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PurposeThis study aims to evaluate this new sequential correction technique for preventing postoperative coronal imbalance.MethodsAdult Spinal deformity (ASD) patients were stratifies into two types: primary thoracolumbar/lumbar (TL/L) curve with compensatory lumbosacral (LS) curve (Type I) and primary LS curve with compensatory TL/L curve (Type II): for Type I patients: correction of major TL/L curve and one- or two-level segmental rod installed at the convexity of the TL/L curve, L4-S1 TLIF to correct fractional curve and a short rod installed on the contralateral side and installation of long rods; for Type II patients: horizontalize L4 and L5, short rod installation at the convexity of the LS curve, distraction of curve with regional rod and installation of long rods. ASD patients were enrolled with inclusion criteria: with pre-op TL/L Cobb angle more than 30°, with pelvic fixation and with UIV over T10. Radiographic parameters were analyzed.ResultsTwenty-one patients were recruited (14 patients Type I and 7 Type II patients). Both Cobb angle and coronal offset were significantly improved after surgery. In Type I patients, Cobb angle was improved from 50.48° to 26.91° and coronal offset from 2.94 to 0.95 cm; in Type II patients, Cobb angle was improved from 61.42° to 28.48° and coronal offset from 2.82 to 1.38 cm. In the 10 patients with baseline coronal imbalance, 9 were corrected to coronal balance after surgery.ConclusionThe sequential correction technique allows decomposing the complex correction surgery into several steps, and each step focuses only on one task. It can also reduce the difficulty of rod installation due to the separated maneuvers and multi-rod system.Level of evidenceIVGraphic abstractThese slides can be retrieved under Electronic Supplementary Material.

Purpose To investigate the prevalence of degenerative lumbar scoliosis (DLS) in Chinese Han population, as well as its correlation with age, gender, bone mineral density (BMD), and body mass index (BMI); and to determine factors that might affect the curve severity. Methods A prospective study was performed on adults visiting the dual-energy X-ray absorption clinics for physical examination from January 2011 to March 2012. 2,395 subjects aged older than 40 years and having no history of previous spinal trauma, surgeries or scoliosis, were enrolled in this study. A logistic regression analysis was performed to determine the independent variables related to the presence of scoliosis. Besides, the relationship between curve severity and these variables was also analyzed with partial linear correlation analysis. Results The prevalence of DLS was approximately 13.3 %. The logistic regression analysis showed that age, T score, and gender all had remarkable correlation with the occurrence of DLS, with the odd ratios being 4.2, 1.5, and 1.6, respectively. According to the receiver operating characteristics curve, the best dividing point for age and T score of female subjects was 65 and −2.0, respectively. Partial linear correlation analysis indicated that there existed no obvious correlation between the above variables and the severity of scoliosis. Conclusion The prevalence of DLS in Chinese Han population aged older than 40 years was approximately 13.3 %, which had a significant correlation with age, gender, and BMD. Osteopenia, gender of female, and aged older than 65 years could contribute to the presence of DLS. The curve severity was not associated with age, gender, BMI, or BMD.

PurposeDistal radius and ulna (DRU) classification scheme has been proposed for predicting skeletal maturity in patients with idiopathic scoliosis (IS). However, the utilization of DRU classification scheme in the assessment of growth peak and curve progression in IS was still inconclusive. This study aimed to correlate the distal radius and ulna stages with several indicators for growth potential and to evaluate the predictive value of DRU system for curve progression in braced female IS patients.MethodsThis was a consecutive longitudinal study including physically immature IS girls receiving standardized bracing treatment and regularly followed up every 3–6 months until brace weaning. The following data of each visit were collected: chronologic age, standing height, Cobb angle, spinal length, Risser sign, digital skeletal age (DSA) scores and DRU scores. The height velocity (HV), spinal growth velocity (SGV) and angle velocity (AV) of each visit were calculated. The correlation among radius stage, ulna stage, Risser sign, height, spinal length, HV, SGV and AV was studied.ResultsForty braced IS girls with 349 longitudinal whole spine X-rays were reviewed. The average DRU scores at initial visit were R6.5 ± 1.1 and U4.5 ± 1.2 for radius and ulna, respectively. Both the radius stages between R5 and R8 and ulna stages between U3 and U6 indicated high SGV and high HV. The DSA scores were 402.1 ± 48.8 and 430.8 ± 44.4 at R7 and R8, respectively. The AV values were − 5.9 ± 12.4°/y and − 0.4 ± 1.5°/y at R5 and R6, which increased to 5.9 ± 17.3°/y, 3.1 ± 15.7°/y and 4.2 ± 12.2°/y at R7, R8 and R9, respectively. The DSA scores were 387.3 ± 65.7 for U5 and 432.9 ± 48.5 for U6, respectively. The AV values were − 3.1 ± 0.3°/y at U3, − 1.7 ± 9.3°/y at U4, 2.3 ± 16.1°/y at U5, 5.4 ± 15.5°/y at U6 and 4.4 ± 12.9°/y at U7.ConclusionsBoth distal radius and ulna scores correlate with the longitudinal growth potential, and thus, the DRU scoring scheme is an alternative predictor for growth potential and curve progression in girls with IS.Graphic abstractThese slides can be retrieved under Electronic Supplementary Material.

Adolescent idiopathic scoliosis (AIS) is a structural deformity of the spine affecting millions of children. As a complex disease, the genetic aetiology of AIS remains obscure. Here we report the results of a four-stage genome-wide association study (GWAS) conducted in a sample of 4,317 AIS patients and 6,016 controls. Overall, we identify three new susceptibility loci at 1p36.32 near AJAP1 (rs241215, P combined =2.95 × 10 −9 ), 2q36.1 between PAX3 and EPHA4 (rs13398147, P combined =7.59 × 10 −13 ) and 18q21.33 near BCL-2 (rs4940576, P combined =2.22 × 10 −12 ). In addition, we refine a previously reported region associated with AIS at 10q24.32 (rs678741, P combined =9.68 × 10 −37 ), which suggests LBX1AS1 , encoding an antisense transcript of LBX1 , might be a functional variant of AIS. This is the first GWAS investigating genetic variants associated with AIS in Chinese population, and the findings provide new insight into the multiple aetiological mechanisms of AIS. The authors perform a genome-wide association study of adolescent idiopathic scoliosis patients of Han Chinese descent, and identify 3 new loci for disease susceptibility.

Objective To evaluate the surgical efficacy of repeated vertebral column resection (Re‐VCR) after instrumentation removal in congenital scoliosis (CS) patients previously undergoing primary posterior spinal correction with VCR, and to analyze complications pertinent to revision surgery. Methods In this retrospective cross‐sectional study, a total of 16 CS patients who underwent Re‐VCR following instrumentation removal between February 2013 and February 2022 were reviewed. Radiographic parameters were assessed pre‐ and post‐primary operation, pre‐removal, pre‐ and post‐revision and at the last follow‐up. Clinical data were also analyzed and recorded for each patient. Results The indications for instrumentation removal were infection, implant failure, patient and family request, and persistent pain. The Cobb angle of the main curve, global kyphosis (GK), coronal balance (CB) and sagittal vertical axis (SVA) significantly progressed after instrumentation removal. The average progression rates of scoliosis and kyphosis were 5.3° ± 4.0°/year and 10.0° ± 7.2°/year. Following revision surgery, the Cobb angle of the main curve, GK, CB showed significant improvement (t = 10.694, p < 0.001; Z = −3.516, p < 0.001; Z = −2.664, p = 0.008). For Re‐VCR, the average extension of the fusion level was 2.9 ± 1.4 vertebrae proximally, 3.0 (2.0, 3.0) vertebrae distally and 5.4 ± 1.6 vertebrae in total. The average correction rates of the Cobb angle of the main curve and GK were 59.5% ± 23.4% and 53.7% ± 18.3% with no significant correction loss during follow‐up (p > 0.05). Compared with pre‐revision, the mean scores of pain, satisfaction, mental health and self‐image on the Scoliosis Research Society‐22 (SRS‐22) questionnaire improved at different levels. Intra‐revision complications included alert of neurophysiological monitoring and dural tear, while breakage of the distal L5 pedicle screw occurred in 1 (6.3%) patient 2 years after revision. Conclusions Severe progression of deformity and trunk imbalance was frequently observed following instrumentation removal. The removal of instrumentation is not routinely recommended, and revision surgery employing Re‐VCR frequently necessitates an extension of the fusion level. Satisfactory radiographic and clinical outcomes following Re‐VCR were effectively maintained throughout the follow‐up period, but great caution should be exercised during Re‐VCR. The average extension of fusion level for repeated vertebral column resection (Re‐VCR) was 5.4 in total and the average correction rates of the Cobb angle of the main curve and kyphosis were 59.5% and 53.7%. Satisfactory radiographic and clinical outcomes after Re‐VCR could be achieved, but great care should be taken.

Objective Hemivertebrae in the cervicothoracic junction in the pediatric population are treated conventionally with a two‐rod instrumentation pattern. However, the increase in complexity, severity, and immaturity of osseous malformation in the cervicothoracic spine presents additional challenges in construct planning. This study aims to introduce an integrated instrumentation strategy named the sequential correction technique in the treatment of congenital cervicothoracic scoliosis caused by hemivertebra (CTS‐HV) and evaluate its feasibility and treatment effects. Methods We retrospectively analyzed a consecutive series of patients with CTS‐HV who underwent posterior‐only HV resection with sequential correction technique from March 2018 to November 2023. This technique employed multiple rods, each being designated for a specific task, to sequentially perform surgical maneuvers involving osteotomy closure, torticollis correction, and implant integration. Individualized adjustments on instrumentation configuration involving rod number, rod type (whole, segmental, or satellite), cervical anchor choice, and connector placement could be made according to the severity of CTS and cervical pedicle dysplasia. Radiographic deformity parameters of the head–neck–shoulder complex were measured preoperatively, postoperatively, and at the latest follow‐up. One‐way repeated measures analysis of variance and Bonferroni correction were used to compare data at different time points. Additionally, any complications that occurred intraoperatively and during follow‐up would be recorded. Results Twenty‐two pediatric and adolescent patients were recruited with a mean age of 8.3 ± 3.7 years. The ratio for the location of the resected CTS‐HVs were C6 (4.6%), C7 (13.6%), T1 (31.8%), T2 (9.1%), T3 (27.6%), and T4 (13.6%). All patients were instrumented with screw‐hook hybrid constructs, of which 3‐rod and 4‐rod constructs accounted for 81.8% and 18.2%, respectively. The cervicothoracic scoliosis, T1 tilt, neck tilt, clavicular angle, head tilt, and head shift were all significantly corrected from 53.1° ± 11.4°, 25.3° ± 10.1°, 19.6° ± 9.3°, 4.5° ± 3.1°, 10.7° ± 8.3°, and 21.8 ± 18.0 mm preoperatively to 20.8° ± 7.6°, 14.4° ± 7.2°, 7.3° ± 6.5°, 2.3° ± 2.6°, 4.4° ± 2.5°, and 9.8 ± 8.8 mm postoperatively (all p < 0.05). No significant correction loss was observed at the final follow‐up (all p > 0.05). The incidences of intraoperative dural tear and iatrogenic Horner's syndrome were both 4.6%. Transitory bilateral nerve root paralysis causing upper limb dysfunction occurred in 1 patient. Additionally, 3 patients suffered severe distal curve progression with trunk tilt and were surgically revised with instrumentation extending to the stable zone. No implant‐related complications were observed. Conclusions This modified sequential correction technique possesses the merits of easy rod installation, satisfying torticollis correction, good symmetry and verticality of the entire instrumentation, and high fixation rigidity with multi‐rod constructs across the cervicothoracic junction. Thus, it is endowed with great application values in the treatment of CTS. Sequential Correction Technique for Congenital Cervicothoracic Scoliosis. A novel multi‐rod construct technique offering effective deformity correction, enhanced symmetry, and robust fixation stability.

Study Design A retrospective and consecutive study. Objective To demonstrate the curve evolution of distal non‐structural compensatory curves in patients with congenital cervicothoracic hemivertebra (CTH) scoliosis undergoing posterior‐only hemivertebra resection and to propose the possible mechanisms of this specific phenomenon. Summary of Background Data Though the spinal alignment could be well corrected via posterior hemivertebra resection in CTH patients, the high prevalence of distal curve progression was remarkable. However, the curve behavior of distal non‐structural compensatory curves and its possible mechanisms were unclear. Methods This study retrospectively reviewed a consecutive series of CTH patients undergoing posterior‐only hemivertebra resection with a minimum 24 months follow‐up. The parameters measured in coronal plane included local scoliosis, clavicle angle, head shift, and the Cobb angle of distal unfused segments. The distal curve was considered as an emerging scoliosis (ES) if with more than 20° progression and the apex of distal curve no less than 2 levels away from the lower instrumented vertebra. Results A total of 51 CTH patients with a mean age of 8.5 ± 3.8 years at surgery and a mean 38.0 ± 5.3 months follow‐up were recruited. The correction of local scoliosis and clavicle angle was statistically significant (p < 0.05 for all). The distal compensatory curve was 11.8 ± 5.3° before surgery and 6.5° ± 4.1° after surgery (p < 0.001), which was slightly increased to 11.6° ± 10.9° (p = 0.002) at the latest follow‐up. During follow‐up, the increase of distal compensatory curve was significantly correlated with the change in clavicle angle (r = 0.49, p = 0.038). The ES was observed in 10 patients (19.6%) with an average value of 28.0 ± 2.1° at diagnosis, including 7 patients within 6 months and 3 patients after 5 years postoperatively. The mean value of ES was 31.9° ± 3.1° at the latest follow‐up, while no patients required revision surgery. The ES was classified into compensatory and idiopathic types according to the typical curve behaviors. The compensatory ES usually presented within 6 months after operation and was responsible for further reconstruction of head and shoulder balance. While the idiopathic ES occurred at adolescent which may be related to the rapid body growth. Conclusions Distal compensatory curve had a tendency toward slight progression during follow‐up in CTH patients with posterior hemivertebra resection surgery. The prevalence of emerging scoliosis was 19.6% and the typical compensatory and idiopathic curve behavior were firstly proposed. Close and longitudinal follow‐up was thus highly recommended for CTH patients with posterior HV resection surgery. Distal compensatory curve had a tendency toward slight progression during follow‐up in CTH patients with posterior hemivertebra resection surgery. The prevalence of emerging scoliosis was 19.6% and the typical compensatory and idiopathic curve behavior were firstly proposed.

Background The gene of pituitary homeobox 1 (PITX1) has been reported to be down-regulated in adolescent idiopathic scoliosis (AIS), of which the cause has not been well addressed. The abnormal DNA methylation was recently assumed to be an important mechanism for the down-regulated genes expression. However, the association between PITX1 promoter methylation and the etiology of AIS was not clear. Methods The peripheral blood samples of 50 AIS patients and 50 healthy controls were collected and the genomic DNA was extracted. The pyrosequencing assay was used to assess the methylation status of PITX1 promoter and real-time quantitative polymerase chain reaction (PCR) was used to detect the PITX1 gene expression. Comparison analysis was performed using independent t test and Chi-square tests, while correlation analysis were performed with 2-tailed Pearson coefficients. Results The mean methylation level was (3.52 ± 0.96)% in AIS and (1.40 ± 0.81)% in healthy controls ( P  < 0.0001). The PITX1 gene expression was 0.15 ± 0.08 in AIS and 0.80 ± 0.55 in healthy controls ( P  < 0.0001). The comparative analysis showed significant difference in age ( P  = 0.021) and Cobb angle of the main curve ( P  = 0.0001) between AIS groups with positive and negative methylation. The methylation level of 6 CpG sites in PITX1 promoters was significantly associated with Cobb angle of the main curve ( P  < 0.001) in AIS. No statistical relationship between PITX1 promoter methylation and gene expression was found in AIS ( P  = 0.842). Conclusion Significantly higher methylation level and lower PITX1 gene expression are found in AIS patients. PITX1 methylation is associated with Cobb angles of the main curves in AIS. DNA methylation thus plays an important role in the etiology and curve progression in AIS.

Objective Surgical decision‐making for congenital kyphosis (CK) with failure of anterior segmentation (type II) has been contradictory regarding the trade‐off between the pursuit of correction rate and the inherent risk of the osteotomy procedure. This study was designed to compare the clinical and radiographic measurement in type II CK underwent SRS‐Schwab Grade 4 osteotomy and vertebral column resection (VCR), the most‐adapted osteotomy techniques for CK, and to propose the strategy to select between the two procedures. Methods This retrospective observational comparative study evaluated surgical outcomes in type II CK patients underwent VCR or SRS‐Schwab Grade 4 osteotomy at our institution between January 2015 and January 2020. Patients operated with VCR and SRS‐Schwab Grade 4 osteotomy were allocated to Group 1 and Group 2 respectively. Radiographic parameters and SRS‐22 quality of life metrics were assessed at pre‐operation, post‐operation, and during follow‐up visits for both groups, allowing for a comprehensive comparison of surgical outcomes. Results Thirty‐one patients (19 patients in Group 1 and 12 patients in Group 2) aged 16.3 ± 10.4 years were recruited. Correction of segmental kyphosis was similar between groups (51.1 ± 17.6° in Group 1 and 48.4 ± 19.8° in Group 2, p = 0.694). Group 1 had significantly longer operation time (365.9 ± 81.2 vs 221.4 ± 78.9, p < 0.001) and more estimated blood loss (975.2 ± 275.8 ml vs 725.9 ± 204.3 mL, p = 0.011). Alert event of intraoperative sensory and motor evoked potential (SEP and MEP) monitoring was observed in 1 patient of Group 2. Both groups had 1 transient post operative neurological deficit respectively. Conclusion SRS‐Schwab Grade 4 osteotomy was suitable for kyphotic mass when its apex is the upper unsegmented vertebrae or the neighboring disc, or when the apical vertebrae with an anterior/posterior (A/P) height ratio of vertebral body higher than 1/3. VCR is suitable when the apex is located within the unsegmented mass with its A/P height ratio lower than 1/3. Proper selection of VCR and SRS‐Schwab Grade 4 osteotomy according to our strategy, could provide satisfying radiographic and clinical outcomes in type II CK patients during a minimum of 2 years follow‐up. Patients undergoing VCR procedure might have longer operation time, more blood loss and higher incidence of peri‐ and post‐operative complications. Illustration of our selection strategy for SRS‐Schwab Grade 4 osteotomy (A, B) and vertebral column resection (C) for patients with type II congenital kyphosis. Both techniques, if selected properly, could provide sufficient correction of kyphosis and satisfying clinical outcome.

Background There was a paucity of valid information on how to rectify the convex coronal imbalance effectively in dystrophic scoliosis secondary to Type I neurofibromatosis (DS-NF1), while postoperative inadvertent aggravation of CCI occurred regularly resulting in poor patient satisfaction. We aimed to identify the risk factors for persistent postoperative CCI in DS-NF1, and to optimize the coronal rebalancing strategies based on the lessons learned from this rare case series. Methods NF1-related scoliosis database was reviewed and those with significant CCI (> 3 cm) were identified, sorted and the outcomes of surgical coronal rebalance were analyzed to identify the factors being responsible for failure of CCI correction. Results CCI with dystrophic thoracolumbar/lumbar apex was prone to remain uncorrected (7 failure cases in 11) when compared to those with thoracic apex (0 failure cases in 4) (63.6% vs. 0.0%, p  = 0.077). Further comparison between those with and without post-op CCI showed a higher correction of main curve Cobb angle (65.9 ± 9.1% vs. 51.5 ± 37.3%, p  = 0.040), more tilted instrumentation (10.3 ± 3.6° vs. 3.2 ± 3.1°, p  = 0.001) and reverse tilt and translation of upper instrumented vertebra (UIV) to convex side (8.0 ± 2.3° vs. -3.4 ± 5.9°, p  < 0.001; 35.4 ± 6.9 mm vs. 12.3 ± 13.1 mm, p  = 0.001) in the uncorrected imbalanced group. Multiple linear regression analysis revealed that △UIV translation (pre- to post-operation) (β = 0.832; p  = 0.030) was significantly correlated with the correction of CBD. Conclusion Thoracolumbar/lumbar CCI in dystrophic scoliosis was prone to suffer high risk of persistent post-op CCI. Satisfying coronal rebalance should avoid UIV tilt and translation to the convex side, tilted morphology of instrumentation and over correction maneuvers for main curve, the upper hemi-curve region in particular.