Search

Background Context: The effect of the degree of lumbar lordosis (LL) correction on proximal junctional kyphosis (PJK) has not been analyzed in context of the age-adjusted sagittal alignment goal., Purpose: To determine the effect of sagittal correction on the incidence of PJK after an age-adjusted analysis in patients with adult spinal deformity (ASD)., Study Design/setting: Retrospective comparative study., Patient Sample: Seventy-eight ASD patients who underwent deformity correction., Outcome Measures: Visual analog scale (VAS), Oswestry Disability Index (ODI), and imaging., Methods: This study included 78 ASD patients who underwent deformity correction and were followed-up more than 2 years. Patients were grouped according to the degree of LL correction relative to pelvic incidence (PI) by adjusting for age using the following formula: (age-adjusted ideal PI - LL) - (postoperative PI - LL). These were group U (undercorrection; <-10˚, N=15), group I (ideal correction; -10˚-10˚, N=34), and group O (over correction, >10˚, N=29). Various clinical and radiological parameters were compared among groups. The risk factors for PJK were also evaluated., Results: The overall incidence of PJK was 32.1% (25/78), with significantly higher PJK rate in group O (48.3%) compared with groups U (13.3%) and I (26.5%) (p=.041). The degree of postoperative LL correction relative to the PI by adjusting for age was a risk factor for the development of PJK (11.4° for PJK vs. 0.2° for non-PJK, p=.033). In addition, 2-year postoperative VAS (7.0 vs. 3.4, p<.001) and ODI (28.9 vs. 24.8, p=.040) scores were significantly higher in the PJK group than in the non-PJK group. A small PI (PI < 45°) was associated with a tendency of overcorrection (73.3%, P < 0.001) and thereby with the high incidence of PJK (53.3%, p=.005)., Conclusions: Overcorrection of LL relative to PI considering age-adjusted ideal sagittal alignment tends to increase the incidence of PJK. The incidence of PJK is expected to be high in patients with low PI (<45°) because of the tendency of overcorrection. To reduce the risk of PJK, surgeons should take age-adjusted parameters into account and exercise caution not to overcorrect patients with low PI, since this can result in suboptimal clinical outcomes., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Study Design: Multicenter retrospective review., Objective: This study aims to address major postoperative complications associated with Scheuermann kyphosis (SK) when compared with adolescent idiopathic scoliosis (AIS) in a large population matched by demographic characteristics, levels fused and operative technique., Summary of Background Data: Prior studies have found that SK patients are 3.86 times more likely to experience major postoperative complications than in AIS. Historically, however, these studies have often had populations that were significantly different between the two groups in terms of disease severity, demographics, and small sample sizes., Methods: AIS patients were compared to SK patients between 2006 and 2018 contemporaneously. All surgeries were conducted by six surgeons among two institutions. Complications and revisions were calculated. A sub-analysis comparing SK and AIS patients by age, sex, and levels-fused in one-to-one matched pairs was performed as well as a sub-analysis matched by levels fused only in one-to-one matched pairs., Results: One thousand three hundred twenty two patients were reviewed (1222 AIS; 100 SK). There were 52 (4.3%) complications in the AIS group compared with 20 (20%) complications in the SK group (P < 0.001), with infections and revisions consisting of the majority of complication rates in both cohorts.When matched by age, sex, and levels fused, there were eight complications in the AIS group and 11 in the SK group (P = 0.63), with infection and revision rates being similar, (P = 0.29) and (P = 0.26) respectively.When matched by levels fused only, EBL, operative time and complication rates remained similar (P > 0.05)., Conclusion: Contrary to previously published literature, our analyses indicate that in a matched population, postoperative complication rates (i.e., infection and revision rates) are not significantly different between SK and AIS patients.Level of Evidence: 4., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To investigate the effectiveness of transvertebral space and under the pedicle osteotomy for thoracolumbar kyphosis caused by old osteoporotic vertebral compression fracture (OVCF)., Methods: The clinical data of 11 patients with thoracolumbar kyphosis caused by old OVCF treated by transvertebral space and under the pedicle osteotomy between January 2016 and December 2020 were retrospectively analyzed. There were 2 males and 9 females, with an average age of 61.3 years (range, 50-77 years) and with a median disease duration of 8 years (range, 6 months to 50 years). Fracture reasons: 9 cases had a clear history of trauma, and 2 cases had no obvious incentive. A total of 11 vertebrae was involved in fracture, including T 12 in 3, L 1 in 7, L 2 in 1. The operation time, intraoperative blood loss, postoperative drainage volume, and complications were recorded. Full-length X-ray films of spine and local X-ray films of the operation area were examined before operation, at 7 days after operation, and at last follow-up. The Cobb angle of thoracolumbar kyphosis was measured, and the correction rate was calculated. The visual analogue scale (VAS) score and Oswestry disability index (ODI) were recorded to assess patients' pain and functional improvement before operation, at 1 month after operation, and at last follow-up., Results: All operations were successfully completed. The average operation time was 188.6 minutes (range, 140-215 minutes); the average intraoperative blood loss was 268.2 mL (range, 100-500 mL); the average postoperative drainage volume was 615.5 mL (range, 160-1 500 mL). One patient developed bilateral thigh rebound pain after operation, which relieved after symptomatic treatment of nutritional nerve and acesodyne. All patients were followed up 14.7 months on average (range, 6-56 months). At last follow-up, osseous fusion was observed in all patients, and no fracture, loose, or displacement of internal fixator was observed on imaging. At 7 days after operation and at last follow-up, the Cobb angle of thoracolumbar kyphosis significantly improved when compared with preoperative one ( P <0.05), and there was no significant difference between at 7 days after operation and at last follow-up ( P >0.05); the correction rates of Cobb angle at 7 days after operation and at last follow-up were 68.0%±9.8% and 60.3%±11.9%, respectively. At 1 month after operation and at last follow-up, the VAS score and ODI significantly improved when compared with preoperative ones, and further improved at last follow-up when compared with those at 1 month after operation, all showing significant differences ( P <0.05)., Conclusion: Transvertebral space and under the pedicle osteotomy is an effective way to treat thoracolumbar kyphosis caused by old OVCF with less trauma, shorter operation time, and less intraoperative blood loss. Patients can obtain good orthopedic results and quality of life.

Background: The study aimed to evaluate the influence of thoracolumbar kyphosis secondary to ankylosing spondylitis (AS) on parameters of S2AI trajectory and to compare the ideal S2AI trajectory with those of the non-deformity patients with AS, sagittal deformity patients without AS, and the normal population reported in literatures., Methods: Sagittal parameters including global kyphosis (GK), pelvic tilt (PT) and sacral slope (SS) were measured. Besides, according to the simulated ideal S2AI trajectory on the CT images, trajectory parameters were measured including Sag angle, Tsv angle, Max-length, Sacral distance and Iliac width. Starting-point parameters were also measured including PSIS distance, Skin distance, Iliac wing and S2 midline., Results: Ninety-four AS-related thoracolumbar kyphosis patients were included. After adjusting the age and gender, twenty non-deformity patients with AS and 20 sagittal deformity patients without AS were selected to compare with patients with AS-related thoracolumbar kyphosis, respectively. Sag angle in deformity patients with AS was smaller than other two groups (P < 0.001). No difference was found in Tsv angle and Sacral distance between AS patients with and without deformity. However, these two parameters were shown significant differences between deformity patients with AS and without AS. In deformity patients with AS, no significant differences were found in all parameters between genders Furthermore, there were strong correlations between PT and the bilateral Sag angle (P < 0.001)., Conclusions: The thoracolumbar kyphosis secondary to AS affects the Sag angle of the ideal S2AI trajectory which was approximately 20° smaller than that in non-deformity patients with AS, sagittal deformity patients without AS, and the normal population. Additionally, the Tsv angle and the Sacral distance in AS patients with thoracolumbar kyphosis were about 10° and 10 mm larger than those in sagittal deformity patients without AS, and the normal population reported in literatures., (© 2022. The Author(s).)

Purpose: Typically, selection of lowest instrumented vertebra (LIV) in Adolescent Idiopathic Scoliosis (AIS) is based on the coronal radiograph; however, increasing evidence suggests that fusions proximal to the stable sagittal vertebrae (SSV) on the lateral radiograph can result in distal junctional kyphosis (DJK). The purpose of this study is to compare rates of DJK in patients with AIS that have a discordance between the Lowest Touched Vertebra (LTV) and the SSV and to identify risk factors for developing DJK., Methods: Patients with AIS Lenke type 1, 2 and 3 curves treated with a posterior spinal fusion were separated into two groups. Group 1 had SSV that was proximal to the LTV whereas group 2 had SSV that was distal to the LTV. Comparisons were made for patients that were fused to the SSV(a), LTV(b) or between(c). Distal junctional angle (DJA) > 5° and increasing kyphosis at the end of the fusion construct were evaluated as risk factors for DJK., Results: The rate of DJK was 0.0% in group 1a, 1b, and 1c compared to 4.3%, 18.5% and 10.0% in groups 2a, 2b and 2c, respectively(p < 0.001). The rate of DJK was 22.9% when the distal junctional angle(DJA) > 5° versus 1.4% when the DJA < 5°(p < 0.001)., Conclusion: There was a low risk for progression of DJK when the SSV was proximal to the LTV, however, those with SSV distal to the LTV represent a high-risk group. Importantly, the development of DJK occurred almost exclusively in patients with LIV at the thoracolumbar junction which demonstrates that surgeons need to be cautious when ending fusions at T11, T12, and L1 in patients at high risk for DJK. Furthermore, having a distal junctional angle 5° or greater increased the risk of developing DJK by roughly 16-fold. At a minimum of 5-year follow-up, the development of DJK did not appear to adversely impact SRS outcomes or revision rates., (© 2021. Scoliosis Research Society.)

Objective: Determine if spinal curvatures, deformities, as well as level of disability (due to back pain) changes with aging in adults with bilateral spastic cerebral palsy after receiving orthopedic interval surgery approach treatment in childhood., Design: Consecutive case-series SETTING: Urban South Africa PARTICIPANTS: Twenty-seven ambulatory adults with cerebral palsy MAIN OUTCOME MEASURES: Spinal curvatures (scoliosis, thoracic kyphosis and lumbar lordosis) and deformities (spondylolysis and spondylolisthesis) were determined with X-rays, while the level of disability was assessed with the Oswestry Disability Index., Results: The prevalence of spinal abnormalities were: 30% scoliosis (mild: <30°), 0% thoracic hyperkyphosis, 15% lumbar hyperlordosis, 0%; spondylolysis, and 0% spondylolisthesis. No changes in scoliosis and lumbar lordosis angles were observed, while the change in thoracic kyphosis angle was smaller than the minimal clinically important difference and moved closer toward the norm-values for typically developing adults. Level of disability remained similar with 63% reporting minimal disability, 26% moderate disability and 11% severe disability. No associations with spinal curvatures were found., Conclusions: No clinically meaningful changes in spinal curvatures, deformities and level of disability due to pain were seen during the 6 years follow-up period in adults with cerebral palsy who have been treated with interval surgery approach in childhood., (Copyright © 2021 The American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: The management of scoliosis and kyphoscoliosis in patients with Type 1 Neurofibromatosis (NF-1) among spinal surgeons is still challenging due to the severity of the deformity especially in dystrophic deformity types. This rapid and progressive condition is likely to be associated with dislocated rib heads into the spinal canal, hence representing a real dilemma on the decision making between its resection versus not resection during the corrective surgery, especially in patients with normal neurological status. The objective of this publication is to discuss the management options in this patient population through a literature review., Methods: A comprehensive systematic literature search was performed for relevant studies using PubMed, Web of Science, and Scopus databases. Previous publications depicting neurologically intact patients with NF-1 and rib dislocation into the canal were reviewed. Articles reporting individual cases or case series/cohorts with patient-discriminated findings were included., Results: The data collection retrieved a total of 55 neurologically intact patients with NF-1 dystrophic scoliosis and rib penetration into the canal who underwent spinal surgery. Among them, 37 patients underwent surgery without head rib resection and 18 patients with rib excision. No patient presented postoperative neurological deficit except for one case of late postoperative neurological deterioration reported in a patient within situ fusion in which the surgeons ignored the presence of previous spinal cord compression., Conclusion: Corrective surgery for patients with NF-1 and rib penetration into the canal in neurologically intact patients can be safely performed without the resection of the dislocated rib heads without a higher risk of neurological compromise., (© 2021. Scoliosis Research Society.)

Background: Increasing kyphosis of the spine in a human is a well-recognized clinical phenomenon that has been associated with back pain, poor physical performance and disability. The pathophysiology of age-related kyphosis is complex and has been associated with physiological changes in vertebrae, intervertebral disc (IVD) and paraspinal musculature, which current cross-sectional studies are unable to demonstrate. Creating an in vivo, paraspinal myopathic animal model for longitudinal study of these changes under controlled conditions is thus warranted., Purpose: To confirm the TSC1 gene knockout effect on paraspinal muscle musculature; to analyze the development of spinal kyphosis, IVD degeneration and vertebra structural changes in a longitudinal manner to gain insights into the relationship between these processes., Study Design: A prospective cohort study of 28 female mice, divided into 4 groups-9-month-old TSC1mKO (n=7), 9-month-old control (n=4), 12-month-old TSC1mKO (n=8), and 12-month-old controls (n=9)., Methods: High resolution micro-computed tomography was used to measure sagittal spinal alignment (Cobb's angle), vertebral height, vertebral body wedging, disc height index (DHI), disc wedge index (DWI), histomorphometry of trabecular bone and erector spinae muscle cross-sectional area. Paraspinal muscle specimens were harvested to assess for myopathic features with H&E stain, muscle fiber size, density of triangular fiber and central nucleus with WGA/DAPI stain, and percentage of fibers with PGC-1α stain. Intervertebral discs were evaluated for disc score using FAST stain., Results: Compared to controls, paraspinal muscle sections revealed features of myopathy in TSC1mKO mice similar to human sarcopenic paraspinal muscle. While there was significantly greater presence of small triangular fiber and density of central nucleus in 9-and 12-month-old TSC1mKO mice, significantly larger muscle fibers and decreased erector spinae muscle cross-sectional area were only found in 12-month-old TSC1mKO mice compared to controls. TSC1mKO mice developed accelerated thoracolumbar kyphosis, with significantly larger Cobb angles found only at 12 months old. Structural changes to the trabecular bone in terms of higher bone volume fraction and quality, as well as vertebral body wedging were observed only in 12-month-old TSC1mKO mice when compared to controls. Disc degeneration was observed as early as 9 months in TSC1mKO mice and corresponded with disc wedging. However, significant disc height loss was only observed when comparing 12-month-old TSC1mKO mice with controls., Conclusions: This study successfully shows the TSC1 gene knockout effect on the development of paraspinal muscle myopathy in a mouse which is characteristic of sarcopenia. The TSC1mKO mice is by far the best model available to study the pathological consequence of sarcopenia on mice spine. With paraspinal muscle myopathy established as early as 9 months, TSC1mKO mice developed disc degeneration and disc wedging. This is followed by kyphosis of the spine at 12 months with concomitant disc height loss and vertebral body wedging due to bone remodeling. Age-related bone loss was not found in our study, suggesting osteoporosis and myopathy-induced vertebral body wedging are likely two independent processes., Clinical Significance: This is the first study to provide key insights on the early and late consequences of paraspinal myopathy on intervertebral disc degeneration, spinal kyphosis, and vertebral body changes. With this new understanding, future studies evaluating therapies for spinal degeneration may be performed to develop time-sensitive interventions., Competing Interests: Declarations of competing interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: A primary etiology of adolescent idiopathic scoliosis (AIS) is currently unknown, but poor postural control of the spinal extensor musculature has been identified as an AIS risk factor. Identifiable postural differences would aid in advancing the precise postural behaviors that should be modified during Physiotherapy Scoliosis Specific Exercise (PSSE) to help limit the progression of AIS., Research Question: Are there any determinable differences in lumbopelvic posture or range of motion between subjects with AIS and controls?, Methods: This prospective cohort pilot study consisted of 53 subjects (27 AIS and 26 control) aged 11-17 years. Subjects had their lumbopelvic posture assessed and monitored using the ViMove DorsaVi sensor package. All subjects underwent a live assessment to obtain initial lumbopelvic (LP) range of motion (ROM) measurements. Subjects were then monitored while continuing with normal activities of daily living (ADLs) for 12 h. With an alpha level of 0.05, nonparametric analyses were performed for each variable via a Mann-Whitney U-test., Results: During the live assessment, controls exhibited a significantly greater anterior pelvic tilt ROM in the sitting position than the AIS group (p = 0.0433). When compared to female controls, females with AIS had a sitting pelvic tilt ROM that was significantly more retroverted (p = 0.0232) and less anteverted (p = 0.0010). During ADLs, female controls exhibited a higher total number of extension events than their female with AIS (p = 0.0263). These associations did not strengthen with greater spinal deformity., Significance: This work demonstrates postural differences between patients with AIS and controls. Further study is necessary to determine why patients with AIS adopt these postures, and if PSSEs can be utilized to limit the progression of AIS., (Copyright © 2022. Published by Elsevier B.V.)

Study Design: This was a retrospective study., Objective: To introduce an anterior surgical technique for myelopathy caused by degenerative cervical kyphosis and stenosis (DCKS) with or without ossification of the posterior longitudinal ligament (OPLL)., Summary of Background Data: The optimal approach in the treatment of DCKS remains a controversy because each anterior or posterior route surgery has advantages and disadvantages., Materials and Methods: In the period from June 2017 through June 2019, a consecutive cohort of adults diagnosed with DCKS underwent anterior canal reconstruction and fusion (ACRF). All patients underwent x-ray, computed tomography, and magnetic resonance imaging of the cervical spine. Radiologic assessment included kyphosis, canal area, canal reconstruction, OPLL, and spinal cord curvature and morphology. The Japanese Orthopaedic Association (JOA) scoring system was used to evaluate the neurological status. Surgery-related and implant-related complications were all recorded. Follow-up was carried out at 3, 6, 12, 24, and 36 months postoperation., Results: Fourty-one patients were included in the study, of which 19 presented with OPLL. Postoperatively, the canal area were significantly greater at last follow-up compared with preoperation (208.4 vs. 123.2 mm2; P=0.001). There was significant kyphosis correction (-17.6 vs. 8.5 degrees, P=0.001) at last follow-up. Ninety-six segmental canal reconstruction were performed, 89 (92.7%) reached bone fusion at both grooves with a mean time of 7.9 months. On sagittal magnetic resonance imaging, 33 (80.5%) patients presented with lordosis in the spinal cord curvature, 8 (19.5%) with straight. The mean JOA score at last follow-up was significantly better than preoperation (15.0 vs. 9.3 points; P<0.01). One patient presented with cerebrospinal fluid leakage, 1 with screw displacement and 2 with dysphagia., Conclusion: ACRF, receiving good correction of kyphosis, amplified canal area, solid instrumented fusion and circumferential decompression, is an effective and safe surgical technique for cervical myelopathy caused by DCKS with or without OPLL., Level of Evidence: Level III-a retrospective analysis., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

The shorter life spans of mice provide an exceptional experimental gerontology scenario. We previously described increased bizarre (disruptive) behaviors in the 6-month-old 3xTg-AD mice model for Alzheimer's disease (AD), compared to C57BL/6J wildtype (NTg), when confronting new environments. In the present work, we evaluated spontaneous gait and exploratory activity at old age, using 16-month-old mice. Male sex was chosen since sex-dependent psychomotor effects of aging are stronger in NTg males than females and, at this age, male 3 × Tg-AD mice are close to an end-of-life status due to increased mortality rates. Mice's behavior was evaluated in a transparent test box during the neophobia response. Stretching, jumping, backward movements and bizarre circling were identified during the gait and exploratory activity. The results corroborate that in the face of novelty and recognition of places, old 3xTg-AD mice exhibit increased bizarre behaviors than mice with normal aging. Furthermore, bizarre circling and backward movements delayed the elicitation of locomotion and exploration, in an already frail scenario, as shown by highly prevalent kyphosis in both groups. Thus, the translational study of co-occurrence of psychomotor impairments and anxiety-like behaviors can be helpful for understanding and managing the progressive functional deterioration shown in aging, especially in AD., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Purpose: Limited dorsal myeloschisis, a form of cervical spinal dysraphism, is a rare anomaly and is typically associated with spinal cord tethering. The objective is to illustrate a rare dysraphic anomaly in the cervicothoracic spine causing myelopathy, not due to tethering but secondary to progressive kyphosis. To our knowledge, such an anomaly has not been described in the literature., Study Design: Case report METHODS: A 16-year-old boy presented with lower extremity spastic paraparesis due to progressive cervicothoracic deformity. The imaging studies revealed extensive posterior arch defects from C1 to T6. The cervical spinal cord and meninges had herniated out of the spinal canal in the hyperlordotic cervical spine, and the thoracic spinal cord was stretched and compressed over the T4/5 kyphotic apex. Free-floating spinous processes were found compressing the cord at the T4-5 level. Tethering was not detected., Results: The patient underwent a posterior vertebral column resection at T5 and excision of the free-floating spinous processes. The patient made a complete neurological recovery. At 8 year follow-up, he was asymptomatic and his deformity was stable., Conclusion: We present a rare congenital cervical dystrophic anomaly causing myelopathy secondary to progressive kyphosis. We speculate that this anomaly was due to the sclerotomal cells' failure to migrate dorsally to the neural tube and fuse in the midline., (© 2021. Scoliosis Research Society.)

Purpose: In developing part of the world, it is common to see complete destruction of vertebral bodies in tuberculosis. Our study aims to assess the effect of spinal tuberculosis with vertebral shortening on pulmonary function., Methods: Fifty cases of spinal TB (14 males, 36 females) managed both operatively and non-operatively, who presented to tertiary care institute between years 2011 and 2016 were assessed. Vertebral height loss was assessed by spinal deformity index (SDI). All patients underwent pulmonary function testing using same equipment sitting in upright position., Results: Mean age was 27.9 years (27.9 ± 11.9). 11 patients with mean SDI of 2.7 ± 1.1 showed normal lung function. 36 patients showed restrictive pattern of which 12 were mild, 14 were moderate and 10 showed severe pattern with a mean SDI of 3.8 ± 1.2, 5.6 ± 1.3 and 6.1 ± 1.4, respectively. 3 cases showed obstructive pattern. As the apex of curve shifted proximally, FVC% reduced. Increase in SDI value was associated with a fall in the vital capacity and FEV 1 . Increase in the kyphotic angle was associated with a deleterious effect on PFT results., Conclusions: Risk stratification of pulmonary dysfunction resulting from vertebral body height loss due to kyphosis will emphasize the need for early detection of spinal tuberculosis before deformity occurs., (© 2021. Scoliosis Research Society.)

In Paleopathology, total lack of a vertebral body is a rare finding, mostly due to infectious diseases or tumors. We report the case of an adult male from the necropolis next to "Temple of the Millions of Years" of Thutmose III dated to the Late Old Kingdom and First Intermediate Period (2345-2055 BCE). He showed a fracture of T12, more than 50%, associated with the complete disappearance of the body of L1 and bilateral transverse process. Infection and tumor involvement were ruled out due to the morphology of the spinal segment. The most likely diagnosis was complete body agenesis. Congenital kyphosis related to vertebral agenesis has been described as a possibility in paleopathology, but it had not been reported until now., (© 2021. Scoliosis Research Society.)

Study Design: Case series, literature review, and technical note., Objectives: To compare two different approaches to treat the spinal deformity with split cord malformation type I (SCM I). To present a new method of one-stage surgical treatment of congenital spinal deformity with wide bony septum (SCM I)., Methods: Analysis of the literature on the different types of combined surgical treatment of spinal deformities with SCM I was performed. We have provided our own data on 27 patients treated for congenital spinal deformity and SCM I, one of which underwent Schwab IV type osteotomy at the apex of the deformity through the bony septum and pedicles. Inclusion criteria were presence of spinal deformity in combination with SCM 1, performed surgery to correct spinal deformity, and follow-up period of at least 2 years., Results: The result of the literature review was controversial and requires additional research. The average age of patients was 8.8 ± 6.6 years old. One-stage treatment of SCM I and spinal deformity was performed in 10 patients (group I) and two-stage in 14 patients (group II). Three patients with severe myelodysplasia, SCM I, and congenital kyphoscoliosis underwent correction of spinal deformity without SCM I removing (group III). The group I had the longest surgery duration (mean 289 ± 75 min) and largest blood loss (mean 560 ± 386 ml), a high percentage of deformity correction (mean 69.6%), and the highest rate of complications (60%). The most optimal was the two-stage treatment with the mean surgery duration 191 ± 137 min, mean blood loss 339 ± 436 ml, mean correction rate 63%, and frequency of complications 21%. The average follow-up time was 6.0 ± 2.6 years., Conclusions: One stage surgery associated with a large surgical invasion and a large number of complications. It can be used in some cases, for example when the wide bony septum (SCM I) is localized at the apex of the congenital scoliosis or kyphosis. In all other cases, it is worth adhering to a two-stage treatment. Many new works demonstrate the relative safety and effectiveness of deformity correction without removing the SCM. In our opinion, indications for treatment of spinal deformity without SCM I removing can be the need to perform a shortening ostetomy outside the SCM zone. The remaining cases require a thorough assessment and a balanced decision., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: The objective of this retrospective study was to provide the radiographic outcomes and complications for pedicle subtraction osteotomy (PSO) performed at the low lumbar spine, i.e., L4 or L5 for ASD patients with fixed sagittal malalignment., Methods: ASD patients who underwent L4 or L5 PSO with a minimum 2-year follow-up were included. Preoperative and postoperative radiographs, and complications were collected. Radiographic analysis included lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), thoracic kyphosis (TK), sagittal vertical axis (SVA), spinal lordosis (SL) ratio and global tilt (GT) on standing long-cassette radiographs., Results: A total of 102 patients from 2 spinal centers were analyzed. 66 patients underwent PSO at L4 and 36 patients at L5. From preoperatively to the final follow-up, significant improvements occurred in LL (from - 31° to - 52°), SVA (from 13 to 5 cm), and GT (from 44° to 27°) (all, p < 0.05). 12 patients had transient neurological deficits, and 8 patients had persistent neurological deficit. 23 patients underwent revision for PJK (2), pseudarthrosis (10), neurological deficit (2), epidural hematoma (1), or deep surgical site infection (8). No PJK was observed in any of the patients with L5 PSO., Conclusions: PSO at the level of L4 or L5 remains a challenging technique but with an acceptable rate of complications and revisions. It enables correction of fixed sagittal malalignment in ASD patients with a globally satisfactory outcome. In comparison with L4 PSO, L5 PSO patients did not show PJK as a mechanical complication. Distal lumbar PSO at the level of L5 may represent one of the factors that may help preventing the proximal junctional kyphosis complication., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

49,XXXXY is the rarest X and Y chromosomal variation, with an incidence of 1 in 80,000-100,000 live male births and has been associated with numerous musculoskeletal abnormalities. Data was collected from an international cohort of boys with 49,XXXXY over 10 years. Children were evaluated by a multidisciplinary team consisting of a pediatric orthopedist, a neurogeneticist, a neurodevelopmentalist, and two physical therapists. Increased rates of torticollis (32.4%), hamstring tightness (42%), radioulnar synostosis (67.6%), pes planus (65.2%), and other foot abnormalities (86.9%) were observed. Several anomalies increased with age, specifically hamstring tightness, kyphosis, and scoliosis. The elucidation of the orthopedic profile of this population is necessary in order to provide healthcare providers with current medical information. This research further supports the necessity for the comprehensive multidisciplinary treatment of boys with 49,XXXXY., (© 2020 Wiley Periodicals, Inc.)

Objective: Proximal junctional kyphosis (PJK), which can worsen a patient's quality of life, is a common complication following the surgical treatment of adult spinal deformity (ASD). Although various radiographic parameters have been proposed to predict the occurrence of PJK, the optimal method has not been established. The present study aimed to investigate the usefulness of the T1-L1 pelvic angle in the standing position (standing TLPA) for predicting the occurrence of PJK., Methods: The authors retrospectively extracted data for patients with ASD who underwent minimum 5-level fusion to the pelvis with upper instrumented vertebra between T8 and L1. In the present study, PJK was defined as ≥ 10° progression of the proximal junctional angle or reoperation due to progressive kyphosis during 1 year of follow-up. The following parameters were analyzed on whole-spine standing radiographs: the T1-pelvic angle, conventional thoracic kyphosis (TK; T4-12), whole-thoracic TK (T1-12), and the standing TLPA (defined as the angle formed by lines extending from the center of T1 and L1 to the femoral head axis). A logistic regression analysis and a receiver operating characteristic curve analysis were performed., Results: A total of 50 patients with ASD were enrolled (84% female; mean age 74.4 years). PJK occurred in 19 (38%) patients. Preoperatively, the PJK group showed significantly greater T1-pelvic angle (49.2° vs 34.4°), conventional TK (26.6° vs 17.6°), and standing-TLPA (30.0° vs 14.9°) values in comparison to the non-PJK group. There was no significant difference in the whole-thoracic TK between the two groups. A multivariate analysis showed that the standing TLPA and whole-thoracic TK were independent predictors of PJK. The standing TLPA had better accuracy than whole-thoracic TK (AUC 0.86 vs 0.64, p = 0.03). The optimal cutoff value of the standing TLPA was 23.0° (sensitivity 0.79, specificity 0.74). Using this cutoff value, the standing TLPA was the best predictor of PJK (OR 8.4, 95% CI 1.8-39, p = 0.007)., Conclusions: The preoperative standing TLPA was more closely associated with the occurrence of PJK than other radiographic parameters. These results suggest that this easily measured parameter is useful for the prediction of PJK.

Background: Proximal junctional kyphosis (PJK) and proximal junction failure are common and costly complications after long-segment adult spinal deformity (ASD) correction. Although much research has focused on the concept of "softening the landing" to prevent proximal junction pathologies, long-segment constructs largely deviate from the force-deformation curve of the physiologic spine. Our novel distributed loading technique for ASD correction is described using multimaterial, long-segment constructs to create a biomechanically sound, yet physiologic, decremental stiffness toward the rostral end., Methods: Operative steps detail the custom-designed constructs of dual-headed pedicle screws and varied rod diameters and materials (cobalt chromium or titanium) for an initial 20 patients (mean 66.6 ± 4.8 years). Standing scoliosis films were obtained preoperatively and at regular intervals postoperatively to assess for PJK., Results: No patient had evidence of PJK or proximal junction failure at latest radiographic follow-up (mean 17.9 months, range 13-25 months). Radiographic findings for sagittal vertical axis averaged 11.2 ± 5.6 cm preoperatively and 3.6 ± 2.3 cm postoperatively. Compared with preoperative parameters, postoperative reductions in pelvic incidence-lumbar lordosis mismatch averaged 28.7 ± 12.9 degrees, and sagittal vertical axis averaged 7.6 ± 5.2 cm while PJA was essentially unchanged., Conclusions: Preliminary results suggest that the distributed loading technique is promising for prevention of PJK with stiffness gradients that mimic the force-deformation curve of the physiologic posterior tension band. Our technique may optimize the degree of stress at the proximal junction without overwhelming the anterior column bony while remodeling and mature arthrodesis takes place., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Coronavirus disease (COVID-19) pandemic has led to millions of deaths worldwide. Old age, immunocompromised state and multiple comorbidities are described as risk factors. Kyphoscoliosis (KS) is the most common spine abnormality and a risk factor of respiratory failure. Management of pneumonia in a patient with severe kyphoscoliosis is challenging to the intensivist. We report successful management of two patients with severe kyphoscoliosis who developed severe COVID-19 pneumonia.

Case: A 14-year-old adolescent boy with congenital kyphoscoliosis with T5 hemivertebra visited our hospital complaining gait disturbance. The T5 hemivertebra was resected posteriorly, and kyphosis at T4 to T7 was corrected from 43° to 36°. However, neurological status gradually deteriorated after surgery. Surgery to reduce kyphosis by bending the rods was performed with intraoperative ultrasonography, which resulted in spinal cord decompression and repulsation of the spinal cord. The muscle strength of the lower extremities improved immediately after surgery., Conclusion: Correction surgery for congenital kyphoscoliosis has high risk of perioperative neurological deterioration. Ultrasonography may be a useful tool for monitoring status of the spinal cord., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B682)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Case: Two patients (ages 5 and 14 years) with Larsen syndrome and severe cervical kyphosis (patient 1) and spondyloptosis (patient 2), as well as complete anterior-posterior dissociation of the cervical spine, presented with severe, progressive myelopathy. Both patients underwent preoperative halo-gravity traction to slowly reduce the deformity followed by staged anterior-posterior decompression and fusion. Both patients demonstrated complete return of neurologic function., Conclusion: Patients with Larsen syndrome should be screened for cervical deformity at the time of diagnosis. Proper screening will facilitate early detection and treatment of significant deformities to prevent neurologic deterioration, which can be catastrophic in these patients., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B588)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Pedicle screw fixation (PSF) has been considered the preferred surgery for the treatment of severe osteoporotic vertebral compression fracture (sOVCF), and sOVCF was traditionally regarded as a relative contraindication to minimally invasive percutaneous kyphoplasty (PKP). Debate has continued regarding the selection of the best surgical method for sOVCF. In the present study, we compared the efficacy and safety between PKP and PSF., Methods: PKP was performed in 376 patients in group 1 and PSF in 121 patients in group 2. The visual analog scale (VAS), Oswestry disability index (ODI), local kyphotic angle, fractured vertebral body height, and complications were evaluated., Results: In the immediate postoperative analysis, the mean VAS score for group 1 was 2.4, significantly lower than the VAS score of 4.7 for group 2. The mean ODI score was 44.4% for group 1, lower than the ODI score of 57.1% for group 2. In addition, group 1 had had a significantly better ODI score at 1 year of follow-up. The local kyphotic angle and fractured vertebral body height had recovered better in group 2. In group 1, 113 patients had experienced cement leakage, and 29 patients had undergone PKP for adjacent new vertebral fractures. In group 2, 2 patients had developed wound infections, 4 had developed pneumonia, 2 had developed urinary tract infection, 3 had experienced asymptomatic screw loosening, and 7 had undergone PKP to treat new vertebral fractures and 1 had undergone removal of internal fixation because of back pain., Conclusions: The results of the clinical and radiological evaluations showed that PKP is comparable to PSF for the treatment of sOVCF with kyphosis, with PKP having the advantages of minimal invasion, quick postoperative pain relief, and functional recovery., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The Classification of Early-Onset Scoliosis (C-EOS) allows providers to differentiate patients, for clinical and research purposes, on the basis of the etiology of their disease as well as radiographic parameters. The Early Onset Scoliosis Questionnaire (EOSQ) is the first disease-specific, parent-reported HRQOL (health-related quality-of-life) outcome measure for this condition. We sought to determine the influence of the C-EOS etiology designation, radiographic parameters, and medical comorbidities on EOSQ scores to differentiate quality of life in this heterogeneous patient population. We hypothesized that baseline EOSQ scores for patients with EOS would be strongly affected by the C-EOS etiology designation., Methods: The analysis included prospectively enrolled patients with EOSQ scores recorded in a multicenter EOS database prior to intervention for the EOS. EOSQ scores were compared across C-EOS etiologies, severity of disease based on radiographic measurements, and patient comorbidities prior to scoliosis intervention., Results: Six hundred and ten patients with EOS were available for analysis; 119 had congenital, 201 had idiopathic, 156 had neuromuscular, and 134 had syndromic EOS. In multivariate analysis, neuromuscular and syndromic etiologies were associated with lower scores than congenital and idiopathic etiologies in many EOSQ domains including general health, transfer, daily living, fatigue/energy level, and emotion. Patients with neuromuscular EOS had the lowest EOSQ scores in general. Congenital and idiopathic EOS did not differ from each other in any EOSQ domain. Coronal Cobb and kyphosis angles had significant inverse but generally weak correlations with EOSQ domains. Individual medical comorbidities had a minor effect on certain domains while American Society of Anesthesiologists (ASA) class and total number of comorbidities had inverse correlations with most domains., Conclusions: The underlying etiology of EOS appears to have a significant influence on the parent-reported HRQOL outcomes of the disease. Specifically, syndromic and neuromuscular C-EOS diagnoses are associated with lower EOSQ scores before treatment compared with congenital and idiopathic diagnoses. Radiographic measurements of severity have a relatively small influence on EOSQ scores. These baseline differences in C-EOS-designated etiology should be accounted for in studies comparing outcomes of treatment for this heterogeneous patient population., Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: This project was supported by the Angela S. M. Kuo award through the Pediatric Orthopaedic Society of North America. Funding was directed to the PSSG. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work; “yes” to indicate that the author had a patent and/or copyright, planned, pending, or issued, broadly relevant to this work; and “yes” to indicate that the author had other relationships or activities that could be perceived to influence, or have the potential to influence, what was written in this work (http://links.lww.com/JBJS/G291)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Objective: We investigated the characteristics and revision rate of junctional failure after surgical correction for thoracolumbar kyphosis in patients with ankylosing spondylitis., Methods: A total of 230 patients had undergone surgical correction for thoracolumbar kyphosis from 2010 to 2019. The state of ankylosis between the uppermost instrumented vertebra (UIV) and UIV+1 and between the lowermost instrumented vertebra (LIV) and LIV-1 was analyzed using a modified Stoke ankylosing spondylitis spine score. Proximal junctional failure (PJF) and distal junctional failure (DJF) were defined as any type of symptomatic junctional failure., Results: Of the 230 patients, 23 (10.0%) had developed junctional failure. Of these 23 patients, 16 had had partial ankylosis and 7 had had complete ankylosis. PJF had developed in 10 patients and DJF in 13. The most common type of junctional failure was a junctional fracture, which developed in 12 patients. PJF had developed by UIV fracture in 4 patients, UIV+1 fracture in 1 patient, and UIV+2 in 1 patient. DJF had developed by LIV fracture in 6 patients, metallic failure in 5, and progression of DJF in 2 patients. The average time to the development of PJF and DJF was 13 months and 12.4 months, respectively. All 10 patients with PJF and 7 of 13 patients with DJF (53.8%) had required reoperation. Of the 12 patients with junctional fracture, 11 (91.7%) had undergone reoperation., Conclusions: Of the 23 patients with junctional failure, 16 had had immature ossification of the anterior longitudinal ligament. Therefore, to prevent junctional failure, the state of ankylosis seems to be important for selecting the fusion level after osteotomy. Once junctional failure has developed, however, reoperation should be considered owing to the stress concentration at the UIV or LIV., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Abstract: To identify the risk factors of the secondary fractures for osteoporotic vertebral compression fractures (OVCFs) after percutaneous vertebroplasty (PVP).We conducted a search of relevant articles using Cochrane Library, PubMed, Medline, Science Direct, Embase, the Web of Science and other databases. The time range we retrieved from establishment of the electronic database to November 2017. Gray studies were found in the references of included literature reports. STATA version 11.0 (Stata Corporation, College Station, Texas) was used to analyze the pooled data.Fourteen studies involving 1910 patients, 395 of whom had fracture secondary to the surgery were included in this meta-analysis. The result of meta-analyses showed the risk factors of the secondary fractures for OVCFs after PVP was related to bone mineral density (BMD) [95%CI (-0.650, -0.164), SMD=-0.407, P=.001], cement leakage ((RR=0.596, 95%CI (0.444,0.798), P = .001)), and kyphosis after primary operation ((SMD=0.741, 95%CI (0.449,1.032), P = .000)), but not to gender, age, body mass index, cement volume, thoracolumbar spine, and cement injection approaches.Bone mineral density, cement leakage, and kyphosis after primary operation are the risk factors closely correlative to the secondary fracture after PVP. There have not been enough evidences to support the association between the secondary fracture and gender, age, body mass index, cement volume, thoracolumbar spine, and cement injection approaches., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Case: We describe thoracolumbar kyphosis with severe vertebral deformation in a 13-year-old boy with cerebral palsy, hip extension contractures, and history of hip flexion-adduction releases., Conclusion: Patients with cerebral palsy and hip extension contractures may develop thoracolumbar kyphosis to maintain sitting balance. It is important to recognize hip extension contractures as the underlying cause of the compensatory kyphosis and to be familiar with treatment options that address the hips and the spine., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B346)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

This study aimed to characterize global sagittal alignment in adolescent idiopathic scoliosis (AIS) with normal kyphosis (NTK, kyphosis > 10°) and with thoracic hypokyphosis (THK, kyphosis < 10°), before and after posterior spinal fusion, and compare them with asymptomatic controls. 27 AIS girls and young adults with right thoracic curves were included (seventeen with age ≤ 18 years, then age > 21). Biplanar radiographies were acquired at baseline, immediate post-operatively, 1-year and 2-year follow-up, and 3D reconstruction of the spine and pelvis was performed. NTK and THK showed different global sagittal alignment, as well as differences compared to controls. AIS with THK at baseline had higher SVA/SFD (2.0 ± 2.9 vs - 0.4 ± 1.9; P < 0.05) and OD-HA (0.2 ± 1.4° vs - 1.3 ± 1.6°; P < 0.05) than controls, indicating that THK had compensated balance with unusual forward leaning posture. Immediately post-operation, SVA/SFD remained high (1.3 ± 3.0) while OD-HA reversed (- 1.2 ± 1.7°), indicating that THK patients had found partially compensated balance. After 2-yeas, both SVA/SFD (- 1.3 ± 2.1) and OD-HA (- 1.4 ± 0.9°) were normalized. The changes in global sagittal alignment and mechanism of balance are different in AIS with or without THK. As the head plays a critical role on balance during immediate and delayed post-operation, OD-HA can be complementary parameter for assessing global balance during post-operative follow-up of AIS patients with THK.

Case: A 4-year-old girl with spastic gait and hand clumsiness who was diagnosed with cervical myelopathy caused by atlantoaxial dislocation and midcervical severe kyphosis associated with chondrodysplasia punctata (CDP). The patient underwent posterior instrumentation and anterior spinal fusion and successful correction with osseous fusion was obtained 8 months after surgery. In addition, the preoperative neurological symptoms were completely recovered., Conclusion: Owing to the characteristics of CDP, the treatment for the cervical lesion is extremely complicated. Successful stabilization and improvement of the neurological symptom were achieved by combining posterior and anterior fusion with instrumentation in this case., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B396)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Our aim was to explore change in kyphosis and vertebral fracture incidence following 8 months of high-intensity resistance and impact training (HiRIT) or machine-based isometric axial compression (IAC) training in men with osteopenia and osteoporosis. HiRIT and IAC improved posture. HiRIT participants did not experience progression or incident vertebral fracture. IAC participants did experience progression and incident vertebral fracture., Introduction: The Lifting Intervention For Training Muscle and Osteoporosis Rehabilitation for Men (LIFTMOR-M) trial examined efficacy and safety of an eight-month, supervised, high-intensity progressive resistance and impact training (HiRIT) program compared with machine-based isometric axial compression (IAC) training in middle-aged and older men with low areal bone mineral density (aBMD). The primary purpose of the current work was to explore change in thoracic kyphosis and incident fracture from vertebral morphology following eight-months of HiRIT or IAC training. The secondary purpose was to explore change in clinical kyphosis measures for HiRIT, IAC and a non-randomized, matched control group., Methods: Men (≥ 45 yrs), with low aBMD, were recruited and randomized to HiRIT or IAC, or designated control. Clinical measures of thoracic kyphosis with inclinometry were determined. Cobb angle of kyphosis and vertebral fracture assessment using the Genant semi-quantitative method were determined from lateral thoracolumbar DXA (Medix DR, Medilink, France). Per-protocol (n = 40) and intention-to-treat (n = 93) analyses were conducted., Results: Forty participants (HiRIT n = 20, IAC n = 20; 66.1 ± 7.8 yrs.; lumbar spine T-score - 0.1 ± 0.8; femoral neck T-score - 1.5 ± 0.5) underwent clinical kyphosis measures and thoracolumbar DXA at baseline and follow-up. No between-group differences were detected in kyphosis change, however, within-group improvements in neutral (HiRIT - 2.3 ± 0.8°; IAC - 2.5 ± 0.8°) and 'standing tall' (HiRIT - 2.4 ± 0.8°; IAC - 2.0 ± 0.8°) postures were observed (p < 0.05). HiRIT improved Cobb angle (- 3.5 ± 1.5°, p = 0.027) from baseline. Over the 8 months, no incident vertebral fractures nor progression of prevalent vertebral fractures occurred for HiRIT participants. Five incident fractures of thoracic vertebrae occurred for IAC and one wedge fracture progressed. Ninety-three participants underwent clinical kyphosis measures at both time-points (HiRIT n = 34, IAC n = 33, control n = 26). HiRIT exhibited a reduction in 'standing tall' kyphosis compared to control (- 2.3 ± 0.6° versus 1.4 ± 0.7°, p < 0.05), but no other between-group differences were detected., Conclusions: Although there was no difference in change between intervention groups, thoracic kyphosis appeared to improve in both HiRIT and IAC with exercise exposure. HiRIT improved 'standing tall' posture in comparison to usual activities. HiRIT was not associated with vertebral fracture progression or incident vertebral fracture, but for some IAC participants there was evidence of progression of vertebral fracture severity and incident vertebral fractures, in our small sample. Larger trials are required to confirm the observations of the current work, which was exploratory in nature.

Study Design: Retrospective chart review., Objective: The aim of this study was to ascertain whether the presence of structural thoracic deformities affects outcomes of permanent SCS placement., Summary of Background Data: Neural modulation via spinal cord stimulators (SCSs) has become an accepted treatment option for various chronic pain syndromes. In most cases, the surgeon desires accurate midline positioning of the paddle lead, allowing for flexibility of unilateral or bilateral coverage of pain patterns. Structural spinal deformities (scoliosis or kyphosis) often result from coronal, sagittal, and rotatory deformity that can make midline placement more difficult., Methods: Between 2013 and 2017, two-hundred forty-one charts of patients who underwent permanent SCS placement at our suburban hospital were reviewed. Demographic information, numerical rating system (NRS) pain scores, Oswestry Disability Index (ODI) scores, and opioid medication usage were recorded at baseline and after permanent stimulator placement. Thoracic scoliosis and kyphosis angles were measured using spinal radiographs. The effect of each structural deformity on NRS, ODI, and narcotic medication usage changes from baseline was analyzed., Results: Overall, 100 patients were included in our cohort. Fifty-six patients had measured thoracic spinal deformities (38% with scoliosis, 31% with kyphosis). There was no significant difference in NRS scores, ODI scores, or narcotic usage change between patients with scoliosis and those without (P = 0.66, P = 0.57, P = 0.75) or patients with kyphosis and those without (P = 0.51, P = 0.31, P = 0.63). Bivariate linear regression analysis showed that scoliotic and kyphotic angles were not significant predictors of NRS (P = 0.39, P = 0.13), ODI (P = 0.45, P = 0.07), and opioid usage (P = 0.70, P = 0.90) change, with multivariate regression analyses confirming these findings., Conclusion: SCSs can be effective options for treating lumbar back pain and radiculopathy. Our study suggests that the presence of mild structural deformities does not adversely affect outcomes of permanent SCS placement and as such should not preclude this population from benefiting from such therapies.Level of Evidence: 4., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

"Pediatric spinal deformities may be associated with pulmonary complications in a patient's lifetime. A review of the diagnosis of spinal abnormalities includes classifications of scoliosis and kyphosis, correlating physical examination findings and radiographic interpretation. The natural history of untreated spine deformities is reviewed along with the associated altered pulmonary compromise. Treatment options for children affected by spinal deformities are discussed, including the relative indications, the efficacy, pros and cons of different treatment options, along with the evidence to support these. This overview of spine deformities includes research outcomes to support the care of these pediatric patients.", Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Study Design: A retrospective study of prospectively collected data., Objective: This study aimed to examine how radiological parameters affect dynamic changes in the cross-sectional area of the spinal cord (CSA) in cervical spondylotic myelopathy (CSM) patients and how they correlate with the severity of myelopathy, by evaluating multi-modal spinal cord evoked potentials (SCEPs)., Summary of Background Data: Appropriate assessments of dynamic factors should reveal hidden spinal cord compression and provide useful information for choosing surgical procedures., Methods: Seventy-nine CSM patients were enrolled. They were examined with kinematic CT myelography (CTM), and the spinal levels responsible for their CSM were determined via SCEP examinations. The C2-7 angle, C2-7 range of motion, and percentage of slip were measured on the midsagittal view during flexion and extension, and the CSA was measured on the axial view in each neck position using kinematic CTM. The patients who exhibited the smallest CSA values during extension and flexion were classified into Groups E and F, respectively., Results: Fifty-two (65.8%) and 27 (34.2%) cases were included in Groups E and F, respectively. The preoperative JOA score did not differ significantly between the groups; however, the preoperative lower-limb JOA score of Group F was significantly lower than that of Group E (2.24 ± 0.82 vs. 2.83 ± 1.09, P = 0.016). In the multiple logistic regression analysis, a small C2-7 angle during extension (β = 5°, odds ratio: 0.69, 95% confidence interval [CI]: 0.54-0.90) and the slip percentage during flexion (β = 5%, odds ratio: 1.42, 95% CI: 1.09-1.85) were identified as significant predictors of belonging to Group F., Conclusion: Exhibiting more severe spinal cord compression during neck flexion was associated with a small C2-7 angle and anterior spondylolisthesis. The neurological status of the patients in Group F was characterized by severe lower limb dysfunction because of a disturbed blood supply to the anterior column.Level of Evidence: 4., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

This case report describes the performance of ultrasound-guided percutaneous nephrolithotomy in a 50-year-old woman who had scoliosis with kyphosis and a history of tuberculosis of the lumbar spine. The operation was performed with the patient under general anesthesia and in the prone position. Residual stones were found in the right lower kidney calyx postoperatively, resulting in a second-phase surgery using the same approach 2 weeks later. All stones were successfully removed during the second surgery. No complications occurred in either operation, and the patient recovered well. This study suggests that ultrasound-guided percutaneous nephrolithotomy is a safe and effective approach in treating renal calculi in patients with scoliosis.

Introduction: The presence of existing osteoporotic vertebral fracture (OVF) increases the mortality risk. However, the influence of the characteristics of OVF is unclear. This study aimed to investigate the influence of new OVF on patients' long-term prognosis using our past cohort study., Method: This is an extension study of our cohort study carried out between 2005 and 2007. In the present extension study, of 420 patients, 197 whose contact information was available at the 6-month follow-up were included in the telephone survey in 2018. Five patients refused to participate in the survey, and 82 could not be contacted. Eventually, 110 patients were enrolled. Of the Demographic data, radiological findings, medical history, and clinical outcome were investigated at injury onset and at the 6-month follow-up. A proportional hazard model was used to investigate the risk factors for mortality., Results: Among 110 patients, 33 died. Male sex and low body mass index (BMI <18.5 kg/m 2 ) were significant risk factors for mortality [hazard ratio (HR) = 6.40, 1.01-40.50; 5.24, 1.44-19.04, respectively]. The history of stroke and liver disease increased the risk of mortality (HR = 13.37, 1.93-92.7; 6.62, 1.15-38.14, respectively). As regards radiological findings, local kyphosis progression per 1° or ≥7° were significant risk factors of mortality (HR = 1.20, 1.06-1.36; 5.38, 1.81-16.03, respectively)., Conclusions: A telephone survey at 12 years after the occurrence of OVF analyzed risk factors for mortality and showed that a progression of local kyphosis in fractures between injury onset and 6 months after injury was a risk factor of poor prognosis.

Background: Globally, 20% to 50% older adults have been found to have thoracic hyperkyphosis. Negative effects on physical performance have been reported. However, there has been a lack of research on the prevalence and negative effects of thoracic hyperkyphosis among Chinese community-dwelling elderly., Design: A cross-sectional study., Setting: The communities in Wuhan, China., Participants: Three hundred and ninety-five Chinese community-dwelling older adults with thoracic hyperkyphosis., Measures: Chinese community-dwelling older adults aged 60 or above lived in Wuhan, China from August to December 2018 were recruited for spine and physical performance assessments. The primary outcome was the prevalence of thoracic hyperkyphosis estimated according to the angle of kyphosis which was measured by manual inclinometers. The secondary outcomes were the effects of thoracic hyperkyphosis on physical performance measured by One-leg Standing Test (OLS), Timed Up AND Go Test (TUG), Chest Expansion Test (CE), Six Minutes Walking Test (6MWT), and Farsi Version of Functional Gait Assessment (FGA). The socio-demographic and health-related information were collected by a questionnaire., Results: Among 395 participants, the mean angle of kyphosis was 49.0° ± 10.5°, 75.2% of participants had the angle of kyphosis >40° (i.e., having thoracic kyperkyphosis). Compared with older adults having no thoracic hyperkyphosis, older adults with thoracic hyperkyphosis had increased risks performing impaired in OLS (OR=4.55, 95% CI 2.18-9.53, p<0.001), TUG (OR=6.08, 95% CI 2.57-14.40, p<0.001), CE (OR=3.23, 95% CI 1.63-6.38, p=0.001), 6MWT (OR=4.64, 95% CI 1.98-10.86, p<0.001), and FGA (OR=5.18, 95% CI 2.25-11.89, p<0.001) after controlling socio-demographic and health-related factors., Conclusion: The thoracic hyperkyphosis had high prevalence and associated with impaired performance in balance, gait, and cardiopulmonary function tests among Chinese community-dwelling older adults, which calls for the future intervention., Competing Interests: The authors has no conflicts.

There are limited data on the longitudinal frequency and severity of the symptoms and complications of achondroplasia. We undertook a retrospective electronic chart review of 114 patients to develop a more thorough understanding of the lifetime impact of achondroplasia. Craniocervical stenosis (involving the foramen magnum with or without cervical vertebrae C1 and/or C2) was noted in nearly 50% of patients with craniovertebral junction imaging; however, corrective decompression surgery was only needed in 6% of patients. No children in our cohort died at 4 years of age or under. Kyphosis was present in most patients but usually resolved in early childhood. Cervical and lumbar stenosis were diagnosed in children and adults while, genu varum, elbow contractures, and radial head dislocations were identified during childhood. Central sleep apnea and obstructive sleep apnea were present in children, while the diagnosis of obstructive sleep apnea was shown to recur in adulthood. Cardiovascular risk factors were present in only 7% of patients. A range of mental health disorders were identified, with most diagnoses being made before 18 years of age. Our data show that achondroplasia has a significant impact on patients' physical health, and complications continue to be reported and require intervention throughout patients' lifetimes. This highlights the need for continuous support beyond pediatric care, by adult care clinicians experienced with managing the long-term complications of achondroplasia., (© 2020 Wiley Periodicals LLC.)

Background: Halo traction has been used as an adjunctive method in the treatment of severe spinal deformities. But there are few reports on the clinical efficacy of halo-pelvic traction (HPT) in the treatment of severe spinal deformities complicated with respiratory dysfunction. This study was to evaluate the clinical efficacy and complications associated with pre-operative HPT in the treatment of severe spinal deformities with respiratory dysfunction., Methods: Thirty patients with severe spinal deformities complicated with respiratory dysfunction treated with short-term pre-operative HPT were retrospectively reviewed. Inclusion criteria were: (1) patients with severe kyphoscoliosis (coronal Cobb angle or kyphosis angle ≥100°) and respiratory failure, (2) patients undergoing HPT until posterior fusion surgery. All patients underwent general anesthesia for HPT application, which the pelvic ring used in this study was a half-ring, and the rods were all placed on the anterolateral side of the truck., Results: The major coronal curve scoliosis averaged 116.00 ± 16.70° and was reduced to 63.23 ± 14.00° after HPT, 46.33 ± 10.70° after surgery. The major kyphosis was 102.40 ± 27.67° and was reduced to 52.23 ± 14.16° after HPT, 42.0 ± 11.92° after surgery. A significantly increased FVC was observed after HPT (p < 0.001), with a significantly improved FVC% (p < 0.001). Similarly, a significantly increased FEV1 was also observed (p < 0.001), with a significantly improved FEV1% (p < 0.001)., Conclusion: This study indicated that the modified HPT could be used to help patients with severe spinal deformities complicated with respiratory dysfunction achieve significant correction in both the coronal and sagittal deformities during the pre-operative treatment period along with improved respiratory function and in the absence of severe complications.

Study Design: Four-year, longitudinal cohort study., Objective: The aim of this study was to investigate the effect of original spinal shape on incidental vertebral fractures (VFs) and to identify the influence of changes in pre- and post-fracture geometrical spinal shape., Summary of Background Data: Clinical evidence demonstrates that VFs cause spinal kyphosis, morbidities, and deteriorating quality of life in elderly people. However, knowledge of geometrical spinal shapes that affect incidental VFs is limited., Methods: Three hundred seventeen volunteers underwent whole spine radiography as part of a health screening in both 2012 and 2016. We extracted volunteers with incidental VF in 2016. Sex- and age-matched volunteers without VF were enrolled as controls. Baseline demographic variables, geometrical spinal shape, and spinopelvic parameters were compared between the two groups. In volunteers with incidental VF, we investigated the association between baseline spinal shape and post-fracture shape., Results: Twenty-seven volunteers (12 men; mean age 75.4 ± 5.4 and 15 women; mean age 71.6 ± 7.9) with VF were enrolled, and 175 volunteers (48 men, 127 women) without VF were selected as controls. In men with VF, the thoracic kyphosis apex was located significantly more posteriorly and caudally than in those without VF. In women with VF, the lordosis apex was located significantly more posteriorly and caudally than in those without VF. After fractures occurring above the inflexion vertebra, the low anterior apex spine (L5) changed its geometrical shape in that the posterior apex and the inflexion vertebra shifted significantly more posteriorly compared to the high anterior apex spine (L4/5)., Conclusion: Original geometrical spinal shape affected the occurrence of VF, and post-fracture spinal shape depended on the positional relationship between the inflexion vertebra and fractured vertebra. Our study helps to understand the influence of geometrical spinal shape on the risks of VF., Level of Evidence: 3.

Background: Cervical sagittal alignment (CSA) is closely related with cervical disk degeneration and impacts the spinal function, especially in the setting of cervical kyphosis (CK). In this study, we evaluated the influence of cervical sagittal parameters on the development of axial neck pain (ANP) in patients with CK., Methods: Data pertaining to 263 patients with CK who visited the outpatient department of our hospital between January 2012 and December 2018 were retrospective analyzed. The most common symptoms of ANP were neck pain, stiffness, or dullness. Visual analog scale (VAS) was used to evaluate ANP. The following radiographic parameters were evaluated: CK types, C2-7 sagittal vertical axis (SVA), thoracic inlet angle (TIA), T1 slope, neck tilt (NT), cranial tilt, and cervical tilt. Sagittal alignment of CK was classified into 2 types: global and regional type. Multivariate logistic regression analysis was performed to identify risk factors for ANP., Results: Patients who complained of ANP were categorized as ANP group (VAS score ≥ 3; n = 92), while those without ANP were categorized as non-ANP group (VAS score < 3; n = 171). There was no significant between-group difference with respect to age (P = 0.196), gender (P = 0.516), TIA (P = 0.139), NT (P = 0.676), CK type (P = 0.533), cranial tilt (P = 0.332), cervical tilt (P = 0.585), or cervical disk degeneration (P = 0.695). The T1 slope and C2-7 SVA in the ANP group were significantly greater than that in the non-ANP group (P < 0.05). On multivariate logistic regression, C2-7 SVA [ odds ratio (OR) 2.318, 95% confidence interval 1.373-4.651, P = 0.003) and T1 slope (OR 2.563, 95% CI 1.186-4.669, P = 0.028) were identified as risk factors for ANP., Conclusions: Our findings suggest a significant effect of cervical sagittal parameters on the occurrence of ANP in patients with CK. Greater T1 slope and larger C2-7 SVA may lead to the development of neck pain.

Posterior vertebral column resection (PVCR) was the most powerful technique for treating severe rigid spinal deformity, but it has been plagued with high neurologic deficits risk. The fluctuations of spinal cord blood flow (SCBF) play an important role in secondary spinal cord injury during deformity correction surgery.The objective of this study was to first provide the characteristic of SCBF during PVCR with spinal column shortening in severe rigid spinal deformity.Severe rigid scoliokyphosis patients received PVCR above L1 level were included in this prospective study. Patients with simple kyphosis, intraspinal pathology and any degree of neurologic deficits were excluded. The deformity correction was based on spinal column shortening over the resected gap during PVCR. Laser Doppler flowmetry was used to monitor the SCBF at different surgical stages.There were 12 severe rigid scoliokyphosis patients in the study. The baseline SCBF was 316 ± 86 perfusion unite (PU), and the SCBF decreased to 228 ± 68 PU after VCR (P = .008). The SCBF increased to 296 ± 102 PU after the middle shortening and correction which has a 121% increased comparison to the SCBF after VCR (P = .02). The SCBF will slightly decrease to 271 ± 65 PU at final fixation. The postoperative neural physical examination of all patients was negative, and the MEP and SSEP of all patients did not reach the alarm value during surgery.These results indicate that PVCR is accompanied by a change in SCBF, a proper spinal cord shortening can protect the SCBF and can prevent a secondary spinal cord injury during the surgery.

Purpose: Cement leakage and adjacent vertebral fractures are not uncommon after percutaneous augmentation. However, conclusive identification of risk factors for postprocedural complications remains elusive. The anticipation of leakage and successive fractures through the identification of risk factors will help physicians better inform patients of potential complications and establish procedural refinements key to risk reduction. The aim of this retrospective study was to summarize available reports of the risk factors for cement leak and adjacent vertebral fracture in or after kyphoplasty for osteoporotic vertebral compression fractures., Methods: A total of 102 cases of bilateral percutaneous kyphoplasty (PKP), performed between January 2014 and December 2016, were retrospectively reviewed. Each case surveyed in this review included a minimum 1-year follow-up and data on age, sex, bone mineral density, Visual Analog Scale score, preoperative compression rate, kyphotic angle, treatment time, the volume of cement, and the intactness of the vertebral posterior wall (computed tomography scan) were collected. Pearson χ test and independent samples test were used to determine the relative risk factors of cement leak and adjacent vertebral fracture in patient subsets., Results: Diabetic status and alteration in the Cobb angle after PKP exhibited a statistically significant correlation with the incidence of new adjacent vertebral fracture (group B) (P<0.05). In addition, the integrity of vertebral walls (P=0.001) and the volume of injected cement (P=0.026) significantly boosted the potential risk of cement leakage (P<0.05), although these variables did not associate with the adjacent fracture. Additional examined variables, including age, sex, Visual Analog Scale scores, number of fractures were not significantly associated with leakage or adjacent vertebral fracture risk., Conclusions: Diabetes and the alteration of the Cobb angle following PKP are factors positively related to the occurrence of postoperative adjacent vertebral fractures. It is also demonstrated that the integrity of vertebral walls and average volumes of injected cement are the possible risk factors of cement leakage while performing the PKP.

Background: Bone cement distribution patterns in percutaneous kyphoplasty (PKP) is the key factor in keeping the vertebral stabilization and curative effect. However, the same cement volume can result in different bone cement distribution patterns and can thereby lead to different clinical outcomes. Therefore we investigated associations between cement distribution patterns and the occurrence rates of recompression in cemented vertebrae after PKP for patients with osteoporotic vertebral compression fractures (OVCFs)., Objectives: The study focuses attention on the influence of compact and dispersive cement distribution patterns in PKP for patients with OVCFs., Study Design: A retrospective cohort study., Setting: An affiliated people's hospital of a university., Methods: According to different cement distribution patterns, patients were assigned to 4 groups. The demographic data, radiographic data, and clinical outcomes were compared between the 4 groups. The Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were evaluated before and 2 days after PKP. Moreover, the relationships between bone cement and clinical outcomes were analyzed. The epidemiologic data, clinical outcomes, and complications of the 4 groups were assessed. Comparisons of the radiologic and clinical results of the 4 groups were made pre- and postoperatively. Anterior height of fractured vertebrae (AH), the kyphotic Cobb angle, and the volumetric cubage index of the fractured vertebrae were measured., Results: A total of 104 subjects were retrospectively analyzed and followed up (median age, 75.01 ± 8.42 years; age range, 56-94 years). The mean procedure duration was 61.26 ± 23.05 minutes (range, 30-140 minutes). The mean follow-up was 12.1 ± 2.2 months (range, 2-15 months). Statistically, there was no significant difference in terms of gender, age, body mass index, and bone mineral density (P > 0.05). The incidence of cement leakage was significantly lower in group A than those in the other groups. The total amount of bone cement injected into 104 cases (104 vertebral bodies in total) was 848.5 mL, and the amount of bone cement injected into a single vertebral body was 7.94 ± 1.38 mL. The amount of bone cement injection in each group was the lowest (6.80 ± 1.66 mL) in group D, followed by (7.94 ± 1.38 mL) group B, and the highest (8.96 ± 1.68 mL) in group A, with a statistically significant difference between the 4 groups (P < 0.05). No serious complications were observed during the follow-up periods. The AH and Cobb angle improved significantly for the 4 groups (P < 0.05). The VAS score decreased from 3.55 ± 0.54, 3.53 ± 0.65, 3.40 ± 0.58, and 3.40 ± 0.66 preoperatively to 0.18 ± 0.39, 0.23 ± 0.41, 0.20 ± 0.40, and 0.15 ± 0.36 at 48 hours postoperatively. The ODI score dropped from 35.65 ± 4.54, 36.45 ± 4.72, 34.12 ± 4.86, and 35.65 ± 4.34 preoperatively to 15.47 ± 1.32, 15.32 ± 1.34, 15.23 ± 1.26, and 15.73 ± 1.17 at 48 hours postoperatively., Limitations: Our estimation of the vertebral body volume is imprecise. In addition, the number of subjects with OVCFs was small in this retrospective study. The volume of the fractured vertebra was not calculated accurately., Conclusions: Significant associations between cement distribution patterns and bone cement leakage affected the clinical outcome in patients after PKP. A higher incidence of bone cement leakage was observed in patients with treated vertebrae exhibiting a single-dispersive or single-compact pattern., Key Words: Percutaneous kyphoplasty, osteoporotic vertebral compression fracture, bone cement distribution patterns.