Growth modulation response in vertebral body tethering depends primarily on magnitude of concave vertebral body growth.

PURPOSE: There is variability in clinical outcomes with vertebral body tethering (VBT) partly due to a limited understanding of the growth modulation (GM) response. We used the largest sample of patients with 3D spine reconstructions to characterize the vertebra and disc morphologic changes that accompany growth modulation during the first two years following VBT. METHODS: A multicenter registry was used to identify idiopathic scoliosis patients who underwent VBT with 2 years of follow-up. Calibrated biplanar X-rays obtained at longitudinal timepoints underwent 3D reconstruction to obtain precision morphological measurements. GM was defined as change in instrumented coronal angulation from post-op to 2-years. RESULTS: Fifty patients (mean age: 12.5 ± 1.3yrs) were analyzed over a mean of 27.7 months. GM was positively correlated with concave vertebra height growth (r = 0.57, p < 0.001), 3D spine length growth (r = 0.36, p = 0.008), and decreased convex disc height (r = - 0.42, p = 0.002). High modulators (patients experiencing GM > 10°) experienced an additional 1.6 mm (229% increase) of mean concave vertebra growth during study period compared to the Poor Modulators (GM < - 10°) group, (2.3 vs. 0.7 mm, p = 0.039), while convex vertebra height growth was similar (1.3 vs. 1.4 mm, p = 0.91). CONCLUSION: When successful, VBT enables asymmetric vertebra body growth, leading to continued postoperative coronal angulation correction (GM). A strong GM response is correlated with concave vertebral body height growth and overall instrumented spine growth. A poor GM response is associated with an increase in convex disc height (suspected tether rupture). Future studies will investigate the patient and technique-specific factors that influence increased growth remodeling.

COVID-19 significantly impacted initial consultation for idiopathic scoliosis.

INTRODUCTION: Since the outbreak of the COVID-19 pandemic, reduction of social activities and rapid adoption of telemedicine, decreasing face-to-face encounters seems to have negatively affected the timely Idiopathic Scoliosis (IS) referral with a spine specialist. We aim to document the progression of IS curves during COVID-19 pandemic reflected by the late presentation of patients at the initial visit with higher Cobb angles and to evaluate its influence on health-related quality of life scores. MATERIALS AND METHODS: All IS patients scheduled for surgery between April 2019 and September 2021 were recruited in a prospective cohort study. The patients were divided into five cohorts of 6 month duration each according to their booking date: 2 periods before the 1st COVID-19 wave, one period during and two periods afterwards. In each cohort, patients were divided into 3: those who were scheduled for posterior spinal fusion (PSF) at 1st visit, those booked for vertebral body tethering (VBT) at 1st visit, and those scheduled for surgery but who have failed brace treatment. Variables included age, gender, Risser grade and preoperative SRS-22 scores. Chi2 and ANOVA tests were used for comparison. RESULTS: 173 patients were analyzed. 33 patients (13.1 ± 3 y.o.) were scheduled between Apr and Sept 2019; 38 (13.1 y.o. ± 2) between Oct 2019 and Mar 2020; 31 (13.4 ± 3 y.o.) between Apr and Sept 2020; 30 (14.3 ± 2 y.o.) between Sept 2020 and Mar 2021; and 41 patients (13.8 ± 2 y.o.) between Apr and Sept 2021. Non-statistically significant differences were found between periods before, during or after the COVID-19 first wave regarding patients' age, gender, Risser grade and SRS-22 scores. Average Cobb angles of patients at their 1st visit after the beginning of the COVID-19 pandemic were significantly higher than those before COVID-19 (52.2° ± 7° and 56.6° ± 13° vs 47.8° ± 12° and 45.2° ± 13°; p = 0.0001). More patients were booked for PSF (p < 0.0000) through the five evaluated periods, while the indication of VBT or surgery in patients previously braced progressively decreased. CONCLUSION: Patients presented at the scoliosis clinic for the 1st time after the 1st COVID-19 wave with significantly larger Cobb angles, and likely contributed to an increased proportion of PSF, as the potential window for bracing or VBT was missed due to a delayed consultation.

Clinical and radiological outcomes of gradual reduction and circumferential fusion of high-grade spondylolisthesis in adolescents: a prospective cohort study of 29 young patients.

AIM: The objective of this study was to evaluate the safety and efficacy of a novel technique of formal reduction and circumferential fusion for pediatric high-grade spondylolisthesis (HGS). PURPOSE: The safety and efficacy of formal reduction for high-grade spondylolisthesis (HGS) has never been thoroughly examined. This study reports the outcomes of 29 children with HGS who underwent a procedure of gradual reduction and circumferential fusion. METHODS: 29 children (13 males, 16 females) were recruited between 2006 and 2010. Radiographic measurements (including % of slip, lumbosacral angle-LSA, pelvic incidence-PI, pelvic tilt-PT, sacral slope-SS, and proximal femoral angle-PFA) and quality of life assessment (SRS-22 questionnaire) were prospectively obtained at baseline and at the last post-operative follow-up (> 2 years post-op). Radiological measurements were used to classify patients according to the Spine Deformity Study Group (SDSG) classification. RESULTS: Mean baseline slip % was 69.9 ± 16.5%. There were 13 patients with a balanced pelvic (SDSG Type 4) and 16 with an unbalanced pelvis (SDSG Type 5 and 6). On average, a reduction of 45.5 ± 15.3% (range 20-86%) was achieved safely with no major complication. In particular, of the 29 patients, only 3 had a L5 radiculopathy postoperatively that was self-resolved at follow-up. From a radiological standpoint, we observed a mean improvement of LSA from 80.3 ± 17.9° to 91.7 ± 13.6°. We also observed a statistically significant improvement in global HRQOL, and in the function and body image domains. CONCLUSION: This prospective study suggests that formal reduction of HGS followed by circumferential fusion is safe when using a standardized surgical technique based on gradual reduction. Performing this intervention could also help improve QOL in some patients.

A modified position for optimized skeletal maturity assessment of AIS patients and its impact on 3D spinal and pelvic parameters.

PURPOSE: A hands-on-wall (HOW) position for low-dose stereoradiography of adolescent idiopathic scoliosis (AIS) patients would allow for skeletal maturity assessment of the hand and wrist. Our aims were twofold: confirm the reliability and validity of skeletal maturity assessment using the HOW radiographs and compare the spinal and pelvic 3D parameters to those of standard hands-on-cheeks (HOC) stereoradiographs. METHODS: Seventy AIS patients underwent two successive stereoradiographs and a standard hand and wrist radiograph on the same day. Patients were randomly assigned to begin with HOW and follow with HOC, or vice versa. Raters assessed digital skeletal age (DSA), Sanders Simplified Skeletal Maturity (SSMS) and Thumb Ossification Composite Index (TOCI). 3D reconstructions of the spine and pelvis bones were performed for each stereoradiograph to measure nine clinically relevant spinal and pelvic 3D parameters. RESULTS: Inter-rater and intra-rater reliabilities were excellent for DSA, SSMS and TOCI with both standard radiographs and HOW (ICC > 0.95). Strong correlation was found between ratings of both imaging types (ICC > 0.95). In the 3D reconstructions, kyphosis and sacral slope were slightly decreased in the HOW position, but within the clinical margin of error. All other parameters did not differ significantly between positions (p < 0.05). CONCLUSION: The results suggest that HOW stereoradiographs allow clinicians to assess skeletal maturity of the hand and wrist with adequate reliability and validity. We recommend that scoliosis clinics adopt the HOW position to assess skeletal maturity because there is no significant clinical impact on the spinal and pelvic evaluation, and on radiation exposure, cost or time.

Construct validity and reliability of a French-Canadian translation of the eating in the absence of hunger questionnaire for children and adolescents.

Eating in the absence of hunger (EAH) has been associated with overweight and obesity during childhood. The gold standard to assess this behavior is a laboratory-based protocol, but a questionnaire to assess EAH more efficiently in children and adolescents has been developed and validated in English. We assessed construct validity (structural and convergent validity) and reliability (internal consistency and temporal stability) of a French translation of the EAH Questionnaire for Children and Adolescents among French-Canadian youths. We recruited participants in Montreal (Canada) aged 7-15 years old, who completed the questionnaire and provided anthropometric data. We asked participants to complete the questionnaire a second time ~4 weeks later. The questionnaire consists of 14 questions and 3 subscales that assess EAH due to negative affect, fatigue/boredom and external cues. We performed an exploratory factor analysis to test the factor structure and we calculated Cronbach alpha coefficients and intra-class correlations to assess internal consistency and temporal stability, respectively. We assessed associations between EAH and BMI z-score using Pearson correlations. We included 196 participants (50% girls; mean (SD) 11.9 (2.3) years old) for the first completion and 153 for the second completion. The exploratory factor analysis generated the same 3 subscales as the original questionnaire: negative affect (α=0.86; ICC=0.78), fatigue/boredom (α=0.75; ICC=0.70), and external cues (α=0.68; ICC=0.68). Participant's BMI z-scores were positively associated with the average scores from the negative affect subscale (r=0.19; ρ=0.009). Our results suggest that this questionnaire had an adequate construct validity, internal consistency, and temporal stability.

Analysis of three-dimensional spine growth for vertebral body tethering patients at 2 and 5 years post operatively.

PURPOSE: Scoliosis can be treated with vertebral body tethering (VBT) as a motion-sparing procedure. However, the knowledge of how growth is affected by a tether spanning multiple levels is unclear in the literature. Three-dimensional true spine length (3D-TSL) is a validated assessment technique that accounts for the shape of the spine in both the coronal and sagittal planes. This study aimed to assess if 3D-TSL increases over a five-year period after VBT implantation in thoracic curves for idiopathic scoliosis. METHODS: Prospectively collected radiographic data from an international pediatric spine registry was analyzed. Complete radiographic data over three visits (post-operative, 2 years, and 5 years) was available for 53 patients who underwent VBT. RESULTS: The mean age at instrumentation of this cohort was 12.2 (9-15) years. The average number of vertebrae instrumented was 7.3 (SD 0.7). Maximum Cobb angles were 50° pre-op, which improved to 26° post-op (p < 0.001) and was maintained at 5 years (30°; p = 0.543). Instrumented Cobb angle was 22° at 5 years (p < 0.001 vs 5-year maximum Cobb angle). An accentuation was seen in global kyphosis from 29° pre-operative to 41° at 5 years (p < 0.05). The global spine length (T1-S1 3D-TSL) started at 40.6 cm; measured 42.8 cm at 2 years; and 44.0 cm at the final visit (all p < 0.05). At 5 years, patients reached an average T1-S1 length that is comparable to a normal population at maturity. Immediate mean post-operative instrumented 3D-TSL (top of UIV-top of LIV) was 13.8 cm two-year length was 14.3 cm; and five-year length was 14.6 cm (all p < 0.05). The mean growth of 0.09 cm per instrumented level at 2 years was approximately 50% of normal thoracic growth. Patients who grew more than 0.5 cm at 2 years had a significantly lower BMI (17.0 vs 19.0, p < 0.05) and smaller pre-operative scoliosis (48° vs 53°, p < 0.05). Other subgroup analyses were not significant for age, skeletal maturity, Cobb angles or number of spanned vertebras as contributing factors. CONCLUSIONS: This series demonstrates that 3D-TSL increased significantly over the thoracic instrumented levels after VBT surgery for idiopathic scoliosis. This represented approximately 50% of expected normal thoracic growth over 2 years.

Three-dimensional vertebral shape changes confirm growth modulation after anterior vertebral body tethering for idiopathic scoliosis.

PURPOSE: To evaluate three-dimensional (3D) vertebra and disk shape changes over 2 years following anterior vertebral body tether (AVBT) placement in patients with idiopathic scoliosis (IS). METHODS: Patients with right thoracic IS treated with AVBT were retrospectively evaluated. 3D reconstructions were created from biplanar radiographs. Vertebral body and disk height (anterior, posterior, left and right) and shape (wedging angle) were recorded over the three apical segments in the local vertebral reference planes. Changes in height and wedging were measured through 2 years postoperatively. Change in patient height was correlated with changes in the spine dimensions. RESULTS: Forty-nine patients (Risser 0-3, Sanders 2-4) were included. The mean age was 12.2 ± 1.4 years (range 8-14). The mean coronal curve was 51 ± 10° preoperatively, 31 ± 9° at first postoperative time point and 27 ± 11° at 2-year follow-up (p < 0.001). The mean patient height increased 8 cm by 2 years (p < 0.001). The left side of the spine (vertebra + disc) grew in height by 2.2 mm/level versus 0.7 mm/level on the right side (p < 0.001). This differential growth was composed of 0.5 mm/vertebral level and 1.0 mm/disk level. Evaluation of the change in disk heights showed significantly decreased height anteriorly (- 0.4 mm), posteriorly (- 0.3 mm) and on the right (- 0.5 mm) from FE to 2 years. Coronal wedging reduced 2.3°/level with 1.1°/vertebral level change and 1.2°/disk level. There was no differential growth in the sagittal plane (anterior/posterior height). Patient height change moderately correlated with 3D measures of vertebra + disk shape changes. CONCLUSIONS: Three-dimensional analysis confirms AVBT in skeletally immature patients results in asymmetric growth of the apical spine segments. The left (untethered) side length increased more than 3 × than the right (tethered) side length with differential effects observed within the vertebral bodies and disks, each correlating with overall patient height change.

Association between the GLP1R A316T Mutation and Adolescent Idiopathic Scoliosis in French Canadian and Italian Cohorts.

Studies have revealed anthropometric discrepancies in girls with adolescent idiopathic scoliosis (AIS) compared to non-scoliotic subjects, such as a higher stature, lower weight, and lower body mass index. While the causes are still unknown, it was proposed that metabolic hormones could play a role in AIS pathophysiology. Our objectives were to evaluate the association of GLP1R A316T polymorphism in AIS susceptibility and to study its relationship with disease severity and progression. We performed a retrospective case-control association study with controls and AIS patients from an Italian and French Canadian cohort. The GLP1R rs10305492 polymorphism was genotyped in 1025 subjects (313 non-scoliotic controls and 712 AIS patients) using a validated TaqMan allelic discrimination assay. Associations were evaluated by odds ratio and 95% confidence intervals. In the AIS group, there was a higher frequency of the variant genotype A/G (4.2% vs. 1.3%, OR = 3.40, p = 0.016) and allele A (2.1% vs. 0.6%, OR = 3.35, p = 0.017) than controls. When the AIS group was stratified for severity (≤40° vs. >40°), progression of the disease (progressor vs. non-progressor), curve type, or body mass index, there was no statistically significant difference in the distribution of the polymorphism. Our results support that the GLP1R A316T polymorphism is associated with a higher risk of developing AIS, but without being associated with disease severity and progression.

Differential vertebral body growth is maintained after vertebral body tethering surgery for idiopathic scoliosis: 4-year follow-up on 888 peri-apical vertebrae and 592 intervertebral discs.

PURPOSE: To radiographically evaluate if vertebral body tethering (VBT) can maintain differential peri-apical vertebral growth at medium-term follow-up of 4 years. METHODS: A prospective, international, multicenter database was queried to identify idiopathic scoliosis patients treated with thoracic VBT. Concave vs. convex vertebral body height, vertebral wedging, and disc wedging of the 3 peri-apical vertebrae were measured by two independent observers at 5 timepoints (pre-operative to 4-year follow-up). RESULTS: 65 skeletally immature patients (60 female, mean 12.8 years old, 21 with open triradiate cartilages) met inclusion criteria. Mean pre-operative maximum scoliosis of 50 ± 8° decreased significantly post-operatively to 27 ± 9° (p < 0.001), which remained stable at 4-year follow-up 30 ± 17° (p = 0.38 vs. post-operative). Mean instrumented scoliosis was 21 ± 14° at 4-year follow-up, which was significantly different than 4-year maximum scoliosis (p < 0.001). Mean pre-operative kyphosis of 30 ± 12° did not significantly change post-operatively (p = 1.0) and remained stable at 4-year follow-up (35 ± 18°; p = 0.05). Mean individual convex vertebral height increased from 17.7 ± 1.9 mm to 19.8 ± 1.5 mm (p < 0.001), while mean individual concave height increased from 14.8 ± 1.9 mm to 17.6 ± 1.6 mm (p < 0.001). Summing the peri-apical heights, the difference in height from pre-operative to 4-year follow-up was greater on the concave (8.3 ± 4.7 mm) than on the convex side (6.2 ± 4.7 mm) (p < 0.001). Mean individual vertebral wedging decreased from 6 ± 2° at pre-operative to 4 ± 2° at 4-year follow-up (p < 0.001). Mean total vertebral and disc wedging started at 29 ± 7° pre-operatively, decreased to 16 ± 6° at post-operative (p < 0.001), then further decreased to 14 ± 8° at 4-year follow-up (p < 0.001). Patients with open triradiate cartilages at the time of surgery had a larger height change over the 4 years compared to those with closed triradiate cartilages (p < 0.001). CONCLUSION: Patients with idiopathic scoliosis treated with VBT demonstrated differential vertebral growth which was maintained at minimum 4-year follow-up. This effect was more pronounced in patients whose triradiate cartilages were open at the time of surgery. LEVEL OF EVIDENCE: III.

Changes in trunk appearance following surgical correction of adolescent idiopathic scoliosis.

PURPOSE: To assess the postoperative appearance of the trunk in surgically treated scoliosis patients after a 2 year follow-up using reliable indices and compare the results with 6-month follow-up. METHODS: Forty-six Adolescent Idiopathic Scoliosis (AIS) patients (female; preop mean age 14.4 ± 2.4 years) who underwent a posterior spinal fusion from 2009 to 2018 were included in this study. All had Lenke 1A thoracic curves, with surface topography taken preoperatively, 6 months and 2 years postoperatively. To assess spinal deformity, we measured the proximal thoracic, main thoracic and thoracolumbar/lumbar Cobb angles in the frontal plane from spinal X-rays and inclinometer angles in the thoracic and lumbar regions. To assess trunk deformity, Back Surface Rotation (BSR) and Trunk Lateral Shift (TLS) were computed along the trunk. We analysed the effect of age, height, weight, Cobb angle, length of follow-up, and surgical technique. We also compared correction rates (CRs) of the spinal and trunk measurements after 6 months and 2 years. RESULTS: Good spinal correction was achieved, with Cobb angles decreasing in the whole cohort. CRs for TLS and BSR were positive (denoting improvement) for 76% and 48% of patients, respectively, after 2 years. Compared with 6 months, the mean TLS CR increased while there was no improvement for BSR on average. We found no significant association after 2 years between truncal index CRs and clinical variables (age, height, weight, preoperative Cobb angles) or surgical technique. However, there were significant correlations between the CRs of TLS and the main thoracic Cobb angle (r = 0.35), and between the CRs of BSR and thoracic inclinometer angle. CONCLUSION: Although more than 55% of the TLS was corrected after 2 years of follow-up, the BSR remained stable over time and the persistence of rib hump on the back surface could be observed. LEVEL OF EVIDENCE: III.

Coronal decompensation following thoracic vertebral body tethering in idiopathic scoliosis.

PURPOSE: Post-operative coronal decompensation (CD) continues to be a challenge in the treatment of adolescent idiopathic scoliosis (AIS). CD following selective spinal fusion has been studied. However, there is currently little information regarding CD following Vertebral Body Tethering (VBT). Thus, the goal of this study is to better understand the incidence and risk factors for CD after VBT. METHODS: Retrospective review of a prospective multicenter database was used for analysis. Inclusion criteria were patients undergoing thoracic VBT, a minimum 2-year follow-up, LIV was L1 or above, skeletally immature (Risser ≤ 1), and available preoperative and final follow-up AP and lateral upright radiographs. Radiographic parameters including major and minor Cobb angles, curve type, LIV tilt/translation, L4 tilt, and coronal balance were measured. CD was defined as the distance between C7PL and CSVL > 2 cm. Multiple logistic regression model was used to identify significant predictors of CD. RESULTS: Out of 136 patients undergoing VBT, 94 patients (86 female and 6 male) met the inclusion criteria. The mean age at surgery was 12.1 (9-16) and mean follow-up period was 3.4 years (2-5 years). Major and minor curves, AVR, coronal balance, LIV translation, LIV tilt, L4 tilt were significantly improved after surgery. CD occurred in 11% at final follow-up. Lenke 1A-R (24%) and 1C (26%) had greater incidence of CD compared to 1A-L (4%), 2 (0%), and 3 (0%). LIV selection was not associated with CD. Multivariate logistic regression analysis yielded 1A-R and 1C curves as a predictor of CD with the odds ratio being 17.0. CONCLUSION: CD occurred in 11% of our thoracic VBT patients. Lenke 1A-R and 1C curve types were predictors for CD in patients treated with VBT. There were no other preoperative predictors associated with CD.

3D analysis of the preoperative deformity in AIS can be used to guide surgical treatment decisions for selective thoracic fusion.

PURPOSE: To identify 3D measures of scoliosis from preoperative imaging that are associated with optimal radiographic outcomes after selective thoracic fusion (STF) for adolescent idiopathic scoliosis (AIS). METHODS: Subjects with primary thoracic curves (Lenke 1-4, B or C modifiers) fused selectively (L1 or above) who had preoperative 3D reconstructions and minimum 2 years of follow-up were included. An optimal outcome at 2 years was defined as having 4 of 5 parameters previously defined in the literature: (1) lumbar curve < 26º, (2) deformity flexibility quotient < 4, (3) C7-CSVL < 2 cm, (4) lumbar prominence < 5º and (5) trunk shift < 1.5 cm. Univariate and CART analyses were performed to identify preoperative variables associated with achieving an optimal outcome 2 years postoperatively. RESULTS: Ninety-nine (88F, 11 M) patients met inclusion. Mean age was 15 ± 2 years. Fifty-one subjects (52%) had an optimal outcome. Seven preoperative deformity measures representing smaller thoracolumbar/lumbar deformity in the optimal group were found to be significant on univariate analysis. CART analysis identified the following variables associated with optimal outcomes: difference in apical rotation > 30° = 27% optimal outcomes, difference in apical rotation ≤ 30° and coronal vertebral wedging of lumbar apex > 3° = 46% optimal outcomes, and difference in apical rotation ≤ 30° and coronal vertebral wedging of lumbar apex ≤ 3° = 80% optimal outcomes (p < 0.05). CONCLUSION: Optimal outcomes after STF were associated with a preoperative difference in apical vertebral rotation in the axial plane less than 30° between thoracic and lumbar curves as well as coronal plane vertebral wedging of the lumbar apical vertebra less than 3°.

Vertebral body tethering for Lenke 1A curves: the lumbar modifier predicts less optimal outcomes.

INTRODUCTION: The addition of the L4 "AR" and "AL" lumbar modifier for Lenke 1A idiopathic scoliosis (IS) has been shown to direct treatment in posterior spinal fusion; however, its utility in vertebral body tethering (VBT) has yet to be evaluated. METHODS: A review of a prospective, multicenter database for VBT in IS was performed for patients with Lenke 1A deformities and a minimum of 2 years follow-up. Patients were categorized by their lumbar modifier (AR vs AL). Less optimal VBT outcome (LOVO) was defined as a final coronal curve > 35°, lumbar adding-on, or revision surgery for deformity progression or adding-on. RESULTS: Ninety-nine patients met inclusion criteria (81% female, mean 12.6 years), with 55.6% being AL curves. Overall, there were 23 instances of tether breakage (23.3%) and 20 instances of LOVO (20.2%). There was a higher rate of LOVO in AR curves (31.8% vs 10.9%, P = 0.01). Patients with LOVO had greater preoperative deformity, greater apical translation, larger coronal deformity on first erect radiographs, and less coronal deformity correction. Failure to correct the deformity < 30° on first erect was associated with LOVO, as was LIV selection short of the last touch vertebra (TV). Independent risk factors for LOVO included AR curves (OR 3.4; P = 0.04) and first erect curve magnitudes > 30 degrees (OR 6.0; P = 0.002). DISCUSSION: There is a 20.2% rate of less optimal VBT following VBT for Lenke 1A curves. AR curves are independently predictive of less optimal outcomes following VBT and require close attention to LIV selection. Surgeons should consider achieving an initial coronal correction < 30 degrees and extending the LIV to at least the TV to minimize the risk of LOVO.

Automatic assessment of scoliosis surgery outcome on trunk shape using left-right trunk asymmetry.

PURPOSE: To present a novel set of Left-Right Trunk Asymmetry (LRTA) indices and use them to assess the postoperative appearance of the trunk in Adolescent Idiopathic Scoliosis (AIS) patients. METHODS: We hypothesize that LRTA measurements provide complementary information to existing trunk asymmetry indices when documenting the outcome of scoliosis surgery. Forty-nine AIS patients with thoracic curves who underwent posterior spinal fusion were included. All had surface topography scans taken preoperatively and at least 6 months postoperatively. We documented spinal curvature using Radiographic Cobb angles, scoliometer readings and coronal balance. To evaluate Global Trunk Asymmetry (GTA), we used the standard measures of Back Surface Rotation (BSR) and Trunk Lateral Shift (TLS). To measure LRTA, we identified asymmetry areas as regions of significant deviation between the left and right sides of the 3D back surface. New parameters called Deformation Rate (DR) and Maximum Asymmetry (MA) were measured in different regions based on the asymmetry areas. We compared the GTA and LRTA changes with those in spinal curvature before and after surgery. RESULTS: The GTA indices, mainly TLS, showed improvement for more than 75% of patients. There was significant improvement of LRTA in the shoulder blades and waist regions (95% and 80% of patients respectively). CONCLUSION: We report positive outcomes for LRTA in the majority of patients, specifically in the shoulder blades and waist, even when no reduction of BSR is observed. The proposed indices can evaluate local trunk asymmetries and the degree to which they are improved or worsened after scoliosis surgery.

Incidence of Tether Breakage in Anterior Vertebral Body Tethering.

BACKGROUND: Thoracic anterior vertebral body tethering (TAVBT) is an emerging treatment for adolescent idiopathic scoliosis. Tether breakage is a known complication of TAVBT with incompletely known incidence. We aim to define the incidence of tether breakage in patients with adolescent idiopathic scoliosis who undergo TAVBT. The incidence of tether breakage in TAVBT is hypothesized to be high and increase with time postoperatively. METHODS: All patients with right-sided, thoracic curves who underwent TAVBT with at least 2 and up to 3 years of radiographic follow-up were included. Tether breakage between 2 vertebrae was defined a priori as any increase in adjacent screw angle >5 degrees from the minimum over the follow-up period. The presence and timing of tether breakage were noted for each patient. A Kaplan-Meier survival analysis was performed to calculate expected tether breakage up to 36 months. χ 2 analysis was performed to examine the relationship between tether breakage and reoperations. Independent t test was used to compare the average final Cobb angle between cohorts. RESULTS: In total, 208 patients from 10 centers were included in our review. Radiographically identified tether breakage occurred in 75 patients (36%). The initial break occurred at or beyond 24 months in 66 patients (88%). Kaplan-Meier survival analysis estimated the cumulative rate of expected tether breakage to be 19% at 24 months, increasing to 50% at 36 months. Twenty-one patients (28%) with a radiographically identified tether breakage went on to require reoperation, with 9 patients (12%) requiring conversion to posterior spinal fusion. Patients with a radiographically identified tether breakage went on to require conversion to posterior spinal fusion more often than those patients without identified tether breakage (12% vs. 2%; P =0.004). The average major coronal curve angle at final follow-up was significantly larger for patients with radiographically identified tether breakage than for those without tether breakage (31 deg±12 deg vs. 26 deg±12 deg; P =0.002). CONCLUSIONS: The incidence of tether breakage in TAVBT is high, and it is expected to occur in 50% of patients by 36 months postoperatively. LEVEL OF EVIDENCE: Level IV.

Ovine model of congenital chest wall and spine deformity: From birth to 3 months follow-up.

Background: The evolution and treatment of lung alterations related to congenital spine and chest wall deformities (CWD) are poorly understood. Most animal models of CWD created postnatally were not evaluated for respiratory function. The goal of our study was to evaluate the effects of a CWD induced in utero on lung growth and function in an ovine model. Methods: A CWD was induced in utero at 70-75 days of gestation in 14 ovine fetuses by resection of the 7th and 8th left ribs. Each non-operated twin fetus was taken as control. Respiratory mechanics was studied postnatally in the first week and at 1, 2, and 3 months. Post-mortem respiratory mechanics and lung histomorphometry were also assessed at 3 months. Results: Eight out of 14 CWD lambs (57%) and 14 control lambs survived the postnatal period. One severe and five mild deformities were induced. At birth, inspiratory capacity (25 vs. 32 mL/kg in controls), and dynamic (1.4 vs. 1.8 mL/cmH2O/kg), and static (2.0 vs. 2.5 mL/cmH2O/kg) respiratory system compliances were decreased in CWD lambs. Apart from a slight decrease in inspiratory capacity at 1 month of life, no other differences were observed in respiratory mechanics measured in vivo thereafter. Postmortem measurements found a significant decrease in lung compliance-for each lung and for both lungs taken together-in CWD lambs. No differences in lung histology were detected at 3 months in CWD animals compared to controls. Conclusions: Our study is the first to assess the effects of a prenatally induced CWD on lung development and function from birth to 3 months in an ovine model. Our results show no significant differences in lung histomorphometry at 3 months in CWD lambs compared to controls. Resolution at 1 month of the alterations in respiratory mechanics present at birth may be related to the challenge in inducing severe deformities.

The Effect of Implant Density on Adolescent Idiopathic Scoliosis Fusion: Results of the Minimize Implants Maximize Outcomes Randomized Clinical Trial.

BACKGROUND: Severe adolescent idiopathic scoliosis (AIS) can be treated with instrumented fusion, but the number of anchors needed for optimal correction is controversial. METHODS: We conducted a multicenter, randomized study that included patients undergoing spinal fusion for single thoracic curves between 45° and 65°, the most common form of operatively treated AIS. Of the 211 patients randomized, 108 were assigned to a high-density screw pattern and 103, to a low-density screw pattern. Surgeons were instructed to use ≥1.8 implants per spinal level fused for patients in the high-implant-density group or ≤1.4 implants per spinal level fused for patients in the low-implant-density group. The primary outcome measure was the percent correction of the coronal curve at the 2-year follow-up. The power analysis for this trial required 174 patients to show equivalence, defined as a 95% confidence interval (CI) within a ±10% correction margin with a probability of 90%. RESULTS: In the intention-to-treat analysis, the mean percent correction of the coronal curve was equivalent between the high-density and low-density groups at the 2-year follow-up (67.6% versus 65.7%; difference, -1.9% [95% CI: -6.1%, 2.2%]). In the per-protocol cohorts, the mean percent correction of the coronal curve was also equivalent between the 2 groups at the 2-year follow-up (65.0% versus 66.1%; difference, 1.1% [95% CI: -3.0%, 5.2%]). A total of 6 patients in the low-density group and 5 patients in the high-density group required reoperation (p = 1.0). CONCLUSIONS: In the setting of spinal fusion for primary thoracic AIS curves between 45° and 65°, the percent coronal curve correction obtained with use of a low-implant-density construct and that obtained with use of a high-implant-density construct were equivalent. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Does radiographic calibration affect linear radiographic measurements in a large pediatric spine registry?

PURPOSE: Large registries are increasingly at the forefront of modern pediatric spine research, with manual, centralized, trained radiographic measurement serving as the gold standard for spine research. However, there is limited data regarding the reliability of registry measurements which may be subject to differences in radiographic calibration. We undertook this study to evaluate reliability of T1-T12 height, L1-S1 height, and coronal balance measurements for a large registry of early onset scoliosis patients. METHODS: Three trained technicians from the Pediatric Spine Study Group measured 43 radiographs for T1-T12, L1-S1, and coronal balance using 3 different calibration techniques. All radiographs were AP views of patients with magnetically controlled growing rods with known diameters. The calibration techniques used a pre-export manually drawn line, a digital automatically generated computerized marker, and the diameter of a magnetically controlled growing rod. The intraclass correlation coefficient (ICC) was calculated to determine reliability. RESULTS: 1161 measurements were performed. For each of the three raters, coronal balance, T1-T12 height and L1-S1 height had excellent agreement regardless of the calibration technique (alpha 0.93-1.0). Among the parameters, coronal balance had the worst inter-rater reliability, whereas there was excellent interrater reliability regarding T1-T12 height and L1-S1 height (alpha 0.91-0.99). CONCLUSION: There was excellent agreement among reviewers and between the 3 different calibration techniques. While calibration using rod diameter served as the gold standard, this data shows that other standard calibration methods were adequate and achieved excellent reliability for registry radiographs.

Pre-operative parameters influencing vertebral body tethering outcomes: patient's characteristics play an important role in determining the outcomes at a minimum of 2 years post-op.

PURPOSE: The aim of this study is to determine preoperative predictors of good radiographic outcomes in VBT patients at a minimum 2-year follow-up. METHODS: From a single-center dataset, we reviewed patients who underwent VBT from January 2014 to November 2018. Data analysis included age, gender, Risser grade and biometric data. Radiographically, maximum Cobb angle, C-DAR and apical vertebral and disc wedging were measured preop and at a minimum 2-year follow-up. Patients were divided into two cohorts following two different outcome measures: (1) vertebral growth modulation, those patients that growth modulated or corrected ≥ 5° and those who did not; and (2) Maximum Cobb angle at 2 years, < and ≥ 40°. Student T and Chi2 tests were used for comparison and a multiple linear correlation test was implemented between statistically significant variables. RESULTS: 79 patients were recruited. 26 patients (33%) did growth modulate their spine at 2-year follow-up. These patients were significantly younger, and more skeletally immature with less height (147 cm vs 155 cm; p < 0.0001), weight (38 kg vs. 45 kg; p = 0.0009) and BMI (17 vs 18.8; p = 0.0229) as those who did not. Multiple linear regression model with these variables resulted in a moderate correlation (r2 = 0.234). 67 patients (85%) finished at a 2-year follow-up with a maximum Cobb angle < 40°. These patients were also younger and skeletally immature. We found significant differences in outcome 2 regarding the average preoperative maximum Cobb angle (48.5° ± 9.5 vs. 59.1° ± 10), average C-DAR (7 ± 1.5 vs. 8.5 ± 2.1), average apical vertebral wedging (6.5° vs. 8.3°), average vertebral/disc wedging ratio (1.5 vs. 2.4) and the average immediate postoperative Cobb angle (25° vs. 38°). These variables predicted a 36% of the variation in final Cobb angle measurement at a 2-year follow-up (r2 = 0.362). CONCLUSION: Curve severity determined by a preoperative C-DAR, preoperative Cobb angles and immediate postoperative Cobb angle are significantly related to curves < 40° at a minimum 2-year follow-up, while the potential to growth modulate the spine is more dependent on skeletal maturity, lower body weight and lower BMI. These patients' characteristics should be considered preoperatively.

A Surgical Treatment Algorithm for Restoring Pelvic Balance and Health-related Quality of Life in High-grade Lumbosacral Spondylolisthesis: Prospective Multicenter Cohort of 61 Young Patients.

STUDY DESIGN: Retrospective multicenter cohort-study. OBJECTIVE: We propose an evidence-based surgical algorithm for achieving normal pelvic balance while optimizing health-related quality of life (HRQoL) in high-grade spondylolisthesis. SUMMARY OF BACKGROUND DATA: The principles of surgical treatment for young patients with high-grade L5-S1 spondylolisthesis remain unclear. There is a growing body of evidence supporting the central role of pelvic balance in the postural control and biomechanics of subjects with high-grade spondylolisthesis. METHODS: This retrospective study assessed a multicenter cohort of 61 patients with high-grade L5-S1 spondylolisthesis. Classification and regression tree analysis was used to identify objective criteria associated with pelvic balance and HRQoL after surgery. RESULTS: The most important predictor of a postoperative balanced pelvis was a postoperative L5 incidence ≤63.5 degrees. With postoperative L5 incidence ≤63.5 degrees,a residual slip percentage 9% and performing an L5-S1 posterior lumbar interbody fusion (PLIF)/transforaminal lumbar interbody fusion (TLIF) increased the likelihood of achieving a balanced pelvis postoperatively. When L5 incidence was 63.5 degrees,a balanced pelvis was most likely achieved with fusion limited to L5 proximally, residual slip percentage ≤40%, and residual lumbosacral angle 98 degrees. Predictors of postoperative HRQoL were the preoperative HRQoL score, L5 incidence and slip percentage. CONCLUSIONS: A surgical algorithm is proposed to achieve normal pelvic balance, while optimizing HRQoL. The first step during surgery is to assess L5 incidence and if L5 incidence is <65 degrees, the next step depends on the pelvic balance. With a preoperative balanced pelvis, it is important not to reduce completely the slip percentage by leaving a slip percentage ≥10%. When the preoperative pelvis is unbalanced, a TLIF/PLIF at L5-S1 is recommended to facilitate correcting the angular deformity at L5-S1. If L5 incidence is ≥65 degrees,a TLIF/PLIF at L5-S1 should be performed to correct the angular deformity at L5-S1, and fusion should ideally end at L5 proximally, in addition to performing gradual reduction of the slip percentage. If fusion up to L4 is required, a lumbosacral angle ≥100 degrees is key.