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Adolescent Idiopathic Scoliosis: A Deformity in Three Dimensions
Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Center for Medical Image Science and Visualization (CMIV). Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Orthopaedics in Linköping.
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Scoliosis is a complex three-dimensional deformity of the spine. Even though it has been known for centuries, treatment of the deformity has focused on correcting only in the frontal plane. In the last decades, the need for three-dimensional assessment regarding scoliosis has been highlighted to better understand the cause and the principles of treating scoliosis. The overall aim of this dissertation is to provide knowledge to assess scoliosis as a three-dimensional problem.

The severity of scoliosis is measured with the Cobb angle from standing radiographs. Computed tomography (CT) examinations are used throughout this thesis. The first paper investigates the difference in Cobb angle measured from standing radiographs and supine CT examinations. The standing radiographs had larger Cobb angles with a mean difference of 11° and a linear correlation between the two examinations from 128 consecutive patients with adolescent idiopathic scoliosis (AIS) planned for surgery.

The second paper compares the axial shape of vertebrae in 20 patients with AIS with a reference group. Clear asymmetry was observed in all vertebrae – superior and inferior end vertebrae as well as the apical vertebra – compared with corresponding vertebrae among the reference group. The asymmetry was most pronounced in the apical vertebra. A novel parameter, frontal vertebral body rotation (FVBR), was introduced to describe the internal rotation of the vertebrae in the axial plane.

Pelvic incidence (PI) is a measurement of the position of the sacrum in relation to the femoral heads. This is relevant in scoliosis because PI determines the pelvic configuration acting as a foundation to the spine. PI has traditionally been measured from standing radiographs. The third study investigates PI three-dimensionally, based on low-dose CT examinations, in 37 patients with Lenke type 1 or 5 curves compared with a reference group. A significantly higher PI was observed in patients with Lenke type 5 curves compared with the reference group and patients with Lenke type 1 curves.

Severe AIS is treated with corrective surgery. Two approaches are available: the predominant posterior approach and the anterior approach. In the fourth paper, these two approaches are evaluated with regard to three-dimensional correction, how well the correction is maintained over a 2-year follow-up and patient-reported outcome measures. Twenty-seven patients treated with the posterior approach and 26 patients treated with the anterior approach, all with Lenke type 1 curves, were included. Fewer vertebrae were fused in the anterior group, but the posterior group had a better correction of the deformity in the frontal plane. No difference was observed regarding three-dimensional correction and patient-reported outcome measures.

AIS is truly a complex three-dimensional deformity. More research is needed to fully comprehend the complexity of the scoliotic spine.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2018. , p. 76
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1635
National Category
Surgery
Identifiers
URN: urn:nbn:se:liu:diva-152572DOI: 10.3384/diss.diva-152572ISBN: 9789176852361 (print)OAI: oai:DiVA.org:liu-152572DiVA, id: diva2:1261510
Public defence
2018-12-14, Berzeliussalen, Campus US, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2018-11-07 Created: 2018-11-07 Last updated: 2018-11-23Bibliographically approved
List of papers
1. A Comparison of Cobb Angle: Standing Versus Supine Images of Late-Onset Idiopathic Scoliosis
Open this publication in new window or tab >>A Comparison of Cobb Angle: Standing Versus Supine Images of Late-Onset Idiopathic Scoliosis
2016 (English)In: Polish Journal Of Radiology, ISSN 1733-134X, Vol. 81, p. 270-276Article in journal (Refereed) Published
Abstract [en]

Background: Scoliosis is traditionally evaluated by measuring the Cobb angle in radiograph images taken while the patient is standing. However, low-dose computed tomography (CT) images, which are taken while the patient is in a supine position, provide new opportunities to evaluate scoliosis. Few studies have investigated how the patient's position, standing or supine, affects measurements. The purpose of this study was to compare the Cobb angle in images from patients while standing versus supine.less thanbr /greater thanMaterial/methods: A total of 128 consecutive patients (97 females and 21 males; mean age 15.5 [11-26] years) with late-onset scoliosis requiring corrective surgery were enrolled. One observer evaluated the type of curve (Lenke classification) and measured the Cobb angle in whole-spine radiography (standing) and scout images from low-dose CT (supine) were taken on the same day.less thanbr /greater thanResults: For all primary curves, the mean Cobb angle was 59 (SD 12) while standing and 48 (SD 12) while in the supine position, with a mean difference of 11 (SD 5). The correlation between primary standing and supine images had an r value of 0.899 (95% CI 0.860-0.928) and an intra-class correlation coefficient value of 0.969. The correlation between the difference in standing and supine images from primary and secondary curves had an r value of 0.340 (95% CI 0.177-0.484).less thanbr /greater thanConclusions: We found a strong correlation between the Cobb angle in images obtained while the patient was standing versus supine for primary and secondary curves. This study is only applicable for patients with severe curves requiring surgical treatment. It enables additional studies based on low-dose CT.

Place, publisher, year, edition, pages
Medical Science International, 2016
Keywords
Scoliosis; Spine; Supine Position
National Category
Radiology, Nuclear Medicine and Medical Imaging
Identifiers
urn:nbn:se:liu:diva-145863 (URN)10.12659/PJR.895949 (DOI)27354881 (PubMedID)
Available from: 2018-03-20 Created: 2018-03-20 Last updated: 2018-11-23Bibliographically approved
2. Vertebral Axial Asymmetry in Adolescent Idiopathic Scoliosis.
Open this publication in new window or tab >>Vertebral Axial Asymmetry in Adolescent Idiopathic Scoliosis.
2018 (English)In: Spine Deformity, ISSN 2212-1358, Vol. 6, no 2, p. 112-120.e1Article in journal (Refereed) Published
Abstract [en]

Study Design

Retrospective study.

Objectives

To investigate parameters of axial vertebral deformation in patients with scoliosis compared to a control group, and to determine whether these parameters correlated with the severity of spine curvature, measured as the Cobb angle.

Summary of Background Data

Adolescent idiopathic scoliosis (AIS) is the most common type of spinal deformity. Many studies have investigated vertebral deformation, in terms of wedging and pedicle deformations, but few studies have investigated actual structural changes within vertebrae.

Methods

This study included 20 patients with AIS (Lenke 1–3, mean age: 15.6 years, range: 11–20). We compared preoperative low-dose computed tomography(CT) examinations of patients with AIS to those of a control group matched for age and sex. The control individuals had no spinal deformity, but they were admitted to the emergency department for trauma CTs. We measured the Cobb angles and the axial vertebral rotation (AVR), axial vertebral bodyasymmetry (AVBA), and frontal vertebral body rotation (FVBR) for the superior end, inferior end, and apical vertebrae, with in-house–developed software. Correlations between entities were investigated with the Pearson correlation test.

Results

The average Cobb angles were 49.3° and 1.3° for the scoliotic and control groups, respectively. The patient and control groups showed significant differences in the AVRs of all three vertebra levels (p < .01), the AVBAs of the superior end and apical vertebrae (p < .008), and the FVBR of the apical vertebra (p = .011). Correlations were only found between the AVBA and FVBR in the superior end vertebra (r = 0.728, p < .001) and in the apical vertebra (r = 0.713, p < .001).

Conclusions

Compared with controls, patients with scoliosis showed clear morphologic differences in the midaxial plane vertebrae. Differences in AVR, AVBA, and FVBR were most pronounced at the apical vertebra. The FVBR provided valuable additional information about the internal rotation and deformation of vertebrae.

Level of Evidence

Level III.

Place, publisher, year, edition, pages
Elsevier, 2018
Keywords
Scoliosis; Morphology; Three-dimensional; Vertebral rotation; Low-dose CT
National Category
Orthopaedics
Identifiers
urn:nbn:se:liu:diva-145864 (URN)10.1016/j.jspd.2017.09.001 (DOI)29413732 (PubMedID)2-s2.0-85032338953 (Scopus ID)
Available from: 2018-03-20 Created: 2018-03-20 Last updated: 2018-11-23Bibliographically approved
3. Three-dimensional pelvic incidence is much higher in (thoraco)lumbar scoliosis than in controls
Open this publication in new window or tab >>Three-dimensional pelvic incidence is much higher in (thoraco)lumbar scoliosis than in controls
Show others...
2018 (English)In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932Article in journal (Refereed) Epub ahead of print
Abstract [en]

Purpose

The pelvic incidence (PI) is used to describe the sagittal spino-pelvic alignment. In previous studies, radiographs were used, leading to less accuracy in establishing the three-dimensional (3D) spino-pelvic parameters. The purpose of this study is to analyze the differences in the 3D sagittal spino-pelvic alignment in adolescent idiopathic scoliosis (AIS) subjects and non-scoliotic controls.

Methods

Thirty-seven female AIS patients that underwent preoperative supine low-dose computed tomography imaging of the spine, hips and pelvis as part of their general workup were included and compared to 44 non-scoliotic age-matched female controls. A previously validated computerized method was used to measure the PI in 3D, as the angle between the line orthogonal to the inclination of the sacral endplate and the line connecting the center of the sacral endplate with the hip axis.

Results

The PI was on average 46.8° ± 12.4° in AIS patients and 41.3° ± 11.4° in controls (p = 0.025), with a higher PI in Lenke type 5 curves (50.6° ± 16.2°) as compared to controls (p = 0.042), whereas the Lenke type 1 curves (45.9° ± 12.2°) did not differ from controls (p = 0.141).

Conclusion

Lenke type 5 curves show a significantly higher PI than controls, whereas the Lenke type 1 curves did not differ from controls. This suggests a role of pelvic morphology and spino-pelvic alignment in the pathogenesis of idiopathic scoliosis. Further longitudinal studies should explore the exact role of the PI in the initiation and progression of different AIS types.

Place, publisher, year, edition, pages
Heidelberg: Springer, 2018
Keywords
Idiopathic scoliosis, Sagittal alignment, Pelvic incidence, Three-dimensional analysis, Computed tomography
National Category
Orthopaedics
Identifiers
urn:nbn:se:liu:diva-152573 (URN)10.1007/s00586-018-5718-6 (DOI)30128762 (PubMedID)2-s2.0-85051834138 (Scopus ID)
Available from: 2018-11-07 Created: 2018-11-07 Last updated: 2018-11-23Bibliographically approved

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