Interrater reliability of three-dimensional reconstruction of the spine : Low-dose stereoradiography for evaluating bracing in adolescent idiopathic scoliosis

Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 

Interrater reliability of three-dimensional reconstruction of the spine : Low-dose stereoradiography for evaluating bracing in adolescent idiopathic scoliosis.

Almansour H1Pepke W1Rehm J2Bruckner T3Spira D2Akbar M4

Orthopade. 2020 Apr;49(4):350-358. doi: 10.1007/s00132-019-03712-x.


Bracing constitutes the mainstay treatment for mild scoliosis. The 3D reconstruction of the spine using low-dose stereoradiographic imaging (LSI) is increasingly being used to determine the true shape of the deformity and to assess the success of bracing.


The aim of the study was to validate the measurement of 3D spinopelvic parameters and vertebral rotation in the setting of bracing treatment via a reliability study conducted in adherence to the guidelines for reporting reliability and agreement studies (GRRAS).


Full spine stereoradiographs of patients with adolescent idiopathic scoliosis (AIS) who underwent Chêneau bracing were retrospectively analyzed. The 3D reconstruction was performed by two experienced operators in a blinded manner and randomized order. Rotation of every vertebra was computed in the coronal, sagittal and axial planes. Sagittal spinopelvic parameters were evaluated. All measurements were statistically compared to determine agreement of the measurement of brace correction using the intraclass correlation coefficient (ICC).


In this study, 45 patients (81% females) aged 12.5 ± 2 years were included. The mean absolute difference was less than 3.5° for all measured angles, less than 4 mm for sagittal vertical axis (SVA) and less than 1.5 mm for lateral pelvic shift. The ICC was high for all parameters (ICC >0.81). Despite the overall high reliability, the reliability of axial rotation was lower in the upper and middle thoracic spine and the lower lumbar spine.


Brace wearing during full spine LSI acquisition does not affect spinal measurements. The LSI under bracing treatment produces reliable measurements of spinopelvic parameters as well as vertebral rotation. These reproducible 3D data enable spine surgeons to assess the true shape of the deformity, to quantify rotation of each vertebra and enhance the understanding of the efficacy of bracing treatment.

Prevalence of the thoracic scoliosis in children and adolescents candidates for strabismus surgery: results from a 1935-patient cross-sectional study in China.

Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 

Prevalence of the thoracic scoliosis in children and adolescents candidates for strabismus surgery: results from a 1935-patient cross-sectional study in China.

Pan XX, Huang CA, Lin JL, Zhang ZJ, Shi YF, Chen BD, Zhang HW, Dai ZY, Yu XP, Wang XY.

Eur Spine J. 2020 Apr;29(4):786-793. doi: 10.1007/s00586-020-06341-7. Epub 2020 Feb 28.


No study so far has paid attention to strabismus-related spinal imbalance. This study aimed to determine the epidemiology of thoracic scoliosis in children and adolescents with strabismus and investigate the association of two diseases.


A cross-sectional study. Study group consists of 1935 consecutive candidates for strabismus surgery (4-18 years); Control group consists of the age- and sex-matched patients with respiratory diseases. All subjects underwent a screening program based on chest plain radiographs using the Cobb method. Their demographic information, clinical variables and results of Cobb angle were recorded and analyzed.


A significantly higher prevalence of thoracic scoliosis (289/1935, 14.94% versus 58/1935, 3.00%) was found in study group compared with control group. Among strabismic patients, the coronal thoracic scoliosis curve mainly distributed in right and in main thoracic (198/289) and in the curves 10°-19° (224/289); Age range 7-9 years (103/1935), female (179/1935) and concomitant exotropia patients (159/851) were more likely to have thoracic scoliosis. According to the logistic regression, thoracic scoliosis had no significant association with age, BMI, duration of illness and onset age (p > 0.05). However, gender, BCVA, type of strabismus and degree of strabismus showed a significant relationship with the prevalence of thoracic scoliosis (p < 0.05).


With a pooled prevalence of 14.94%, strabismus patients showed a great higher risk of developing thoracic scoliosis. Screening for scoliosis in strabismus patients can be helpful to discover a high prevalence of potential coronal scoliosis. More attention should be paid to ophthalmological problems in patients with scoliosis. These slides can be retrieved under Electronic Supplementary Material.

Adolescents with and without idiopathic scoliosis have similar self-reported level of physical activity: a cross-sectional study

Diarbakerli E, Grauers A, Moller H, Abbott A, Gerdhem P

Scoliosis Spinal Disord. 2016 Jul 28;11:17. doi: 10.1186/s13013-016-0082-y. eCollection 2016

BACKGROUND: Little is known about physical activity levels in individuals with idiopathic scoliosis. The aim of this study was to describe the level of physical activity in adolescents with and without idiopathic scoliosis.

METHODS: Two hundred thirty-nine adolescents, median (25th, 75th percentile) age 16.0 (14.4, 17.6) with idiopathic scoliosis and 58 randomly recruited population-based individuals without scoliosis aged 14.6 (12.8, 16.3) participated. The 239 idiopathic scoliosis patients consisted of 88 untreated, 43 previously braced, 36 with ongoing brace-treatment and 72 surgically treated individuals. Main outcome measure was the proportion achieving at least moderate activity level, as estimated by the International Physical Activity Questionnaire short form (IPAQ-SF). Other outcome measures were Metabolic Equivalent Task (MET) minutes/week, time spent sitting, spare time activity level and sporting activities. Statistical analyses were adjusted for age and sex.

RESULTS: The proportion of individuals with scoliosis with moderate activity level was 180 out of 239 (75 %) and for individuals without scoliosis 49 out of 58 (85 %) (p = 0.14). Median MET-minutes/week (25th,75th percentile) was for individuals with scoliosis scoliosis 1977 (840,3777) and for individuals without scoliosis 2120 (887,4598) (p = 0.11). Sporting activities did not differ (p = 0.28). The ongoing brace-treatment group had a significantly higher proportion of individuals categorizing themselves at high spare time activity level compared to the surgically treated and previously braced individuals (p = 0.046). No difference was seen between the treatment groups regarding the proportion achieving moderate activity (p = 0.11) and sporting activities (p = 0.20). Median MET minutes/week was 2160 (794,3797) for the untreated group, 989 (661,2706) for the previously braced group, 2055 (1010, 4026) for the surgery group and 2106 (990,4480) for the ongoing brace-treatment group (p = 0.031).

CONCLUSION: Adolescents with idiopathic scoliosis show similar levels of self-reported physical activity as individuals without idiopathic scoliosis. Bracing and surgery do not appear to inhibit physical activity.

Risk of revision surgery for adult idiopathic scoliosis: a survival analysis of 517 cases over 25 years

Riouallon G, Bouyer B, Wolff S Eur Spine J. 2016 Aug;25(8):2527-34. doi: 10.1007/s00586-016-4505-5. Epub 2016 Mar 10.

Purpose: Little is known about the long-term status of patients operated for spine deformities. The aim of this study was to determine the survival of primary fusion in adult idiopathic scoliosis and identify the risk factors of revision surgery.

METHODS: Adult patients who underwent primary fusion for idiopathic scoliosis between 1983 and 2011 were included in a continuous monocentric retrospective series. Any additional surgery was registered for survival analysis. Survival and follow-up were estimated by the Kaplan-Meier method and an analysis was performed to identify the risk factors of revision surgery.

RESULTS: This series included 447 women (86.5 %) and 70 men (13.5 %) reviewed after a mean follow-up of 7 years (range 0-26.4). Mean age was 44.4 years. Fusion was performed on a median 11 levels (range 3-15); revision rate was 13 % (CI 10-17), 18 % (CI 14-23) and 20 % (CI 16-26) at 5, 10 and 15 years, respectively. Revision surgery was associated with age, anterior release, length of fusion, the inferior limit of fusion, post-operative sagittal balance and junctional kyphosis. The length of fusion (HR 1.13 per vertebrae fused, p = 0.007) and the lower limit of fusion (HR 5.9, p < 0.001) remained independent predictors of revision surgery on multivariate analysis.

CONCLUSION: This series evaluated the risk of revision surgery following spinal fusion for idiopathic scoliosis. Our results show that the risk seemed to increase linearly with a rate of nearly 20 % after 10 years. The length and lower limit of fusion are the main risk factors for revision surgery. Level IV (e.g. case series).

What do astronauts and 80% of the world’s population have in common? A galactic back pain …!

We are talking about that pain that affects, especially between 40 and 50 years, the column between the costal margin and the lower gluteal line. Back pain is, in fact, a pathology that continues to be among the most widespread according to data from the Global Burden Disease Study (2017): the study compared both the major causes of global disabilities over time and the data from 1990 and 2017.

The result? Low back pain maintains the podium in the causes of disability, with particular reference to countries with a high socio-demographic index (since it identifies where the country is located in terms of development by schooling, income and birth rate).

Consequently, there has been no improvement over time in the management capacity of this problem. Most cases still pose a challenge in terms of therapeutic management as their specific cause is unknown (George E. Ehrlich, Bulletin of the World Health Organization 2003; 81: 671-676).

Let’s go back to our spacemen. Because floating in space can be incredible, but unfortunately, half of the astronauts complain of back pain when they return, just like a good part of the rest of the population who pass their time on Earth.
Prolonged exposure to microgravity causes the muscles around the spine to relax and are less “trained” because they are not used. To put it like Luca Parmitano, one of the most famous Italian astronauts, “the spinal column in orbit seems to lengthen”.

In a recent study (Jeannie F. Bailey et al. 2018), the researchers evaluated some anatomical and functional parameters of the spine of some NASA astronauts before and after six months spent in orbit aboard the International Space Station and found that the prolonged exposure to the lack of gravity weakens the muscles that support the astronauts’ back.
“It has been seen that the atrophy of the muscles of the column rather than the protrusion of the intervertebral disc – explains Dr Francesca Di Felice, physician of Isico – is strongly associated with the reduction of lordosis (anterior curve of the column that allows a better distribution of the load to the lower limbs) and with the increase of the stiffness of the column and its weakening. This reduction in muscle strength increases back pain in astronauts once they return to Earth. It is easy to deduce the implications that these results also have for the deconditioned backs of sedentary subjects who live on Earth in gravity: what would happen to the laziest and most sluggish to physical activity would be superimposable to the anatomical and functional alterations recorded for experienced astronauts in a microgravity environment “.

Surgical Versus Nonsurgical Treatment for High-Grade Spondylolisthesis in Children and Adolescents: A Systematic Review and Meta-Analysis

Xue X, Wei X, Li L, Medicine (Baltimore). 2016 Mar;95(11):e3070. doi: 10.1097/MD.0000000000003070

The optimal management of high-grade spondylolisthesis in children and adolescent is controversial. There is a paucity of literature regarding operatively or nonoperative management in this setting. To assessment of the current state of evidence regarding high-grade spondylolisthesis treatment with the goal of obtaining outcome comparisons in these patients managed either operatively or nonoperatively.

We performed a systematic literature search up to November 2014, using Medline, Embase, and The Cochrane Library.

The analysis and eligibility criteria were documented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-guidelines) and Cochrane Back Review Group editorial board.

We used the Newcastle-Ottawa quality assessment scale (NOS-scale) to assess the quality. Five observational studies were considered eligible for analysis based on the evaluation of 1596 identified papers.

The mean overall difference in the Scoliosis Research Society questionnaire 22 between the surgical and nonsurgical groups was not statistically significant (95% CI: -0.17 to 0.21, P = 0.84). The pooled mean difference in progression of slip between the surgical and nonsurgical groups was no significant difference (OR: 0.47, 95% CI: 0.12-1.81, P = 0.27, I = 0%). B

ecause of the preponderance of uncontrolled case series, low-quality evidence indicates that the quality of life and progression of slips was no significant difference between surgery and nonoperation group.

Nonoperative patients had no radiologic progression of their slip during the follow-up period.

Please find here the abstract of the article:

Advantages and Disadvantages of Adult Spinal Deformity Surgery and its Impact on Health-related Quality of Life.

Every year, the Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers.

Advantages and Disadvantages of Adult Spinal Deformity Surgery and its Impact on Health-related Quality of Life.

Oshida G, Boissiere L, Larrieu D, Bourghli A, Vital JM, Gille O, Pointillart V, Challier V, Mariey R, Pellise F, Vila-Casademunt A, Perez-Grueso FJ, Alanay A, Acaroglu E, Kleinstuck F, Obeid I
Spine (Phila Pa 1976). 2016 Jul 7.

STUDY DESIGN: Prospective multicenter study of adult spinal deformity (ASD) surgery.

OBJECTIVE: To clarify the impact of ASD surgery on each health-related quality of life (HRQOL) subclass/domain.

SUMMARY OF BACKGROUND DATA: For ASD patients, surgery offers superior radiological and HRQOL outcomes compared to non-operative care. However, HRQOL may be affected by surgical advantages related to corrective effects, yielding adequate spinopelvic alignment and stability or disadvantages because of long segment fusion. METHODS: The study included 170 consecutive ASD patients from a multicenter database with >2-year follow-up period. We analyzed each HRQOL domain/subclass [short form-36 items (SF-36), Oswestry Disability Index (ODI), Scoliosis Research Society-22 questionnaire (SRS-22)], and radiographic parameters preoperatively and at 1 and 2 years postoperatively. We divided the patients into two groups each based on lowest instrumented vertebra (LIV; above L5 or S1 to ilium) or surgeon-determined preoperative pathology (idiopathic or degenerative). Improvement rate (%) was calculated as follows: 100 x |pre.-post.|/preoperative points (%) (+, advantages; -, disadvantages).

RESULTS: The scores of all SF-36 and SRS-22 subclasses improved at 1 and 2 years after surgery, regardless of LIV location and preoperative pathology. However, personal care and lifting in ODI were not improved after 1 year. These disadvantages were correlated to sagittal modifiers of SRS-Schwab classification similar to other HRQOL. The degree of personal care disadvantage mainly depended on LIV location and preoperative pathology. Although personal care improved after 2 years postoperatively, no noticeable improvements in lifting were recorded.

CONCLUSION: HRQOL subclass analysis indicated two disadvantages of ASD surgery, which were correlated to sagittal radiographic measures. Fusion to the sacrum or ilium greatly restricted the ability to stretch or bend, leading to limited daily activities for at least 1 year postoperatively, although this effect may subside after another year. Consequently, spinal surgeons should note the impact of surgical treatment on each HRQOL domain and counsel patients on the implications of surgery.

Eurospine: a participant’s comment

In September Isico attended the International Eurospine Congress in Barcelona. Dr. Francesca Di Felice presented a poster titled Adolescent idiopathic bracing success rates influenced by time in brace: Comparative effectiveness analysis of the BrAIST and ISICO cohorts, while Dr. Fabio Zaina delivered an oral presentation about the study, ISYQOL discriminates adolescents with spinal deformities subgroups better than the SRS-22 questionnaire.

The aim of Eurospine is to optimize patient care and prevention of spinal disorders, stimulating the exchange of knowledge and ideas in the field of research, prevention, and treatment of spine diseases. In recent years, the society, mostly represented by surgeons, has offered different surgical courses, but a novel development has occurred in Barcelona with the birth of Non-Surgical Interprofessional Courses: the EUROSPINE Diploma in Interprofessional Spine Care (EDISC). The non-surgical task force includes Dr. Fabio Zaina as responsible of the module on spinal deformities.

“We want to underline the great value in the field of research of Prof. Martin E. Schwab ‘s Medal Lecture at the conference: New therapies to repair the neuronal hardware and improve functional recovery after spinal cord injury,” says Dr. Di Felice. “Prof Schwab presented a clinical trial for anti-Nogo-A in acute spinal cord injury, promising in the rehabilitation of spinal cord injury (SCI). Nogo A is a suppressor of nerve fiber growth in the adult central nervous system (CNS); neutralization of Nogo-A by antibodies after CNS injury allows the enhancement of long-distance regeneration of injured fibers, the stimulation of compensatory fiber growth by speared systems, and a functional recovery.

An interesting topic has been the surgical symposium on Adolescent Spinal Deformities and Treatment Options in which the anterior surgery was debated. Anterior scoliosis correction and vertebral body tethering are examples of that: these techniques can be considered less invasive approaches compared to posterior surgery. The first one can also be used in curves over 65 degrees, stiff curves in mature adolescents and adults; the second one can be used in flexible curves less than 65 degrees in the growing spine”.