Background: Cerebral palsy (CP) is the leading cause of permanent physical disability in children. Although hip surveillance is a global standard, spinal surveillance remains inconsistent, often leading to reactive rather than proactive management of neuromuscular scoliosis. This study aims to establish an international consensus on a risk-based spinal surveillance protocol. Methods: A three-round modified Delphi process was conducted in 2024 with 15 international pediatric spine surgeons, identified through purposive sampling. The process adhered to CREDES standards and focused on establishing standards for timing, frequency, and radiographic surveillance. Consensus thresholds were defined a priori as excellent (≥80%) and good (≥73%) agreement. Results: The panel reached excellent consensus (93%) on a "Traffic Light" system based on the Gross Motor Function Classification System (GMFCS) levels. Green Group (Walkers, GMFCS I-II): Clinical surveillance. Amber Group (Poor Walkers, GMFCS III, and asymmetric hemiplegic GMFCS I-II): Annual radiographs starting at ages 3-8. Red Group (Non-Walkers, GMFCS IV-V): Six-monthly radiographs starting at ages 3-5. There was 100% consensus on the mandatory use of sitting radiographs for non-ambulatory patients to prevent masking true pelvic decompensation. Critical referral triggers were identified as a Cobb angle >20°, pelvic obliquity ≥5°, or a progression rate ≥1° per month. Conclusions: The "Traffic Light" protocol helps identify the "window of opportunity" for intervention before reaching the 90° "point of no return," where surgical risks increase nonlinearly. This proactive approach aims to reduce surgical complications and systemic delays in specialized care.

Duchenne muscular dystrophy (DMD) causes progressive skeletal, respiratory and cardiac muscle weakness in affected males. Most DMD patients develop scoliosis following loss of ambulation. This narrative review describes recommendations for the management of scoliosis in DMD patients using a review of the current literature evidence and a consensus review by the DMD Care UK Spinal Surgery Working Group. Advances in medical treatments have improved life expectancy for DMD patients. Spinal bracing is not effective in preventing the deterioration of scoliosis. Seating and wheelchair adaptations can provide postural support. The multidisciplinary assessment of patients with DMD requiring treatment for scoliosis is reviewed, with particular focus on bone, cardiac and respiratory health. The indications, surgical techniques, and type of spinal instrumentation for surgical management for progressively severe scoliosis with or without pelvic obliquity are discussed. Anaesthetic techniques, intraoperative neuromonitoring, perioperative care, and postoperative management in the ICU are discussed for the optimal management of DMD patients undergoing surgery to correct spinal deformity. Finally, regional and holistic functional assessments, patient satisfaction and long-term health, quality of life, and life expectancy for DMD patients undergoing treatment for spinal deformity are reviewed.

The diagnosis and management of bone and joint infection, both in the context of the native skeleton and in the presence of prostheses, is one of the greatest tasks facing modern orthopaedic surgeons and patients. Anatomical, physiological, microbiological and mechanical factors render these infections especially complex. Successful eradication of infection with concomitant maintenance of a mechanically functional skeleton poses a unique challenge requiring complex surgical decision making and cohesive multidisciplinary collaboration. These infections, which cause significant patient morbidity, mortality, and elevated healthcare costs, are on the rise and are becoming an integral part of the orthopaedic workload. Although bone and joint infection is a rapidly evolving field, consensus has not been achieved on many clinical aspects. This review summarizes the presentation, diagnosis and current management strategies for native joint septic arthritis, osteomyelitis, spondylodiscitis, fracture-related infection and prosthetic joint infection in the adult patient population.

To evaluate the long-term clinical, functional, psychosocial, and radiographic outcomes of untreated, braced, and surgically treated adolescent idiopathic scoliosis (AIS) into adulthood. A narrative synthesis of key studies - including prospective cohorts, retrospective analyses, systematic reviews, and patient-reported outcome measure-based investigations - was conducted. Data were organized into three domains: The natural history of untreated AIS, outcomes of bracing, and surgical treatment. Comparative analyses were performed across functional capacity, curve progression, health-related quality of life, patient satisfaction, and complication rates. Untreated AIS with curves < 50° often follows a benign course, with minimal functional limitation, preserved health-related quality of life, and no increase in mortality. However, curves ≥ 50° are associated with progressive deformity, cosmetic dissatisfaction, and potential pulmonary compromise. Bracing is effective in halting progression in skeletally immature patients, particularly when in-brace correction exceeds 50% and daily compliance exceeds 18 hours. Surgically treated patients report the highest long-term satisfaction, particularly in self-image and cosmetic outcomes, though fusion may result in some loss of spinal mobility. Delaying surgery into adulthood increases the risks of operative morbidity, extensive fusion levels, and reoperation. AIS is a heterogeneous condition requiring individualized, evidence-informed care. Observation is appropriate for non-progressive, moderate curves; bracing remains a first-line intervention for growing patients with moderate deformity; and surgery is indicated for progressive or severe curves, with favorable long-term outcomes when timed appropriately. Patient-reported outcomes, psychosocial considerations, and shared decision-making should be integral to treatment planning. Continued prospective research and standardization of bracing and surgical protocols are essential to optimize outcomes across the lifespan.

Spondylolysis is a defect in the posterior vertebral arch, most commonly in L5, and spondylolisthesis is a forward slippage of a vertebra upon another, in children most commonly L5 on S1. In children, symptomatic spondylolysis generally warrants treatment by activity modifications, and treatment options such as bracing or surgical spondylolysis repair can be considered for specific cases. In progressive, low-grade spondylolisthesis that has failed to respond to conservative treatment options, spinal fusion can be performed to halt progression and correct the local deformity. High-grade spondylolisthesis requires surgical stabilization to prevent further progression of the lumbo-sacral kyphosis and progressive slip, restore global sagittal balance and prevent a decline in long-term quality of life.

The spine is a fascinating structure originating from just a few embryonic precursors appearing early during embryo implantation and developing into a complex multi-component architecture, evolutionary selected to ensure structural support, protect the spinal cord and enable bipedal mobility in humans. A broad range of developmental disorders can affect the spine leading to malformed vertebrae, neurological impairments and premature degeneration. The developmental mechanisms causing these disorders remain poorly understood, thus limiting therapeutic interventions to palliative treatments. In this short review, we cover the fundamentals of spinal embryogenesis and highlight developmental mechanisms associated with selected spinal developmental disorders observed in the clinic in the hope that the reader will gain a better grasp of the origins of complex spinal developmental abnormalities.

Major trauma is a common occurrence globally and a leading cause of death in younger patients. Its definition and epidemiology is described in depth elsewhere in the symposium. In the UK there are approximately 22,000 cases presenting per year. Overall management strategy dictates that major trauma is directed to centres experienced in its management. It is, however, important that all clinicians recognize and are aware of it, with implications for resource utilization. The spine can be injured through a variety of mechanisms but importantly in major trauma it is unusual for the spine to be injured in isolation, unless a direct impact is sustained. Conversely, it is critical to be aware of the possibility of vertebral and spinal cord injury which may be masked by distracting injury. Strategies and guidelines for the management of the spine in major trauma will be discussed, and some case examples will be shown in order to demonstrate key concepts and pitfalls.

Skeletal dysplasia includes numerous genetic disorders marked by abnormal bone and cartilage growth, causing various spinal issues. The 2023 nosology identifies 771 distinct dysplasias involving 552 genes, with achondroplasia being the most common and significantly affecting the spine. Other disorders include type II collagenopathies, sulphation defects, Filamin B disorders, and osteogenesis imperfecta, presenting with short stature, limb deformities, joint contractures, and spinal abnormalities. Spinal pathology often impacts physeal growth areas, leading to conditions like foramen magnum stenosis, atlantoaxial instability, spinal stenosis, kyphosis, and scoliosis. Non-orthopaedic symptoms can include hearing and vision loss, neurological issues like hydrocephalus, and cardiac abnormalities. The incidence is around 1 in 4000 to 5000 births, with achondroplasia at about 1 in 30000 live births. Advances in genetics and imaging enable prenatal diagnosis, though milder cases may go undetected. Effective management requires a multidisciplinary approach involving various specialists. This review emphasises early diagnosis, continuous monitoring, and comprehensive management of spinal pathology in skeletal dysplasia. In the current article, the authors present a thorough review on spinal conditions associated with skeletal dysplasia, their pathophysiology and management options.

The use of neurophysiology has been widely accepted as standard of care and a prerequisite in order to safely proceed with complex spinal surgery. This increases the safety against the existing risk of neurological damage that can occur when spinal deformity correction or major neurosurgical treatment is performed. The techniques of intraoperative neuromonitoring have progressed significantly with the use of multimodal somatosensory and motor recordings increasing the reliability and efficacy in detecting neural events. The ability of the surgical, neurophysiology and anaesthetic teams to work in good coordination and with a clear treatment plan reduces considerably the frequency of false monitoring events, as well as the incidence of major neurological complications. The role of neurophysiology extends to include preoperative diagnostic testing that can facilitate detection of neural abnormalities that would affect spinal surgery. In addition, postoperative neurophysiology can be extremely useful when the patient sustained a neurological deficit and close monitoring of the functional recovery is required. This can also assist making the decision regarding the timing to return to surgery if the index procedure had to be abandoned due to an irreversible intraoperative neuromonitoring event. This review explores the use of neurophysiology and its available modalities in complex spinal surgery.

Congenital spinal deformities develop due to the presence of congenital anomalies that impact one or more vertebrae, leading to asymmetrical vertical growth of the spine, with the curvature worsening as skeletal development progresses. In Part 1 of this review, the aetiology, classification and associated anomalies related to the congenital spinal deformity are discussed. In Part 2 of this review, the evaluation of patients presenting with a congenital spinal deformity, necessary investigations, as well as both conservative and surgical treatment strategies are discussed. Accurate and timely identification of the specific type of congenital spinal deformity and the likelihood of progression of the curve will determine the initiation of appropriate treatment. Bracing has proven ineffective in managing congenital scoliosis other than when trying to control structural compensatory curves that develop at the levels above or below the congenital vertebral defect. Surgical interventions are designed to promote balanced spinal growth and prevent both severe deformities and neurological complications. Surgical management may include in situ fusion, growth arrest techniques, hemivertebra excision, posterior correction and instrumented spinal fusion, and growth-sparing techniques, each carrying varying risks of significant medical and neurological complications. In cases of severe deformities with risk of spinal cord compression, spinal osteotomies and vertebral column resection may be necessary.

Congenital anomalies of the spine occur due to faults in the embryological development of the immature vertebrae as an isolated defect or in association with a systemic condition. The result of the presence of these abnormalities is an asymmetrical growth affecting the longitudinal development of the spine and often producing an aggressive deformity involving the coronal and/or the sagittal planes. Recognition of the anatomical nature of the vertebral anomalies, their location along the spine and relationship to adjacent levels can predict the risk of deformity development and curve deterioration. Treatment is recommended at an early stage for those vertebral defects that are likely to produce a progressive deformity. The key to successful treatment in congenital spinal deformity is to diagnose in a timely manner those patients who are at risk to develop a severe deformity and apply early, prophylactic surgical treatment when the associated risks of major complications are more limited.

Adolescent idiopathic scoliosis is a relatively common condition, being observed in 2–3% of 10–18 year olds-a key period of a patient's life in terms of physical, social and emotional development. Of this group 10% may require intervention, with approximately 10% of this subgroup requiring surgical intervention. We discuss definitions and a scheme for management of scoliosis in this particular population. Treatment options are described relative to the degree of curvature, rate of progression and patient psychosocial and cosmetic aspects, with an overview of outcomes. Elements of bracing and advances are reviewed and an introduction into surgical correction approaches, techniques and implants outlined.

The advent of spinal deformity is a common musculoskeletal co-morbidity in patients with an underlying neuromuscular pathology. The implications of a spinal deformity in this frequently physiologically challenged patient population can be profound, with significant limitations to global function, quality of life and provision of basic nursing needs. The vast number of underlying conditions and variable severity of overall disability in which a neuromuscular spinal deformity can be encountered necessitates a personalized approach to management with multidisciplinary input. Given the heterogeneity and relative rarity of implicated pathologies, some generalization of principles in surgical management is inevitable, though the array of potential management techniques and technologies is ever increasing. The aims of this work are to provide a contemporary overview of current concepts in assessment and management common to all aetiologies of neuromuscular spinal deformity, in addition to highlighting areas of controversy and future directions.

Spinal infections (SIs) are uncommon yet serious conditions involving the vertebrae, intervertebral discs, and surrounding soft tissues. They may arise via haematogenous dissemination, direct inoculation from surgical procedures or trauma, or contiguous spread from adjacent infections. The clinical presentation is often non-specific, leading to delayed diagnosis and increased risk of neurological deficits. Pyogenic and tuberculous infections remain the most common forms, each with distinct epidemiological, clinical, and radiological profiles. Accurate diagnosis relies on a combination of elevated inflammatory markers, microbiological cultures, histopathology and imaging. MRI remains the gold standard for early detection, while fluorodeoxyglucose positron emission tomography and CT-guided biopsies enhance diagnostic accuracy in equivocal cases. Differentiating tubercular from pyogenic spondylodiscitis is crucial, as treatment protocols differ significantly. Management is typically conservative in the early stages, involving pathogen-directed antimicrobial therapy and spinal bracing. Surgical intervention is indicated for patients with progressive neurological deficits, instability, severe deformity, or lack of response to medical therapy. Advances in spinal instrumentation and minimally invasive techniques have expanded the surgical options, improving functional outcomes and deformity correction. Special attention is given to anterior column reconstruction in cases of extensive vertebral destruction, particularly in spinal tuberculosis. A multidisciplinary, timely, and aetiology specific approach is essential to optimize outcomes and minimize complications. This review synthesizes current evidence to guide clinicians in the effective diagnosis and management of spinal infections.

Surgical management of adolescent idiopathic scoliosis [AIS] is a complex undertaking with the primary goals to correct the deformity, maintain sagittal balance, preserve pulmonary function, maximize postoperative function, and improve or at least not harm the function of the lumbar spine. The evolution of surgical techniques for AIS has been remarkable, transitioning from rudimentary methods of spinal correction to highly refined, biomechanically sound procedures. Modern techniques incorporate advanced three-dimensional correction strategies, often leveraging pedicle screw constructs, which provide superior rotational control of the vertebral column. A number of surgical techniques have been described in the literature, each having its own pros and cons. This narrative review provides a detailed analysis of the contemporary surgical techniques used in the treatment of patients with AIS.

The aim of this review is to report on the diagnosis, treatment guidelines and main syndromic/genetic conditions that are related with the development of scoliosis, as well as their management. Syndromes associated with scoliosis include connective tissue disorders, conditions related to the altered rat sarcoma viral oncogene/mitogen/activated protein kinase pathway or RASopathies, skeletal dysplasias and other pathologies often related to low muscle tone. Ehlers–Danlos syndrome, osteogenesis imperfecta, Marfan syndrome, neurofibromatosis, Noonan syndrome, achondroplasia, mucopolysaccharidoses, Down syndrome, Prader–Willi syndrome, and DiGeorge syndrome are all conditions commonly associated with scoliosis. Syndromic scoliosis is, therefore, an umbrella term that encompasses several different pathologies that display scoliosis, as well as other musculoskeletal or systemic features. Scoliosis patterns in syndromic patients can share traits with idiopathic scoliosis but are more often dystrophic or atypical with characteristics secondary to loss of muscle tone, joint laxity, and tumour formation. Treatments include observation, bracing or surgical correction in the more severe cases. Surgical technique in syndromic scoliosis in the past few years has followed similar trends to adolescent idiopathic scoliosis with a tendency to favour one stage posterior spinal fusion based on pedicle screw segmental correction and fixation. The treatment of syndromic scoliosis is often made more challenging due to the presence of co-morbidities and the consequent higher risk of perioperative complications when compared to patients with adolescent idiopathic scoliosis. Management of this rare and diverse group of pathologies requires a multidisciplinary approach in a specialized spinal unit. Complications following surgical correction of syndromic scoliosis share common trends such as neurological damage, increased infection rates and non-union, although each syndrome presents specific issues.

Congenital spinal deformities arise from congenital anomalies that impact one or more vertebrae, leading to asymmetrical vertical growth of the spine, with the curvature worsening as skeletal development progresses. In Part 1 of this review, the aetiology, classification and anomalies associated with the congenital spinal deformity are discussed. Congenital vertebral anomalies manifest during the embryonic phase of spinal development and can be categorized into failures of formation, segmentation, or mixed anomalies. Timely identification of the specific vertebral anomaly is crucial for predicting prognosis of the deformity and initiating treatment prior to the onset of a severe curvature. Factors such as the anatomy, location, and number of abnormalities, along with their relation to surrounding spinal structures, influence the likelihood of deformity progression. In Part 2 of this review, the evaluation of patients presenting with congenital spinal deformity, necessary investigations, as well as conservative and surgical treatment strategies are discussed.

Numerical modeling has been extensively employed to understand the biomechanics of the spine. Often, patient-specific models developed from medical scans, which are specific to an individual and their particular clinical case, are used. The aim of this study was to develop a generic model of the full adolescent spine, which includes ribs, muscles, and ligaments, that can effectively simulate realistic spinal biomechanics. The model was developed using computer-aided design, incorporating anatomical parameters to represent a 15-year-old adolescent full-spine geometry. Essential components like the ribcage and related musculature were included to capture realistic biomechanics. The model appraisal involved mesh sensitivity analysis and tests on selected functional spinal units (FSUs) in each spinal region to assess the biomechanics of specific components of the full spine. Biomechanical responses, including range of motion, intradiscal pressure, and facet joint forces, were evaluated across multiple simulated loading tasks. Results were compared to previous in vitro and in silico studies. Our model demonstrated good agreement with previous experimental and numerical studies. The ribcage inclusion simulated the stiffening effect observed in vivo satisfactorily. Ligamentous effect tests on thoracic and lumbar FSUs indicated that the model satisfactorily replicated expected biomechanical responses. The study shows that the developed model can be employed effectively to simulate real-life spine motions. The developed model will be used for future AIS research, enabling the investigation of surgical treatment outcomes across diverse clinical scenarios.

Paediatric spine deformity surgery is a high-stakes procedure. It demands the surgeon to have exceptional anatomical knowledge and precise visuospatial awareness. There is increasing demand for precision medicine, which rapid advancements in computational technologies have made possible with the recent explosion of AI and machine learning (ML). We present the surgical and ethical applications of AI and ML in diagnosis, prognosis, image processing, and outcomes in the field of paediatric spine deformity. Cite this article: Bone Jt Open 2025;6(5):569–581.

Idiopathic scoliosis is a commonly occurring condition, universal in terms of incidence across race and socio-economic backgrounds. In this review, we address technical definitions, clinical assessment and initial investigation as a prelude to management, which is discussed in a separate chapter of this issue. Generally, patients who need intervention are managed in specialist centres; it is, however, important for the general orthopaedic surgeon to recognize the condition, have an understanding of potential risks for progression and offer patients adequate advice on prognosis and treatment expectations. Knowledge of anomalies which suggest a different aetiology of scoliosis is essential for differential diagnosis and these are also covered in this review.