BACKGROUND CONTEXT: Abnormal somatosensory evoked potentials (SEPs) have been documented in patients with adolescent idiopathic scoliosis (AIS) with different cure severity. However, few studies investigated whether abnormal SEPs were the cause or effect of idiopathic scoliosis.PURPOSE: The purpose of this study was to investigate the significance of abnormal SEPs in patients with AIS, and to explore its effect on the etiopathogenesis of AIS.STUDY DESIGN/SETTING: This study evaluated SEPs in patients with AIS and congenital scoliosis (CS) with similar curve pattern and severity both in coronal and sagittal planes.PATIENT SAMPLE: Female patients with AIS and CS in our spine surgery center from 2000 to 2009 were recruited for this study.OUTCOME MEASURES: Rate of abnormal SEPs.METHODS: Posterior tibial nerve SEPs (PTN-SEPs) were performed on female patients with AIS and CS. The inclusion criteria were patients with AIS with a Lenke type 1 curve and patients with CS with right thoracic curve (apex between T5 and T12) and normal sagittal profile (kyphosis less than 50 degrees measured from T2 to T12). All patients were evaluated with total spine magnetic resonance imaging, and those with neural axis abnormalities were excluded. The patients with neurological deficits on detailed physical examination were also excluded. Absence of SEPs waveforms or prolongation of peak latency or asymmetrical peak latency were defined as pathological change. The incidence of pathological SEPs and clinical characteristics were compared between patients with AIS and patients with CS.RESULTS: Forty-six patients with AIS and 33 patients with CS were included in this study. There was no significant difference in coronal and sagittal Cobb angle between the two groups. The rate of abnormal SEPs was 32.6% (15/46) and 12.1% (4/33) in AIS and CS groups, respectively, and the difference was statistically significant (p < .05).CONCLUSION: Somatosensory pathway dysfunction could be found in both AIS and CS without neural axis abnormalities, and the patients with AIS tended to have higher rates of somatosensory disorders than patients with CS with similar scoliosis curve, which indicates that both scoliosis curve and primary etiopathogenic factor contribute to the sensory deficit in patients with AIS. (C) 2014 Elsevier Inc. All rights reserved.

Background: Previous studies have shown a significant association between osteopenia and adolescent idiopathic scoliosis (AIS). And initial bone mineral density (BMD) was proposed to serve as a new prognostic factor of curve progression in AIS. However, it remains unknown whether there is a link between the initial bone mineral status and the outcome of brace treatment. This study aimed to investigate whether the initial bone mineral status could influence the final outcome of brace treatment in AIS. Methods: Girls with AIS treated with brace treatment were recruited. These patients either completed brace treatment, or were indicated for correction surgery with a curve magnitude of >45 degrees. Patients with a progressed scoliosis (group A) and those with a nonprogressed scoliosis (group B) were identified. The associations between the bracing outcome and the indices before bracing, including growth status, anthropometric measurements, BMD status, curve magnitude, and curve pattern were evaluated using univariate analysis and regression analysis. Results: Sixty-eight patients were included. There were 17 girls (25%) in group A and 51 girls (75%) in group B, respectively. The girls in group A had a significantly larger initial Cobb angle (32.3±6.6 vs. 29.1±5.3 degrees), a significantly lower BMD of lumbar spine from L2 to L4 value (0.80±0.11 vs. 0.88±0.12 g/cm2), and a marginally significantly lower Risser grade (1.4±1.5 vs. 2.2±1.4), than in group B. In comparison with group B, more girls in group A were found to be premenarche (P=0.008), osteopenic (P=0.003), with a lower Risser grade (P=0.079), a greater curve magnitude (P=0.159), and a main thoracic pattern (P=0.122) before the initiation of bracing treatment. As revealed by the multiple logistic regression analysis, osteopenia (P=0.002) was identified as an independent risk factor in curve progression in AIS girls, during the total duration of bracing treatment. Conclusions: Osteopenia is identified to serve as a new independent risk factor in the curve progression during the duration of bracing treatment. The evaluation of initial BMD status before bracing may help to predict the outcome of brace treatment. Level of Evidence: Level II.

Standing posterior-anterior (PA) radiographs from our clinical practice show that the concave and convex ilia are not always symmetrical in patients with adolescent idiopathic scoliosis (AIS). Transverse pelvic rotation may explain this observation, or pelvic asymmetry may be responsible. The present study investigated pelvic symmetry by examining the volume and linear measurements of the two hipbones in patients with AIS. Forty-two female patients with AIS were recruited for the study. Standing PA radiographs (covering the thoracic and lumbar spinal regions and the entire pelvis), CT scans and 3D reconstructions of the pelvis were obtained for all subjects. The concave/convex ratio of the inferior ilium at the sacroiliac joint medially (SI) and the anterior superior iliac spine laterally (ASIS) were measured on PA radiographs. Hipbone volumes and several distortion and abduction parameters were measured by post-processing software. The concave/convex ratio of SI-ASIS on PA radiographs was 0.97, which was significantly < 1 (P < 0.001). The concave and convex hipbone volumes were comparable in patients with AIS. The hipbone volumes were 257.3 ± 43.5 cm(3) and 256.9 ± 42.6 cm(3) at the concave and convex sides, respectively (P > 0.05). Furthermore, all distortion and abduction parameters were comparable between the convex and concave sides. Therefore, the present study showed that there was no pelvic asymmetry in patients with AIS, although the concave/convex ratio of SI-ASIS on PA radiographs was significantly < 1. The clinical phenomenon of asymmetrical concave and convex ilia in patients with AIS in preoperative standing PA radiographs may be caused by transverse pelvic rotation, but it is not due to developmental asymmetry or distortion of the pelvis.

Objective To investigate the influence of fusion to upper end vertebra(UEV)or not on the correction outcomes of Lenke type 5 idiopathic scoliosis with anterior selective fusion.Methods From January 2002 to December 2006,36 AIS patients with a Lenke type 5 curve received anterior single-rod selective fusion and had a minimum 2-year follow-up.According to the level of upper instrumented vertebra,the patients were divided into two groups:Group A(n=21),fused to UEV,and Group B(n=15),fused to the vertebra below UEV.Patients of Group A and B had a mean age of 15.3 and 15.5 years,a mean thoracolumbar/lumbar curve of 46.2° and 46.7°,and a mean proximal thoracic curve of 26.3° and 29.6°,respectively.During the surgery,average 5.3 and 4.8 levels of vertebrae were fused in Group A and B,respectively.Results Group A and B had a mean follow-up of 31 and 33 months,respectively.The correction rate of major curves in Group A was marginally higher than in Group B(79％ versus 70％,P=0.062),and the spontaneous correction rate of proximal curves in Group A was higher than in Group B(46％ versus 29％,P=0.044).Regarding the pre-operative sagittal profile,similar lumbar lordosis and sacral slope were observed between both groups,and a slight negative balance was maintained.Thoracic kyphosis showed a mild increment in both groups.Thoracolumbar junctional kyphosis resulted in a trivial kyphotic trend.Proximal junctional measurement showed a slight increment in kyphosis,and instrumented segment angle displayed a decreasing lordotic trend.Conclusion Fusion to UEV in anterior selective fusion of Lenke type 5 curve might lead to a better correction of the thoracolumbar/lumbar curve and the unfused proximal thoracic curve,while have no significant influence on the sagittal reconstruction.

Objectives: To evaluate the rib length asymmetry in patients with thoracic scoliosis secondary to Chiari malformation and to correlate it to rib hump(RH) deformity,so as to elucidate whether the rib length asymmetry is primary or secondary.Methods: There were 38 patients in the group of scoliosis secondary to Chiari malformation(SSCM,group A) with a mean Cobb angle of 44.9°±23.5°(range,26°-108°),a mean age of 12.3±3.6 years(range,9-17yrs),a mean height of 155.4±10.8cm and the apical vertebrae ranging from T7 to T9.There were 58 patients in AIS group(group B) with a mean Cobb angle of 43.9°±17.2°(range,28°-102°),a mean age of 13.7±2.6 years(range,10-18yrs) and a mean height of 157.6±11.5cm.All AIS patients had a major thoracic curve,and the apical vertebrae ranged from T7 to T9.Rib hump was measured with scoliometer.The length of all ribs was measured from the tip of costal head to the end of the same rib by built-in software on spiral computed tomography.The rib length discrepancy was compared between concave and convex sides at apical vertebral level,end vertebral level and no scoliosis levels.The correlation of rib length discrepancy with the magnitude of the Cobb angle and RH at apical vertebral level.Results: At the levels of the apical vertebrae,the vertebrae above and below the apex,the mean rib length was significantly bigger in the concave side in both SSCM group and AIS group(P0.01),with no difference observed at the end vertebral level.The RH averaged at 12.7°±4.0° and 11.9°±3.5° in SSCM group and AIS group,respectively.The rib length discrepancy between concave and convex sides at apical vertebral level was significantly correlated with the magnitude of the Cobb angle and RH in both AIS and SSCM groups(Cobb angle: for AIS group,r=0.463,P=0.003;for SSCM group,r=0.562,P=0.001;RH: for AIS group,r=0.328,P=0.02;for SSCM group,r=0.373,P=0.01).Conclusions: Rib length asymmetry at the apex vertebral level is similar in both scoliotic groups,and significantly correlated with RH deformity,which points strongly to the fact that the rib length asymmetry in apical region is most likely secondary to the scoliosis deformity.

OBJECTIVE:To investigate the early outcome of vertical expandable prosthetic titanium rib (VEPTR) technique in treating early-onset scoliosis.METHODS:This study recruited 11 early-onset scoliosis patients (8 boys and 3 girls) who received VEPTR treatment from December 2006 to July 2011 with a minimum follow-up of 12 months. The average age at initial surgery was (7 ± 3) years (range, 3.1 to 9.8 years). VEPTR device, either rib to rib or rib to lumbar, was implanted at initial surgery. During the regular post-operative follow-ups, expansion surgeries were scheduled at an interval of 6 to 12 months. Measurements of primary curve magnitude, apical vertebral translation, thoracic height and T(1)-S(1) height were performed on radiographs, and were compared between those of preoperatively, postoperatively, and at latest follow-up through paired-t tests.RESULTS:All patients had a mean follow-up of (32 ± 11) months. Totally 41 surgeries were performed, averagely 3.7 surgeries per patient; and 30 expansion surgeries were carried out, averagely 2.7 surgeries per patient. The average interval for each expansion surgery was 8 months. From preoperatively to latest follow-up, the Cobb angle of primary curves was averagely corrected from 78° ± 18° to 55° ± 11° (t = 4.931, P < 0.05), and apical vertebral translation and thoracic kyphosis displayed slight improvement. Average thoracic height increased from (13.3 ± 2.0) cm to (17.2 ± 2.4) cm (t = 8.365, P < 0.001), and average T(1)-S(1) height from (24.4 ± 3.8) cm to (32.5 ± 5.3) cm (t = 9.080, P < 0.001). After initial surgery with VEPTR instrumented, gains in thoracic height and T(1)-S(1) height per expansion surgery averaged (0.8 ± 0.3) cm and (1.8 ± 0.4) cm, respectively. Eight complications occurred in 6 patients, including rib cradle dislodgements, displayed infection, intraoperative pleura rupture and loosening of lumbar pedicle screws.CONCLUSIONS:VEPTR technique proves to be an effective way of preventing curve progression in early-onset scoliosis patients while allowing growth of spine and chest. Yet, indications for such a technique need to be strictly selected because of the relatively high complication rate.

OBJECTIVE:To study the long term outcomes and complications of video-assisted thoracoscopic surgery (VATS) in correcting thoracic adolescent idiopathic scoliosis (T-AIS) with more than five-year follow-up.METHODS:The T-AIS patients underwent corrective surgery by VATS between June 2002 and December 2006 and experienced more than five-year follow-up were retrospectively reviewed. Nine female patients with T-AIS were recruited with a mean age of 14.3 years (range 11 - 16 years) at operation. Radiological parameters including thoracic and lumbar curves, thoracic kyphosis (T(5)-T(12)), sagittal alignment of the thoracolumbar junction (T(10)-L(2)) and lumbar lordosis (T(12)-S(1)) were measured on the X-rays taken preoperatively, 3 months, 2 year postoperatively and at latest follow-up. Complications occurred after operation and during follow-up were retrieved. The Chinese edition SRS-22 was finished by patients at the latest follow-up. Repeated-measures analysis of variance and paired t test were used for statistical analysis.RESULTS:The patients were followed for a mean of 6.2 years (5 - 7.5 years) after VATS. The mean thoracic curve was corrected from 51° ± 8° preoperatively to 20° ± 8° at 3 months post-operation, and 21° ± 12° and 25° ± 13° at 2 year post-operation and latest follow-up, respectively. During the follow-up, no significant changes were observed regarding to coronal and sagittal radiological parameters (P > 0.05). Rod breakage occurred in 1 patient and Adding on was found in another one patient 2 year post-operation. Revision surgery was not needed for the solid fusion achieved and lack of correction loss. The mean score of SRS-22 at final follow-up was 4.3 ± 0.3, with high score in most of the domains.CONCLUSIONS:Loss of curve correction and implant-related complication are found in VATS-treated T-AIS patients at the long-term follow-up. Although the patients show high scores in SRS-22, which indicated higher functional outcome and satisfaction to the operation, special care should be taken for applying VATS to T-AIS patients for the concern of long-term complication.

OBJECTIVES:To investigate the incidence of thoracic curve decompensation or proximal adding-on phenomenon after anterior selective fusion of thoracolumbar or lumbar curve in Lenke type 5 adolescent idiopathic scoliosis (AIS), and to identify its risk factors.METHODS:From June 2001 to December 2008, 130 Lenke type 5 AIS patients with a Cobb angle of 40° - 73° treated with anterior selective thoracolumbar or lumbar fusion, and with a minimum 2-year postoperative regular follow-up were recruited in this study. The average age, Cobb angle and Risser sign of all patients was 14.8 ± 1.6 years, 46° ± 6° of major thoracolumbar or lumbar curve (TL or L), 25° ± 7° of proximal thoracic curve and 0-5, respectively. The patients were grouped according to the relationship between the upper instrumented vertebrae (UIV) and the upper end vertebrae (UEV), the patients' Risser sign and the relationship between UIV and C(7) plumb line (C(7)PL). The radiographic data of the patients were compared between patients with and without proximal adding-on by using t test, and the incidence of proximal adding-on was analyzed in terms of determination of UIV and Risser sign to identify the risk factors of this phenomenon by using Fisher's exact test.RESULTS:Eleven patients were identified with proximal adding-on, thus the incidence of it was 8.5%. At last follow-up postoperatively, the average Cobb angle of TL or L and proximal thoracic curve was 9° ± 4° and 11° ± 5°, respectively. Moreover, the incidence of adding-on in Rissex sign grade 0 to 1 (3/8) was higher than that of grade 2 to 3 (12.1%) and grade 4 to 5 (4.5%). In addition, the incidence of adding-on in UIV lower than UEV group (20.6%) was obviously higher than that of UIV higher than or equal to UEV group (4.2%). The incidence of adding-on for patients with C(7)PL falls away from UIV (19.5%) were obviously higher than that of patients with C(7)PL falls between the pedicle and lateral margin of UIV (3.6%) and between bilateral pedicles of UIV (3.0%). Each group showed significant difference for the incidence of adding-on by Fisher's exact test (P < 0.05).CONCLUSIONS:There exists the risk of proximal thoracic curve decompensation, with a not low rate, after anterior selective fusion for major TL or L curve AIS. The determination of UIV relative to UEV and the skeletal maturity of the patient are the two factors closely associated with the presence of such a phenomenon.

Study Design. A retrospective radiographical study investigated the sagittal alignment in healthy Chinese girls and Chinese girls with idiopathic thoracic scoliosis (T-AIS). Objective. To evaluate the sagittal alignment of the pelvis and spine in Chinese girls with idiopathic scoliosis and healthy girls and to assess whether the pelvic morphology differed between white and Chinese girls with AIS. Summary of Background Data. It has been shown that patients with AIS have an abnormal spinopelvic balance and pelvic morphology. Race is a determinant factor of sagittal spinal alignment and serves as a reminder when planning surgical reconstruction for spinal deformity. Until now, there have been no studies documenting the sagittal lumbosacral spine morphology in Chinese girls with T-AIS. Methods. In this study, 95 patients with T-AIS and 33 healthy age-matched adolescents were recruited consecutively. Sagittal spinal and pelvic parameters were measured from the standing lateral radiograph, including thoracic kyphosis (TK), lumbar lordosis (LL), upper arc of LL, lower arc of LL, pelvic incidence (PI), sacrum slope (SS), and pelvic tilt (PT). Analysis of variance was used in the comparison of each dependent variable between patients with AIS and healthy adolescents. The relations between all parameters were determined via Pearson correlation coefficient (r). Results. For all the sagittal parameters, only the TK and the upper arc of the LL showed significant differences between girls with AIS and healthy girls. The LL, lower arc of the LL, and 3 pelvic parameters were similar for both groups. The TK was found to be strongly correlated with LL and the upper arc of the LL in both groups. However, the TK was not related to the lower arc of the LL, nor were the 3 pelvic parameters in either group. In addition, LL was found to be associated with PI and SS in both groups. The lower arc of the LL was also correlated with PI for both groups. The PI was related to PT and SS in both groups; however, no correlation was found between PT and SS. In this study, the TK (15.7°), SS (35.1°), and PI (44.2°) were found to be significantly lower in Chinese patients with T-AIS than the values reported in the AIS cohort. Conclusion. In our study, the Chinese girls with T-AIS had similar PI, PT, and SS values when compared with the age-matched healthy girls. There were significant differences in pelvic morphology between Chinese and white girls with AIS. These results suggest that race may influence an individual's spinopelvic morphology. Although we have shown that the TK could affect LL through the upper arc of the LL directly, the evaluation of the thoracolumbar morphology of T-AIS before surgery is important for surgical planning.

目的:探讨全椎弓根螺钉矫正青少年特发性脊柱侧凸(AIS)术中出血量和手术时间的影响因素.方法:对2006年4月～2009年8月100例(女84例,男16例)接受单纯后路矫形内固定的AIS患者的临床资料进行回顾性分析.以手术时间、Cobb角、年龄、性别、体重、融合节段数、植入螺钉数、植骨方式以及Lenke分型作为变量,通过多元回归分析探讨影响术中出血量和手术时间的因素.结果:患者出血量为300～4 300 ml(平均1 732 ml),手术时间为180～390 min(平均282 min).多元回归分析显示,手术时间和融合节段数对术中出血量有显著影响(P＜0.01),植入螺钉数对手术时间有显著影响(P＜0.01).Cobb角、年龄、性别、体重、植骨方式和Lenke分型对术中出血量和手术时间均无影响(P＞0.05).结论:手术时间和固定节段数是术中出血量的显著影响因素,植入螺钉数是手术时间的显著影响因素.

Objective:To investigate the safety and accuracy of pedicle screw placement in pediatric scoliosis patients and its possible risk factors.Methods:Forty one consecutive cases from Feb.2008 to Jul.2008 undergoing posterior pedicle screw instrumentation were retrospectively reviewed.There were 15 girls and 26 boys,with a mean age of 5.4 years at surgery(range,2-10 years).The diagnoses included congenital scoliosis(n=36),idiopathic scoliosis(n=2),neuromuscular scoliosis(n=2),scoliosis associated with achondroplasia(n=1).Free-hand pedicle screw placement was performed based on the anatomic landmark.Postoperative CT scans were performed in all cases.The extent of medial,lateral and anterior perforation were measured using Pacs Client software(PACS).The distance between aorta and screw tip was measured if the left pedicle screw penetrated lateral wall or anterior vertebral cortex.The misplacement was defined as pedicle screws breaking medial,lateral,anterior vetebral cortex more than 2mm or perforating endplate and neural foramen.Result:A total of 242 pedicle screws were inserted,128 in thoracic spine and 114 in lumbar area,with an average of 5.8 screws for each patient.208 screws(86.0%) were sited completely in pedicle.18 screw malposition was noted(breaking more than 2mm),5 of which penetrated lateral pedicle cortex,8 penetrated medial pedicle cortex,and 5 penetrated vertebral anterior cortex.The vertebra with malformation or at the concave side had higher perforation rate(24.1% and 17.9% respectively).The mean distance between the screw tip and the anterior wall was 2.3mm for eight screws breaking the anterior wall.Screw loosening occurred in one patient.Conclusions:For children less than 10 years old,free-hand screw placement is of high accuracy and safety;however the vertebra with malformation or at the concave side should be paid attention.

STUDY DESIGN:A comparative study. OBJECTIVE:To investigate the difference of disc and vertebral wedging between patients with adolescent idiopathic scoliosis (AIS) and Chiari malformation-associated scoliosis (CMS). SUMMARY OF BACKGROUND DATA:The wedging of disc and vertebral wedging of AIS are well investigated. However, the comparison of that wedging between AIS and CMS is not found in the literature. METHOD:This study included 35 cases of AIS and 31 cases of CMS. The disc and vertebral wedging was measured by Cobb method. The percentage of single disc and vertebral wedging in the whole thoracic or lumbar curve was calculated. The difference between disc and vertebral wedging, the apical vertebra and average adjacent vertebrae wedging, the apical discs and adjacent discs wedging in the same curve location, same diagnosis and similar Cobb angle group was compared. The difference of disc or vertebral wedging between AIS and CMS, Cobb angle <60 degrees and ≥60 degrees was also compared. The correlation between the apical vertebral wedging angle and Cobb angle was performed by Pearson correlation analysis. RESULTS:The difference between disc and vertebral wedging in the same curve location, same diagnosis, and similar Cobb angle group was statistically significant (P<0.05). No significant difference of the disc or vertebral wedging was found between AIS and CMS in the same curve location and the similar Cobb angle group (P>0.05). No significant difference of the disc or vertebral wedging was found between Cobb angle <60 degrees and ≥60 degrees groups in the same curve location and the same diagnosis (P>0.05). There was a positive correlation between the apical vertebra wedging angle and Cobb angle in AIS patients and CMS patients. The wedging of apical vertebra and disc was more than that in the adjacent disc and vertebra in the same curve. CONCLUSIONS:The relative wedging of intervertebral disc and vertebrae with AIS patients is similar to that of scoliosis with known cause (CMS). The wedging of discs and vertebrae in AIS patients may be an adaptive change secondary to some extravertebral factors.

Study Design Prospective clinical study. Objective To compare the surgical outcomes of vertebral coplanar alignment (VCA) technique against the derotation maneuver with segmental pedicle screw instrumentation in patients with Lenke type 1 idiopathic scoliosis. Summary of Background Data Nowadays the majority of scoliosis correction begins with rod rotation and translation from the concave side, which bears potential neurovascular risks. The technique of VCA was introduced by Vallespir with the intention of correcting rotation and translation and restoring the normal sagittal profile of thoracic scoliosis simultaneously. Methods The fusion levels were decided according to the Lenke criteria. In group A (24 cases), the VCA technique was used. The pedicle screws were inserted at each vertebral level on the convex side and at every other level on the concave side, an extended coplanar tube was secured in line with screw axis to each pedicle screw. Two rigid bars were inserted through the top of the slotted tube. The first rod was kept in this position, whereas the second bar was gently driven down through the slotted tube toward the bottom end. This causes the pedicle screws to align in the sagittal plane, and hence, correct both translation and rotation. The thoracic kyphosis was restored with spacers, which separate the coplanar tubes apart. The derotation maneuver was applied in group B (24 cases). Multiple clinical and radiographic parameters were evaluated and compared. Results The preoperative data were similar between the 2 groups in terms of age, sex, Risser sign, and curve magnitude. In group A, the coronal Cobb angle was corrected from an average of 58 to 16 degrees with a correction rate of 71.8%, and the thoracic kyphosis was restored from an average of 18 to 28 degrees. In group B, the coronal Cobb angle was reduced from 55 to 17 degrees with a correction rate of 68.4%, and the thoracic kyphosis was increased from an average of 15 to 18 degrees. Patients were followed for an average of 17 months (14 to 20 mo) with both groups showing no significant loss of correction. There were no vascular or neurological complications related to pedicle screw insertion or scoliosis correction. Two screws pullout occurred on the concave side in group B. There was 1 case of hemothorax related to a thoracoplasty procedure in group B. No pseudarthrosis occurred during follow-up in both the groups. Conclusions In treating thoracic scoliosis, the VCA technique could achieve as good correction and clinical outcome as the derotation technique. The advantage lies in its superior renormalization effect of thoracic kyphosis compared with the derotation technique from the concave side.

：Objective To analyze theoutcomes of bracing treatment for girls with adolescent idiopathic scoliosis (AIS), and toinvestigate the predictive factors of the protocol. Methods This study included 142 girlswith AIS who finished standardized bracing treatment from July 2003 to July 2009. Thesepatients had a mean age of 13.1±1.5 years, a mean main curve of 29.6°±5.4°, and a meanRisser grade of 2.0±1.5 before bracing treatment. Curve progression was defined that Cobbangle was greater than 6° compared to bracing initiation or was aggravated to more than45° (indicative for surgery). The outcomes of bracing treatment were assessed based onthe ratio of curves of progression or indicative for surgery. Chi-square and Logisticregression Analyses were performed to investigate the predictive factors of bracingtreatment. Results The duration of bracing treatment averaged 2.5±1.0 years. Twenty-sevengirls with curve progression (19%)and 115 girls (81%) with non-progression were found.Final curve which was greater than 45° was found in 18 girls (13%) who need a correctionsurgery, the remaining 124 girls (87%) had completed bracing treatment and avoidedsurgery. Chi-square analyses revealed that curve progression were more common in youngergirls with lower Risser grade, with initial larger Cobb angle and with a main thoraciccurve pattern.Logistic regression analyses found that premenarchal status and a mainthoracic curve pattern were the independent risk factors of curve progression despitebracing. While initial Cobb angle which was greater than 30° was the additionalindependent risk factor of progression requiring surgery. Conclusion Bracing treatmentcould effectively prevent curve progression in most girls with AIS. The degree of growthmaturity, the pattern and grade of curve are the influencing factor for bracing treatment.

OBJECTIVE:To investigate the effect of potential spinal growth on the posterior-only spinal instrumentation of adolescent idiopathic scoliosis (AIS).METHODS:From June 2003 to October 2007, 40 patients received posterior-only spinal instrumentation. Group of open triradiate cartilage (Group A) included 16 female AIS patients with mean age of 11.8, and group of closed triradiate cartilages (Group B) covered 24 female AIS patients with mean age of 13.7. The mean preoperative Cobb angles of Group A and B were 53.3° and 49.6° respectively, and the mean kyphosis in the sagittal plane was 27.7° and 27.8° respectively.RESULTS:The post-operative Cobb angles were 22.2° (Group A) vs. 20.7° (Group B) (P = 0.34) with correction rate of 58.3% (Group A) vs. 57.7% (Group B) (P = 0.83). The mean Cobb angles at final follow-up were 24.8° (Group A) vs. 21.1° (Group B) (P = 0.05) with the correction loss of 5.3% (Group A) vs. 1.0% (Group B) (P = 0.01). In the sagittal plane, the average post-operative kyphosis was 22.5° (Group A) vs. 23.9° (Group B) (P = 0.49) with correction of 5.2° (Group A) vs. 3.9°(Group B) (P = 0.63). The mean kyphosis at final follow-up was 20.8°(Group A) vs. 24.7°(Group B) (P = 0.04) with the correction loss of -1.7° (Group A) vs. 0.8°(Group B) (P = 0.01). Group A showed obvious correction loss in the coronal plane and decrease of kyphosis in the sagittal plane. Adding on phenomenon was found in 2 cases with Lenke type I with selected fusion in Group A, but not in Group B.CONCLUSIONS:Although similar post-operative correction is found in AIS patients with OTRC or CTRC, the loss of correction and "adding on phenomenon" are more likely to happen in patients with OTRC.

STUDY DESIGN:In all, 4 cases of the coexistence of congenital spinal deformity (CSD) and ankylosing spondylitis (AS) were reviewed.OBJECTIVE:To provide an insight into the unusual association between CSD and AS.SUMMARY OF BACKGROUND DATA:CSD combined with musculoskeletal anomalies, including clubfeet, Sprengel deformity, Klippel-Feil syndrome, and developmental dysplasia of the hip, has been described in the literature. Additionally, the rare coexistence between AS and other inflammatory joint diseases, such as systemic lupus erythematosus, mixed connective tissue disease, or Behçet disease, has also been reported. However, to the authors' knowledge, the coexistence of CSD and AS has not been described in the literature.METHODS:In all, 4 patients presented with symptoms of lower back pain for at least 1 year. Among them, 3 patients (cases 1, 2, and 3) were initially diagnosed as CSD, and classified as butterfly vertebra in 2 patients (case 1, case 3), incarcerated hemivertebra in 1 patient (case 2). Furthermore, a diagnosis of coexistence of CSD and AS was proposed in these 3 cases with a delay in the diagnosis of AS for 1 to 10 years. The fourth patient sought initial medical attention in our hospital without delay in diagnosis. In case 1, polysegmental Smith-Petersen osteotomy and transpedicular fixation were performed, and drugs were administrated. Case 2, case 3, and case 4 were treated with amethopterin, folic acid, salicylazosulfapyridine, and celecoxib.RESULTS:At the latest follow-up, 4 patients had no back pain and were satisfied with the outcome.CONCLUSION:The coexistence of CSD and AS is very rare. However, it is necessary to consider the diagnosis of AS in CSD patients who present with symptoms such as inflammatory low back pain, morning stiffness, loss of global sagittal balance, and other clinical features can not be exclusively explained by CSD solely.

Study Design. An association study between radiologic measurements and cosmetic appearance in adolescent idiopathic scoliosis (AIS) patients with Lenke 5 and 6 curve types.Objective. The present study aimed at investigating the correlation between radiologic measurements and clinical cosmetic assessment indices in AIS with Lenke 5 and 6 curve types.Summary of Background Data. Cosmetic truncal and pelvic distortions are of important concern to patients with AIS. In the clinical assessment of AIS, over reliance on radiologic evaluations without corresponding objective assessment of the external physical appearance is commonly practiced. Patients having the same radiologic findings could be quite different in their physical appearance and the reverse could also happen. These observations imply that discrepancies could well exist in the cosmetic versus radiologic evaluation in AIS.Methods. A total of 52 AIS patients with dominant lumbar/thoracolumbar curve including 36 Lenke type 5 and 16 Lenke type 6 were recruited. Cobb angles, coronal balance, thoracic containment, apical vertebral translation (AVT), pelvic oblique, apical vertebral rotation were measured in the standard long-standing posteroanterior radiographs. Waistline Height Index, Waistline Depth Index, Waistline Area Index, Waist Area Index, and hump index (alpha) were measured clinically and the 5 parameters combined into a composite cosmetic Index (CCI). Pearson rank correlation coefficient was used to assess measurement reliability for the cosmetic indices; correlation analysis and multiple linear regression analysis were made between the radiologic measurements and CCI.Results. The correlation coefficients between radiologic measurements and CCI ranged from -0.29 to 0.57, among which AVT was found to have the highest correlation coefficient, but not the Cobb angle. AVT, Cobb angle, coronal balance, thoracic containment were found to be significantly correlated with CCI (P < 0.05) with all correlation coefficients below 0.6. From linear regression analysis, CCI could be predicted by the equation (CCI = 98.0-1.18 x AVT-0.29 x Cobb angle) with adjusted R-2 of 0.33 (implying that 33% of CCI variation could be accounted for by Cobb angle and AVT).Conclusion. The present study showed that a number of radiologic indices could only partially reflect the objective cosmetic appearances in Lenke type 5 and 6 curves in AIS. Spine surgeons should put more emphasis in the clinical cosmetic evaluations and not relying solely on the radiologic assessment in AIS.

Objective:To investigate the improvement of physical appearance in thoraclumbar/lumbar adoles-cent idiopathic scoliosis (AIS) patients who underwent posterior correction,and to explore the correlation be-tween the improvement of physical appearance and radiological index.Method:Twenty eight AIS patients with lumbar/thoracolumbar curve as the main curve were recruited for this study,including 12 lenke 5 curve type AIS patients and 16 lenke 6 curve type AIS patients.Cobb angles and apical vertebral translation (AVT) were measured in the standing posteroanterior radiographs before and after surgery.Waistline height index (WLHI),waistline depth index (WLDI),waistline area index(WLAI) and waist area index(WAI) were mea-sured from the standing photographs.Pearson′s rank correlation coefficient was used to assess measurement re-liability for the cosmetic indexes,t test was used for the comparison of cosmetic and radiological indexes be-fore and after surgery,the correlation analysis were performed between the improvement of cosmetic indexes and radiological changes.Result:The Pearson correlation coefficients of repeat measurements for WLHI,WLDI, WLAI,WAI were 0.99,0.91,0.91,0.92,and all reached statistically significant.The cosmetic indexes improved along with the improvement of Cobb angle and AVT after surgery.Cobb,AVT correlated significantly with WLHI,WLDI,WLAI,WAI,but besides AVT and WLDI,all the other correlation coefficients were less than 0.8.Conclusion:After posterior spine surgery,the cosmetic indeces improved along with the improvement of radiological indeces in thoraclumbar/lumbar AIS patients,but radiological improvement could only partially reflecte cosmetic improvement.

Objective The purpose of this study is to explore the surgical indications and evaluate clinical results of patients with tuberculosis of the cervical spine.Methods There were 8 male and 3 female patients,with a mean age of 50 years at presentation(range,21～75 years).There were 2 patients with tuberculosis of the atlanto-axial spine,and 9 with the lower cervical spine.Of the two patients with tuberculosis of the atlanto-axial spine,neurological deficit were Frankel D in one,Frankel E in another.Of the nine patients with subcervical tuberculosis,neurological status was Frankel C in two,Frankel D in two,Frankel E in five.Of the 11 patients,two surgical strategies were adopted,7 patients were treated by anterior debridement and fusion,and 4 patients underwent posterior fixation and fusion in one-stage,anterior debridement and fusion in second-stage.Results The average duration of follow-up was 24 months.All cases had bony fusion.There was no relapse of the disease in any of our patients.One patient with tuberculosis of atlantoaxial spine with Frankel D had complete recovery at final follow-up.Two patients with Frankel C and two with Frankel D of the lower cervical spine had complete recovery at final follow-up.Conclusion With appropriate indication,surgical treatment of cervical spine tuberculosis can achieve cure disease;maintain cervical stability,and recover neurological function.

Objective:To evaluate the efficacy of preoperative Halo-gravity traction in the treatment of severe pediatric scoliosis and kyphosis.Method:17 patients with severe scoliosis and kyphosis received Halo-gravity traction prior to posterior spine fusion were studied retrospectively.There were 8 males and 9 females,with a mean age of 6.8 years(range,4-8 years).The Cobb angle of coronal major curve and the thoracic kyphosis(T5-T12) were 116.4° and 90.2° respectively.All patients underwent preoperative Halo-gravity traction,and after the maximum weight traction for 4-15 weeks,a posterior instrumentation and fusion was performed.The correction rate of coronal major curve under supine position and that after Halo-gravity traction and after surgery was compared.Result:The maximum traction weight averaged 9kg.All patients were followed up for at least 18-month.One patient experienced transient brachial plexus palsy which resolved completely by decreasing the traction weight.No neurologic complication,death and respiratory failure occurred after surgery.Compared with the correction rate of 15.4% in supine position,the correction rate of coronal major curve after Halo-gravity traction increased 23%(P<0.05).The postoperative correction rate of coronal major curve and thoracic kyphosis were 48.3% and 38.8% respectively.At final follow-up,the loss of coronal and sagittal correction averaged 2.3% and 2.9% respectively.The pulmonary function and blood gas test improved significantly after Halo traction.Conclusion:Preoperative Halo-gravity traction followed by posterior instrumentation is effective for pediatric severe scoliosis and kyphosis due to improved flexibility and pulmonary function.However,the traction related complications should not be ignored.