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Study Design: Longitudinal., Objectives: To evaluate whether the rate of patients who report low health-related quality of life (HRQOL) scores at 2 years following surgical correction of adolescent idiopathic scoliosis (AIS) improves by 5 years postoperatively., Summary of Background Data: HRQOL scores are dependent upon a number of factors and even in instances of good surgical correction of a spinal deformity, are not guaranteed to be high postoperatively. Understanding how a low HRQOL score varies over the postoperative period can help surgeons more effectively counsel patients and temper expectations., Methods: A multicenter database was reviewed for patients with both 2 and 5-year follow-up after spinal fusion and instrumentation for AIS. From a cohort of 916 patients, 52 patients with low HRQOL scores at their 2-year follow-up were identified and reevaluated at 5-year follow-up. A low HRQOL outcome was defined as having SRS-22 domain or total scores less than 2 standard deviations below the mean score. Reoperations were also evaluated to determine if they were associated with HRQOL scores., Results: Of those patients with low SRS-22 HRQOL scores at 2 years postoperatively, improvements were seen in all SRS-22 domains and total scores at the 5-year time point. The greatest change was seen in the satisfaction category where 41 patients showed improvement. The rate of reoperations during this period did not significantly impact patient-reported outcomes., Conclusions: Having a low HRQOL score 2 years after surgery for AIS does not guarantee a low score 5 years after surgery. Promisingly, most patients demonstrate some improvement in all domains for patient-reported SRS-22 scores at 5-year compared to 2-year follow-up. Understanding the longer term postoperative evolution in patient-reported outcomes may help surgeons to effectively manage and counsel patients who are dissatisfied in the short term.Level of Evidence: 3., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective review of a prospective multicenter database., Objective: The aim of this study was to study the effects of thoracic kyphosis (TK) restoration in adolescent idiopathic scoliosis (AIS) Type 1 and 2 curves on postoperative thoracic volume (TV) and pulmonary function., Summary of Background Data: Surgical correction of AIS is advocated to preserve or improve pulmonary function, prevent progressive deformity and pain, and improve self-appearance. Restoration of sagittal and 3D alignment, particularly TK, has become increasingly emphasized in efforts to improve pulmonary function, TVs, sagittal balance, and prevent adjacent-segment degeneration and deformity., Methods: AIS patients 10 to 21years undergoing surgical correction of Lenke Type 1 and 2 curves with baseline, 1-erect-postoperative, and 5-year (5Y) postoperative visits including stereoradiographic assessment and pulmonary function tests (PFTs) were included. 3D-radiographic analysis was performed to assess spinal-alignment, chest-wall, and rib-cage dimensions at each time point. Outcome variables were analyzed between time points with one-way analysis of variance and between variables with linear regression analysis., Results: Thirty-nine patients (37 females, 14.4 ± 2.2 years) were included. 3D-spinal-alignment analyses demonstrated significant reduction in preoperative to first-erect thoracic and lumbar Cobb-angles, an increase in TK:T2-12 (19.67°-39.69°) and TK:T5-12 (9.47°-28.05°), and reduction in apical vertebral rotation (AVR) (P < 0.001 for all). Spinal-alignment remained stable from 1-erect to 5Y. 3D rib-cage analysis demonstrated small reductions in baseline to first-erect depth (145-139 mm), width (235-232 mm), and increase in height (219-230 mm, P < 0.01), but no significant change in volume (5161-5222 cm,P = 0.184). From 1-erect to 5Y, significant increases in depth, width, height, and volume (all P < 0.001) occurred. PFTs showed preoperative to 5Y improvement in first second of Forced Expiratory Volume (FEV1) (2.74-2.98 L, P = 0.005) and forced vital capacity (FVC) (3.23-3.47 L, P = 0.008); however, total lung capacity (TLC) did not change (P = 0.517). Percent-predicted TLC decreased (Pre: 101.3% to 5Y: 89.3%, P < 0.001); however, percent-predicted forced expiratory volume and FVC did not (P = 0.112 and P = 0.068)., Conclusion: Although TK increases, coronal-Cobb and AVR decrease postoperatively; these do not directly influence TV, which increases from 1-erect to 5Y due to growth, corresponding with increases in FEV1 and FVC at 5Y; however, surgical restoration of kyphosis does not directly improve pulmonary function., Level of Evidence: 3.

Study Design: Prospective cohort study., Objective: To prospectively compare radiographic, perioperative, and functional outcomes between anterior spinal instrumentation and fusion (ASIF) and posterior spinal instrumentation and fusion (PSIF) in Lenke 5C curves., Summary of Background Data: Historically, ASIF has been the treatment of choice for treatment of thoracolumbar adolescent idiopathic scoliosis. More recently, PSIF has gained popularity for its ease, versatility, and amount of correction achieved. Current literature lacks a prospective comparative analysis between these two approaches to better aid treating surgeons in decision making when treating Lenke 5C curves., Methods: A prospective, longitudinal multicenter adolescent idiopathic scoliosis database was used to identify 161 consecutive patients with Lenke 5C curves treated by ASIF with a dual rod system, or PSIF with a pedicle screw-rod construct. Pre- and 2-year postoperative radiographic data, Scoliosis Research Society outcome scores, and perioperative comparisons were made between the two approaches., Results: A total of 69 patients were treated with ASIF and 92 patients with PSIF. Curve extent, magnitude, stable, and end vertebrae distribution before surgery were similar between the two groups. At 2-year follow-up, there were no significant differences in percentage correction of the main curve (ASIF: 59.1%, PSIF: 59.6%), C7 decompensation (ASIF: -0.6 ± 1.2, PSIF: -0.3 ± 1.4 cm), length of hospital stay (ASIF: 5.6 days, PSIF: 5.7 days), postoperative day conversion to oral pain medication (ASIF: 3.2 days, PSIF: 3.2 days), and SRS outcome scores (P = 0.560) between the two groups. The number of levels fused was significantly lower in ASIF group (ASIF: 4.7, PSIF: 6.3; P < 0.001), but PSIF resulted in significantly less disc angulation below lowest instrumented vertebrae (ASIF: 3.4°, PSIF: 1.7°; P = 0.011), greater lumbar lordosis (P < 0.001), and greater % correction of lumbar prominence (P = 0.017)., Conclusion: The amount of correction achieved was similar between ASIF and PSIF. ASIF resulted in shorter fusions (average 1.6 levels) compared with PSIF. This was at the expense of increased disc angulation below the lowest instrumented vertebrae, less lumbar lordosis, and a lower % correction of the lumbar prominence than PSIF., Level of Evidence: 2.

Study Design: A prospective analysis., Objective: This study aims to 1) establish a baseline for the SRS-22 in South East Asia and 2) evaluate the influence of patient demographics on the SRS-22., Summary of Background Data: Previous studies have established a baseline for the SRS-22 in the US and described the impact of patient demographics. While the SRS-22 is used internationally, limited normative data are available., Methods: After approval from the local hospital and school board, 1200 adolescents (age 10-18 years) were asked to anonymously complete the SRS-22 in English. The following demographic factors were assessed: height, weight, age, gender, household income (range <$30K to >$200K), and household status (single/dual parent income). Participants with a prior spine history or active medical problems were excluded. Statistical analysis was done with a Pearson correlation followed by an analysis of variance (ANOVA)., Results: One thousand nineteen unaffected adolescents completed the SRS-22 (mean age 14.4 ± 1.6 years). Demographics were as follows: gender (42%F, 58%M), household status (640 single/379 dual), height (157 ± 12 cm), weight (46 ± 11.2 kg), body mass index (BMI; 18.5 ± 3.6). SRS-22 score for all patients and by gender: Mean [4.0 ± 0.4, (F)4.0 ± 0.4, (M)3.9 ± 0.4, P < 0.0001], Activity [3.9 ± 0.4, (F)4.0 ± 0.5, (M)3.9 ± 0.6], Pain [4.3 ± 0.6; (F)4.4 ± 0.6, (M)4.2 ± 0.7, P < 0.001], Image [3.9 ± 0.6, (F)3.9 ± 0.6, (M)3.9 ± 0.6], and Mental [3.7 ± 0.6, (F)3.8 ± 0.6, (M)3.7 ± 0.6, P < 0.001]. Male gender was associated with worse pain (-0.15), mental health (-0.11), and overall SRS-22 score (-0.11). Age was correlated with a worse image (r = -0.17, P = < 0.000), while higher BMI was associated with less pain (0.07/0.02)., Conclusion: Younger age, female gender, and higher BMI correlated with a better SRS-22 score. Income and household status did not affect SRS-22. These findings contrast data gathered in the US but should be considered in conjunction with the minimal clinically important difference (MCID). This study establishes the first normative baseline for the SRS-22 in SE Asia and analyzed the effect of demographics on the outcome score., Level of Evidence: 2.

Study Design: Cross-cultural adaptation and validation of the Body Image Disturbance Questionnaire-Scoliosis (BIDQ-S)., Objective: The aim of this study was to validate the Chinese version of BIDQ-S (C-BIDQ-S) in adolescent idiopathic scoliosis (AIS) patients in Mainland China., Summary of Background Data: A modified version of the Body Image Disturbance Questionnaire instrument has been validated in AIS patients (BIDQ-S) to assess the perception of spinal appearance and psychological disturbance. However, there is no culturally adapted, reliable, and validated BIDQ-S for the Chinese population., Method: The BIDQ-S was translated into simplified Chinese, and the cross-cultural adaptation of the original BIDQ-S was performed according to international guidelines. A total of 100 AIS patients were recruited into this study. Validation including reliability, internal consistency, and convergent validity was evaluated by comparing the C-BIDQ-S with Scoliosis Research Society (SRS)-22 and Spinal Appearance Questionnaire (SAQ) instruments. The relationship between C-BIDQ-S score and patient characteristics was also assessed., Results: Internal consistency for the C-BIDQ-S was satisfactory with a Cronbach alpha value of 0.877. The construct validity test demonstrated significant correlations between the C-BIDQ-S score and all SRS-22 domains as well as between the C-BIDQ-S score and most of SAQ domains. Although the C-BIDQ-S score was not correlated with age or BMI, patients with Cobb angle >40° presented a significantly higher (poorer) C-BIDQ-S score., Conclusion: The Simplified Chinese version of BIDQ-S showed good internal consistency, strong psychometric properties, and satisfactory reliability. This concise questionnaire is suitable for widespread use in Mainland China.

Study Design: This is a prospective, randomized, double-blinded comparison of tranexamic acid (TXA), epsilon aminocaproic acid (EACA), and placebo used intraoperatively in patients with adult spinal deformity., Objective: The purpose of this study was to provide high-quality evidence regarding the comparative efficacies of TXA, EACA, and placebo in reducing blood loss and transfusion requirements in patients undergoing posterior spinal fusion surgery., Summary of Background Data: Spine deformity surgery usually involves substantial blood loss. The antifibrinolytics TXA and EACA have been shown to improve hemostasis in large blood loss surgical procedures., Methods: Fifty-one patients undergoing posterior spinal fusion of at least 5 levels for correction of adult spinal deformity were randomized to 1 of 3 treatment groups. Primary outcome measures included intraoperative estimated blood loss, total loss, (estimated blood loss + postoperative blood loss), and transfusion rates., Results: Patients received TXA (n = 19), EACA (n = 19), or placebo (n = 13) in the operating room (mean ages: 60, 47, and 43 yr, respectively); TXA patients were significantly older and had larger estimated blood volumes than both other groups. Total losses were significantly reduced for EACA versus control, and there was a demonstrable but nonsignificant trend toward reduced intraoperative blood loss in both antifibrinolytic arms versus control. EACA had significant reductions in postoperative blood transfusions versus TXA., Conclusion: The findings in this study support the use of antifibrinolytics to reduce blood loss in posterior adult spinal deformity surgery., Level of Evidence: 1.

Study Design: A prospective multicenter study and retrospective chart review., Objective: To compare health-related quality of life (HRQOL) measures and sagittal deformity in operative Scheuermann kyphosis (SK), operative adolescent idiopathic scoliosis (AIS), and normal populations., Summary of Background Data: No study to date has evaluated patient reported HRQOL measures before surgery in operative patients with SK., Methods: HRQOL data were prospectively collected pretreatment for operative patients with SK using the SRS-22 outcomes instrument and visual analogue scale (VAS). Comparison was made with the SRS-22 from operative AIS and normal populations. Eighty-six patients with SK enrolled in the prospective study were compared with 184 patients with AIS from a prospective database and 31 normal controls. To study the correlation between T5-T12 kyphosis magnitude and SRS-22 score, patients with AIS and SK were pooled together to create a larger continuum of kyphosis. Analysis of covariance, Pearson correlation analysis, and Bonferroni pairwise comparisons were used to determine statistical differences between group demographics, HRQOL indicators, and radiographical variables., Results: Patients with SK had significantly lower scores in all domains of the SRS-22 than patients with AIS. Patients with SK with a thoracolumbar apex reported significantly lower mean scores in the pain domain than those with a thoracic apex. Significant negative correlations were found between all domains of the SRS-22 and T5-T12 kyphosis-the self-image domain demonstrated the highest correlation (r = 0.37). VAS score in the SK population correlated negatively to the pain, self-image, and mental health domains., Conclusion: Increasing sagittal plane deformity as a result of SK has a significant impact on HRQOL as determined by the SRS-22 outcome instrument. In this study, patients with SK reported significantly decreased (worse) scores in all subdomains of the SRS-22 compared with patients with AIS., Level of Evidence: 1.

Study Design: Prospective, consecutive, nonrandomized, multicenter study., Objective: The purpose of this study was to compare the outcomes of idiopathic scoliosis treatment for Lenke 1 curves with 3 treatment approaches., Summary of Background Data: Surgical treatment options for Lenke 1 or primary main thoracic curve pattern in adolescent idiopathic scoliosis include thoracoscopic anterior spinal fusion, open anterior spinal fusion, and posterior spinal fusion (PSF) and instrumentation procedures., Methods: This was a prospective, consecutive, nonrandomized, multicenter study of surgical correction in adolescent idiopathic scoliosis. Patients with Lenke type 1 curve patterns from 7 sites were enrolled in this minimum 2-year follow-up study. Changes in pre- to postoperative radiographs, pulmonary function tests, Scoliosis Research Society questionnaire scores, and trunk rotation measures were compared., Results: A total of 149 patients (age: 14.5 ± 2 yr) were included (91% follow-up at 2 yr). The 3 groups were similar preoperatively in thoracic and lumbar curve size. There were 55 patients with thoracoscopic anterior spinal fusion, 17 patients with open anterior spinal fusion, and 64 patients with PSF. The fusion included on average 3 to 4 more levels in PSF than the 2 anterior approaches (P ≤ 0.001). Surgical time tended to be greater in the anterior groups by approximately 2 to 3 hours; however, blood loss was greatest with PSF. At 2 years, all 3 approaches showed similar improvements in the thoracic Cobb angle, coronal balance, the lumbar Cobb angle, Scoliosis Research Society questionnaire scores, and trunk rotation measures. The PSF approach resulted in overall reduction in kyphosis compared with the anterior approaches. Postoperative hyperkyphosis was an issue only in the 2 anterior groups. Major complication rates were similar., Conclusion: All 3 approaches resulted in similarly satisfactory outcomes for the majority of patients with specific advantages to each technique. The patients with PSF had more levels fused, yet with the shortest operative time. The thoracoscopic anterior spinal fusion group had the smallest incisions and the lowest requirement for transfusion. The open anterior spinal fusion group had a modest loss of pulmonary function without any clear advantages compared with the other 2 groups., Level of Evidence: 2.

Study Design: Prospective, longitudinal cohort (nonrandomized)., Objective: To compare thoracoplasty (Th), direct vertebral body derotation (DVBD), and Th and DVBD with respect to correction of the rib prominence and Scoliosis Research Society (SRS) self-image scores in patients undergoing surgery for adolescent idiopathic scoliosis (AIS)., Summary of Background Data: Rib prominence correction is one of the main goals of AIS surgery. Th and DVBD are powerful tools for correction of the rib prominence; however, a paucity of literature exists comparing Th, DVBD, and Th and DVBD., Methods: A prospective longitudinal database was queried to identify patients with AIS who underwent a posterior spinal fusion with pedicle screws and 2 years of follow-up. A total of 326 patients were identified and divided into 3 groups: (1) Th alone (N = 47), (2) DVBD alone (N = 196), and (3) both Th and DVBD (N = 83). Patients were subdivided into categories on the basis of their preoperative inclinometer reading: (1) ≤9° (mild), (2) 10 to 15° (moderate), and (3) ≥ 16° (severe). Pre- and postoperative inclinometer readings and SRS self-image scores were compared using analysis of variance., Results: Overall, the groups were similar preoperatively except for the DVBD group having higher percentage of thoracic flexibility. The preoperative rib prominence values were Th = 13.2, DVBD = 14.0, and Th and DVBD = 12.9 (P = 0.27). Taken collectively, the postoperative 2-year inclinometer readings were similar for all 3 groups (Th = 5.2, DVBD = 7.0, Th and DVBD = 5.6; P = 0.66). However, the SRS-22 self-image scores were significantly better for patients having both Th and DVBD (Th = 3.37, DVBD = 3.44, Th and DVBD = 3.76; P < 0.01). When patients were stratified by severity of preoperative rib prominence, all patients with mild prominences achieved similar corrections, although SRS self-image scores were highest in the Th and DVBD group. In patients with larger rib prominences, the addition of Th was necessary for optimal rib prominence correction, but there was no difference in SRS-22 self-image scores., Conclusion: Our results suggest that Th alone, DVBD alone, or both Th and DVBD provide equivalent inclinometer results in patients with mild preoperative rib prominences (≤ 9°), but higher SRS-22 self-image scores are achieved using both Th and DVBD. For larger rib prominences, better inclinometer readings are achieved with Th, although SRS-22 self-image scores are comparable.

Study Design: A cross-sectional study., Objective: The purpose of this study was to assess intervertebral segmental and cumulative motion in the distal unfused segments of the spine in patients with adolescent idiopathic scoliosis after instrumentation as a function of the lowest instrumented level., Summary of Background Data: The implications of hyper- or hypomobility in the unfused segments of the spine after instrumentation are poorly understood. There is little research on changes in functional movement capabilities of the spine after thoracolumbar spinal fusion., Methods: Patients were prospectively offered inclusion into this institutional review board-approved cross-sectional study at their routine 2-, 3-, 4-, or 5-year postoperative visits at 1 of the 5 participating centers. Motion was assessed by standardized radiographs acquired in maximum right, left and forwarding bending positions. The intervertebral angles were measured via digital radiographic measuring software at each level from T12 to S1. The relationship of the vertebral segmental motion for each interspace to the lowest instrumented vertebrae was evaluated with an analysis of variance. The relationship between the cumulative preserved motion and each domain of the Scoliosis Research Society questionnaire were evaluated using a Pearson correlation coefficient., Results: The data for 100 patients are included. The lowest instrumented vertebrae ranged from T10 to L4. In lateral bending, an association was detected between the lowest fused vertebral level and the degree of motion at the distal unfused segments. With a more distal instrumented vertebrae, there was significantly greater L2-L3, L3-L4, and L4-L5 segment motion (P = 0.002, 0.009, and 0.001, respectively). A similar trend was noticed at L5-S1 level. In addition, the summed motion from L3 to S1 also increased with a more distal fusion (P = 0.001). Similar results were not found in forward bending. None of the domains of the Scoliosis Research Society questionnaire correlated with the preserved L3-S1 motion., Conclusion: In a group of postoperative patients with adolescent idiopathic scoliosis, evaluation of the distal unfused intervertebral motion showed that preservation of vertebral motion segments allowed greater distribution of functional motion across more levels. With each distal fusion level, motion was significantly increased at the L2-L3, L3-L4, and L4-L5 segmental levels in lateral bending. The relationship between the increased motion and subsequent disc degeneration with a more distal fusion is unknown, but suspected.

Study Design: Multicenter retrospective review of prospectively collected data., Objective: To determine the extent of rib deformity correction that can be expected with direct vertebral body derotation (DVBD) and investigate factors that may correlate with improved rib deformity correction., Summary of Background Data: DVBD is a powerful tool in the surgical correction of axial rotation in adolescent idiopathic scoliosis. The application of DVBD has decreased the use of thoracoplasty for cosmetic rib deformity correction, but the outcomes of DVBD without adjuvant thoracoplasty have not been well defined., Methods: A multicenter database was retrospectively queried to identify patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion with at least 2 years of follow-up and Lenke type 1 to 3 curves. All patients had undergone DVBD maneuvers during their surgery, and patients having undergone concurrent thoracoplasty were excluded from the study. The absolute change and percentage change from preoperative inclinometer readings were correlated with preoperative clinical and radiographic data., Results: A total of 148 patients fulfilled the inclusion criteria. The mean age was 14.7 ± 2.1 years with a mean primary thoracic curve of 55.3° ± 9.3°. The mean preoperative inclinometer reading was 14.8° ± 4.5°, which reduced to 7.5° ± 4.0° postoperatively. Patients had a mean improvement of 54% ± 29% in rib prominence using DVBD. We attempted to correlate 23 of the most commonly used preoperative clinical, radiographic, and operative measures with postoperative inclinometer improvement. Interestingly, none correlated with rib deformity correction, including preoperative rib deformity (P = 0.16), thoracic curve flexibility (P = 0.71), presence of osteotomies (P = 0.60), and thoracic curve magnitude (P = 0.78)., Conclusion: Utilizing DVBD, the surgeon can expect approximately 50% reduction in the rib deformity as assessed by inclinometer. This is irrespective of preoperative inclinometer measures, thoracic curve flexibility, and vertebral body rotation on standing and bending radiographs.

Study Design: Multicenter, retrospective study., Objective: To compare the outcomes of three surgical treatments for congenital spinal deformity due to a hemivertebra., Summary of Background Data: Congenital anomalies of the spine can cause significant and progressive scoliosis and kyphosis. Their management may be challenging and controversy remains over the "best" surgical treatment., Methods: A multicenter retrospective study of patients with congenital spinal deformity due to 1 or 2 level hemivertebra(e) was performed. The surgical treatments included hemiepiphysiodesis or in situ fusion (group 1), instrumented fusion without hemivertebra excision (group 2), or instrumented hemivertebra excision (group 3)., Results: Seventy-six patients with minimum 2-year follow-up were evaluated. The mean age was 8 years (range: 1-18). The hemivertebra were fully segmented, nonincarcerated (67%), incarcerated (1%), and semisegmented (32%). There were 65 patients with single hemivertebra and 11 patients with double hemivertebra. There were 14 (18.4%) group 1, 20 (26.3%) group 2, and 42 (55.3%) group 3 patients. Group 1 (37 ± 14°) and group 3 (35 ± 26°) patients had smaller preoperative curves than group 2 patients (55 ± 26°) (P < 0.01). Group 3 had better percent correction at 2 years than groups 1 and 2 (P < 0.001). Group 3 had shorter fusion (P = 0.001), less estimated blood loss (EBL, P = 0.03), and a trend toward shorter operative times than group 2 (P = 0.10). The overall complication rate for the entire group was 30% group 1 (23%), group 2 (17%), and group 3 (44%) (P = 0.09)., Conclusion: While hemivertebra resection for congenital scoliosis had a higher complication rate than either hemiepiphysiodesis/in situ fusion or instrumentated fusion without resection, posterior hemivertebra resection in younger patients resulted in better percent correction than the other two techniques.

Study Design: Prospective analysis., Objective: The purpose of this study was to: (1) evaluate the influence of variable demographic factors on the Scoliosis Research Society (SRS)-22 performance and (2) evaluate SRS-22 performance in normal adolescents without scoliosis to establish a comparative baseline for adolescent idiopathic scoliosis., Summary of Background Data: The SRS-22 instrument has been used widely to evaluate patients with scoliosis but no study has characterized how variable patient demographics in normal, unaffected individuals may influence SRS-22 scores., Methods: Healthy adolescents at a high school clinic and at referring pediatricians' private offices were asked to anonymously complete the SRS-22 instrument: 22 questions scaled 1-5 (highest). Additional questions assessed household income, race (white, Hispanic, African-American, other), gender, household status (single vs. dual parent), and body mass index. ANOVA and multivariate regression analyses were used to identify statistically significant factors (P < 0.05)., Results: Four hundred fifty unaffected adolescents completed the SRS-22 (62% female, 38% male; mean age 16 (range, 9.3-21.8), mean body mass index 22.8 (range, 13.5-47.5). Mean SRS-22 performance was 4.1 ± 0.5 (Activity: 4.0 ± 0.6; Pain: 4.3 ± 0.6; Image: 4.2 ± 0.6; Mental: 3.8 ± 0.8, Mean: 4.1 ± 0.5). Whites scored higher in the activity domain than Hispanic and other ethnicities, while African Americans scored higher in the pain domain than Hispanics (P < 0.05 for both). From the lowest income range to 125,000 dollars/yr, household income had a positive effect on the activity, image and mean SRS-22 score (P < 0.05 for all). Males scored higher than females in the mental health domain and mean SRS-22 (P < 0.0001). Dual parent versus single parent households had higher activity and mean SRS-22 scores (P < 0.005)., Conclusion: We report that male gender, dual parent household, white race and increased household income were predictive of higher SRS-22 scores in healthy adolescents without scoliosis. The impact of these factors represents a meaningful clinical difference in SRS-22 performance.

Study Design: Retrospective analysis of prospectively collected multicenter series., Objective: To evaluate the sagittal profile of surgically treated adolescent idiopathic scoliosis (AIS) patients., Summary of Background Data: With the increasing popularity of segmental pedicle screw spinal instrumentation, thoracic kyphosis (TK) is often sacrificed to achieve coronal and axial plane correction., Methods: Radiographs of AIS patients with a Lenke type 1 deformity and minimum 2-year follow-up after selective thoracic fusion (lowest instrumented vertebra of T11, T12, or L1) were evaluated. Changes in TK were correlated with changes in lumbar lordosis (LL). Patients were divided according to approach (open/thoracoscopic anterior vs. posterior). Analysis of variance was used to compare pre and postoperative radiographic measures., Results: Two hundred fifty-one patients (age: 14 +/- 2 years) were included. Sixty seven percentages of the patients had anterior surgery (97 open anterior, 71 thoracoscopic) and 33% (83 patients) had posterior spinal fusion. A decrease in postoperative TK was significantly correlated (P < or = 0.001) with a decrease in LL at first erect (r = 0.3), 1 year (r = 0.4) and 2 years (r = 0.4), independent of surgical approach. LL decreased significantly at the first erect regardless of approach (P = 0.003); however, at 2-year postoperative TK and LL were significantly decreased after a posterior approach (P < or = 0.001) when compared with an anterior approach that added kyphosis. The decrease in LL (5.6 degrees +/- 9.7 degrees) was nearly twice the decrease in TK (2.8 degrees +/- 11.4 degrees) in the posterior group at 2-years., Conclusion: Given that thoracic AIS is often associated with a preexisting reduction in TK, ideal surgical correction should address this deformity. Procedures which further reduce TK also reduce LL. It is unclear if the loss of LL from thoracic scoliosis correction will compound the loss of LL that occurs with age and lead to further decline in sagittal balance. With this concern, we recommend a posterior column lengthening and/or an anterior column shortening to achieve restoration of normal TK and maximal LL.

Study Design: Retrospective review., Objective: The purpose of this study was to assess the preoperative neurologic risk in a consecutive series of spinal deformity patients undergoing correction surgery at one institution., Summary of Background Data: During spinal deformity correction surgery, neurologic monitoring techniques are commonly applied to reduce the risk of neurologic deficits. While previous studies have demonstrated risk factors for neurologic changes in the setting of spinal surgery, these involved long time spans and heterogeneous patient populations., Methods: Of 301 cases performed over 1 year, 281 cases were monitorable. Patients were grouped according to diagnosis: neuromuscular (NM) scoliosis, Sagittal Plane deformity, and Scoliosis. Demographic and surgical data were collected for neurologically monitorable patients. Coronal and sagittal parameters were measured using digital images of radiographs. Neurologic status was measured with somatosensory-evoked potentials and/or motor-evoked potentials., Results: Primary NM scoliosis cases had the highest incidence of neurologic monitoring changes (NMC) (10%) while revision sagittal plane deformity had the second highest (9.8%). Sensitivity and specificity were both 100%. Overall incidence of neurologic deficit was 1.1%. Of the 13 NMCs patients, 3 patients had persistent neurologic deficit. Majority of NMCs occurred before deformity correction. In patients with NM scoliosis, NMCs increased with hybrid constructs with wires (P < 0.01). In patients with scoliosis, NMCs increased with increased body mass index, estimated blood loss, operative time, and postoperative coronal thoracolumbar curve magnitude (P < 0.04). In patients with primarily sagittal plane deformity, NMCs increased with preoperative proximal curve, postoperative proximal and thoracolumbar curves, and postoperative kyphosis and lordosis (P < 0.04)., Conclusion: Primary NM scoliosis and revision sagittal plane deformities appear to carry greatest incidence of NMCs during surgical intervention. Most observed NMCs did not result in a permanent neurologic deficit. Neuromonitoring should be assessed throughout the entire surgical procedure. This study may aid surgeons and patients to better assess neurologic risks related to spinal deformity surgery.

Study Design: Retrospective review., Objective: To compare the results of spinal fusion in patients with open triradiate cartilages (OTRC) and closed triradiate cartilages (CTRC)., Summary of Background Data: Patients with OTRC at the time of spinal fusion may be at increased risk of developing postoperative changes related to growth., Methods: From a database of patients with adolescent idiopathic scoliosis, we identified 44 patients with OTRC (mean age, 11.6 years) and 450 patients with CTRC (mean age, 15.6 years) and a minimum follow-up of 2 years. Patients in both groups were treated with anterior-only, posterior-only, or combined anterior and posterior spinal fusion; none had all-pedicle screw posterior instrumentation., Results: In the OTRC group, anterior or posterior instrumentation, but not the combined approach, resulted in a significant mean late increase in the main curve (4.4 degrees and 7.3 degrees vs. 0 degrees , respectively; P = 0.002), an approach-related difference not seen in the CTRC group. Significantly more OTRC patients had proximal levels added on after surgery than did CTRC patients (18% vs. 8%, respectively; P = 0.02), and there was a trend toward this phenomenon distally (29% vs. 19%, respectively; P = 0.10). Proximal and distal junctional kyphosis was not significantly different between the 2 groups. Reoperation rate was 11% and 7% for OTRC and CTRC patients, respectively. For the selectively fused Lenke 1C curves in OTRC and CTRC patients, there was a trend in the uninstrumented lumbar curve toward a smaller lumbar curve before surgery (36 degrees and 41 degrees , respectively; P = 0.07) and a larger curve after surgery (27 degrees and 24 degrees , respectively; P = 0.07)., Conclusion: Patients with scoliosis and OTRC have a greater risk of adding-on proximally and of loss of correction with anterior-only instrumentation; they may also have less predictable lumbar correction from selective thoracic fusion. However, after combined surgery, they have results similar to those of more skeletally mature patients.

Study Design: A retrospective chart review and radiographic analysis., Objective: To evaluate the association between thoracic hyperkyphosis and patient quality of life measures as determined by the Scoliosis Research Society (SRS) outcomes instrument., Summary of Background Data: Although validated outcomes questionnaires (e.g., Pediatric Outcomes Data Collection Instrument and SRS) have been used to evaluate patients with scoliosis, there has been little written about the effects of sagittal plane alignment on these functional outcome measurements., Methods: Data from the SRS outcomes instrument were collected from patients with thoracic hyperkyphosis as well as those with normal spinal alignment. A total of 50 patients with thoracic kyphosis >or=45 degrees were compared with 50 normal patients with thoracic kyphosis <45 degrees . Correlation analysis was performed to identify significant relationships between the magnitude of the major kyphotic curve and the 4 SRS outcome questionnaire domains (Total Pain, General Self-Image, General Function, and Activity). Lower SRS scores indicate an increase in symptoms., Results: The average age of the subjects was 14 +/- 4 years (range, 8-18 years). The thoracic kyphosis varied between 11 degrees and 95 degrees for all subjects. Significant negative correlations were found between kyphosis magnitude and the total pain, general self-image, general function, overall level of activity, and total SRS scores (P < 0.0001). Of the 4 domains, self-image had the highest correlation with kyphosis magnitude while activity had the lowest., Conclusion: These findings indicate that higher kyphosis magnitudes were associated with increased pain, lower self-image, and decreased function and activity. Patients with thoracic hyperkyphosis were significantly more symptomatic than normal subjects in all domains. The r values for this analysis of kyphosis (0.40-0.66), in fact were substantially greater than those previously reported for scoliosis magnitude versus SRS Questionnaire scores (0.16-0.26), suggesting this instrument may be even better suited for the evaluation of hyperkyphosis patients.

Study Design: Retrospective chart review and radiographic analysis., Objective: To determine if differences exist in the sagittal alignment of adolescent idiopathic scoliosis (AIS) patients with thoracic versus thoracolumbar curve patterns., Summary of Background Data: Relative anterior overgrowth has been suggested as the possible pathomechanism behind thoracic scoliosis. Given the proposed importance of the sagittal alignment on the development of AIS and the known association between pelvic parameters and sagittal alignment, the authors postulate that pelvic incidence may influence the location of vertebral column collapse associated with different AIS curve types., Methods: A multicenter surgical database was used to compare preoperative radiographic measurements between patients with primary thoracic curves (Lenke 1A, B), primary thoracolumbar curves (Lenke 5), and normal adolescents., Results: Pelvic incidence was significantly greater in both groups of AIS patients compared with normal adolescents. Patients in the primary thoracic curve group were found to have a significantly increased sacral slope and a decreased thoracic kyphosis relative to the control group. Patients in the primary thoracolumbar curve group had a significantly increased pelvic tilt; however, a relatively normal thoracic kyphosis, lumbar lordosis, and sacral slope compared with the respective control values., Conclusion: An increased pelvic incidence, associated with both thoracic and thoracolumbar curves when compared with the normal adolescent population, does not appear to be the potential determinant of the development of thoracic versus thoracolumbar scoliosis, but may be a risk factor for the development of adolescent idiopathic scoliosis. The theory of anterior overgrowth may be supported by the identification of thoracic hypokyphosis, despite an increased pelvic incidence and lumbar lordosis, in patients with thoracic scoliosis. The association between sagittal measurements and the etiology of thoracolumbar curve formation is less clear; however, regional anterior overgrowth in the lumbar spine may also be responsible for the deformity.

Study Design: The association of capping and fusion of the iliac apophysis, and closure of the proximal humerus and rib epiphyseal growth plates to the end of spinal growth, was evaluated in a cohort of patients with juvenile and adolescent idiopathic scoliosis., Objectives: To determine the association of closure of the proximal rib epiphysis growth plate, the proximal humeral epiphyseal growth plate, and capping (Risser 4), and fusion (Risser 5) of the iliac apophysis to growth cessation in patients with idiopathic scoliosis., Summary of Background Data: Accurate evaluation of remaining spinal growth is the basis of decision-making in skeletally immature patients with scoliosis. The ossification of the iliac apophysis (Risser sign) has been the main indicator used for making this determination. The accuracy of this sign has been called into question and may be supplemented with data from other growth centers., Methods: A total of 101 patients with juvenile or adolescent idiopathic scoliosis undergoing brace treatment were followed for a minimum of 2 years following termination of bracing. Serial height measurements and evaluation of iliac apophysis ossification, proximal humerus, and rib epiphysis growth center closure were performed for each patient., Results: The iliac apophysis capped (Risser 4) at a mean age of 14.9 years for girls and 16.0 years in boys. Seventy-six of the 101 patients (75.2%) had further growth after Risser 4 status. The mean growth was 1.75 cm in the girls and 2.46 cm in the boys. No growth occurred after iliac apophysis fusion (Risser 5) or closure of either the rib epiphysis or proximal humerus growth plates., Conclusions: Capping of the iliac apophysis is not the final indicator for the end of spinal growth. Other growth centers should be evaluated in conjunction with serial height measurements when making decisions on the management of the scoliosis patient.