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More severe thoracic idiopathic scoliosis is associated with a greater three-dimensional loss of thoracic kyphosis

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Abstract

Study design

Retrospective.

Objectives

Utilize three-dimensional (3D) measurements to assess the relationship between thoracic scoliosis severity and thoracic kyphosis in a large, multicenter cohort, and determine impact of 3D measurements on adolescent idiopathic scoliosis (AIS) curve classification.

Summary of background data

Research has demonstrated differences in two-dimensional (2D) and 3D assessment of the sagittal plane deformity in AIS. A prior smaller, single-institution study demonstrated an association between scoliosis severity and loss of 3D thoracic kyphosis.

Methods

Data included retrospective compilation of prospectively enrolled bracing candidates and prospectively enrolled surgical candidates with thoracic AIS. Analysis included two groups based on thoracic curve magnitude: moderate (20–45°) and severe (> 45°). Imaging was performed using 2D radiographs. 3D thoracic kyphosis was calculated using a 2D to 3D conversion formula. Kyphosis was categorized according to the Lenke classification sagittal plane modifier.

Results

Analysis included 3032 patients. 2D kyphosis was significantly less in the moderate group (21 ± 12 vs 23 ± 14, p = 0.028). However, estimated 3D kyphosis was significantly greater in the moderate group (13 ± 10 vs 5 ± 12, p < 0.001). In the moderate group, the rate of normokyphosis was 78% with 2D measures and 61% with 3D measures of T5–T12 kyphosis. In the severe group, this rate changed from 72 to 32% with use of 2D and 3D measures, respectively. In the moderate group, 16% of patients were classified as hypokyphotic using 2D measures while this rate increased 38% with 3D measures (p < 0.001). In the severe group, this rate changed from 18 to 68% using 2D and 3D measures, respectively (p < 0.001).

Conclusions

Increased coronal curve severity was associated with decreased thoracic kyphosis. Hypokyphosis was more pronounced in 3D. 2D radiographs increasingly underestimate kyphosis with increasing coronal severity. Assessment of sagittal alignment from 2D radiographs can be improved with a 2D–3D conversion formula. Findings indicate potential for classification system improvement with use of 3D sagittal plane measurements.

Level of evidence

IV.

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Acknowledgements

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Arthritis And Musculoskeletal And Skin Diseases or the National Institutes of Health. Braist Investigators: Antony Kallur-Antony, MD, University of New Mexico. Charles T. Mehlman, DO, MPH, Cincinnati Children’s Hospital. Christopher W. Reilly, MD, British Columbia Children’s Hospital. Daniel W. Green, MD, Hospital for Special Surgery. Elizabeth A. Szalay, MD, University of New Mexico. Henry J. Iwinski, MD, Shriner’s Hospital for Children, Lexington. J. Timothy Hresko, MD, Children’s Hospital of Boston. Jacques L. d’Astous, MD, Shriner’s Hospital for Children, Salt Lake City. James G. Wright, MD, Hospital for Sick Children. James O. Sanders, MD, University of Rochester. Jean A. Ouellet, MD, Shriner’s Hospital for Children, Montreal. John B. Emans, MD, Children’s Hospital of Boston. John M. Flynn, MD, Children’s Hospital of Philadelphia. Joseph A. Gerardi, MD, Children’s Hospital of Central California. Kim W. Hammerberg, MD, Shriner’s Hospital for Children, Chicago. Kit Song, MD, Seattle Children’s Hospital. Mark F. Abel, MD, University of Virginia. Matthew B. Dobbs, MD, Washington University of St. Louis and Shriner’s Hospital for Children, St. Louis. Matthew Halsey, MD, Children’s Hospital of Central California. Michael L. Schmitz, MD, Children’s Orthopaedics of Atlanta. Munish C. Gupta, MD, Shriner’s Hospital for Children, Northern California. Nigel J. Price, MD, Children’s Mercy Hospital, Kansas City. Oheneba Boachie-Adjei, MD, Hospital for Special Surgery. Peter Sturm, MD, Shriner’s Hospital for Children, Chicago. Richard Schwend, MD, Children’s Mercy Hospital, Kansas City. Suken A. Shah, MD, Alfred I. duPont Hospital for Children. W. Timothy Ward, MD, Children’s Hospital of Pittsburgh. Walter F. Krengel, III, MD, Seattle Children’s Hospital. Harms Study Group Investigators: Aaron Buckland, MD; New York University. Amer Samdani, MD; Shriners Hospitals for Children—Philadelphia. Amit Jain, MD; Johns Hopkins Hospital. Baron Lonner, MD; Mount Sinai Hospital. Benjamin Roye, MD; Columbia University. Burt Yaszay, MD; Rady Children’s Hospital. Chris Reilly, MD; BC Children’s Hospital. Daniel Hedequist, MD; Boston Children’s Hospital. Daniel Sucato, MD; Texas Scottish Rite Hospital. David Clements, MD; Cooper Bone & Joint Institute New Jersey. Firoz Miyanji, MD; BC Children’s Hospital. Harry Shufflebarger, MD; Nicklaus Children's Hospital. Jack Flynn, MD; Children’s Hospital of Philadelphia. Jahangir Asghar, MD; Cantor Spine Institute. Jean Marc Mac Thiong, MD; CHU Sainte-Justine. Joshua Pahys, MD; Shriners Hospitals for Children—Philadelphia. Juergen Harms, MD; Klinikum Karlsbad-Langensteinbach, Karlsbad. Keith Bachmann, MD; University of Virginia. Larry Lenke, MD; Columbia University. Mark Abel, MD; University of Virginia. Michael Glotzbecker, MD; Boston Children’s Hospital. Michael Kelly, MD; Washington University. Michael Vitale, MD; Columbia University. Michelle Marks, PT, MA; Setting Scoliosis Straight Foundation. Munish Gupta, MD; Washington University. Nicholas Fletcher, MD; Emory University. Patrick Cahill, MD; Children’s Hospital of Philadelphia. Paul Sponseller, MD; Johns Hopkins Hospital. Peter Gabos, MD: Nemours/Alfred I. duPont Hospital for Children. Peter Newton, MD; Rady Children’s Hospital. Peter Sturm, MD; Cincinnati Children’s Hospital. Randal Betz, MD; Institute for Spine & Scoliosis. Ron Lehman, MD; Columbia University. Stefan Parent, MD: CHU Sainte-Justine. Stephen George, MD; Nicklaus Children's Hospital. Steven Hwang, MD; Shriners Hospitals for Children—Philadelphia. Suken Shah, MD; Nemours/Alfred I. duPont Hospital for Children. Tom Errico, MD; Nicklaus Children's Hospital. Vidyadhar Upasani, MD; Rady Children’s Hospital

IRB approval was obtained.

Funding

Research support is gratefully acknowledged from grants from the following: (1) BrAIST was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (R21AR049587 and R01AR052113), the Children’s Miracle Network, the Canadian Institutes of Health Research, the Shriners Hospitals for Children, the University of Rochester, and the Children’s Mercy Hospital and Clinics. (2) Research grants to the Setting Scoliosis Straight Foundation from DePuy Synthes Spine, EOS imaging, K2M, Medtronic, NuVasive and Zimmer Biomet in support of Harms Study Group research.

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Authors and Affiliations

  1. Department of Orthopaedics, University of California, San Diego, CA, USA

    Thomas Barrett Sullivan & Peter O. Newton

  2. Department of Orthopedics, Rady Children’s Hospital, 3020 Children’s Way, MC5062, San Diego, CA, 92123, USA

    Tracey P. Bastrom, Carrie E. Bartley & Peter O. Newton

  3. Department of Orthopedics, University of Iowa, Iowa City, IA, USA

    Lori A. Dolan & Stuart L. Weinstein

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  1. Thomas Barrett Sullivan
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  2. Tracey P. Bastrom
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  3. Carrie E. Bartley
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  4. Lori A. Dolan
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  5. Stuart L. Weinstein
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  6. Peter O. Newton
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Contributions

TBS, TPB, CEB, LAD, SLW, and PON: conception or design of the work; or acquisition, analysis, or interpretation of data for the work, drafting or critically revising the work, and final approval of the version to be published.

Corresponding author

Correspondence to Peter O. Newton.

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Study conducted at Rady Children’s Hospital, San Diego, USA.

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Sullivan, T.B., Bastrom, T.P., Bartley, C.E. et al. More severe thoracic idiopathic scoliosis is associated with a greater three-dimensional loss of thoracic kyphosis. Spine Deform 8, 1205–1211 (2020). https://doi.org/10.1007/s43390-020-00149-7

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