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1.  Health-related quality-of-life in adolescent idiopathic scoliosis patients 25 years after treatment 
Scoliosis  2015;10:22.
Since 1962 to the mid eighties the Harrington Rod instrumentation was the Golden standard for surgical treatment of Adolescent Idiopathic Scoliosis (AIS). The Boston braces were introduced in the 1970´s and are still used as a conservative treatment, for curves less than 40°. Very few long-term studies exists, focusing on the health related quality of life. The purpose of this study was to evaluate the long-term health related outcome, in a cohort of AIS patients, treated 25 years ago.
219 consecutive patients treated with Boston brace (Brace) or posterior spinal fusion (PSF) using Harrington- DDT instrumentation between 1983 and 1990 at Rigshospitalet Copenhagen, were invited to participate in a long-term evaluation study. A validated Danish version of the Scoliosis Research Society 22R (SRS22R) and Short Form-36 (SF36v1) were administrated to the patients two weeks before the clinical and radiological examination.
159 (72,6 %) patients participated in the clinical follow up and questionnaires, 11 patients participated only in the questionnaires, 8 emigrated, 4 were excluded due to progressive neurological disease and 2 were deceased. The total follow up was 170 patients (83 %), and the average follow up was 24.5 years (22–30 years).
SRS22R domain scores were within the range described as normal for the general population with no statistical difference between the groups except in the Satisfaction domain, where the PSF group had better scores than the braced group.
The SF36 PCS and MCS scores in both AIS cohorts were similar to the scores for the general population.
HRQOLs, as measured by the SRS22R and SF-36, of adult AIS patients treated with Boston brace or PSF during adolescence were similar to the general population. No clinical progression of the deformity has been detected during the 25-year follow up period. The PSF group had a small but statistically significant higher score in the Satisfaction domain compared to the braced group.
Trial registration
S-20110025 Regional Committees on Health Research Ethics for Southern Denmark.
PMCID: PMC4502518  PMID: 26180541
Long-term outcome; Health related quality of life; Adolescent idiopathic scoliosis; Harrington-DTT; Boston braces
2.  Relationship between bone density and bone metabolism in adolescent idiopathic scoliosis 
Scoliosis  2015;10:19.
Several authors have confirmed that 27 to 38 % of AIS patients had osteopenia. But few studies have assessed bone metabolism in AIS. This study assessed bone mineral density and bone metabolism in AIS patients using the bone metabolism markers, BAP and TRAP5b. The subjects were 49 consecutive adolescent AIS patients seen at our institutes between March 2012 and September 2013. Sixty-five percent of AIS patients had osteopenia or osteoporosis and 59 % of AIS patients had high values for TRAP5b. The AIS patients with high values of TRAP5b had lower Z scores than those with normal values of TRAP5b. Higher rates of bone resorption are associated with low bone density in AIS patients.
PMCID: PMC4464881  PMID: 26075016
3.  Adolescent idiopathic scoliosis and spinal fusion do not substantially impact on postural balance 
Scoliosis  2015;10:18.
The spinal curvature in patients with Adolescent Idiopathic Scoliosis (AIS) causes an asymmetry of upper body postural alignment, which might affect postural balance. However, the currently available studies on balance in AIS patients are not consistent. Furthermore, it is not known whether potential deficits are similar between patients with single and double curves. Finally, the effects of a corrective posterior spinal fusion on postural balance have not yet been well established.
Postural balance was tested on a force plate, in 26 female subjects with AIS (12–18 years old; preoperative Cobb-angle: 42-71°; single curve n = 18, double curve n = 6) preoperatively, at 3 months and 1 year postoperatively. We also conducted a balance assessment in 18 healthy age-matched female subjects. Subjects were tested during quiet double-leg standing in four conditions (eyes open/closed; foam/solid surface), while standing on one leg, while performing a dynamic balance (weight shifting) task and while performing a reaching task in four directions.
AIS subjects did not demonstrate greater COP velocities than controls during the double-leg standing tasks. In the reaching task, however, they achieved smaller COP displacements than healthy controls, except in the anterior direction. AIS patients with double curves had significantly greater COP velocities in all test conditions compared to those with a single curve (p < 0.05). For the AIS group, a slight increase in COP velocities was observed in the foam eyes closed and right leg standing condition at 3 months post surgery. At 1-year post surgery, however, there were no significant differences in any of the outcome measures compared to the pre-surgery assessment, irrespective of the curve type.
Postural balance in AIS patients scheduled for surgery was similar to healthy age matched controls, except for a poorer reaching capacity. The latter finding may be related to their reduced range of motion of the spine. Patients with double curves demonstrated poorer balance than those with a single curve, despite the fact that they have a more symmetrical trunk posture. Postural balance one year after surgery did not improve as a result of the better spinal alignment, neither did the reduced range of trunk motion inherent to fusion negatively affect postural balance.
PMCID: PMC4459442  PMID: 26056528
Adolescent idiopathic scoliosis; Postural balance; Spinal fusion
4.  Scoliosis Research Society members attitudes towards physical therapy and physiotherapeutic scoliosis specific exercises for adolescent idiopathic scoliosis 
Scoliosis  2015;10:16.
Attitudes regarding non-operative treatment for adolescent idiopathic scoliosis (AIS) may be changing with the publication of BRAiST. Physiotherapeutic Scoliosis Specific Exercises (PSSE) are used to treat AIS, but high-quality evidence is limited. The purpose of this study is to assess the attitudes of members of the Scoliosis Research Society towards PSSE.
A survey was sent to all SRS members with questions on use of Physical Therapy (PT) and PSSE for AIS.
The majority of the 263 respondents were from North America (175, 67 %), followed by Asia (37, 14 %) and Europe (36, 14 %). The majority of respondents (166, 63 %) prescribed neither PT nor PSSE, 28 (11 %) prescribed both PT and PSSE, 39 (15 %) prescribe PT only and 30 (11 %) prescribe PSSE only. PT was prescribed by 67 respondents, as an adjunct to bracing (39) and in small curves (32); with goals to improve aesthetics (27) and post-operative outcomes (25). Of the 196 who do not prescribe PT, the main reasons were lack of evidence (149) and the perception that PT had no value (112).
PSSE was prescribed by 58 respondents. The most common indication was as an adjunct to bracing (49) or small curves (41); with goals to improve aesthetics (36), prevent curve progression (35) and improve quality of life (31). Of the respondents who do not prescribe PSSE, the main reasons were lack of supporting research (149), a perception that PSSE had no value (108), and lack of access (63). Most respondents state that evidence of efficacy may increase the role of PSSE, with 85 % (223 of 263) favoring funding PSSE studies by the SRS.
The results show that 22 % of the respondents use PSSE for AIS, skepticism remains regarding the benefit of PSSE for AIS. Support for SRS funded research suggests belief that there is potential benefit from PSSE and the best way to assess that potential is through evidence development.
PMCID: PMC4459052  PMID: 26056527
Adolescent idiopathic scoliosis; Scoliosis specific exercise; Survey
5.  Analytical comparison study of the clinical and radiological outcome of spine fixation using posterolateral, posterior lumber interbody and transforaminal lumber interbody spinal fixation techniques to treat lumber spine degenerative disc disease 
Scoliosis  2015;10:17.
Degenerative disc disease is a common cause of chronic and disabling back pain that requires surgical intervention, posterolateral and posterior instrumental fixation (PLF), posterior lumber interbody fusion (PLIF) and transforaminal lumber interbody fusion (TLIF) are the techniques used to deal with such a problem.
To compare the clinical and radiological outcome of the variable surgical techniques used to deal with Lumber degenerative disc disease and to recommend the technique of choice.
120 patients were treated between 2003 and 2010 at king Abdullah university hospital for lumber disc disease. The patients were divided into three groups: Group I (PLF n = 30 [59 levels]); Group II (PLIF n = 40 [70 levels]); and Group III (TLIF n = 50 [96 levels]). All patients had the same pre- and postoperative clinical and radiological evaluations (using Stanford score and local criteria and Oswestry Disability Index [ODI],). All cases had three months and then yearly for five years follow ups.
There was no observed difference in the rates of intra-operative complications (Group I: 10 %; Group II: 8 %; Group III: 14 %; p = 0.566) and postoperative complications (Group I: 13.3 %, Group II:17.5 %, Group III: 18 % with p = 0.332). Among the groups. There was a vital decrease in the ODI scores over time (p < 0.005) but no major difference among the groups at different follow-up times. Radiographic fusion rates for Groups I, II and III were 90 %, 92.5 % and 94 %, respectively.
The surgical outcome of PLF, PLIF and TLIF used to treat degenerative disc disease is almost similar, there is no significant differences observed in complications and clinical outcomes. However, TILF may have better radiological outcome.
PMCID: PMC4487990  PMID: 26136814
Degenerative disc disease (DDD); Spinal fixation; Transforaminal lumber interbody fusion (TILF); Posterolateral fusion (PLF); Posterior lumber interbody fusion (PLIF)
6.  Axial pullout strength comparison of different screw designs: fenestrated screw, dual outer diameter screw and standard pedicle screw 
Scoliosis  2015;10:15.
The pullout strength of pedicle screws is influenced by many factors, including diameter of the screws, implant design, and augmentation with bone cement such as PMMA. In the present study, the pullout strength of an innovative fenestrated screw augmented with PMMA was investigated and was compared to unaugmented fenestrated, standard and dual outer diameter screw.
Twenty four thoracolumbar vertebrae (T10-L5, age 60 to 70 years) from three cadavers were implanted with the four different pedicle screws. Twelve screws of each type were instrumented into either left or right pedicle with standard screw paired with unaugmented and dual outer diameter screw paired with augmented fenestrated screw in any given vertebra. Axial pullout testing was conducted at a rate of 5 mm/min. Force to failure (Newtons) for each pedicle screw was recorded.
The augmented fenestrated screws had the highest pullout strength, which represented an average increase of 149%, 141%, and 78% in comparison to unaugmented, standard, and dual outer diameter screws, respectively. Pullout strength of unaugmented screws was comparable to that of standard screws, however it was significantly lower than dual outer diameter screws.
Fenestrated screws augmented with PMMA improve the fixation strength and result in significantly higher pullout strength compared to dual outer diameter, standard and unaugmented fenestrated screws. Screws with dual outer diameter provided enhanced bone-screw purchase and may be considered as an alternative technique to increase the bone-screw interface in cases where augmentation using bone cement is not feasible. Unaugmented screws can be left in the pedicle even without cement and provide similar pullout strength to standard screws.
PMCID: PMC4422437  PMID: 25949274
Pullout strength; Fenestrated screws; Biomechanical study; Pedicle screws; Large diameter screws
7.  Complications associated with surgical repair of syndromic scoliosis 
Scoliosis  2015;10:14.
There are a number of syndromes that have historically been associated with scoliosis e.g.: Marfan, Down, and Neurofibromatosis. These syndromes have been grouped together as one etiology of scoliosis, known as syndromic scoliosis. While multiple studies indicate that these patients are at high risk for perioperative complications, there is a paucity of literature regarding the collective complication rates and surgical needs of this population.
PubMed and Embase databases were searched for literature encompassing the surgical complications associated with the surgical management of patients undergoing correction of scoliosis in the syndromic scoliosis population. Following exclusion criteria, 24 articles were analyzed for data regarding these complications.
The collective complication rates and findings of these articles were categorized based on specific syndrome. The rates and types of complications for each syndrome and the special needs of patients with each syndrome are discussed. Several complication trends of note were observed, including but not limited to the universally nearly high rate of wound infections (>5% in each group), high rate of pulmonary complications in patients with Rett syndrome (29.2%), high rate (>10%) of dural tears in Marfan and Ehlers-Danlos syndrome patients, high rate (>20%) of implant failure in Down and Prader-Willi syndrome patients, and high rate (>25%) of pseudarthrosis in Down and Ehlers-Danlos patients.
Though these syndromes have been classically grouped together under the umbrella term “syndromic,” there may be specific needs for patients with each of these ailments. Given the high rate of complications, further research is necessary to understand the unique needs for each of these patient groups in the preoperative, intraoperative, and postoperative settings.
PMCID: PMC4422098  PMID: 25949273
Syndromic; Scoliosis; Complications; Surgical; Down; Marfan; Rett; Nuerofibromatosis
8.  Ultrasound-assisted brace casting for adolescent idiopathic scoliosis, IRSSD Best research paper 2014 
Scoliosis  2015;10:13.
Brace treatment is the most effective non-surgical treatment for AIS. High initial in-brace correction increases successful brace treatment outcomes. The objective of this study was to investigate if real-time ultrasound (US) can aid orthotists in selecting the pad pressure level and location resulting in optimal in-brace correction of the spine.
Twenty six AIS subjects participated in this pilot study with 17 (2 M, 15 F) in the control group and 9 (2 M, 7 F) in the intervention group. For the control group, the standard method was used to design their braces. In addition to the standard of care, a medical 3D ultrasound (US) system, a custom pressure measurement system and in-house software were used to select pad placement and pressure levels for the intervention group. The orthotist used a custom standing Providence brace design system to apply pressures against the patient’s torso. The applied pad pressures were recorded. A real-time US spinal image was displayed. Cobb angle measurements from the baseline and the assessment scan were performed. The orthotist then decided if an adjustment was needed in terms of altering the pad locations and pressure levels. The procedures may be repeated until the orthotist attained the best simulated in-brace correction configuration to cast the brace.
In the control group, 8 of 17 (47%) subjects needed a total of 16 brace adjustments after initial fabrication requiring a total of 33 in-brace radiographs. For the intervention group, the orthotist tried additional configurations in 7 out of 9 cases (78%). Among these 7 revised cases, 5 showed better stimulated in-brace corrections and were subsequently used to cast the brace. As a result, only 1 subject required a minor adjustment after initial fabrication. The total number of in-brace radiographs in the intervention group was 10.
The use of the 3D ultrasound system provided a radiation-free method to determine the optimum pressure level and location to obtain the best stimulated in-brace correction during brace casting. The average number of radiographs per subject taken prior to final brace implementation with the interventional group was significantly lower than the control group.
PMCID: PMC4399410  PMID: 25883676
Adolescent idiopathic scoliosis; 3D ultrasound imaging; Brace treatment; Brace design; Optimum brace pressure
9.  Efficacy of the Osaka Medical College (OMC) brace in the treatment of adolescent idiopathic scoliosis following Scoliosis Research Society brace studies criteria 
Scoliosis  2015;10:12.
The efficacy of brace treatment for patients with adolescent idiopathic scoliosis (AIS) remains controversial. To make comparisons among studies more valid and reliable, the Scoliosis Research Society (SRS) has standardized criteria for brace studies in patients with AIS. The purpose of this study was to evaluate the efficacy of the Osaka Medical College (OMC) brace for AIS in accordance with the modified standardized criteria proposed by the SRS committee on bracing and non-operative management.
From 1999 through 2010, 31 consecutive patients with AIS who were newly prescribed the OMC brace and met the modified SRS criteria were studied. The study included 2 boys and 29 girls with a mean age of 12 years and 0 month. Patients were instructed to wear the brace for a minimum of 20 hours per day at the beginning of brace treatment. The mean duration of brace treatment was 4 years and 8 months. We examined the initial brace correction rate and the clinical outcomes of main curves evaluated by curve progression and surgical rate, and the compliance evaluated by the instruction adherence rate for all cases. The clinical course of the brace treatment was considered progression if ≥6° curvature increase occurred and improvement if ≥6° curvature decrease occurred according to SRS judgment criteria.
The average initial brace correction rate was 46.8%. In 10 cases the curve progressed, 6 cases the curve improved, and 15 cases the curve remained unchanged (success rate: 67.7%). The mean instruction adherence rate, that was defined the percentage of the visits that patients declared they mostly followed our instruction to total visits, was 53.7%. The success rate was statistically higher in the patient group whose instruction adherence rate was greater than 50% (88.2%) as compared with in those 50% or less (42.8%).
OMC brace treatment for AIS patients could alter the natural history and significantly decreased the progression of curves to the threshold for surgical intervention. Better instruction adherence of brace wear associated with greater success.
PMCID: PMC4415349  PMID: 25932040
Adolescent idiopathic scoliosis (AIS); Osaka Medical College (OMC) brace; Conservative treatment; Hanging total spine x-ray; Standardized inclusion and assessment criteria; Scoliosis Research Society (SRS)
10.  Predictive factors of Osaka Medical College (OMC) brace treatment in patients with adolescent idiopathic scoliosis 
Scoliosis  2015;10:11.
Factors influencing clinical course of brace treatment apply to adolescent idiopathic scoliosis (AIS) patients remain unclear. By making clear them, we may select suitable patients for brace treatment and alleviate overtreatment. The purpose of this study was to explore predictive factors of Osaka Medical College (OMC) brace treatment for AIS patients in accordance with the modified standardized criteria proposed by the Scoliosis Research Society (SRS) committee on bracing and non-operative management.
From 1999 through 2010, 31 consecutive patients with AIS who were newly prescribed the OMC brace and met the modified SRS criteria were studied. The study included 2 boys and 29 girls with a mean age of 12 years and 0 month. We investigated the clinical course and evaluated the impacts of compliance, initial brace correction rate, curve flexibility, curve pattern, Cobb angle, chronological age, and Risser stage to clinical outcomes. The clinical course of the brace treatment was considered progression if ≥6° curvature increase occurred and improvement if ≥6° curvature decrease occurred according to SRS judgment criteria.
The curve progressed in 10 cases, the curve improved in 6 cases, and the curve remained unchanged in 15 cases (success rate: 67.7%). The success rate was statistically higher in the patient group whose instruction adherence rate was greater than 50% as compared with in those 50% or less. Initial brace correction rate, curve flexibility, curve pattern, the magnitude of Cobb angle, chronological age, and Risser stage did not have any significant effect for clinical courses. However, success rate was insignificantly higher in the cases whose Cobb angle in brace was smaller than that in hanging position.
OMC brace treatment could alter the natural history of AIS, however, that was significantly affected by compliance of brace wear.
PMCID: PMC4395903  PMID: 25873992
Adolescent idiopathic scoliosis (AIS); Osaka Medical College (OMC) brace; Conservative treatment; Predictive factor; Standardized inclusion and assessment criteria; Scoliosis Research Society (SRS)
11.  “Bone-οn-Bone” surgical reconstruction of moderate severity, flexible single curve adolescent idiopathic scoliosis: continuing improvements of the technique and results in three scoliosis centers after almost twenty years of use 
Scoliosis  2015;10:10.
The “bone-on-bone” reconstruction for adolescent idiopathic scoliosis is reviewed in this article. Extensive use over the past 18 years has identified it’s functional benefits outstanding clinical results, and very limited complications. This is an extensive update of it’s application, since it’s introduction, 18 years ago.
Electronic supplementary material
The online version of this article (doi:10.1186/s13013-015-0032-0) contains supplementary material, which is available to authorized users.
PMCID: PMC4440536  PMID: 26000031
12.  Relationship between bone density and bone metabolism in adolescent idiopathic scoliosis 
Scoliosis  2015;10:9.
Several authors have confirmed that 27 to 38% of AIS patients had osteopenia. But few studies have assessed bone metabolism in AIS. This study assessed bone mineral density and bone metabolism in AIS patients using the bone metabolism markers, BAP and TRAP5b. The subjects were 49 consecutive adolescent AIS patients seen at our institutes between March 2012 and September 2013. Sixty-five percent of AIS patients had osteopenia or osteoporosis and 59% of AIS patients had high values for TRAP5b. The AIS patients with high values of TRAP5b had lower Z scores than those with normal values of TRAP5b. Higher rates of bone resorption are associated with low bone density in AIS patients.
PMCID: PMC4422325  PMID: 25949272
13.  Recommendations for research studies on treatment of idiopathic scoliosis: Consensus 2014 between SOSORT and SRS non–operative management committee 
Scoliosis  2015;10:8.
The two main societies clinically dealing with idiopathic scoliosis are the Scoliosis Research Society (SRS), founded in 1966, and the international Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT), started in 2004. Inside the SRS, the Non-Operative Management Committee (SRS-NOC) has the same clinical interest of SOSORT, that is the Orthopaedic and Rehabilitation (or Non-Operative, or conservative) Management of idiopathic scoliosis patients. The aim of this paper is to present the results of a Consensus among the best experts of non-operative treatment of Idiopathic Scoliosis, as represented by SOSORT and SRS, on the recommendation for research studies on treatment of Idiopathic Scoliosis. The goal of the consensus statement is to establish a framework for research with clearly delineated inclusion criteria, methodologies, and outcome measures so that future meta- analysis or comparative studies could occur. A Delphi method was used to generate a consensus to develop a set of recommendations for clinical studies on treatment of Idiopathic Scoliosis. It included the development of a reference scheme, which was judged during two Delphi Rounds; after this first phase, it was decided to develop the recommendations and 4 other Delphi Rounds followed. The process finished with a Consensus Meeting, that was held during the SOSORT Meeting in Wiesbaden, 8–10 May 2014, moderated by the Presidents of SOSORT (JP O’Brien) and SRS (SD Glassman) and by the Chairs of the involved Committees (SOSORT Consensus Committee: S Negrini; SRS Non-Operative Committee: MT Hresko). The Boards of the SRS and SOSORT formally accepted the final recommendations. The 18 Recommendations focused: Research needs (3), Clinically significant outcomes (4), Radiographic outcomes (3), Other key outcomes (Quality of Life, adherence to treatment) (2), Standardization of methods of non-operative research (6).
Electronic supplementary material
The online version of this article (doi:10.1186/s13013-014-0025-4) contains supplementary material, which is available to authorized users.
PMCID: PMC4360938  PMID: 25780381
14.  Reviewer acknowledgement 2014 
Scoliosis  2015;10:7.
Contributing reviewers
The Editor of Scoliosis would like to thank all our reviewers who have contributed to the journal in Volume 9 (2014).
PMCID: PMC4336484  PMID: 25705247
15.  Does bracing affect bone health in women with adolescent idiopathic scoliosis? 
Scoliosis  2015;10:5.
Adolescent idiopathic scoliosis (AIS) is often associated with low bone mineral content and density (BMC, BMD). Bracing, used to manage spine curvature, may interfere with the growth-related BMC accrual, resulting in reduced bone strength into adulthood. The purpose of this study was to assess the effects of brace treatment on BMC in adult women, diagnosed with AIS and braced in early adolescence.
Participants included women with AIS who: (i) underwent brace treatment (AIS-B, n = 15, 25.6 ± 5.8 yrs), (ii) underwent no treatment (AIS, n = 15, 24.0 ± 4.0 yrs), and (iii) a healthy comparison group (CON, n = 19, 23.5 ± 3.8 yrs). BMC and body composition were assessed using dual-energy X-ray absorptiometry. Differences between groups were examined using a oneway ANOVA or ANCOVA, as appropriate.
AIS-B underwent brace treatment 27.9 ± 21.6 months, for 18.0 ± 5.4 h/d. Femoral neck BMC was lower (p = 0.06) in AIS-B (4.54 ± 0.10 g) compared with AIS (4.89 ± 0.61 g) and CON (5.07 ± 0.58 g). Controlling for lean body mass, calcium and vitamin D daily intake, and strenuous physical activity, femoral neck BMC was statistically different (p = 0.02) between groups. A similar pattern was observed at other lower extremity sites (p < 0.05), but not in the spine or upper extremities. BMC and BMD did not correlate with duration of brace treatment, duration of daily brace wear, or overall physical activity.
Young women with AIS, especially those who were treated with a brace, have significantly lower BMC in their lower limbs compared to women without AIS. However, the lack of a relationship between brace treatment duration during adolescence and BMC during young adulthood, suggests that the brace treatment is not the likely mechanism of the low BMC.
PMCID: PMC4343046  PMID: 25729407
Adolescence; Adulthood; Bone; Brace; DXA; Exercise; Female; Growth; Maturation; Nutrition; Physical activity
16.  Physical activities of Patients with adolescent idiopathic scoliosis (AIS): preliminary longitudinal case–control study historical evaluation of possible risk factors 
Scoliosis  2015;10:6.
To our knowledge there are no publications that have evaluated physical activities in relation to the etiopathogenesis of adolescent idiopathic scoliosis (AIS) other than sports scolioses. In a preliminary longitudinal case–control study, mother and child were questioned and the children examined by one observer. The aim of the study was to examine possible risk factors for AIS. Two study groups were assessed for physical activities: 79 children diagnosed as having progressive AIS at one spinal deformity centre (66 girls, 13 boys) and a Control Group of 77 school children (66 girls, 11 boys), the selection involving six criteria.
A structured history of physical activities was obtained, every child allocated to a socioeconomic group and examined for toe touching. Unlike the Patients, the Controls were not X-rayed and were examined for surface vertical spinous process asymmetry (VSPA). Statistical analyses showed progressive AIS to be positively associated with social deprivation, early introduction to indoor heated swimming pools and ability to toe touch. AIS is negatively associated with participation in dance, skating, gymnastics or karate and football or hockey classes, which might suggest preventive possibilities. There is a significantly increased independent odds of AIS in children who went to an indoor heated swimming pool within the first year of life (odds ratio 3.88, 95% CI 1.77-8.48; p = 0·001). Furthermore fourteen (61%) Controls with VSPA compared with 9 (17%) Controls without VSPA had been introduced to the swimming pool within their first year of life (P < 0.001). Early exposure to indoor heated swimming pools for both AIS and VSPA, suggests that the AIS findings do not result from sample selection.
PMCID: PMC4393567  PMID: 25866554
Scoliosis; Physical activities; Risk factors; Etiology; Swimming pools; Toe touching
17.  Factors affecting intradiscal pressure measurement during in vitro biomechanical tests 
Scoliosis  2015;10(Suppl 2):S1.
To assess the reliability of intradiscal pressure measurement during in vitro biomechanical testing. In particular, the variability of measurements will be assessed for repeated measures by considering the effect of specimens and of freezing/thawing cycles.
Thirty-six functional units from 8 porcine spines (S1: T7-T8, S2: T9-T10, S3: T12-T11, S4: T14-T13, S5: L1-L2 and S6: L3-L4) have been used. The intervertebral discs were measured to obtain the frontal and sagittal dimensions. These measurements helped locate the center of the disc where a modified catheter was positioned. A fiber optic pressure sensor (measuring range: -0.1 to 17 bar) (360HP, SAMBA Sensors, Sweden) was then inserted into the catheter. The specimens were divided into 3 groups: 1) fresh (F), 2) after one freeze/thaw cycle (C1) and 3) after 2 freeze/thaw cycles (C2). These groups were divided in two, depending on whether specimens were subjected to 400 N axial loading or not. Ten measurements (insertion of the sensor for a period of one minute, then removal) were taken for each case. Statistical analyses evaluated the influence of porcine specimen and the vertebral level using a MANOVA. The effect of repeated measurements was evaluated with ANOVA. The difference between freeze/thaw cycles were analysed with U Mann-Whitney test (P≤0.05).
Without axial loading, the F group showed 365 mbar intradiscal pressure, 473 mbar for the C1 group, and 391 mbar for the C2 group. With 400N axial load, the F group showed intradiscal pressure of 10610 mbar, the C1 group 10132 mbar, the C2 group 12074 mbar. The statistical analysis shows a significant influence of the porcine specimen (p<0.001), with or without axial loading and of the vertebral level with (p=0.048) and without load (p<0.001). The results were also significantly different between the freeze/thaw cycles, with (p<0.001) and without load (p=0.033). Repeated measurement (without load p = 0.82 and with p = 0.56) did not show significant influence.
The results tend to support that freezing/thawing cycles can affect intradiscal pressure measurement with significant inter-specimen variability. The use of the same specimen as its own control during in vitro biomechanical testing could be recommended.
PMCID: PMC4331726  PMID: 25810751
18.  Rib hump deformity assessment using the rib index in adolescent idiopathic scoliotics treated with full screw or hybrid constructs: aetiological implications 
Scoliosis  2015;10(Suppl 2):S10.
Review of literature reveals that in Idiopathic Scoliosis (IS) children, the post-operative rib hump (RH) correction using full transpedicular screw construct has never been compared to hybrid constructs, applying the Rib-Index (RI) method. Therefore the aim of this report is to study which of the above two constructs offers better postoperative Rib Hump Deformity (RHD) correction.
Twenty five patients with Adolescent Idiopathic Scoliosis (AIS) were operated using full pedicle screw construct or hybrid construct. Sixteen underwent full screw instrumentation (group A) and nine an hybrid one (group B). The median age for group A was 15 years and for group B 17.2 years. The RHD was assessed on the lateral spinal radiographs using the RI. The RI was calculated by the ratio of spine distances d1/d2, where d1 is the distance between the most extended point of the most extending rib contour and the posterior margin of the corresponding vertebra on the lateral scoliosis films and d2 is the distance from the least projected rib contour and the posterior margin of the same vertebra. Moreover the amount of RI correction was calculated by subtracting the post-operative RI from the pre-operative RI.
Although within group A the RI correction was statistical significant (the pre-op RI was 1.93 and the post-op 1.37; p<0.001) and similarly in group B (the mean pre-op RI was 2.06 while the mean post-op 1.51; p=0.008), between group A and B the post-operative RI correction mean values were found to be no statistically significant, (p=0.803).
Although the pre- and post-operative RI correction was statistically significant within each group, this did not happen post-operatively between the two groups. It appears that the RHD correction is not different, no matter what the spinal construct type was used. Provided that the full screw construct is powerful, the post-operative derotation and RHD correction was expected to be better than when an hybrid construct is applied, which is not the case in this study. It is therefore implied that the RHD results more likely from the asymmetric rib growth rather than from vertebral rotation, as it has been widely believed up to now. In 2013 Lykissas et al, reported that costoplasty combined with pedicle screws and vertebral derotation significantly improved RH deformity as opposed to pedicle screws and vertebral derotation alone. Another interesting implication is that the spinal deformity is the result of the thoracic asymmetry, implication in line with the late Prof. John Sevastikoglou’s (Sevastik’s) thoracospinal concept.
PMCID: PMC4331727  PMID: 25810758
19.  Flexible growing rods: a pilot study to determine if polymer rod constructs may provide stability to skeletally immature spines 
Scoliosis  2015;10(Suppl 2):S16.
Surgical treatments for early onset scoliosis (EOS), including growing rod constructs, involve many complications. Some are due to biomechanical factors. A construct that is more flexible than current instrumentation systems may reduce complications. The purpose of this preliminary study was to determine spine range of motion (ROM) after implantation of simulated growing rod constructs with a range of clinically relevant structural properties. The hypothesis was that ROM of spines instrumented with polyetheretherketone (PEEK) rods would be greater than metal rods and lower than noninstrumented controls. Further, adjacent segment motion was expected to be lower with polymer rods compared to conventional systems.
Biomechanical tests were conducted on 6 skeletally immature porcine thoracic spines (domestic swine, 35-40 kg). Spines were harvested after death from swine that had been utilized for other studies (IACUC approved) which had not involved the spine. Paired pedicle screws were used as anchors at proximal and distal levels. Specimens were tested under the following conditions: control, then dual rods of PEEK (6.25 mm), titanium (4 mm), and CoCr (5 mm) alloy. Lateral bending (LB) and flexion-extension (FE) moments of ±5 Nm were applied. Vertebral rotations were measured using video. Differences were determined by two-tailed t-tests and Bonferroni correction with four primary comparisons: PEEK vs control and PEEK vs CoCr, in LB and FE (α=0.05/4).
In LB, ROM of specimens with PEEK rods was lower than control at each instrumented level. ROM was greater for PEEK rods than both Ti and CoCr at every instrumented level. Mean ROM at proximal and distal noninstrumented levels was lower for PEEK than for Ti and CoCr. In FE, mean ROM at proximal and distal noninstrumented levels was lower for PEEK than for metal. Combining treated levels, in LB, ROM for PEEK rods was 35% of control (p<0.0001) and 270% of CoCr rods (p<0.01). In FE, ROM with PEEK was 27% of control (p<0.001) and 180% of CoCr (p<0.01).
PEEK rods decreased flexibility versus noninstumented controls, and increased flexibility versus metal rods. Smaller increases in ROM at proximal and distal adjacent motion segments occurred with PEEK compared to metal rods, which may help decrease junctional kyphosis. Flexible growing rods may eventually help improve treatment options for young patients with severe deformity.
PMCID: PMC4331734  PMID: 25810752
20.  HRQoL assessment by SRS-30 for Chinese patients with surgery for Adolescent Idiopathic Scoliosis (AIS) 
Scoliosis  2015;10(Suppl 2):S19.
Health-related quality of life (HRQoL) outcome questionnaire, Scoliosis Research Society (SRS)-30, had been well received since its establishment in 2003. Literatures from Asia on the use of SRS-30 mainly focused on the translation process and validation process, but not on measuring outcomes, particularly in the Chinese community. We carried out a prospective cohort study to evaluate the HRQoL of Chinese AIS adolescents with severe scoliosis after surgery.
One hundred and four Chinese AIS patients with severe scoliosis undergoing posterior spinal fusion between 2009 and 2013 were recruited in this study. They completed SRS-30 questions before surgery, before hospital discharge, and at follow-up. Mean scores and percentages of individual scores in different domains, and composite scores in terms of subtotal and total scores were calculated referring to the scoring system. Gender-specific and period-specific descriptive analyses were described. Correlation of mean domain scores at the three time points were explored to look for any time-specific relationship. Linear regression analysis looking for potential risk factors on domain scores at different time points by gender were also carried out.
Mean age was 16.28 at surgery, and 83.6% were female. Significant correlations between pre-op scores and scores after surgery were observed in function/activity domain (p=0.05) in males, and pain (p=0.04) and satisfaction with management (p=0.04) domains in females. No gender difference in all 5 domain scores at the 3 time points was found. Pre-op maximum Cobb angle and corrected angle were found to be risk factors on self-image, as well as satisfaction with management, in male and female patients.
This is the first report on the evaluation of the clinical HRQoL outcomes of Chinese AIS patients with severe scoliosis after surgery. Medical professionals should pay attention to take care of the difference in personal perceptions of feelings between boys and girls. Special care should also be allocated to AIS patients, and try to arrange earlier surgical intervention.
PMCID: PMC4331737  PMID: 25810753
Quality of Life; Questionnaires; Adolescent; Scoliosis; Asian Continental Ancestry Group
21.  Scoliosis corrective force estimation from the implanted rod deformation using 3D-FEM analysis 
Scoliosis  2015;10(Suppl 2):S2.
Improvement of material property in spinal instrumentation has brought better deformity correction in scoliosis surgery in recent years. The increase of mechanical strength in instruments directly means the increase of force, which acts on bone-implant interface during scoliosis surgery. However, the actual correction force during the correction maneuver and safety margin of pull out force on each screw were not well known. In the present study, estimated corrective forces and pull out forces were analyzed using a novel method based on Finite Element Analysis (FEA).
Twenty adolescent idiopathic scoliosis patients (1 boy and 19 girls) who underwent reconstructive scoliosis surgery between June 2009 and Jun 2011 were included in this study. Scoliosis correction was performed with 6mm diameter titanium rod (Ti6Al7Nb) using the simultaneous double rod rotation technique (SDRRT) in all cases. The pre-maneuver and post-maneuver rod geometry was collected from intraoperative tracing and postoperative 3D-CT images, and 3D-FEA was performed with ANSYS. Cobb angle of major curve, correction rate and thoracic kyphosis were measured on X-ray images.
Average age at surgery was 14.8, and average fusion length was 8.9 segments. Major curve was corrected from 63.1 to 18.1 degrees in average and correction rate was 71.4%. Rod geometry showed significant change on the concave side. Curvature of the rod on concave and convex sides decreased from 33.6 to 17.8 degrees, and from 25.9 to 23.8 degrees, respectively. Estimated pull out forces at apical vertebrae were 160.0N in the concave side screw and 35.6N in the convex side screw. Estimated push in force at LIV and UIV were 305.1N in the concave side screw and 86.4N in the convex side screw.
Corrective force during scoliosis surgery was demonstrated to be about four times greater in the concave side than in convex side. Averaged pull out and push in force fell below previously reported safety margin. Therefore, the SDRRT maneuver was safe for correcting moderate magnitude curves. To prevent implant breakage or pedicle fracture during the maneuver in a severe curve correction, mobilization of spinal segment by releasing soft tissue or facet joint could be more important than using a stronger correction maneuver with a rigid implant.
PMCID: PMC4331738  PMID: 25810754
22.  Are the mediolateral joint forces in the lower limbs different between scoliotic and healthy subjects during gait? 
Scoliosis  2015;10(Suppl 2):S3.
The quantification of internal joint efforts could be essential in the development of rehabilitation tools for patients with musculo-skeletal pathologies, such as scoliosis. In this context, the aim of this study was to compare the hips joint mediolateral forces during gait, between healthy subjects and adolescents with left lumbar or thoracolumbar scoliosis (AIS), categorized by their Cobb angle (CA).
Material and methods
Twelve healthy subjects, 12 AIS with CA between 20° and 40° and 16 AIS in pre-operative condition (CA : > 40°) walked at 4 km/h on an instrumented treadmill. The experimental set-up include six infrared cameras allow the computation of the tridimensional (3D) angular displacement and strain gauges located under the motor-driven treadmill allow the computation of ground reaction forces (GRF). The hips joint mediolateral forces were calculated using a 3D inverse dynamic of human body. One-way ANOVA was performed for the maximum, the minimum and the range of medio-lateral forces at each joint of the lower limbs. When appropriate, a Tukey's post hoc was performed to determine the differences.
The mediolateral forces were significantly lower at the right hip for AIS with CA between 20° and 40° compared to healthy subject.
The spinal deformation leads to a reduced medio-lateral force at the right hip, which could gradually change the scheme of postural adjustments for AIS during gait. Further research on the quantification of the joint lower limb efforts should include the knee and ankle joints to evaluate the impact of spinal deformation on the lower limb dynamic behaviour in AIS patients.
PMCID: PMC4331763  PMID: 25810755
Idiopathic scoliosis; Gait; Hip; Medio-lateral force; Inverse dynamics; Human body
23.  The impact of the leg-lengthening total hip arthroplasty on the coronal alignment of the spine 
Scoliosis  2015;10(Suppl 2):S4.
Coronal imbalance of the pelvis is recognized to lead to the development of degenerative lumbar scoliosis. We hypothesized that an abrupt change of pelvic obliquity may show a reproducible trend of coronal compensation in the lumbosacral spine. The aim of the study was to classify the change of coronal alignment of spine after THA.
This is a retrospective study based on the radiological analysis of 195 patients who underwent THA between 2009 and 2010. The mean age at surgery was 61.5 years old, and minimum follow up period was 24 months. Pelvic obliquity (POb) and Cobb’s angle of lumbar scoliosis (LS) in coronal plane were measured. Over 3.5 degrees of change in POb was regarded as ΔPOb(+) and over 10 degrees of lumbar scoliosis was regarded as LS(+). The change of LS were classified into 3 subtypes; ΔLS(+), over 5 degrees of progress in LS, ΔLS(-), over 5 degrees of improvement in LS, and ΔLS(n), changes in LS within 5 degrees.
Over 3.5 degrees of change in POb was significantly correlated with the change in LS. Among195 patients, 120 patients improved their pelvic obliquity (ΔPOb(+)), and 75 patients did not have an improved pelvic obliquity (ΔPOb(-)). 99 patients out of 120 ΔPOb(+) patients did not show changes (54, ΔLS(n)) or improvement in scoliosis (45, ΔLS(-)).The remaining 21 patients showed progress or development of de novo scoliosis. Patients who failed to compensate for the POb change at lumbosacral area developed de novo lumbar scoliosis (7 cases), showed progression in lumbar scoliosis (7 cases) or developed coronal trunk shift over 20mm (7 cases)
The patterns of compensation in lumbar or lumbosacral spine in coronal plane after leg lengthening THA were classified with regards to pelvic obliquity and Cobb’s angle. 89.2% of 195 patients showed acceptable compensation in lumbar spine, 21 patients developed coronal imbalance. THA therefore is considered to be safe, as regards to spinal balance in coronal plane. However we have to keep in mind that preoperative rigid scoliosis could have a risk in progress for spinal imbalance.
PMCID: PMC4331764  PMID: 25810756
24.  The rib index is not practically affected by the distance between the radiation source and the examined child 
Scoliosis  2015;10(Suppl 2):S8.
All lateral spinal radiographs in idiopathic scoliosis (IS) show a Double Rib Contour Sign (DRCS) of the thoracic cage, a radiographic expression of the rib hump. The outline of the convex overlies the contour of the concave ribs. The rib index (RI) method was extracted from the DRCS to evaluate rib hump deformity in IS patients. The RI was calculated by the ratio of spine distances d1/d2 where d1 is the distance between the most extended point of the most extending rib contour and the posterior margin of the corresponding vertebra on the lateral scoliosis films, while d2 is the distance from the least projection rib contour and the posterior margin of the same vertebra, (Grivas et al 2002). In a symmetric thorax the “rib index” is 1.
This report is the validity study of DRCS, ie how the rib index is affected by the distance between the radiation source and the irradiated child.
The American College of Radiology's (2009) guidelines for obtaining radiographs for scoliosis in children recommends for the scoliotic - films distance to be 1,80 meters.
Normal values used for the transverse diameter of the ribcage in children aged 6-12 years were those reported by Grivas in 1988.
Using the Euclidean geometry, it is shown that in a normal 12-year old child d1/d2 = 1.073 provided that the distance ΔZ ≈ 12cm (11,84) and EA = 180cm, with transverse ribcage diameter of the child 22 cm.
This validity study demonstrates that the DRCS is substantially true and the RI is not practically affected by the distance between the radiation source and the irradiated child. The RI is valid and may be used to evaluate the effect of surgical or conservative treatment on the rib cage deformity (hump) in children with IS. It is noted that RI is a simple method and a safe reproducible way to assess the rib hump deformity based on lateral radiographs, without the need for any other special radiographs and exposure to additional radiation.
PMCID: PMC4331768  PMID: 25810757
25.  Which is the best schedule of autologous blood storage for preoperative adolescent idiopathic scoliosis patients? 
Scoliosis  2015;10(Suppl 2):S11.
It is critically important for AIS patients to avoid perioperative allogeneic blood transfusions. Toward this aim, many institutes use autologous blood storage to perform perioperative transfusions. However, there is no standard timeline for collecting blood for storage. Therefore, the objective of this prospective cohort study was to compare the outcome of two different schedules for collecting autologous blood before operation in adolescent idiopathic scoliosis (AIS) patients.
Inclusion criteria are AIS patients, younger than 20 years old, female, operated between 2009 and 2013 with posterior spinal fusion and instrumentation who had 1600 mL autologous blood collected before operation. A total of 61 patients were participated in this study. They were randomly divided into 2 groups based on the storage interval. Weekly group (1W-G) consisted of 30 patients with a total of 1600mL blood collected weekly beginning 4 weeks before the operation. Biweekly group (2W-G) consisted of 31 patients with a total of 1600 mL blood collected biweekly beginning 8 weeks before the operation. The instrumented levels, total bleeding, complications during blood transfusion, and hematological examinations (RBC, Hb, Hct, MCH, MCV, MCHC) were evaluated. A hematological examination was performed before blood collection, before the operation, and on postoperative days 1, 3, and 7. Vasovagal reflex (VVR) was evaluated as complications during blood drawing.
Mean age, height, and weight did not differ significantly between the 2 groups. There were no significant differences in instrumented levels, bleeding during operation, after operation, and collected blood during operation. With the autologous blood, allogeneic blood transfusion was completely avoided. VVR was more frequent in the biweekly group significantly (1W-G 4.2% vs 2W-G 15.3%). In terms of hematological examination, all values showed no significant differences between two groups in the pre-drawing and the pre-operation stage. However, the postoperative Hb and Hct values were higher in the weekly group. Also, MCV and MCHC showed the same behavior with higher values in the weekly group.
A weekly schedule of autologous blood storage is better than a biweekly storage schedule.
PMCID: PMC4331728  PMID: 25815051
adolescent idiopathic scoliosis; autologous blood storage; autologous blood transfusion; allogeneic blood transfusion; adverse event; anemia

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