Twenty-nine patients with CS were included with a mean age of 44.4±3.8 years (79.3% female), and 85 patients with JIS with a mean age of 43.7±4.2 years (89.4% female). Of the SF-36 domains, only the vitality score (60.6±18.0 for CS and 58.1±17.6 for JIS cohort) and mental health score (70.0±18.4 for CS and 72.1±18.1 for JIS cohort) were significantly lower compared with the general population (68.6±19.3 for vitality, and 76.8±17.4 for mental health). These decreased scores were larger than the determined minimum clinically important difference threshold of 4.37. Surgically treated JIS patients had a significantly lower score on the SRS-22r pain domain than their nonsurgically treated peers (3.6±0.9 vs 4.1±0.7l p=.019). Surgically treated CS patients had a significantly higher score on the SRS-22r mental health domain than their nonsurgically treated peers (4.3±0.5 vs 3.5±1.0; p=.023). No significant differences were found in the other domains. CONCLUSIONS: Except for vitality and mental health domains, congenital and juvenile idiopathic scoliosis patients treated during skeletal growth had similar HRQoL on most SF-36 domains in adulthood compared with national norms. Surgical treated JIS patients experienced more pain compared with brace treated patients, while braced CS patients had a significantly lower mental scores compared with surgical treated patients. These long-term outcomes are essential to inform patients and can guide shared decision-making between clinicians and patients.

The Dutch version of the Spinal Appearance Questionnaire for adolescents with idiopathic scoliosis: patient-based cross-cultural adaptation and measurement properties evaluation.

PURPOSE: Adolescent idiopathic scoliosis (AIS) affects the appearance of spine and trunk. The Spinal Appearance Questionnaire (SAQ) assesses the perception of appearance in AIS patients. The aim of this study is to translate and culturally adapt the recommended short version of the SAQ into Dutch and to test its measurement properties. METHODS: A Dutch SAQ (14-item; appearance and expectations domains) was developed following guidelines for translation and cross-cultural adaptation. The COSMIN Study Design checklist was used for measurement properties evaluation. In this multicenter study, the Dutch SAQ, SRS-22R and NPRS (back pain) were administered to 113 AIS patients (aged 15.4 years [SD 2.2], 21.2% male). Floor and ceiling effects were evaluated for content analysis. For reliability, internal consistency (Cronbach's alpha) and test-retest reliability (ICC; n = 34) were evaluated. Predefined hypotheses of relationships with other questionnaires and between subgroups based on scoliosis severity (radiological and clinical) were tested for construct validity. Exploratory factor analysis (EFA) was performed to investigate the validity of the underlying structure of this 14-item questionnaire. RESULTS: No floor and ceiling effects were found for domains and total scores. Cronbach's alpha ranged from 0.84 to 0.89. ICCs varied from 0.76 to 0.77. For construct validity, 89% (8/9) of the predefined hypotheses were confirmed. Significant higher scores for the appearance domain were found for subgroups based on radiological (Cobb angle; > 25.0°) and clinical outcomes. (Angle of Trunk Rotation; > 9.0°). A two-factor structure was found (EV 5.13; 36.63% explained variance). CONCLUSION: The Dutch SAQ is an adequate, valid and reliable instrument to evaluate patients' perception of appearance in AIS. LEVEL OF EVIDENCE: Level I-diagnostic studies.

The impact of being overweight or obese on 12 month clinical recovery in patients following lumbar microdiscectomy for radiculopathy.

BACKGROUND CONTEXT: The proportion of patients who undergo lumbar microdiscectomy due to lumbar radiculopathy who are also overweight or obese is high. However, whether high body mass index (BMI) affects clinical outcomes is not well-studied. PURPOSE: To investigate the difference in the clinical course between normal weight, overweight, and obese patients with radiculopathy who underwent lumbar microdiscectomy followed by physical therapy and to evaluate whether high BMI is associated with poor recovery. STUDY DESIGN/SETTING: A prospective cohort study with a 12-month follow-up was conducted in a multidisciplinary clinic. PATIENT SAMPLE: We included 583 patients (median [IQR] age: 45 [35-52] years; 41% female) with clinical signs and symptoms of lumbar radiculopathy, consistent with magnetic resonance imaging findings, who underwent microdiscectomy followed by postoperative physical therapy. OUTCOME MEASURES: Outcomes were leg pain and back pain intensity measured with a visual analogue scale, disability measured with the Roland Morris Disability Questionnaire at 3 and 12-month follow-ups, and complications. METHODS: Patients were classified as being normal weight (46.9%), overweight (38.4%), or obese (14.7%). A linear mixed-effects model was used to assess the difference in the clinical course of pain and disability between the three BMI categories. The association between BMI and outcomes was evaluated using univariable and multivariable logistic regression analyses. RESULTS: All three patient groups experienced a significant improvement in leg pain, back pain, and disability over 3 and 12-month follow-up. Patients who were overweight, obese, or normal weight experienced comparable leg pain (p=.14) and disability (p=.06) over the clinical course (p=.14); however, obese patients experienced higher back pain (MD=-6.81 [95%CI: -13.50 to -0.14]; p=.03). The difference in back pain scores was not clinically relevant. CONCLUSIONS: In the first year following lumbar microdiscectomy, patients demonstrated clinical improvements and complications that were unrelated to their preoperative BMI.

Validity and reliability of the adapted Dutch version of the Brace Questionnaire (BrQ).

BACKGROUND AND PURPOSE: The Brace Questionnaire (BrQ) is a disease-specific health-related quality of life (HRQOL) instrument for measuring perceived health status of scoliosis patients undergoing brace treatment. The purpose of this study is to evaluate the validity and reliability of a translated and culturally adapted Dutch version of the BrQ. PATIENTS AND METHODS: The original Greek BrQ was translated into Dutch and a cross-cultural adaptation and validation processes were conducted. Subsequently, 80 adolescent idiopathic scoliosis (AIS) patients undergoing active brace treatment were included from 4 scoliosis centers to evaluate the validity and reliability of the Dutch version of the BrQ. The questionnaire's floor and ceiling effects, internal consistency, and test-retest reliability were assessed. Concurrent validity was evaluated by comparing the BrQ with the revised Scoliosis Research Society 22-item questionnaire (SRS-22r) scores. RESULTS: The mean total BrQ score was 75.9 (standard deviation [SD] 11.3) and the mean domain scores varied between 3.4 (SD 0.9) and 4.2 (SD 0.7) for the domains "vitality" and "bodily pain," respectively. There were no floor and ceiling effects for the total BrQ score. The BrQ showed satisfactory internal consistency in most subdomains with a Cronbach's α ranging between 0.35 for the domain "general health perception" and 0.89 for the domain "self-esteem and aesthetics." Excellent test-retest reproducibility was observed for the total BrQ score (ICC 0.91), and the BrQ was successfully validated against the SRS-22r. CONCLUSION: The translated and culturally adapted Dutch version of the BrQ is a valid and reliable HRQOL instrument for AIS patients undergoing brace treatment.

Neurological Outcomes and the Need for Retreatments Among Multiple Myeloma Patients With High-Grade Spinal Cord Compression: Radiotherapy vs Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Up to 30% of Multiple Myeloma (MM) patients are expected to experience Epidural Spinal Cord Compression (ESCC) during the course of their disease. To prevent irreversible neurological damage, timely diagnosis and treatment are important. However, debate remains regarding the optimal treatment regimen. The aim of this study was to investigate the neurological outcomes and frequency of retreatments for MM patients undergoing isolated radiotherapy and surgical interventions for high-grade (grade 2-3) ESCC. METHODS: This study included patients with MM and high-grade ESCC treated with isolated radiotherapy or surgery. Pre- and post-treatment American Spinal Injury Association (ASIA) impairment scale and retreatment rate were compared between the 2 groups. Adjusted multivariable logistic regression was utilized to examine differences in neurologic compromise, pain, and retreatments. RESULTS: A total of 247 patients were included (Radiotherapy: n = 154; Surgery: n = 93). After radiotherapy, 82 patients (53%) achieved full neurologic function (ASIA E) at the end of follow-up. Of the surgically treated patients, 67 (64%) achieved full neurologic function. In adjusted analyses, patients treated with surgery were less likely to experience neurologic deterioration within 2 years (OR = .15; 95%CI .05-.44; P = .001) and had less pain (OR = .29; 95%CI .11-.74; P = .010). Surgical treatment was not associated with an increased risk of retreatments (OR = .64; 95%CI .28-1.47; P = .29) or death (HR = .62, 95%CI .28-1.38; P = .24). CONCLUSIONS: After adjusting for baseline differences, surgically treated patients with high-grade ESCC showed better neurologic outcomes compared to patients treated with radiotherapy. There were no differences in risk of retreatment or death.

Health-related quality of life of adult, non-surgically treated patients with idiopathic scoliosis and curves above 45°: a cross-sectional study at an average follow-up of 30 years.

BACKGROUND CONTEXT: Previous studies on the natural history of moderate to severe idiopathic scoliosis show contradictory results. Some studies reported an increased incidence of back pain and disability in severe curves, while other studies reported no difference in health-related quality of life (HRQoL) compared to age-matched adult controls. None of these studies addressed HRQoL using currently recommended and validated questionnaires. PURPOSE: To examine the long-term HRQoL in non-surgically treated adult idiopathic scoliosis patients with a curve of 45° or higher. METHODS: In this retrospective cohort study, all patients were retrospectively identified in the hospital's scoliosis database. Patients (1) with idiopathic scoliosis; (2) born before 1981 (to ensure 25-year follow-up after skeletal maturity); (3) with a curve of 45° or more by Cobb's method at the end of growth; and (4) no spinal surgical treatment were selected. Patients received digital questionnaires of the Short Form-36, Scoliosis Research Society-22, Oswestry Disability Index and Numeric Rating Scale. Outcomes of the SF-36 were compared with a national reference cohort. Additional measures with questions regarding choice of education and occupation were used. RESULTS: Forty-eight of 79 (61%) eligible patients completed the questionnaires, at an average follow-up time of 29.9 ± 7.7 years. Their average age was 51.9 ± 8.0, and median Cobb angle at adolescence was 48.5°. Five of the eight SF-36 subdomains were significantly lower in the scoliosis group compared to the nationwide cohort: physical functioning (73 vs 83, p = 0.011), social functioning (75 vs 84, p = 0.022), role physical functioning (63 vs 76, p = 0.002), role emotional functioning (73 vs 82, p = 0.032), and vitality (56 vs 69, p = < 0.001). The scoliosis-specific SRS-22r score of the patients was 3.7 ± 0.7 on a 0-5 scale. The mean NRS score for pain of all patients was 4.9 ± 3.2, and eight patients (17%) reported a NRS of 0 and 31 (65%) a NRS above 3. At the Oswestry Disability Index, 79% of the patients reported minimal disabilities. Thirty-three patients (69%) reported that their scoliosis had influenced their choice of education. Fifteen patients (31%) reported that their scoliosis had influenced their choice of work. CONCLUSION: Patients with idiopathic scoliosis and curves of 45° or higher have reduced HRQoL. Although many patients experience back pain, the disability reported on the ODI was limited. Scoliosis had noteworthy effect on choice of education.

Are torso asymmetry and torso displacements in a computer brace model associated with initial in-brace correction in adolescent idiopathic scoliosis?

BACKGROUND: Lack of initial in-brace correction is strongly predictive for brace treatment failure in adolescent idiopathic scoliosis (AIS) patients. Computer-aided design (CAD) technology could be useful in quantifying the trunk in 3D and brace characteristics in order to further investigate the effect of brace modifications on initial in-brace correction and subsequently long-term brace treatment success. The purpose of this pilot study was to identify parameters obtained from 3D surface scans which influence the initial in-brace correction (IBC) in a Boston brace in patients with AIS. METHODS: Twenty-five AIS patients receiving a CAD-based Boston brace were included in this pilot study consisting of 11 patients with Lenke classification type 1 and 14 with type 5 curves. The degree of torso asymmetry and segmental peak positive and negative torso displacements were analyzed with the use of patients' 3D surface scans and brace models for potential correlations with IBC. RESULTS: The mean IBC of the major curve on AP view was 15.9% (SD = 9.1%) for the Lenke type 1 curves, and 20.1% (SD = 13.9%) for the type 5 curves. The degree of torso asymmetry was weakly correlated with patient's pre-brace major curve Cobb angle and negligible correlated with major curve IBC. Mostly weak or negligible correlations were observed between IBC and the twelve segmental peak displacements for both Lenke type 1 and 5 curves. CONCLUSION: Based on the results of this pilot study, the degree of torso asymmetry and segmental peak torso displacements in the brace model alone are not clearly associated with IBC.

The incidence of vertebral compression fractures and spinal instability in newly diagnosed multiple myeloma patients.

Background: Multiple myeloma (MM) is a hematologic malignancy, characterized by clonal proliferation of plasma cells in the bone marrow. These plasma cell proliferations frequently result in scattered osteolytic bone lesions and extensive skeletal destruction. Myeloma bone lesions are frequently located in the spine, and are associated with debilitating bone pain and an increased rate of pathologic fractures and mortality. The aim of this study was to investigate the incidence of vertebral compression fractures (VCFs) and spinal instability in patients with MM. Patients and methods: Newly diagnosed patients with MM with computed tomography (CT) scans of the spine within three months of diagnosis were identified through an electronic patient database. Clinical baseline data were manually extracted from the patient charts. Fractured levels were graded on CT scans following the Genant grading system, and spinal instability was assessed through the Spinal Instability Neoplastic Score (SINS). Results: A total of 385 patients with 6289 eligible vertebrae were eligible for inclusion. The mean age at diagnosis was 67 years, and 60% were male. At least one VCF was present in 180 patients (47%). A quarter of fractures were classified as severe. The incidence of fractures increased with more advanced disease stages, and men were more likely to have a fracture than women. Conclusions: Our data show that 47% of MM patients present with one or more VCFs at the onset of their disease, of which 20% were classified as unstable, meaning a surgical consultation is recommended.

Prosthetic Joint Infection and Wound Leakage After the Introduction of Intraoperative Wound Irrigation With a Chlorhexidine-Cetrimide Solution: A Large-Scale Before-After Study.

Background: Intraoperative chlorhexidine irrigation could be a valuable additive to systemic antibiotics to prevent infections after total joint arthroplasties. However, it may cause cytotoxicity and impair wound healing. This study evaluates the incidence of infection and wound leakage before and after the introduction of intraoperative chlorhexidine lavage. Methods: All 4453 patients receiving a primary hip or knee prosthesis between 2007 and 2013 in our hospital were retrospectively included. They all underwent intraoperative lavage before wound closure. Initially, wound irrigation with 0.9% NaCl was standard care (n = 2271). In 2008, additional irrigation with a chlorhexidine-cetrimide (CC) solution was gradually introduced (n = 2182). Data on the incidence of prosthetic joint infections and wound leakage, as well as relevant baseline and surgical characteristics, were derived from medical charts. Chi-square analysis was used to compare the incidence of infection and wound leakage between patients with and without CC irrigation. Multivariable logistic regression was used to assess robustness of these effects by adjusting for potential confounders. Results: The prosthetic infection rate was 2.2% in the group without CC irrigation vs 1.3% in the group with CC irrigation (P = .021). Wound leakage occurred in 15.6% of the group without CC irrigation and in 18.8% of the group with CC irrigation (P = .004). However, multivariable analyses showed that both findings were likely due to confounding variables, rather than by the change in intraoperative CC irrigation. Conclusions: Intraoperative wound irrigation using a CC solution does not seem to affect the risk of prosthetic joint infection or wound leakage. Observational data easily yield misleading results, so prospective randomized studies are needed to verify causal inference. Level of Evidence: Level III-uncontrolled before and after the study.

In-Brace versus Out-of-Brace Protocol for Radiographic Follow-Up of Patients with Idiopathic Scoliosis: A Retrospective Study.

The purpose of this retrospective study was to compare two standardized protocols for radiological follow-up (in-brace versus out-of-brace radiographs) to study the rate of curve progression over time in surgically treated idiopathic scoliosis (IS) patients after failed brace treatment. In-brace radiographs have the advantage that proper fit of the brace and in-brace correction can be evaluated. However, detection of progression might theoretically be more difficult. Fifty-one IS patients that underwent surgical treatment after failed brace treatment were included. For 25 patients, follow-up radiographs were taken in-brace. For the other 26 patients, brace treatment was temporarily stopped before out-of-brace follow-up radiographs were taken. Both groups showed significant curve progression compared to baseline after a mean follow-up period of 3.4 years. The protocol with in-brace radiographs was noninferior regarding curve progression rate over time. The estimated monthly Cobb angle progression based on the mixed-effect model was 0.5 degrees in both groups. No interaction effect was found for time, and patients' baseline Cobb angle (p = 0.98), and for time and patients' initial in-brace correction (p = 0.32). The results of this study indicate that with both in-brace and out-of-brace protocols for radiographic follow-up, a similar rate of curve progression can be expected over time in IS patients with failed brace treatment.

Educating Parents Improves Their Ability to Recognize Adolescent Idiopathic Scoliosis: A Diagnostic Accuracy Study.

(1) In countries where scoliosis screening programs ended, the responsibility for detection shifted from healthcare professionals to parents. Since recognizing scoliosis is difficult for parents, more patients are presenting late. Increased awareness of scoliosis may favor earlier detection. This study examines the effect of educating parents to recognize scoliosis. (2) In this cross-sectional study a consecutive group of parents completed a digital assessment. They had to complete two identical series of fourteen cases (eight with scoliosis and six without). Each case displayed two photographs of the child's back; one in standing position and one during forward-bending. Based on visual inspection, parents had to indicate if the child had to be referred to a physician. After assessing the first series, information was given on how to detect scoliosis. Subsequently, parents assessed the second series of cases. Sensitivity and specificity were calculated before and after education. (3) A total of 100 parents completed the assessment. The sensitivity to detect scoliosis was slightly but significantly higher after education (68.8% versus 74.0%; p = 0.002), while specificity was not (74.0% versus 74.8%; p = 0.457). (4) This study showed that educating parents improved their ability to recognize scoliosis without increasing the false positive referral rate. Although written instructions can bridge the gap with professional screening programs, the overall sensitivity in this study remained low. Therefore, education can improve the awareness and ability to detect scoliosis, but will not replace screening by professionals.

Pulmonary function in children and adolescents with untreated idiopathic scoliosis: a systematic review with meta-regression analysis.

BACKGROUND CONTEXT: One of the controversies in untreated idiopathic scoliosis is the influence of curve size on respiratory function. Whereas scoliosis patients with curves over 90 to 100 degrees are agreed to be at risk for cardiorespiratory failure in later life, the impairment of curves below 90 degrees is generally considered mild. Although various studies showed that pulmonary function is affected in patients with scoliosis, quantification of the relation between curve size and pulmonary function is lacking. PURPOSE: This systematic review with meta-regression analysis aims to characterize the relation between pulmonary function tests and scoliosis severity in children and adolescents with idiopathic scoliosis. STUDY DESIGN: Systematic review with meta-regression analysis. METHODS: Pubmed, Embase, Cochrane, and CINAHL were systematically searched until November 3, 2020, for original articles that reported (1) severity of scoliosis quantified in Cobb angle, and (2) pulmonary function tests in children and adolescents with untreated idiopathic scoliosis. Exclusion criteria were other types of scoliosis, non-original data, post-treatment data, and case reports. All study designs were included, and relevant study details and patient characteristics were extracted. The primary outcome was the effect of Cobb angle on pulmonary function as expressed by the slope coefficient of a linear meta-regression analysis. RESULTS: A total of 126 studies, including 8,723 patients, were retrieved. Meta-regression analysis revealed a statistically significant inverse relation between thoracic Cobb angle and absolute and predicted forced vital capacity in 1 second, forced vital capacity, vital capacity, and total lung capacity. For these outcomes, the slope coefficients showed a decrease of 1% of the predicted pulmonary function per 2.6 to 4.5 degrees of scoliosis. A multivariable meta-regression analysis of potential confounders (age, year of publication, and kyphosis) hardly affected the majority of the outcomes. CONCLUSION: This meta-regression analysis of summary data (means) from 126 studies showed an inverse relationship between the thoracic Cobb angle and pulmonary function. In contrast to previous conclusions, the decline in pulmonary function appears to be gradual over the full range of Cobb angles between <20 and >120 degrees. These findings strengthen the relevance of minimizing curve progression in children with idiopathic scoliosis.