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Diffuse idiopathic skeletal hyperostosis (DISH) is a noninflammatory skeletal disease characterized by the progressive ectopic ossification and calcification of ligaments and enthuses. However, specific pathogenesis remains unknown. Bone marrow mesenchymal stem cells (BMSCs) are a major source of osteoblasts and play vital roles in bone metabolism and ectopic osteogenesis. However, it is unclear whether BMSCs are involved in ectopic calcification and ossification in DISH. The current study aimed to explore the osteogenic differentiation abilities of BMSCs from DISH patients (DISH-BMSCs). Our results showed that DISH-BMSCs exhibited stronger osteogenic differentiation abilities than normal control (NC)-BMSCs. Human cytokine array kit analysis showed significantly increased secretion of Galectin-3 in DISH-BMSCs. Furthermore, Galectin-3 downregulation inhibited the increased osteogenic differentiation ability of DISH-BMSCs, whereas exogenous Galectin-3 significantly enhanced the osteogenic differentiation ability of NC-BMSCs. Notably, the increased Galectin-3 in DISH-BMSCs enhanced the expression of β-catenin as well as TCF-4, whereas attenuation of Wnt/β-catenin signaling partially alleviated Galectin-3-induced osteogenic differentiation and activity in DISH-BMSCs. In addition, our results noted that Galectin-3 interacted with β-catenin and enhanced its nuclear accumulation. Further in vivo studies showed that exogenous Galectin-3 enhanced ectopic bone formation in the Achilles tendon in trauma-induced rats by activating Wnt/β-catenin signaling. The current study indicated that enhanced osteogenic differentiation of DISH-BMSCs was mainly attributed to the increased secretion of Galectin-3 by DISH-BMSCs, which enhanced β-catenin expression and its nuclear accumulation. Our study helps illuminate the mechanisms of pathological osteogenesis and sheds light on the possible development of potential therapeutic strategies for DISH treatment. © 2022 American Society for Bone and Mineral Research (ASBMR).

Purpose: This study aimed to analyze neuroendocrine neoplasm (NEN) bone metastasis (BM) and gallium-68 (68Ga)-DOTA-TATE performance and to explore their correlation with the immunohistochemical proliferation index (Ki-67). Procedures: A total of 112 patients with BMs were screened from 1082 NEN patients who underwent [68Ga]Ga-DOTA-TATE imaging. All patients had pathological results, and BMs were affirmed by clinical/imaging follow-up and/or histopathology. The maximum standard uptake value (SUVmax) ratio of BM to normal bone determined for each patient was used in the final analysis. Results: The incidence rate of BMs in NENs was 10.35%. BMs occurred in the spine (75%), pelvis (72.3%), ribs (58%), clavicles and scapulae (41.1%), limbs (37.5%), and skull (28.6%). Most cases were associated with liver metastases (70.5%) and lymph node metastases (65.2%) simultaneously. The SUVmax ratio of G3b (median ratio = 3.77, Ki-67 >55%) was significantly lower than that of G1 (11.43, Ki-67 ≤2%) and G2a (11.15, 3% ≤ Ki-67 ≤10%) separately (p < 0.05), while no differences were found for G2b (8.5, 11% ≤ Ki-67 ≤55%) and G3a (6.64, Ki-67 >55%) groups. In the total patients, there was a significant negative correlation between the SUVmax ratio of BMs to normal bone and Ki-67 (r = −0.267, p < 0.01). According to the changes in bone density on CT scans, the cases were divided into 4 groups: osteogenesis, osteolysis, no change, and a mixed group (median Ki-67: 6.5%, 15%, 12%, and 22.5%). The Ki-67 values were significantly different between the osteogenesis group and the other groups (p < 0.05). Conclusion: BM is present in 10.35% of NEN patients and most have simultaneous liver and/or lymph node metastases. The occurrence of osteogenesis indicates relatively good differentiation, and there is a negative correlation between SUVmax ratio of BMs and NEN proliferation.

This study aimed to assess the efficacy of dual-tracer [We retrospectively enrolled 74 GEP-NEN patients with BMs from two centers, who underwent dual-tracer PET/CT from January 2014 to March 2021. We compared and analyzed effectiveness of the dual PET/CT imaging techniques on the BMs, based onThe detection efficiencies of dual-tracer PET/CT imaging in patients with different pathologies showed discordant for detecting liver metastases and BMs in group neuroendocrine tumor (NET) G3

Study Design: A retrospective study. Objectives: To investigate the incidence, management and outcome of delayed deep surgical site infection (SSI) after the spinal deformity surgery. Methods: This study reviewed 5044 consecutive patients who underwent spinal deformity corrective surgery and had been followed over 2 years. Delayed deep SSI were defined as infection involving fascia and muscle and occurring >3 months after the initial procedure. An attempt to retain the implant were initially made for all patients. If the infection failed to be eradicated, the implant removal should be put off until solid fusion was confirmed, usually more than 2 years after the initial surgery. Radiographic data at latest follow-up were compared versus that before implant removal. Results: With an average follow-up of 5.3 years, 56 (1.1%) patients were diagnosed as delayed deep SSI. Seven (12.5%) patients successfully retained instrumentation and there were no signs of recurrence during follow-up (average 3.4 years). The remaining patients, because of persistent or recurrent infection, underwent implant removal 2 years or beyond after the primary surgery, and solid fusion was detected in any case. However, at a minimum 1-year follow-up (average 3.9 years), an average loss of 9° in the thoracic curve and 8° in the thoracolumbar/lumbar curves was still observed. Conclusions: Delayed deep SSI was rare after spinal deformity surgery. To eradicate infection, complete removal of implant may be required in the majority of delayed SSI. Surgeons must be aware of high likelihood of deformity progression after implant removal, despite radiographic solid fusion.

STUDY DESIGN A retrospective study. OBJECTIVE The aim of this study was to investigate the ability of Global Alignment and Proportion (GAP) score to predict the occurrence of adjacent segment degeneration (ASD) after fusion surgery for lumbar degenerative diseases. SUMMARY OF BACKGROUND DATA The recently developed GAP score was applied to predict postoperative complications for adult spinal deformity, as well as to facilitate future outcome-based research on optimal treatment for various spinal conditions. However, it remains unclear whether reconstruction of alignment according to GAP score can reduce the ASD rates. METHODS This study retrospectively reviewed 126 consecutive patients who had undergone lumbar fusion and had been followed over 2 years. Pre- and postoperative radiographs and MRI were analyzed for ASD. GAP scores were calculated based on the early postoperative spinopelvic parameters. Cochran-Armitage test of trend was performed to investigate the association between GAP score and the occurrence of ASD. Receiver-operating characteristic curves were used to analyze the predictive accuracy of the GAP score for ASD. RESULTS Radiographical ASD (R-ASD) and symptomatic ASD (S-ASD) were diagnosed in 44 (34.9%) patients and in 13 (10.3%) patients, respectively. The patients with a proportioned spinopelvic state according to the GAP score had significantly lower rates of ASD (R-ASD and S-ASD) or S-ASD than those with a moderately or severely disproportioned spinopelvic state. The area under curve for the GAP score predicting ASD and S-ASD was 0.691 (95% confidence interval [CI]: 0.596∼0.785, P

Purpose. This study aimed to assess the efficacy of dual-tracer [68Ga-DOTA-somatostatin receptor analogs (SSAs) and 18F-fluorodeoxyglucose (FDG)] positron emission tomography/computed tomography (PET/CT) imaging for detecting bone metastases (BMs) in patients with gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs). Methods. We retrospectively enrolled 74 GEP-NEN patients with BMs from two centers, who underwent dual-tracer PET/CT from January 2014 to March 2021. We compared and analyzed effectiveness of the dual PET/CT imaging techniques on the BMs, based on 18F-FDG and 68Ga-DOTA-SSAs. Specifically, we analyzed the imaging results using χ2 tests for classification variables, paired-sample tests for number of BMs, Wilcoxon’s signed rank test for number of lesions, and the Kruskal–Wallis test for standard uptake value (SUV) ratio comparison. The correlation of dual-tracer SUVmax with Ki-67 index was analyzed by Spearman’s correlation coefficient. Results. The detection efficiencies of dual-tracer PET/CT imaging in patients with different pathologies showed discordant for detecting liver metastases and BMs in group neuroendocrine tumor (NET) G3, 68Ga-DOTA-SSAs was better at detecting BMs for NET G3 ( P = 0.049 for SUVT/B and P = 0.026 for the number of metastatic lesions). In addition, statistical significance was found among osteogenesis group, osteolysis group, and the no-change group (for bone SUVT/B value detected by 18F-FDG and Ki-67 index, osteogenesis group < osteolysis group; for bone SUVT/B detected by 68Ga-DOTA-SSAs, osteogenesis group > the no-change group). What is more, liver and bone SUVmax and Ki-67 index were positively correlated in 18F-FDG imaging ( P < 0.001 for liver; P = 0.002 for bone), and negatively correlated in 68Ga-DOTA-SSAs imaging ( P < 0.001 for liver; P = 0.039 for bone). Conclusions. 68Ga-DOTA-SSAs was superior to 18F-FDG for detecting BMs in NET G1/G2 (well and moderately differentiated NETs), as well as in NET G3 (poorly differentiated NETs). Relatively good differentiation was observed in the osteogenesis group. In addition, dual-tracer PET/CT imaging results were observably correlated with tumor differentiation.

To investigate the effect of end plate morphology on cage subsidence and to compare the surgical outcomes among patients with different vertebral end plate morphologies.We reviewed a series of consecutive patients from January 2009 to January 2016 who had undergone monosegment L4/5 transforaminal lumbar interbody fusion (TLIF) with a follow-up2 years. The enrolled patients were divided into 3 groups based on the preoperative vertebral end plate morphology on T1-weighed sagittal magnetic resonance scans: concave group (C group), flat group (F group), and irregular group (Ir group). Lumbar lordosis (LL), segmental lordosis (SL), and disc height (DH) were measured on the plain image at each follow-up, and three-dimensional computed tomography (3D-CT) was obtained at 1 year follow-up to evaluate the cage subsidence and solid fusion.A total of 145 consecutive patients (41 males and 104 females) were included in this study, with a mean follow-up of 33.8 ± 12.3 months. The age was significantly older in the Ir group than in the C group or F group (P0.05). Cage subsidence was detected in 23 patients (15.9%) at 1 year follow-up through 3D-CT. The incidence of cage subsidence was significantly higher in the Ir group than in the F group or C group (P0.05). Patients in the Ir group had significant loss of DH, SL, and LL at the latest follow-up, compared with those in the C group and F group (P 0.05). Patients with cage subsidence had a significantly older age (P0.05). The presence of cage subsidence was associated with end plate morphology as shown by logistic regression analysis (P0.05). Before surgery, Oswestry Disability Index and visual analog scale back pain scores were significantly higher in the Ir group than in the C and F groups (P0.05). After surgery and until the latest follow-up, each group experienced significant improvement in contrast to preoperative scores regardless of end plate morphology (P0.05).Morphology of the end plate plays an important role in the development of cage subsidence after TLIF surgery. Fused segments with irregular end plates are prone to cage subsidence. Although cage subsidence does not affect short-term clinical outcomes, measures should be taken to prevent cage subsidence-related loss of SL and total LL.

Study design Retrospective radiographical clinical study. Objective To investigate the incidence and risk factors of coronal imbalance (CI) after three-column osteotomy (3-CO) in patients with thoracolumbar congenital kyphoscoliosis (CKS). Summary of background data The incidence and risk factors of postoperative CI have been reported in adolescent idiopathic and degenerative lumbar scoliosis. However, limited data exists for patients with CKS after 3-CO. Methods We reviewed a consecutive series of patients with CKS who underwent posterior-only 3-CO. Coronal curve patterns were classified according to absolute C7 translation values into: Type A, C7 translation is less than 30 mm; Type B, C7 translation more than or equal to 30 mm and C7 plumb line (C7PL) shifted to the concave side of the main curve; and Type C, C7 translation more than or equal to 30 mm and C7PL shifted to the convex side. CI was defined as C7 translation on either side more than or equal to 30 mm. According to C7 translation at the latest follow-up, patients was subdivided into an imbalanced group and a balanced group. Results One-hundred-thirty patients (mean age, 17.7 ± 5.2 yr) were recruited. The mean follow-up was 41.3 ± 18.5 months. Twenty-six patients (20%) were identified as having CI at the latest follow-up. Compared with the balanced group, the imbalanced group had a larger proportion of preoperative Type C pattern, higher main curve correction, and greater lowest instrumented vertebra (LIV) tilt before and after surgery. Multiple logistic regression showed that risk factors for CI were preoperative type C pattern, preoperative LIV tilt more than or equal to 23.5° and immediate postoperative LIV tilt more than or equal to 12.3°. Conclusion The incidence of CI in patients with CKS after 3-CO was 20%. A preoperative type C pattern, preoperative LIV tilt more than or equal to 23.5°, and immediate postoperative LIV tilt more than or equal to 12.3° were found to be associated with CI at the latest follow-up. Level of evidence 3.

This study aimed to analyze neuroendocrine neoplasm (NEN) bone metastasis (BM) and gallium-68 (68Ga)-DOTA-TATE performance and to explore their correlation with the immunohistochemical proliferation index (Ki-67).A total of 112 patients with BMs were screened from 1082 NEN patients who underwent [68Ga]Ga-DOTA-TATE imaging. All patients had pathological results, and BMs were affirmed by clinical/imaging follow-up and/or histopathology. The maximum standard uptake value (SUVmax) ratio of BM to normal bone determined for each patient was used in the final analysis.The incidence rate of BMs in NENs was 10.35%. BMs occurred in the spine (75%), pelvis (72.3%), ribs (58%), clavicles and scapulae (41.1%), limbs (37.5%), and skull (28.6%). Most cases were associated with liver metastases (70.5%) and lymph node metastases (65.2%) simultaneously. The SUVmax ratio of G3b (median ratio = 3.77, Ki-6755%) was significantly lower than that of G1 (11.43, Ki-67 ≤2%) and G2a (11.15, 3% ≤ Ki-67 ≤10%) separately (p0.05), while no differences were found for G2b (8.5, 11% ≤ Ki-67 ≤55%) and G3a (6.64, Ki-6755%) groups. In the total patients, there was a significant negative correlation between the SUVmax ratio of BMs to normal bone and Ki-67 (r = -0.267, p0.01). According to the changes in bone density on CT scans, the cases were divided into 4 groups: osteogenesis, osteolysis, no change, and a mixed group (median Ki-67: 6.5%, 15%, 12%, and 22.5%). The Ki-67 values were significantly different between the osteogenesis group and the other groups (p0.05).BM is present in 10.35% of NEN patients and most have simultaneous liver and/or lymph node metastases. The occurrence of osteogenesis indicates relatively good differentiation, and there is a negative correlation between SUVmax ratio of BMs and NEN proliferation.

BACKGROUND: The relationship between structural damage and inflammation of the spine and the sagittal imbalance in ankylosing spondylitis (AS) is not well understood. The present study aimed to investigate the correlation between structural damage and inflammation of the lumbar spine and the sagittal imbalance in AS patients with thoracolumbar kyphosis. METHODS: Forty-five AS patients with thoracolumbar kyphosis were retrospectively reviewed. Six sagittal spinal parameters, including the C7 tilt (C7T), spino-sacral angle (SSA), global kyphosis (GK), the sagittal vertical axis (SVA), thoracic kyphosis (TK), and lumbar lordosis (LL), were measured. Structural damage of the lumbar spine was assessed by the modified Stoke AS Spine Score (mSASSS) on radiographs. Lumbar spinal inflammation was evaluated by the AS spinal magnetic resonance imaging (MRI) activity (ASspiMRI-a) on MRI. Correlation analysis was performed using the paired sample t-test. Multivariable linear regression models were constructed to analyze the contributions of mSASSS and ASspiMRI-a to the sagittal parameters. RESULTS: The average values of the sagittal parameters C7T, SSA, GK, SVA, TK, and LL were 68.1°, 80.1°, 77.3°, 168.7 mm, 47.7°, and −0.7°, respectively. The average mSASSS and ASspiMRI-a scores were 9.8 and 10.8, respectively. Correlation analysis showed that the mSASSS and ASspiMRI-a were correlated with C7T, SSA, SVA, and LL (the Spearman correlation coefficients were −0.439, −0.390, 0.424, and 0.530 for mSASSS; −0.406, −0.402, 0.378, and 0.486 for ASspiMRI-a; P

Study Design: A retrospective studyObjectives: To investigate the impact of radiological and surgical factors as well as proximal rod contouring angle (PRCA) on the development of proximal junctional kyphosis (PJK) in early-onset scoliosis(EOS) patients after growing rod (GR) treatment.Methods: We reviewed a consecutive series of EOS patients who had undergone growing rod (GR) treatment between 2009 and 2018 (minimum follow-up of 2 years) at a single institution. Patients were divided into PJK and non-PJK groups according to the occurrence of PJK or not during the follow-up periods. The demographic data, surgical strategies, and radiographic parameters were recorded and compared between the PJK and non-PJK groups. PJK was defined as a PJA＞10° at the last follow-up. PRCA was defined as the angle between the cephalad endplate of the UIV and the lower endplate of the second vertebra caudal to UIV and the PJA-PRCA was defined as the difference between the values of PJA and PRCA. Logistic regression was also performed to identify the risk factors for the occurrence of PJK.Results: This study finally included 95 patients. The mean age at the index surgery was 6.5±2.2 years. Mean follow-up lasted 4.4±1.9 years. Lengthening procedures averaged 4.0 ± 1.8 times. There were 20 patients who were observed with PJK (the incidence, 21.1%). In comparison with the non-PJK group, the PJK group showed a larger preoperative coronal cobb angle (81.8±20.6° vs 70.4±12.4°, P=0.041) and global kyphosis (GK) (56.0±15.3° vs. 45.9±12.9°, P=0.044), as well as a larger GK correction (40.4%±10.0% vs. 30.0%±14.2%, P=0.035). In addition, the PJK group had significantly larger postoperative PJA (10.8±3.1 vs. 5.3±3.1, P＜0.001) and greater postoperative PJA-PRCA (5.3±3.0 vs. 3.66±2.9, P=0.031). The proportion of patients with a value of PJA-PRCA greater than 5° in PJK group was significantly higher than that in the non-PJK group. Multiple logistic regression showed that preoperative GK＞50°, postoperative PJA＞10 and postoperative PJA-PRCA＞5° were the risk factors in predicting PJK after GR treatment.Conclusions: More than one-fifth EOS patients experienced PJK after GR treatment. Besides greater preoperative GK and larger postoperative PJA, PJA-PRCA mismatch may be an independent risk factor of PJK occurrence.

BACKGROUND: The distraction-based growth-friendly technique has become a mainstay of treatment for young children with long-spanned congenital scoliosis. However, in patients who are 9 years to 11 years old, the choice is much less clear, and posterior spinal fusion is also a potential option. QUESTIONS/PURPOSES: Comparing growth-friendly scoliosis surgery and posterior spinal fusion, which technique (1) provides greater correction of spinal deformity, (2) is associated with more surgical complications, and (3) results in greater improvement in pulmonary function tests, health-related quality of life scores, other patient-reported outcomes? METHODS: Between 2009 and 2017, one spinal center performed 212 spinal interventions for scoliosis in patients aged between 9 years and 11 years old and who had open triradiate cartilage, including 40 patients with growth-friendly approaches (34 with growing-rod technique and six with a vertical expandable prosthetic titanium rib) and 172 with one-stage posterior spinal fusion, respectively. During this period, our general indications for using growth-friendly surgery were patients with open triradiate cartilage, major curve higher than 40°, and upper and lower end vertebrae involving at least eight segments. Twelve patients with a median (range) age of 9.3 years (9 to 11) treated with growth-friendly surgery met the following inclusion criteria: (1) had at least two lengthening procedures before definitive spinal fusion along with 2 years of follow-up after definitive spinal fusion; (2) had been followed until skeletal maturity (Risser grade ≥ 4); and (3) with complete radiographic and clinical data (health-related quality of life (HRQoL) and pulmonary function test results) preoperatively and at the latest follow-up. A group of patients between 9 years and 11 years old and underwent one-stage posterior spinal fusion was selected from our database of patients with congenital scoliosis. Our general indications for using one-stage posterior spinal fusion were patients with a major curve greater than 40°, and with thoracic height higher than 18 cm. Sixty-two patients who had open triradiate cartilage and had been followed until skeletal maturity (Risser grade ≥ 4) were accounted for. In this retrospective, controlled study, we matched patients in the posterior spinal fusion group to those 12 patients who had growth-friendly surgery by age, sex, pathologic findings, major curve size, and location of the apex of the major curve (2:1 matching provided 24 patients in the control group). The median (range) age was 9.8 years (9 to 11). We then compared the groups in terms of magnitude of correction and postoperative complications. Surgical complications, including infection, implant-related complications, and alignment-related complications were evaluated and classified using the surgical complications grading system. Pulmonary function tests and HRQoL were also compared between groups. Pulmonary function tests were performed at the same center with a spirometer. HRQoL were assessed by questionnaire, including the 24-item Early-onset Scoliosis questionnaire for parent-reported outcomes and the Scoliosis Research Society-22 questionnaire for patient-reported outcomes. All patients involved in this study gave their informed consent. RESULTS: The posterior spinal fusion group achieved a greater correction magnitude at the latest follow-up (median [range] 46% [28 to 70] versus median 34% [9 to 58], difference of medians = 11%; p < 0.001) than the growth-friendly group. A higher proportion of patients in the growth-friendly group had complications than in the posterior spinal fusion group (7 of 12 versus 4 of 24; p = 0.03). There were no between-group differences in terms of pulmonary function tests. Few differences were found between the groups in terms of 24-item Early-onset Scoliosis parental impact (median [range] 60 [44 to 83] for the growth-friendly group versus median 71 [55 to 87] for the posterior spinal fusion group, difference of medians = 13; p = 0.001), financial burden (median 44 [30 to 55] for the growth-friendly group versus median 62 [53 to 75] for the posterior spinal fusion group, difference of medians = 16; p < 0.001) and the Scoliosis Research Society-22 self-image scores (median 3.8 [3.2 to 4.3] for the growth-friendly group versus median 4.4 [4.1 to 4.6] for the posterior spinal fusion group, difference of medians = 0.5; p = 0.006) at the latest follow-up, and those differences that were observed all favored the posterior spinal fusion group. CONCLUSIONS: In light of the superior deformity correction and fewer observed complications with posterior spinal fusion, and the absence of important differences in validated outcomes scores or pulmonary function tests, posterior spinal fusion might be a better choice for 9- to 11-year-old children with long-spanned congenital scoliosis and limited growth potential in the intended instrumentation area. LEVEL OF EVIDENCE: Level III, therapeutic study.

OBJECTIVE The objective of this study was to investigate the incidence and risk factors of coronal imbalance (CI) in patients with early-onset scoliosis (EOS) who underwent growing rod (GR) treatment. METHODS A consecutive series of 61 patients with EOS (25 boys and 36 girls, mean age 5.8 ± 1.7 years) who underwent GR treatment was retrospectively reviewed. Postoperative CI was defined as postoperative C7 translation on either side ≥ 20 mm. Patients were divided into an imbalanced and a balanced group. Coronal patterns were classified into three types: type A (C7 translation < 20 mm), type B (C7 translation ≥ 20 mm with C7 plumb line [C7PL] shifted to the concave side of the curve), and type C (C7 translation ≥ 20 mm and a C7PL shifted to the convex side of the curve). RESULTS Each patient had an average of 5.3 ± 1.0 lengthening procedures and was followed for an average of 6.2 ± 1.3 years. Eleven patients (18%) were diagnosed with CI at the latest distraction, 5 of whom graduated from GRs and underwent definitive fusion. However, these patients continued to present with CI at the last follow-up evaluation. The proportion of preoperative type C pattern (54.5% vs 16.0%, p = 0.018), immediate postoperative apical vertebral translation (30.4 ± 13.5 mm vs 21.2 ± 11.7 mm, p = 0.025), lowest instrumented vertebra tilt (11.4° ± 8.2° vs 7.3° ± 3.3°, p = 0.008), and spanned obliquity angle (SOA) (9.7° ± 10.5° vs 4.1° ± 4.5°, p = 0.006) values in the imbalanced group were significantly higher than in the balanced group. Multiple logistic regression demonstrated that a preoperative type C pattern and immediate postoperative SOA > 11° were independent risk factors for postoperative CI. CONCLUSIONS The incidence of CI in patients with EOS who underwent GR treatment was 18%. This complication could only be slightly improved after definitive spinal fusion because of the autofusion phenomenon. A preoperative type C pattern and immediate postoperative SOA > 11° were found to be the risk factors for CI occurrence at the latest follow-up.

OBJECTIVEDystrophic lumbar scoliosis secondary to neurofibromatosis type 1 (DLS-NF1) may present an atypical, unique curve pattern associated with a high incidence of coronal imbalance and regional kyphosis. Early surgical intervention is complicated and risky but necessary. The present study aimed to assess the unique characteristics associated with the surgical treatment of DLS-NF1.METHODSThirty-nine consecutive patients with DLS-NF1 treated surgically at a mean age of 14.4 ± 3.9 years were retrospectively reviewed. Patients were stratified into three types according to the coronal balance classification: type A (C7 translation < 30 mm), 22 patients; type B (concave C7 translation ≥ 30 mm), 0 patients; and type C (convex C7 translation ≥ 30 mm), 17 patients. Types B and C were considered to be coronal imbalance. The diversity of surgical strategies, the outcomes, and the related complications were analyzed.RESULTSThe posterior-only approach accounted for 79.5% in total; the remaining 20.5% of patients received either additional anterior supplemental bone grafting (12.8%) to strengthen the fixation or convex growth arrest (7.7%) to reduce growth asymmetry. The lower instrumented vertebra (LIV) being L5 accounted for the largest share (41%), followed by L4 and above (35.9%), the sacrum (15.4%), and the pelvis (7.7%). Type C coronal imbalance was found in 23 patients (59%) postoperatively, and the incidence was significantly higher in the preoperative type C group (14/17 type C vs 9/22 type A, p = 0.020). All the patients with postoperative coronal imbalance showed ameliorative transition to type A at the last visit. The rate of screw malposition was 30.5%, including 9.9% breached medially and 20.6% breached laterally, although no serious neurological impairment occurred. The incidence of rod breakage was 16.1% (5/31) and 0% in patients with the posterior-only and combined approaches, respectively. Four revisions with satellite rods and 1 revision with removal of iliac screw for penetration into the hip joint were performed.CONCLUSIONSSurgical strategies for DLS-NF1 were diverse across a range of arthrodesis and surgical approaches, being crucially determined by the location and the severity of dystrophic changes. The LIV being L5 or lower involving the lumbosacral region and pelvis was not rare. Additional posterior satellite rods or supplementary anterior fusion is necessary in cases with insufficient apical screw density. Despite a high incidence of postoperative coronal imbalance, improvement of coronal balance was frequently confirmed during follow-up. Neurological impairment was scarce despite the higher rate of screw malposition.

OBJECTIVEScheuermann kyphosis (SK) could require surgical treatment in certain situations. A posterior reduction is the most widespread treatment so far, although the development of proximal junctional kyphosis (PJK) is one of the possible complications of this procedure. The contour of the proximal part of the rod could influence the occurrence of PJK in SK patients. The objective of this study was to analyze the impact of the proximal rod contour on the occurrence of a PJK complication in SK patients.METHODSThis retrospective monocentric study was performed in the Nanjing Spine Surgery Department. All eligible patients had undergone posterior correction surgery with pedicle screws only between 2002 and 2017 and had at least 24 months of follow-up. The presence of PJK was quantified on radiographs using the proximal junctional angle (PJA > 10° at the last follow-up). The authors propose a new radiological parameter to measure the angulation of the proximal part of the instrumentation: the proximal contouring rod angle (PCRA) is the angle between the upper endplate of the upper instrumented vertebra (UIV) and the lower endplate of the second vertebra caudal to the UIV. The patients were analyzed according to the presence or absence of PJK. A t-test, receiver operating characteristic (ROC) curve analysis, and logistic regression analysis were performed for statistical analysis.RESULTSSixty-two patients treated for SK were included in this study. The mean age was 18.6 ± 8.5 years, and the mean follow-up was 42.5 ± 16.4 months. The mean correction rate of global kyphosis was 46.4% ± 13.7%. At the last follow-up, 17 patients (27.4%) presented with PJK. No significant difference was found between the PJK and non-PJK groups in terms of age and other preoperative variables. A significant difference in the postoperative PCRA was found between the PJK and non-PJK groups (8.2° ± 4.9° vs 15.7° ± 6.6°, respectively; p = 0.001). A postoperative PCRA less than 10.1° predicted a significantly higher risk for PJK (p = 0.002, OR 2.431, 95% CI 1.781–4.133).CONCLUSIONSUnder-contouring of the proximal part of the rods (lower than 10°) is a risk factor for PJK after posterior correction of SK.

OBJECTIVEThis study aimed to evaluate the correction results of traditional dual growing rods (DGRs) on axial rotation using CT scans and to further explore the relationships between axial and torso deformities in patients with early-onset scoliosis (EOS).METHODSPatients with EOS who were treated with traditional DGRs between January 2006 and December 2014 were retrospectively reviewed. Plain radiographs were used to assess the degree of coronal and sagittal deformity. The apical vertebral rotation (AVR) and rib hump (RH) were measured on CT scans at the apical vertebra. Pearson or Spearman rank correlation analyses were used to analyze the associations between spinal and torso deformities.RESULTSA total of 27 patients (10 boys and 17 girls, average age 6.5 ± 1.7 years) were enrolled in this study. The average number of lengthenings per patient was 5.0 ± 1.9, with a mean follow-up duration of 52.9 ± 18.2 months. The apical vertebral translation, apical vertebral body–rib ratio (AVB-R), AVR, and RH parameters were significantly decreased after the initial surgery (p < 0.05) but showed notable progression at the latest follow-up evaluation (p < 0.05). The preoperative AVR and its correction after index surgery were significantly correlated with the preoperative values as well as with the corrections of the major Cobb angle, AVB-R, and RH. During the follow-up period, significant correlations were found between the deterioration of AVR and the AVB-R and also between the deterioration of AVR and the RH from the initial surgery to the latest follow-up.CONCLUSIONSSignificant AVR correction can be achieved by DGR techniques after the initial surgery. However, this technique weakly prevents the deterioration of AVR during the follow-up period.

Background Previous studies have reported favorable short-term outcomes after posterior-only hemivertebra resection and short fusion in patients with LSHV. However, there is a paucity of data evaluating the long-term outcomes following this procedure. The aim of the study is to evaluate the radiological outcomes following posterior-only hemivertebra resection and short fusion for the treatment of congenital scoliosis (CS) secondary to lumbosacral hemivertebra (LSHV) with a minimum of a 5-year follow-up. Methods A total of 23 patients treated with one-stage posterior-only LSHV resection and short fusion with a minimum of a 5-year follow-up were reviewed. Radiographic parameters including the Cobb angles of the lumbosacral curve and compensatory curve, the upper instrumented vertebra (UIV) tilt, and trunk shift were measured. The complications were recorded accordingly. Results The mean duration of follow-up was 88.6 ± 28.5 months, and the average age at surgery was 7.8 ± 3.5 years. Fusion levels averaged 3.0 ± 0.7 segments. The lumbosacral curve was corrected from 30.7 ± 10.4° to 6.7 ± 7.1° after surgery (P P Conclusion One-stage posterior-only hemivertebra resection with short fusion is an effective procedure for LSHV, and the correction can be well maintained during longitudinal follow-up. Great attention should be paid to the restoration of lumbosacral horizontalization.

Background Lumbosacral spondylolisthesis-induced scoliosis is a rare clinical entity. Sagittal reconstruction and the coronal curve evolution after surgery for spondylolisthesis have not been investigated in depth. Objective To compare the curve characteristics between sciatic scoliosis and olisthetic scoliosis and to further investigate the effects of lumbosacral transforaminal lumbar interbody fusion (TLIF) on scoliosis evolution. Methods Adolescents with sciatic scoliosis group (SS group) or olisthetic scoliosis group (OS group) who underwent L5/S1 TLIF from 2010 to 2017 and were followed up for at least 2 yr were retrospectively reviewed. Radiographic parameters and patient-reported outcomes were evaluated. Results There were 20 patients in the SS group (M/F: 8/12; age: 15.6 ± 2.2 yr) and 16 in the OS group (M/F: 6/10; age: 16.8 ± 2.5 yr). Both groups had similar preoperative Cobb angles, but more patients with coronal imbalance were observed in the SS group. Moreover, the OS group showed significantly larger L5 tilt and rotation. After surgery, the slip reduction rate of the SS group and OS group were 76.1% ± 12.4% and 79.4% ± 9.6%, respectively. Scoliosis resolution was observed in all patients in the SS group but only in 9 patients (56.2%) in the OS group. Patients with failed scoliosis resolution in the OS group were older and had a larger Cobb angle and L5 rotation compared with those with successful scoliosis resolution. Conclusion Lumbosacral TLIF can achieve satisfactory slip reduction and scoliosis resolution. Sciatic scoliosis often presents with coronal imbalance but also a preferable curve prognosis. A large Cobb angle and L5 rotation may hinder the resolution of olisthetic scoliosis.

Background Contiguous double-level lumbar spondylolytic spondylolisthesis is an extremely rare condition. There is a paucity of data of lumbosacral deformity and sagittal spino-pelvic malalignment among these patients. Moreover, the effect of transforaminal lumbar interbody fusion (TLIF) on sagittal realignment still remains largely unknown. The aim of the study is to investigate the reconstruction of sagittal alignment and the improvement of clinical outcomes after posterior instrumented double-level or single-level TLIF. Methods From January 2010 to September 2018, the records of patients with contiguous L4/5 and L5/S1 double-level spondylolytic spondylolisthesis were retrospectively reviewed. Patients who had undergone double-level or single-level TLIF and a minimum of 2 years’ follow-up were included. The slippage parameters and spino-pelvic parameters were measured preoperatively, postoperatively, and at the latest follow-up. Results A total of 58 patients (21 males and 37 females, mean age of 57.1 ± 6.9 years) were enrolled. Thirty-eight patients were treated with double-level TLIF and the remaining 20 with single-level TLIF (L4/5 in 14; L5/S1 in 6). After surgery, the spondylolisthesis was significantly reduced at both L4/5 and L5/S1 level (all P

Background: Gorham-Stout syndrome (GSS) involving the spine is a rare clinical entity, and there is a paucity of comprehensive study on its radiological features. We aimed to present the radiological changes and spinal deformities in patients with spinal GSS. Methods: From January 2005 to December 2017, 11 consecutive GSS patients with spinal deformity were identified. Their medical records and imaging features were retrospectively reviewed. Computed tomography (CT) and magnetic resonance imaging (MRI) were used for a precise evaluation of spinal involvement. Posteroanterior and lateral standing radiographs were used to evaluate the spinal deformity. Results: CT showed multi-level generalized osteolytic lesions, with ill-defined fluid attenuation adjacent to the osseous changes. MRI demonstrated hyperintense signals on both T1- and T2-weighted images, while the unaffected segments showed normal signal intensity. Seven patients (63.6%) had a dominant feature of kyphosis, and 4 (36.4%) had scoliosis when spinal GSS was diagnosed. Kyphosis variably spanned from C7 to L1, averaged 94° (range, 53° to 158°), and was associated with sagittal imbalance in 4 cases. In our series, the apex of kyphosis and scoliosis coincided within the most seriously osteolytic segment. All patients received medication for GSS. Two adolescents taking Boston braces showed a relatively stable deformity. Four patients received long posterior spinal fusion, but two had fusion failure. Conclusions: CT and MRI investigations are important in the initial diagnosis and continued management for spinal GSS. A typical spinal deformity secondary to GSS presents as kyphosis or kyphoscoliosis, which is usually highly variable but highly concordant with osteolysis in terms of span and apex.

STUDY DESIGN Retrospective study. OBJECTIVE The current study aimed to evaluate the effectiveness of the hybrid growing rod (GR) technique for the treatment of young children with congenital scoliosis (CS). SUMMARY OF BACKGROUND DATA Congenital vertebral anomalies within long-spanned kyphoscoliosis were difficult to be managed by either definitive spinal fusion or standard GR technique. Hybrid technique of one-stage posterior osteotomy with short fusion and GR distraction was proposed in previous studies. There is, however, paucity of data regarding its effectiveness. METHODS Thirteen patients (mean age, 5.4 ± 2.0 yr) who had undergone hybrid GR treatment were retrospectively reviewed, including 8 patients treated with single GR and 5 patients with dual GR. All of their radiographic data were measured, and surgical complications were recorded. RESULTS On average, the current cohort had 4.1 ± 1.7 lengthening procedures. After the index surgery, the major curve improved remarkably from 86.4° ± 11.9° to 37.3° ± 12.4° (P

OBJECTIVEThis study aimed to quantify the response of the cervical spine to the surgical correction of Scheuermann’s kyphosis (SK) and to postoperative proximal junctional kyphosis (PJK).METHODSFifty-nine patients (mean age 14.6 ± 2.3 years) were enrolled in the study: 35 patients in a thoracic SK (T-SK) group and 24 in a thoracolumbar SK (TL-SK) group. The mean follow-up period was 47.2 ± 17.6 months. Radiographic data, PJK-related complications, and patient-reported outcomes were compared between groups.RESULTSThe global kyphosis significantly decreased postoperatively, and similar correction rates were observed between the two groups (mean 47.1% ± 8.6% [T-SK] vs 45.8% ± 9.4% [TL-SK], p = 0.585). The cervical lordosis (CL) in the T-SK group notably decreased from 21.4° ± 13.3° to 13.1° ± 12.4° after surgery and was maintained at 14.9° ± 10.7° at the latest follow-up, whereas in the TL-SK group, CL considerably increased from 7.2° ± 10.7° to 11.7° ± 11.1° after surgery and to 13.8° ± 8.9° at the latest follow-up. PJK was identified in 16 patients (27.1%). Its incidence in the TL-SK group was notably higher than it was in the T-SK group (41.6% [n = 10] vs 17.1% [n = 6], p = 0.037). Compared with non-PJK patients, PJK patients had greater CL and lower pain scores on the Scoliosis Research Society–22 questionnaire (p < 0.05).CONCLUSIONSHyperkyphosis correction eventually resulted in reciprocal changes in the cervical spine, with CL notably decreased in the T-SK group but significantly increased in the TL-SK group. Patients developing PJK have increased CL, which seems to have a negative effect on patients’ health-related quality of life.

Previous studies have reported various predictors for curve progression in braced adolescent idiopathic scoliosis (AIS) patients. However, the reported predictors might be insufficient for patients with early AIS. The aim was to investigate whether the initial vertebra-disc ratio (VDR) could serve as an effective predictor for curve progression in early thoracic AIS (premenarchal and Risser 0) undergoing brace treatment.This study reviewed a consecutive series of early thoracic AIS girls with thoracic curve. All patients had accepted brace treatment and had regular follow-up. According to the bracing outcomes, patients were divided into two groups: Group P (progressed, curve progressed over six degrees or indicated for surgery) and Group NP (non-progressed).Totally 203 girls were included. There were 73 and 130 patients in Groups P and NP, respectively. The patients in Group P had greater initial VDR (1.9 ± 0.5 vs. 0.8 ± 0.4, P 0.01) than Group NP. During the follow-up, it showed continuous higher values in Group P than Group NP. The logistic regression analysis revealed that initial VDR had an effective value for predicting curve progression in the braced early AIS girls. The ideal cut-off point of initial VDR was 1.5 for the prediction of curve progression.The initial VDR could serve as an effective predictor for curve progression in braced early AIS girls. Evaluation of this new parameter should be carefully performed at the bracing initiation.

OBJECTIVEAs scoliosis in arthrogryposis multiplex congenita (AMC) is unusual and the number of cases reviewed in previous studies is also relatively small, no previous study exists that has directly compared the results of spinal deformity correction between AMC and adolescent idiopathic scoliosis (AIS) patients. The aim of this study was to compare the radiographic and clinical outcomes of surgical correction of spinal deformity associated with AMC versus AIS.METHODSTwenty-four adolescents with AMC were matched with 48 AIS patients in terms of Cobb angle of main curve, curve pattern, sex, age at surgery, Risser grade, and length of follow-up. Patients in both groups underwent posterior-only spinal correction and fusion procedures. The surgical outcomes and complications were analyzed and compared between the 2 groups.RESULTSIn comparison to the AIS group, the AMC group had a significantly longer mean operation time (5.6 vs 4.4 hours, p = 0.002), more blood loss (1620 ± 250 ml vs 840 ± 260 ml, p < 0.001), and more fusion levels (14.1 ± 2.3 levels vs 12.4 ± 2.5 levels, p = 0.007) as well as a lower correction rate (44.3% ± 11.1% vs 70.8% ± 12.4%, p < 0.001) and a higher rate of loss of correction (5.0% ± 3.1% vs 2.1% ± 1.9%, p < 0.001). Nine patients in the AMC group had preoperative pelvic obliquity, which was corrected from a mean of 14.2° ± 8.4° to a mean of 4.3° ± 3.2° (p < 0.001) after the surgery. The thoracic lordosis and sagittal vertical axis were significantly improved in the AMC group. Notably, however, the AMC group was found to have higher rates of screw malpositioning (15.9% vs 9.5%, p = 0.002) and complications (8/24 [33.3%] vs 4/48 [8.3%], p = 0.016) as compared to the AIS group.CONCLUSIONSCorrection of AMC-associated scoliosis tends to require a longer operating time and involve more fusion levels but results in less correction, more blood loss, and more complications, in comparison with AIS. In addition, more attention should be paid to pelvic obliquity and sagittal hyperlordosis in AMC patients.

STUDY DESIGN A retrospective study. OBJECTIVE To determine the incidence and risk factors of coronal decompensation after posterior-only thoracolumbar hemivertebra (HV) resection and short fusion in patients younger than 5-years old. SUMMARY OF BACKGROUND DATA Postoperative coronal decompensation may occur in operated patients during the follow up. However, there is a paucity of valid data regarding this complication in very young patients with thoracolumbar HV. METHODS This study reviewed a consecutive series of patients (younger than 5 years) who had undergone posterior-only hemivertebrectomy and short fusion from January 2006 to December 2014. They had a minimum follow-up of 24 months. According to the coronal compensation behavior, they were divided into two groups: Group P (progressed, curve decompensated beyond twenty degrees) and Group NP (nonprogressed, curve well compensated). RESULTS There were 179 patients included in this study. Mean age at surgery was 38 ± 11 months. Mean follow-up was 41 ± 11 months. Postoperative coronal decompensation was identified in 18 patients (rate, 10.1%) who constituted Group P. The remaining 161 patients had a well-compensated pattern. In contrast to Group NP, the patients in Group P had greater preoperative lowest instrumented vertebra (LIV) translation (18.5 mm ± 6.4 mm vs. 10.5 mm ± 4.9 mm, P

BACKGROUND CONTEXT Correction of kyphosis in Scheuermann's Kyphosis (SK) patients can be effectively achieved via a multilevel Ponte osteotomies pedicle screw-based instrumentation. However, the risk of developing proximal junctional kyphosis remains an important issue after surgeries for SK. The influence of the proximal rod contouring on the occurrence of PJK has not been investigated in SK patients. PURPOSE The aim of this study was to evaluate the influence of the proximal rod contouring on the radiographic results in patients with Scheuermann's Kyphosis. STUDY DESIGN/SETTING Single-center retrospective study. PATIENT SAMPLE This study included 59 patients with SK (57 men, 2 women), who had undergone posterior correction surgery between 2002 and 2015, and had been followed at least 12 months. OUTCOME MEASURES The proximal contouring rod angle (PCRA) is the angle between the upper endplate of the upper instrumented vertebra (UIV) and the lower endplate of the second vertebra caudal to UIV (UIV-2). A PJK was defined by the presence of a proximal junctional angle (PJA) greater than 10° at the latest follow-up, and the increase of this angle by more than 10° compared with preoperatively. METHODS Patients were separated into 2 groups: PJK group and non-PJK group. Comparisons were performed in terms of T-test between these two groups. ROC curve analysis and logistic regression analysis were performed. RESULTS The mean age was 20.24 ± 9.47 years old and the follow-up average were 16.3 months ± 8.3. No significant difference was found between two groups with regards to their ages, the PJA and the PCRA at preoperative time. At the last follow-up, 31,7% of the patients developed PJK, the mean value of PJA was 19.21 ± 4.6 in PJK group and was 7.76 ± 3.72 in non-PJK group (p CONCLUSIONS Patients whose PCRA angle are lower than 10° after surgery are more likely to develop PJK, demonstrating that under-contouring of the proximal rod is a risk factor for PJK in SK. So, proximal portion of the rod should be bent more kyphotic (more than 10° ). FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.