Vertebrae morphology appears to have genetic and ethnic variations. Knowledge of the vertebra and pedicle morphology is essential for proper selection and safe application of transpedicular screws. The aim of this study is to create a morphometric database for thoracolumbar and lumbar vertebrae (T9–L5) among individuals of both sexes in the Greek population. The morphometric dimensions of T9–L5 vertebrae on computed tomography (CT) scan images were measured in 100 adults (79 males and 21 females), without spinal pathology, age from 33 to 87 years old (mean 70 ± 8.73 years). The anterior vertebral body height (AVBH), the posterior vertebral body height (PVBH), the angle formed by the upper end plate of vertebral body and the horizontal line in the sagittal plane, the inner cancellous and outer cortical pedicle height and width, the angle formed by the longitudinal trajectory of the right- and left-sided pedicles and the midline anteroposterior axis of the vertebra (pedicle axis angle (PAA)), and the postero-anterior trajectory’s length of the pedicle from the entry point to the anterior cortex of the vertebra (PTLP), for the right- and left-sided pedicles, were calculated. The Mann-Whitney U tests were conducted to compare the differences in various morphometric characteristics between sexes. The collected data were statistically analyzed using the SAS/STAT software 3.1.3 and SPSS version 22. The statistical significance was set at the level of p < 0.05. The intra- and inter-observer reliability of the measured parameters was also calculated. The L5 vertebra had the maximum AVBH with a mean of 28.47 mm (SD ± 2.55 mm) in males and 26.48 mm (SD ± 1.61 mm) in females. The maximum PVBH in males was at L1 vertebra with a mean of 27.77 mm (SD ± 1.64 mm) and in females at L2 vertebral with a mean of 27.11 mm (SD ± 1.27 mm). Regarding the left pedicle dimensions, the maximum inner cancellous and outer cortical pedicle height was at T11 with a mean of 12.86 mm (SD ± 1.26 mm) and 18.82 mm (SD ± 1.37 mm) in males and 10.24 mm (SD ± 1.88 mm) and 16.19 mm (SD ± 3.27 mm) in females, respectively. The maximum inner cancellous and outer cortical pedicle width was at L5 with a mean of 11.57 mm (SD ± 1.97 mm) and 17.08 mm (SD ± 1.97 mm) in males and 10.24 mm (SD ± 1.88 mm) and 16.27 mm (SD ± 3.27 mm) in females, respectively. The largest PAA was found at the L5 with a mean angle of 26.23° (SD ± 2.65°) in males and 23.63° (SD ± 4.59°) in females, respectively. The maximum PTLP was found at the level of L4 with a mean of 55.31 mm (SD ± 4.52 mm) in males and 48.7 mm (SD ± 4.17 mm) in females, respectively. Regarding the right pedicle dimensions, the maximum inner cancellous and outer cortical pedicle height was found at T12 with a mean of 13.03 mm (SD ± 2.01 mm) and 18.01 mm (SD ± 1.56 mm) in males and 10.24 mm (SD ± 1.23 mm) and 16.14 mm (SD ± 1.23 mm) in females, respectively. The maximum inner cancellous and outer cortical pedicle width was at L5 with a mean of 11.3 mm (SD ± 2.86 mm) and 16.34 mm (SD ± 2.98 mm) in males and 12 mm (SD ± 3.18 mm) and 15.69 mm (SD ± 2.59 mm) in females, respectively. The greater PAA was at the L5 vertebral with a mean of 25.7° (SD ± 5.19°) in males and 25.56° (SD ± 5.31°) in females, respectively. The maximum PTLP was at the level of L3 with a mean of 54.86 mm (SD ± 3.18 mm) in males and 49.01 mm (SD ± 2.97 mm) in females, respectively. At all vertebrae, the only statistically significant difference (p < 0.0001) between the two sexes was the mean PTLP of the right and the left pedicle. The L5 vertebra was found to have the largest AVBH, PAA, and pedicle width in male and female populations. This study provides a database of morphometric characteristics on thoracolumbar and lumbar vertebrae from T9 to L5 in the Greek population. This database may prove to be of great significance for forthcoming comparative studies. It can also serve as a basis in order to detect pathological changes in the spine and furthermore to plan operative interventions. It was found that the dimensions of thoracolumbar and lumbar vertebrae in the Greek population are sex-dependent. In the current study, vertebra and pedicle dimensions seem to have some similarities compared to other Western populations. However, in the thoracolumbar region, the pedicles of T9 and T10 may hardly accommodate a 4.00-mm pedicle screw given the narrow inner cancellous pedicle width. Importantly, the vertebra and pedicle dimensions measured in the current study can be used to guide the selection of transpedicular screws in the Greek population and to guide further research.
Myelomeningocele (MMC) is a congenital disorder that causes a variety of acute as well as late complications. Numerous health problems in adulthood have been described by the persons with MMC but not studied in clinical setting. This study gives implications for organization of the follow-up in adulthood. To investigate the need for follow-up from different medical specialists as well as the need for organized focused rehabilitation among adults with MMC. Retrospective cohort study on adults with MMC including multiple departments in a university hospital in Norway. The number and cause of specialized hospital consultations were recorded for every patient. Correlation between childhood health condition related to MMC and the need for specialized consultations in adulthood as well as correlations between number of consultations and anatomical level of MMC, age, and observation time was performed for the whole group. In total, 38 patients had 672 consultations related to MMC. The most frequent departments were neurology, neurosurgery, urology, gastroenterology, and orthopedics. Most consultations were planned. Complexity of MMC-related health condition correlated to number of specialist consultations (rho = 0.420, p = 0.009). Anatomical level of MMC, age, and length of observation time did not correlate with consultations. Pain and shunt failure were the most common reasons for consultations. Persons with MMC have a need for continuous, life-long multispecialized follow-up and rehabilitation. This is crucial for optimal function, satisfaction with life, and for long-term survival. Systematic follow-up together with rehabilitation will optimize health service.
The purpose of this study was to describe the relationship between pelvic inclination (PI) and lumbar lordosis (LL). Pelvic inclination and pelvic tilt are two different names for the same metric. The geometrical parameters of the spine and pelvis were measured using surface topography scanning, and the data was explored for any physical relationships using principal component analysis. Once widely assumed to be a direct correlation, research in the 1980s first cast doubt upon the PI to LL relationship. And yet, other studies have suggested a relationship does exist. Decades later, the rehabilitation professionals often still rely on this supposed correlation when making decisions about rehabilitation treatment interventions. This theoretical relationship requires further clarification, which is explored herein. Surface topography imaging is a technology that has proven to be a radiation-free way to produce accurate, reliable skeletal alignment measures. Patient data from one physical rehabilitation clinic was collected at the time of initial assessment. Patients presented with a wide range of musculoskeletal complaints. Surface topography scans were performed on 107 patients at the commencement and completion of their therapy. Principal component analysis was performed on the collected data to determine how these spine and pelvic alignment parameters changed between the two points in time and what trends and/or relationships exist between the parameters. Our analysis evaluated eight spinal and pelvic measurements as input and focused on LL and PI as the two principal components at time points of beginning and completion of treatment. Pelvic inclination and lumbar lordosis changed during treatment but were not correlated. Our data demonstrates that pelvic inclination and lumbar lordosis do not have a predictable relationship as previously assumed.
BACKGROUND:Postural stability deficits have been proposed to influence the onset and progression of adolescent idiopathic scoliosis (AIS). This study aimed to systematically identify, critically evaluate and meta-analyse studies assessing postural stability during unperturbed stance with posturography in AIS compared to typically developed adolescents.METHODS:Studies from four electronic databases (PubMed, Scopus, CINAHL, PEDro) were searched and case-control methodological quality assessed using a risk-of-bias assessment tool and a posturography methodological quality checklist. Pooled data regarding centre of pressure (COP) parameters such as sway area, Mediolateral (ML) and Anteroposterior (AP) position and range were compared for AIS and typically developed adolescents using Cohen's d effect size (ES) and homogeneity estimates.RESULTS:Eighteen studies for quality analysis and 9 of these for meta-analysis were identified from 971 records. Risk-of-bias assessment identified 6 high, 10 moderate and 2 low risk-of-bias studies. The posturography methodological quality checklist identified 4 low, 7 moderate and 7 high-quality studies. Meta-analysis was performed for sway area whereas ML and AP are presented in three different meta-analyses due to divergent measurement units used in the studies: ML position 1 (MLP1), ML position 2 (MLP2) and ML range (MLR); AP position 1 (APP1), AP position 2 (APP2) and AP range (APR). Cohen's d showed a medium ES difference in sway area 0.65, 95% CI (0.49-0.63), whereas ML showed no (MLP1, MLP2) and large (MLR) ES differences; MLP1 0.15, 95% CI (0.08-0.22); MLP2 0.14, 95% CI (0.08-0.19); and MLR 0.94, 95% CI (0.83-1.04). Cohen's d for AP showed small ES (APP1) and large ES difference (APP2 and APR); APP1 0.43, 95% CI (0.31-0.54); APP2 0.85, 95% CI (0.72-0.97); and APR 0.98, 95% CI (0.87-1.09). Cochran's Q and Higgins I2 showed homogeneity between studies.CONCLUSIONS:There is moderate quality evidence for decreased postural stability in AIS measured as COP parameters sway area, ML and AP range with a positional shift posteriorly in the sagittal plane. The findings support studying postural stability in early stage AIS and also prospectively identify cause and effect of the curvature as well as effectiveness of postural control interventions in the prevention of scoliosis progression.
Increased implant number is thought to provide better control on the scoliotic spine, but there is limited scientific evidence of improved deformity correction and surgical outcomes with high-density constructs. The objective is to assess key anchor points used by experienced spinal deformity surgeons and to evaluate the effect of implant density pattern on correction techniques.
Bracing is used as a valid non-surgical treatment for adolescent idiopathic scoliosis (AIS) to avoid progression of the deformity and thereby surgery. The effect of bracing treatment on quality of life of patients with AIS has been a topic of interest in the international literature. The aim of this study was to evaluate the quality of life and patient satisfaction during bracing treatment for AIS of a pediatric hospital.
We have read with great interest the article by Minsk et al. in Scoliosis and Spinal Disorders. However, the authors reported a conclusion that is based on possible selection bias in surgical candidates. Physicians are trained in the interpretation of scientific articles; however, not everybody is able to do this. Especially in open access journals, a biased conclusion may have big consequences and may be misleading for patients and family members who can read these articles for free on the internet.
BACKGROUND:The physiological sagittal spinal curvature represents a typical feature of good body posture in the sagittal plane. The cervical and the lumbar spine are curved anteriorly (lordosis), while the thoracic segment is curved posteriorly (kyphosis). The pelvis is inclined anteriorly, and the lower limbs' joints remain in a neutral position. However, there are many deviations from the optimal body alignment.The aim of this paper is to present the most common types of non-structural misalignments of the body posture in the sagittal plane.MAIN BODY OF THE ABSTRACT:The most common types of non-structural misalignments of body posture in the sagittal plane are as follows: (1) lordotic, (2) kyphotic, (3) flat-back, and (4) sway-back postures. Each one may influence both the skeletal and the muscular system leading to the functional disturbance and an increased strain of the supporting structures. Usually, the disturbances localized within the muscles are analyzed in respect to their shortening or lengthening. However, according to suggestions presented in the literature, when the muscles responsible for maintaining good body posture (the so-called stabilizers) are not being stimulated to resist against gravity for an extended period of time, e.g., during prolonged sitting, their stabilizing function is disturbed by the hypoactivity reaction resulting in muscular weakness. The deficit of the locomotor system stability triggers a compensatory mechanism-the stabilizing function is overtaken by the so-called mobilizing muscles. However, as a side effect, such compensation leads to the increased activity of mobilizers (hyperactivity) and decreased flexibility, which may finally lead to the pathological chain of reaction within the musculoskeletal system.CONCLUSIONS:There exist four principal types of non-structural body posture misalignments in the sagittal plane: lordotic posture, kyphotic posture, flat-back posture, and sway-back posture. Each of them can disturb the physiological loading of the musculoskeletal system in a specific way, which may lead to a functional disorder.When planning postural corrective exercises, not only the analysis of muscles in respect to their shortening and lengthening but also their hypoactivity and hyperactivity should be considered.
To our knowledge, no studies have reported the exact structural leg length discrepancies (LLDs) in patients with adolescent idiopathic scoliosis (AIS). Therefore, this study aimed to evaluate the differences between functional and structural LLDs and to examine the correlations between LLDs and spinopelvic parameters in patients with AIS using an EOS imaging system, which permits the three-dimensional reconstruction of spinal and lower-limb bony structures.
Background: The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) produced its first guidelines in 2005 and renewed them in 2011. Recently published high-quality clinical trials on the effect of conservative treatment approaches (braces and exercises) for idiopathic scoliosis prompted us to update the last guidelines' version. The objective was to align the guidelines with the new scientific evidence to assure faster knowledge transfer into clinical practice of conservative treatment for idiopathic scoliosis (CTIS). Methods: Physicians, researchers and allied health practitioners working in the area of CTIS were involved in the development of the 2016 guidelines. Multiple literature reviews reviewing the evidence on CTIS (assessment, bracing, physiotherapy, physiotherapeutic scoliosis-specific exercises (PSSE) and other CTIS) were conducted. Documents, recommendations and practical approach flow charts were developed using a Delphi procedure. The process was completed with the Consensus Session held during the first combined SOSORT/IRSSD Meeting held in Banff, Canada, in May 2016. Results: The contents of the new 2016 guidelines include the following: background on idiopathic scoliosis, description of CTIS approaches for various populations with flow-charts for clinical practice, as well as literature reviews and recommendations on assessment, bracing, PSSE and other CTIS. The present guidelines include a total of 68 recommendations divided into following topics: bracing (n = 25), PSSE to prevent scoliosis progression during growth (n = 12), PSSE during brace treatment and surgical therapy (n = 6), other conservative treatments (n = 2), respiratory function and exercises (n = 3), general sport activities (n = 6); and assessment (n = 14). According to the agreed strength and level of evidence rating scale, there were 2 recommendations on bracing and 1 recommendation on PSSE that reached level of recommendation "I" and level of evidence "II". Three recommendations reached strength of recommendation A based on the level of evidence I (2 for bracing and one for assessment); 39 recommendations reached strength of recommendation B (20 for bracing, 13 for PSSE, and 6 for assessment). The number of paper for each level of evidence for each treatment is shown in Table 8. Conclusion: The 2016 SOSORT guidelines were developed based on the current evidence on CTIS. Over the last 5 years, high-quality evidence has started to emerge, particularly in the areas of efficacy of bracing (one large multicentre trial) and PSSE (three single-centre randomized controlled trials). Several grade A recommendations were presented. Despite the growing high-quality evidence, the heterogeneity of the study protocols limits generalizability of the recommendations. There is a need for standardization of research methods of conservative treatment effectiveness, as recognized by SOSORT and the Scoliosis Research Society (SRS) non-operative management Committee.
Both limb length inequality and scoliosis are associated with pelvic obliquity.
Adolescent idiopathic scoliosis (AIS) is the most common form of idiopathic scoliosis, and surgery is considered as one of the therapeutic options. However, it is associated with a variety of irreversible complications, in spite of the benefits it provides. Here, we evaluated the long-term outcome of posterior spinal fusion (PSF) of AIS to shed more light on the consequences of this surgery.
BACKGROUND:The current increase in types of scoliosis braces defined by a surname or a town makes scientific classification essential. Currently, it is a challenge to compare braces and specify the indications of each brace. A precise definition of the characteristics of current braces is needed. As such, the International Society for Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) mandated the Brace Classification Study Group (BCSG) to address the pertinent terminology and brace classification. As such, the following study represents the first part of the SOSORT consensus in addressing the definitions and providing a visual atlas of bracing.METHODS:After a short introduction on the braces, the aim of the BCSG is described and its policies/general consideration are outlined. The BSCG endeavor embraces the very important SOSORT - Scoliosis Research Society cooperation, the history of which is also briefly narrated. This report contains contributions from a multidisciplinary panel of 17 professionals who are part of the BCSG. The BCSG introduced several pertinent domains to characterize bracing systems. The domains are defined to allow for analysis of each brace system.RESULTS:A first approach to brace classification based on some of these proposed domains is presented. The BCSG has reached a consensus on 139 terms related to bracing and has provided over 120 figures to serve as an atlas for educational purposes.CONCLUSIONS:This is the first clinical terminology tool for bracing related to scoliosis based on the current scientific evidence and formal multidisciplinary consensus. A visual atlas of various brace types is also provided.
length discrepancy is the result of relative anterior lengthening or relative posterior shortening.Objective To define the discrepancy of the three-dimensional CT measured anterior-posterior length of the spinal column in idiopathic scoliosis versus controls.Methods IRB approval and patient consent was obtained.Consecutive series of high-resolution pre-operative CT scans of 80 moderate to severe AIS patients (Cobb angle: 46-109°) and scans of 30 non-scoliotic agematched controls were analyzed.The height of the anterior and posterior vertebral bodies and discs, as well as the height of the laminae, interlaminar spaces, spinous processes and interspinous spaces of the thoracic curve, and corresponding levels in controls, were measured semi-automatically in the true mid sagittal plane of each individual vertebra. Results and discussionsIn AIS, the anterior height of the vertebral bodies and discs of the thoracic curve was 3.6±2.8%longer as compared to the posterior height, 2.0±6.1% longer than the length along the laminae and 8.7±7.1% longer than the length along the spinous processes and differed from controls (controls: -2.7±2.4%,-7.4±5.2% and +0.7±7.8%;p<0.001), with the non-osseous structures contributing significantly more to the length discrepancies.In absolute lengths, the anterior side of the disc of the thoracic curve was higher in AIS (5.4±0.8 mm) than controls (4.8±1.0 mm; p<0.001), whereas the interspinous space was smaller in AIS (12.3±1.4 mm versus 14.0±1.6 mm; p<0.001) and the absolute lengths of the osseous parts differed not significantly between AIS and controls. Conclusions and significanceThe true three-dimensional anterior-posterior length discrepancy of the scoliotic thoracic curves occur through both anterior column lengthening as well as posterior column shortening, with the facet joints as the fulcrum.In moderate to severe AIS, the vertebral bodies contribute partly to the anterior-posterior length discrepancy accompanied by more significant and possibly secondary increased anterior intervertebral discs height.
“The authors are retracting this article [1] at the request of one of the patients. Consent to publish was obtained but subsequently withdrawn. The article is no longer available online in order to protect the privacy of the individual. The authors apologize to readers for the inconvenience.”
Posterior spinal fusion for adolescent idiopathic scoliosis is one of the most invasive surgical procedures performed in children and adolescents. Because of the extensive surgical incision and massive tissue trauma, posterior spinal fusion causes severe postoperative pain. Intravenous patient-controlled analgesia with opioids has been the mainstay of postoperative pain management in these patients. However, the use of systemic opioids is sometimes limited by opioid-related side effects, resulting in poor analgesia. To improve pain management while reducing opioid consumption and opioid-related complications, concurrent use of analgesics and analgesic modalities with different mechanisms of action seems to be rational. The efficacy of intrathecal opioids and nonsteroidal anti-inflammatory drugs as components of multimodal analgesia in scoliosis surgery has been well established. However, there is either controversy or insufficient evidence regarding the use of other analgesic methods, such as continuous ketamine infusion, perioperative oral gabapentin, acetaminophen, continuous wound infiltration of local anesthetics, a single dose of systemic dexamethasone, and lidocaine infusion in this patient population. Moreover, appropriate combinations of analgesics have not been established. The aim of this literature review is to provide detailed information of each analgesic technique so that clinicians can make appropriate choices regarding pain management in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion.
This study aims to determine if (1) loss of lumbar lordosis (LL), often associated with degenerative scoliosis (DS), is structural or rather largely due to positional factors secondary to spinal stenosis; (2) only addressing the symptomatic levels with a decompression and posterolateral fusion in carefully selected patients will result in improvement of sagittal malalignment; and (3) degree of sagittal plane correction achieved with such a local fusion could be predicted by routine pre-operative imaging.
Limb length Inequality (LLI) in children and adults may affect posture, gait, and several truncal parameters, and it can cause spinal scoliosis. In literature, however, there is a paucity of assessment of truncal and spinal changes due to mild LLI in children. This report presents children with LLI, and it aims to provide information in pelvic imbalance, spinal posture, and scoliotic curve, using surface topography analysis which is a novel methodological approach for this condition.
Acute pancreatitis has been described as potential complication of both abdominal and non-abdominal surgeries. The pathogenetic mechanism underlying acute pancreatitis in spine surgery may include intraoperative hemodynamic instability causing prolonged splanchnic hypoperfusion, as well as mechanical compression of the pancreas due to scoliosis correction, with a higher risk in cases of more extended fusions, especially in young adults with lower body mass index (BMI).
Currently, there is little consensus on how or when to discontinue bracing in adolescent idiopathic scoliosis (AIS). An expert spine surgeon national survey could aid in elucidate discontinuation of the brace.
