Adolescent idiopathic scoliosis

SSAT-Swin: Deep Learning-Based Spinal Ultrasound Feature Segmentation for Scoliosis Using Self-Supervised Swin Transformer

OBJECTIVE

Scoliosis, a 3-D spinal deformity, requires early detection and intervention. Ultrasound curve angle (UCA) measurement using ultrasound images has emerged as a promising diagnostic tool. However, calculating the UCA directly from ultrasound images remains challenging due to low contrast, high noise, and irregular target shapes. Accurate segmentation results are therefore crucial to enhance image clarity and precision prior to UCA calculation.

METHODS

We propose the SSAT-Swin model, a transformer-based multi-class segmentation framework designed for ultrasound image analysis in scoliosis diagnosis. The model integrates a boundary-enhancement module in the decoder and a channel attention module in the skip connections. Additionally, self-supervised proxy tasks are used during pre-training on 1,170 images, followed by fine-tuning on 109 image-label pairs.

RESULTS

The SSAT-Swin achieved Dice scores of 85.6% and Jaccard scores of 74.5%, with a 92.8% scoliosis bone feature detection rate, outperforming state-of-the-art models.

CONCLUSION

Self-supervised learning enhances the model's ability to capture global context information, making it well-suited for addressing the unique challenges of ultrasound images, ultimately advancing scoliosis assessment through more accurate segmentation.

Comparisons of Interapical Distance and Coronal Balance Measurements Among Standing Positions in Participants With and Without Adolescent Idiopathic Scoliosis Using 3D Ultrasound Imaging

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

The objective of this study was to quantify whether interapical distance and coronal balance measured on 3D ultrasound (3DUS) images differed among 10 standing positions of participants with and without adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Apical vertebral translation (AVT) is an indicator of clinical symptoms and treatment outcomes in AIS. Stereoradiography simultaneously captures a frontal and lateral image, yet patients are required to elevate their arms during the examination and varied positioning may impact coronal plane measurements. Ultrasound can assess these measurements without exposing participants to radiation.

MATERIALS AND METHODS

Females with and without AIS were recruited from a scoliosis clinic, and e-mail advertisements, respectively. Participants underwent 3DUS scans in 10 positions: standing; arms anteriorly supported in 60° of shoulder flexion; fingers to clavicles, chin, zygomatic processes, and eyebrows; shoulders abducted at 90° with hands open and thumbs on shoulders; hands on anterior wall with and without blocks; and hands unsupported. AVT and coronal balance measurements were obtained using custom software. Positions and groups were compared using repeated measures ANOVAs with Sidak pairwise comparisons.

RESULTS

Fifty-nine females had a mean age, height, and weight of 17.5±4.9 years, 162.8±5.8 cm, and 56.2±10.6 kg, respectively. Seventeen single and 14 double curve participants were included with mean maximum curve angles of 26.4°±3.6° and 25.2°±3.1°, respectively. Overall, there were no statistically significant differences in interapical distance or coronal balance among the 10 positions, as well as in coronal balance between the groups ( P >0.05). The interapical distance of participants without AIS significantly differed from those with single curves in eight positions and from those with double curves in all 10 positions.

CONCLUSIONS

The positions evaluated may be interchangeable for coronal plane lateral deviation measurements of females with AIS.

Comparison between anterior and posterior approaches in selective instrumentation of juvenile idiopathic scoliosis in children and adolescents: a systematic review and meta-analysis

This study analyzes data comparing anterior and posterior selective instrumentation to determine the optimal surgical approach for Juvenile Idiopathic Scoliosis correction. Systematic Review and Meta-analysis. We consulted the databases MEDLINE, CENTRAL, LILACS, and Embase on January 20th, 2024. We included cohort, case-control, and clinical trial studies involving patients aged 21 or younger with Juvenile Idiopathic Scoliosis (JIS) treated with selective instrumentation, comparing anterior and posterior approaches. We excluded studies with combined anterior and posterior instrumentation, thoracoscopic-assisted approaches, and vertebral body tethering. We assessed the studies' risk of bias using the Newcastle-Ottawa Scale. Our meta-analyses compared Cobb angle correction rates and secondary intra- and postoperative outcomes. The analysis included 15 cohort studies (928 patients) 514 underwent anterior instrumentation and 414 posterior instrumentation. No deaths occurred. The average operative time was 260.7 minutes for anterior and 190.4 minutes for posterior procedures. Average blood loss was 398.4 mL (anterior) and 413.4 mL (posterior). Cobb angle correction rates were 61.7% (anterior) and 66% (posterior). Meta-analyses revealed no significant differences in Cobb angle correction rates between groups (p = 0.774, 95% CI: -0.331 to 0.444; p = 0.365, 95% CI: -0.23 to 0.62). Anterior and posterior selective instrumentation achieve similar Cobb angle correction rates, and the choice for JIS in patients under 21 years remains highly individualized. Both approaches show comparable outcomes in correction, bleeding, and SRS-22 scores. Posterior instrumentation reduces operative time and hospital stays, while anterior instrumentation requires fewer instrumented vertebrae. The lack of clinical trials and incomplete outcome reporting may limit some analyses, though supplementary meta-analyses mitigated these constraints.

Enhanced recovery after surgery for adolescent idiopathic scoliosis: a revised systematic review and meta‑analysis

PURPOSE

Adolescent idiopathic scoliosis surgery (AIS) is often associated with high costs and significant recovery challenges. Enhanced recovery after surgery (ERAS) protocols aim to improve outcomes, reducing hospital stays and complications compared to traditional (TD) pathways. This study evaluates the impact of ERAS protocols on AIS treatment.

METHODS

Following PRISMA guidelines, a systematic review identified 30 studies (n = 15,954 patients). Search terms included "ERAS," "adolescent idiopathic scoliosis," and "posterior spinal fusion." Outcomes assessed included surgical metrics, recovery milestones, complications, and pain. A meta-analysis was performed, and the risk of bias was evaluated using the MINORS score.

RESULTS

ERAS patients (n = 5582) had shorter surgical durations (- 23 min, p = 0.08) and reduced blood loss (- 126 mL, p = 0.033) compared to TD patients (n = 7916). Recovery milestones improved, including earlier ambulation (- 37.4 h, p < 0.0001), patient-controlled analgesia discontinuation (- 1.1 days, p < 0.0001), catheter removal (- 0.75 days, p < 0.001), and shorter hospital stays (- 1.7 days, p < 0.0001). Complications were lower in the ERAS group (4% vs. 8%, p = 0.0074), while wound-related complications and 30-day readmission rates were comparable. Pain scores were significantly reduced from surgery day to postoperative day 2 (p < 0.0181).

CONCLUSION

ERAS protocols improve recovery and reduce complications in AIS surgery, with shorter hospital stays and enhanced patient outcomes. These findings support broader implementation and further randomized trials to evaluate long-term benefits and patient satisfaction.

Comparison of postoperative and outpatient opioid use in adolescent idiopathic scoliosis patients treated with posterior spinal fusion surgery and vertebral body tethering

PURPOSE

Surgical treatments for adolescent idiopathic scoliosis (AIS) include posterior spinal fusion (PSF) and vertebral body tethering (VBT), but there is limited data that compares pain between these groups. We aimed to compare postoperative pain between these patients through inpatient opioid use and opioid prescriptions post-discharge.

METHODS

A retrospective review of patients diagnosed with AIS who underwent PSF or VBT surgery was reviewed to determine LOS, inpatient opioid use, and opioids prescribed post-discharge. Only PSF patients who received liposomal bupivacaine and intrathecal (IT) hydromorphone, and VBT patients who received a paravertebral catheter of lidocaine and in addition to IT hydromorphone were included. Opioid amounts were reported as oral morphine equivalents (OMEs).

RESULTS

Of 198 AIS patients that met inclusion, there were 89 PSF and 109 VBT patients. PSF patients had an increased LOS by 0.6 days compared to VBT patients (p < 0.001). Patients in the PSF group were administered a mean of 30.0 OMEs/day compared with the VBT group who received 12.5 OMEs/day (p < 0.001). At discharge, PSF patients were initially prescribed a mean of 227.7 OMEs while VBT patients' mean prescription was 139.7 (p < 0.001). PSF patients received more refills (Χ2 (1, n = 198) = 26.8, p < .001) and had a higher mean total of outpatient OMEs prescribed when compared to VBT patients (359.4 vs 185.8, p < 0.001).

CONCLUSION

In AIS patients undergoing surgical correction, those who underwent PSF had longer LOS, received more inpatient OMEs, and were prescribed more OMEs both at initial discharge and total as an outpatient, when compared to VBT patients.

LEVEL OF EVIDENCE

Level III: (retrospective cohort study).

Statistical Shape Modeling and Prediction of Lumbar Spine Morphology in Patients With Adolescent Idiopathic Scoliosis

A lumbar spine statistical shape model (SSM) was developed to explain morphological differences in a population with adolescent idiopathic scoliosis (AIS). Computed tomography (CT) was used to collect data on the lumbar spine vertebrae and curvature of 49 subjects. The CT data were processed by segmentation, landmark identification, and template mesh mapping, and then SSMs of the individual vertebrae and entire lumbar spine were established using generalized Procrustes analysis and principal component analysis (PCA). Scaling was the most prevalent variation pattern. The weight coefficient was optimized using the Levenberg-Marquardt (LM) algorithm, and multiple regression analysis was used to establish a prediction model for age, sex, height, and body mass index (BMI). The effectiveness of the SSM and prediction model was quantified based on the root-mean-square error (RMSE). An automatic measurement method was developed to measure the anatomical parameters of the geometric model. The lumbar vertebrae size was significantly affected by height, sex, BMI, and age, with men having lower vertebral height than women. The trends in anatomical parameters were consistent with previous studies. The vertebral SSMs characterized the shape changes in the processes, while the lumbar spine SSM described alignment changes associated with translatory shifts, kyphosis, and scoliosis. Quantifying anatomical variation with SSMs can inform implant design and assist clinicians in diagnosing pathology and screening patients. Lumbar spine SSMs can also support biomechanical simulations of populations with AIS.

Prevalence and Characteristics of Idiopathic Scoliosis in Dancers: A Systematic Review and Meta-Analysis

BACKGROUND

The prevalence of Idiopathic Scoliosis (IS) is 2% to 3% in the general population. The presence of a hump can be detected clinically, but only X-rays can confirm the diagnosis. Early detection and treatment can prevent IS progression and complications. There is a lack of knowledge about the actual prevalence and predictors of IS among dancers.

PURPOSE

To investigate the prevalence of IS in dancers, how it is diagnosed and classified, and explore possible predictors. Study Design: Prevalence systematic review with meta-analysis.

METHODS

PubMed, Embase, Scopus, CINAHL Plus databases and the Cochrane Central Register of Controlled Trials were searched up to August 2024.

STUDY SELECTION CRITERIA

Original research involving dancers who received a diagnosis of IS and reporting a measure of its prevalence, or sufficient data to compute it, were included.

DATA SYNTHESIS

Random-effects model meta-analysis. The risk of bias was assessed using the Joanna Briggs Institute checklists. The certainty of evidence was judged using the GRADE approach.

RESULTS

Fifteen studies, accounting for 5709 dancers aged 8 to 41 years, were included in the analysis. The overall prevalence of IS was 15.8% (10%-22%). When X-rays were not performed, clinical examination alone skewed the prevalence, making it appear 48.1% to 73.4% higher.

CONCLUSIONS

The prevalence of IS in dancers, regardless of level of training or age, has been found to be at least three times higher than in the general population. However, the lack of standardized assessment and diagnostic tools makes these results questionable. Dancers' screening for scoliosis, with standardized testing procedures, should be used for X-rays referral, to allow for early diagnosis and treatment.Trial RegistrationRegistered on PROSPERO the 01/05/2023: CRD42023418019.

Equal image quality and reduced radiation exposure in whole-spine X-ray imaging with slot-scanning technique compared with stitched radiography

Repeated whole-spine imaging in children and adolescents with scoliosis causes significant cumulative radiation exposure. Low-dose slot-scanning imaging can reduce radiation exposure. The aim of this study was to compare whole-spine imaging using the slot-scanning technique (SST) with conventional stitched radiography (SR) with regard to image quality and radiation dose.We recruited 30 patients with a clinical indication for whole-spine imaging by SST, who had prior whole-spine imaging by SR available. 41 images acquired using both techniques were analyzed. The dose area product (DAP) and patient age, weight, height, and body-mass index were recorded. Image quality was assessed for 28 anatomical landmarks on a 4-point Likert scale by 4 raters. Group-wise comparisons were performed using paired t-tests. Interrater rating reliability was assessed using the interrater correlation coefficient.The mean DAP was significantly lower for SST than for SR (SST 8.0 ± 5.7 cGy · cm², SR 32.5 ± 34.5 cGy · cm², p < 0.001). The image quality was rated good for both modalities (means: SST 2.8 ± 0.6, SR 2.7 ± 0.5, p = 0.38). There was no significant difference in image quality ratings between both modalities. The inter-rater reliability was excellent with an inter-rater correlation coefficient of 0.86. Orthopedic surgeons rated the image quality of SST significantly better than that of SR.This study shows a significant reduction in radiation exposure for slot-scanning whole-spine imaging compared to stitched radiography with equal image quality, which facilitates the reduction of radiation exposure for repeated whole-spine imaging in children and adolescents to 25%. · Image quality is comparable between slot-scanning and stitched whole-spine imaging.. · The slot-scanning technique had a significantly lower dose area product compared with stitched radiographs.. · Orthopedic surgeons rated the image quality of slot-scanning significantly better than that of stitching.. · Radiation exposure in scoliosis whole-spine imaging can be reduced to 25%.. · Liebscher H, Scherzer M, Meißner C et al. Equal image quality and reduced radiation exposure in whole-spine X-ray imaging with slot-scanning technique compared with stitched radiography. Rofo 2025; DOI 10.1055/a-2564-0580.

Increased Prevalence of Scoliosis in Female Professional Ballet Performers

BACKGROUND

Musculoskeletal abnormalities have been reported among female professional ballet performers due, in part, to intrinsic predispositions related to joint and/or connective tissue laxity and extrinsic effectors such as reduced energy availability, low body mass, and high training volumes that may increase the risk of developing idiopathic scoliosis (IS). The purpose of this investigation was to characterize IS prevalence in this population. We hypothesized that there would be elevated prevalence in female performers and that those with IS would exhibit reduced bone mineral density (BMD), body mass, fat mass, and lean mass.

METHODS

A retrospective analysis of whole-body anteroposterior radiographs was performed on 98 professional ballet dancers (49 male performers [mean age, 25 ± 6 years] and 49 female performers [mean age, 27 ± 5 years]) from a single company. Body composition and BMD were assessed via dual x-ray absorptiometry. The criterion for IS was defined as a Cobb angle of >10°. The frequency of IS was plotted against general-population norms. A t test was used to compare demographic characteristics, anthropometrics, and BMD between performers with and without IS and to compare the Cobb angles between sexes. A Fisher exact test was used to compare the IS prevalence between sexes. The Type-I error was set at α = 0.05.

RESULTS

Compared with male performers, female performers had greater spinal asymmetry (mean Cobb angle, 7.98° [95% confidence interval (CI) width, 1.76°] for men and 4.02° [95% CI width, 1.00°] for women; p = 0.027). The prevalence of IS among male performers (3 [6.12%] of 49) was comparable with the general-population norms (0.31% to 5.60%). Women had an elevated prevalence of IS compared with men (10 [20.41%] of 49; p = 0.037) and with general-population norms (0.65% to 8.90%). Among women, performers with IS were observed to have a reduced percentage of body fat (p = 0.021) and reduced fat mass (p = 0.040) compared with performers without IS.

CONCLUSIONS

Female professional ballet performers demonstrate a heightened prevalence of IS that, in addition to intrinsic predisposition, is associated with modifiable factors such as reduced fat mass commonly associated with reduced energy availability known to impact musculoskeletal health in athletes. Future investigations should seek to determine the prevalence of IS in other young female athlete populations commonly exposed to high degrees of activity and reduced energy availability.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Stiffness-Related Disability Following Surgical Correction for Adolescent Idiopathic Scoliosis: A Comparative Analysis According to the Lowest Instrumented Vertebra Level

Background

Extensive spinal fusion inevitably results in loss of mobility, which may induce stiffness-related disability (SRD) during activities of daily living. Few studies have examined SRD after surgical correction for adolescent idiopathic scoliosis (AIS). This study aimed to investigate SRD following surgical treatment in AIS patients particularly with respect to the lowest instrumented vertebra (LIV).

Methods

Patients who underwent surgical correction for AIS between 2014 and 2021 and were followed up for 2 years were included. The degree of SRD was evaluated using the Stiffness-Related Disability Index (SRDI), which consists of 4 categories, each containing 3 questions, giving a total of 12 components of the questionnaire. The SRDI scores were compared according to the LIV level. Correlation analysis was performed to examine the relationship between the SRDI and legacy health-related quality of life (HRQOL) measurements.

Results

This study included 174 patients (47 men and 127 women) with a mean age of 13.8 years. Among the 12 items of the SRDI, the scores of 9 items showed a significant increase after surgery. The total sum of the SRDI scores also significantly increased after surgery. Pearson correlation analysis showed that the SRDI scores were significantly correlated with Oswestry disability index, nearly all domains, and the total sum of Scoliosis Research Society-22 questionnaire, and 36-Item Short Form Survey. No differences in the SRDI score were found among cases with the LIV between T12 and L3. However, the SRDI scores of patients with LIV at L4 were significantly higher than those of patients with other LIV levels.

Conclusions

Various degrees of SRD occurred after spinal fusion for AIS. The SRDI was significantly correlated with the HRQOL measurements. The SRDI score was highest in patients with the LIV at L4 when compared to those with other LIV levels. Fusion can be safely extended to L3 without significantly increasing SRD.

Patient-reported outcomes following surgery for adolescent idiopathic scoliosis performed in adolescence versus adulthood

INTRODUCTION

The Scoliosis Research Society 22r (SRS-22r) questionnaire is a proven tool in assessing healthcare-related quality of life (HRQoL) in idiopathic scoliosis and is the adopted patient-reported outcome measure for the deformity pathway recorded into the British Spinal Registry (BSR). Surgery for adolescent idiopathic scoliosis (AIS) is performed frequently in teenagers; however, patients also present with curves in the surgical range into adulthood. This work aimed to assess HRQoL differences between patients following surgery for AIS performed in adolescence and adulthood using SRS-22r data collected from the BSR.

METHODS

An anonymised BSR search of pre- and postoperative SRS-22r scores for patients with diagnoses of AIS and adult idiopathic scoliosis was conducted. Data from all subdomains were compared preoperatively and at the two-year postoperative timepoint.

RESULTS

Preoperative SRS-22r scores were analysed for 1,912 patients with AIS and 65 with adult idiopathic scoliosis. Patients with adult idiopathic scoliosis had significantly lower preoperative SRS-22r scores in all subdomains (p<0.05). By two years postoperatively, both groups of patients had improved SRS-22r scores significantly compared with baseline in all subdomains (p<0.001). A cross-group analysis revealed patients with AIS had significantly better function scores years postoperatively than their adult counterparts (p=0.005).

CONCLUSIONS

This work confirms there are benefits following surgery for AIS in improving HRQoL, but has also provided HRQoL data in adult patients, who again show similar improvements following surgery from baseline. This is of value when counselling patients regarding anticipated benefits of surgery performed in childhood and adulthood.

Genome-wide methylation association study in monozygotic twins discordant for curve severity of adolescent idiopathic scoliosis

BACKGROUND CONTEXT

Emerging evidence suggests that abnormal DNA methylation patterns may play a role in the progression of adolescent idiopathic scoliosis (AIS). However, the mechanisms underlying the influence of DNA methylation on curve severity remain largely unknown.

PURPOSE

To characterize the DNA methylation profiles associated with the curve severity of AIS.

STUDY DESIGN

Retrospective study with prospectively collected clinical data and blood samples.

METHODS

A total of 7 AIS monozygotic twin pairs discordant for curve severity were included. Genome-wide methylation profile from blood samples were quantified by Illumina Infinium MethylationEPIC BeadChip (850K chip). Cell type composition of the samples was estimated by RefbaseEWAS method. Differentially methylated CpG sites were identified through comparison between patients with low and high Cobb angle. We also performed a gene-based collapsing analysis using mCSEA by aggregating the CpG sites based on promoter region. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis were performed using clusterProfiler package.

RESULTS

Genome-wide DNA methylation analysis identified multiple differentially methylated positions across the genome. Gene-based collapsing analysis identified 212 differentially methylated genes (FDR adjusted p<.05), most of which (186/212) were hypermethylated in the group with high Cobb angle. Some of the identified genes were well-documented in AIS literature, such as TBX1, PAX3 and LBX1. Functional enrichment analysis revealed that the differentially methylated genes (DMGs) were involved in pattern specification process, skeletal development, muscle function, neurotransmission and several signaling pathways (cAMP, Wnt and prolactin).

CONCLUSIONS

The study represents the largest systematic epigenomic analyses of monozygotic twins discordant for curve severity and supports the important role of altered DNA methylation in AIS.

CLINICAL SIGNIFICANCE

The identified CpG sites provide insight into novel biomarkers predicting curve progression of AIS. Furthermore, the differentially methylated genes and enriched pathways may serve as interventional therapy target for AIS patients.

Comparative efficacy and safety of high-dose versus low-dose tranexamic acid in adolescent idiopathic scoliosis: A systematic review and meta-analysis

OBJECTIVE

The objective of this meta-analysis was to evaluate the comparative effectiveness and safety of high-dose versus low-dose tranexamic acid (TXA) in adolescents undergoing treatment for idiopathic scoliosis.

METHODS

A comprehensive literature search was conducted across PubMed, Web of Science, Embase, Cochrane Library, and China National Knowledge Infrastructure (CNKI) databases up to March 2024. We sought to identify randomized controlled trials (RCTs) and retrospective controlled studies (RCSs) assessing the impact of high-dose compared to low-dose TXA on perioperative blood loss and transfusion requirements in spinal fusion procedures for adolescent idiopathic scoliosis. The study was registered in INPLASY (Registration number: INPLASY202480018).

RESULTS

Our meta-analysis included data from six studies: two high-quality RCTs and four lower-quality RCSs, comprising a total of 611 participants. Subgroup analysis revealed that high-dose TXA significantly reduced intraoperative blood loss and transfusion rates in RCSs, whereas no significant differences were observed in RCTs. The combined findings showed that high-dose TXA was associated with a significant reduction in intraoperative blood loss [weighted mean difference (WMD) =  -215.48, 95% confidence interval (CI) (-367.58, -63.37), P <  0.001], as well as a decreased likelihood of transfusion [risk ratio (RR) =  0.40, 95% CI (0.30, 0.53), P <  0.001]. Operative time did not differ significantly, and no thromboembolic events were reported in either treatment group. The differences between high and low doses varied widely across studies.

CONCLUSION

This meta-analysis indicates that high-dose TXA does not significantly reduce intraoperative blood loss, transfusion rates, or operative time compared to low-dose TXA in adolescent idiopathic scoliosis. While RCSs showed some benefit, our analysis places more emphasis on the results from RCTs, which did not show significant differences. Further high-quality RCTs are needed to confirm its effectiveness and safety.

Effectiveness of bracing combined with exercise-based treatment of adolescent idiopathic scoliosis: Assessing the synergistic benefits: A systematic review

The purpose of this study was to evaluate evidence on the effectiveness of combined bracing and exercise on adolescent idiopathic scoliosis (AIS). From inception to April 28, 2022, PubMed and Web of Science searched for randomized clinical and nonrandomized prospective studies reporting Cobb angle (CA), angle of trunk rotation (ATR), quality of life (QoL), and pulmonary function (PF) in AIS patients treated with exercise and braces (10 years-skeletal maturity). Two authors analyzed and extracted data for this review. The PEDro scale was used to assess the risk of bias (RoB). Therapy protocols and basic data have been collected. Each CA, ATR, QoL, and PF study's evidence and strength were also included. A total of 12 studies with 714 patients with AIS were included. Five studies used a control group with exercises and 7 with braces. The results showed that exercise-brace can decrease CA and ATR and increase QoL and PF with AIS; however, the strength of conclusion for all outcomes was moderate. In this review, 4 studies were categorized as low RoB, 3 as moderate RoB, and 5 as high RoB. Level of evidence analysis revealed that 12 studies were classified as level of evidence B. The current studies do not sufficiently support the effects of exercise and brace therapy on CA, ATR, QoL, and PF in patients with AIS.

Evaluating exercise therapies in adolescent idiopathic scoliosis: a systematic review with Bayesian network meta-analysis

Background

Exercise therapy represents a financially prudent and readily applicable intervention that has gained considerable traction in the treatment of adolescent idiopathic scoliosis (AIS) in recent years. Nevertheless, a definitive agreement on the superiority of one method over another remains elusive.

Methods

A comprehensive search was performed across the PubMed, Cochrane Library, Embase, and Web of Science databases for randomized controlled trials pertaining to exercise and AIS, concluding on August 20, 2024. Four independent researchers conducted a thorough review of the literature, engaged in meticulous data extraction, and assessed the risk of bias. A Bayesian network meta-analysis was performed utilizing the R programming language (version 4.3.4) and MetaInsight tool (version V6.0.1).

Results

A total of 23 studies were incorporated into the analysis, encompassing 1,289 participants with AIS. Compared to the control group, the primary meta-analysis showed that both SchrothCo and physiotherapeutic scoliosis-specific exercises (PSSE) modalities significantly improved Cobb angle (MD = -4.79, 95% CI [-8.56 to -1.11] MD = -3.11, 95% CI [-5.27 to -0.9]), axial trunk rotation (ATR) (MD = -3.03, 95% CI [-4.68 to -1.46]; MD = -2.37, 95% CI [-3.59 to -1.14]), and SRS-22 scores (MD = 0.66, 95% CI [0.39-0.94]; MD = 0.44, 95% CI [0.22-0.66]). The secondary meta-analysis showed that within the PSSE modality, Schroth therapy significantly reduced Cobb angle (MD = -2.3, 95% CI [-5.45 to -0.66]), while in the SchrothCo modality, both Schroth + Core and Schroth + Hippotherapy significantly improved Cobb angle (MD = -5.27, 95% CI [-14.15 to -3.5]). For ATR, Schroth therapy within PSSE (MD = -2.79, 95% CI [-6.4 to -0.1]), and Schroth + Core (MD = -4.03, 95% CI [-9.37 to -0.98]), Schroth + Sling (MD = -3.12, 95% CI [-10.05 to -2.94]), and Schroth + Hippotherapy (MD = -3.39, 95% CI [-10.29 to -2.84]) within the SchrothCo modality all showed significant reductions. Significant differences in SRS-22 scores were found only in the PSSE modality with Schroth therapy (MD = 0.48, 95% CI [0.02-0.9]) and in the SchrothCo modality with Schroth + Core (MD = 0.79, 95% CI [0.13-1.43]).

Conclusions

According to the latest findings, the integration of the Schroth method with core stabilization training (Schroth + Core) is regarded as the optimal strategy for addressing AIS. The integration of core stabilization training with the Schroth method reveals a markedly enhanced effectiveness. Future inquiries should encompass more rigorous studies to establish a more robust evidence foundation and facilitate progress in this domain.

Effects of Physiotherapeutic Scoliosis-Specific Exercise for Adolescent Idiopathic Scoliosis Cobb Angle: A Systematic Review

Background

The study of physiotherapeutic scoliosis-specific exercise (PSSE) for adolescent idiopathic scoliosis (AIS) is rapidly progressing. However, there are limited reports on the medium- to long-term effects of PSSE on scoliosis.

Methods

A systematic review and meta-analysis feasibility study were conducted according to the Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In our exhaustive search, we employed nine search formulas and four search databases according to a preregistered protocol. Identification, screening, eligibility, inclusion, and meta-analysis were performed through repeated meetings involving all coauthors. Each process was conducted by three or more authors.

Results

A total of 1,518 studies were identified in the initial search. After manually reviewing abstracts and full texts, 11 studies were chosen for evaluation and reporting. The overall risk-of-bias was high in approximately half of the studies and moderate in the other half, with none found to have a low risk-of-bias. Only two randomized controlled trials (RCTs) specifically evaluated the therapeutic effect of PSSE on over a 1-year clinical course and the preventive ability of PSSE on surgery. One RCT reported that Cobb angle was substantially smaller in the PSSE group than in the control group at the final follow up, whereas the other found no significant difference between the groups. The methods of exercise intervention, control group selection, and timing of outcome assessments were not standardized in the selected studies. Thus, conducting a meta-analysis of the literature was deemed unfeasible at this time.

Conclusions

The certainty of the evidence that PSSE reduces the progression of Cobb angle in patients with AIS in the short and long term was extremely low. Accordingly, healthcare providers should carefully examine the current evidence when explaining and applying PSSE in such patients. High-quality studies addressing the long-term changes in Cobb angle and Cobb angle at bone maturity as primary outcomes are warranted.

Level of Evidence

Level 1.

Trunk endurance differences between female adolescents with and without idiopathic scoliosis

PURPOSE

This study compared trunk muscle endurance between female adolescents with idiopathic scoliosis (AIS) and non-AIS groups.

METHODS

This cross-sectional study included 91 females. Trunk muscle endurance was assessed using the Ito-Shirado and Biering-Sørensen tests. Anthropometric and radiographic data were collected. The Mann-Whitney U test compared endurance and abdominal-to-paraspinal endurance ratio between groups. Spearman's correlation assessed relationships between endurance and participant characteristics.

RESULTS

The AIS group's performance on the Ito-Shirado and Biering-Sørensen tests was 57% and 68% of the non-AIS group's test durations, respectively (p = 0.001). However, there was no significant difference in the abdominal-to-paraspinal endurance ratio between the two groups (p = 0.7). Additionally, a low negative correlation was observed between paraspinal muscle endurance and both weight (rho = - 0.29, p = 0.006)) and BMI (rho = - 0.3, p = 0.005) in the AIS group, while abdominal endurance correlated negatively with height (rho = - 0.25, p = 001).

DISCUSSION

Females with AIS exhibit significantly reduced endurance in both paraspinal and abdominal muscles compared to healthy controls, despite maintaining a similar abdominal-to-paraspinal endurance ratio. The findings suggest the need for trunk muscle endurance evaluation and training in rehabilitation programs for individuals with AIS.

Treatment of Adolescent Idiopathic Scoliosis with the Conservative Schroth Method: A Randomized Controlled Trial

Objective: The objective of this study was to determine the effectiveness of the conservative Schroth method in patients with adolescent idiopathic scoliosis. Methods: A total of 34 respondents, 24 male and 10 female, aged between 11 and 16 years, participated in the research. The study was a single-blind randomized trial, in which subjects were divided into control and experimental groups by stratified randomization according to the stratum of the Cobb angle. The control group performed the Schroth method at home without the supervision of Schroth therapists, while the experimental group performed the Schroth method under the supervision of Schroth therapists three times a week for 90 min over eight weeks. Initial and final outcome measurements were performed: Cobb angle, angle of trunk rotation, vital capacity, forced vital capacity, forced expiratory volume in the first second, the percentage of forced expiratory volume in the first second in forced vital capacity, and chest expansion. Results: There was a statistically significant improvement in all measured outcomes in the experimental group, while no statistically significant changes were recorded in the control group. The Cobb angle decreased by 2.12°, while ATR decreased by 2.88°; VC increased by 0.15 L, FVC by 0.13 L, FEV1 by 0.1 L, and CE increased by 0.78 cm. Conclusions: The application of an eight-week therapy program using Schroth method by subjects with adolescent idiopathic scoliosis had statistically significant changes in all measured outcomes in the group that was supervised by Schroth's therapists, while there was no statistically significant improvement in the group that applied therapy at home without supervision.

Positive rate and influencing factors of adolescent idiopathic scoliosis among school children aged 9 to 18 years in Xiamen, China

OBJECTIVE

The present study aimed to investigate the positive rate of adolescent idiopathic scoliosis (AIS) among school children in Xiamen, Fujian province, China, and evaluate its possible risk factors.

METHODS

The study was a school-based, cross-sectional scoliosis screening program in Xiamen city. A total of 19,315 school children aged 9-18 years in Xiamen were recruited using a multistage sampling approach. Scoliosis screening was performed through visual inspection of clinical signs, Adams forward bending test, and measurement of trunk rotation angles using a scoliometer. Demographic data, clinical characteristics, and behavioral factors were collected using a questionnaire, and logistic regression analysis was conducted to analyze the possible risk factors.

RESULTS

The overall positive rate of AIS among school children was 7.12%. Among underweight students, 10.36% were confirmed to have a positive diagnosis of AIS. Multivariable logistic regression models demonstrated age and sex (AOR: 5.00, 95% CI: 4.33-5.76) were associated with AIS. Girls who had experienced menarche (AOR: 1.39, 95% CI: 1.10-1.77) had a higher risk of developing AIS. Students with low body mass index (BMI) (AOR: 1.75, 95% CI: 1.39-2.19), insufficient sleep duration (AOR: 1.67, 95% CI: 1.45-1.93), and carrying single-shoulder bags (AOR: 2.73, 95% CI: 2.38-3.13) were more likely to develop AIS.

DISCUSSION

The positive rate of AIS among school children in Xiamen was 7.12%. Older age, girls, low BMI, insufficient sleep duration, and carrying single-shoulder bags were risk factors for AIS.

How is familial idiopathic scoliosis transmitted? Analysis of 26 pedigrees

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spine, affecting 1-3 % of the population, predominantly female patients, especially for severe curves. Its etiology is still debated, but a genetic involvement is certain, alongside with epigenetic and environmental factors. Isolated or sporadic cases are frequent, but AIS also affect families, with a reported heritability up to 38%.

HYPOTHESIS

The main hypothesis of this study was that a particular form of AIS, familial AIS, displays specific forms of transmission, linked to gender.

PATIENTS AND METHODS

Pedigree of 26 families with at least 2 confirmed cases of AIS were studied in affected individuals, as well as the absence of scoliosis signs in healthy relatives. The prevalence of AIS was calculated after correction for bias. The transmission was first analyzed globally, then according to the gender of the affected parents and children.

RESULTS

26 families were included, consisting of 94 patients affected with AIS, adjusted to 66 patients and 160 healthy relatives in the analysis corrected by the proband method, for a prevalence of 29.2%. The transmission of AIS was higher to daughters (49%) than to sons (17%) of affected parent, suggesting a Carter effect (differential transmission according to the gender). Moreover, out of 66 AIS patients in the proband-adjusted analysis, 49 (74.2%) were female and 17 (25.8%) male (ratio = 3), demonstrating the higher penetrance in female for familial AIS.

DISCUSSION

This study underlines an autosomic dominant mode of inheritance in familial idiopathic scoliosis, with an incomplete penetrance (transmission rate <50%). Clinicians should be aware of a specific form of familial AIS, to counsel families.

LEVEL OF EVIDENCE

IV; Prognostic study.

3D Sagittal Parameters Can Guide the Indications for Anterior Release in Thoracic AIS ≥70°

Study DesignRetrospective, multicenter.ObjectivesThis study aims to evaluate the immediate postoperative effect of, and define indications for, an anterior release (discectomy) in large AIS curves utilizing 3D deformity analysis.MethodsA multicenter registry was queried for AIS patients with main thoracic curves ≥70° treated with either anterior/posterior (AP) or posterior-only surgery and biplanar stereoradiographic pre-operative and first-erect (FE) postoperative images. Standard 2D radiographic and 3D parameters were analyzed using custom MATLAB software. 3D thoracic kyphosis (3DTK) was calculated by removing the error induced by axial rotation and coronal deformity.Results109 patients were included, 21 AP and 88 posterior-only. The AP group had larger (89° vs 76°, P < .001), less flexible (9% vs 21%, P = .001) curves, though greater percent correction (79% vs 71%, P = .003), producing similar postoperative curve magnitude (19° vs 22°, P = 0.1). The AP group had less preoperative 3DTK (-15° vs -3°, P < .001), though similar postoperative 3DTK (24° vs 20°, P = .1), nearly double the improvement (39° vs 23°, P < .001). No cases with preoperative 3DTK < -18° achieved postoperative 3DTK >25° without anterior release. Segmental data of each motion segment demonstrated anterior release led to greater change in the coronal (P < .001) and sagittal (P = .003) planes, though not axial rotation of the apical vertebra (P = .157).ConclusionIn a cohort of AIS patients with thoracic curve magnitude >70°, 3D analysis comparing anterior/posterior vs posterior-only approach demonstrated improved correction in the coronal and sagittal, but not the axial plane. If 3DTK preop was <-18° only anterior release patients achieved postoperative 3DTK >25°.Level of EvidenceIII.

Three-dimensional markerless surface topography approach with convolutional neural networks for adolescent idiopathic scoliosis screening

Adolescent idiopathic scoliosis (AIS) is a three-dimensional lateral and torsional deformity of the spine, affecting up to 5% of the population. Traditional scoliosis screening methods exhibit limited accuracy, leading to unnecessary referrals and exposure to ionizing radiation from x-ray examinations. The 3D markerless surface topography (ST) technique quantifies trunk asymmetry and can be a potential scoliosis screening tool. However, differences in trunk asymmetry between individuals with scoliosis and those with a typically developing spine have yet to be thoroughly studied. Using the ST method, this study aims to distinguish adolescents with AIS from those with typically a developing spine. Participants aged 10 to 18 years, comprising of 285 individuals with confirmed AIS and 273 with typically developing spines, were included in the study (total scans including follow-ups: 693 for the AIS group and 298 for the control group). The positive for AIS group was identified through radiographic exams, specifically with curves ranging from 10° to 45°, while the negative (control) group qualified if their scoliometer test measured less than 7° and they had no known scoliosis diagnosis. The dataset comprised of surface torso scans captured either using stationary Minolta cameras or with the Structure sensor. ST analysis involved the reflection of the 3D geometry of the torso, aligning it with the original torso by minimizing the distance between corresponding points. Deviations between the original and reflected torso over the back surface and torso surface depth were mapped onto 102 × 102 grids. A convolutional neural network (CNN) was developed using deviations and depth (distance between the back surface and frontal plane) maps as inputs to classify the torso surface of typically developing adolescents and those with AIS. 10-fold cross-validation was applied during model development. 20% of the data was used as a holdout for final testing. Classification results of the proposed model were compared to the ground truth. The average training and validation accuracy across the ten folds was 100% and 94%, respectively. The classifications from the testing sets using the best performing model from the 10-fold cross-validation obtained accuracy, sensitivity, and specificity of 95%, 97%, and 90%, respectively. The positive likelihood ratio (PLR) of the testing set was 9.7. Likewise, a negative likelihood ratio (NLR) of 0.032 was also attained. The model sensitivity for detecting curves with Cobb greater than 25° was 99%. The sensitivity for detecting mild cases (Cobb < 25°) was 96%. The proposed CNN predictive model to detect AIS using ST showed excellent classification results. Markerless surface topography can serve as a dependable and non-invasive method for screening AIS.

Evaluation of Primary Correction and Its Influencing Factors in Adolescent Idiopathic Scoliosis After Treatment with the Charleston Bending Brace as the Sole Intervention

BACKGROUND

All-day braces are predominantly used for the conservative treatment of adolescent idiopathic scoliosis (AIS). The Charleston Bending Brace is a pure nighttime brace. The aim of this study was to investigate the primary in-brace correction of the main curve of AIS when treated with the Charleston Bending Brace. Specifically, the factors influencing major curve correction were examined.

METHODS

The retrospective analysis included 97 patients with AIS who were treated between October 2010 and September 2020. Patients with secondary scoliosis or orthotic pretreatment were excluded. Standardized radiographs were used to determine the Cobb angle of the major and minor curves. Curve correction in relation to Lenke's classification, the Risser stage, and rotation were assessed at four different time points (t0: before treatment, t1: 6-12 months, t2: 13-24 months, and t3: 25-36 months during treatment).

RESULTS

The average Cobb of the main curve at the beginning of the study was 25.7°. The night brace achieved excellent in-brace correction at t1, with nearly half of the patients (43%) showing a correction exceeding 80%. Curve localization, the Lenke type, and the Nash-Moe rotation significantly influenced initial in-brace curve correction at t1. At t2, there was also a significant in-brace correction of the initial Cobb by 93.0%. Similar improvements were observed at t3 for in-brace correction as well as without the brace (p < 0.031).

CONCLUSIONS

The results of the study revealed good primary in-brace correction of the main curve of the AIS with the nighttime brace, which was at least equivalent when compared to values from the literature for the Chêneau brace. Also, while restricted to medium-term results due to our study limitations, the percentage of correction in out-of-brace data of our patients was similar to weaned 24 h brace patients.

A deep learning model for radiological measurement of adolescent idiopathic scoliosis using biplanar radiographs

BACKGROUND

Accurate measurement of the spinal alignment parameters is crucial for diagnosing and evaluating adolescent idiopathic scoliosis (AIS). Manual measurement is subjective and time-consuming. The recently developed artificial intelligence models mainly focused on measuring the coronal Cobb angle (CA) and ignored the evaluation of the sagittal plane. We developed a deep-learning model that could automatically measure spinal alignment parameters in biplanar radiographs.

METHODS

In this study, our model adopted ResNet34 as the backbone network, mainly consisting of keypoint detection and CA measurement. A total of 600 biplane radiographs were collected from our hospital and randomly divided into train and test sets in a 3:1 ratio. Two senior spinal surgeons independently manually measured and analyzed spinal alignment and recorded the time taken. The reliabilities of automatic measurement were evaluated by comparing them with the gold standard, using mean absolute difference (MAD), intraclass correlation coefficient (ICC), simple linear regression, and Bland-Altman plots. The diagnosis performance of the model was evaluated through the receiver operating characteristic (ROC) curve and area under the curve (AUC). Severity classification and sagittal abnormalities classification were visualized using a confusion matrix.

RESULTS

Our AI model achieved the MAD of coronal and sagittal angle errors was 2.15° and 2.72°, and ICC was 0.985, 0.927. The simple linear regression showed a strong correction between all parameters and the gold standard (p < 0.001, r2 ≥ 0.686), the Bland-Altman plots showed that the mean difference of the model was within 2° and the automatic measurement time was 9.1 s. Our model demonstrated excellent diagnostic performance, with an accuracy of 97.2%, a sensitivity of 96.8%, a specificity of 97.6%, and an AUC of 0.972 (0.940-1.000).For severity classification, the overall accuracy was 94.5%. All accuracy of sagittal abnormalities classification was greater than 91.8%.

CONCLUSIONS

This deep learning model can accurately and automatically measure spinal alignment parameters with reliable results, significantly reducing diagnostic time, and might provide the potential to assist clinicians.

Reactive Balance in Adolescent Idiopathic Scoliosis: A Prospective Motion Analysis Study

Background/Objectives: Traditional fusion leads to a loss of spine mobility across the fused vertebrae. Vertebral body tethering (VBT) was developed with the goal of increasing flexibility and maintaining some spinal mobility. However, it is not known if the additional mobility leads to significant functional improvement. This prospective motion analysis study evaluates functional outcomes, specifically gait stability, in pre-operative, post-fusion, and post-VBT patients by using postural perturbations on a treadmill. Methods: Overall, 79 subjects underwent a computer-controlled treadmill study with postural perturbations, which simulated trips and slips. The subjects were harnessed for safety. Overall, 21 subjects were healthy controls, 18 patients were at least one-year post-VBT, 15 patients were at least one-year post-fusion, and 25 were pre-operative scoliosis patients. Subject weight, height, and treadmill acceleration were recorded and used to determine anteroposterior single (ASSTs, PSSTs) and multiple (AMSTs, PMSTs) stepping thresholds to describe the maximum torque a patient could withstand before failing to recover from the simulated trip. Independent t-tests were run to compare groups under the advice of a master statistician with expertise in orthopedic surgery. Results: Pre-operative scoliosis patients had lower PSSTs than healthy controls (uncorrected p = 0.036). No significant differences were observed between pre-operative and post-operative groups for both fusion and VBT. There was no significant difference in ASST, AMST, or PMST between any of the groups. Conclusions: The lower PSST in pre-operative scoliosis patients compared to healthy controls may reflect impaired reactive balance and potentially increased fall risk. Interestingly, there was no significant difference in reactive balance measures between pre-operative and post-operative scoliosis patients or between post-fusion and post-VBT patients.

Factors contributing to severe scoliosis after open chest surgery for congenital heart disease: a case-control analysis

PURPOSE

Previous reports have identified factors associated with open chest surgery for congenital heart disease (CHD) and scoliosis. However, these reports included conditions such as Down syndrome and Marfan syndrome, which involve both cardiac disease and scoliosis. The relationships between these factors and open chest surgery remain unclear. This study aimed to identify factors contributing to severe scoliosis in CHD patients who have undergone open chest surgery.

METHODS

Seventy-four post-CHD surgery patients with severe scoliosis (Scoliosis group) and 30 post-CHD surgery patients without scoliosis (NS group), excluding those with any syndrome or intellectual disability, were retrospectively analyzed. Patient background characteristics and radiographic parameters were compared between the NS and Scoliosis groups. Furthermore, the patients in the Scoliosis group were classified into three categories, namely, mild scoliosis, moderate scoliosis, and severe scoliosis, and the results were compared among the four groups.

RESULTS

Eighteen patients in the NS group and 63 in the Scoliosis group met the inclusion criteria. Compared with the NS group, the Scoliosis group included significantly more girls and patients who had younger ages at first CHD surgery and multiple open chest surgeries. Severe scoliosis progression was observed in patients who underwent multiple surgeries for severe CHD with cardiomegaly.

CONCLUSIONS

Progression to severe scoliosis was noted in patients with younger ages at first CHD surgery and those who underwent multiple surgeries for severe CHD. Assessing spinal deformities should be a key aspect of postoperative care for CHD, particularly in patients with severe CHD who are undergoing multiple chest surgeries.

LEVEL OF EVIDENCE

III.

A team approach to improve outcomes in pediatric scoliosis surgery: a review of the current literature

STUDY DESIGN

Review article.

OBJECTIVE

To review the literature on the effect of specialized pediatric spine teams on clinical outcomes.

RESULTS

Thirty-eight studies were identified in the review. There were 11 studies discussing the efficacy of the dual-surgeon strategy, 5 studies discussing the benefits of adult dedicated spine teams, 3 studies discussing the benefits of dedicated pediatric spine teams, 8 studies discussing the healthcare professional composition of multidisciplinary spine teams, and 20 studies discussing various clinical markers evaluating the efficacy of new team- or protocol-based interventions.

CONCLUSION

Pediatric spinal deformity surgery is a highly invasive procedure with room for intervention to minimize surgical complications and enhance patient outcomes. The use of standardized spine teams, comprising surgeons and various healthcare professionals from diverse disciplines, has proven to be an effective strategy for improving both quality and efficiency of care. Furthermore, implementing uniform protocols among these teams has led to reductions in surgical duration, hospitalization periods, and risks such as infections at the surgical site and excessive bleeding. Further studies are necessary to evaluate additional benefits that specialized pediatric spine teams can offer in terms of clinical outcomes.

Gut microbiota alterations in adolescent idiopathic scoliosis: a comparison study with healthy control and congenital scoliosis

PURPOSE

This study aims to compare the composition of GM isolated from individuals with AIS or congenital scoliosis (CS) and age-matched control (Ctr).

METHODS

A total of 48 patients with AIS, 24 patients with CS, and 31 healthy individuals were recruited as the discovery cohort, and 9 pairs of siblings where one was affected by AIS were recruited as the validation cohort. The GM profile was determined with 16S rRNA sequencing, and the alpha-diversity and beta-diversity metrics were performed with Mothur. Linear discriminant analysis (LDA) analysis was performed to identify the enriched species.

RESULTS

The α diversity (Chao1 index) was significantly lower in AIS patients with low BMI (< 18.5) than those with normal BMI. The PcoA analysis showed a trend of clustering of GM in AIS compared to that in Ctr and CS groups (r2 = 0.0553, p = 0.001). METASTAT analysis showed Cellulomonadaceae was significantly enriched in AIS groups compared to CS and Ctr. LDA analysis showed 9 enriched species in AIS patients. Compared to Ctr, two species including Hungatella genus and Bacteroides fragilis were significantly enriched, while the Firmicutes versus Bacteroidetes (F/B) ratio and the Ruminococcus genus were significantly decreased in AIS but not CS groups. The significantly reduced F/B ratio and Ruminococcus genus in AIS were replicated in the validation cohort.

CONCLUSIONS

Our study elucidated an association between low BMI and GM diversity in AIS patients. The reduced F/B ratio and Ruminococcus genus in AIS patients were identified and validated in 9 pairs of AIS patients and their unaffected siblings. Our pilot results may help understand the anthropometric discrepancy in these patients and support a possible role of GM in the pathogenesis of AIS.

Anatomical landmark detection on bi-planar radiographs for predicting spinopelvic parameters

INTRODUCTION

Accurate landmark detection is essential for precise analysis of anatomical structures, supporting diagnosis, treatment planning, and monitoring in patients with spinal deformities. Conventional methods rely on laborious landmark identification by medical experts, which motivates automation. The proposed deep learning pipeline processes bi-planar radiographs to determine spinopelvic parameters and Cobb angles without manual supervision.

METHODS

The dataset used for training and evaluation consisted of 555 bi-planar radiographs from un-instrumented patients, which were manually annotated by medical professionals. The pipeline performed a pre-processing step to determine regions of interest, including the cervical spine, thoracolumbar spine, sacrum, and pelvis. For each ROI, a segmentation network was trained to identify vertebral bodies and pelvic landmarks. The U-Net architecture was trained on 455 bi-planar radiographs using binary cross-entropy loss. The post-processing algorithm determined spinal alignment and angular parameters based on the segmentation output. We evaluated the pipeline on a test set of 100 previously unseen bi-planar radiographs, using the mean absolute difference between annotated and predicted landmarks as the performance metric. The spinopelvic parameter predictions of the pipeline were compared to the measurements of two experienced medical professionals using intraclass correlation coefficient (ICC) and mean absolute deviation (MAD).

RESULTS

The pipeline was able to successfully predict the Cobb angles in 61% of all test cases and achieved mean absolute differences of 3.3° (3.6°) and averaged ICC of 0.88. For thoracic kyphosis, lumbar lordosis, sagittal vertical axis, sacral slope, pelvic tilt, and pelvic incidence, the pipeline produced reasonable outputs in 69%, 58%, 86%, 85%, 84%, and 84% of the cases. The MAD was 5.6° (7.8°), 4.7° (4.3°), 2.8 mm (3.0 mm), 4.5° (7.2°), 1.8° (1.8°), and 5.3° (7.7°), while the ICC was measured at 0.69, 0.82, 0.99, 0.61, 0.96, and 0.70, respectively.

CONCLUSION

Despite limitations in patients with severe pathologies and high BMI, the pipeline automatically predicted coronal and sagittal spinopelvic parameters, which has the potential to simplify clinical routines and large-scale retrospective data analysis.

Automated spinopelvic measurements on radiographs with artificial intelligence: a multi-reader study

PURPOSE

To develop an artificial intelligence (AI) algorithm for automated measurements of spinopelvic parameters on lateral radiographs and compare its performance to multiple experienced radiologists and surgeons.

METHODS

On lateral full-spine radiographs of 295 consecutive patients, a two-staged region-based convolutional neural network (R-CNN) was trained to detect anatomical landmarks and calculate thoracic kyphosis (TK), lumbar lordosis (LL), sacral slope (SS), and sagittal vertical axis (SVA). Performance was evaluated on 65 radiographs not used for training, which were measured independently by 6 readers (3 radiologists, 3 surgeons), and the median per measurement was set as the reference standard. Intraclass correlation coefficient (ICC), mean absolute error (MAE), and standard deviation (SD) were used for statistical analysis; while, ANOVA was used to search for significant differences between the AI and human readers.

RESULTS

Automatic measurements (AI) showed excellent correlation with the reference standard, with all ICCs within the range of the readers (TK: 0.92 [AI] vs. 0.85-0.96 [readers]; LL: 0.95 vs. 0.87-0.98; SS: 0.93 vs. 0.89-0.98; SVA: 1.00 vs. 0.99-1.00; all p < 0.001). Analysis of the MAE (± SD) revealed comparable results to the six readers (TK: 3.71° (± 4.24) [AI] v.s 1.86-5.88° (± 3.48-6.17) [readers]; LL: 4.53° ± 4.68 vs. 2.21-5.34° (± 2.60-7.38); SS: 4.56° (± 6.10) vs. 2.20-4.76° (± 3.15-7.37); SVA: 2.44 mm (± 3.93) vs. 1.22-2.79 mm (± 2.42-7.11)); while, ANOVA confirmed no significant difference between the errors of the AI and any human reader (all p > 0.05). Human reading time was on average 139 s per case (range: 86-231 s).

CONCLUSION

Our AI algorithm provides spinopelvic measurements accurate within the variability of experienced readers, but with the potential to save time and increase reproducibility.

Learning curve and long-term outcomes of minimally invasive correction and fusion for adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

This study sought to report the long-term outcomes of patients that underwent minimally invasive surgery (MIS) correction for Adolescent Idiopathic Scoliosis (AIS) in terms of radiographic, clinical, and patient-reported outcomes. Furthermore, we examined the learning curve of MIS technique over the course of 13 years. Both MIS and open techniques are used to surgically address AIS. MIS techniques are purported to preserve the midline spinal musculature and to decrease estimated blood loss (EBL) and hospital length of stay (LOS).

METHODS

Data were collected at a single tertiary care center of all consecutive AIS patients undergoing deformity surgery from January 2008 to October 2021. Demographic, clinical, and radiographic data were collected at various intervals. Descriptive and inferential analyses were conducted.

RESULTS

70 AIS patients were included in the study. Mean patient age was 16.2 years of which 95.7% were female, with a mean BMI of 21.7. The majority of the patients were Lenke type 1A (60%) followed by Lenke 1B (18.6%) with mean preop Cobb angle as 52.2°. The mean follow-up was approximately 6 years with 35.7% of our cohort meeting the long-term follow-up landmark (> 5 years, 2-11). The mean number of spinal levels treated was 9.3 with mean ASA score of 1.7. Overall, mean EBL was 151 cc with mean OR of 308 min. The mean LOS was 3.94 days with postop Day 1 as the initiation of ambulation. Overall, the percent correction at the last visit was significantly greater than preop (Cobb: 77.6%, p < 0.05). Mean loss of correction on follow-ups was less than 5º. The overall revision rate was 2.9%. At 2 years postop, 98.6% (69/70) of the patients achieved fusion with 100% (24/24) at 5 years, and 96% (24/25) beyond the 5-year mark. Surgeon's technical proficiency in performing MIS for the treatment of AIS corrections was achieved after 23 cases.

CONCLUSIONS

Based on our cohort's 2-11 year follow-up data, we conclude that MIS provides an effective treatment option for AIS reconstruction. Our study indicates that MIS can achieve adequate deformity correction and positive long-term clinical outcomes as indicated by Cobb angle, VAS, ODI, and SRS-22r scores during follow-ups. If the individual goals of AIS surgery can be achieved, consideration should be given to less-invasive techniques.

LEVEL OF EVIDENCE

IV.

Investigating the long-term outcomes and efficacy of surgical intervention in patients with adolescent idiopathic scoliosis and Cobb angles ranging between 40 and 50 degrees

PURPOSE

Patients with adolescent idiopathic scoliosis (AIS) are either managed with non-operative strategies or surgery depending on the severity of lateral curvature and impact on quality of life. However, supportive evidence for the appropriate treatment approach is lacking in AIS patients with Cobb angles between 40 and 50 degrees. Therefore, we investigated differences in long-term patient-centered outcomes in AIS patients with Cobb angles between 40 and 50 degrees who received either operative or non-operative management.

METHODS

A total of 919 patients aged 10-21 years old with adolescent idiopathic scoliosis and 40-50 degree Cobb angles were identified from the HARMS Study Group (HSG) registry and dichotomized based on operative or non-operative management. Baseline and 2 year follow-up SRS-22 scores from these patients were analyzed for significant differences between the total score values, domain values, and the magnitude of score change over time using multiple comparisons analyses. Multivariable regressions adjusting for age, body mass index, location of spinal deformity, and management strategy were also performed.

RESULTS

Operative versus non-operative strategy was significantly, independently associated with differences in SRS-22 total and domain scores over time (effect likelihood ratio test, p < 0.03 for all regressions). Operatively managed patients had significantly greater improvement in SRS-22 total and domain scores over the follow-up duration compared to non-operatively managed patients (p < 0.02 for all comparisons).

CONCLUSIONS

This preliminary analysis suggests that operatively managed patients may have had better long-term outcomes than non-operatively managed patients within this AIS subpopulation. These findings support the need for further prospective investigation to determine the optimal management strategy to improve evidence-based, patient-reported outcomes for AIS patients with Cobb angles between 40 and 50 degrees.

LEVEL OF EVIDENCE

Level III.

Persistence of Primitive Reflexes as Possible Predictive Factors for Progression, Prevention, and Early Rehabilitation Intervention in Idiopathic Scoliosis

Background and objectives: Idiopathic scoliosis is a three-dimensional spinal deformity characterized by a lateral curvature exceeding 10 degrees in the frontal plane accompanied by vertebral rotation in the transverse plane. Despite extensive research on genetic and neurological factors, its etiology is uncertain. This prospective observational study aims to investigate the relation between the primitive reflexes, specifically, the asymmetric tonic neck reflex (ATNR), symmetric tonic neck reflex (STNR), and spinal Galant reflex (SGR), which play key roles in early motor development and postural control and the severity of idiopathic scoliosis (measured via the Cobb angle and the Nash-Moe rotational quota. Additionally, the study evaluated whether the retention of primitive reflexes correlates with increased progression risk over 12 months of conservative treatment. Materials and Methods: Our study cohort included 162 patients, aged 7-19 years, diagnosed with idiopathic scoliosis, who underwent clinical examination and assessment of retained primitive reflexes using standardized grading systems. Results: A total of 162 patients (95 girls, 67 boys; mean age: 12.73 ± 2.74 years) met the inclusion criteria. In 73.5% of the cases, scoliosis was detected, with the majority occurring in the dorsal region (40.1%). The mean initial Cobb angle was 13.49° ± 7.14°, with no significant change after 12 months of conservative treatment (p = 0.584). Nash-Moe rotation scores were 1 in 52.5% and 2 in 22% of the cases. Retention of the following primitive reflexes were identified at baseline: Moro (19.1%), ATNR (38.3%), STNR (44.4%), and GSR (27.8%). GSR retention significantly correlated with the Cobb angle (p = 0.011; R = 0.233). All the reflex scores decreased significantly after 12 months, but no correlation existed between the retained reflexes and scoliosis progression. Patients with a history of quadrupedal locomotion had significantly lower ATNR (p = 0.002), STNR (p < 0.001), and GSR (p = 0.017) retention. Conclusions: These findings suggest that primitive reflex testing could serve as an early screening tool in scoliosis risk stratification, being a cost-effective, non-invasive instrument for identifying at-risk children before clinically significant deformity develops.

The True Cost of Late Presentation in Adolescent Idiopathic Scoliosis: A 5-Year Follow-up Study

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is the most prevalent pediatric spinal condition. During growth, moderate scoliosis is treated with a brace to minimize the risk of progression to the surgical range. However, a minority of patients meet brace indications, with a greater number presenting late, already appropriate for surgery. This study determines the treatment cost differential between brace candidates and late-presenting patients within a public health care setting.

METHODS

This is a retrospective review of 373 consecutive AIS patients seen for initial consultation in 2014 and followed for 5 years, with a cost-analysis of the 166 patients that either met brace indications (n=63) or presented late (n=103). Patients meeting the Scoliosis Research Society's brace indications presented with a coronal curve magnitude between 25 and 40 degrees inclusive and were skeletally immature with a Risser ≤2. Late-presenting patients had coronal curve magnitudes of ≥50 degrees (n=73) or were presented with coronal curve magnitudes of >40 degrees and were skeletally immature with Risser ≤2 (n=30). Total treatment cost was estimated for 3 scenarios: (1) use of predetermined cut points for treatment prescription, (2) real-world approximation reflecting actual, nuanced clinical decision-making, and (3) the ideal situation, such that all late patients were instead seen as brace candidates.

RESULTS

Each patient who was prescribed a brace and avoided progression to the surgical range saved $23,000 in treatment costs. Eliminating late presentation of AIS would save at least $2 to $3 million per year at a single institution.

CONCLUSION

Significant cost savings can be found by optimizing the number of patients treated with a brace and minimizing the number of patients that present late as likely surgical candidates. This study provides financial impetus for early AIS detection, decreasing the number of avoidable surgeries. Scoliosis screening recommendations in primary care should be re-examined, alongside the development of educational tools, equipping primary care providers, and youth and their caregivers with appropriate knowledge on how to identify AIS.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Sensitivity of intraoperative electrophysiological monitoring for scoliosis correction in identifying postoperative neurological deficits: a retrospective chart review of the Scoliosis Research Society morbidity and mortality database

BACKGROUND

Surgical intervention is the ultimate treatment for scoliosis, but iatrogenic spinal cord injury is one of the major concerns. Although intraoperative electrophysiological monitoring can aid in detecting and reducing postoperative neurological complications, its use is still controversial.

METHODS

A retrospective chart review of 6,577 scoliotic patients who underwent surgery for curve correction with a reported complication was conducted. Our dataset was sourced from the morbidity and mortality database of the Scoliosis Research Society spanning the period from 2013 to 2023. The sensitivity of intraoperative monitoring was evaluated.

RESULTS

Intraoperative monitoring was used in 60% of surgeries, while 26% of the reported complications in the study cohort were new postoperative neurologic deficits. The overall monitoring performance indicated a sensitivity of 45%. Neurogenic motor evoked potential showed the best outcomes among the individual monitoring methods. The highest sensitivity (60.4%) was achieved using four monitoring methods, demonstrating significantly better results than one, two, and three methods.

CONCLUSIONS

The monitoring practice benefits in distinguishing postoperative neurologic deficits within the scoliosis population. Employing four monitoring techniques yielded the most favourable outcomes.

Comparison of accuracy of pedicle screw placement for adolescent idiopathic scoliosis using freehand fluoroscopic, navigation, and robotic-assisted techniques - a systematic review and bayesian network meta-analysis

Adolescent idiopathic scoliosis (AIS) is a prevalent spinal deformity, often requiring surgical intervention. Posterior pedicle spine instrumentation, a common procedure for correcting AIS, can be performed using freehand fluoroscopic (FHF), navigation-assisted (NVA), or robotic-assisted (RBA) techniques for pedicle screw insertion. This study aimed to evaluate the accuracy and clinical outcomes of these techniques through a Bayesian network meta-analysis (BNMA) of 764 patients and 8,144 screws from twelve studies. Our findings suggest that RBA offers superior accuracy in pedicle screw placement compared to both FHF and NVA. However, RBA is associated with longer operative times. NVA, in contrast, provides a balanced approach by offering good accuracy with relatively shorter surgery times. No significant differences were observed in blood loss, Cobb angle correction, or hospital stay between the techniques. Additionally, no statistically significant differences were found between RBA and NVA in terms of operative duration or blood loss. These results have important clinical implications, indicating that RBA may be the preferred option for achieving high precision, particularly in complex cases, while NVA remains a viable alternative for quicker procedures. Further research is needed to assess the long-term outcomes, radiation exposure, and cost-effectiveness of these techniques in clinical practice.

Enhancing Orthotic Treatment for Scoliosis: Development of Body Pressure Mapping Knitwear with Integrated FBG Sensors

Bracing is a widely used conservative treatment for adolescent idiopathic scoliosis (AIS) patients, yet there is no consensus on the optimal amount of force applied. Although a number of different sensors have been developed to continuously monitor the applied pressure and force, they have several limitations, including inadequate overall force distribution and displacement. They also cause discomfort with limited wearability. In this study, body pressure mapping knitwear (BPMK) integrated with fourteen silicone-embedded fiber Bragg grating (FBG) sensors is developed to monitor immediate and overall changes in force during the bracing treatment. A wear trial of the BPMK is conducted by using a validated soft AIS mannequin, and prediction equations have been formulated for the FBG sensors at individual locations. The findings indicate that the measured forces are in good agreement with those obtained from clinical studies, with peak forces around the padding regions reaching approximately 2N. This was further validated by using finite element (FE) models. When comparing X-ray images, the estimated differences in Cobb angles were found to be 0.6° for the thoracic region and 2.1° for the lumbar region. This model is expected to provide valuable insights into optimal force application, thus minimizing the risk of injury and enhancing bracing compliance and efficacy. Ultimately, this innovative approach provides clinicians with data-driven insights for safer and more effective bracing applications, thus improving the quality of life of AIS patients.

Predicting Surgical and Non-surgical Curvature Correction by Radiographic Spinal Flexibility Assessments for Patients With Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic Review and Meta-analysis.

OBJECTIVES

This systematic review and meta-analysis aimed to: (1) synthesize the prevalent application ratios of 2 radiographic spinal flexibility assessment methods in AIS patients treated with PSF or bracing; and (2) quantitatively evaluate the accuracy of these methods in predicting post-intervention correction outcomes.

METHODS

A systematic search was conducted across 5 electronic databases: CINAHL, Embase, Ovid, PubMed, and Web of Science. Meta-analyses were performed to investigate the accuracy of the spinal flexibility rate in predicting the post-intervention correction rate in AIS patients treated with PSF surgery or bracing, using RevMan 5.4.1 software.

RESULTS

The results of 31 studies, involving 1868 AIS patients, showed that the side-bending method was utilized more frequently than the fulcrum-bending method in both treatments. Meanwhile, the spinal flexibility evaluated by the fulcrum-bending method may provide a more accurate prediction of post-surgical correction compared to the side-bending approach, particularly for main curves. For the bracing treatment, only a few studies have preliminarily reported good capability of the side-bending method in predicting the initial in-brace correction.

CONCLUSIONS

This review quantitatively assessed the clinical application ratio and effectiveness of side-bending and fulcrum-bending radiographs in predicting post-intervention curve corrections in AIS patients undergoing surgical or bracing treatments. The results of the current review supported to adopt the fulcrum-bending approach for AIS patients undergoing PSF surgery with main thoracic curves, and the side-bending approach for those with thoracolumbar/lumbar curves. For patients receiving bracing treatment, further research is still needed to confirm the clinical value of the side-bending method.

Does transitioning to a dual surgeon approach improve outcomes for posterior spinal fusion of adolescent idiopathic scoliosis and neuromuscular scoliosis?

STUDY DESIGN

Retrospective, chart review.

PURPOSE

Improvements in operative time, blood loss, and length of stay (LOS) when using a dual surgeon approach for the treatment of scoliosis have been suggested in the literature; however, the external validity of these findings has been debated. In this study, we examined the impact of transitioning from a single surgeon to a dual surgeon approach in the treatment of adolescent idiopathic scoliosis (AIS) and neuromuscular scoliosis (NMS) across non-contemporary periods at a single institution.

METHODS

Through a retrospective chart review we identified 208 adolescent patients who underwent spinal fusion for the treatment of AIS or NMS between November 2015 and January 2022. The 73 cases meeting inclusion criteria were analyzed for operative time, blood loss, pre-and post-operative Cobb angles, and hospital length of stay.

RESULTS

The dual surgeon AIS group was found to have a shorter hospital (3.6 vs. 5.2 days, p < 0.001) and ICU length of stay (0.3 vs. 3.7 days, p < 0.001), greater Cobb angle correction (35.6 vs. 23.3 degrees, p < 0.001), and lower transfusion requirement compared to the single surgeon AIS group (0.1 vs. 0.7 units, p = 0.003). Total operative time and estimated blood loss (EBL) were not significantly different. The dual surgeon NMS group only showed shorter ICU length of stay (2.9 vs. 9.1 days, p = 0.043).

CONCLUSIONS

Utilizing a dual surgeon approach for AIS patients could improve hospital and ICU length of stay, blood transfusion requirements, and Cobb angle correction without an increase in operative time.

LEVEL OF EVIDENCE

Level III, retrospective, comparative study.

Machine learning algorithms for predicting future curve using first and second visit data in female adolescent idiopathic scoliosis patients

PURPOSE

This study was designed to develop a machine learning (ML) model that predicts future Cobb angle in patients with adolescent idiopathic scoliosis (AIS) using minimal radiographs and simple questionnaires during the first and second visits.

METHODS

Our study focused on 887 female patients with AIS who were initially consulted at a specialized scoliosis center from July 2011 to February 2023. Patient data, including demographic and radiographic data based on anterior-posterior and lateral whole-spine radiographs, were collected at the first, second, and final visits. ML algorithms were employed to develop individual regression models for future Cobb angles of each curve type (proximal thoracic: PT, main thoracic: MT, and thoracolumbar/lumbar: TLL) using PyCaret in Python. Multiple models were explored and analyzed, with the selection of optimal models based on the coefficient of determination (R2) and median absolute error (MAE).

RESULTS

For the future curve of PT, MT, and TLL, the top-performing models exhibit R2 of 0.73, 0.63, and 0.61 and achieve MAE of 2.3°, 4.0°, and 4.2°.

CONCLUSIONS

The ML-based model using items commonly evaluated at the first and second visits accurately predicted future Cobb angles in female patients with AIS.

A noninvasive spinal device for measuring adolescent idiopathic scoliosis: validity, reliability, and factors influencing measurement difference

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is a common deformity, requiring regular screening and monitoring. While radiological measurements are considered the gold standard, X-ray exposure poses significant risks. A noninvasive spinal device offers a radiation-free alternative for measuring spinal curvature. This study evaluates the validity and reliability of its measurements and explores factors associated with measurement discrepancy.

METHODS

This study involved AIS patients in an outpatient setting from June to August 2023. Participants underwent device measurements to assess the scoliosis angle (SA) in the frontal plane, which were evaluated by two orthopedists and compared to radiological measurements (Cobb angle) from EOS images.

RESULTS

A total of 112 patients were included in the study. The Cobb angle measured on EOS images was 30.3°± 12.4°. The SA measurements by observer 1, observer 2, and their average were 25.5° ± 10.9°, 25.4° ± 10.3°, and 25.4° ± 9.9°, respectively. The reliability analysis showed good agreement between observers (ICC = 0.77) and within observers (ICCs of 0.81 and 0.86). The validity analysis showed a very strong correlation between the SA and Cobb angle (r = 0.76). Logistic regression analysis indicated that high BMI, great scoliosis magnitude, and large maximal vertebral rotation (MVR) were associated with measurement discrepancy. Multivariate linear regression formula was: Cobb angle = 0.83×SA + 0.55×TRA + 0.21×BMI.

CONCLUSION

This device measurement demonstrated good reliability and validity compared with radiological measurement, highlighting its safety and feasibility for screening and monitoring AIS progression. However, high BMI, great scoliosis magnitude, and large MVR were associated with measurement inaccuracy.

Which Method of the Radiologic Measurements of the Angle of Curvature in Idiopathic Scoliosis is the Most Reliable for an Inexperienced Researcher?

Aim

The aim of the examination was to determine which of the three measurement methods Cobb (CB), Ferguson (FR), and Centroid (CN) has the best repeatability and reliability when the measurements are made by inexperienced researchers.

Methods

Three researchers (from the student research group) measured the angle of spine curvature on X-rays of the entire spine in standing anteroposterior view in 50 patients with severe idiopathic scoliosis qualified for surgery. Cobb, Ferguson, and Centroid methods were used. One of the researchers repeated all examinations twice at 3-week intervals. The measurements were compared with each other using the intraclass correlation coefficient (ICC) method. Values less than 0.5 are indicative of poor reliability, values between 0.5 and 0.75 indicate moderate reliability, values between 0.75 and 0.9 indicate good reliability and values greater than 0.90 indicate excellent reliability.

Results

The ICC (inter-rater) between the researchers' measurements was 0.9387 for CB, 0.9169 for FR, and 0.9061 for CR. Whereas the ICC (intra-rater) between measurements taken by a single researcher was 0.9824 for CB, 0.9088 for FR, and 0.9546 for CR.

Conclusions

The above results show that Cobb angle measurement method is the most reliable for measuring the curvature angle of the spine for novice researchers. Although it seems to be difficult to measure, it provides the most repeatable results.

Organization of a Pediatric Scoliosis Surgery Task Force and Analysis of Clinical and Radiographic Outcomes

Objective  To demonstrate how a surgical task force can help provide access to surgical procedures for many patients waiting for surgery in the Brazilian Unified Health System (Sistema Único de Saúde - SUS, in Portuguese) waiting list. Methods  This is a retrospective cohort study involving 28 patients on the SUS waiting list included in a pediatric scoliosis surgery task force. We analyzed medical records, epidemiological data, and clinical and radiographic outcomes. Results  The data showed that the postoperative outcomes of curve correction and complications, such as infections, surgical wounds, pain, or other events, were consistent with the literature on the subject. Conclusion  Therefore, we believe a task force is critical for facilitating access to surgical procedures and restoring the quality of life of hundreds of patients.

Assessment of Adolescent and Parent Willingness to Participate in a Comparative Study of Scoliosis Braces

OBJECTIVE

Adolescents with idiopathic scoliosis (IS) are often prescribed an orthosis to prevent curve progression and avoid surgery. Standard-of-care scoliosis orthoses are designed for full-time (FT) wear, which can be burdensome for some patients. Nighttime (NT) hypercorrective scoliosis orthoses are another option that has a lower impact on daily life, however, additional research is needed to guide the prescription of NT orthoses. The aim of this study was to assess the willingness of patients with IS and their parents/guardians to enroll in a randomized controlled study on bracing in scoliosis.

METHODS

A cross-sectional study was conducted to survey adolescents with IS and their parents/guardians. Eligibility criteria for adolescent participants included: (1) diagnosis of IS, (2) no previous orthosis use, (3) currently seeing a provider for their scoliosis, and (4) able to communicate in English. Parent/guardian participants were the parent or guardian of an adolescent participant and were able to communicate in English. Separate online surveys were designed for adolescents and their parents/guardians. Surveys provided information about a hypothetical study and queried respondents about whether they would participate in the study, their willingness to randomize brace treatment, and their preferences for NT or FT bracing. Descriptive statistics were used to summarize survey data.

RESULTS

One hundred four adolescent/parent dyads completed the survey (104 adolescents and 103 parents). Most participants (adolescents: 55.8%, parents: 55.3%) indicated an interest in study participation, and approximately one-third of participants (adolescents: 31.8%, parents: 30.1%) reported that they would be willing to randomize to brace type. Most participants (adolescent: 77.0%, parent: 81.6%) preferred the NT brace if they needed brace treatment.

CONCLUSIONS

High-quality evidence is needed to inform the use of FT and NT scoliosis orthoses. Approximately a third of respondents would enroll in a randomized trial, indicating that multiple collaborative sites will be needed to recruit a sufficient sample into a randomized study on scoliosis bracing. Study findings also demonstrate support from adolescents and their parents/guardians for research on scoliosis bracing.

Timeline of curve progression around menarche in small adolescent idiopathic scoliosis curves without influence of braces: a single-center longitudinal cohort study of 1,090 patients

BACKGROUND CONTEXT

Menarche is widely recognized as one of the prognostic factors for curve progression in patients with adolescent idiopathic scoliosis (AIS). However, few studies focus on the relationship between small AIS curves without brace treatment and menarche, presenting a challenge to building further evidence.

PURPOSE

This study aims to investigate the chronological changes in curve progression and risk of final brace initiation around menarche in small AIS curves under 25°.

STUDY DESIGN

This was a retrospective cohort study.

PATIENT SAMPLE

We longitudinally examined 1,090 AIS patients with a curve of less than 25° at the initial visit.

OUTCOME MEASURES

Patients were followed up until they achieved skeletal maturity or initiated brace treatment.

METHODS

Curve progression based on time from menarche was analyzed using a t-test. Receiver operating characteristic curve analysis was performed based on the time from menarche, with curve magnitude as the independent variable and the final initiation of brace treatment as the dependent variable.

RESULTS

Overall, 1,090 female patients were included, with a mean initial visit age of 12.9 years (standard deviation [SD]: 1.5) and a mean coronal Cobb angle of 17.5° (SD: 4.3). Curve progression was significantly decreased between 0-1 and 1-2 years post-menarche (0-1 year post-menarche: 2.9°/year vs. 1-2 years post-menarche: 1.3°/year; p=.03). After 2 years from menarche, the mean curve progression was less than 0.4°/year. The cut-off value of the curve magnitude for the final initiation of brace treatment at the timing of menarche was 20.5° (area under the curve: 0.89, p<.001, 95% confidence interval: 0.86-0.91).

CONCLUSIONS

This study highlights that in small AIS curves under 25°, minimal curve progression was observed after 2 years post-menarche, aiding follow-up strategies for AIS conservative treatment.

Feasibility of generating sagittal radiographs from coronal views using GAN-based deep learning framework in adolescent idiopathic scoliosis

BACKGROUND

Minimizing radiation exposure is crucial in monitoring adolescent idiopathic scoliosis (AIS). Generative adversarial networks (GANs) have emerged as valuable tools being able to generate high-quality synthetic images. This study explores the use of GANs to generate synthetic sagittal radiographs from coronal views in AIS patients.

METHODS

A dataset of 3,935 AIS patients who underwent spine and pelvis radiographic examinations using the EOS system, which simultaneously acquires coronal and sagittal images, was analyzed. The dataset was divided into training-set (85%, n = 3,356) and test-set (15%, n = 579). GAN model was trained to generate sagittal images from coronal views, with real sagittal views as reference standard. To assess accuracy, 100 subjects from the test-set were randomly selected for manual measurement of lumbar lordosis (LL), sacral slope (SS), pelvic incidence (PI), and sagittal vertical axis (SVA) by two radiologists in both synthetic and real images.

RESULTS

Sixty-nine synthetic images were considered assessable. The intraclass correlation coefficient ranged 0.93-0.99 for measurements in real images, and from 0.83 to 0.88 for synthetic images. Correlations between parameters of real and synthetic images were 0.52 (LL), 0.17 (SS), 0.18 (PI), and 0.74 (SVA). Measurement errors showed minimal correlation with scoliosis severity. Mean ± standard deviation absolute errors were 7 ± 7° (LL), 9 ± 7° (SS), 9 ± 8° (PI), and 1.1 ± 0.8 cm (SVA).

CONCLUSION

While the model generates sagittal images visually consistent with reference images, their quality is not sufficient for clinical parameter assessment, except for promising results in SVA.

RELEVANCE STATEMENT

AI can generate synthetic sagittal radiographs from coronal views to reduce radiation exposure in monitoring adolescent idiopathic scoliosis (AIS). However, while these synthetic images appear visually consistent with real ones, their quality remains insufficient for accurate clinical assessment.

KEY POINTS

AI can be exploited to generate synthetic sagittal radiographs from coronal views. Dataset of 3,935 subjects was used to train and test AI-model; spinal parameters from synthetic and real images were compared. Synthetic images were visually consistent with real ones, but quality was generally insufficient for accurate clinical assessment.

Deep learning based decision-making and outcome prediction for adolescent idiopathic scoliosis patients with posterior surgery

With the emergence of numerous classifications, surgical treatment for adolescent idiopathic scoliosis (AIS) can be guided more effectively. However, surgical decision-making and optimal strategies still lack standardization and personalized customization. Our study aims to devise proper deep learning (DL) models that incorporate key factors influencing surgical outcomes on the coronal plane in AIS patients to facilitate surgical decision-making and predict surgical results for AIS patients. A total of 425 AIS patients who underwent posterior spinal fixation were collected. Variables such as age, gender, preoperative and final follow-up horizontal and vertical coordinate vectors, and screw positioning data were preprocessed by parameterizing image data and transforming various data types into a unified, continuous high-dimensional feature space. Four deep learning models were designed, including Multi-Layer Perceptron model, Encoder-Decoder model, CNN-LSTM Attention model and Deep FM model. For the implementation of deep learning, 70% of the data was adopted for training and 30% for evaluation. The mean square error (MSE), mean absolute error (MAE) and curve fitting between the predicted and corresponding real postoperative spinal coordinates of the test set were adopted to validate and compare the efficacy of the DL models. A total of 425 patients with an average age of 14.60 ± 2.08 years, including 77 males and 348 females, were enrolled in this study. The Lenke type 1 and 5 AIS patients accounted for the majority of the included patients. The results showed that the Multi-Layer Perceptron model achieved the best performance among the four DL models, with a mean square error of 2.77 × 10-5 and an average absolute error of 0.00350 on the validation set. Moreover, the results predicted by the Multi-Layer Perceptron model closely matched the actual coordinate positions on the original postoperative images of patients with Lenke type 1 and AIS patients. Deep learning models can provide alternative and effective decision-making support for AIS patients undergoing surgery. Regarding the learning curve and data volume, the optimal DL models should be adjusted and refined to meet future demands.

Clinical and Topographic Screening for Scoliosis in Children Participating in Routine Sports: A Prevalence and Accuracy Study in a Spanish Population

Background: Idiopathic scoliosis (IS) is a common spinal deformity affecting 0.5% to 5.2% of children worldwide, with a higher reported range in Spain (0.7-7.5%). Early detection through screening is crucial to prevent the progression of mild cases to severe deformities. Clinical methods such as the ADAM test and trunk rotation angle (TRA) are widely used, but the development of three-dimensional (3D) surface topography (ST) technologies has opened new avenues for non-invasive screening. The objectives of this study were (1) to perform clinical and ST-based scoliosis screening in a sample of healthy children involved in club sports, (2) to estimate the agreement between clinical and ST screening methods, (3) to describe the prevalence of scoliosis by sport, sex, and age, and (4) to evaluate the diagnostic performance of both screening approaches using available radiographs as a reference standard. Methods: A total of 343 children (58.7% males, 41.3% females; mean age 11.69 ± 2.05 years) were screened using both clinical and ST methods. Clinical screening included the ADAM test and TRA measurement, while ST screening was performed using BackSCNR®, a markerless 3D scanning software. The children with positive screening results were recommended to obtain radiographs to confirm the diagnosis. Kappa agreement, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for both screening modalities using radiographic results as the gold standard. Results: The prevalence of scoliosis was 3.2% (n = 11) based on radiographic confirmation. The prevalence by sport was highest in swimming (17.6%), with minimal differences by sex (males 3.6%, females 2.5%). The clinical screening showed a sensitivity of 73%, specificity of 97%, PPV of 47%, NPV of 99%, and accuracy of 96%. The ST screening showed a sensitivity of 36%, specificity of 99%, PPV of 80%, NPV of 97%, and accuracy of 97%. The kappa values indicate a moderate influence of chance for both methods (clinical κ = 0.55; ST κ = 0.48). The balanced accuracy was 84% for the clinical screening and 68% for the ST screening. Conclusions: The clinical screening method showed superior sensitivity and balanced accuracy compared to ST screening. However, ST screening showed higher specificity and PPV, suggesting its potential as a complementary tool to reduce the high positive predictive value. These results highlight the importance of combining screening methods to improve the accuracy of the early detection of IS in physically active children, with the radiographic confirmation of the positive screened cases remaining essential for accurate diagnosis.

Intelligent measurement of adolescent idiopathic scoliosis x-ray coronal imaging parameters based on VB-Net neural network: a retrospective analysis of 2092 cases

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is a complex three-dimensional deformity, and up to now, there has been no literature reporting the analysis of a large sample of X-ray imaging parameters based on artificial intelligence (AI) for it. This study is based on the accurate and rapid measurement of x-ray coronal imaging parameters in AIS patients by AI, to explore the differences and correlations, and to further investigate the risk factors in different groups, so as to provide a theoretical basis for the diagnosis and surgical treatment of AIS.

METHODS

Retrospective analysis of 3192 patients aged 8-18 years who had a full-length orthopantomogram of the spine and were diagnosed with AIS at the First Affiliated Hospital of Zhengzhou University from January 2019 to March 2024. After screened 2092 cases were finally included. The uAI DR scoliosis analysis system with multi-resolution VB-Net convolution network architecture was used to measure CA, CBD, CV, RSH, T1 Tilt, PT, LLD, SS, AVT, and TS parameters. The results were organized and analyzed by using R Studio 4.2.3 software.

RESULTS

The differences in CA, CBD, CV, RSH, TI tilt, PT, LLD and SS were statistically significant between male and female genders (p < 0.05); Differences in CA, CBD, T1 Tilt, PT, SS, AVT and TS were statistically significant in patients with AIS of different severity (p < 0.001), and T1 Tilt, AVT, TS were risk factors; Differences in CA, CBD, CV, RSH, T1 Tilt, PT, LLD, SS, AVT and TS were statistically significant (p < 0.05) in patients with AIS of different curve types, and TS was a risk factor; Analyzing the correlation between parameters revealed a highly linear correlation between CV and RSH (r = 0.826, p < 0.001), and a significant linear correlation between CBD and TS, and PT and SS (r = 0.561, p < 0.001; r = 0.637, p < 0.001).

CONCLUSION

Measurements based on VB-Net neural network found that x-ray coronal imaging parameters varied among AIS patients with different curve types and severities. In clinical practice, it is recommended to consider the discrepancy in parameters to enable a more accurate diagnosis and a personalized treatment plan.

Predicting pediatric patient rehabilitation outcomes after spinal deformity surgery with artificial intelligence

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is the most common type of scoliosis, affecting 1-4% of adolescents. The Scoliosis Research Society-22R (SRS-22R), a health-related quality-of-life instrument for AIS, has allowed orthopedists to measure subjective patient outcomes before and after corrective surgery beyond objective radiographic measurements. However, research has revealed that there is no significant correlation between the correction rate in major radiographic parameters and improvements in patient-reported outcomes (PROs), making it difficult to incorporate PROs into personalized surgical planning.

METHODS

The objective of this study is to develop an artificial intelligence (AI)-enabled surgical planning and counseling support system for post-operative patient rehabilitation outcomes prediction in order to facilitate personalized AIS patient care. A unique multi-site cohort of 455 pediatric patients undergoing spinal fusion surgery at two Shriners Children's hospitals from 2010 is investigated in our analysis. In total, 171 pre-operative clinical features are used to train six machine-learning models for post-operative outcomes prediction. We further employ explainability analysis to quantify the contribution of pre-operative radiographic and questionnaire parameters in predicting patient surgical outcomes. Moreover, we enable responsible AI by calibrating model confidence for human intervention and mitigating health disparities for algorithm fairness.

RESULTS

The best prediction model achieves an area under receiver operating curve (AUROC) performance of 0.86, 0.85, and 0.83 for individual SRS-22R question response prediction over three-time horizons from pre-operation to 6-month, 1-year, and 2-year post-operation, respectively. Additionally, we demonstrate the efficacy of our proposed prediction method to predict other patient rehabilitation outcomes based on minimal clinically important differences (MCID) and correction rates across all three-time horizons.

CONCLUSIONS

Based on the relationship analysis, we suggest additional attention to sagittal parameters (e.g., lordosis, sagittal vertical axis) and patient self-image beyond major Cobb angles to improve surgical decision-making for AIS patients. In the age of personalized medicine, the proposed responsible AI-enabled clinical decision-support system may facilitate pre-operative counseling and shared decision-making within real-world clinical settings.