Efficacy of Routine Intraoperative Cranio-Femoral Traction in Surgical Treatment of Adolescent Idiopathic Scoliosis Curves Measuring Between 50° and 90°

Study Design Retrospective Comparative Study, Level III. Objective In patients with scoliosis >90°, cranio-femoral traction (CFT) has been shown to obtain comparable curve correction with decreased operative time and blood loss. Routine intraoperative CFT use in the treatment of AIS <90° has not been established definitively. This study investigates the effectiveness of intraoperative CFT in the treatment of AIS between 50° and 90°, comparing the magnitude of curve correction, blood loss, operative time, and traction-related complications with and without CFT. Methods 73 patients with curves less than 90° were identified, 36 without and 37 with cranio-femoral traction. Neuromuscular scoliosis and revision surgery were excluded. Age, preoperative Cobb angles, bending angles, and curve types were recorded. Surgical characteristics were analyzed including number of levels fused, estimated blood loss, operative time, major curve correction (%), and degree of postoperative kyphosis. Results Patients with traction had significantly higher preoperative major curves but no difference in age or flexibility. Lenke 1 curves had significantly shorter operative time and improvement in curve correction with traction. Among subjects with 5 to 8 levels fused, subjects with traction had significantly less EBL. Operative time was significantly shorter for subjects with 5-8 levels and 9-11 levels fused. Curves measuring 50°-75° showed improved correction with traction. Conclusion Intraoperative traction resulted in shorter intraoperative time and greater correction of major curves during surgical treatment of adolescent idiopathic scoliosis less than 90°. Strong considerations should be given to use of intraoperative CFT for moderate AIS.

Hybrid versus total sublaminar wires in patients with spinal muscular atrophy undergoing scoliosis surgery

Background Early versions of spinal muscular atrophy (SMA) scoliosis correction surgery often involved sublaminar devices. Recently, the utilization of pedicle screws has gained much popularity. Pedicle screws are generally believed to provide additional deformity correction, but pedicle size and rotational deformity limit their application in the thoracic spine, resulting in a hybrid construct involving pedicle screws and sublaminar wire. Studies of the efficacy of hybrid instrumentation in SMA scoliosis are often limited by the scarcity of the disease itself. In this study, we aimed to compare the surgical outcomes between hybrid constructs involving pedicle screws and sublaminar wire and sublaminar wire alone in patients with SMA scoliosis. Methods We retrospectively reviewed the clinical records and radiographic assessments of patients with SMA scoliosis who underwent corrective surgery between 1993 and 2017. The radiographic assessments included deformity correction and progressive changes in the major curve angle, pelvic tilt (PT) and coronal balance (CB). The correction of deformities was observed postoperatively and at the patient’s 2-year follow-up to test the efficacy of each type of construct. Results Thirty-three patients were included in this study. There were 14 and 19 patients in the wiring and hybrid construct groups, respectively. The hybrid construct group demonstrated a higher major curve angle correction (50.5° ± 11.2° vs. 36.4° ± 8.4°, p < 0.001), a higher apical vertebral rotation correction (10.6° ± 3.9° vs. 4.8° ± 2.6°, p < 0.001), and a reduced progression of the major curve angle at the 2-year follow-up (5.1° ± 2.9° vs. 8.7° ± 4.8°, p < 0.001). A moderate correlation was observed between the magnitude of correction of the apical vertebral rotation angle and the major curve (r = 0.528, p = 0.002). Conclusion This study demonstrated that hybrid instrumentation can provide a greater magnitude of correction in major curve and apical rotation as well as less major curve progression than sublaminar wire instrumentation alone in patients with SMA scoliosis. Level of evidence III

Two-staged posterior osteotomy surgery in complex and rigid congenital scoliosis in younger than 10 years old children

Background Congenital scoliosis caused by failure of multiply vertebral segmentation with concave fused rib or unsegmented bar combined with contralateralhemivertebra is usually rigid and produces enormous asymmetric growth. Fusionless techniques have less advantage and come with some complications. Paucity of data was reported for children with complex congenital scoliosis using two-staged osteotomy surgery. Methods From 2006 to 2016, 11 patients less than 10 years old undergoing two staged osteotomy surgery for complex rigid congenital scoliosis were retrospectively reviewed. The analysis included age at initial surgery, second surgery and at the latest follow-up, and complications. Changes in coronal major curve, thoracic kyphosis, lumbar lodorsis, apex vertebra translation, T1-T12 length, T1-S1 length, trunk shift, and SVAwere included in radiological evaluation. Results In all, the mean follow-up was 72.5 ± 23.8 (42 to 112) months. The mean flexibility of the spine was 17.4 and 17.8 % before two surgeries. The mean age at the initial surgery was 6.6 ± 2.6 (2.5–10) years. The mean fusion level was 4.6 ± 1.3 (2 to 6) segments. The mean scoliosis improved from 67.4° to 23.7° after initial surgery and was 17.4° at the latest follow-up. The average increase of T1-S1 length was 0.92 cm per year. No patients had neurological complications. Conclusions Two-staged osteotomy surgery including hemivertebrae resection or Y-shaped osteotomy can achieve good radiological and clinical outcomes without severe complications. This procedure can be an option of treatment for complex congenital scoliosis.

Intraoperative halo-femoral traction during posterior spinal arthrodesis for adolescent idiopathic scoliosis curves between 70° and 100°: a randomized controlled trial

OBJECTIVE Surgical management of scoliosis curves between 70° and 100° remains controversial. The authors designed this randomized controlled trial to validate the efficacy of intraoperative halo-femoral traction (IOHFT) in patients with adolescent idiopathic scoliosis (AIS), Cobb angles between 70° and 100°, and flexibility < 35%. METHODS The authors prospectively recruited and randomized 29 patients with severe AIS scheduled for posterior surgery into a traction group or control (nontraction) group. The primary outcome measures were operative time, blood loss, and length of hospital stay. Secondary outcomes included degree of spine deformity correction, traction-related complications, and health-related quality of life. RESULTS In the traction group, the average preoperative Cobb angle was 83.2°, with an average 20.6% flexibility. The average postoperative Cobb angle was 16.1° and the major curve was 18.3° at the final follow-up. In the control group, the average preoperative major curve was 80.3° with 22.8% flexibility. The average postoperative Cobb angle was 16.1° and the major curve was 18.1° at the final follow-up. The operative duration was 325.7 minutes for the traction group and 385.4 minutes for the control group (p = 0.018). Compared with the control group, the traction group had a 29.5% reduction in intraoperative blood loss and a significantly lower rate of blood transfusion (13.3% vs 50.0%, p = 0.033). There were no neurological complications in either group. One patient in the traction group had a superficial infection at the traction site. CONCLUSIONS Use of IOHFT contributed to significant reductions in operative time and blood transfusion requirements, with no added morbidity. It is an effective and safe method to assist correction of AIS curves between 70° and 100° and flexibility < 35%.

Hybrid versus Total Sublaminar Wires in Patients With Spinal Muscular Atrophy Undergoing Scoliosis Surgery

BackgroundEarly versions of spinal muscular atrophy (SMA) scoliosis correction surgeries often involved sublaminar devices. Recently the utilization of pedicle screw is gaining much popularity. Pedicle screw generally believed to provide additional deformity correction, but pedicle size and rotational deformity limit the application of pedicle screw in the thoracic spine, resulting in a hybrid construct of the pedicle screw and sublaminar wire. Studies of the efficacy of hybrid instrumentation in SMA scoliosis is often limited by the scarcity of the disease itself. In this study, we aimed to compare the surgical outcome of using hybrid constructs of the pedicle screw and sublaminar wire and that of sublaminar wire alone in patients with SMA scoliosis.MethodsWe retrospectively reviewed the clinical records and radiographic assessments of patients with SMA scoliosis who underwent corrective surgery between 1993 and 2015. The radiographic assessments included the deformity correction and the progressive change of major curve angle, pelvic tilt (PT) and coronal balance (CB). The correction of deformities was observed postoperatively and at the patient’s 2-year follow-up to test the efficacy of each type of constructs.ResultsThirty-three patients were included in this study. There were 14 and 19 patients in the wiring and the hybrid construct groups, respectively. The hybrid construct demonstrated a higher major curve angle correction (50.5° ± 11.2° vs. 36.4° ± 8.4°, p < 0.001), a higher apical vertebral rotation correction (10.6° ± 3.9° vs. 4.8° ± 2.6°, p < 0.001), and reduced the progression of major curve angle after the 2-year follow-up (5.1° ± 2.9° vs. 8.7° ± 4.8°, p < 0.001). A moderate correlation was observed between the magnitude of correction of apical vertebral rotation angle and major curve (r = 0.528, p = 0.002).ConclusionThis study demonstrated that hybrid instrumentation can provide a greater magnitude of correction in major curve and apical rotation, as well as less major curve progression in comparison with sublaminar wire in patients with SMA scoliosis.Level of evidence III

Higher pedicle screw density does not improve curve correction in Lenke 2 adolescent idiopathic scoliosis

Purpose Higher pedicle screw density posterior spinal fusion (PSF) constructs have not been shown to result in improved curve correction in Lenke 1 and 5 adolescent idiopathic scoliosis (AIS) but do increase cost. The purpose of this study questioned whether higher screw density constructs improved curve correction and maintenance of correction in Lenke 2 AIS. Secondary goals were to identify predictive factors for correction and postoperative magnitude of curves in Lenke 2 AIS. Methods We identified patients 11 to 17 years old who underwent primary PSF for Lenke 2 AIS between 2007 and 2017 who had minimum follow-up of 2 years. Demographic and radiographic data were collected to perform regression and elimination analysis. Results Thirty patients (21 females, 9 males) were analyzed. Average age and SD at time of surgery was 14.0 ± 1.8 years (range, 11–17 years), and median follow-up was 2.8 years (IQR 2.1–4.0 years). Implant density did not predict final postoperative curve magnitude. Predictors of final postoperative curve magnitude were sex and preoperative curve magnitude. Predictors of percentage of correction of major curve were sex and age at the time of surgery. Predictors of final postoperative thoracic kyphosis were sex and percent flexibility preop. Females had lower final postoperative major curve magnitude, a higher percent curve correction, and lower postoperative thoracic kyphosis. Conclusions Increased implant density is not predictive of postoperative curve magnitude in Lenke 2 AIS. Predictors of postoperative curve magnitude are sex and preoperative curve magnitude. Level of evidence Level III, retrospective observational

“Higher Pedicle Screw Density Does Not Result in Improved Curve Correction in Lenke 2 Adolescent Idiopathic Scoliosis”

Purpose: Higher pedicle screw density posterior spinal fusion (PSF) constructs have not been shown to result in improved curve correction in Lenke 1 and 5 adolescent idiopathic scoliosis (AIS) but do increase cost. The purpose of this study questioned whether higher screw density constructs improved curve correction and maintenance of correction in Lenke 2 AIS. Secondary goals were to identify predictive factors for correction and postoperative magnitude of curves in Lenke 2 AIS. Methods: We identified patients 11 to 17 years old who underwent primary PSF for Lenke 2 AIS between 2007 and 2017 who had minimum follow up of 2 years. Demographic and radiographic data were collected to perform regression and elimination analysis. Results: Thirty patients (21 Female, 9 male) were analyzed. Average age and SD at time of surgery was 14.0 ± 1.8 years (range, 11-17 years) and median follow-up was 2.8 years (IQR 2.1-4.0 years). Implant density did not predict final postoperative curve magnitude. Predictors of final postoperative curve magnitude were sex and preoperative curve magnitude. Predictors of percentage of correction of major curve were sex and age at the time of surgery. Predictors of final postoperative thoracic kyphosis were sex and percent flexibility preop. Females had lower final postoperative major curve magnitude, a higher percent curve correction, and lower postoperative thoracic kyphosis.Conclusions: Increased implant density is not predictive of postoperative curve magnitude in Lenke 2 AIS. Predictors of postoperative curve magnitude are sex and preoperative curve magnitude.Level of Evidence: Level III Retrospective Observational

The predictor for Preoperative Coronal Imbalance in patients with Degenerative Lumbar Scoliosis--A related analysis on spinopelvic parameters

Background: The mechanism of coronal imbalance is still unclear. The relationships among CBD and major curve, L4 and L5 tilt have been reported, which were not explicit although. The aim of this retrospective study was to explore and examine the association between spinopelvic parameters and coronal balance distance (CBD) in degenerative lumbar scoliosis (DLS) patients.Methods Following institutional ethics approval, the radiographs of 161 DLS patients were retrospectively reviewed. The coronal measurements involving CBD, L4 coronal tilt, L5 coronal tilt, fractional curve, pelvic coronal tilt, the Cobb angle and included vertebras of major curve were documented. All of those participants were divided into group A (CBD≥30mm) and group B (CBD < 30mm). Statistical analysis was performed to compare the difference of continuous and categorical variables. Pearson-Correlation, and Multiple-Regression Analysis were performed to explore the related parameter with CBD.Results The CBD in 31 (19.25%) DLS patients at pre-operation was over 30mm. With similar major Cobb angle, main curve of patients in the group A had less involving vertebras (P=0.009), but more rotation of the apical vertebra (P<0.001) compared with that in the group B respectively. Additionally, the L4 coronal tilt in group A was much larger (P=0.02). Pearson-correlation analysis showed that CBD had significant relationship with L4/L5 coronal tilt(P<0.001), weak relationship with fractional curve (P=0.027), but linearly independent with pelvic tilt and major Cobb. Stepwise Multiple- regression analysis revealed that only L4 tilt was the independent predictor for major Cobb and CBD.Conclusions The prevalence of coronal imbalance at pre-operation in DLS patients is about 20%. With similar major Cobb, the less the number of involving vertebra, the higher the incidence of coronal imbalance in DLS patients. L4 coronal tilt would be the predictive variable for progression of scoliosis and global coronal malalignment. Pelvis, the foundation of spine, had less effect on full-spine coronal balance.

The tough Westerner

This chapter explores Power’s work within the Western genre. When Power was cast in the title role of Hollywood’s first ‘A Western’ of the 1930s: Jesse James (Henry King) in 1939 it marked the first major curve in Power’s career trajectory. When it became Twentieth Century-Fox’s biggest hit of the year this proved that audiences were ready to accept Power in more masculine roles at the close of the decade. Released in the period directly preceding America’s entry into World War II, the film was integral in developing a much-needed shift in Power’s screen masculinity, appearance and performance style, reflecting the shifting industrial and social context in which it was made. In advancing his star image away from a womaniser, and instead placing it within an overtly homosocial environment, Power was able to convincingly demonstrate male bonding and leadership through a tougher masculinity which was essential for both the historical timeframe and Power’s own upcoming real-life war service. Despite the film’s huge success, it was another 12 years before Power starred in another Western, and made just four in overall: Jesse James, Rawhide (Henry Hathaway, 1951), Pony Soldier (Joseph M. Newman, 1952) and The Mississippi Gambler (Rudolph Maté, 1953).

Influence of curve morphology and location on the efficacy of rigid conservative treatment in patients with adolescent idiopathic scoliosis

Aims The aim of the present study was to answer the question whether curve morphology and location have an influence on rigid conservative treatment in patients with adolescent idiopathic scoliosis (AIS). Methods We retrospectively analyzed AIS in 127 patients with single and double curves who had been treated with a Chêneau brace and physiotherapeutic specific exercises (B-PSE). The inclusion criteria were the presence of structural major curves ≥ 20° and < 50° (Risser stage 0 to 2) at the time when B-PSE was initiated. The patients were divided into two groups according to the outcome of treatment: failure (curve progression to ≥ 45° or surgery) and success (curve progression < 45° and no surgery). The main curve type (MCT), curve magnitude, and length (overall, above and below the apex), apical rotation, initial curve correction, flexibility, and derotation by the brace were compared between the two groups. Results In univariate analysis treatment failure depended significantly on: 1) MCT (p = 0.008); 2) the apical rotation of the major curve before (p = 0.007) and during brace treatment (p < 0.001); 3) the initial and in-brace Cobb angles of the major (p = 0.001 and p < 0.001, respectively) and minor curves (p = 0.015 and p = 0.002); 4) major curve flexibility (p = 0.005) and the in-brace curve correction rates (major p = 0.008, minor p = 0.034); and 5) the length of the major curve (LoC) above (p < 0.001) and below (p = 0.002) the apex. Furthermore, MCT (p = 0.043, p = 0.129, and p = 0.017 in MCT comparisons), LoC (upper length p = 0.003, lower length p = 0.005), and in-brace Cobb angles (major p = 0.002, minor p = 0.027) were significant in binary logistic regression analysis. Conclusion Curve size, location, and morphology were found to influence the outcome of rigid conservative treatment of AIS. These findings may improve future brace design and patient selection for conservative treatment. Cite this article: Bone Joint J 2021;103-B(2):373–381.