Comparison of Robot Versus Fluoroscopy-Assisted Pedicle Screw Instrumentation in Adolescent Idiopathic Scoliosis Surgery

The aim of this study is to explore whether robot-assisted technique has advantages over conventional fluoroscopy-assisted technique in clinical and radiological outcomes and whether it could decrease the incidence of mis-implantations of pedicle screws in AIS correction surgery.A total of 101 AIS patients were recruited (RA group: 45 patients underwent robot-assisted screw insertion; FA group: 56 patients underwent fluoroscopy-assisted screw insertion). When compared the radiological data between two groups, major and secondary curve were both corrected proficiently with no difference in the Cobb angle comparison at last follow-up, suggesting that both robot-assisted technique and fluoroscopy-assisted technique could lead to efficient radiographic correction and similar clinical outcomes (all, P<0.05). In RA group, operation time, blood loss and transfusion volume were significantly greater than those in FA group, while the accuracy of screw implantations in AIS patients with thoracic scoliotic curve in RA group was higher than that in FA group.In conclusion, both robot-assisted and fluoroscopy-assisted technique could reach proficient radiographic correction and similar clinical outcomes in AIS surgery. Compared with conventional fluoroscopy technique, robot-assisted technique might improve the accuracy of screw implantations in AIS patients with thoracic scoliotic curve, while the increased operation time, blood loss and transfusion volume might be the disadvantages due to preliminary stage of learning curve.

Diagnosis and treatment of congenital scoliosis

Background: Congenital scoliosis is caused by anomalies of the vertebra, such as hemivertebra or unsegmented bar, which result in asymmetric growth of the spine. The disruption of vertebra development during embryogenesis may be accompanied by other congenital multi-organ anomalies. The progression of the scoliotic curve may also hinder the development of other organs.Current Concepts: Hemivertebra excision and short spinal fusion have demonstrated favorable outcomes. However, the need for spinal growth and lung development has led to new treatment modalities. Growth-friendly surgeries, such as with a growing rod or vertical expandable rib-based distraction device, have demonstrated good results with curve correction while maintaining spinal growth. Although the outcome of conservative treatment for congenital scoliosis is questionable, casting may be effective as a “time-buying strategy” to delay the need for surgery.Discussion and Conclusion: It is essential to decide on a treatment plan considering the progression of the curve and growth of the spine and lungs through an individualized approach.

Evaluating Lumbar Intervertebral Disc Degeneration on a Compositional Level Using Chemical Exchange Saturation Transfer: Preliminary Results in Patients with Adolescent Idiopathic Scoliosis

Lumbar intervertebral disc (IVD) degeneration is characterized by structural and compositional changes. This study aimed to assess the glycosaminoglycan (GAG) content of IVDs of patients with adolescent idiopathic scoliosis (AIS) and healthy controls using GAG chemical exchange saturation transfer (gagCEST) imaging. Ten AIS patients (mean age 18.3 ± 8.2 years) and 16 healthy controls (mean age 25.5 ± 1.7 years) were included. Clinical standard morphologic MR images (T1w-, T2w-, and STIR-sequences), to rule out further spinal disorders and assess IVD degeneration using the Pfirrmann score, and compositional gagCEST sequences were acquired on a 3T MRI. In AIS patients, the most distal scoliotic curve was determined on whole-spine conventional radiographs and morphological MRI and IVDs were divided as to whether they were affected by scoliotic deformity, i.e., proximal (affected, aIVDs) or distal (unaffected, uaIVDs) to the stable vertebra of the most distal scoliotic curve. Linear mixed models were used to compare mean gagCEST-values. Over all segments, AIS-patients’ IVDs exhibited significantly lower gagCEST-values than the controls: 2.76 [2.32, 3.20]% (AIS), 3.51 [3.16, 3.86]% (Control); p = 0.005. Meanwhile, no significant differences were found for gagCEST values comparing aIVDs with uaIVDs. In conclusion, as a powerful diagnostic adjunct, gagCEST imaging may be prospectively applied to detect early compositional degenerative changes in patients suffering from AIS.

Reducing the kyphosis effect of anterior short thoracolumbar/lumbar scoliosis correction with an autograft fulcrum effect

Background Anterior scoliosis correction is a powerful technique with the disadvantage of a kyphotic effect on lumbar and thoracolumbar curves. We aimed to investigate whether a cognizant interposition of a rib graft anteriorly and at the concave side of the scoliotic curve causes significant fulcrum effect to enforce scoliosis correction and to reduce interfusional kyphosis in anterior scoliosis corrections. Methods Twenty otherwise comparable patients with lumbar and thoracolumbar adolescent idiopathic scoliosis (AIS) curves undergoing anterior short scoliosis correction with (n = 10) or without (n = 10, matched for age, gender and degree of deformity) fulcrum effect were retrospectively compared by means of radiographic measurements (sagittal and coronal profile, Cobb angles and intersegmental deformity correction angles) to evaluate the effect of this modified surgical technique. Results The overall amount of scoliosis correction was similar with 74 and 60% of initial curves of 57° and 53° in the case and control group respectively with a mean of 3 fused segments (4 screws). Statistically relevant differences were found for intersegmental coronal cobb angles at the apex of 20° to 3° and 17° to 9° with and without fulcrum, respectively (p < 0.05). Creation of kyphosis in the fused segments was reduced with an interfusional kyphotic sagittal cobb angle of 15° pre-operatively vs. 3° post-operatively compared to the control group (13° pre-operatively vs. 18° post-operatively), (p < 0.05). Conclusions Interfusional hyperkyphosis associated with anterior scoliosis correction for thoracolumbar/lumbar curves can be reduced with cognizant positioning of the bone autograft at the antero-lateral (concave) site in the intervertebral region to create a fulcrum effect. Trial registration Registered at swissethics: BASEC No.: 2018–00180.

Continuous lengthening potential after four years of magnetically controlled spinal deformity correction in children with spinal muscular atrophy

Magnetically controlled growing rods (MCGR) are commonly implanted for the treatment of early-onset scoliosis. While most authors report favorable short-term results, little is known about long-term deformity correction. This prospective cohort study assesses spinal deformity control in a homogeneous spinal muscular atrophy (SMA) patient group treated with MCGR implants, a standardized lengthening protocol and a minimum follow-up of four years. 17 SMA patients with progressive scoliosis were treated with MCGR implanted parallel to the spine with rib-to-pelvis fixation. Radiologic measurements were performed before and after MCGR implantation and during external lengthening procedures. These included measurements of the scoliotic curve, kyphosis, lordosis, pelvic obliquity and the spinal length. Additional clinical data of the complications were also analyzed. 17 children (mean age 7.4 years) were surgically treated and underwent a total of 376 lengthenings. Complication rates were 3.5% in respect to all interventions or 41% of the patients had complications during 3.5% of the lengthening sessions. The initial implantation significantly reduced the main scoliotic curve by 59%, with the correction remaining constant throughout the follow-up. Pelvic obliquity was also significantly and permanently corrected by 72%, whereas kyphosis and lordosis were not influenced. The spinal length could be significantly increased mostly during the first year of treatment. Bilateral implantation of MCGRs for correction of spinal deformity in children with SMA showed no decrease of the lengthening potential during a four-year follow-up. Therefore, the previously described ‘law of diminishing returns’ could not be applied to this patient population.Level of Evidence/Clinical relevance: Therapeutic Level IV.

A Semi-Analytic Elastic Rod Model of Pediatric Spinal Deformity

The mechanism of the scoliotic curve development in healthy adolescents remains unknown in the field of orthopedic surgery. Variations in the sagittal curvature of the spine are believed to be a leading cause of scoliosis in this patient population. Here, we formulate the mechanics of S-shaped slender elastic rods as a model for pediatric spine under physiological loading. Second, applying inverse mechanics to clinical data of the subtypes of scoliotic spines, with characteristic 3D deformity, we determine the undeformed geometry of the spine before the induction of scoliosis. Our result successfully reproduces the clinical data of the deformed spine under varying loads, confirming that the prescoliotic sagittal curvature of the spine impacts the 3D loading that leads to scoliosis.

Spinal deformity in adolescent idiopathic scoliosis at the end of Chêneau brace treatment

Background. Brace treatment is frequently used in adolescent idiopathic scoliosis (AIS). However, due to different brace models, long-term results on spinal deformity development at the end of Chneau brace treatment are not often described and differ in results. Aim. The aim of this work was to analyze clinical and radiological data of AIS patients treated with Chneau braces from the beginning of treatment until the end of growth and brace therapy in order to define realistic treatment results and expectations in an everyday setting. Materials and methods. 52 AIS patients with Chneau brace treatment were followed from the beginning of treatment until the end of growth. Clinical data such as the initial Risser sign, age at treatment, gender, curve patterns and body mass index were analyzed. Results. At the beginning of brace therapy, the average age was 13.1 years and patients showed a mean scoliotic curve angle of 30.9. Four months of brace use reduced the scoliotic curve to 20.1. Nine months after the end of brace treatment and an average treatment duration of 17 months, scoliosis has increased up to 30.3 again. In children with a lower maturity status, the initial scoliotic curve was less than in more mature patients leading to less spinal deformity at the end of treatment. In addition, obese children had less scoliosis correction during brace therapy than normalweight children. Conclusion. In patients with AIS treated with a Chneau brace, the initial curvature correction was 35%. Nine months after the end of brace treatment, scoliotic curves identical to the deformities at the beginning of treatment could be observed.

Association between Bone Turnover Markers, Leptin, and Nutritional Status in Girls with Adolescent Idiopathic Scoliosis (AIS)

The link between scoliotic deformity and bone metabolism in adolescent idiopathic scoliosis (AIS) has not been well researched. Moreover, the data concerning the cross-talk between fat tissue content/hormonal activity and bone markers in this group of patients are lacking. The aim of the study was to assess whether there exists a significant relationship between the severity of AIS and bone turnover markers and leptin levels. The study group was consisted of 77 AIS girls, aged 14.7 ± 2.17 years. Scoliotic curve severity assessed by Cobb’s angle was categorized as mild (10–19°), moderate (20–39°), or severe (≥40°). Corrected height, weight, and waist and hip circumferences were measured and body mass index (BMI), corrected height Z-score, BMI Z-score, and waist/height ratio (WHtR) were calculated for the entire group. Body composition parameters: fat mass (FAT), fat-free mass (FFM), and predicted muscle mass (PMM) were determined using a bioelectrical impedance analyzer. Bone turnover markers (osteocalcin (OC) and amino terminal of collagen cross-links (NTx) and leptin levels were assessed in serum. Multiple regression analysis showed that, OC, NTx (negatively with p < 0.05), and leptin (positively with p < 0.01) were significantly associated with curve severity in AIS girls. Moreover, Cobb’s angle was positively correlated with W/HtR (p < 0.01) and FAT (p < 0.05). One-way analysis of variance (ANOVA) revealed significant differences in leptin (p < 0.05 vs. mild only), OC (p < 0.05 vs. mild and moderate), and W/HtR (p < 0.01 and p < 0.05 vs. mild and moderate, respectively) between the three AIS severity subgroups. OC was significantly lower in the severe AIS subgroup, while leptin and W/HtR were significantly higher. Significant correlations between leptin and anthropometrical parameters as BMI z-score and W/HtR were shown. Leptin level correlated also significantly with BMI z score (p < 0.001), W/HtR (p < 0.0001), and body composition parameters (p < 0.000001). Moreover, there was a significant negative correlation between NTx and leptin level (p < 0.05). Bone metabolism in AIS girls seems to be altered and significantly related to the scoliotic curve severity. Leptin may be a crucial link in the cross-talk between bone turnover and body composition in this group of patients. Further studies concerning interrelationship between nutritional status and bone metabolism in patients with AIS are warranted.

Adolescent idiopathic scoliosis (AIS) non-operative treatment in HUCSK of Kosova- a 7 month study

Introduction: Scoliosis is defined as a deviation from midline in the frontal plane, and rotation of the apex of the curve from more than 10 degrees, in AP radiography. Treatment of scoliosis is based in type of scoliosis, region of scoliotic curve, curve magnitude, bone maturity, gender, risk of scoliotic curve progression, other symptoms like and opinion of the patient about his spine shape. Treatment choices of AIS are observation, physical therapy, corsets and surgical treatment. Purpose: Research of patients with AIS focusing in its characteristics, clinical presentation, diagnosis and a detalized research in non-operative treatment of AIS focusing in treatment choices and criteria of treatment. Material and methods: The study is based in retrospective research September 2018- March 2019 (7 months) in HUCSK- Specialized outpatient clinics of Orthopaedics. Data is taken with special permission from Personal Data Protection Office and Ethico-Professional Commity from specialized outpatient clinics of Orthopaedics systems archive for patients with AIS of 10-18 years old. Results: During September 2018-March 2019 period in specialized outpatient clinics of Orthopaedics-HUCSK, 250 cases with AIS of 10-18 years old with Cobb angle more than 10 degrees; are diagnosed and treated. The disease has a prevalence 1.40%. Based in gender women are more affected than men in a ratio 2.01:1. Most common form of AIS is the one that affects thoraco-lumbal region of spine with 60.8% of cases. There has been found a correlation between scoliosis and kyphosis in higher levels of spine. About 89.7% of cases are light scoliotic curves according to Cobb angle and the female \\ male ratio increases at women with an increase of Cobbs angle. Patients are treated with one or more forms of non-operative treatment: observation 10.4% of cases, observation and physical therapy 89.6% of cases and observation, physical treatment and corset TLSO 25.6% of cases. Cases that have undergone three forms of non-operative treatment are with Cobb angle of more than 20 degrees.