A malignant tumor would also hurt at rest. As for Scheuermann and scoliosis, we should be given some physical data because the patient presents with a specific examination that would give us the diagnosis.

A 13-year-old boy presents dorsal pain of several months of evolution, only when standing and walking, what diagnosis should we consider?

Back pain during growth.

It is wrong to believe that back pain only burdens adults: the yearly incidence during growth ranges from 10-20%, continuously increasing from childhood to adolescence. Rapid growth-related muscular dysbalance and insufficiency, poor physical condition in an increasingly sedentary adolescent community or - vice versa - high level sports activities, account for the most prevalent functional pain syndromes. In contrast to adults the correlation of radiographic findings with pain is high: the younger the patient, the higher the probability to establish a rare morphologic cause such as benign or malignant tumours, congenital malformations and infections. In children younger than 5 years old, the likelihood is more than 50%. The following red flags should lower the threshold for a quick in-depth analysis of the problem: Age of the patient <5 years, acute trauma, functional limitation for daily activities, irradiating pain, loss of weight, duration >4 weeks, history of tumour, exposition to tuberculosis, night pain and fever. High level sport equals a biomechanical field test which reveals the biologic individual response of the growing spine to the sports-related forces. Symptomatic or asymptomatic inhibitory or stimulatory growth disturbances like Scheuermann disease, scoliosis or fatigue fractures represent the most frequent pathomorphologies. They usually occur at the disk-growth plate compound: intraspongious disk herniation, diminuition of anterior growth with vertebral wedging and apophyseal ring fractures often occur when the biomechanical impacts exceed the mechanical resistance of the cartilaginous endplates. Spondylolysis is a benign condition which rarely becomes symptomatic and responds well to conservative measures. Associated slippage of L5 on S1 is frequent but rarely progresses. The pubertal spinal growth spurt is the main risk factor for further slippage, whereas sports activity - even at a high level - is not. Therefore, the athlete should only be precluded from training if pain persists or in case of high grade slips. Perturbance of the sagittal profile with increase of lumbar lordosis, flattening of the thoracic spine and retroflexion of the pelvis with hamstrings contractures are strong signs for a grade IV olisthesis or spondyloptosis with subsequent lumbosacral kyphosis. Idiopathic scoliosis is not related to pain unless it is a marked (thoraco-) lumbar curve or if there is an underlying spinal cord pathology. Chronic back pain is an under recognised entity characterised by its duration (>3 months or recurrence within 3 months) and its social impacts such as isolation and absence from school or work. It represents an independent disease, uncoupled from any initial trigger. Multimodal therapeutic strategies are more successful than isolated, somatising orthopaedic treatment. Primary and secondary preventive active measures for the physically passive adolescents, regular sports medical check-up's for the young high level athletes, the awareness for the rare but potentially disastrous pathologies and the recognition of chronic pain syndromes are the cornerstones for successful treatment of back pain during growth.

[One hundred years of orthopedics in the Netherlands. IV. Spinal abnormalities].

In recent years there has been spectacular progress in the approach to various disorders of the spinal column. Owing to improved methods of osteosynthesis there is no longer so much need for long periods of postoperative bed rest. Of all the scolioses, idiopathic scoliosis is most common. The vast majority of these cases are not clinically significant. What is seen in the remaining cases if left untreated is a progression in the curvature during growth. Progressive idiopathic scoliosis can be effectively treated using conservative methods. Screening at school is an important part of this process. If the curvature proves progressive and skeletal growth is not complete a brace can be prescribed. Use of this strategy and form of treatment can avoid progression of the curvature and development of serious deformities. This conservative therapy has markedly reduced the need for corrective surgery. Scheuermann's disease is characterized by a fixed dorsal thoracic kyphosis. Progressive Scheuermann's kyphosis can be effectively treated using a brace. The majority of fractures of the vertebral bodies can be treated conservatively. However, serious fractures normally require surgical intervention. In the industrialised Western world, low back pain is a major health problem and the foremost cause of disability and unfitness for work. Low back pain caused by degenerative disease of the spinal column should be treated using a multidisciplinary approach. The development of advanced operative techniques and osteosynthesis methods has made it possible to treat metastases of the spine surgically. The effects of this treatment on the quality of life are encouraging.

Benefits of F.E.D. treatment in Scheuermann's disease.

Scheuermann's disease or deforming vertebral osteochondritis affects about 5% of the population. These patients become permanent users of rehabilitation services due to their discomfort. In periods of acute pain patients can only receive palliative and not very effective treatment. In this study 30 patients who fulfil the criteria for diagnosis of Scheuermann's disease were treated with the F.E.D. device. By using this method, a back pressure of up to 100 kg can be applied at the apex of the kyphosis, stretching the anterior common vertebral ligament in an attempt to diminish complaint. There were 14 men and 16 women with ages ranging from 15 to 35 years old. The mean kyphotic angle was 53 degrees (range, 45-65). Patients had an average Risser of 4.75 (range, 3-5). Schöber's test disclosed a range of values from 0 to 2.5 cm (mean, 0.78). The average period of treatment was 4 months (80 sessions of treatment). SUMMARY OF RESULTS AND FINDINGS: All the 30 patients referred disappearance of thoracic back pain after treatment. This pain relief effect was permanent for the time of follow-up. Kyphotic angle decreased from a mean of 30 degrees Cobb to 45 degrees (16% correction). A home physiotherapy program was recommended to all the patients in order to maintain dorsal elasticity as measured by Schöber's test. After treatment, the mean Schöber test value was 2.92. In cases treated during the growing period, where alterations in the spine were minimal or did not show radiographic alterations, progression of the kyphotic deformity was stopped. The F.E.D. device has shown to be a promising method both for the treatment of complaints in stabilised Scheuermann's disease and control of the progression of kyphotic deformity in the growing spine.

[Adult Scheuermann's disease as cause of mechanic dorsalgia].

Scheuermann's disease (SD) or vertebral osteochondrosis is the most frequent cause of non postural kyphosis and one of more frequent cause of adolescent's dorsalgia. The criteria for the diagnosis are: more than 5 degrees of wedging of at least three adjacent vertebrae at the apex of the kyphosis; a toracic kyphosis of more than 45 of Cobb's degree; Schmorl's nodes and endplates irregularities. In addition to classic SD, there are radiological alterations that remain asymptomatic for a long time to reveal in adult age: in that case it speaks of adult Scheuermann's disease (ASD). We considered the diagnosis of patients came from April 2006 to April 2007 on Day Hospital in our Clinic. ASD was diagnosed, besides, in 10 of these patients. 7 patients had previous diagnosis such as: dorsal Spondiloarthrosis (4 subjects); Osteoporosis with vertebral fractures (3 subjects). All these diagnosis was not confirmed by us. In case of chronic dorsalgia of adult, ASD is rarely considered as differential diagnosis. Besides, the vertebral dorsalgia, even in absence of red flags as fever, asthenia,hypersedimetry, functional loss and aching spinal processes to tapping, could hide a serious scene that lead us to be careful in the differential diagnosis, because of similar radiological pictures of the MSA to other pathology as spondylodiscitis, primitive or metastasic spinal tumors, and brittleness vertebral fractures.

Untreated Scheuermann's disease: a 37-year follow-up study.

There are only a few follow-up studies of untreated Scheuermann's disease. The aim of this study was to investigate the relationship between vertebral changes, back pain, and disability in patients with untreated Scheuermann's disease after a 37-year follow-up. Eighty patients responded to a postal questionnaire concerning back pain and disability and 49 of them had classic Scheuermann's disease. Degree of kyphosis, lordosis, scoliosis, the number of affected vertebrae, and mean and maximum wedge angles were measured from radiographs. Back pain and disability scores were compared to a sample of the general Finnish population (n = 3,835). At follow-up, the patients were on average 59 (SD 8) years old (range 44-79 years), and the mean follow-up time was 37 (SD 7) years (26-54 years). The patients comprised more males than females (3.1:1). At follow-up, male patients were on average 3 cm taller than controls (p = 0.007). At age 20, female patients compared to controls were on average 6 kg heavier (p = 0.016) and had higher body mass index (BMI) (mean 23.9 kg/m(2) vs. 20.8 kg/m(2), p = 0.001). Scheuermann's patients had 2.5-fold [odds ratio (OR); 95% confidence interval (CI); 1.4-4.5, p = 0.003] increased risk for constant back pain compared to controls. The risk for disability because of back pain during the past 5 years (OR 2.6; 95% CI 1.4-4.7, p = 0.002), risk for back pain during the past 30 days (OR 3.7; 95% CI 1.9-7.0, p < 0.001) and risk for sciatic pain (OR 2.3; 95% CI 1.3-4.3, p = 0.005) were higher compared to controls. Scheuermann's patients had higher risk for difficulties in mounting stairs (OR 5.4; 95% CI 2.8-10.3, p < 0.001) and in carrying a 5 kg load for at least 100 m (OR 7.2; 95% CI 3.9-13.3, p < 0.001). Scheuermann's patients had a higher risk for back pain and disabilities during activities of daily living than controls. However, the degree of thoracic kyphosis among Scheuermann's patients was not related to back pain, quality of life, or general health.

[The particularities of the adult Scheuermann's disease: study about 45 patients].

Our aim was to find out which factors favor the occurrence of pain in adult patients with Scheuermann's disease--a juvenile manifestation of osteochondrosis of the spine, to study the clinical and radiological signs, the role of rehabilitation and the means to avoid the recurrence of pain. Descriptive and retrospective study about 45 adults treated by rehabilitation. A data sheet listed the patient's occupation, current practice of sport, antecedents (violent sport, traumatism, pain), presence of a family form, motive of consultation, clinical and paraclinical examinations and immediate and long-term results of rehabilitation. Average age 35 years (18 to 65), male predominance (1.8:1), occupational risk factors: 16%; only 24% practiced sports currently. sports 49%, spinal column traumatism 13%, dorsal and lumbar pain during adolescence 16%. Consultation motive: abnormal posture 4% and pain 96%. According to the examination: abnormal spinal column in 80% of cases. According to radiography, our patients were divided into 49% who were carriers of growth vertebral dystrophy and 51% who were carriers of the real Scheuermann's disease. The immediate results of rehabilitation were satisfactory, 75% of the results were very good and good. Between six months and four years, 70% of the results were very satisfactory. Exercises were observed in only 11% of the cases, and stopped after two months on average. Scheuermann's disease in adults is a different entity from that of the teenager for the major manifestation is pain and not aesthetic quality. The patient's occupation is rather sedentary; sport is beneficial. The functional rehabilitation is the basic treatment and recourse to surgery or dorso-lumbar braces is rare.

Scheuermann's disease: an update.

Scheuermann's disease is a juvenile osteochondrosis of the spine. It is a disease of the growth cartilage endplate, probably due to repetitive strain on the growth cartilage weakened by a genetic background. The radiographic aspects are related to the vertebral endplate lesions and include vertebral wedging, irregularity of the vertebral endplate, and Schmorl's node (intraossous disk herniation). Disc alterations are frequent and may be secondary to dysfunction of the disc-vertebra complex. The definitions of Scheuermann's disease are varied; it can refer to the classical form of juvenile kyphosis, described by Scheuermann as well as asymptomatic radiographic abnormalities. Lumbar involvement is probably as frequent as the thoracic form and might be more painful. The first-line treatment is medical and includes rehabilitation and bracing. The earlier the start of treatment, the better the outcome, which highlights the importance of early diagnosis. Surgery is uncommon and must be limited to severe involvement after failure of conservative treatment. The natural history of Scheuermann's disease is unknown, but it might be associated with increased risk of back pain. The evolution of thoracolumbar and lumbar disease is unknown.

[The protrusion of thoracic intervertebral disc-thoracic spondylosis (author's transl)].

The protrusion of cervical intervertebral discs was divided into three pathological entities by Spurling; soft disc, hard disc and spondylosis. We applied these concept to the dorsal intervertebral disc disease and treated two cases of thoracic spondylosis. Case 1. A 41-year-old male entered the hospital because of the gradual progression of weakness of both legs of two months' duration. Since ten days before admission he had not had an errection and had not been to able to walk and micturate. He also complained of paresthesia radiating down the abdomen into both legs. There were no visceral complaints. Neurological examination revealed severe weakness of both legs with bilateral impairment of deep sensations and hypalgesia up to the level of T6. Reflexes in both legs were hyperactive with sustained clonus. Plantar responses were extensor bilaterally. Though plain X-rays showed no changes, tomography revealed a calcified intervertebral spur formation at the T5-6 interspace. A myelogram showed a complete block of the contrast medium at the level of the upper part of T6. The patient underwent a complete laminectomy from T3 through T6 and extradural anterior decompression with the removal of the calcified disc at the T5-6 interspace using an air drill. Postoperatively, he demonstrated an immediate improvement in sensation and a gradual recovery in motor power. At his follow-up examination 14 months after surgery he could walk without assistance. Case 2. A 47-year-old dwarfish woman (130 cm) with a low back pain and difficulty in walking for a few years duration was admitted. A few months before admission she felt pain at her left lateral abdomen. There was weakness of both legs, greater in the left. Reflexes in her left lower extremity were hyperactive with sustained clonus. Plantar responces were flexor bilaterally. Palin X-rays showed scoliosis of thoracic spine with the top at T7 level and calcified intervertebral masses at T10-11, T11-12 and T12-L1, extending into the canal that were confirmed more clearly by tomography. Myelography by a cisternal puncture disclosed a complete block at the level of T10. The patient underwent total laminectomy of T9 through L2 and extradural anterior decompression with the removal of calcified discs. At her follow-up examination 12 months after surgery she could walk for herself with some residual neurological signs, minimal weakness in the right leg and hypesthesia up to the level of T12 in the left. We have discussed the incidental, related diagnostic and operative problems of this disease.

Scoliosis

See also Back brace Kyphosis Lordosis Neuromechanics of idiopathic scoliosis Pott disease Scheuermann's disease Schooliosis Scoliosis Research Society References External links Early Onset Scoliosis is the abnormal, side-to-side curve of the spine in children under five years old, often including children with congenital scoliosis (present at birth, with spine abnormalities) and infantile scoliosis (birth to three years). Questions and Answers about Scoliosis in Children and Adolescents – US National Institute of Arthritis and Musculoskeletal and Skin Diseases Bones of the vertebral column Congenital disorders of musculoskeletal system Deforming dorsopathies Wikipedia medicine articles ready to translate

Australopithecus afarensis

Australopithecines, in general, seem to have had a high incidence rate of vertebral pathologies, possibly because their vertebrae were better adapted to withstand suspension loads in climbing than compressive loads while walking upright. Lucy presents marked thoracic kyphosis (hunchback) and was diagnosed with Scheuermann's disease, probably caused by overstraining her back, which can lead to a hunched posture in modern humans due to irregular curving of the spine. Because her condition presented quite similarly to that seen in modern human patients, this would indicate a basically human range of locomotor function in walking for A. afarensis. The original straining may have occurred while climbing or swinging in the trees, though, even if correct, this does not indicate that her species was maladapted for arboreal behaviour, much like how humans are not maladapted for bipedal posture despite developing arthritis. KSD-VP-1/1 seemingly exhibits compensatory action by the neck and

Scheuermann's disease

While there is no explanation for what causes Scheuermann's Disease, there are ways to treat it. For less extreme cases, manual medicine, physical therapy and/or back braces can help reverse or stop the kyphosis before it does become severe. Because the disease is often benign, and because back surgery includes many risks, surgery is usually considered a last resort for patients. In severe or extreme cases, patients may be treated through an extensive surgical procedure in an effort to prevent the disease from worsening or harming the body. In Germany, a standard treatment for both Scheuermann's disease and lumbar kyphosis is the Schroth method, a system of specialized physical therapy for scoliosis and related spinal deformities. The method has been shown to reduce pain and decrease kyphotic angle significantly during an inpatient treatment program.

Copenhagen disease

Signs and Symptoms Clinical Studies and Case Reports 15‐Year‐Old Male A 15-year-old male presented with major thoracolumbar kyphosis with spinal stiffness. However, there was no presentation of pain, scoliosis, neurologic symptoms, or trouble with ambulating. Through a combination of MRI of the spine, radiography findings, and absence of sacroiliac joint movement, Copenhagen disease was diagnosed. In this individual, exam findings showed anterior vertebral body fusion, as well as multilevel lumbar anterior disc space obliteration and erosion. The narrowing and erosion of end plates can occur in early childhood and progress during adolescence as well. The narrowing can extend posteriorly, leading to complete vertebral fusion. In this 15-year-old male, trans-pedicle osteotomy of T12-L1 was performed in order to treat the individual. 12‐Year‐Old Female

Scoliosis

Society and culture The cost of scoliosis involves both monetary losses and lifestyle limitations that increase with severity. Respiratory deficiencies may also arise from thoracic deformities and cause abnormal breathing. This directly affects exercise and work capacity, decreasing the overall quality of life. In the health care system of the United States, the average hospital cost for cases involving surgical procedures was $30,000 to $60,000 per person in 2010. As of 2006, the cost of bracing has been published as up to $5,000 during rapid growth periods, when braces must be consistently replaced across multiple follow-ups. Research Genetic testing for adolescent idiopathic scoliosis, which became available in 2009 and is still under investigation, attempts to gauge the likelihood of curve progression. See also Back brace Kyphosis Lordosis Neuromechanics of idiopathic scoliosis Pott disease Scheuermann's disease Schooliosis Scoliosis Research Society References

Spinal fusion

Lumbar and cervical spinal fusions are more commonly performed than thoracic fusions. Degeneration happens more frequently at these levels due to increased motion and stress. The thoracic spine is more immobile, so most fusions are performed due to trauma or deformities like scoliosis, kyphosis, and lordosis. Conditions where spinal fusion may be considered include the following: Degenerative disc disease Spinal disc herniation Discogenic pain Spinal tumor Vertebral fracture Scoliosis Kyphosis (e. g., Scheuermann's disease) Lordosis Spondylolisthesis Spondylosis Posterior rami syndrome Other degenerative spinal conditions Any condition that causes instability of the spine

Kümmell' s disease: A rare spine entity in a young adult.

Over 100 years ago, Dr Hermann Kümmell described a rare clinical entity in which patients, after a trivial trauma and an asymptomatic period, developed a progressive vertebral body collapse and a painful kyphosis. We present the case of a 31years old heavy labourer, fitting Kümmell's criteria. The patient referred to us in an incapacitated state, due to persistent back pain. Radiographic examination revealed a body collapse of L1 vertebra. The patient had no previous medical record, other than a prolonged history of transient back pain episodes, related to heavy-weight lifting. Last attack was 1 year before presentation. Through course of time, he had undergone several clinical and radiological evaluations, by different orthopaedists, on different occasions, including the last episode, with no major findings. After an extensive workup, a percutaneous kyphoplasty of the affected vertebra was performed and a biopsy was obtained. The histologic examination of the specimen revealed vertebral osteonecrosis. A triggering pattern of repetitive spinal loading in hyperflexion is, for the first time, being recognized. We conclude that Kümmell's disease, although a rare condition, should be considered in any patient with refractory back pain symptoms. In such patients, vigorous follow-up turns to be of the essence.

Pediatric cervical kyphosis in the MRI era (1984-2008) with long-term follow up: literature review.

Cervical kyphosis is rare in the pediatric population. It may be syndromic or acquired secondary to laminectomy, neoplasia, or trauma. Regardless, this should be avoided to prevent progressive spinal deformity and neurological deficit. Long-term follow-up is needed to evaluate fusion status, spine growth, potential instability, and neurological function. A retrospective review of 27 children (6 months to 16 years) with cervical kyphotic deformity was performed and limited to the MRI era until 2008, to provide a long-term follow-up after which complex instrumentation was available. There were 27 patients, 19 syndromic (average age 5.36 years), and 8 non-syndromic (average age 14 years). Syndromes encountered were spondyloepiphyseal dysplasia (SED) 4, spondylometaphyseal dysplasia 1, unnamed collagen abnormality syndrome 1, osteogenesis imperfecta (OI) 2, Aarskog syndrome 1, Weaver syndrome 1, Larsen syndrome 1, multiple cervical level disconnection syndrome 1, Klippel-Feil 3, congenital absence of C2 pars 4. Non-syndromic cases; 2 with neurofibromatosis (NF1) and prevertebral tumors, fibromatosis 1, spontaneous kyphosis 1, and postlaminectomy 4. Factors considered were age, pathology, flexibility on cervical spine dynamic films, reduction with traction and spinal cord compression. Patients with flexible kyphosis underwent dorsal fixation. Children with non-flexible ventral compression/kyphosis had crown halo traction. Irreducible kyphosis had ventral decompression and fusion as well as dorsal fusion. Eleven of 19 syndromic children with flexible and reducible kyphosis underwent dorsal fixation alone. Four of 8 non-syndromic (2 NF1) needed ventral and dorsal approaches. The preoperative deformity (global and local Cobb angles) as well as neurological status improved. Growth during follow-up was not impaired, and we did not encounter instability or junctional kyphosis. The only complications were seen in syndromic patients. One patient with SED showed delayed cantilever bending of the ventral fusion mass requiring reoperation, and 1 other OI child had left C5 and C6 nerve root weakness after anterior C4 and C5 decompression which resolved over 1 year. One child with SED developed cervicothoracic junction scoliosis 18 years later after thoracic scoliosis surgery. Syndromic pathology presented early with neurological dysfunction and 24% had rigid kyphosis. An attempt at traction/reduction was successful as in Tables 1 and 2. The majority exhibited long-term improvement in kyphosis and function. A treatment algorithm and literature review is presented. Table 1 Motor function of the modified Japanese Orthopedic Association (JOA) score in children [24, 37] Score Upper extremity •Unable to move hands or feed oneself 0 •Can move hands; unable to eat with spoon 1 •Able to eat with spoon with difficulty 2 •Able to use spoon; clumsy with buttoning 3 •Healthy; no dysfunction 4 Lower extremity •Unable to sit or stand 0 •Unable to walk without cane or walker 1 •Walks independently on level floor but needs support on stairs 2 •Capable to walking, clumsy 3 •No dysfunction 4 Table 2 Pediatric cervical kyphosis-preoperative evaluations Case ID, year presented Age Sex Diagnosis Presentation Imaging Apex Cobb angle degree Reducibility Preop traction Syndromic #1 2003 4 years M SED Progressive quadriparesis Bladder incontinence Severe C2-4 kyphosis with cord compression C3-4 85° No No #2 2001 3 years M SED Progressive quadriparesis C2-3 kyphosis. No dorsal C2. Buckled cord C2-3 25° No No Recurrent weakness after recovery 2 years later Kyphosis at fusion site C2-3 33° No No #3 1997 13 years M SED Neck pain. Hand weakness. Thoracic scoliosis C1-3 kyphosis Os odontoideum C2-3 30° Yes No #4 2006 6 years F SED Tingling in hands Bladder incontinence Deformed C2 body and odontoid C1-2 instability C2-3 27° Yes No #5 1997 4 years M SMD Quadriparesis. Previous C2-3 kyphosis with O-C3 dorsal fusion elsewhere Fixed C1-2 dislocation. C2-3 kyphosis. O-C4 fusion C2 35° Partial Yes 4 days #6 2007 13 years F Syndromic collagen abnormality Neck pain. Leg length discrepancies. T-L scoliosis. Quadriparesis Bilateral C2 and partial C3 spondylolysis C-T levoscoliosis C2-3 35° Partial Yes 4 days #7 2003 14 years F Osteogenesis imperfecta (OI) Only able to use right upper extremity C3-5 kyphosis. Canal diameter 4 mm at C4 C4 25° No No #8 1989 3 years F OI - Bruck's syndrome Quadriparesis age 9 months. Had C1-C3 posterior decompression and fusion elsewhere Progressive kyphosis Worse weakness Bend in fusion C1-2 40° No No #9 1996 11 years M Aarskog syndrome Neck pain with limited neck motion Cervical myelopathy Psychomotor delay C4-5 spondylolysis C5-6 kyphosis C5 30° No Yes 3 days #10 1989 3½ years F Weaver syndrome Quadriparesis age 2 years. Elsewhere C1-C3 dorsal rib fusion and wires Fusion failure C2-3 subluxation Cord compression C2-3 3° Yes Yes 1 day #11 1986 11 years F Larsen syndrome Neck pain in extension Quadriparesis C2-3 kyphosis. Deformed bodies C2-5 Os odontoideum C1-2 instability C2-3 28° Yes Yes 1 day #12 1996 5 years M Multilevel cervical disconnect syndrome Horner pupil on right Small right arm Quadriparesis C4, C5 vertebral bodies behind C5 C5 body in canal Left vertebral artery in C5 body C4-5 35° No No #13 1985 3 years F Klippel-Feil Neck pain. Weak hands Atlas assimilation C3-4 kyphosis No posterior bony arches C3, C4 C3-4 40° Yes No #14 1994 3 years F Klippel-Feil Unable to sit. Floppy. Quadriparesis C2-3 kyphosis No posterior arches C2-3 and L4 C2-3 45° Yes No #15 1993 11 months F Tuberous sclerosis Spondylolysis C2 Salam seizures Quadriparesis No pars C2 C2-3 kyphosis C2-3 30° Yes No #16 1998 2 years M C2 spondylolysis Quadriparesis, arms worse than legs C2 spondylolysis C2-3 kyphosis C2-3 35° Yes No #17 1998 6 months M C2 spondylolysis Failure to thrive Apneic spells Weak in arms after endoscopy C2-3 kyphosis No C2 lamina Cord compression C3-4 on MRI C2-3 45° Yes No #18 1990 4 years F C2 spondylolysis Developmental delay Quadriparesis C2 spondylolysis C2-3 kyphosis C3 45° Yes No #19 1994 4 years F Klippel-Feil No posterior C2 Torticollis age 6 mo Quadriparesis C2-3 kyphosis No posterior arch C2 Fused C3-4 bodies C2-3 45° Yes No Non-syndromic #20 1996 15 years M NF1. Ventral prevertebral plexiform neurofibroma Neck pain Weak arms Cervical myelopathy C4-5 kyphosis Cord draped over C4-5 Enhanced prevertebral tumor C4-5 60° Partial Yes 4 days #21 1996 6 years M NF1 Age 6 mo had C1-3 laminectomies elsewhere Progressive kyphosis Quadriparesis C3-5 plexiform neurofibromas C2-4 kyphosis C3-4 45° No No #22 1993 11 years M "Fibromatosis" Neck pain Gag ↓ Right hemiparesis C2 body and odontoid curved dorsally C2-3 kyphosis C2 40° No Yes 3 days #23 2007 13 F Mid-cervical kyphosis Neck pain Unable to move neck C3-4 kyphosis C3-4 45° Yes Halo vest elsewhere 6 weeks Repeat traction on referral #24 1998 12 years M Chiari I Syringohydromyelia Difficulty swallowing Quadriparesis Previous posterior fossa and C1-3 decompression Basilar invagination C3-4 kyphosis C3-4 50° Yes Halo traction 3 days #25 1994 16 years M Chiari I. SHM Difficult speech Quadriparesis Previous posterior fossa and C1-4 laminectomies C3-4 kyphosis Basilar invagination C3-4 55° Yes Halo traction 3 days #26 2002 11 years M Chordoma C3-5 Initial quadriparesis improved after posterior decompression then worse Dorsal and lateral tumor C3-4 C3-4 20° Yes Traction 3 days #27 2006 13 years M C4 lamina Aneurysmal bone cyst Neck and shoulder pain C4 laminectomy for tumor resection Worse 4 months later C4-5 kyphosis C3-4 40° Yes No Table 3 Pediatric cervical kyphosis-postoperative evaluations Case ID Diagnosis Treatment-operation Complication PO orthosis F/U time Fusion status Preop Cobb Postop Cobb Preop JOA Postop JOA Comments Syndromic #1 SED Crown halo traction 1. Median mandibular glossotomy. Resection C2-3 bodies with rib graft fusion 2. Dorsal O-C3 rib graft fusion None Halo vest 3 months Soft collar 3 months 8 years Complete anterior and posterior fusion 85° 10° 2 8 Complete neurological recovery #2 SED Crown halo traction 1. Median mandibular glossotomy. C2-4 corpectomies. C2-5 anterior rib graft fusion Recurrent weakness 2 years s later Halo vest 3 months 2 years Fused 25° 20° 4 5 T. scoliosis. Cardiac abnormalities. Walking then quadriparesis Redo ventral resection and C1-4 iliac bone graft Worsening quadriparesis Minerva brace 1 year 18 years Fused 33° 15° 3 5 Much improved in 6 months #3 SED Crown halo traction Dorsal O-C4 fusion with loop and rib graft None Miami J collar 3 months 10 years Fused 30° 13° 4 7 Works in bookstore #4 SED Crown halo traction Dorsal O-C3 fusion with loop and rib graft 4 years later developed C-T scoliosis after T. scoliosis surgery Miami J collar 3 months 14 years Fused 27° 5° 5 7 C-T scoliosis developed after thoracic scoliosis correction #5 SMD Crown halo traction Transoral C2 odontoid resection None Minerva brace 6 months 20 years No from preop status 35° 10° 1 4 In wheelchair. Works as programmer #6 Collagen abnormality Crown halo traction C2-5 ACDF C2-5 plate with C3-4 lag screws Junctional kyphosis 7 years later after scoliosis correction Miami J collar 6 weeks 12 years Fused 36° 5° 4 7 Abnormal vertebral arteries. Thoracic outlet syndrome May-Thurner syndrome #7 OI Crown halo traction C3-5 corpectomies C2-6 Orion plate with iliac crest graft None Soft collar 4 years Fused 25° 30° 1 5 Restrictive lung disease. Multiple fractures Expired #8 OI - Bruck syndrome 1. Redo C1-2 dorsal rib graft fusion No change Molded Minerva brace 4 years Fused 40° 35° 3 4 Increased weakness age 7 2. 11 years age anterior C3-7 decompression and plate C3-7 Worsening left deltoid and biceps function Molded Minerva brace 30 years Fused 52° 34° 3 5 Lives alone. Wheelchair. Computer technologist Uses hands well #9 Aarskog syndrome Crown halo traction C2-6 anterior cervical fusion with iliac crest graft None Molded Minerva brace 20 years Fused 30° 14° 4 7 Works on a farm. No myelopathy. Syndrome in family #10 Weaver syndrome Crown halo traction Redo C1-4 dorsal rib graft fusion None Miami J collar 2 years Fused 3° 10° 2 5 Neuroblastoma age 3 months. Chemotherapy Stable #11 Larsen syndrome Crown halo traction O-C5 dorsal fusion None Halo vest 6 weeks Miami J 3 months 6 years Fused 28° 10° 3 7 Doing well #12 Multilevel cervical disconnect syndrome Crown halo traction C5 corpectomy C4-6 iliac bone fusion anteriorly Dorsal C4-6 fusion None Halo vest 3 months 5 years Fused 35° 5° 3 7 Persistent Horner pupil #13 Klippel-Feil Crown halo traction C2-6 posterior rib graft fusion None Halo vest 3 months 19 years Fused 40° 12° 3 7 Hearing loss Genitourinary abnormalities Sprengel's deformity #14 Klippel-Feil Crown halo C2-5 dorsal rib graft fusion None Halo vest 3 months 35 years Fused 45° 10° 1 6 Hearing loss Genitourinary abnormalities #15 Tuberous sclerosis Spondylolysis C2 C1-4 dorsal interlaminar rib fusion None Halo vest 3 months 6 years Fused 30° 5° 1 6 Psychomotor delay #16 C2 spondylolysis C1-4 dorsal interlaminar fusion None Halo vest 3 months 4 years Fused 35° 10° 2 6 Recovered full function in one year #17 C2 spondylolysis Tracheostomy Molded cervicothoracic brace None Mold brace 4 years 6 years Formed C2 posterior arches 45° 20° 1 3 Reformed C2 at 4 years on CT Parents did not wish surgery #18 C2 spondylolysis Intraoperative traction C1-3 dorsal rib graft fusion None Neck brace 4 months 8 years Fused 45° 12° 2 5 Developed C2 posterior elements #19 Klippel-Feil Intraoperative traction O-C4 fusion with rib graft None Molded brace 6 months 1 years Fused O-C2 dorsally 45° 16° 1 4 Able to sit and use hands Non-syndromic #20 NF1 Resection of ventral tumor C3-6 C4-5 corpectomies; C4-5 iliac graft; C3-7 Orion plate None Halo vest 6 weeks 14 years Fused 60° 15° 3 7 Recovered in 6 weeks. Works on a farm #21 NF1 Intraoperative traction Resect prevertebral tumor C2-5 kyphectomies; C2-6 anterior fusion iliac crest None Halo vest 3 months 2 years Fused 45° 20° 3 5 Initial C1-3 decompression done elsewhere #22 Fibromatosis 1. Transoral C2 decompression 2. Dorsal O-C3 fusion with loop None Brace 3 months 12 years Fused 40° 12° 4 6 Age 2 years had neck mass resected. Diagnosis "fibromatosis" #23 Mid-cervical kyphosis Traction C2-5 lateral mass fusion with screws, rods and rib grafts Worse after removal of initial traction Brace 3 months 8 years Fused 45° 15° 7 8 Doing well #24 Chiari I SHM Intraoperative traction O-C5 rib graft fusion None Halo vest 3 months 21 years Fused 50° 7° 2 6 Facets atrophied C2, C3 at surgery #25 Chiari I SHM Intraoperative traction O-C5 dorsal fusion with loop and rib None Miami J brace 4 months 22 years Fused 55° 10° 3 6 Facets atrophied C2-4 at surgery #26 Chordoma C3-4 1. Dorsal lateral C3-6 fusion 2. C2-5 anterior fusion with iliac bone None Miami J brace 6 months 18 years Fused 20° 12° 5 8 Weak in hands after initial surgery elsewhere #27 ABC tumor C4 Anterior C3-5 fusion with plate and bone None Miami J brace 4 weeks 12 years Fused 40° 15° 5 8 No recurrence SED spondyloepiphyseal dysplasia, SMD spondylometaphyseal dysplasia, JOA Japanese Orthopedic Association, MRI magnetic resonance imaging, SHM syringohydromyelia, NF1 neurofibromatosis type 1, f/u follow up, OI osteogenesis imperfecta, CT computed tomography, JK junctional kyphosis.

The True Ponte Osteotomy: By the One Who Developed It.

Technique and applications. To define the anatomy, biomechanics, indications, and surgical technique of the true Ponte osteotomy. The Ponte osteotomy, originally developed for thoracic kyphosis, was the first one to obtain posterior shortening of the thoracic spine, maintaining the anterior column load-sharing capacity. It has become a widely applied technique in various types of spine deformities and a frequent topic of presentations at meetings and in scientific articles. Several of them offer unquestionable evidence of an incorrect execution, with consequently distorted outcomes and erroneous conclusions. A clearing up became essential. Our original experience is based on a series of 240 patients with thoracic hyperkyphosis operated in the years 1969-2015, at first with a standard posterior Harrington technique and then by using the Ponte osteotomy with different instrumentations. A series of 78 of them, operated in the years 1987-1997, who had Ponte osteotomies at every level, is presented. The average preoperative kyphosis has been corrected from 80° (range 61°-102°) to 31° (range 15°-50°) by a substantial posterior shortening. A number of publications use the term Ponte osteotomy loosely for by far incomplete resections and mixing it up with Smith-Petersen's osteotomy. The true Ponte osteotomy is capable of producing marked flexibility in extension, flexion and rotation, justifying its wide use in thoracic deformities, mainly in scoliosis. An exact performance of the osteotomy with adequate bony resections, including the laminae, is an absolute condition to take full advantage of its properties. Level IV, therapeutic study.

Scheuermann's juvenile kyphosis.

Two cases are discussed to illustrate two different presentations, progressions and treatments of Scheuermann's juvenile kyphosis. In one case, a 13-yr-old boy suffered from a 2-yr history of lower back pain. Radiographs demonstrated irregularity of the upper lumbar vertebral endplates, associated with Schmorl's nodes. The second case is one of a 14-yr-old boy who was seen in an orthopedic outpatient clinic. Radiographs revealed wedging of the anterior border of T6, T7, and T8 vertebrae with a thoracic spine kyphotic deformity measuring 72 degrees. The first case was treated conservatively. The patient maintained his improvement at 6 month follow-up. The second case was initially treated with a brace that the patient did not wear regularly as directed. The kyphotic deformity progressed from 72 degrees to 92 degrees. An operation was performed to reduce the kyphotic curve and prevent further progression. On review 6 yr later, the patient was well without back pain or other complications. The kyphotic curve measured 65 degrees. Scheuermann's juvenile kyphosis is a common spinal deformity in the adolescent. A radiographic appearance of wedging of the anterior portion of the vertebral bodies with marked kyphotic deformity suggests the diagnosis of classical Scheuermann's disease. However, the lumbar type of Scheuermann's disease should be considered in young patient with radiographic evidence of irregular vertebral endplates, Schmorl's nodes and a decreased disc space without wedging. Nevertheless, significant progression of the curve in both the typical and atypical types of Scheuermann's disease is rare, but can occur. An algorithm is presented to facilitate decision making in the management of Scheuermann's juvenile kyphosis.

[Lumbar and lumbo-sacral fusion using Twinflex devices in 114 cases with minimal follow-up of 1 year].

The author presents a series of 114 cases of lumbo-sacral fusion with a minimum follow-up of 1 year and a mean of 21.7 months.Since the use of the first transpedicular screws (1963 R. Roy-Camille) spinal instrumentation has considerably eased post-operative care in lumbo-sacral fusion as well as fusion rate. Recently, instrumentation has became more and more rigid. But rigidity has it's limits. Pain as well as poor bone grafting frequently occurs eventhough surgery was performed correctly. This is why the author has developed a concept of flexible transpedicular instrumentation. The aims are: - To avoid stress-shielding of the graftsimplify implantation during surgery - Avoid excessive stress on the bone and adjacent disc - Improved short and long term acceptance of instrumentation - Avoid removal of implants. Some elements guided instrumentation design. Low profile - Ease of removal - restricted number of implants and instruments. The system developed is based on transpedicular screws with 2.5 mm rods. Stainless steel was prefered to Titanium because of it's flexibility. The mechanical results of the first prospective series of 114 cases are studied. Follow up ranges from 12 to 39 months maximum with an average of 21.7 months. 65% of the patients are female. Age ranges from 14 to 89 years old with an average of 50 years.•Pathologies are : 74 cases of discopathy with or without associated disc, 8 cases of degenerative lumbar scoliosis and 32 cases of spondylolisthesis with 13 cases of isthmus lysis and 19 cases of degenerative spondylolisthesis.During the post operative period patients stand between 24 and 48 hours. Walking is allowed with twill corset during the day for the first 3 months.•Length of fixation: In 32 cases it is a floating arthrodesis (L4-5 18 cases, others 14 cases). In 82 cases sacrum is included in the fusion (L3-S1.15 cases, L4-S1.35 cases, L5-S1 20 cases, others 12 cases).• No infections were seen. No phlebitis or pulmonary embolism.•Mechanical complications: They are analysed with an average follow up of 21.7 months and a minimum of 12 months. Screw fractures: Only one case occured at 4 months post op in a L4-5 isthmic spondylolisthesis. Fusion was still obtained within the usual 6 months. Patient went back to work on the 8 th post op month without further complication 14th month post operative. Rod fractures: Fracture of the rod is the demonstration of a pseudarthrosis when occuring between 8 to 12 months post-op. The average pseudarthrosis rate is 3.5% (4 cases). In this series we used two different size of rods. The first group consists of 65 cases with 2 mm diameter rods. The second group consists of 49 cases with 2.5 mm rods. All the pseudarthroses occured in the first group (4 cases). In the second group with an average follow up of 17.2 month no pseudarthroses occured.In 4 cases (3.5%) revision surgery was necessary. Two cases were related to pseudarthrosis and 2 cases to remove instrumentation.Fusion rate in this first prospective series is 96.5%. Rod failure in the first post operative year is the demonstration of pseudarthrosis. On the reverse non failure is a way of assessing fusion without doubt.This homogeneous series demontrates the ability of flexible fixation to obtain a high rate of fusion and a good medium term acceptibility for the patient. Instrumentation was removed only in two cases at patient request.

Familial lumbar Scheuermann disease with idiopathic scoliosis in China: First case report.

Given that Scheuermann disease rarely occurs in the lumbar region and that the co-occurrence of Scheuermann disease and idiopathic scoliosis (IS) has not been reported-the etiology of Scheuermann disease and IS is not clear. In this case report, we present familaiar lumbar Scheuermann disease with IS, in a Chinese proband, who was successfully treated with surgery. A 16-year-old boy presented at the Second XiangYa Hospital of Central South University with a chief complaint of kyphotic deformity in the lower back for 4 years and obvious lower back pain. In addition, he complained of limited lumbar activity. And The proband's family history was obtained by routine inquiring. In this Chinese family with 17 members over 3 generations. The 3 patients (proband, proband's sister and father) shared the characteristics of vertebral wedging from L1 to L3 and a kyphosis Cobb angle of 37°, 70°, or 73°, respectively. The main deformity of the proband's mother was at T7-L1 with a Cobb angle of 102° in the coronal plane at T7-L1, thoracic kyphosis of 73°, and lumbar lordosis of 62°. Scheuermann's disease. Clinical history, physical examination, laboratory tests, and radiographs of those in the pedigree were recorded, and the related literature was reviewed. The proband accepted osteotomy and orthopedic surgery for treatment. After 3 months of treatment, postoperative lateral radiographs showed a significantly improved sagittal vertical axis (SVA). The other patients were continued to be seen in follow-up visits. This series of lumbar Scheuermann patients with IS in a pedigree support the genetic contribution to Scheuermann disease. Therefore, this study provides some insight into the genetic etiology of Scheuermann disease with IS.

Kyphosis

Scheuermann's kyphosis (M42.0) is significantly worse cosmetically and can cause varying degrees of pain, and can also affect different areas of the spine (the most common being the midthoracic area). Scheuermann's kyphosis is considered a form of juvenile osteochondrosis of the spine and is more commonly called Scheuermann's disease. It is found mostly in teenagers and presents a significantly worse deformity than postural kyphosis. A patient suffering from Scheuermann's kyphosis cannot consciously correct posture. The apex of the curve, located in the thoracic vertebrae, is quite rigid. The patient may feel pain at this apex, which can be aggravated by physical activity and by long periods of standing or sitting. This can have a significantly detrimental effect on their lives, as their level of activity is curbed by their condition; they may feel isolated or uneasy amongst peers if they are children, depending on the level of deformity. Whereas in postural kyphosis, the vertebrae

Spinal intramedullary arachnoid cyst: case report and literature review.

Intramedullary arachnoid cysts are extremely rare; only 14 cases have been reported in the literature so far. We report on the case of a 31-year-old woman who presented with back pain and progressive paraparesis secondary to a dorsal intramedullary arachnoid cyst detected on magnetic resonance imaging (MRI): the surgical planning and clinico-radiological outcome are discussed along with a review of the relevant literature. Case report and literature review. One patient affected by intramedullary arachnoid cyst. Magnetic resonance imaging and pathological findings from operative specimens were used to confirm the diagnosis. A 31-year-old woman presented with a 7-year history of back pain that had worsened 3 months before admission to our department; for this reason, the patient had undergone a spinal MRI revealing the presence of a 1-cm cystic intramedullary lesion at the level T11-T12, with no contrast enhancement. After 2 months, the patient presented with a worsening of clinical symptoms complaining of severe back pain radiating to the lower extremities associated with a progressive paraparesis, urinary incontinence, and abdominal pain. Referred to our department, at the time of admission the patient was bedridden because of the impossibility of maintaining a standing position. The patient underwent a T11-T12 laminectomy with fenestration of the cyst. She experienced an immediate relief of pain symptoms, and by the seventh postoperative day she was able to stand without help and walk a few meters with assistance. By the sixth postoperative month, the patient had significantly improved, having gained the ability to walk alone without assistance with complete resolution of the bladder dysfunctions, with no cyst recurrence after approximately 2 years of follow-up. Intramedullary arachnoid cysts should be considered in the differential diagnosis for intramedullary cystic lesions. A particular consideration deserves their occurrence in asymptomatic patients, who should be adequately informed on the possible natural evolution: when symptomatic, surgical therapy should be promptly offered, considering that a postoperative complete recovery is usually observed, regardless of the surgical technique.

Evaluation of spinal fusion using autologous anterior strut grafts and posterior instrumentation for thoracic/thoracolumbar kyphosis.

A retrospective cohort study. To evaluate anterior strut grafts in spinal fusion for thoracic/thoracolumbar kyphosis. Autologous strut grafts harvested from the fibula, iliac crest, and rib are frequently used for treating severe kyphosis and kyphoscoliosis. However, a majority of the studies have presented mixed patient populations kyphosis and/or scoliosis, treated either with anterior or anteroposterior fusion. Very few reports have presented an evaluation of autologous strut grafts for anterior fusion with posterior instrumentation for the treatment of kyphotic deformities. A total of 23 patients comprised the study. Diagnosis was granulomatous infection (9 patients), congenital (6), posttraumatic (4), neurofibromatosis (1), ankylosing spondylitis (1), Scheuermann disease (1), and plasmacytoma of the vertebral body with pathologic fracture (1). Average age at surgery was 41 years (range 6-77). Indication for surgery was pain with or without progression in 15 patients and additional progressive neurologic deficit in the other 8. Anterior strut grafts consisted of the autologous fibula (9 patients), iliac (10), fibula and ribs (2), fibula and iliac (1), and fibula, iliac, and ribs (1). The fusion areas were thoracic (11 patients), thoracolumbar (11), and cervicothoracic (1). Anterior decompression was performed in 8 patients because of the presence of neurologic symptoms caused by cord compression. Dorsal fusion was performed in all patients with third-generation systems. Average 4.2 vertebrae were fused anteriorly. Mean follow-up bracing time was 9.7 months. Average kyphosis measured 50.9 degrees before surgery and 32.5 at a mean follow-up of 4.5 years (P < 0.0001). No graft breakages were noted at final follow-up. Solid fusion was achieved in all patients. No donor site complications were observed. Of the 8 patients presenting with neurologic deficits, 4 had full recovery, 3 had partial recoveries, and 1 had no improvement. Loss of postoperative correction > 5 degrees was observed in 3 patients. At final follow-up, 3 patients complained of occasional pain, and 1 complained of pain when lying on the back, particularly on hard surfaces. Adequate correction was maintained throughout an average follow-up of 4.5 years, and solid fusion was obtained in all patients. Anterior strut grafts, supplemented with posterior fusion with instrumentation provide a good treatment alternative for the treatment of kyphosis deformity of the spine as a result of various etiologies.

[Evolution-linked, stress-related damage to the spine].

During physiological growth of the juvenile vertebral column, various stages of stability occur which are characterized by the condition of the marginal rim of the vertebral bodies. If the vertebral juvenile column is overstrained, these variations in stability result in a variety of damage to the vertebral bodies and vertebral disks. One of these lesions corresponds to Scheuermann's disease (osteochondrosis of vertebral epiphyses in juveniles). Damage of the vertebral column due to overstrain can occur only if the overstrain is applied in upright position. Since Man alone can damage his vertebral column in upright position (as a result of his evolutionary development), Scheuermann's thesis is confirmed that Scheuermann's disease is confined to Man. Spondylolysis/spondylolisthesis is also a damage caused by overstrain. Here, too, the damage can occur only if the load is exercised in upright position, with the exception of a slanted positioning of the intervertebral components.

Severe Thoracic and Spinal Bone Abnormalities in neurofibromatosis type 1.

Neurofibromatosis type 1 (NF1) is an autosomal dominant, multi-system, neurocutaneous disorder that predisposes to the development of benign and malignant tumors. Classical skeletal abnormalities encompass sphenoid wing dysplasia, congenital bowing of the long bones and vertebral osteopathy associated with non-dystrophic or dystrophic scoliosis found in about 10% of NF1 patients. We report a 17-year-old boy affected by NF1 with extreme severe spinal and thoracic malformations affecting bone and lung tissues, including hypoplasia of the right lung, unilateral costal agenesis and severe dystrophic scoliosis characterized by association of hemivertebra, fusion of adjacent vertebral bodies and defective pedicles. At birth, he presented an acute respiratory distress requiring invasive ventilator support. The diagnosis of NF1 was confirmed at age 5 by the identification of a de novo heterozygous mutation c.4537C > T, p.Arg1513* in NF1. Trio-based Whole Exome Sequencing (WES) was performed to exclude coexistence of a second hit but no clearly other pathogenic variant has been identified. Until now, only one similar NF1 patient suffering from the same association of severe scoliosis and chest deformity leading to respiratory insufficiency was described. The severe prenatal NF1-related scoliosis could explain the lung abnormal development by absence of mechanical constraints. Severe Thoracic and Spinal Bone Abnormalities may be part of the NF1 bone phenotype and should be taken into account to allow adequate genetic counseling.

[Spinal deformations as a cause for the clinical signs of spinal cord neoplasm].

An attempt was made to explain the unusual clinical manifestations at the example of an observation of a spinal-marrow tumor, which had the neurological lesion symptoms only below the upper-thoracic level. Scoliosis with a minor spinal deformation at the level of the fourth thoracic vertebra was a tumor symptom. It is suggested that the spinal scoliosis, having a mechanical impact on the spinal marrow and on its provision with blood in the minor-deformation location, was the reason of impaired sensitivity and movements, which is indicative of the spinal-marrow lesion not only in the mentioned locations but also in the total length of tumor localization. Since scoliosis can be, for some time, a single sign of the spinal-marrow lesion, the authors believe it advisable to make the magnetic-resonance therapy (MRT) in all patients with persistent scoliosis for the purpose of an early detection of a spinal-marrow neoplasm, thus, ensuring better treatment results.

Tumoral calcinosis presenting as a deformity of the thoracic spine.

The authors describe a rare case of tumoral calcinosis (TC) of the thoracic spine in a 13-year-old boy with thoracic scoliosis. The patient presented with a 2-year history of back pain. He had no personal or family history of bone disease, deformity, or malignancy. Magnetic resonance imaging revealed a heterogeneously enhancing mass involving the T-7 vertebral body and the left pedicle. Computed tomography findings suggested that the mass was calcified and that this had resulted in scalloping of the vertebral body. The lesion was resected completely by using a left T-7 costotransversectomy and corpectomy. The deformity was corrected with placement of a vertebral body cage and pedicle screw fixation from T-5 to T-9. Pathological analysis of the mass demonstrated dystrophic calcification with marked hypercellularity and immunostaining consistent with TC. This represents the third reported case of vertebral TC in the pediatric population. Pediatric neurosurgeons should be familiar with lesions such as TC, which may be encountered in the elderly and in hemodialysis-dependent populations, and may not always require aggressive resection.

[Significance of isthmic spondylolisthesis in expert assessment of occupational disease of the lumbar spine].

In Germany, disc-related disease of the lumbar spine is eligible for workmen's compensation if caused by long-standing work requiring heavy lifting or carrying or extreme trunk-bending (BK 2108). The appraisal of causality is particularly difficult if conditions like isthmic spondylolisthesis preexist. 250 consecutive appraisals in nurses concerning the BK 2108 were analysed, 12 applicants (4.8%) had isthmic spondylolisthesis (4.6% of females and 5.9% of males). The literature about the natural history of isthmic spondylolisthesis is reviewed. A person who has isthmic spondylolisthesis is up to 25% more likely to have significant back trouble during his life than one who does not. Back pain in adults associated with spondylolisthesis is usually heralded by back pain in the late teens or early twenties. Progression of the slip is rarely seen after maturity. Due to the loss of protection by the posterior elements the disc is prone to premature degeneration which, however, does not become clinically apparent in most cases. Longstanding vocational heavy lifting or excessive stooping can negatively influence the natural history of isthmic spondylolisthesis. It can produce symptomatic disease in a person who would otherwise have remained asymptomatic, or it can cause a deterioration in those with preexisting symptoms. Criteria for the appraisal of causality are proposed. It is stressed that the course of the disease in relation to age and vocational strains has to be analysed in each individual case.

Neuromechanics of idiopathic scoliosis

Physiology Cobb angle is a common measure to classify scoliosis. The greater the angle, the more serious is the disease but the smaller is the number of patients. One to three out of every hundred people have idiopathic scoliosis curves greater than 10° with an equal proportion of boys and girls. One to three out of every thousand people have idiopathic scoliosis curves greater than 30° with a ratio of eight girls for every one boy. Scoliosis is also classified according to the region(s) they affect. The vertebral column can be deformed at the thoracic level, at the lumbar level or at both. In the lumbar region, scoliosis induces perturbations to standing balance. The thoracic region is the location that most impacts movement strategies. Scoliosis impedes on the movement of the ribs, places the respiratory muscles at a mechanical disadvantage and displaces the various organs of the thoracic cavity.

[Long-term results of the Harrington operation. Apropos of a series of 200 cases (1964-1986)].

The authors present a series of 200 patients who underwent vertebral arthrodesis with Harrington's distraction rods for idiopathic scoliosis reviewed after a mean follow-up of 7.5 years (maximum: 24 years). The surgical procedure consisted of either simple distraction or distraction associated with convex compression or a transverse traction device or insertion of double rods according to Armstrong's technique. The operative gain was 44%, the angular loss was 12% and the definitive gain was 32%. The results were better in girls and in juvenile scoliosis type III and adolescent scoliosis. The best long-term correction was obtained in cases of lumbar scoliosis. The best operative reduction was obtained in thoracic and thoracolumbar scoliosis and the greatest angular loss was observed with major double scolioses. The most favourable results were obtained in cases of scoliosis were severe angulation. The best system was Armstrong's followed by Dollar's and the least effective was simple distraction. Heavy pre- and intra-operative vertebral traction improved the angular score. Rupture of the rod, when it occurred late, was not equivalent to pseudarthrosis. Angular deterioration over time was essentially observed over the first 10 years but led to disappointing results.

The Effect of Schroth Therapy on Thoracic Kyphotic Curve and Quality of Life in Scheuermann's Patients: A Randomized Controlled Trial.

Randomized controlled single-blinded clinical trial. To evaluate the efficacy of Schroth therapy on thoracic curve angle, pain, and self-perceived body image (SPBI) of the back in Scheuermann's patients in comparison with the efficacy of classic anti-gravitation exercises. Scheuermann disease is the most common cause of hyperkyphosis of the thoracic and thoracolumbar spine during adolescence. However, very few studies evaluated the effect of exercises on the progression of kyphosis in Scheuermann patients. Schroth three-dimensional exercise therapy was found in several studies to be effective in the treatment of adolescent scoliosis, however, we found no randomized controlled trials that evaluated the efficacy of this method in Scheuermann patients. A total of 50 young adults (males and females) with Scheuermann's disease were randomly divided into either the experimental group (Schroth therapy treatment, n=25) or the control group (classic anti-gravitation exercises, n=25). Participants in both the groups were provided a course of individual treatment sessions during few weeks, with one appointment per week. They were required to perform the exercises daily throughout the study period (12 months) and fill their performance in a research log. We evaluated the thoracic Cobb angle (main outcome measure), pain, SPBI, flexion of the shoulder (supine), flexion of the shoulder (standing), kyphotic deformity measured using inclinometer, and L5 kyphosis apex line (L5-KAL) as well as administered the Scoliosis Research Society-22 Questionnaire for the participants before the treatment, after 6 months, and 1 year postoperatively. These results were then compared. In the mixed analysis of variance, the main effect of time was significant in the thoracic kyphosis (F [1]=5.72, p=0.02), and in the L5-KAL (F [1]=5.76, p=0.02). The main effect of time on the kyphotic deformity, measured using an inclinometer, did not reach the significance level; however, it showed the tendency (F [1]=2.80, p=0.07). In the group-by-time interaction, a significant difference was found in the thoracic kyphosis (F [1]=4.91, p=0.03) and in the kyphotic deformity, measured using an inclinometer (F [1]=4.05, p=0.02). Thus, the Schroth therapy group showed significantly greater improvement than the classic anti-gravitation exercises group. The present findings indicate that back exercises in general, and Schroth therapy in particular, is an effective treatment for preventing and significantly improving the thoracic Cobb angle and symptomatic representation in Scheuermann's patients.

[Spine deformities induced by irradiation of Wilm's tumors (author's transl)].

A follow-up study on spine deformities of 59 consecutive Wilm's tumors treated between 1950 and 1963 was conducted. The selected cases had no metastasis at any time and had reached end of growth (16 years old of bone age). Treatment was surgery, chemotherapy and radiationtherapy mostly was 200 KV and partially with CO 60. This study showed 65p. 100 kyphosis greater than 10 degree between T9 and L3 (normal less than 5 degree) and 40p. 100 scoliosis both induced by alteration of vertebral growth and by sclerosis of soft tissues. -- Kyphosis even slight seemed to induce more pain in adult age than scoliosis. -- This work demonstrates also that growth spurt produces increased deformities. Therefore it is necessary to wait the end of growth before the evaluation of the results. Finally the most important for prevention is to irradiate as symmetrically as possible in the 3 planes of the body. The results of surgical treatment are reported and principles of early bracing for prevention are mentioned.