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IntroductionIn adult spinal deformity (ASD), sagittal imbalance and sagittal malalignment have been extensively described in the literature during the past decade, whereas coronal imbalance and coronal malalignment (CM) have been given little attention. CM can cause severe impairment in adult scoliosis and ASD patients, as compensatory mechanisms are limited. The aim of this paper is to develop a comprehensive classification of coronal spinopelvic malalignment and to suggest a treatment algorithm for this condition.MethodsThis is an expert’s opinion consensus based on a retrospective review of CM cases where different patterns of CM were identified, in addition to treatment modifiers. After the identification of the subgroups for each category, surgical planning for each subgroup could be specified.ResultsTwo main CM patterns were defined: concave CM (type 1) and convex CM (type 2), and the following modifiers were identified as potentially influencing the choice of surgical strategy: stiffness of the main coronal curve, coronal mobility of the lumbosacral junction and degeneration of the lumbosacral junction. A surgical algorithm was proposed to deal with each situation combining the different patterns and their modifiers.ConclusionCoronal malalignment is a frequent condition, usually associated to sagittal malalignment, but it is often misunderstood. Its classification should help the spine surgeon to better understand the full spinal alignment of ASD patients. In concave CM, the correction should be obtained at the apex of the main curve. In convex CM, the correction should be obtained at the lumbosacral junction.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

Introduction The surgical strategies to treat idiopathic scoliosis on adolescents and young adults need a basic reliable classification. King’s and Lenke’s classification are inappropriate because they fail to take shoulders and pelvis into account. Methods We propose the answer for the following three questions: Why are we challenging King’s and Lenke’s systems of classification? How many frontal and possibly sagittal curves do we need to be able to develop a strategy which is applicable to almost all cases? How should scoliotic curves be classified? Results In double thoracic and lumbar (thoracic predominant) scoliosis, the concepts of “pelvis included” and “pelvis excluded” are not simply based on a semantic distinction, but correspond to different physiopathological entities and require different surgical strategies. In double thoracic curves the concepts of “real double thoracic” and “potential double thoracic” curves are keys to obtain post operative shoulder balance. In lumbar scoliosis the concepts of “real lumbar” and “lumbosacral” curves are necessary to compare results of posterior or anterior approach in surgical strategies. The system proposed in this work involves ten basic curves. Conclusion The surgical strategies used to treat idiopathic scoliosis in adolescents and young adults depend on the school of thought as to whether the anterior or posterior approach is preferable and the extent of the vertebral instrumentation. A consensus system of classification of scoliotic curves is required to compare the results obtained using various methods. This has been done in the improved version of King’s system proposed here and should provide an efficient tool for use in comparative studies on surgical methods.

To characterize clinically measurable endophenotypes, implicating the TBX6 compound inheritance model. Patients with congenital scoliosis (CS) from China(N=345, cohort 1), Japan (N=142, cohort 2), and the United States (N = 10, cohort 3) were studied. Clinically measurable endophenotypes were compared according to the TBX6 genotypes. A mouse model for Tbx6 compound inheritance (N=52) was investigated by micro computed tomography (micro-CT). A clinical diagnostic algorithm (TACScore) was developed to assist in clinical recognition of TBX6-associated CS (TACS). In cohort 1, TACS patients (N=33) were significantly younger at onset than the remaining CS patients (P=0.02), presented with one or more hemivertebrae/butterfly vertebrae (P=4.9×10‒8), and exhibited vertebral malformations involving the lower part of the spine (T8–S5, P=4.4×10‒3); observations were confirmed in two replication cohorts. Simple rib anomalies were prevalent in TACS patients (P = 3.1×10‒7), while intraspinal anomalies were uncommon (P = 7.0 × 10‒7). A clinically usable TACScore was developed with an area under the curve (AUC) of 0.9 (P = 1.6 × 10‒15). A Tbx6-/mh (mild-hypomorphic) mouse model supported that a gene dosage effect underlies the TACS phenotype. TACS is a clinically distinguishable entity with consistent clinically measurable endophenotypes. The type and distribution of vertebral column abnormalities in TBX6/Tbx6 compound inheritance implicate subtle perturbations in gene dosage as a cause of spine developmental birth defects responsible for about 10% of CS.

BackgroundEarly-onset scoliosis (EOS), defined by an onset age of scoliosis less than 10 years, conveys significant health risk to affected children. Identification of the molecular aetiology underlying patients with EOS could provide valuable information for both clinical management and prenatal screening.MethodsIn this study, we consecutively recruited a cohort of 447 Chinese patients with operative EOS. We performed exome sequencing (ES) screening on these individuals and their available family members (totaling 670 subjects). Another cohort of 13 patients with idiopathic early-onset scoliosis (IEOS) from the USA who underwent ES was also recruited.ResultsAfter ES data processing and variant interpretation, we detected molecular diagnostic variants in 92 out of 447 (20.6%) Chinese patients with EOS, including 8 patients with molecular confirmation of their clinical diagnosis and 84 patients with molecular diagnoses of previously unrecognised diseases underlying scoliosis. One out of 13 patients with IEOS from the US cohort was molecularly diagnosed. The age at presentation, the number of organ systems involved and the Cobb angle were the three top features predictive of a molecular diagnosis.ConclusionES enabled the molecular diagnosis/classification of patients with EOS. Specific clinical features/feature pairs are able to indicate the likelihood of gaining a molecular diagnosis through ES.

Objective To propose a novel classification system for stratifying coronal curve patterns in congenital cervicothoracic scoliosis with hemivertebrae (CTS-HV). Methods Type A: regional cervicothoracic deformity only disturbing the balance of head-neck-shoulder complex; Type B: cervicothoracic deformity with significant trunk tilt to the convex side; Type C: cervicothoracic deformity with a significant compensatory thoracic curve. The reliability and reproducibility were assessed via the Kappa test. The differences among different subtypes in deformity parameters and bony structures were compared to identify the causative factors predisposing to different subtypes. Results 98 patients were classified into Type A (47 cases), Type B (31 cases), and Type C (20 cases). The Kappa test showed excellent reliability (Kappa value = 0.847) and reproducibility (Kappa value = 0.881). The proportions of Klippel-Feil syndrome in Types B (71.0%) and C (85.0%) were significantly higher than in Type A (46.8%; all P  < 0.05). Type A (66.0%) and Type B (71.0%) predominantly had their hemivertebra (HV) at T3 or T4, while Type C (75%) mostly had HV at T1 or T2. Type B exhibited the most severe trunk tilt, head shift, neck tilt, head tilt, and coronal balance distance (all P  < 0.05). Type C had the lowest T1 tilt and first rib angle despite the greatest cervicothoracic Cobb angle (all P  < 0.05). Conclusions This novel reliable classification allows a better understanding of structural diversity and different coronal compensatory mechanisms for the natural progression of CTS-HV. It can contribute to determining the individualized treatment strategy and standardizing academic communication for this rare clinical entity.

Adult scoliosis is defined as a spinal deformity in a skeletally mature patient with a Cobb angle of more than 10 degrees in the coronal plain. Adult scoliosis can be separated into four major groups: Type 1: Primary degenerative scoliosis, mostly on the basis of a disc and/or facet joint arthritis, affecting those structures asymmetrically with predominantly back pain symptoms, often accompanied either by signs of spinal stenosis (central as well as lateral stenosis) or without. These curves are often classified as \"de novo\" scoliosis. Type 2: Idiopathic adolescent scoliosis of the thoracic and/or lumbar spine which progresses in adult life and is usually combined with secondary degeneration and/or imbalance. Some patients had either no surgical treatment or a surgical correction and fusion in adolescence in either the thoracic or thoracolumbar spine. Those patients may develop secondary degeneration and progression of the adjacent curve; in this case those curves belong to the type 3a. Type 3: Secondary adult curves: (a) In the context of an oblique pelvis, for instance, due to a leg length discrepancy or hip pathology or as a secondary curve in idiopathic, neuromuscular and congenital scoliosis, or asymmetrical anomalies at the lumbosacral junction; (b) In the context of a metabolic bone disease (mostly osteoporosis) combined with asymmetric arthritic disease and/or vertebral fractures. Sometimes it is difficult to decide, what exactly the primary cause of the curve was, once it has significantly progressed. However, once an asymmetric load or degeneration occurs, the pathomorphology and pathomechanism in adult scoliosis predominantly located in the lumbar or thoracolumbar spine is quite predictable. Asymmetric degeneration leads to increased asymmetric load and therefore to a progression of the degeneration and deformity, as either scoliosis and/or kyphosis. The progression of a curve is further supported by osteoporosis, particularly in post-menopausal female patients. The destruction of facet joints, joint capsules, discs and ligaments may create mono- or multisegmental instability and finally spinal stenosis. These patients present themselves predominantly with back pain, then leg pain and claudication symptoms, rarely with neurological deficit, and almost never with questions related to cosmetics. The diagnostic evaluation includes static and dynamic imaging, myelo-CT, as well as invasive diagnostic procedures like discograms, facet blocks, epidural and root blocks and immobilization tests. These tests may correlate with the clinical and the pathomorphological findings and may also offer the least invasive and most rational treatment for the patient. The treatment is then tailored to the specific symptomatology of the patient. Surgical management consists of either decompression, correction, stabilization and fusion procedures or a combination of all of these. Surgical procedure is usually complex and has to deal with a whole array of specific problems like the age and the general medical condition of the patient, the length of the fusion, the condition of the adjacent segments, the condition of the lumbosacral junction, osteoporosis and possibly previous scoliosis surgery, and last but not least, usually with a long history of chronified back pain and muscle imbalance which may be very difficult to be influenced. Although this surgery is demanding, the morbidity cannot be considered significantly higher than in other established orthopaedic procedures, like hip replacement, in the same age group of patients. Overall, a satisfactory outcome can be expected in well-differentiated indications and properly tailored surgical procedures, although until today prospective, controlled studies with outcome measures and pre- and post-operative patient's health status are lacking. As patients, who present themselves with significant clinical problems in the context of adult scoliosis, get older, minimal invasive procedures to address exactly the most relevant clinical problem may become more and more important, basically ignoring the overall deformity and degeneration of the spine.

Classification systems for Adolescent Idiopathic Scoliosis (AIS) play an important role in guiding both surgical planning and conservative treatments. Traditional 2D classification systems, such as the Lenke, King and Lehnert‐Schroth classifications, have been widely used for the clinical diagnosis and treatment of scoliosis. However, with the growing understanding of the three‐dimensional nature of scoliosis and advancements in 3D reconstruction technologies, 3D classification systems are gaining increasing attention. This paper reviews the current applications, advantages, and limitations of different 2D and 3D classification systems, focusing on their clinical significance in treatment planning. While 3D classification systems offer clear advantages in capturing the complexity of spinal deformities, their clinical implementation faces challenges such as high costs and technical complexity. Additionally, studies show that computer‐assisted technologies, artificial intelligence can significantly improve the accuracy and consistency of classification systems, reducing human errors. The paper also explores the future directions of classification system development, emphasizing the potential of combining 2D and 3D technologies and the impact of these advancements on personalized scoliosis treatment. This study compares traditional 2D scoliosis classification systems (e.g., King, Lenke, and PUMC) with emerging 3D systems. It highlights the limitations of 2D methods and the advantages of integrating 3D models for more precise treatment planning and outcomes. The analysis shows that while 3D classification offers high reliability and comprehensive insights, challenges like complex modeling and clinical integration remain.

Human spine is a complex structure that plays a vital role in the movement, protection, and support of the body so it is very important to follow proper spine bio-mechanics to avoid any unwanted effect on body. Spinal diseases can cause compression or pulling the nerve roots, which can lead to radicular symptoms like back pain or leg pain. On the other hand, it may cause deformities which are most common at C4-C7 and L4-S1 level. Localization of vertebra bones that make up the spine is key in spinal disease diagnosis such as calculating cobb angles, shape detection, detecting vertebra fractures and other abnormalities. In this paper, we have covered four modules, first, for the vertebrae localization we used detection transformer to localize 68 corner points, Secondly, we have used a SegFormer to do the segmentation of the spine. Thirdly, center profile of the spine was generated using center point technique for localization and morphological thinning for segmentation. In the final step of shape analysis process, we take the profile of spine to calculates the features and classify the data into normal, Single-bend (C-shaped) and Double bend (S-shaped) spine. DETR gives mAP value of 0.96 at 0.5 IOU threshold and SegFormer achieves a dice score of 0.93 in segmenting spinal images. For the classification of the data, we have used different classifier (SVM, RF, KNN and NB). We have used three features from both Segformer and DETR techniques. Features acquired from localization technique (DETR) and Segmentation (SegFormer) yield better accuracy when using a random forest classifier. Random forest performs best for AASCE MICCAI 2019 dataset with an accuracy of 98.3%. The MAE 2.7 and SMAPE 4.37 of our proposed approach is slightly good than that of other methodologies.

The prognoses of patients who undergo open spinal endoscopy (OSE) decompression significantly differ by scoliosis type and symptom despite the use of uniform standards and procedures for the decompression surgery. These differences may be directly related to the selection and formulation of surgical strategies but their cause remains unclear. The aim of this study was to verify and evaluate the efficacy of the \"Symptom, Stenosis and Segment classification (SSS classification)\" in determining an appropriate surgical strategy and to analyze the differences in the outcomes of different patients after receiving the selected surgical strategy. The results of this study ultimately provide a theoretical basis for the specific optimization of surgical strategies guided by the \"SSS classification\". This work was a retrospective study. We reviewed 55 patients with scoliosis and spinal stenosis who underwent \"pear-shaped\" decompression under OSE from May 2021 to June 2023 treated by our surgical team. To classify different types of patients, we defined the \"SSS classification\" system. The permutation and combination of subtypes in Symptom (including three subtypes: Convex = v, Concave = c and Bilateral = b), Stenosis (including three subtypes: Convex = v, Concave = c and Bilateral = b), and Segment (including two subtypes: Edge = e and Inside = i) yields 18 possible types (details in Table 1) in this classification system. To classify different types of surgeries, we also defined the operation system. The VAS Back and VAS Leg scores after surgical treatment were significantly lower in all patients 3 months after surgery than before surgery. (**P < 0.05). The Svve type accounted for the greatest proportion of patients (62.50%) in the VAS back remission group, and the Scce type accounted for the greatest proportion (57.14%) in the VAS back ineffective group. According to the VAS leg score, the percentage of patients in whom Svve was detected in the VAS leg remission group reached 60.87%, and the percentage of patients in whom Svve was detected in the VAS leg ineffective group reached 44.44%. Svve accounted for the greatest proportion of cases (61.22%) in the JOA-effective group, and Scce accounted for the greatest proportion of cases (50.00%) in the JOA-ineffective group. In the JOA-effective group, the Ovv type accounted for the greatest proportion (up to 79.59%), while in the JOA-ineffective group, Occ and Ovv accounted for 50.00% of the cases each. The proportions of Svve type were the highest in the healthy group (up to 60.00%) and the ODI-effective group (up to 50.00%). The Ovv type accounted for the greatest proportion of patients in the ODI-effective group (up to 80.00%), and the Occ type accounted for the greatest proportion of patients in the ODI-ineffective group (up to 60.00%). Most of the surgical plans formulated by the \"SSS classification\" method were considered appropriate, and only when the symptoms of patients were located on the concave side did the endoscopic decompression plan used in the present study have a limited ability to alleviate symptoms.

Objective Emerging scoliosis (ES) is a rare phenomenon after hemivertebra (HV) resection and short segmental fusion. Since the introduction of the ES, there have been rare in‐depth studies. The aim of the present study was to further analyze the characteristics, risk factors, treatment, and prognosis of ES. Methods A retrospective study analyzed patients with congenital scoliosis due to a single HV who underwent posterior correction and short fusion from 2002 to 2022. ES was defined as a Cobb angle ≥20° from its initial value and an apical vertebra located ≥2 levels away from the fusion region. ES patients and non‐ES patients were matched at a 1:2 ratio. Both demographics and radiological parameters were compared. Univariate analysis and multivariate logistic analysis were used to identify the risk factors of ES. Results Among 261 patients, 13 patients (5.0%) experienced ES. There were eight females and five males. The mean age of the ES patients at the time of primary surgery was 6.6 ± 3.7 years old (2.0–13.2 years old), with a mean follow‐up of 64.2 ± 47.9 months (12–156 months). The ES could be further divided into three types: balance‐related ES, complication‐related ES, and separated ES. There were three balance‐related ESs, six complication‐related ESs, and four separated ESs. At the last follow‐up, six patients were under observation, six patients underwent brace treatment, and one patient underwent revision surgery. Multivariate logistic analysis showed that the magnitude of postoperative compensatory curve (CC) was an independent risk factor for ES (OR = 1.172, p = 0.014). Conclusions ES is an extraordinary phenomenon after HV resection and short fusion, and it can be divided into three types. The magnitude of postoperative CC was an independent risk factor for ES. According to the severity of ES, observation, brace, or surgery can be chosen. Currently, research on ES is scarce, and only two studies have focused on this rare postoperative phenomenon. After the concept of ES was proposed, no further in‐depth research was conducted on it. We believe that present research can enrich current research on ES, providing direction for further in‐depth research and reference for clinical diagnosis and treatment.