Concomitant low-grade isthmic L5-spondylolisthesis does not affect the course of adolescent idiopathic scoliosis.

BACKGROUND: Scoliosis with spondylolisthesis was described in 4.4-48%. No information on clinical impact or outcome is available. PURPOSE: To determine the prevalence of this pathology and to investigate its affect on the course of adolescent idiopathic scoliosis (AIS). METHODS: A retrospective comparative study using patients' records, radiographs, the national inpatient registry, and Patient-rated outcome measures (PROM): Oswestry disability index (ODI), modif.SRS-24 questionnaire, WHO-Quality of life index (WHOQoL), Numerical rating scale (NRS) for pain. Clinical follow-up time was 4.4 (4.3) years, and follow-up rate was 95%. PROM follow-up time 26.4 (2.8) years χ2 statistics and t-tests were applied. Significance threshold was set at P < 0.05. RESULTS: Out of 1531 consecutive Caucasian AIS patients, aged 13.9 (1.8) years, primary curve 29.2 (11.5) drs., 120 (7.8%) had low-grade isthmic L5-slip of mean 15.0 (8.3)% (Study group = S). The distribution of the curve types in the study group was comparable to the remaining 1411 patients with AIS only. In comparison with a pair-matched control group (C) at admission, back pain interfering with activities of daily living had 4.2% of the study group and 1.7% of the control group, at clinical follow-up 2.6/4.2% resp. (n.s.). Between groups S/C, there was no significant difference concerning scoliosis treatment: observation 38.3/45.8%, bracing 48.3/46.6%, surgery 10.8/10.2%. Results of treatment were equal in both groups. Long-term outcomes (ODI, SRS-24, WHOQoL, NRS-back/leg pain) were comparable. CONCLUSIONS: The prevalence of low-grade isthmic L5-spondylolisthesis in AIS patients was 7.8%. The presence of low-grade isthmic spondylolisthesis did not influence the curve type of AIS nor did it affect the course or long-term outcome. These slides can be retrieved under Electronic Supplementary Material.

Operative treatment of isthmic spondylolisthesis in children: a long-term, retrospective comparative study with matched cohorts.

The purpose of the present study was to compare the long-term clinical, functional and radiographic outcomes of young patients operated on before or at the onset of puberty (Children) and those operated on after that (Adolescents). The study group consisted of 298 patients operated on under the age of 20 years; 55 of them were operated on before or at the onset of growth spurt (29 females<12.5 years, 26 males<14.5 years). Preoperative data were retrieved from patients' records. After mean follow-up of 17 years (10.7-26.3), physical examination, radiographic measurements and functional testing were performed by independent observers. SRS-24, Oswestry Disability Index (ODI), and Visual Analogue Scale (VAS) were utilised to evaluate health-related quality of life. The data were compared between the two age groups in the whole study population and in 41 pairs of patients matched by gender, operative method, severity of preoperative slip, and age at follow-up. Preoperatively, one-third of children did not have significant pain symptoms. They were operated upon for resistant postural anomalies in combination with high risk of slip progression. All of the adolescents had low-back pain as the main clinical symptom. The outcomes were satisfactory in both groups in the whole population (children vs. adolescents; low-grade slip: SRS-24: 95.9 vs. 92.0, ODI: 5.2 vs. 7.5, VAS low-back pain: 18.9 vs. 21.2; high-grade slip: SRS-24: 95.6 vs. 90.6, ODI: 3.4 vs. 6.9, VAS low-back pain: 10.5 vs. 22.1). The differences were statistically significant for ODI and VAS in high-grade patients in favor of the children. The clinical relevance of these differences seems to be minimal. The results of the comparison of the matched cohorts were comparably good. One-fifth of the whole study group had a non-union which did not affect the final outcome. In the children with high-grade slips, there was a mean slip improvement of 14 percentage points due to remodelling. The overall complication rate in the whole population was 7.7%. In conclusion, spinal fusion can be carried out at an early age for low- and high-grade spondylolisthesis with good long-term clinical, functional, radiographic and health-related quality-of-life outcomes when the indications are met.

Treatment of spinal deformities in patients with diastrophic dysplasia: a long-term, population based, retrospective outcome study.

STUDY DESIGN: A long-term, population based, retrospective follow-up study. OBJECTIVE: To evaluate long-term outcomes of brace and surgical treatment for spinal deformities in patients with diastrophic dysplasia (DD). SUMMARY OF BACKGROUND DATA: Literature on the brace treatment and surgery of spinal deformities in patients with DD is limited. METHODS: All patients with DD undergoing either brace treatment or surgery for spinal deformity with a minimum of 2 years follow-up were identified in our country. Eight patients had undergone brace treatment and 12 had been treated operatively. Two patients had early progressive and the rest idiopathic-like scoliosis. Five patients underwent posterior only, 1 anterior only, and 6 anteroposterior surgery. Patients' mean age at the beginning of brace treatment was 6.9 (range, 0.9-12.7) years and at the time of surgery 13.4 (range, 6.5-20.1) years. The follow-up time averaged 17 (range, 6.6-44.3) years for the brace and 14.0 (range, 2.1-37.2) years for the surgical treatment group. The radiographic follow-up rate was 100%. RESULTS: Both thoracic and lumbar curves progressed during brace treatment (mean major curve progression 12%, range, -43%-53%). Before surgery, the mean Cobb angle of the thoracic curve was 68 degrees (range, 42 degrees-100 degrees) and 46 degrees (25 degrees-68 degrees) in the lumbar spine. At final follow-up visit, the mean correction was 23% (-6%-76%) for the thoracic curve and 25% (-68%-82%) for the lumbar curve. The correction of the major curve was higher in patients undergoing anteroposterior versus posterior only (40% vs. 13%, P = 0.017). Five (42%) operated patients had significant complications. The SRS-24 yielded 92 (79-103) points for the brace treatment and 93 (73-114) points for the surgical group, respectively. CONCLUSION: Brace treatment does not prevent progression of the spinal deformity in patients with DD. Anteroposterior surgery is indicated in patients with severe spinal deformities. The risk for major complications is high especially in patients with marked kyphosis.

Long-term health-related quality of life after surgery for adolescent idiopathic scoliosis and spondylolisthesis.

BACKGROUND: The aim of surgical treatment for adolescent idiopathic scoliosis is primarily to prevent progression and secondarily to correct the deformity, whereas the goal of surgical treatment of pediatric spondylolisthesis is mainly to relieve pain and, in patients with a high-grade slip, to prevent progression. The aim of this study was to compare the long-term health-related quality of life after surgery for idiopathic scoliosis and spondylolisthesis in adolescence. METHODS: One hundred and ninety patients, with a mean age of fifteen years, who were treated surgically for adolescent idiopathic scoliosis and 270 patients, with a mean age of sixteen years, who were treated surgically for low-grade or high-grade spondylolisthesis participated in the present study. The mean duration of follow-up was 14.8 years for the scoliosis group and 17.0 years for the spondylolisthesis group. Radiographs were made preoperatively, at the time of the two-year follow-up, and at the time of the final follow-up. Additionally, a physical examination was performed, and the Scoliosis Research Society-24 and Short Form-36 questionnaires were completed at the final follow-up evaluation. RESULTS: The median total score on the Scoliosis Research Society questionnaire was 102 (range, 63 to 118) for the scoliosis group and 95 (range, 42 to 115) for the spondylolisthesis group (p < 0.001). After adjusting for age at the time of surgery, gender, and duration of follow-up, the patients with scoliosis had a significantly higher odds ratio for a good total score (> or = 90 points) on the Scoliosis Research Society questionnaire than did patients with spondylolisthesis (odds ratio, 2.65 [95% confidence interval, 1.58 to 4.44]; p = 0.0002). Patients in the scoliosis group had better values for general self-image, postoperative self-image, and postoperative function than did patients in the spondylolisthesis group (p < 0.001). Sixteen patients in both groups reported that they had back pain often or very often at rest. The standardized physical component scale on the Short Form-36 yielded slightly but significantly better values for the scoliosis group (median, 53.8 points; range, 32 to 61 points) compared with the spondylolisthesis group (median, 53.4 points; range, 27 to 59 points) (p = 0.01). CONCLUSIONS: Patients have good long-term health-related quality of life after surgery for idiopathic scoliosis and spondylolisthesis in adolescence. Patients who have surgery for idiopathic scoliosis are likely to have better long-term outcomes than are patients who have surgery for spondylolisthesis. It is possible that back pain in adolescence may affect quality of life more than spinal deformity does.

Uninstrumented in situ fusion for high-grade childhood and adolescent isthmic spondylolisthesis: long-term outcome. Surgical technique.

BACKGROUND: Intermediate-term radiographic studies have shown that anterior and circumferential techniques result in high fusion rates in patients with high-grade spondylolisthesis, whereas posterolateral fusion is less successful. We are not aware of any long-term comparative studies in which these three methods have been evaluated with regard to functional outcome, including systematic spinal mobility and trunk strength measurements. METHODS: Sixty-nine of eighty-three consecutive patients with high-grade isthmic spondylolisthesis who underwent posterolateral (twenty-one), anterior (twenty-three), or circumferential (twenty-five) uninstrumented spondylodesis between 1977 and 1991 participated in the study. The average duration of follow-up was 17.2 years. Radiographs that were made preoperatively and at the time of the most recent follow-up were assessed with regard to fusion quality and degenerative changes. Outcome was assessed at the time of the most recent follow-up by independent observers on the basis of a physical examination, spinal mobility and nondynamometric trunk strength measurements, and Oswestry Disability Index scores. RESULTS: The mean preoperative vertebral slip was 61% in the posterolateral fusion group, 63% in the anterior fusion group, and 71% in the circumferential fusion group. The final fusion rate was 86% (eighteen of twenty-one) in the posterolateral fusion group, 100% (twenty-three of twenty-three) in the anterior fusion group, and 96% (twenty-four of twenty-five) in the circumferential fusion group. A decrease in lumbar intervertebral disc height at the first mobile level superior to the fusion was noted in five patients in the posterolateral fusion group, seven patients in the anterior fusion group, and one patient in the circumferential fusion group (p = 0.037). The mean Oswestry Disability Index score was 9.7 for the posterolateral fusion group, 8.9 for the anterior fusion group, and 3.0 for the circumferential fusion group (p = 0.035). Nondynamometric trunk strength measurements corresponded with referential values. Abnormally low lumbar flexion affected the posterolateral and circumferential fusion groups more often than the anterior fusion group (p = 0.0015). The percentage of slip showed inverse correlations with lumbar flexion, lumbar extension, and trunk side-bending. CONCLUSIONS: As assessed on the basis of patient-based outcomes, circumferential in situ fusion provided slightly better long-term results than did posterolateral or anterior in situ fusion. When the radiographic and functional results were combined with the patient-based outcomes, the overall differences between the three groups were small.

Uninstrumented in situ fusion for high-grade childhood and adolescent isthmic spondylolisthesis: long-term outcome.

BACKGROUND: Intermediate-term radiographic studies have shown that anterior and circumferential techniques result in high fusion rates in patients with high-grade spondylolisthesis, whereas posterolateral fusion is less successful. We are not aware of any long-term comparative studies in which these three methods have been evaluated with regard to functional outcome, including systematic spinal mobility and trunk strength measurements. METHODS: Sixty-nine of eighty-three consecutive patients with high-grade isthmic spondylolisthesis who underwent posterolateral (twenty-one), anterior (twenty-three), or circumferential (twenty-five) uninstrumented spondylodesis between 1977 and 1991 participated in the study. The average duration of follow-up was 17.2 years. Radiographs that were made preoperatively and at the time of the most recent follow-up were assessed with regard to fusion quality and degenerative changes. Outcome was assessed at the time of the most recent follow-up by independent observers on the basis of a physical examination, spinal mobility and nondynamometric trunk strength measurements, and Oswestry Disability Index scores. RESULTS: The mean preoperative vertebral slip was 61% in the posterolateral fusion group, 63% in the anterior fusion group, and 71% in the circumferential fusion group. The final fusion rate was 86% (eighteen of twenty-one) in the posterolateral fusion group, 100% (twenty-three of twenty-three) in the anterior fusion group, and 96% (twenty-four of twenty-five) in the circumferential fusion group. A decrease in lumbar intervertebral disc height at the first mobile level superior to the fusion was noted in five patients in the posterolateral fusion group, seven patients in the anterior fusion group, and one patient in the circumferential fusion group (p = 0.037). The mean Oswestry Disability Index score was 9.7 for the posterolateral fusion group, 8.9 for the anterior fusion group, and 3.0 for the circumferential fusion group (p = 0.035). Nondynamometric trunk strength measurements corresponded with referential values. Abnormally low lumbar flexion affected the posterolateral and circumferential fusion groups more often than the anterior fusion group (p = 0.0015). The percentage of slip showed inverse correlations with lumbar flexion, lumbar extension, and trunk side-bending. CONCLUSIONS: As assessed on the basis of patient-based outcomes, circumferential in situ fusion provided slightly better long-term results than did posterolateral or anterior in situ fusion. When the radiographic and functional results were combined with the patient-based outcomes, the overall differences between the three groups were small.

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

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

Long-term outcome after posterolateral, anterior, and circumferential fusion for high-grade isthmic spondylolisthesis in children and adolescents: magnetic resonance imaging findings after average of 17-year follow-up.

STUDY DESIGN: A cross-sectional study to evaluate the long-term result of posterolateral (PLF), anterior (AF), and circumferential fusion (CF) for isthmic spondylolisthesis. OBJECTIVES: To assess the long-term effects of PLF, AF, or CF for high-grade isthmic spondylolisthesis on lumbar spine in children and adolescents by using MRI. SUMMARY OF BACKGROUND DATA: Short- and mid-term clinical and plain radiographic results of isthmic spondylolisthesis and of PLF, AF, and CF in severe slip are well documented. The long-term effect of the fusion on soft tissues, on the intervertebral discs inside and above fusion in particular, is, however, unclear. METHODS: Between 1977 and 1991, PLF (n = 21), AF (n = 22), or CF (n = 24) was performed on 67 patients (42 females, 25 males) with high-grade (slip > or =50%) isthmic spondylolisthesis. The average age of patients at the time of operation was 14.4 (range, 8.9-19.6) years. Clinical, spinal mobility and trunk strength in addition to MRI and plain radiograph examinations were performed on these patients after an average follow-up time of 17.3 years (range, 10.7-26.0 years). RESULTS: Three (14%) patients in the PLF and AF groups, but none in the CF group, reported back pain often or very often at rest. The mean Oswestry Disability Index (ODI) was 9.7 (range, 0-62) in the PLF, 8.1 (0-32) in the AF, and 2.3 (0-14) in the CF group (P < 0.05). The mean slip before surgery was 66% (range, 50%-100%) and at the last follow-up visit 66% (range, 26%-106%). Disc degeneration was most common in the PLF group (P = 0.0014) and inside the fusion and in the lowest moving intervertebral disc spaces in all subgroups. Only 1 patient had an asymptomatic prolapse. In MR images, none of the patients had lumbar central canal stenosis inside or above the fusion. In contrast, the spinal canal was wide at the spondylolysis and spondylolisthesis level in 23 (34%) patients. Of the patients, 19 (28%) patients (32 neural foramens) had severe narrowing of the neural foramen with impingement of the nerve root. No patients had clinically confirmed L5 nerve root symptoms. Muscle degeneration was found in 29 (43%) of patients. Longer fusion and muscle degeneration, but not disc degeneration, were associated with lower performance in spinal mobility and trunk-strength measurement tests. CONCLUSIONS: The clinical outcome was best in the CF group as measured by ODI. Degenerative changes were most commonly found at the level of the slip and above the fusion level. The prevalence of disc prolapses was low. Spinal fusion for isthmic spondylolysis is not associated with central canal stenosis above the fusion. Radiologic nerve root stenosis was common but asymptomatic. Mild muscle atrophy was common.

Treatment of severe spondylolisthesis in adolescence with reduction or fusion in situ: long-term clinical, radiologic, and functional outcome.

STUDY DESIGN: Retrospective follow-up study with two cohorts: one treated with reduction and the other with fusion in situ. OBJECTIVE: To assess the long-term effects of reduction versus fusion in situ on lumbar spine in children and adolescents with severe L5 isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA: Severe isthmic spondylolisthesis is commonly treated with fusion in situ, but modern surgical techniques and instrumentation permit the reduction of a severely slipped fifth lumbar vertebra. Advocates of one or another of these procedures present different claims to defend their choice. However, to our knowledge, no long-term results of the reduction maneuver exist. METHODS: Between 1983 and 1991, 22 adolescents with severe (more than 60%) slip were treated surgically. In 11 of them, reduction was performed with a Magerl/Dick transpedicular device, followed by fusion posteriorly from L4 or L5 to S1 and anteriorly from L5 to S1. In the others, fusion was performed in situ posteriorly from L4 (n = 7) or L5 (n = 4) to S1 and anteriorly from L5 to S1. The average age of patients at surgery was 14.7 years (range 10.7-18.5). Radiographs obtained before surgery, after surgery, and at the final follow-up evaluation were assessed for quality of fusion. In addition, magnetic resonance imaging was obtained at the last follow-up visit. Average follow-up time was 14.8 years (range 11.6-18.7). Physical examination, spinal mobility, and nondynamometric trunk strength measurements were used to assess, and Oswestry Disability Index and Scoliosis Research Society scores were used to calculate outcome at the last follow-up visit. RESULTS: In the reduction group, mean Oswestry Disability Index was 7.2 (range 0-20) and in the fusion in situ group, was 1.6 (range 0-4) (P = 0.0096). The Scoliosis Research Society total score averaged 90.0 (range 39-107) in the reduction group and 103.9 (range 93-120) in the fusion in situ group (P = 0.046). At the last follow-up evaluation, mean vertebral slip had decreased from the preoperative value of 90% to 57% in the reduction group but remained the same (80% vs. 78%) in the fusion in situ group (P = 0.04 and 0.013, respectively, for preoperative and postoperative comparison). On magnetic resonance imaging, disc degeneration above the fusion was more common in the reduction group (P = 0.004). None of the patients had spinal stenosis above the fusion. Nerve root canal impingement at the L5-S1 level was more common in the fusion in situ group (P = 0.03), but all patients were free of L5 nerve root symptoms. There was no difference in spinal mobility or trunk strength measurements between the groups. CONCLUSIONS: The fusion in situ group seems to perform better in almost all clinical parameters measured. These findings suggest that fusion in situ should be considered as a method of choice in severe L5 isthmic spondylolisthesis.

Direct repair for treatment of symptomatic spondylolysis and low-grade isthmic spondylolisthesis in young patients: no benefit in comparison to segmental fusion after a mean follow-up of 14.8 years.

The aim of the present study was to assess the long-term clinical, functional, and radiographic outcome of direct repair of spondylolysis using cerclage wire fixation according to Scott in young patients with symptomatic spondylolysis or low-grade isthmic spondylolisthesis as compared to the outcome after uninstrumented posterolateral in situ fusion. Twenty-five out of 28 patients of the direct repair group (89%) and 23 out of 28 of the fusion group (82%) were available for follow-up examination. The assessment by independent observers included a structured interview (Oswestry questionnaire [ODI], visual analogue scale, SRS questionnaire), a clinical examination, functional testing, plain radiography, and MRI. The groups were comparable as to the mean age at operation (18.2 vs. 16.2 years.), the follow-up time (14.8 vs. 15.0 years), and the amount of preoperative slip (7.2 vs. 13.1%). The mean ODI and SRS total scores were significantly better in the fusion group (4.3 [0-16] and 96 [57-117]) as compared to the direct repair group (11.4[0-52] and 87[53-107]; P=0.02 and P=0.011, respectively). In functional testing, both groups reached normal values for abdominal and back muscle strength. The lumbar spine flexion and extension ROM was decreased in both groups showing no statistical difference between the groups. Significant progressive narrowing of the olisthetic disc was detected on the plain radiographs after direct repair. On the flexion-extension radiographs, in the direct repair group, the mobility in the lytic/olisthetic segment was decreased in comparison to normal values from the literature. The mobility at the level above the operated segment was decreased in the direct repair group as compared to the fusion group (P=0.057). On T2-weighted MR images in the direct repair group, the signal intensity of the disc below the affected vertebra was decreased in 17/23 (74%) patients. There was no difference between the groups in the nucleus signal intensity of the adjacent disc above the operated segment. No association between the disc degeneration on MRI and the outcome of the patients could be established. In the direct repair group the following complications were seen: transient nerve root irritation (2), superficial infection (1), UTI (1); in the fusion group the complications were: subcutaneous seroma (2) and UTI (1). There were six re-operations, cerclage removal(4), conversion into segmental fusion(2) in the direct repair group, and one re-operation, instrumented respondylodesis, in the fusion group. In conclusion, the results of direct repair of the spondylolysis using cerclage wire fixation according to Scott were very satisfactory in 76% of the patients after a mean follow-up of 14.8 years. After direct repair, the ODI deteriorated with time leading to a clinically moderate but statistically significant difference in favour of segmental fusion. Lumbar spine mobility was decreased after direct repair. Secondary segmental instability above the spinal fusion was not detected. The procedure does not seem to be capable of preventing the olisthetic disc from degeneration. The theoretical benefits of direct repair could not be proven.

Posterolateral, anterior, or circumferential fusion in situ for high-grade spondylolisthesis in young patients: a long-term evaluation using the Scoliosis Research Society questionnaire.

STUDY DESIGN: A retrospective, comparative follow-up study. OBJECTIVE: To compare clinical and radiographic outcomes after posterolateral, anterior, or circumferential fusion in situ for high-grade spondylolisthesis in children and adolescents. SUMMARY OF BACKGROUND DATA: Controversial opinions still exist about the surgical treatment of severe isthmic spondylolisthesis. There are no long-term comparative studies of different fusion in situ techniques in these patients. METHODS: A total of 21 patients treated using posterolateral, 23 using anterior, and 26 using the circumferential fusion technique without instrumentation for high-grade isthmic spondylolisthesis (>or=50% slip) participated. Their mean age at surgery was 14.4 years (range 8.0-19.6). The follow-up rate was 84% after a mean of 17.2 years (range 10.7-26.0). Radiographs were obtained before surgery, at 2-year follow-up, and at final follow-up. The Scoliosis Research Society (SRS) and Oswestry Disability Index questionnaires were completed, and a physical examination was performed at the final follow-up visit. RESULTS: Progression of lumbosacral kyphosis (>or=10 degrees ) was found in 9 (43%), 3 (13%), and 3 (12%) patients of the posterolateral, anterior, and circumferential fusion groups, respectively (P = 0.017). The SRS total score averaged 89.7 (range 56-105) in the posterolateral, 93.2 (range 66-114) in the anterior, and 100.0 (range 71-117) in the circumferential fusion groups (P = 0.021). Patients in the circumferential fusion group had better values for pain (P = 0.023) and function from back condition domains (P = 0.079) than patients in the posterolateral or anterior groups. The Oswestry Disability Index averaged 9.7 (range 0-62) in the posterolateral, 8.9 (range 0-32) in the anterior, and 3.0 (range 0-16) in the circumferential fusion groups (P = 0.035). CONCLUSIONS: Circumferential fusion provided significantly better long-term clinical, radiographic, and SRS total score than posterolateral or anterior fusion for high-grade isthmic spondylolisthesis.

Effectiveness of the Providence nighttime bracing in adolescent idiopathic scoliosis: a comparative study of 36 female patients.

The aim of the study was to assess the results of treatment of adolescent idiopathic scoliosis (AIS) with the Providence nighttime brace at 1.8 years after discontinuation of bracing. A total of 36 consecutive female patients with an average Cobb angle of 28.4 degrees and an apex below T 10 were studied prospectively. For comparisons, 36 matched patients treated with the Boston full-time brace were studied retrospectively. With the Providence night brace an average of 92% for brace correction of the primary curve was achieved and during follow-up progression of the curve >5 degrees occurred in 27% of the patients. In the control group of the Boston full-time brace patients, brace correction was 50% and the progression of the major curve occurred in 22% of the patients. We conclude that the Providence night brace may be recommended for the treatment of AIS with curves less than 35 degrees in lumbar and thoracolumbar cases.

Predictors of neck pain: a cohort study of children followed up from the age of 11 to 22 years.

Body height is an alleged risk factor for low back pain in adulthood, but its importance regarding non-specific neck pain is obscure during childhood and adolescence. We studied anthropometric measurements for their associations with the incidence of neck pain in a population study of 430 children who were examined five times: at the age 11-14 and 22 years. Body height and weight and the degrees of trunk asymmetry, thoracic kyphosis and lumbar lordosis were measured at every examination. The history of neck pain was obtained by a structured questionnaire at the final examination. The incidence of neck pain was defined as pain occurring in eight or more days during the past year. Short stature at 11 years of age predicted the incidence of neck pain. Adjusted for sex, the odds ratio (with 95% confidence interval) per an increment of one standard deviation of body height was 0.78 (0.62-0.97). At 22 years of age there was accordingly an inverse association between current body height and neck pain history, the odds ratio being 0.62 (0.45-0.86). Male sex was found to protect against neck pain; the odds ratio was 0.28 (0.18-0.44). Anthropometric measurements other than body height were not found to predict neck pain. The role of anthropometric factors in the development of neck pain at young adulthood seems only modest. Short stature may be a risk determinant of neck pain.

No correlation between patient outcome and abnormal lumbar MRI findings 21 years after posterior or posterolateral fusion for isthmic spondylolisthesis in children and adolescents.

Between 1977 and 1987, posterior (n=29) or posterolateral (n=73) fusion was performed for mild to moderate (slip <50%) isthmic spondylolisthesis on 102 patients (46 females, 56 males). The patients' average age at the time of operation was 15.9 (range, 8.1-19.8) years. Clinical (physical examination and Oswestry disability index (ODI)) and radiological (MRI and plain radiographs) examinations were performed on these patients after an average follow-up time of 21.0 (range, 26.2-15.1) years. In the radiographs, the mean slip preoperatively was 27% (range, 5-50%) and at the last follow-up visit 26% (range, 5-78%). Inside the fusion, there were a total of 148 intervertebral discs, 121 (82%) of them had decreased signal intensity in T2-weighted MR images and 113 (76%) were narrowed. Above the fusion level, 27 (27%) discs were speckled and 27 (27%) were black; 21 (21%) intervertebral disc spaces were narrowed. Two levels above the fusion level the numbers were 8 (8%), 16 (16%) and 16 (16%), respectively. Six (6%) patients had a prolapse. Degenerative facet joint hypertrophy above fusion was seen at 80 (79%) of the levels studied. When compared to healthy subjects higher frequency of disc and facet joint degeneration was found. In MR images, none of the patients had lumbar spinal stenosis inside or above the fusion. Narrowing of one or both of the neural foramina at the level of the L5-S1 interververtebral disc was noted in 32 (31%) patients. Seventeen (17%) of the patients had, usually mild, muscular atrophy of the psoas and 33 (32%) of the paraspinal muscles. There was no difference in frequency of abnormal MRI findings between patients (n=93) with ODI 20 or less compared with patients (n=9) with ODI more than 20. In situ fusion due to isthmic spondylolsthesis at adolescence is associated with moderate degenerative changes in the lumbar spine during a 20-year follow-up. Changes were most commonly found at the level of the spondylolisthesis and above fusion level. Neural foramina stenosis seems to be associated with spondylolisthesis and its severity to severity of the slip. Muscle atrophy tended to be mild. However, there was no correlation between patient outcome (ODI) and abnormal lumbar MRI findings.

Development of spinal posture in a cohort of children from the age of 11 to 22 years.

Spinal posture and the resultant changes during the entire pubertal growth period have not been reported previously. No cohort study has focused on the development of spinal posture during both the ascending and the descending phase of peak growth of the spine. The growth and development of a population-based cohort of 1060 children was followed up for a period of 11 years. The children were examined 5 times, at the ages of 11, 12, 13, 14 and 22 years. A total of 430 subjects participated in the final examination. Sagittal spinal profiles were determined using spinal pantography by the same physician throughout the study. Thoracic kyphosis was more prominent in males at all examinations. The increasing tendency towards thoracic kyphosis continued in men, but not in women. The degree of lumbar lordosis was constant during puberty and young adulthood. Women were more lordotic at all ages. Thoracic hyperkyphosis of > or =45 degrees was as prevalent in boys as girls at 14 years, but significantly (P<0.0001) more prevalent in men (9.6%) than in women (0.9%) at 22 years. The degree of mean thoracic kyphosis and the prevalence of hyperkyphosis increased in men during the descending phase of peak growth of the spine, but decreased in women.

Anthropometric measurements and growth as predictors of low-back pain: a cohort study of children followed up from the age of 11 to 22 years.

Body height is an alleged risk factor for low-back pain (LBP) in adulthood, but its importance is obscure during childhood and adolescence. We studied growth for its association with the incidence of LBP in a population study of 430 children who were examined five times: at the age 11,12,13,14 and 22 years. Body height and weight and the degrees of trunk asymmetry, thoracic kyphosis and lumbar lordosis were measured at every examination. The history of LBP was obtained by a structured questionnaire at the ages of 14 and 22 years. The incidence of LBP was defined as pain, which occurred on eight or more days during the past year among those 338 children who had been free from LBP until 14 years of age. Growth of body height between 11 years and 14 years of age predicted the incidence of LBP. Adjusted for sex, the odds ratio (with 95% confidence interval) per an increment of one SD (4.3 cm) was 1.32 (1.06--1.65), the P value for trend being 0.03. Growth after 14 years of age was inversely related to the incidence of LBP, but the association did not reach statistical significance (P for trend=0.06). Other anthropometric measurements or their changes were not found to predict LBP. Our results are not compatible with the old myth that spinal growth actually contributes to LBP. But abundant growth in early adolescence may be a risk factor for subsequent LBP.

Does gender affect outcome of surgery in adolescent idiopathic scoliosis?

STUDY DESIGN: A retrospective follow-up study comparing 2 matched groups. OBJECTIVE: To compare long-term results of operative treatment of adolescent idiopathic scoliosis (AIS) between males and females matched for age, curve magnitude and type, and the instrumentation used. SUMMARY OF BACKGROUND DATA: It has been suggested that in AIS, the spine is more rigid in males than in females, because brace treatment fails to halt progression of the curves in males. However, there are no studies comparing the results of surgical treatment of AIS between males and females. METHODS: Thirty male and female pairs were matched for age (+/-1 year), major curve magnitude (+/-5 degrees), curve type according to the King classification, and the instrumentation used (Harrington in 11 pairs, Cotrel-Dubousset in 9 pairs, and Universal Spine System in 10 pairs). The mean age at the time of operation was 16.2 +/- 2.6 years for the males and 15.5 +/- 2.3 years for the females. The mean follow-up times were 14.3 years (range 6.7-23.0 years) and 14.1 year (range 6.4-23.7 years), respectively. Radiographs were obtained presurgery and after surgery, at the 2-year follow-up assessment, and at the final follow-up visit. In addition, a physical examination was performed, and the Scoliosis Research Society (SRS) questionnaire was completed. Spine mobility and nondynamometric trunk strength were measured at the final follow-up visit. RESULTS: Before surgery, the mean Cobb angle of the thoracic curve was 55 degrees (range 42-83 degrees) in the males and 56 degrees (range 43-80 degrees) in the females. In bending radiographs, the major curve reduced significantly more in females than in males (P = 0.027). The mean angles of the thoracic and lumbar curves were similar at all follow-up visits. The final correction of the thoracic curves was 30% (range -19-65%) in the males and 33% (range -7-71%) in the females (not significant). No significant difference was observed in thoracic kyphosis or lumbar lordosis between the study groups at the final follow-up. The total SRS questionnaire score averaged 96 (range 66-113) in the males and 95 (range 75-108) in the females. None of the males and 2 of the females reported back pain often or very often in the questionnaire. Nondynamometric trunk strength measurements corresponded with reference values, on average, and were similar in both groups. Abnormal trunk side bending tended to be more common in the males than in the females (43% vs. 23%, P = 0.10, not significant). CONCLUSIONS: Curves in males appear to be more rigid than in females with AIS. However, posterior surgery for AIS provides similar short and long-term results in males and females.

Scoliosis research society outcome instrument in evaluation of long-term surgical results in spondylolysis and low-grade isthmic spondylolisthesis in young patients.

STUDY DESIGN: A retrospective follow-up study of low-grade (slip < or = 50%) isthmic spondylolisthesis after posterior or posterolateral fusion in young patients. OBJECTIVE: To evaluate the usefulness of the Scoliosis Research Society questionnaire and compare it with Oswestry Disability Index and radiographic parameters in patients with isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA: A few studies have examined long-term patient outcome using validated questionnaires or compared it with radiographic parameters after surgery for isthmic spondylolisthesis in young patients. The Scoliosis Research Society questionnaire provides patient-oriented information on back pain, cosmetic aspects, patient satisfaction, and level of activity and might therefore be suitable for evaluation of surgical outcome after isthmic spondylolisthesis in young patients. However, there are no studies assessing the usefulness of the Scoliosis Research Society questionnaire for these patients. METHODS: One hundred and eight patients treated at a mean (range) age of 15.9 (range, 8.1-19.8) years with posterior (n = 29) or posterolateral (n = 79) in situ fusion for isthmic spondylolisthesis participated in the present study. The follow-up rate was 83% after a mean of 20.8 (range, 15.1-25.9) years. The mean age at follow-up observation was 36.7 years. Radiographs were obtained before surgery, at 2-year follow-up observation, and at final follow-up review. The Scoliosis Research Society and Oswestry Disability Index questionnaires were completed, and a physical examination was performed at the final follow-up visit. RESULTS: Nonunion after primary operation was found in 10 (34%) patients after posterior fusion and in 10 (13%) patients after posterolateral fusion (P = 0.0017). The mean (range) anterior slip was 25.2% (0-50%) before surgery and 24.2% (0-78%) at final follow-up observation. Lumbosacral kyphosis increased significantly during the follow-up period. The Scoliosis Research Society questionnaire yielded a total of 94.0 (range, 44-114) points. On the Scoliosis Research Society questionnaire, 14 (14%) patients reported back pain often or very often at rest. The Oswestry Disability Index scores averaged 8.2 (range, 0-68). There was a significant correlation between the Scoliosis Research Society total score and the Oswestry Disability Index. The percentage slip showed significant inverse correlations with the scores for appearance in clothes, attractiveness, and self image (Scoliosis Research Society questions 5, 14, and 15). CONCLUSIONS: Long-term clinical and radiographic outcomes after posterolateral fusion of low-grade spondylolisthesis were satisfactory. Cosmetic aspects of this deformity should be included as one of the outcome measurements, since cosmetic questions on the Scoliosis Research Society questionnaire showed inverse correlations between the amount of slip at final follow-up observation. The Scoliosis Research Society questionnaire could be used as a primary patient-oriented outcome tool after back surgery in young patients.

Long-term clinical, functional and radiological outcome 21 years after posterior or posterolateral fusion in childhood and adolescence isthmic spondylolisthesis.

Long-term radiological studies have shown that a high rate of fusion can be achieved with posterolateral spondylodesis. Radiological findings, however, do not always correlate with patient satisfaction and outcome. No studies have been conducted on the long-term results of functional outcome, including spinal mobility and trunk strength measurements, after operative treatment of spondylolysis and spondylolisthesis, as compared with the reference population. Of 129 consecutive patients with isthmic spondylolisthesis operated on with spondylodesis between 1977 and 1987, 107 (83%) participated in the study. Posterior spondylodesis was performed in 29 (27%) patients and posterolateral spondylodesis in 78 (73%) patients. The average follow-up time was 20.9 years (range 15.1-26.2 years). Radiographs obtained preoperatively and at the 2-year and final follow-ups were assessed for quality of the fusion and degenerative changes. Outcome was assessed at the last follow-up by physical examination, spinal mobility and non-dynamometric trunk strength measurements, and calculation of Oswestry disability index (ODI) scores. The fusion rate was 66% after posterior fusion and 83% after posterolateral fusion. Degenerative changes in the lumbar intervertebral discs above the fusion level were noted in 13 (12%) patients. At the final follow-up 14% of patients reported back pain often or very often. The mean ODI score was 7.6 (0-68). Moderate disability was found in 6% of patients and severe disability in 1%; one patient was crippled. No correlation was found between disc degeneration or solidity of the fusion and the ODI score. Non-dynamometric trunk strength measurements corresponded with the reference values. Lumbar flexion, but not extension, was diminished when compared with that of the reference population. The overall long-term clinical outcome is good in patients with spondylolysis and spondylolisthesis operated on with posterior or posterolateral fusion. The clinical and radiological outcomes do not, however, appear to correlate with each other. Lumbar flexion is diminished, but the patients perform, on average, as well as the general population in non-dynamometric trunk strength measurements.