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The aim of this study was to determine age-related changes and sex-specific differences in sagittal alignment, range of motion (ROM), and intervertebral disc height of the thoracolumbar spine in healthy subjects. Lateral neutral and flexion-extension radiographs of the thoracolumbar spine of 627 asymptomatic subjects (307 males and 320 females; average age, 49.6 ± 16.5 years) were evaluated. We included at least 50 males and 50 females in each decade of life between the 20s and the 70s. Intervertebral disc height from T10/T11 to L5/S1, local lordotic alignment, and ROM from T10-T11 to L5-S1 were measured. T10-L2 kyphosis and T12-S1 lordosis as well as flexion, extension, and total ROM were measured. T10-L2 kyphosis did not markedly change with age in subjects of either sex but a sudden increase was noted in the 70s females. T12-S1 lordosis increased with age in both sexes, except the 70s. Flexion, extension, and total ROM at T10-L2 and T12-S1 decreased with age in most subjects. The levels from L3-L4 to L5-S1 were conspicuous as mobile segments. Intervertebral disc height gradually increased from T10/T11 to L4/L5; the shortest was at T10/T11 and the longest at L3/L4 or L4/L5 in all subjects. Age-related decreases in intervertebral disc height were most prominent at L4/L5 in middle-aged and elderly individuals of both sexes. Normative values of sagittal alignment, ROM, and intervertebral disc height at each segmental level were established in both sexes and all age groups in healthy subjects., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

BACKGROUND This retrospective clinical study aimed to compare the efficacy of preoperative halo-gravity traction with postoperative halo-femoral traction after posterior spinal release in corrective surgery for patients with severe kyphoscoliosis. MATERIAL AND METHODS A retrospective clinical study included patients who underwent elective corrective surgery for severe kyphoscoliosis (N=60) between 2013 and 2015. Two patient groups were compared, the postoperative halo-femoral traction after posterior spinal release (R-HF) group (N=30) and the preoperative halo-gravity traction (HGT) group (N=30). Demographic and clinicopathological data included age, gender, Cobb angle, degree of spinal curvature, history of osteotomy, and etiological factors. Patients in the two study groups were matched. Postoperative surgical outcome was evaluated by the radiographic coronal Cobb angle, global kyphosis, coronal balance, and the sagittal vertical axis (SVA). Clinical outcome was assessed using the Scoliosis Research Society Outcomes Questionnaire (SRS-22). RESULTS The preoperative Cobb angle was similar between the R+HF group and the HGT group (123.5±12.7° vs. 123.1±14.1°; P=0.909). Following postoperative traction, a significantly higher correction rate was found in the R+HF group than the HGT group (31.8±7.8% vs. 19.3±12.9%; P=0.001). The postoperative correction rate in the R+HF group was significantly higher than the HGT group (44.7±7.8% vs. 39.0±12.8%; P=0.042). In both study groups, the postoperative SRS-22 scores were significantly improved with no statistical difference between the two groups, and no neurological complications occurred. CONCLUSIONS Patients with severe kyphoscoliosis who underwent postoperative halo-femoral traction after posterior spinal release achieved satisfactory radiographic correction.

Purpose: This study aims to describe the spinopelvic sagittal alignment in transfemoral amputees (TFAs) from a radiologic study of the spine with a postural approach to better understand the high prevalence of low back pain (LBP) in this population., Methods: TFAs underwent X-rays with 3-D reconstructions of the full spine and pelvis. Sagittal parameters were analyzed and compared to the literature. Differences between TFAs with and without LBP were also observed., Results: Twelve subjects have been prospectively included (TFA-LBP group (n = 5) and TFA-NoP group (n = 7)). Four of the five subjects of the TFA-LBP group and two of the seven in TFAs-NoP group had an imbalanced sagittal posture, especially regarding the T9-tilt, significantly higher in the TFA-LBP group than in the TFA-NoP (p = 0.046). Eight subjects (6 TFA-NoP and 2 TFA-LBP) had abnormal low value of thoracic kyphosis (TK). Moreover, the mean angle of TK in the TFA-NoP group was lower than in the TFA-LBP group (p = 0.0511)., Conclusion: In the considered sample, TFAs often present a sagittal imbalance. A low TK angle seems to be associated with the absence of LBP. It can be hypothesized that this compensatory mechanism of the sagittal imbalance is the most accessible in this population. This study emphasizes the importance of considering the sagittal balance of the pelvis and the spine in patients with a TFA to better understand the high prevalence of LBP in this population. It should be completed by the analysis of the spinopelvic balance and the lower limbs in 3D. These slides can be retrieved under Electronic Supplementary Material.

The static sagittal balance of the normal spine is a physiological alignment of the spine in the most efficient manner by the muscular forces. During gait, this balance is constantly thwarted by single-foot support. This analysis involves the study of parameters which are now well defined. The pelvic incidence is constant, and the sacral slope and the pelvic tilt are positional. The cervical parameters are the upper (O-C2) and lower cervical curvatures (C2-C7), the C7 slope, the spino-cranial angle and the vertical cervical offset. At the thoracic and lumbar level, they are, respectively, kyphosis and lordosis. The OD-HA (odontoid hip axis) angle is the most efficient parameter to analyse the global balance. The average values of these parameters are reported with the new 3D measurements by Le Huec et al. The relationship between these different parameters was analysed, and Roussouly proposed his classification of the different spine shape. Ageing makes it possible to show compensation mechanisms at three levels: spinal, pelvic and lower limbs. Understanding these different data allows for better planning of the surgical management of the patients. Global evaluation of the entire spine and the measurement of the aforementioned parameters allow to determine the extent of the correction to be performed during surgery. Taking these parameters into account also enables us to understand the complications involved in this type of surgery: transitional syndromes or junctional syndromes. Integration of these parameters into the study of gait is an area still under investigation. These slides can be retrieved under Electronic Supplementary Material .

Purpose: To clarify the relationship between sarcopenia and spinopelvic parameters., Methods: Among outpatients of spine surgery department, 126 patients (mean age 77.2 years. M/F = 71/55) were included. We diagnosed patients with sarcopenia using the diagnostic algorithm of the Asian Working Group for Sarcopenia. Spinopelvic parameters and the prevalence of spinopelvic mismatch (pelvic incidence minus lumbar lordosis ≥ 10°) were investigated and compared between patients with and without sarcopenia. Furthermore, we compared the spinopelvic parameters between the Sarcopenia and No Sarcopenia groups under each condition of spinopelvic match and mismatch., Results: The prevalence of sarcopenia in this study was 21.4%. Overall, the spinopelvic parameters except thoracic kyphosis (TK) (Sarcopenia: 34.7°, No Sarcopenia: 24.3°, p < 0.01) were not significantly different between the Sarcopenia and No Sarcopenia groups. Prevalence of patients with spinopelvic mismatch was also not significantly different between the Sarcopenia and No Sarcopenia groups (37.0% vs. 42.4%, p = 0.66). Among patients without spinopelvic mismatch, there was no spinopelvic parameter with a significant difference between the 2 groups. However, among patients with spinopelvic mismatch, sagittal vertebral axis (SVA) (115.7 mm vs. 58.7 mm, p < 0.01) and TK (36.6° vs. 21.3°, p < 0.01) of the Sarcopenia group were significantly larger than those of the No Sarcopenia group. Moreover, sarcopenia was independently related to a significant increase in SVA (β = 50.7, p < 0.01) and TK (β = 14.0, p < 0.01) in patients with spinopelvic mismatch, after adjustment for age., Conclusions: Sarcopenia is related to spinal sagittal imbalance because of insufficient compensation by flattening thoracic kyphosis in patients with spinopelvic mismatch. These slides can be retrieved under Electronic Supplementary Material.

Purpose: To present a novel technique for anterior instrumentation and reconstruction with PVCR for treatment of severe neglected congenital kyphosis through posterior approach., Methods: Between 2010 and 2014, all patients with severe congenital kyphosis more than 90° were included. PVCR augmented with anterior vertebral body instrumentation was done for all patients through the same posterior approach. Cobb angle of the main kyphosis and scoliosis curves, the global sagittal and coronal balance were measured preoperatively, postoperatively and at 2-year follow-up. The functional outcome was assessed using the SRS-22 questionnaire preoperatively and at 2-year follow-up., Results: Fourteen patients with mean age of 19.4 years were included. The mean follow-up period was 38 months. The mean number of resected vertebrae was 2.4 vertebrae per patient. The mean height of the anterior defect after resection was 6.4 cm. The mean preoperative local kyphosis angle was 104.6° that was corrected to a mean of 22.8° at 2-year follow-up. The sagittal vertical axis improved from 62.7 mm preoperatively to 21.4 mm at 2-year follow-up. The mean coronal Cobb angle was 71.2° preoperatively and 25.6° at 2-years follow-up. The mean coronal balance was 32.4 mm preoperatively and 13.6 mm at 2-year follow-up. All patients had significant improvement of the SRS-22 questionnaire at the last follow-up., Conclusion: Addition of anterior instrumentation to PVCR allows controlled gradual correction and more biomechanical stability. This technique should be preserved for high degrees of sagittal plane deformities. These slides can be retrieved under Electronic Supplementary Material.

Purpose: To determine the short-term effect of bracing of adolescent idiopathic scoliotic (AIS) patients on the relationships between spinopelvic parameters related to balance, by comparing their in and out-of-brace geometry and versus healthy subjects., Methods: Forty-two AIS patients (Cobb angle 29° ± 12°, ranging from 16° to 61°) with a prescription of orthotic treatment were included retrospectively and prospectively. They all underwent biplanar radiography and 3D reconstruction of the spine and pelvis before bracing as well as less than 9 months after bracing. Eighty-three age-matched healthy adolescents were also included as control group and underwent biplanar radiography and 3D reconstruction., Results: Sacral slope was higher in AIS than healthy patients (p = 0.005). Bracing induced large changes of pelvic tilt (between - 9° and 9°), although patients' sagittal spinopelvic alignment tended to remain within the normality corridors defined by the healthy patients. Patients had flatter backs compared to healthy subjects and bracing further reduced their spinal curves. The head tended to remain above the pelvis in-brace., Conclusion: Analysis of sagittal alignment from head to pelvis showed that bracing further flattened the patients' backs and induced large compensating reorientations of the pelvis. Sagittal balance should be included in the planning and evaluation of brace treatment, since it could play a role in its outcome. These slides can be retrieved under Electronic Supplementary Material.

OBJECTIVE To investigate whether hemivertebra subtype as determined via CT was associated with breed and Cobb angle (a measure of the degree of spinal curvature) in apparently neurologically normal French Bulldogs, English Bulldogs, and Pugs. ANIMALS Client-owned French Bulldogs (n = 58), English Bulldogs (30), and Pugs (12) with thoracic hemivertebrae that underwent CT for reasons unrelated to spinal disease. PROCEDURES CT scans of each dog were evaluated, and hemivertebrae were categorized by subtype (ventral aplasia, ventral hypoplasia, lateral aplasia, lateral hypoplasia, ventrolateral aplasia, ventrolateral hypoplasia, ventral and median aplasia, ventral and median hypoplasia, and symmetric hypoplasia). The Cobb angle was measured, and kyphosis was defined as a Cobb angle > 10°. Results were compared among breeds. RESULTS 243 hemivertebrae were identified in the French Bulldog group, 100 in the English Bulldog group, and 19 in the Pug group. Breed was significantly associated with hemivertebra subtype. Pugs were more likely than French and English Bulldogs to have ventral hypoplasia and less likely to have ventral and median hypoplasia. English Bulldogs were more likely than French Bulldogs to have ventral and median hypoplasia. Compared with other hemivertebra subtypes, ventral hypoplasia was associated with a greater Cobb angle and a higher likelihood of kyphosis. Pugs were more likely than the other 2 breeds to have kyphosis. CONCLUSIONS AND CLINICAL RELEVANCE Pugs had a different spectrum of hemivertebra subtypes than French and English Bulldogs in this study. Additional research is necessary to evaluate the clinical relevance of this finding.

Background Context: One of the characteristics of reported observations in adolescent idiopathic scoliosis (AIS) is that the thoracic spine is longer anteriorly than posteriorly, more pronounced around the apex than the transitional zones. This reversal of the normal kyphotic anatomy of the thoracic spine is related to questions of etiopathogenesis of AIS. The changes in the anatomy of the anterior column have been described rather in detail; however, the role of the posterior spinal column and the laminae has so far not been elucidated. If the posterior column exhibits a longitudinal growth disturbance, it could act as a tether, leading to a more or less normal anterior column with a deformed and shorter posterior aspect of the spine. So far, it has remained unclear whether this anterior-posterior length discrepancy is the result of relative anterior lengthening or relative posterior shortening, and which tissues (bone, disc, intervertebral soft tissue) are involved., Purpose: The present study aimed to compare the discrepancy of the anterior-posterior length of the spinal column in the "true" midsagittal plane of each vertebra in patients with idiopathic scoliosis versus controls, using three-dimensional computed tomography (CT) scans., Study Design/setting: This is a cross-sectional study., Patient Sample: The sample consisted of computed tomography scans of 80 patients with moderate to severe AIS (Cobb angle: 46°-109°) before scoliosis navigation surgery and 30 non-scoliotic age-matched controls., Outcome Measures: The height of the osseous and non-osseous structures from anterior to posterior in the "true" midsagittal plane has been determined: the anterior side of the vertebral body and disc, the posterior side of the vertebral body and disc, the lamina and interlaminar space and the spinous process and interspinous space, as well as the height ratios between the anterior column and posterior structures of the primary thoracic and lumbar AIS curves and corresponding levels in non-scoliotic controls., Methods: Semiautomatic software was used to reconstruct and measure the parameters in the true midsagittal plane of each vertebra and intervertebral structure that are rotated and tilted in a different way., Results: In AIS, the anterior height of the thoracic curve was 3.6±2.8% longer than the posterior height, 2.0±6.1% longer than the length along the laminae, and 8.7±7.1% longer than the length along the spinous processes, and this differed significantly from controls (-2.7±2.4%, -7.4±5.2%, and +0.7±7.8%; p<.001). The absolute height of the osseous parts did not differ significantly between AIS and controls in the midsagittal plane. In contrast, the intervertebral structures contributed significantly to the observed length discrepancies. In absolute lengths, the anterior side of the disc of the thoracic curve was higher in AIS (5.4±0.8 mm) than controls (4.8±1.0 mm; p<.001), whereas the interspinous space was smaller in AIS (12.3±1.4 mm vs. 14.0±1.6 mm; p<.001)., Conclusions: Based on this in vivo analysis, the true three-dimensional anterior-posterior length discrepancy of AIS curves was found to occur through both anterior column lengthening and posterior column shortening, with the facet joints functioning as the fulcrum. The vertebrae contribute partly to the anterior-posterior length discrepancy accompanied by more significant and possibly secondary increased anterior intervertebral discs height., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Study Design: This was a cross-sectional study., Objective: The aim of this study was to describe the spinopelvic alignment of subjects with Down syndrome (DS)., Summary of Background Data: Subjects with DS are known to suffer from a large prevalence of scoliosis. While scoliosis is known to significantly affect postural alignment, there are currently no studies on the spinopelvic alignment of subjects with DS., Materials and Methods: In total, 41 subjects (28 female subjects and 13 male subjects) with DS, age and sex-matched to 41 asymptomatic subjects, underwent biplanar x-rays with 3-dimensional reconstructions of their spines and pelvises, followed by measurement of commonly used spinopelvic sagittal and coronal alignment parameters. Subjects were then classified into one of Roussouly's 4 types of sagittal alignment. Alignment parameters and prevalence of alignment patterns were compared between the 2 groups., Results: Subjects with DS were found to be relatively hypokyphotic (T4-T12=-29.0 vs. -37.5 degrees; P<0.001) and hyperlordotic (L1-L5=53.8 vs. 44.3 degrees; P<0.001) with larger pelvic incidence (53.2 vs. 45.1 degrees; P<0.001), sacral slope (47.7 vs. 36.8 degrees; P<0.001), Cobb angle (10.2 vs. 8.0 degrees; P=0.005), and axial rotation of the apical vertebra (6.6 vs. 3.7 degrees; P<0.001) but had smaller pelvic tilt (4.9 vs. 8.1 degrees; P<0.001) compared with control subjects. Roussouly's type 4 was found to be the most frequent pattern in DS subjects (68.3% vs. 14.6%; P<0.001)., Conclusions: Subjects with DS were found to have a peculiar pattern of hypokyphosis, hyperlordosis, large pelvic incidence, and small pelvic tilt. The altered spinopelvic alignment found in DS could predispose these subjects to hip instability and osteoarthritis., Level of Evidence: Level III.

Purpose: The line of sight when whole-spine radiographs are taken has not been defined. In our 2012 health screening study (TOEI study), whole-spine radiographs were taken with the volunteers in the most relaxed position and with a horizontal gaze. However, in the TOEI 2014 study, a mirror was placed in front of their faces to unify their line of sight. To our knowledge, there are no reports on how the sagittal alignment changes when radiographs are taken using a mirror. The purpose of this study was to investigate how mirror placement impacted sagittal spinal alignment in whole-spine radiographs taken while standing., Methods: Volunteers who participated in both the TOEI 2012 and 2014 studies were recruited. Pelvic tilt (PT), lumbar lordosis (LL), thoracic kyphosis (TK), cervical lordosis (CL), slope of McGregor's line (McGS), and C7 sagittal vertical axis (C7 SVA) were examined using software., Results: Three hundred fifty-four volunteers (142 males, 212 females, average age in 2012: 72 years) whose radiographs were evaluated in both previous studies were enrolled. The average parameters of 2012 and 2014 were: PT: 18° and 21° (P < 0.01), LL: 40° and 40°, TK: 34° and 34°, CL: 13° and 23° (P < 0.01), McGS: 2° ± 11° and - 9° ± 8° (P < 0.01), and C7 SVA: 46 and 23 mm (P < 0.01), respectively. In the Levene test, the McGS variation in 2014 [95% confidence interval (CI) 0.9-3.4] was significantly smaller than that in 2012 (95% CI - 9.7 to - 8.0, P < 0.01)., Conclusion: The smaller McGS variation in the TOEI 2014 study suggested that mirror placement could standardize the head's position. These results showed that the mirror placement retroflexed cervical alignment and caused the head to lean backward. It is important that a mirror is placed to unify the line of sight.

Purpose: To investigate coronal plane trunk asymmetry (TA) and its association with sagittal postural alignment in healthy subjects before pubertal peak growth., Methods: In this cross-sectional baseline study, 1190 healthy pre-peak growth velocity subjects were included. Coronal plane TA was evaluated using back surface topography. Whole-body sagittal alignment (previously validated and objectively classified as neutral, sway-back or leaning-forward) and sagittal spinopelvic profile (trunk lean, lumbar lordosis, thoracic kyphosis, sacral inclination and length of the posteriorly inclined thoracolumbar segment) were determined, as were height, proportion of trunk to body length, body mass index, generalized joint laxity, and handedness., Results: Logistic regression analysis yielded overall sagittal posture class to be independently associated with coronal plane TA: having a leaning-forward posture associated with a nearly three times higher odds of coronal TA (p < 0.001) compared to neutrals. A sway-back was 2.2 times more likely to show TA (p = 0.016) than a neutral, yet only in boys. Significant associations with coronal TA were also found for trunk lean, thoracic kyphosis and body mass index. These correlations, however, were gender and posture class specific. The spinal region where asymmetry is seen, varies according to the whole-body sagittal alignment type: primary thoracic curves were the most frequent in leaning-forwards, whereas primary curves in the lumbar or declive thoracolumbar segment were the most common in sway-backs., Conclusions: In immature spines without known scoliosis, coronal plane TA is associated with whole-body sagittal alignment. It is more often seen in non-neutral than neutral sagittal posture types. Whether adolescent idiopathic scoliosis is related with postural characteristics before pubertal growth peak, should be addressed in future prospective studies.

Purpose: This study aims to establish normative data for parameters of spino-pelvic and spinal sagittal alignment, gender related differences and age-related changes in asymptomatic subjects., Methods: A total of 626 asymptomatic volunteers from Japanese population were enrolled in this study, including 50 subjects at least for each gender and each decade from 3rd to 8th. Full length, free-standing spine radiographs were obtained. Cervical lordosis (CL; C3-7), thoracic kyphosis (TK; T1-12), lumbar lordosis (LL; T12-S1), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS) and sagittal vertical axis (SVA) were measured., Results: The average values (degrees) are 4.1 ± 11.7 for CL, 36.0 ± 10.1 for TK, 49.7 ± 11.2 for LL, 53.7 ± 10.9 for PI, 14.5 ± 8.4 for PT, and 39.4 ± 8.0 for SS. Mean SVA is 3.1 ± 12.6 mm. Advancing age caused an increase in CL, PT and SVA, and a decrease in LL and SS. There was a significant gender difference in CL, TK, LL, PI, PT and SVA. From 7th decade to 8th decade, remarkable decrease of LL & TK and increase of PT were seen. A large increase of SVA was also seen between 60' and 70'., Conclusion: Standard values of spino-pelvic sagittal alignment were established in each gender and each decade from 20' to 70'. A remarkable change of spino-pelvic sagittal alignment was seen from 7th decade to 8th decade in asymptomatic subjects.

Objective: To study the difference of spino-pelvic sagittal alignment between lumbar disc herniation(LDH) and lumbar canal stenosis(LCS) in adults., Methods: The integrated imaging data of 88 patients with lumbar disc herniation (42 cases) or lumbar canal stenosis(46 cases) were searched from January 1, 2015 to September 10, 2016 in our hospital.Twenty-two cases were excluded because of age factor, 36 cases of LDH (LDH group) and 30 cases of LCS (LCS group) were internalized in the study. The spino-pelvic parameters were measured including pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), thoracic kyphosis (TK), thoracolumbar junction (TLJ), sagittal vertical axis (SVA), sagittal vertical axis location (SVA-Location), T₁-spinopelvic inclination (T₁-SPI), T9-spinopelvic inclination (T₉-SPI). Independent sample t test was used in order to analyze the above data., Results: Thoracic kyphosis (TK) in LDH group was smaller than that of LCS group (difference was about 6 degree), there was significant difference between two groups ( P =0.031). And there were no significant differences in other parameters between two groups ( P >0.05)., Conclusions: The patients with lumbar disc herniation, the kyphosis of the thoracic spine is smaller, the truncus prones to the straight. The lumbar kyphosis is greater in patients with lumbar spinal stenosis, and the sagittal curvature of the lumbar spine is more obvious., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose., (Copyright© 2018 by the China Journal of Orthopaedics and Traumatology Press.)

Background: Current assessment of spine growth for patients undergoing growth friendly surgical treatment for early-onset scoliosis (EOS) is the use of serial, 1-dimensional standard-of-care coronal vertical spine height (SoCVH) measurements. Any growth of the spine out of the coronal plane is missed by the SoCVH, which may underestimate the actual growth of the spine. This study set to validate the novel 3-dimensional true spine length (3DTSL) radiographic measurement technique for measuring growth of EOS patients., Methods: 3DTSL measurement accuracy, reliability, and repeatability was assessed using 10 physical model configurations. In addition, interrater and intrarater reliabilities (IRRs) were assessed using interclass coefficient (ICC) analyses of 23 retrospective EOS patient clinical radiographs. 3DTSL measurements were compared with SoCVH measurements., Results: The model assessment showed excellent accuracy with a mean error of 1.2 mm (SD=0.9; range, 0.0 to 3.0) and mean ICC of 0.999.IRR ICCs of the clinical radiographs averaged 0.952 for the 3DTSL and 0.975 for the vertical height whereas IRRs averaged 0.944 and 0.965, respectively (all P<0.001).Mean clinical 3DTSL curve lengths were 193.9 mm (SD=30.0; range, 142.8 to 276.8), whereas the SoCVH averaged 156.1 mm (SD=29.7; range, 74.7 to 207.3). The mean difference between the matched 3DTSL and SoCVH measurements was 37.8 mm (SD=21.4; range, 1.3 to 95.4) and was statistically significant (P<0.0001). On average, the 3DTSL of the measured spines was 124.2% of the measured SoCVH, with a progressive difference as the Cobb or kyphosis angles increased., Conclusions: The novel 3DTSL measurement is accurate, repeatable, and complements the current growth assessments for EOS treatments., Level of Evidence: Level II-diagnostic study-development of a diagnostic criteria on basis of consecutive patients, with gold standard.

A 6-month randomized controlled trial of spine-strengthening exercise and posture training reduced both radiographic and clinical measures of kyphosis. Participants receiving the intervention improved self-image and satisfaction with their appearance. Results suggest that spine-strengthening exercise and postural training may be an effective treatment option for older adults with hyperkyphosis., Introduction: The purpose of the present study is to determine in a randomized controlled trial whether spine-strengthening exercises improve Cobb angle of kyphosis in community-dwelling older adults., Methods: We recruited adults ≥60 years with kyphosis ≥40° and enrolled 99 participants (71 women, 28 men), mean age 70.6 ± 0.6 years, range 60-88, with baseline Cobb angle 57.4 ± 12.5°. The intervention included group spine-strengthening exercise and postural training, delivered by a physical therapist, 1-h, three times weekly for 6 months. Controls received four group health education meetings. The primary outcome was change in the gold standard Cobb angle of kyphosis measured from standing lateral spine radiographs. Secondary outcomes included change in kyphometer-measured kyphosis, physical function (modified Physical Performance Test, gait speed, Timed Up and Go, Timed Loaded Standing, 6-Min Walk), and health-related quality of life (HRQoL) (PROMIS global health and physical function indexes, SRS-30 self-image domain). ANCOVA was used to assess treatment effects on change from baseline to 6 months in all outcomes., Results: There was a -3.0° (95% CI -5.2, -0.8) between-group difference in change in Cobb angle, p = 0.009, favoring the intervention and approximating the magnitude of change from an incident vertebral fracture. Kyphometer-measured kyphosis (p = 0.03) and SRS-30 self-esteem (p < 0.001) showed favorable between-group differences in change, with no group differences in physical function or additional HRQoL outcomes, p > 0.05., Conclusions: Spine-strengthening exercise and posture training over 6 months reduced kyphosis compared to control. Our randomized controlled trial results suggest that a targeted kyphosis-specific exercise program may be an effective treatment option for older adults with hyperkyphosis., Trial Registration Number and Name of Trial Register: ClinicalTrials.gov; identifier NCT01751685.

Purpose: To describe reciprocal changes in cervical alignment after adult spinal deformity (ASD) correction and subsequent development of proximal junctional kyphosis (PJK). This study also investigated these changes using two novel global sagittal angular parameters, cervical-thoracic pelvic angle (CTPA) and the T1 pelvic angle (TPA)., Methods: Multicenter, retrospective consecutive case series of ASD patients undergoing thoracolumbar three-column osteotomy (3CO) with fusion to the pelvis. Radiographs were analyzed at baseline and 1 year post-operatively. Patients were substratified into upper thoracic (UT; UIV T6 and above) and lower thoracic (LT; UIV below T6). PJK was defined by >10° angle between UIV and UIV + 2 and >10° change in the angle from baseline to post-op., Results: PJK developed in 29 % (78 of 267) of patients. CTPA was linearly correlated with cervical plumbline (CPL) as a measure of cervical sagittal alignment (R = 0.826, p < 0.001). PJK patients had significantly greater post-operative CTPA and SVA than patients without PJK (NPJK) (p = 0.042; p = 0.021). For UT (n = 141) but not LT (n = 136), PJK patients at 1 year had larger CTPA (4.9° vs. 3.7°, p = 0.015) and CPL (5.1 vs. 3.8 cm, p = 0.022) than NPJK patients, despite similar corrections in PT and PI-LL., Conclusions: The prevalence of PJK was 29 % at 1 year follow-up. CTPA, which correlates with CPL as a global analog of cervical sagittal balance, and TPA describe relative proportions of cervical and thoracolumbar deformities. Patients who develop PJK in the upper thoracic spine after thoracolumbar 3CO also develop concomitant cervical sagittal deformity, with increases in CPL and CTPA.

Conspicuous vertebral column abnormalities in humpback dolphins (genus Sousa) were documented for the first time during 3 photo-identification field studies of small populations in Taiwan, Senegal and Angola. Seven Taiwanese humpback dolphins S. chinensis taiwanensis with vertebral column anomalies (lordosis, kyphosis or scoliosis) were identified, along with 2 possible cases of vertebral osteomyelitis. There was evidence from several individuals photographed over consecutive years that the anomalies became more pronounced with age. Three Atlantic humpback dolphins S. teuszii were observed with axial deviations of the vertebral column (lordosis and kyphosis). Another possible case was identified in a calf, and 2 further animals were photographed with dorsal indents potentially indicative of anomalies. Vertebral column anomalies of humpback dolphins were predominantly evident in the lumbo-caudal region, but one Atlantic humpback dolphin had an anomaly in the cervico-thoracic region. Lordosis and kyphosis occurred simultaneously in several individuals. Apart from the described anomalies, all dolphins appeared in good health and were not obviously underweight or noticeably compromised in swim speed. This study presents the first descriptions of vertebral column anomalies in the genus Sousa. The causative factors for the anomalies were unknown in every case and are potentially diverse. Whether these anomalies result in reduced fitness of individuals or populations merits attention, as both the Taiwanese and Atlantic humpback dolphin are species of high conservation concern.

Study Design: A retrospective study., Objective: To explore the relationship between the change of lumbar lordosis (LL) and thoracic kyphosis (TK) in AIS patients after correction surgery., Summary of Background Data: TK tends to decrease in Lenke 1 and Lenke 2 AIS patients after correction surgery using pedicle screws, with the compensation of LL decrease. We hypothesize that lumbar lordosis minus thoracic kyphosis (LL-TK) remains constant after correction surgery to achieve the sagittal balance in AIS patients., Methods: Medical records of Lenke 1 or Lenke 2 AIS patients who received posterior correction surgery using pedicle screws in our hospital from January 2010 to January 2013 were reviewed. General characters of patients and radiological parameters were evaluated before the surgery and at two years' follow-up. Correlation analysis between TK and LL was conducted. LL-TK and the change of LL and TK were analyzed at preoperation and final follow-up., Results: A total of 76 Lenke 1 and Lenke 2 AIS patients were included. Both TK and LL decreased significantly after correction surgery (P = 0.019 and P = 0.040, respectively). There were significant correlations between TK and LL before and after surgery, respectively (preoperative: r = 0.234, P = 0.042; postoperative: r = 0.310, P = 0.006). Preoperative and postoperative LL-TK was 23.80° and 25.09°, respectively, and no significant difference of LL-TK was observed (P = 0.372). The same tendency was observed in the change of LL and TK, and significant correlation was also found between the change of TK and LL (r = 0.626, P = 0.002)., Conclusion: The same change of LL and TK and no significant difference in LL-TK indicated that LL-TK might be an important compensatory mechanism in keeping sagittal balance.

Study Design: A case report of treatment of extreme tuberculous kyphosis using spinal osteotomy and halopelvic traction., Objective: The aim of this study was to describe the process and outcome of treatment of a case with extreme tuberculous kyphosis using spine osteotomy and halo-pelvic traction., Summary of Background Data: Spinal tuberculosis causes destruction, deformity, and paraplegia. Long-standing kyphosis may progress with growth in children, and produces respiratory insufficiency, and neurologic deficit. Surgery may help to prevent or reverse the neurological deterioration, while improving pulmonary function in cases with significant spinal deformity., Methods: Review of records and radiographs., Results: A 24-year-old female with tuberculous angular kyphosis presented with bilateral lower extremities paresis and dyspnea. The vertebral bodies from T3 to T9 were severely destructed, with a Cobb's angle of 180°on radiographs. The total duration of distraction using halopelvic apparatus kept 10 months. During the duration of traction, the patient underwent a posterior release surgery because flexibility of the kyphosis was not sufficient. Pedicle subtraction osteotomy and pedicle screw fixation were performed to achieve final correction when the Cobb's angle decreased to about 80°. After the whole treatment of halopelvic traction and spine ostetomy, the patient's height increased nearly 30 cm, whereas the angular kyphosis was corrected to a Cobb's angle of 30°. The patient had no complication and neurological deterioration during the treatment. Correction angle and good sagittal balance were well maintained in the duration of 2 years' follow-up., Conclusion: The halo-pelvic apparatus produces high corrective forces applied over a long period, and it provides a slow and safe correction of deformity. In cases of extreme kyphotic deformity, halopelvic traction is an appropriate technique, while avoiding many serious complications from a rapid, one-stage correction., Level of Evidence: N/A.

Five white-beaked dolphins Lagenorhynchus albirostris with outwardly vertebral kyphosis, kyphoscoliosis or lordosis were identified during a photo-identification survey of over 400 individuals (2002-2013) in Faxaflói and Skjálfandi Bays, Iceland. In addition, 3 stranding reports from Denmark, The Netherlands and the UK were analysed, providing both external observation and post mortem details of axial deviations of the vertebral column in this species. Two of the free-ranging cases and 2 of the stranded specimens appeared to have an acquired disease, either as a direct result of trauma, or indirectly from trauma/wound and subsequent infection and bony proliferation, although we were unable to specifically identify the causes. Our data represent a starting point to understand vertebral column deformations and their implications in white-beaked dolphins from the eastern North Atlantic. We recommend for future necropsy cases to conduct macro- and microscopic evaluation of muscle from both sides of the deformed region, in order to assess chronic or acute conditions related to the vertebral deformations and cause of death.

Purpose: Despite the high prevalence of low back pain during pregnancy there is still a lack in the understanding of its aetiology. Changes of the spinal posture due to the anatomical changes of the pregnant body seem to be in part responsible for the back pain. In this pilot study we assessed the potential to accurately measure the spinal posture and pelvic position during pregnancy without any harmful radiation using a spine and surface topography system., Methods: Thirteen pregnant women were examined during the second and third trimester of their pregnancy, and postpartum. Twenty female, non-pregnant volunteers comprised the control group. The spinal posture and pelvic position were measured with a radiation-free spine and surface topography system., Results: We found a significant increase in thoracic kyphosis during the course of pregnancy, but no increased lumbar lordosis. The lateral deviation of the spine also decreased significantly. However, we did not measure significant changes of the pelvic position during or after pregnancy., Conclusions: The results of our study show that pregnancy has an effect on the spinal posture, and that spine and surface topography can be used to measure these changes three-dimensionally and without any harmful radiation. In future studies this technique could allow to further evaluate the relationship between posture and low back pain during pregnancy, helping to understand the aetiology of low back pain in pregnancy as well as to identify methods for its prevention and treatment.

Twenty-eight patients with osteoporotic vertebral compression fractures (OVCF) were treated with single-balloon bipedicular kyphoplasty (Group A), and 40 patients were treated with double-balloon bipedicular kyphoplasty (Group B). Visual Analogue Scale (VAS) score, vertebral height, and kyphotic angle (KA) were evaluated pre-operatively, post-operatively (3 days after surgery) and at final follow-up. Operative time, X-ray exposure frequency and costs were recorded. The mean operative time and X-ray exposure frequency in Group A were greater than in Group B (p<0.05). Significant improvement of the VAS score was noted in each group, and remained unchanged at final follow-up. Mean increases of anterior and middle height of the fractured vertebral body were 5.14mm and 4.14mm in Group A, respectively, and 6.22mm and 5.06mm in Group B, respectively, and the differences between the groups were statistically significant (p<0.05). Mean reduction of KA was 6.9° in Group A and 8.8° in Group B, which was statistically significant (p<0.05). No statistically significant difference was observed in terms of cement leakage between groups. The mean cost of Group A (US$4202) was significantly less than that of Group B (US$6220) (p<0.001). Single-balloon bipedicular kyphoplasty is a safe and cost-effective surgical method for the treatment of OVCF. It can achieve pain relief comparable with double-balloon bipedicular kyphoplasty. However, double-balloon bipedicular kyphoplasty is more efficacious in terms of the restoration of vertebral height and reduction of KA, and the operative time and X-ray exposure frequency are lower., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Purpose: The purpose of this study was to assess the ability of short inversion time inversion-recovery (STIR) in magnetic resonance imaging for predicting the prognosis of osteoporotic vertebral fractures., Methods: We analyzed 63 vertebrae of 56 patients who had osteoporotic vertebral fracture (Th10-L2) prospectively. Image finding of a homogeneous high signal change on a fractured vertebra was evaluated and all vertebrae were divided into "homogenous high signal change group" or "non-homogenous high signal change group". On the other hand, image finding of linear black signal area was evaluated and all vertebrae were divided into "linear black signal area group" or "non-linear black signal area group"., Results: Sixteen and 24 vertebrae were included in the homogenous high signal change group or the linear black signal area group, respectively. The 16 homogenous high signal change cases did not result in non-union, and 47 non-homogenous high signal change cases resulted in 14 non-unions, a significant difference. Twenty-four linear black signal area and 39 non-linear black signal area cases resulted in 10, and 4 non-unions, respectively, also a significant difference. The kyphosis progression rate of the linear black signal area group (mean 35%) was significantly higher than that of non-linear black signal area group (mean 23%). The visual analog scale of back pain of the linear black signal area group (mean 35 mm) was significantly higher than that of the non-linear black signal area group (mean 23 mm)., Conclusions: STIR was useful for predicting bone union, kyphosis, and back pain in patients with osteoporotic vertebral fracture.

Paget's disease is the second most common metabolic bone disease after osteoporosis and is characterized by abnormal bone turnover and remodeling that can lead to pain, pathological fracture, bony deformity and nerve compression syndromes. The lumbar region is the most commonly affected site within the spine followed by the thoracic and cervical spine. Even though the spine is affected very commonly in Paget's disease, malignant degeneration is exceptionally rare. Multilevel monostotic spine involvement due to Paget's disease is very uncommon. An unusual clinico-radiological manifestation of multilevel thoracic Paget's disease with sarcomatous degeneration presenting as a neurosurgical emergency is reported with a pertinent review of the literature., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Recent studies have indicated a role for a MECOM allele in susceptibility to osteoporotic fractures in humans. We have generated a mutation in Mecom in mouse (termed ME(m1)) via lacZ knock-in into the upstream transcription start site for the gene, resulting in disruption of Mds1 and Mds1-Evi1 transcripts, but not of Evi1 transcripts. We demonstrate that ME(m1/m1) mice have severe kyphoscoliosis that is reminiscent of human congenital or primary kyphoscoliosis. ME(m1/m1) mice appear normal at birth, but by 2weeks, they exhibit a slight lumbar lordosis and narrowed intervertebral space. This progresses to severe lordosis with disc collapse and synostosis, together with kyphoscoliosis. Bone formation and strength testing show that ME(m1/m1) mice have normal bone formation and composition but are osteopenic. While endochondral bone development is normal, it is markedly dysplastic in its organization. Electron micrographs of the 1week postnatal intervertebral discs reveals marked disarray of collagen fibers, consistent with an inherent weakness in the non-osseous connective tissue associated with the spine. These findings indicate that lack of ME leads to a complex defect in both osseous and non-osseous musculoskeletal tissues, including a marked vertebral osteopenia, degeneration of the IVD, and disarray of connective tissues, which is likely due to an inherent inability to establish and/or maintain components of these tissues., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: A comparative study of the spinopelvic sagittal alignment in patients with lumbar disc degeneration or herniation (LDD/LDH) in normal population was designed to analyse the role of sagittal anatomical parameter (pelvic incidence, PI) and positional parameters in the pathogenesis and development of the disease. Several comparative studies of these patients with asymptomatic controls have been done. However, in previous studies without lumbar MRI, a certain number of asymptomatic LDD patients should have been included in the control group and then impacted on the results., Methods: Based on MRI findings, we divided 60 LDD or LDH patients and 110 asymptomatic volunteers into the normal group (NG) and the degeneration group (DG), which was further subdivided into the symptomatic (SDG) and asymptomatic (ADG) subgroups according to patients' symptoms. Standing full spine radiographs were used to measure sagittal parameters, including PI, sacral slope (SS), pelvic tilt (PT), lumbar lordosis (LL), thoracic kyphosis (TK), sagittal vertical axis (SVA), and sacrum-bicoxofemoral distance (SFD)., Results: The PI, SS and LL in DG were significantly lower than NG, while the SVA and SFD were significantly greater (P < 0.05). PI correlated well with the SS and LL in all subjects. However, the trend lines of SS or LL over PI were downward in DG. PI was similar in SDG and ADG (P = 0.716) but SS and LL were significantly lower and SVA was significantly greater (P < 0.05)., Conclusions: PI may play a predisposing role in the pathogenesis of lumbar disc degenerative diseases. The secondary structural and compensatory factors would lead to a straighter spine after disc degenerative change.

Purpose: To assess the correction effect of hemivertebra resection for unbalanced multiple hemivertebrae by measuring corresponding parameters in both coronal and sagittal planes on series posteroanterior and lateral radiographs and report the related complications., Methods: Twelve children with unbalanced multiple hemivertebrae were operated on by hemivertebra resection through a combined anterior and posterior approach or a posterior-only procedure. Mean age at time of surgery was 9.8 years (range 2-14 years). They were retrospectively studied with a mean follow-up of 48.7 months (range 30-60 months)., Results: The mean Cobb angle of the main curve was 65.3° (range 45°-92°) before surgery and 13.8° (range 4°-30°) at the last follow-up. The correction rate was 80.0% (range 65.5-92.4 %). The compensatory cranial curve was corrected from 25.8° (range 5°-53°) to 11.7° (range 0°-34°) with a correction rate of 65.9% (range 33.3-100%), and the compensatory caudal curve was corrected from 32.4° (range 17°-57°) to 7.1° (range 0°-20°) with a correction rate of 81.4% (range 53.1-100%). The angle of segmental kyphosis was 41.3° (range 12°-76°) before surgery and 17.0° (range -12° to 45°) at the final follow-up. The coronal imbalance was -1.0 cm (range -3.5 to 3 cm) before surgery and 0.0 cm (range -1.0 to 1.5 cm) at the most recent follow-up. The sagittal imbalance was 0.9 cm (range -3.2 to 3 cm) before surgery and 0.6 cm (range -3.0 to 3.5 cm) at the most recent follow-up. Complications including pedicle fractures, and pseudarthrosis were found in two patients (20 %)., Conclusions: In the patients with unbalanced multiple hemivertebrae, hemivertebra resection allows for excellent correction in both the coronal and sagittal planes, and great care should be taken to reduce the rate of complications.

Study Design: Imaging study of thoracic spine., Objective: The purpose of this study was to investigate dynamic alignment and range of motion (ROM) at all segmental levels of thoracic spine. Thoracic spine is considered to have restricted ROM because of restriction by the rib cage. However, angular movements of thoracic spine can induce thoracic compressive myelopathy in some patients. Although few previous studies have reported segmental ROM with regard to sagittal plane, these were based on cadaver specimens. No study has reported normal functional ROM of thoracic spine., Methods: Fifty patients with cervical or lumbar spinal disease but neither thoracic spinal disease nor compression fracture were enrolled prospectively in this study (34 males, 16 females; mean age 55.4 ± 14.7 years; range 27-81 years). After preoperative myelography, multidetector-row computed tomography scanning was performed at passive maximum flexion and extension position. Total and segmental thoracic kyphotic angles were measured and ROM calculated., Results: Total kyphotic angle (T1/L1) was 40.2° ± 11.4° and 8.5° ± 12.8° in flexion and extension, respectively (P < 0.0001). The apex of the kyphotic angle was at T6/7 in flexion. Total ROM (T1/L1) was 31.7° ± 11.3°. Segmental ROM decreased from T1/2 to T4/5 but increased gradually from T4/5 to T12/L1. Maximum ROM was at T12/L1 (4.2° ± 2.1°) and minimum at T4/5 (0.9° ± 3.0°)., Conclusions: Thoracic spine showed ROM in sagittal plane, despite being considered a stable region. These findings offer useful information in the diagnosis and selection of surgical intervention in thoracic spinal disease.

Background Context: Knowledge of sagittal spinopelvic parameters is important for the treatment of cerebral palsy (CP) because they differ in the normal population and can induce symptoms., Purpose: To analyze the sagittal spinal alignment and the pelvic orientation in CP., Study Design: Radiological analysis of patients with CP., Methods: The study and control groups comprised 57 CP patients and 24 healthy volunteers, respectively. All the patients underwent lateral radiography of the whole spine including hip joints. The radiographic parameters examined were sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), S1 overhang (OH), thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), lumbar lordosis (LL1 and 2), and sagittal balance (SB). Statistical analysis was performed to identify the significant differences between the two study groups. In addition, correlations were sought between the parameters and symptoms., Results: The PT and OH were significantly smaller in the CP patients, whereas SS, TLK, LL1, LL2, and SB were significantly greater (p<.05). Correlation analysis revealed significant relationships between the sagittal parameters. Specifically, PI was found to be associated with SS, PT, and OH, whereas the spinal parameters LL1 and LL2 were found to be related to TK and SB. Between spine and pelvic parameters, LL1 and LL2 were found to be related to SS, PT, PI, and OH and in addition, SB was found to be related to TLK, LL1, and LL2. An analysis of relations between the symptoms and parameters revealed a positive correlation between the severities of symptoms and PT, OH, and TLK (r=0.300, p=.023; r=0.306, p=.020; r=0.289, p=.029, respectively)., Conclusions: A significant difference was observed in the sagittal spinopelvic parameters in the CP and normal control groups and was possibly related to the symptoms. The study shows that the evaluations of sagittal spinopelvic parameters could be useful during the treatment of disorders associated with CP., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To investigate the incidences and characteristics of the ribs and intraspinal abnormalities in surgical patients with congenital scoliosis., Methods: We conducted a retrospective study of the medical records and spine radiographs of 118 patients underwent surgical treatment between January 2010 and March 2011 with congenital scoliosis. The average age was 14 years (3-50 years).Fifty-two were male and 66 were female patients. The rib and intraspinal abnormalities were compared in different vertebral anomalies. Pearson's χ(2) test were used to analyze the incidence of anomalies of the ribs and vertebrae, as well as intraspinal anomalies., Results: A total of 57 (48.3%) patients were found to have intraspinal abnormalities.Split cord deformities were identified to be the most common intraspinal anomaly (32.2%), followed by syringomyelia (21.2%).Sixty-nine patients (58.5%) had rib anomalies, which occurring on the concavity of the scoliosis was most frequent. The patients with mixed deformity and failure of segment were found to have a higher incidence of rib anomaly than those with failure formation (χ(2) = 14.05, P < 0.01). The patients with multiple level malformations were found to have significantly higher incidence of rib anomaly than those with single level malformation (χ(2) = 27.50, P < 0.01).Intraspinal anomalies occurred in 42 of 69 patients (60.9%) with rib anomalies and 15 of 49 patients (30.6%) without rib anomalies in congenital scoliosis. The occurrence of intraspinal malformation has significant difference with or without rib anomalies in congenital scoliosis (χ(2) = 10.5, P < 0.01)., Conclusions: The intraspinal malformation is common in patients with mixed defects and failures of segmentation. The rib anomalies occurring on the concavity of the scoliosis is most frequent. The incidence of intraspinal anomaly is significant higher in the patients with rib anomalies than those without rib anomalies. Both the occurrence and type of rib anomaly, combined with vertebral deformity are helpful in forecasting the occurrence of intraspinal abnormalis.

Background Context: Lumbar degenerative kyphosis (LDK) is characterized by sagittal imbalance resulting from a loss of lumbar lordosis (LL). The pelvic incidence (PI) regulates the sagittal alignment of the spine and pelvis., Purpose: The purpose of this study is to evaluate the spinopelvic parameters in patients with LDK and to compare them with those of a normal population., Study Design/setting: A cross-sectional study., Patient Sample: The selected patients showed characteristic clinical features of LDK. As control group, asymptomatic volunteers without spinal pathology were recruited., Outcome Measures: Full-length radiographs of the spine in the anteroposterior and lateral planes were taken, extending from the base of the skull to the proximal femur. Pelvic incidence, sacral slope (SS), pelvic tilt (PT), main thoracic kyphosis (TK), thoracolumbar junction (TLJ), LL, and sagittal vertical axis (SVA) were evaluated., Methods: In terms of PI, the patient and control groups were divided into three groups: low (PI≤45°), middle (45°60°). All the spinopelvic parameters were compared between each group and between the patient and control groups in each group. The correlations between each of the parameters were analyzed., Results: We evaluated 172 patients with symptomatic LDK and 39 healthy volunteers. The number of LDK patients with low, middle, and high PI groups were 44 (25.6%), 72 (44.8%), and 51 (29.6%), respectively. In the control group, the number of low, average, and high PI patients were 18 (46.2%), 15 (38.5%), and 6 (15.4%), respectively. In the control group, PI determined all spinopelvic parameters except SVA. In the LDK group, PI also determined spinopelvic parameters except for TK and SVA. Lumbar degenerative kyphosis with low PI was associated with pronounced kyphosis in LL and TLJ; LDK with a high PI was associated with relatively preserved lordosis in LL with a flat or lordotic TLJ. In terms of pelvic parameters, low PI showed flattened SS and low PT, whereas high PI showed steep SS and high PT., Conclusions: The results of this study suggest the importance of the key anatomical parameter, PI, in the determination of sagittal contour in symptomatic LDK patients and normal population. Spinopelvic parameters and pelvic compensatory mechanisms in LDK patients differ according to PI. Identifying the spinopelvic parameters is useful when correcting deformities., (Copyright © 2012 Elsevier Inc. All rights reserved.)

The interspinous distraction devices are used to treat variable pathologies ranging from facet syndrome, diskogenic low back pain, degenerative spinal stenosis, diskopathy, spondylolisthesis, and instability. The insertion of a posterior element with an interspinous device (ISD) is commonly judged responsive to a relative kyphosis of a lumbar segment with a moderate but persistent increase of the spinal canal and of the foraminal width and area, and without influence on low-grade spondylolisthesis. The consequence is the need of shared specific biomechanical concepts to give for each degenerative problem the right indication through a critical analysis of all available experimental and clinical biomechanical data. We reviewed systematically the available clinical and experimental data about kyphosis, enlargement of the spinal canal, distraction of the interspinous distance, increase of the neural foramina, ligamentous structures, load of the posterior annulus, intradiskal pressure, strength of the spinous processes, degeneration of the adjacent segment, complications, and cost-effectiveness of the ISD. The existing literature does not provide actual scientific evidence over the superiority of the ISD strategy, but most of the experimental and clinical data show a challenging potential. These considerations are applicable with different types of ISD with only few differences between the different categories. Despite--or because of--the low invasiveness of the surgical implantation of the ISD, this technique promises to play a major role in the future degenerative lumbar microsurgery. The main indications for ISD remain lumbar spinal stenoses and painful facet arthroses. A clear documented contraindication is the presence of an anterolisthesis. Nevertheless, the existing literature does not provide evidence of superiority of outcome and cost-effectiveness of the ISD strategy over laminectomy or other surgical procedures. At this time, the devices should be used in clinical randomized independent trials in order to obtain more information concerning the most advantageous optimal indication or, in selected cases, to treat tailored indications.

Study Design: Retrospective analysis., Objective: To determine, in pediatric patients with neuromuscular deformity undergoing vertebral column resection (VCR), the (1) characteristics of the surgery performed; (2) amount of pelvic obliquity restoration, and coronal and sagittal correction achieved; (3) associated blood loss and complications; and (4) extent to which curve type and VCR approach influenced correction, blood loss, and complications., Summary of Background Data: VCR allows for correction of severe, rigid spinal deformity. This technique has not been previously reported in children with neuromuscular disorders., Methods: We retrospectively reviewed the records of 23 children with neuromuscular disorders (mean age, 15 years) and spinal deformities (severe scoliosis, 9; global kyphosis or angular kyphosis, 4; kyphoscoliosis, 10) who underwent VCR. The Student t test was used to compare correction differences (statistical significance, P < 0.05)., Results: A mean 1.5 vertebrae (27 thoracic and 6 lumbar) were resected per patient. Significant corrections were achieved in pelvic obliquity (11°, from 19° ± 13° to 8° ± 7°), in major coronal curve (56°, from 94° ± 36° to 38° ± 20°), and in major sagittal curve (46°, from 86° ± 37° to 40° ± 19°). There was no difference in correction between various curve types. VCR was associated with substantial blood loss (mean, 76% [estimated blood loss per total blood volume]), which correlated with patient weight and operating time. Overall, 6 patients experienced major complications: spinal cord injury, pleural effusion requiring chest tube insertion, pneumonia, pancreatitis, deep wound infection, and prominent implant requiring revision surgery. There were no deaths or permanent neurological injuries., Conclusion: VCR achieved significant pelvic obliquity restoration and coronal and sagittal correction in children with neuromuscular disorders and severe, rigid spinal deformity. However, this challenging procedure involves the potential for major complications.

Purpose: Three column thoracic osteotomy (TCTO) is effective to correct rigid thoracic deformities, however, reasons for residual postoperative spinal deformity are poorly defined. Our objective was to evaluate risk factors for poor spino-pelvic alignment (SPA) following TCTO for adult spinal deformity (ASD)., Methods: Multicenter, retrospective radiographic analysis of ASD patients treated with TCTO. Radiographic measures included: correction at the osteotomy site, thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic tilt (PT), and pelvic incidence (PI). Final SVA and PT were assessed to determine if ideal SPA (SVA < 4 cm, PT < 25°) was achieved. Differences between the ideal (IDEAL) and failed (FAIL) SPA groups were evaluated., Results: A total of 41 consecutive ASD patients treated with TCTO were evaluated. TCTO significantly decreased TK, maximum coronal Cobb angle, SVA and PT (P < 0.05). Ideal SPA was achieved in 32 (78%) and failed in 9 (22%) patients. The IDEAL and FAIL groups had similar total fusion levels and similar focal, SVA and PT correction (P > 0.05). FAIL group had larger pre- and post-operative SVA, PT and PI and a smaller LL than IDEAL (P < 0.05)., Conclusions: Poor SPA occurred in 22% of TCTO patients despite similar operative procedures and deformity correction as patients in the IDEAL group. Greater pre-operative PT and SVA predicted failed post-operative SPA. Alternative or additional correction procedures should be considered when planning TCTO for patients with large sagittal global malalignment, otherwise patients are at risk for suboptimal correction and poor outcomes.

Introduction: The sagittal profile of conventionally and surgically treated scoliotic spines is usually analyzed via lateral views of whole-spine X-rays in an upright position. Due to a more hypokyphotic configuration of scoliotic spines, the view onto the upper thoracic vertebrae is often difficult. We investigated whether additional supine MRI measurement supports valid kyphosis angle measurement., Patients and Methods: Twenty patients with either short (n = 10, Halm-Zielke, VDS) or long spondylodesis (n = 10, dorsoventral) were assessed 5 years after surgery with standing radiographs and supine whole-spine MRI., Results: Up to 90% of the upper thoracic vertebrae were invisible on radiographs, whereas MRI allowed visibility of almost many vertebrae. No significant difference in thoracal kyphosis angles could be observed in the comparison of X-ray and MRI data., Conclusion: Thoracal kyphosis measurement of postoperative spines in MRI is a valid diagnostic tool with reliability comparable to that of X-ray. These results cannot be transferred to lumbar lordosis measurement and transferred only partly to coronal COBB angle measurement.

Introduction: Standing in an erect position is a human property. The pelvis anatomy and position, defined by the pelvis incidence, interact with the spinal organization in shape and position to regulate the sagittal balance between both the spine and pelvis. Sagittal balance of the human body may be defined by a setting of different parameters such as (a) pelvic parameters: pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS); (b) C7 positioning: spino-pelvic angle (SSA) and C7 plumb line; (c) shape of the spine: lumbar lordosis., Biomechanical Adaptation of the Spine in Pathology: In case of pathological kyphosis, different mechanical compensations may be activated. When the spine remains flexible, the hyperextension of the spine below or above compensates the kyphosis. When the spine is rigid, the only way is rotating backward the pelvis (retroversion). This mechanism is limited by the value of PI. Hip extension is a limitation factor of big retroversion when PI is high. Flexion of the knees may occur when hip extension is overpassed. The quantity of global kyphosis may be calculated by the SSA. The more SSA decreases, the more the severity of kyphosis increases. We used Roussouly's classification of lumbar lordosis into four types to define the shape of the spine. The forces acting on a spinal unit are combined in a contact force (CF). CF is the addition of gravity and muscle forces. In case of unbalance, CF is tremendously increased. Distribution of CF depends on the vertebral plate orientation. In an average tilt (45°), the two resultants, parallel to the plate (sliding force) or perpendicular (pressure), are equivalent. If the tilt increases, the sliding force is predominant. On the contrary, with a horizontal plate, the pressure increases. Importance of curvature is another factor of CF distribution. In a flat or kyphosis spine, CF acts more on the vertebral bodies and disc. In the case of important extension curvature, it is on the posterior elements that CF acts more. According to the shape of the spine, we may expect different degenerative evolution: (a) Type 1 is a long thoraco-lumbar kyphosis and a short hyperlordosis: discopathies in the TL area and arthritis of the posterior facets in the distal lumbar spine. In younger patients, L4 S1 hyperextension may induce a nutcracker L5 spondylolysis. (b) Type 2 is a flat lordosis: Stress is at its maximum on the discs with a high risk of early disc herniation than later with multilevel discopathies. (c) Type 3 has an average shape without characteristics for a specific degeneration of the spine. (d) Type 4 is a long and curved lumbar spine: this is the spine for L5 isthmic lysis by shear forces. When the patient keeps the lordosis curvature, a posterior arthritis may occur and later a degenerative L4 L5 spondylolisthesis. Older patients may lose the lordosis curvature, SSA decreases and pelvis tilt increases. A widely retroverted pelvis with a high pelvic incidence is certainly a previous Type 4 and a restoration of a big lordosis is needed in case of arthrodesis., Conclusion: The genuine shape of the spine is probably one of the main mechanical factors of degenerative evolution. This shape is oriented by a shape pelvis parameter, the pelvis incidence. In case of pathology, this constant parameter is the only signature to determine the original spine shape we have to restore the balance of the patient.

Study Design: Prospective randomized study., Objective: To evaluate the clinica! and radiologic outcome of posterior multilevel vertebral osteotomy (PMVO) in patients with severe kyphoscoliosis., Summary of Background Data: Authors have developed and reported results of PMVO for correction of neuromuscular scoliosis. PMVO has advantages such as, posterior-only procedure which avoids risk to pulmonary complications and gives satisfactory correction. However, its effect in correcting severe scoliosis in presence of rigid kyphosis has not been reported., Methods: Thirteen patients (7 idiopathic, 4 cerebral palsy, and 2 congenital scoliosis) with severe and rigid kyphoscoliosis were operated by posterior-only correction with pedicle screw fixation using PMVO. As per pathology, and associated severity of kyphosis little modification in the original technique was applied while correction and osteotomy. Neuromonitoring was applied in all patients during operation. The radiologic and clinical results were evaluated with an average follow-up of 42.9±11 months. All postoperative complications were also noted during the follow-up period., Results: Average number of osteotomy was 4.2±0.8 (range, 3-5). Average preoperative Cobb angle, pelvic obliquity, thoracic kyphosis, and lumbar lordosis were 99.2°±29.6°, 8.6°±9°, 73.6°±56.9°, and -47.2°±63.2°, respectively, which improved after surgery to 44.7°±12.3°, 2.8°±2.9°, 45.3°±15.9°, and -47.7°±12.2°. All corrections were maintained at final follow-up. A 54.3% correction was achieved in coronal plane; and, full correction was achieved in sagital plane as thoracic kyphosis was restored within normal range. Average blood loss and operative time was 3015±1213 mL and 6.01±1.09 hours, respectively. Three patients had postoperative respiratory complications; 2 had hemothorax and 1 had atelectasis; none had follow-up consequences. All pulmonary complications were due to associated thoracoplasty during which pleura was ruptured intraoperatively. Two patients had complication related with the implants; 1 screw breakage and other screw prominence. There was no neurologic injury intraoperatively on motor-evoked po- tentials (MEP) or clinically after surgery., Conclusion: PMVO exhibited satisfactory clinical and radiologic results in patients with severe and rigid scoliosis associated with hyperkyphosis at minimum 2-year follow-up. It can be safely applied with modifications in original technique for complex congenital scoliosis with multilevel hemi or block vertebrae and idiopathic/nonidiopathic spinal deformities.

Study Design: In a retrospective study, we report on 16 patients with congenital kyphosis due to progressively ossifying anterior unsegmented bars., Objective: To specify the therapeutic strategy in such malformation., Summary of Background Data: Congenital kyphosis due to progressively ossifying anterior unsegmented bars is a particular and uncommon entity of congenital kyphosis. Progressive anterior vertebral bars result in slowly progressive kyphosis, which rarely lead to neurological compromise. Sagittal equilibrium of the spine is maintained by compensatory curves adjacent to the primary curve., Methods: All patients had clinical assessment and successive measurements of segmental angle made on a standing lateral radiograph of the spine. Magnetic resonance imaging was obtained in four patients. Six patients were just observed. A brace was used in three. And seven were treated surgically., Results: The compensatory capacity of the spine is reduced in lumbar area where there are few discs spaces below the bar. Presentation therefore tends to be at an earlier age and pain is more common.Magnetic resonance imaging enables definition of the structures immediately posterior to the bar and provides information regarding the integrity of the intervertebral disc., Conclusion: There is usually no need for surgery in thoracic and thoracolumbar localization. In lumbar localization, if the diagnosis is done early in childhood and if magnetic resonance imaging shows beyond the anterior ossification a normal T2-weighted magnetic resonance imaging disc space signal, desepiphysiodesis bar resection and cement interposition is mandatory. If the disc magnetic resonance imaging signal is abnormal or if the disc space is totally ossified, we propose a surgical correction of the kyphosis. For such cases a posterior wedge osteotomy seems to be the more suitable procedure.

The impact of sagittal plane alignment on the treatment of spinal disorders is of critical importance. A failure to recognise malalignment in this plane can have significant consequences for the patient not only in terms of pain and deformity, but also social interaction due to deficient forward gaze. A good understanding of the principles of sagittal balance is vital to achieve optimum outcomes when treating spinal disorders. Even when addressing problems in the coronal plane, an awareness of sagittal balance is necessary to avoid future complications. The normal spine has lordotic curves in the cephalad and caudal regions with a kyphotic curve in between. Overall, there is a positive correlation between thoracic kyphosis and lumbar lordosis. There are variations on the degree of normal curvature but nevertheless this shape allows equal distribution of forces across the spinal column. It is the disruption of this equilibrium by pathological processes or, as in most cases, ageing that results in deformity. This leads to adaptive changes in the pelvis and lower limbs. The effects of limb alignment on spinal posture are well documented. We now also know that changes in pelvic posture also affect spinal alignment. Sagittal malalignment presents as an exaggeration or deficiency of normal lordosis or kyphosis. Most cases seen in clinical practise are due to kyphotic deformity secondary to inflammatory, degenerative or post-traumatic disorders. They may also be secondary to infection or tumours. There is usually pain and functional disability along with concerns about self-image and social interaction due to inability to maintain a horizontal gaze. The resultant pelvic and lower limb posture is an attempt to restore normal alignment. Addressing this complex problem requires detailed expertise and awareness of the potential pitfalls surrounding its treatment.

There are only a few studies that address the frequency and type of spinal involvement in patients with chronic recurrent multifocal osteomyelitis (CRMO) as well as the outcome of these patients treated with pamidronate (PAM). We performed a retrospective study on patients with CRMO and analyzed clinical and pain assessments as well as regional and whole body MRI findings and compared with posttreatment findings. Of 102 children and adolescents with CRMO, 27 (26%) had involvement of the spine. Vertebral deformities were seen in 14 of these 27 patients, scoliosis or kyphosis in 6. After routine whole body MRI, 19 complained of back pain, whereas eight were asymptomatic with spinal lesions detected incidentally. A total of 72 spinal lesions were detected, thoracic vertebrae being the most commonly affected. Seven patients were treated with PAM; all of whom had vertebral deformities and ongoing back pain. Pain resolution was achieved within 3 months of PAM treatment in every case. One patient subsequently developed a pain amplification syndrome. Repeat MRI performed at a mean interval of 13 months revealed partial or complete resolution of vertebral hyperintensities in every patient. Improvement of vertebral height was seen in a total of three vertebrae in two patients. Severe side effects were not observed. In conclusion, we demonstrated that spinal involvement and associated vertebral deformities with or without kyphoscoliosis are not rare in CRMO, and PAM appears to be an effective and safe treatment for this condition. Although controlled studies are urgently needed, the use of PAM for refractory CRMO with extended spinal involvement (vertebral deformities, kyphosis, and scoliosis) should be considered, especially after failing of conventional therapy.

Study Design: Radiographic analysis of sagittal spinal alignment of paraplegics in a standing position under surface neuromuscular electrical stimulation (NMES)., Objectives: Describing the radiographic parameters of the sagittal spinal alignment of paraplegics going through a rehabilitation program with NMES., Setting: The University Hospital's Ambulatory (UNICAMP), Campinas, São Paulo, Brazil., Methods: Panoramic X-ray images in profile were taken for 10 paraplegics. All patients participated in the rehabilitation program and were able to perform gait through NMES of the femoral quadriceps muscles. The radiographic parameters used for the analysis were the same as those described in the literature for healthy people. The results were didactically organized into three groups: anatomical shape of the spine, morphology and kinetics of the pelvis and spinopelvic alignment., Results: The physiological curvature of the spine in paraplegics showed average values similar to those described in the literature for healthy patients. The inversion of the pelvic tilt and the increase in the sacral slope were defined by the anterior backward rotation of the pelvis. The existing theoretical mathematical formulas that define lumbar lordosis, pelvic incidence and pelvic tilt showed normal values, despite the anterior intense sagittal imbalance., Conclusions: The adaptive posture of the spine in paraplegics standing through the stimulation of the femoral quadriceps does not allow for a neutral sagittal alignment. This novel radiographic detailed description of the various segments of the spine can be of assistance toward the understanding of the global postural control for such subjects.

Surgery in late stage ankylosing spondylitis (AS) most often tends to correct the sagittal balance with an extension osteotomy of the spine. In the literature, extension osteotomy was first described as an open wedge osteotomy but recently closed wedge osteotomy resecting the pedicles and posterior elements have become more popular. Only a limited number of cases have been reported in the literature and with limited focus on outcome of this major surgery. In this study, we reported the results of a large series of extension osteotomy in a population of patients with AS focusing on the technical aspects, complication rates, correction obtained and outcome evaluation using newer spine outcome measuring instruments. In the period from 1995 to 2005, 36 consecutive patients fulfilled the criteria where the files, radiographs and patients were available for further studies. The following data were recorded: Age, sex, comorbidity, indication, operation time and blood loss, level of osteotomy and estimated Correction. Furthermore, perioperative complications and all late complications were registered. The average follow-up was 50 months (3-128). Twenty-one patients also filled out questionnaires (SF36 and Oswestry Disability Index) preoperatively. At the end of the period all patients were contacted and filled out the same questionnaires. Fifteen of the patients had two pedicular resection osteotomies performed, 21 had one, and two had polysegmental osteotomies. Mean operation time was 180 min, bleeding was mean 2,450 ml, stay at the hospital was 13 days. One patient had partial paresis of the lower extremities all other complications were minor. The median correction was 45 degrees . The median Oswestry score improved significantly from 54 (range 20-94) preoperatively to 38 (range 2-94) postoperatively. The SF-36 score significantly increased, when evaluated on the major components Physical Component Summary (PCS) and Mental Component Summary (MCS). The thoracolumbar closed wedge pedicular resection osteotomy used in this series was a safe method for correction of incapacitating kyphosis in AS. There was an acceptable rate of perioperative complications and no mortality. The correction obtained was in average 45 degrees . All of the patients except one maintained their good correction and restored function. Outcome analysis showed a significant improvement in SF-36 and Oswestry Disability Index, and the mental component of the SF-36 showed improvement to values near the normative population. It is concluded that corrective osteotomy of the thoracolumbar spine in AS is an effective and safe treatment with improvements in quality of life.

This is a radiographic study of ankylosing spondylitis patients with severe fixed kyphotic deformity who underwent pedicle subtraction osteotomy. Our goal was to measure and validate new angle to assess global kyphosis and to evaluate the radiological outcomes after surgery. This is the first report which describes new angle to assess global kyphosis (T1-S1). Pre and postoperative controls were compared according to the Pelvic Incidence. The sagittal parameters ankylosing spondylitis patients were compared with 154 asymptomatic patients. In addition to the pelvic parameters and the C7 tilt, we used the spino-sacral angle. Pelvic incidence in ankylosing spondylitis patients was higher than asymptomatic population (61 vs. 51 degrees). For a same tilt of C7 for both groups, the low pelvic incidence group had a lower sacral slope and pelvic tilt and a higher global kyphosis (spino-sacral angle = 90 degrees) than the high pelvic incidence group (spino-sacral angle = 98 degrees ). In the adult volunteers, the C7 tilt and spino-sacral angle measured, respectively, 95 and 135 degrees. The preoperative C7 tilt measured 73 degrees and increased to 83 degrees (p = 0.0025). The preoperative spino-sacral angle measured 96 degrees and increased to 113.3 degrees (p = 0.003). A low pelvic incidence pelvis has a lower sacral slope than in high pelvic incidence and can support a bigger kyphosis. All the parameters were improved by the pedicle subtraction osteotomy, but the average spino-sacral angle remained lower than the control group. When C7 tilt was useful to assess the improvement of the balance, SSA allowed a better evaluation of the correction of kyphosis itself.

Study Design: A historical cohort study., Objective: To evaluate the reproducibility of this measure in proximal junctional kyphosis (PJK) and to determine whether differences exist between first and second vertebrae angles., Summary of Background Data: There are no previous studies on the precision and accuracy of selecting the first or the second vertebra above the upper instrumented vertebrae to determine the degree of spinal angulation after surgery.In several studies, the first or the second vertebrae above the upper instrumented vertebrae (UIV) have been selected to measure the angle of PJK in a surgical setting. However, to our knowledge, no studies have addressed the reliability of this measure.We aimed to evaluate the reproducibility of this measure in PJK and to determine whether differences exist between first and second vertebrae angles., Methods: A total of 38 randomly ordered radiologic digital images were obtained at 2 different times from 19 consecutive patients (aged 18.4 +/- 6.0 years at intervention) surgically treated for scoliosis. Using these images in a blinded manner, 2 surgeons independently measured angles at both the first and second vertebrae above the UIV. The measures were repeated in different periods to test intra- and intersurgeon concordances., Results: For 152 measures, intrasurgeon concordance correlation coefficients ranged from 0.78 to 0.92 (high to very high reproducibility) and comparative intersurgeon concordance correlation coefficients ranged from 0.55 to 0.80 (moderate to high reproducibility). No differences were found between the first and the second vertebrae angles., Conclusion: Good reproducibility and agreement using the first and second vertebrae above the UIV to measure the angle of PJK was found in this study.

Study Design: In vitro biomechanical study on 6 fresh frozen human thoracolumbar spine specimens., Objective: Using a novel high viscosity polymethylmethacrylate (PMMA) cement and vertebroplasty kit to correct the kyphosis angle of wedge compression fractures (AO/ASIF 1.2)., Summary of Background Data: Vertebroplasty is typically used to stabilize vertebral compression fractures in situ without correcting kyphosis, with the main target to reduce pain and disability. The vertebroplasty system investigated in this study comprises a high viscosity PMMA cement and uses a hydrostatic pressure hand piece for enhanced cement allocation and flow control. A recent clinical trial demonstrated a significantly reduced incidence of cement leakage with this system., Methods: Six spinal segments (Th11-L1 and Th12-L2) were loaded in a spine tester with pure moments of 7.5 Nm in lateral bending, flexion/extension and axial rotation. The segmental range of motion (ROM) was continuously recorded. The tested states of the specimens were: intact (a), fractured (b), treated with vertebroplasty (c), after loading with 50 to 250 N (d), 50 to 450 N (e) and 50 to 650 N (f) of 1000 cycles each. In each state (a-f), the kyphosis angle was documented fluoroscopically., Results: Kyphosis angle was significantly reduced between intact and fractured states (P<0.02). Between treated and fractured states, we found highly significant difference (P<0.001), indicating full correction. During 3000 loading cycles (50-250, 50-450, and 50-650 N), the kyphosis angle remained constant compared to the treated state (P=1.0). We noted a logistic relationship between injected cement volume and extent of kyphosis correction (R=0.89, P<0.001). In the fractured state, the ROM in flexion/extension increased to 252% of the intact state (P<0.001). The vertebroplasty treatment decreased ROM to 72% of fractured state in flexion/extension (P<0.001). Macroscopic inspection of the vertebrae after testing showed an intact interface and tight mechanical interlocking of cement filling and trabecular bone., Conclusion: High viscosity vertebroplasty effectively reduced and stabilized thoracolumbar wedge compression fractures and may represent a one-step solution for restoring vertebral body dimensions following thoracolumbar compression fractures, while minimizing the risk of cement leakage and associated complications in vivo.