Selective Thoracolumbar/Lumbar Fusion in Adolescent Idiopathic Scoliosis: A Comprehensive Review of the Literature

In Adolescent Idiopathic Scoliosis (AIS), correction surgery can correct the maximum movement and balance of the spine. Under certain conditions for two simultaneous curvatures, the procedure, in which correcting one of the curvatures can result in the automatic correction of another curvature, is called selective fusion, attracting spine surgeons' interest because of more movement in the spine. However, the majority of surgeons have not used this technique due to the lack of sufficient information. The current study aimed to totally investigate selective thoracolumbar/lumbar fusion and to provide accurate information on outcomes and complications of surgery for spinal surgeons. This technique can also help spinal surgeons have a better selection of patients' surgical procedures.

Reliability and Validity of the Persian Version of the Body Image Disturbance Questionnaire-Scoliosis in Patients with Adolescent Idiopathic Scoliosis Who Did Not Have Surgical Indication

Background

Adolescent Idiopathic Scoliosis (AIS) is the most common spinal deformity disorder associated with bad posture and reduced quality of life. The Body Image Disturbance Questionnaire-Scoliosis (BIDQ-S) is a self-report instrument that assesses the concerns of scoliotic patients. This study aimed to translate and evaluate the reproducibility and internal consistency of the BIDQ-S in the Persian-speaking population worldwide suffering from AIS.

Methods

The BIDQ-S was translated into Persian by two native-speaking Iranian translators and back-translated into English by two native-English translators. The resulting back-translated English BIDQ-S was then sent to the authors of the English BIDQ-S questionnaire for validation. After translation, it was provided for 41 AIS patients from those who referred to the outpatient clinics of Shafa Yahyaian Hospital from January 2020 to January 2021. Patients were asked to complete the Persian BIDQ-S and Persian Scoliosis Research Society-22 (SRS-22) inventories. Internal consistency and reproducibility were assessed using Cronbach's alpha and interclass correlation coefficients (ICC), respectively. The validity of the questionnaire was evaluated by comparing the scores obtained on the Persian BIDQ-S (P-BIDQ-S) inventory with those obtained on the SRS-22 subscales.

Results

The consistency and reliability of the P- BIDQ-S inventory were confirmed by Cronbach's alpha of 0.856 and interclass correlation coefficients of 0.882. The P-BIDQ-S scores directly correlated with the level of education of patients (r=0.21, P=0.041). The correlation coefficient between the P-BIDQ-S inventory and the SRS-22 questionnaire was -0.56 (P=0.001). A significant correlation was also observed between the P-BIDQ-S items and all of the SRS-22 subscales (P<0.05).

Conclusion

The P-BIDQ-S inventory maintains adequate reliability, internal consistency, and reproducibility for the evaluation of Persian-speaking AIS patients.

Shoulder Imbalance in Adolescent Idiopathic Scoliosis: A Systematic Review of the Current State of the Art

Background

Shoulder imbalance (SI) is among the most rated manifestations of adolescent idiopathic scoliosis (AIS) pointed to by patients and spine surgeons. It serves as a criterion to assess the outcome of scoliosis surgery and is also a cause of dissatisfaction for the patients postoperatively. Despite the availability of multiple studies on this issue, a comprehensive survey of the risk factors and preventive measures has yet to be elucidated. The present study aimed to highlight the most recent approach to the evaluation and management of SI, as well as medical counseling about the expectations and limitations of the surgery.

Methods

A systematic literature review using electric databases was conducted, including PubMed, Embase, the Cochrane Library, and Google Scholar, with a well-defined search strategy on SI definition, risk factors, and preventive and surgical recommendations.

Results

A total of 69 articles were identified; SI > 2 cm was the most used cut-off, and its risk factors included the main thoracic Cobb angle > 80˚, preoperative level shoulder, high left shoulder, and higher Risser grade. The most stated strategies to preclude SI were the sufficient correction of the proximal thoracic curve, and moderate correction of the main thoracic and lumbar curve (LC).

Conclusion

Shoulder imbalance should be prevented not only for appearance or satisfaction but also for possible complications such as distal adding-on, new LC progression, or trunk shift postoperatively in AIS patients.

Validity and Reliability of an Adapted Persian Version of the Scoliosis Research Society-30 Questionnaire

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is a common type of spinal deformity confronting surgeons. The Scoliosis Research Society Health-Related Quality of Life (SRS-30) Questionnaire has been translated into Persian to evaluate its internal consistency, reliability, validity, and cross-cultural adaptability in the Persian population.

METHODS

The translation and cultural adaptation process was based on the American Academy of Orthopaedic Surgeons guidelines. A total of 102 AIS patients referring to our institution were enrolled in this study within March 2014-March 2016. The 36-item Short Form (SF-36) was used for adapting the Persian SRS-30 questionnaire. The convergent validity of the Persian SRS-30 was examined using the Pearson correlation coefficient. Furthermore, its internal consistency and validity were tested using Cronbach α with bootstrapped 95% confidence interval. Interclass Correlation Coefficient (ICC) was used to test and retest reliability.

RESULTS

The total correlation coefficient between the Persian SRS-30 and SF-36 was obtained at 0.74 (0.67-0.80), which was statistically significant (P=0.001). The total Cronbach α for the Persian SRS-30 was estimated at 0.84, ranging from 0.51 in satisfaction with management domains to 0.88 in mental health domains. The Persian SRS-30r domains indicated satisfactory test-retest reliability with ICC rage of 0.79-0.87.

CONCLUSION

The Persian SRS-30 translation was reliable and valid for the AIS Iranian patients. The internal consistency of this instrument was found to be good and excellent in all domains except satisfaction with management, which was moderate. The authors believe that the Persian version of SRS-30 is simple and easy to use and now it can be applied in clinical settings for future outcome studies in Iran.

Osteoid Osteoma of Odontoid: Case Report and Literature Review

Osteoid osteoma (OO) is a small tumor of bone that affects the spine in 10% of the cases. The tumor has a tendency to neural arc, and the lumbar spine is the most common site of presentation. Lesions of the odontoid process are very rare. We presented the case of a 20-year-old man who had cervical pain for 8 months. The pain responded to medical therapy. After investigation, there was a lytic lesion at the odontoid process with the characteristic features of OO in computed tomography scan and magnetic resonance imaging. Firstly, medical treatment was initiated with the administration of nonsteroidal anti-inflammatory drugs; however, due to adverse effects and worsening of his pain, the patient underwent surgical treatment with intralesional curettage from the transoral approach. In addition, the posterior fusion of the first and second cervical vertebrae was performed. The pain disappeared, and the patient was symptom-free after one year of follow-up.

Complications of Fusionless Correction of Early Onset Scoliosis Using Dual Growing Rods

BACKGROUND

Growing rods are increasingly used for treatment of early onset scoliosis (EOS) worldwide. Beside promising outcomes, some authors are concerned about high rates of complications. In the current clinical trial, complications of EOS surgery using dual growing rods were investigated.

METHODS

Between June 2006 and February 2017, twenty-two consecutive patients with a coronal curve >45 degrees underwent serial surgical correction using dual growing rods at Shafa Orthopedic hospital, Tehran, I.R. Iran. The rods were secured using hooks or screws or both. The patients were followed for 5.2 ± 1.7 years on average. Wilcoxon test was utilized to compare the pre- and post-operative values. P < 0.05 was considered significant.

RESULTS

The scoliotic and kyphotic curves decreased significantly from 52 ± 24° to 38 ± 19° and from 78 ± 22° to 60 ± 17°, respectively (P < 0.001). Total rate of implant-related complications (IRCs) and surgical site complications (SSCs) were 54.5% (12 patients) and 22.7% (5 patients), respectively. Malpositioned pedicular screw was found in 2 patients.

CONCLUSION

EOS can be effectively corrected using dual growing rods, however, considerable rates of IRC are of concern (54.5%). It seems necessary to compare the efficacy and complication rate of newer devices with those of growing rods in future studies.

Long-term outcome of posterior spinal fusion for the correction of adolescent idiopathic scoliosis

Background

Adolescent idiopathic scoliosis (AIS) is the most common form of idiopathic scoliosis, and surgery is considered as one of the therapeutic options. However, it is associated with a variety of irreversible complications, in spite of the benefits it provides. Here, we evaluated the long-term outcome of posterior spinal fusion (PSF) of AIS to shed more light on the consequences of this surgery.

Methods

In a cross-sectional study, a total of 42 AIS patients who underwent PSF surgery were radiographically and clinically inspected for the potential post-operative complications. Radiographic assessments included the device failure, union status, and vertebral tilt below the site of fusion. Clinical outcomes were evaluated using the Oswestry disability index (ODI) and visual analogue scale (VAS).

Results

The mean age of the surgery was 14.4 ± 5.1 years. The mean follow-up of the patients was 5.6 ± 3.2 years. Complete union was observed in all patients, and no device failure was noticed. Pre- and post-operative vertebral tilt below the site of fusion were 11.12° ± 7.92° and 6.21° ± 5.73°, respectively (p < 0.001). The mean post-operative ODI was 16.7 ± 9.8. The mean post-operative VAS was 2.1 ± 0.7. ODI value was positively correlated with follow-up periods (p = 0.04, r = 0.471). New degenerative disc disease (DDD) was observed in 6 out of 37 (16%) patients.

Conclusion

In spite of the efficacy and safety of PSF surgery of AIS, it might result in irreversible complications such as DDD. Moreover, the amount of post-operative disability might increase over the time and should be discussed with the patients.

Epidemiology of the Upper Extremity Trauma in a Traumatic Center in Iran

<p><strong>INTRODUCTION: </strong>Orthopedic injuries are the most common types of traumatic injuries and present<strong> </strong>as fractures of the limbs, pelvis, and vertebrae or lesions in soft tissues, muscles, ligaments, and tendons. The upper limb fractures occur in distal radius and ulna, metacarpals, fingers, scapula, and carpal bones, Proximal, diaphysis, distal humerus, clavicle, proximal ulna and radio and distal humero and humero, radio, ulna, and metacarpo. The objective of this project was to accurately describe the occurrence of injuries of the upper extremity and the mechanisms of such injuries in a representative sample of Iranian population.</p><p><strong>METHOD: </strong>This prospective case series was performed on the patients admitted to Shafa Yahyaian Hospital through the emergency ward within 6 months. Patients’ demographic features, the information about the mechanism of injury in soft tissues, bones and joints which obtained using clinical examination and imaging techniques, also the findings during the surgery were recorded in the information form. All analyses were performed using SPSS software, version 21. The independent t test or Mann-Whitney test and the Chi-square test or Fisher’s exact test was used to compare the data. The results were significant at P&lt;0.05.</p><p><strong>RESULTS: </strong>This study was performed on 1287 patients with upper limb fracture. The male and<strong> </strong>female patients respectively comprised of 998 (77.5%) and 289 (22.5%) subjects. About 113 patients suffered injuries at shoulder joint or its surrounding bones. The most common traumatic mechanisms in this group included falls from the standing position (49.2%), direct hit (19.5%), and then falling down (12.58%). Humerus fractures were observed in 68 patients. There was a significant correlation between humerus fractures and the mechanisms (P=0.000). The patients with traumas around the elbow comprised of 182 individuals. Sex distribution of fractures around the elbow shows a significant correlation between sex and elbow fractures. Forearm fractures were observed in 233 patients, and there was a significant correlation between age groups and forearm fractures. Fractures around the wrist were observed in 333 patients<strong>.</strong> There was a significant correlation between patients with fractures around the wrist (36.88±23.81 years) and patients without fractures (30.84±18.99 years) around the wrist in terms of the mean age. Hand fractures were observed in 358 patients<strong>.</strong> There was a significant correlation between hand fractures and sex<strong>.</strong></p><p><strong>CONCLUSION: </strong>The result of the current study which shows the epidemiology of these injuries and how such injuries occur in this area can well help the healthcare planners to design preventive and therapeutic measures.</p>

Epidemiological Review of Relation between Gender and Traumatic Injuries in Hospitals in Iran

<p><strong>BACKGROUND:</strong> Orthopedic injury including fractures of limbs, hip or spine or the injuries of soft tissue, muscles, ligaments and tendons lesions are the most common traumatic injuries these days, and impose a significant material and spiritual cost to the communities every year. The aim of this study is to evaluate the relation between injuries and the mechanism of injuries and gender.</p><p><strong>METHODS:</strong> In these studies 2480 patients with mean age of 29.9±17.8 referred to Shafa Yahyaeian Hospital in Tehran, Iran were participated. Some information of patients has been recorded during April-October in 2013. Information includes demographic characteristics, the exact mechanism of injury, radiographic imaging, CT scan, MRI were recorded. The statistical analysis performed on data with t-test, Mann-Whitney and Chi-Square tests.</p><p><strong>RESULTS:</strong> From 685 patients with lower extremity fractures, 500 (73%) were male and 185 (27%) female. Also from 332 patients with soft tissue injuries, the males were 281 (84.5%) and 51 (15.5%) female. In this study no significant relation between gender and upper and lower extremity injuries were not seen (P=0.69). The most common mechanism of trauma in male patients were fall from standing position 34.8%, direct trauma 24.6%, motorcycle crash 10% and fall from height 7.9%. Also the most common mechanism of trauma in female patients was fall from standing position 54.2%, direct trauma 15.8% and falling from stairs 7.5%. There were no significant relation between sex and trauma mechanism in this study (P=0.00).</p><p><strong>CONCLUSIONS:</strong> According to the results the frequency of fractures and soft tissue injuries were higher in male than female. The main mechanisms of injury in both groups were fall from the standing position.</p>

Predictors of curve flexibility in adolescent idiopathic scoliosis: a retrospective study of 100 patients

Curve flexibility in adolescent idiopathic scoliosis (AIS) was one of the major concerns of spinal surgeons since the evolution of surgical correction techniques. In this respect, many tried to identify which criteria denote more rigid curve. In the present study, we aimed toward determining important factors influencing AIS curve flexibility on supine bending films. We assessed radiographs of 100 patients with AIS for direction of curves, number of involved vertebrae, apical vertebral translation and rotation, magnitude of main thoracic curve and T5-T12 kyphosis. Statistical analysis performed via stepwise linear regression model with these variables plus age and sex against flexibility index. According to regression analysis, there was a clear relationship between flexibility indexes (FI) and magnitude of main thoracic curve at all (P<0.001). When we consider flexible curves (FI>50%) against rigid curves, apical vertebral rotation was a major determinant of curve flexibility also (P<0.001). Adolescent idiopathic scoliosis curves with larger Cobb's angle and apical vertebral rotation show less flexibility on supine bending films.

Case report: a new surgical approach to cervical hyperlordosis

INTRODUCTION

Cervical hyperlordosis is a rare pediatric deformity leading to gaze and postural disturbances. The cornerstone of treatment consists of spinal manipulative therapy (SMT) combined with positional traction.

CASE PRESENTATION

We report a new surgical approach in a 7-year-old female patient suffering from stiff cervical hyperlordosis, desiring to correct forward head posture as well as gaze disturbance. The patient had a chief complaint of restricted range of motion of the neck for the past 4 years. Posture examination revealed several abnormalities, including apparent thoracic hump with shifting to right side, slight elevation of the right shoulder, with back pain. She also had difficulties performing her assignments. Radiological investigations revealed a 95˚ cervical lordosis and forward head posture (FHP) assessed by two separate measurements. There was no considerable response to conservative treatment, (which included 30 sessions of SMT combined with positional traction). Consequently, she underwent radical resection of cervical paraspinal muscles, followed by halo traction. She was discharged with a halo-vest. Specific instructions for home exercise were provided to the patient. Post-trial radiographs showed a reduction of cervical lordosis to 51˚ and a reduction in FHP of 73 mm. The symptoms were alleviated at the end of the treatment.

DISCUSSION

This new approach appeared to correct postural abnormalities, and had an obvious positive effect on the patient's chief complaint.

Comparison of harrington rod and cotrel-dubousset devices in surgical correction of adolescent idiopathic scoliosis

Background

Since the time of Paul Harrington numerous implants have been introduced for correction of scoliosis, but none are ideal. Newer devices are very expensive, and in our country some patients cannot afford them.

Objectives

The aim of this study was to compare the results of the Harrington rod (HR) device and the newer Cotrel-Dubousset (CD) device in treatment of adolescent idiopathic scoliosis (AIS).

Materials and Methods

A retrospective review assessed patients with AIS admitted for spinal curve correction treated with HR (n = 120) and CD devices (n = 138) between October 1988 to April 2001 at the Shafa Yahyaeian Hospital, Tehran, Iran. We extracted information from the patient’s file and radiographs before, after and two years post-operation.

Results

The mean age of patients was 16.7 ± 2.5 years. There was no statistically significant difference between the two groups regarding gender, age, curve before surgery, and percentage of flexibility. The mean curvature was 70 ± 20.7 in the HR and 64.81 ± 19.4 in the CD group before surgery (P = 0.09); and the mean curvature was 40 ± 16.3 and 26.58 ± 15.37 in HR and CD groups respectively after surgery (P = 0.156). The mean curvature was 47.2 ± 15.9 in HR and 31.2 ± 15.4 in CD groups at two years follow-up (P = 0.156).

Conclusions

Results of many studies have shown no significant impairment in long-term quality of life and function in patients treated with Harrington rods. According to previously performed studies and the current study, surgical correction with Harrington rods seem to be comparable with the newer more expensive CD device. Although there is no doubt that the preference is to use newer devices in view of some disadvantages of HR, but this does not preclude using it for patients that cannot afford the newer devices.

Preservation of thoracic kyphosis is critical to maintain lumbar lordosis in the surgical treatment of adolescent idiopathic scoliosis

Restoration of the sagittal alignment is one of the fundamental goals in scoliosis correction surgery. Having an increase in popularity of segmental spinal instrumentation, thoracic kyphosis (TK) is often sacrificed to achieve frontal and axial plane correction. Patients with a Lenke type 1 deformity underwent selective thoracic fusion (lowest instrumented vertebra of T12 or L1) using corrective segmental spinal instrumentation (Hook-Rod) and were followed up for 2 years. They were evaluated before and after operation for coronal and sagittal alignments using standing anteroposterior and lateral radiographs. There were 63 patients (21 male, 42 female) with a mean age of 15.8 ± 2.1 years included to this study. TK reduction had significant correlation (P≤0.001) with lumbar lordosis (LL) decrease at preoperative (r=0.47), immediately postoperative (r=0.37) and at 2-year follow-up (r=0.5). The decrease in LL after 2-years was less than decrease in TK (4.5 ± 8.5 vs 6 ± 10, respectively).

Results of Milwaukee and Boston braces with or without metal marker around pads in patients with idiopathic scoliosis

Bracing is the non-operative treatment of choice for adolescent idiopathic scoliosis (AIS) and careful application of pads on apical segment of curve is very important for correction. Control of pads` appropriate site in brace is not easy by clinical evaluation. Therefore, we decided to compare results of braces which for better control of pads by radiographs, metal marker inserted around pads with those without metal marker. We evaluated 215 consecutive cases (182 female, 33 male) of AIS with 342 major curves from 1993 to 2003. Mean initial age was, 13.2 ± 1.8 years (9-16) and mean duration of follow-up was, 16.1 ± 16.4 months (0-114) that treated by 4 type of brace; 89 with type 1(Milwaukee with metal pads), 87 with type 2 (Milwaukee with simple pads), 17 with type 3 (Boston with metal pads) and 22 with type 4(Boston with simple pads). Cobb angle recorded at 5 stages (initial, best, wean, stop and final follow-up). Mean initial Cobb was 36.2°, at stop stage, 35.2° and reached 38° at final follow-up. Overall, 21.3% improved, 42.2% were the same and 36.5% failed. Failure for braces type 1 to 4 were, 40.5%, 34%, 38% and 24% at final follow-up. A total of 59 patients (27.4%) underwent spinal fusion that for brace type 1 to 4 , was, 33, 21, 2 and 3 patients respectively. From 16 cases with initial Cobb of 50°, at follow-up, 12 were ≥50° or had spinal fusion. Correction of lumbar (P=0.008) and main thoracic curves (P=0.002) was better by Boston than Milwaukee, however, In general difference between 4 types of braces was not significant and metal marker had no significant effect on results. Two important predictors of brace failure were, initial curve magnitude and brace type, but using metal marker around pads had no effect in results. It seems that bracing did not alter the natural history of scoliosis in early Risser stages with large magnitude of initial curves. Insertion of metal marker around pads is easy and cheap way that facilitate control of pad sites well, so, we recommend to use.

The prevalence of distal junctional kyphosis following posterior instrumentation and arthrodesis for adolescent idiopathic scoliosis

Distal junctional kyphosis (DJK) is a radiographic finding in patients that undergo spinal instrumentation and fusion, since there is an abrupt transition between fixed and mobile spinal segments.The true incidence of DJK is variable in literature and seems that has a multifactorial etiology. A consecutive series of 130 patients (mean age 15.6 years) with adolescent idiopathic scoliosis who underwent posterior spinal fusion and instrumentation were evaluated by analyzing coronal and sagittal angulation and balance measurements from standing radiographs obtained pre-operatively, within 6 weeks post-operation, at two years postoperative and at the latest follow-up. There was 35 male and 95 female. The mean time of follow-up was 36 months. The incidence of DJK at latest follow-up was 6.9% (9 patients). In DJK group, distal junctional angle from pre-operative of -12.5° lordosis (-30 to 0) reached to -5.5° (P=0.015) at 6 weeks postoperation and to -1.4° (-20 to 12°) (P=0.000) at 2 years follow-up,with mean of 12.1° kyphotic change (10-20°). In non DJK group, distal junctional angle from pre-operative angle of -7.5° reached -8.1° at 2 years follow-up (P=0.43). The mean age of DJK group at surgery was 17 years and for non-DJK group was 15.4 years (P=0.022). Distal junctional kyphosis was less common in this study than previous reports and stabilized after two years. The magnitude of coronal cobb angles or multiplicity of coronal curves had no effect in developing DJK that may be prevented by incorporation of the first lordotic disc into the fusion construct.

Radiographic outcome of surgical treatment of adolescent idiopathic scoliosis in males versus females

BACKGROUND

Studies on adolescent idiopathic scoliosis have well documented the differences between natural history of male and female patients. There are also differences in responses to nonoperative treatment, but the results of operative treatment in male patients compared with females have not been widely reported. Only few studies had compared the outcomes of operative treatment between male and female patients with different results.

METHODS

We retrospectively reviewed the outcome of 150 (112 girls and 38 boys) consecutive patients with diagnosis of adolescent idiopathic scoliosis who were managed surgically between May 1996 and September 2005. Next, male radiographic parameters were compared with female ones pre- and postoperatively. Then, a subgroup of 38 matched girls was compared regarding the age, curve type, curve magnitude, and the instrumentation we used.

RESULTS

In comparing male patients with unmatched girls, the boys had greater mean age (17.3 +/- 2.3 vs. 16.3 +/- 2.9; p = 0.049), greater primary curve (71.4 +/- 21.3 degrees vs. 62.7 +/- 17.5 degrees ; p = 0.013), less flexibility (30.1 +/- 13.5% vs. 40.3 +/- 17.8%; p = 0.01), and less correction percentage (51.3 +/- 12.9% vs. 58.8 +/- 16.5%; p = 0/013). The loss of correction was comparable between the two groups. In the matched comparison, the flexibility in boys was less than girls (30.1 +/- 13.5% vs. 38.1 +/- 17.5%; p = 0.027). Also, the boys had a smaller correction percentage compared to the girls, but this finding was not statistically significant.

CONCLUSION

There was similar distribution curve pattern between male and female patients with AIS. Males had more rigid primary curves compared to females but a similar degree of postoperative scoliosis correction. Male AIS patients were older at the time of surgery. These preoperative gender differences, however; did not compromise the radiological outcomes of surgical treatment and the results were comparable between the genders.

Mycetismus in Hamadan, of west Iran

Mycetismus or mushroom poisoning is defined in Anisworth and Brisby's Dictionary of the Fungi as distress resulting from the consumption of a fungal organism. This is in contrast to mycotoxicosis where the fungus, usually a hyphomycete, acts on some foodstuff of humans or animals and alters it. The paper describes three incidents of poisoning by the mushroom Amanita virosa in the Hamadan region of Iran. Two poisoning incidents occurred in adults and one in a child. All patients were associated with severe gastrointestinal symptoms including profuse diarrhea, vomiting and intestinal pain. For identification of A. virosa, in addition to the case history and the symptoms, examination of kitchen waste was done and mushroom remains examined with 2% aqueous KOH, Melzer's reagent, using the identification keys of Bresinsky. Because this fungus is likely to be confused with edible mushrooms and mushroom hunting is a popular endeavor in some areas of the Hamadan region, it is important to educate people about the dangers involved.