The goal of this thesis was to assess the validity of a computer simulated Radiostereometric Analysis (RSA) environment and assess the use of novel migration origin styles for use in the assessment of spinal fusion success in post-surgical adolescent idiopathic scoliosis patients. A parallel precision study was conducted with a physical phantom and identical computed simulated spinal fusion model. This study was used to conduct a precision validation of the simulate RSA environment. The origin style assessment was done in comparison with the translational and rotational Limits of Clinical Significance defined by Pape et al (2002) and Johnsson et al (2002) respectively [1], [2]. This thesis concluded that the use of a simulated environment is an acceptable method for the creation of phantom RSA research studies. It was also shown that both the Apex and Dual Origin Styles equally accurate and precise.

INTRODUCTION: Adolescent Idiopathic Scoliosis (AIS) is one of the most common spinal abnormalities in children, affecting 2% to 3% of adolescents in the United States. Its cause remains unclear. Many previous studies conclude that AIS may be caused by a combination of genetic and environmental factors, with very few consistencies. Severe scoliosis is usually treated with corrective surgery, and the etiology of post-surgical pain is even more unclear and has the opportunity to affect the patient well into adulthood. STUDY AIMS: By following a monozygotic twin pair with identical DNA, our retrospective case study can control for genetic disposition, and can look toward other possible causes for the pain the patients experienced. This study attempts to shed light on the complexities of AIS and pain with a focus on environmental and psychosocial factors. CASE PRESENTATION: We present a single pair of monozygotic twins treated for AIS with comparable spinal fusion surgeries performed at a large northeast urban children's hospital. Twin A and Twin B were initially treated with a brace for their scoliosis. Despite bracing, their curves progressed and warranted spinal fusion, with Twin A having a Cobb angle of 53°, and Twin B with 50°. The surgery was conducted simultaneously at the age of 13 by two different orthopedic surgeons. At age 7.5, Twin B was treated for Ebstein's anomaly of the tricuspid valve and significant dysrhythmias. METHODS: After the patients were discharged, a comprehensive retrospective chart review of the patients' pre-op, inpatient, and post-op pain and drug regiment was conducted. The patients were also asked to note their pain as they recovered after discharge. The patients and their mother completed self-report measures of multiple psychosocial variables both before and after surgery through REDCap. A Quantitative Sensory Test (QST) was also performed by the patients to assess their sensory sensitivity and pain thresholds. Mechanical, pressure, and thermal scores were obtained with the use of von Frey hairs, a pressure Algometer, and a Thermode. The QST was administered on the patients' palm/ thenar eminence (distant non-surgical site), and on their lower back (surgical site). The QST results were compared to a previous study's median cohort data, to discern if the patients presented hyper- or hyposensitivity for that particular test. RESULTS: Due to the limitations of case studies, the results presented here should be considered strictly preliminary. Twin B experienced more significant pain during both the acute and chronic recovery phases after surgery, and showed lower sensitivities during most pre-op QST trials. Twin B also scored markedly higher on a number of sub-variables in the psychosocial surveys. A notable correlation was the parent protective measure, indicating that the mother may have been more protective of Twin B. CONCLUSIONS: What is unique to this study is that age, gender, Cobb angle, fusion length, and genetic disposition are all controlled for, allowing us to analyze the patients based on other risk factors. Twin B shows consistently higher pain scores while in the hospital as well as while recovering at home. The parent self-report measures support these findings, showing a slight bias in favor of Twin B in regards to protectiveness, which also coincides with large-scale studies. Although preliminary, it is important not to underestimate the role environmental and psychosocial factors play in post-surgical pain.

As alterações posturais da coluna vertebral, em especial a escoliose por ser um problema ortopédico funcional ou estrutural encontrado na infância e na adolescência, trazem riscos de evolução e devem ser diagnosticados e tratados o mais precocemente possível. Nosso objetivo foi avaliar a prevalência de postura escoliótica em escolares de uma escola pública e uma privada do ensino fundamental do município de Guarapuava-PR, bem como identificar a altura e o lado da convexidade das curvaturas escolióticas e a presença de gibosidade em relação à faixa etária e ao sexo dos sujeitos envolvidos. Esta pesquisa é de cunho quantitativo e trata-se de um estudo transversal não experimental. A coleta de dados foi realizada em duas escolas do município de Guarapuava, sendo uma privada e outra pública, em agosto de 2005. Envolveu 964 escolares de ambos os sexos, respeitando-se os princípios éticos estabelecidos na Resolução nº196 do CNS/MS, sendo previamente aprovada pelo Comitê de Ética em Pesquisa da Escola de Enfermagem de Ribeirão Preto-USP. A avaliação postural utilizada no presente trabalho foi elaborada considerando-se o alinhamento vertebral descrito Loudon, Bell Johnston (1999) e a partir de observações clínicas propostas por Santos (2001) e também a pesquisa de gibosidade, preconizada por Cailliet (1977). Quando foi detectada uma alteração postural, os pais ou responsáveis do escolar avaliado receberam uma carta de comunicação, na qual sugerimos a investigação diagnóstica através de exames complementares em consulta a um especialista de sua preferência. Os dados coletados foram descritos através da utilização do Software Statistical Package for Social Siences (SPSS, 1999). Entre os 655 escolares avaliados, detectamos, em ambos os sexos, 26% de posturas escolióticas, sendo 53% de curvaturas torácicas à esquerda e 20% à direita, 13% de toracolombares à esquerda e 6% à direita e 2% de lombares à esquerda. Não detectamos curvaturas lombares à direita como curvas únicas, somente em associações de duplas curvas, que correspondem a 6%. Nossos resultados foram semelhantes aos de outras pesquisas sobre posturas escolióticas e discutidos em relação à literatura referente sobre prevalência de escoliose estruturada ou não. Com base nestes resultados reforçamos a necessidade de programas preventivos como o rastreamento de posturas escolióticas durante a fase escolar, considerando-se que as alterações de postura podem ser uma das causas de agravamento de distúrbios da coluna vertebral na fase adulta, os quais apresentam, no Brasil, um alto índice de afastamento ao trabalho ou aposentadoria por invalidez. Faz-se necessário o estabelecimento de parcerias com outros profissionais da área da saúde para a implantação de ações preventivas e de diretrizes que promovam a saúde do escolar, principalmente sistematizando pesquisas periódicas para detecção de distúrbios vertebrais. / The posture alterations in the vertebral column, especially when there is scoliosis, which may be a functional or structural orthopedic problem found in childhood or adolescence, need to be diagnosed and treated as soon as possible, since there is a chance for scoliosis to develop and get worse. Our aim with the present work was to study the prevalence of scoliosis posture in pupils from a public and a private primary/junior high school in Guarapuava-PR, as well as identify the size of the scoliosis curvatures, the side of their convexity, and if there was gibbosity concerning the participants age and gender. The present research has a quantitative purpose, and it is a transversal and not experimental study. The data were collected in two different schools in Guarapuava-PR (one school is private and the other is public) in August 2005. We studied 964 male/female pupils, respecting the ethical principles of the CNS/MS 196 Resolution, and all the search procedures had the approval of the Ethic Committee of the Nursing School of Ribeirão Preto-USP. The postural evaluation we used in the present work was elaborated from the vertebral alignment described by Loudon and Bell Johnston (1999), from clinical observations suggested by Santos (2001), and from the gibbosity research recommended by Cailliet (1977). If we found a postural alteration in the participant pupil, we sent their parents or the relative in charge of them a letter, advising them to seek a professional of their preference in order to diagnose the problem with complementary examinations. The collected data were described with the help of the Software Statistical Package for Social Sciences (SPSS, 1999). From the 655 female/male participant pupils, we found that 26% of them had scoliosis postures: 53% with thoracic curvatures on the left and 20% on the right, 13% with thoracolumbar on the left and 6% on the right, and 2% with lumber on the left. We didn t find any lumbar curvatures on the right as single curves, but only in association with double curves, which correspond to 6% of the participant female/male pupils having posture problems. Our results were similar to those of other pieces of work related to scoliosis posture, and their discussion was based on the literature about the prevalence of structured or not structured scoliosis. From the results of the present study, we reinforce the necessity of prevention programs such as the diagnosis of scoliosis posture during the primary/junior high school period. We need to consider that the posture alterations may be one of the causes that lead to vertebral column disorders in adulthood. In Brazil, there is a high level of people who stop working or retire due to their disability caused by column disorders. It is necessary to establish partnerships with other health professionals in other to consolidate prevention programs and plans which improve the pupils health, especially by carrying out frequent research that seeks to find vertebral disorders in them.

A hemodiluição normovolêmica aguda (HNA) é terapia mundialmente reconhecida como vantajosa em cirurgias que possuem grande potencial para sangramento, mas o edema provocado pela maior infusão de fluidos pode ser danoso em alguns pacientes. No intuito de avaliar as repercussões hemodinâmicas e laboratoriais da utilização da solução salina hipertônica a 7,5% como líquido parcial de reposição na HNA foram estudados 20 pacientes submetidos à artrodese para correção de escoliose de coluna. No grupo 1 (SS 0,9%, n=10) o sangue retirado na HNA, realizada momentos antes da cirurgia, foi reposto por solução salina 0,9% em um volume três vezes maior que o retirado. No grupo 2 (SS 7,5%, n=10) a metade do que foi retirado foi reposto com solução a 0,9% (três vezes o volume retirado) e a outra metade por 4 ml.kg-1 de solução salina hipertônica 7,5%. Nenhum dos pacientes apresentou distúrbios do equilíbrio ácido-básico e as alterações metabólicas (aumento da osmolaridade, sódio e cloro plasmáticos) foram passageiras. Os pacientes mantiveram-se hemodinamicamente estáveis e não foi observado sangramento anormal intra-operatório. A incidência de transfusão sangüínea foi semelhante embora os pacientes do grupo solução hipertônica tenham ficado clinicamente menos edemaciados. Mesmo não sendo objeto do estudo, observou-se menor incidência de infecções pós-operatórias nos pacientes submetidos à infusão de solução hipertônica, o que pode significar potencial efeito protetor da solução. Embora mais estudos com números maiores de pacientes sejam necessários para se comprovar esses efeitos, a solução hipertônica mostrou-se barata, simples e segura como maneira de redução do volume infundido na HNA. / The acute normovolemic hemodilution (ANH) is a therapy recognized as benefic in surgeries that have a great potential for bleeding but the swelling caused by solutions infused intra-operative can be harmful in some kind of patients. Twenty patients submitted to arthrodesis for scoliosis correction were studied in order to evaluate the hemodynamic and laboratory effects of 7.5% hypertonic saline solution as a partial fluid replacement in ANH. In group 1 (SS 0.9%, n = 10) the collected blood in ANH was replaced by saline solution 0.9% in a volume three times greater than the withdrawal. In group 2 (SS 7.5%, n = 10), half of the blood removed was restored by 0.9% solution (three times the amount withdrawn) and the other half by 4 ml.kg-1 of 7.5% solution. None of the patients presented acid-base disorders. Metabolic changes - enhanced of plasmatic levels of sodium, chlorine and osmolarity - were all transitory. Patients remain hemodynamic stable and no abnormal bleeding was observed. They had similar incidence of blood transfusion but the ones in hypertonic solution group were clinically less swollen. Lower incidences of post-operative infections were found in this group, which could mean a possible protector potential of hypertonic solution. SS 7.5% was a cheap, simple and safe alternative to reduce volume infused in ANH.

Previous studies of the effect of exercise therapy on scoliosis have demonstrated progression of spinal curves despite vigorous exercise regimens. This study presents evidence to the contrary. Ten children with functional scoliosis and attendant upper thoracic asymmetries were analyzed both before and after a specific exercise therapy programme, in order to determine the effect of the therapy on spinal functionality and the scoliotic curve. The effect of this intensive treatment, in which the subjects underwent a five-month exercise training programme with a total of 60 one-hour sessions, was investigated in a controlled clinical trial. A subjective and objective appraisal of posterior trunk asymmetry in schoolchildren aged 7-18 is reported. Selected functional and anthropometric measurements were made before and after the treatment, and antero-posterior x-rays were used to indicate changes in the scoliotic curve. New methods are described for quantifying the scoliotic curves in each child. Post-treatment tests showed a significant (p<0.05) decrease in Cobb's angles as well as a significant reduction in all the spinal and thoracic functional asymmetries observed in the study. The findings suggest that selective exercise programmes can contribute to improvement in cases of functional scoliosis. The study sheds new light on problems related to scoliosis and the benefits of exercise rehabilitation. Data on the incidence of scoliosis amongst 1052 black children are also presented and discussed.

A escoliose idiopática do adolescente (EIA) é uma deformidade tridimensional da coluna vertebral. Dados epidemiológicos sobre sua prevalência nas regiões do hemisfério sul não são suficientes. Primeiramente, o objetivo deste estudo foi estimar a prevalência da EIA em cidades do interior do estado de São Paulo; secundariamente, identificar fatores demográficos, clínicos e relacionados ao estilo de vida e à postura associados à ocorrência da escoliose e avaliar a validade e capacidade preditiva do escoliômetro®. Foram avaliados 2.562 adolescentes (1.490 meninas e 1.072 meninos), entre 10 e 14 anos. Os adolescentes eram estudantes de escolas públicas estaduais pertencentes à Diretoria Regional de Ensino de Mogi Mirim/SP. O rastreamento para EIA foi feito pela mensuração do ângulo de rotação de tronco (ART) no teste de Adams por meio do escoliômetro® e pelo exame radiográfico. Adolescentes com ART >= 7º foram encaminhados para radiografia e diagnosticou-se a escoliose quando o ângulo de Cobb foi maior ou igual a 10º. A avaliação postural foi realizada por fotografias analisadas no Software de Avaliação Postural (SAPO) dos adolescentes com suspeita (ART >= 7º e Cobb < 10º) e com escoliose (ART >= 7º e Cobb >= 10º). Os resultados mostraram prevalência de 1,5% (IC95%: 1 - 1,9%), sendo maior para o sexo feminino (2,2%; IC95%: 1,4 - 2,9%) do que masculino (0,5%; IC95%: 0,1 - 0,9%). Os fatores associados à ocorrência da escoliose foram o sexo feminino (odds ratio: 4,7; IC95%: 1,8 - 12,2; p=0,001), as idades de 13 e 14 anos (odds ratio: 2,2; IC95%: 1 - 4,8; p=0,035) e o desnivelamento dos ombros (odds ratio: 1,4; IC95%: 1,1 - 1,8; p=0,011). Houve predomínio de curvas duplas (59,4%) e de lateralidade à direita (56,8%), porém de baixa magnitude (75% com ângulo de Cobb até 22º) e fator de progressão (75% com fator de até 1,2). As curvas à direita apresentaram maior magnitude (ângulo de Cobb: 20,8º (7,3º)) do que aquelas à esquerda (13,8º (4,1º)) (p=0,003). O encaminhamento ao exame radiográfico foi de 5%. O escoliômetro® apresentou melhor sensibilidade aos 45º de flexão anterior de tronco (53,8% (IC95%: 43,7 - 64)) e melhores especificidade e valor preditivo positivo aos 60º (75% (IC95%: 66,2 - 83,9%) e 78,4% (IC95%: 70 - 86,8%), respectivamente). Concluiu-se, portanto, que a prevalência da EIA em cidades do estado de São Paulo (1,5%) foi semelhante à descrita na literatura (2%), sendo também mais prevalente no sexo feminino e nas idades mais próximas à puberdade (13 e 14 anos). Considerando que a puberdade ocorre em momentos distintos entre os sexos, sendo mais tardio para o masculino, a recomendação de se realizar programas de rastreamento escolar para escoliose na mesma faixa etária (10-14 anos) para ambos os sexos deve ser repensada. A validade e capacidade preditiva do escoliômetro® foram melhores aos 60º de flexão de tronco. Em relação aos aspectos posturais, o alinhamento horizontal dos acrômios, que avalia o desnivelamento dos ombros, está associado à presença de escoliose idiopática do adolescente e deve ser considerado na rotina de avaliação dos adolescentes seja no ambiente clínico ou escolar / Adolescent idiopathic scoliosis is a common three-dimensional spinal deformity. Epidemiological data about the condition in South Hemisphere are insufficient. First, the objective of this study was to estimate the adolescent idiopathic scoliosis prevalence rate in cities of São Paulo, Brazil. Second to identify demographic, clinical, lifestyle and body posture factors associated with adolescent idiopathic scoliosis, and to assess the Scoliometer accuracy. We assessed 2,562 adolescents (1,490 girls and 1,072 boys), between 10 and 14 years of age. The adolescents studied in public schools belong to Education Regional Board of Mogi Mirim/SP. The screening procedure included the measurement of Angle of Trunk Rotation (ATR) using a Scoliometer in the Adams test and the radiographic examination. The adolescents with ATR >= 7o were referral to radiographic examination and body photographic. A Cobb angle >= 10o on standing radiographs were classified as adolescent idiopathic scoliosis. We used Postural Assessment Software (PAS) to analyze posture and we divided into adolescents with scoliosis suspicion (ATR >= 7o and Cobb angle < 10o) and with scoliosis (ATR >= 7o and Cobb angle >= 10o). The adolescent idiopathic scoliosis prevalence rate was 1.5% (95% CI: 1 - 1.9%), higher to females (2.2%; 95% CI: 1.4 - 2.9%) than males (0.5%; 95% CI: 0.1 - 0.9%). The following factors were associated with adolescent idiopathic scoliosis: female gender (odds ratio, 4.7; 95% CI: 1.8 - 12.2; p=0.001), the 13 and 14-year age group (odds ratio, 2.2; 95% CI: 1 - 4.8; p=0.035) and shoulder imbalance (odds ratio, 1.4; 95% CI: 1.1 - 1.8; p=0.011). The double curves and right laterality were more frequent (59.4% and 56.8%, respectively), but with low magnitude (75% with Cobb angle until 22o) and progression factor (75% with progression factor until 1.2). The right curves (20.8º (7.3º)) showed high magnitude than the left ones (13.8º (4.1º)) (p=0.003). The referral to radiography was 5%. Scoliometer sensitivity was better at 45o forward bending test (53,8% (95% CI: 43,7 - 64)), and the specificity and positive predictive value were better at 60o (75% (95% CI: 66.2 - 83.9%) and 78.4% (95% CI: 70 - 86.8%), respectively). We concluded that the prevalence of adolescent idiopathic scoliosis in cities of São Paulo (1.5%) was similar to the literature (2%) and was also more prevalent in females and in puberty ages (13 and 14 years). Whereas puberty occurs at different times between gender, and later for males, the recommendation to screen the same age group (10-14 years) for both genders must be rethought. Scoliometer accuracy was better at 60o forward bending test. The shoulder imbalance assessed by horizontal alignment of acromion was associated with the presence of adolescent idiopathic scoliosis and should be considered as an assessment routine for adolescents in clinical or school environment

Chronic pain is an ever-present issue and some estimate its cost to society at $635 billion per year. Not only does chronic pain cause increased visits to medical personnel, it also complicates other medical conditions and lowers productivity in the workplace. One area of study includes Chronic Post Surgical Pain (CPSP) in children that have undergone spinal fusion surgery for Adolescent Idiopathic Scoliosis (AIS). Some of the major factors that may lead to CPSP include preoperative pain, psychosocial factors, age, intraoperative nerve injury, acute postoperative pain, and genetics. In order to explore the psychological factors, our lab has employed an Unpredictable Chronic Mild Stress (UCMS) paradigm, which models unforeseen life stressors and depression. Some sensory testing was conducted included Hot Plate and von Frey fiber testing. Previous studies from this lab have shown that adult male mice have hyperalgesia to thermal stimuli following a UCMS paradigm. To further explore this finding, a younger mice cohort of both sexes and a cohort that underwent Maternal Deprivation (MD) were added. Maternal Deprivation is a model of early-childhood stress and older female mice have been shown to have changes in thermal sensitivities as a result of early childhood stressors. Our lab found that stressed young females also exhibit a heightened sensitivity to thermal stimuli at 49°C compared to their male and control counter parts. These results indicate that the thermal sensitivity of young females can be affected by early childhood stress and depression.

INTRODUCTION: Spinal deformities, including adult spinal deformities (ASD) and adolescent idiopathic scoliosis (AIS), can cause significant pain and disability. Radiographic parameters are measured in order to establish quantitative relationships among spinal alignment and health related quality of life metrics. Various classification systems including the Scoliosis Research Society (SRS)-Schwab and Global Alignment Proportion (GAP) score have been developed to correlate radiographic parameters with relevant clinical outcomes. While the SRS-Schwab Classification is both a coronal and sagittal categorization that correlates to health related quality of life metrics, the GAP score is a newly developed 13-point scale that focuses on sagittal alignment to predict mechanical failure postoperatively. The study aims to evaluate the utility of the GAP score as a method of evaluating radiographic correction and maintenance over one year. METHODS: This was a retrospective analysis of ASD and AIS patients who underwent operative intervention. Patients were evaluated for GAP score changes from preoperative to postoperative and then to a one year follow up. Of the 285 screened patients, 73 had suitable radiographs for measurements. This included 45 ASD patients, 32 of which had one year follow up radiographs, and 28 AIS patients, of which only 19 had one year follow up radiographs. Measurements were obtained by three independent readers. These included pelvic incidence (PI), pelvic tilt (PT), L1-S1 lumbar lordosis (L1-S1 LL), L4-S1 lumbar lordosis (L4-S1 LL), sacral slope (SS), global tilt (GT), and sagittal vertical axis (SVA). GAP score subcategories were calculated and summed to produce the GAP score. RESULTS: The 73 included patients had an average age of 41.8 ± 24.1, BMI of 26.2 ±6.3, and consisted of 51 females (69.9%). All but one radiographic parameters exhibited an Intra Class Correlation (ICC) of over 0.66. PI had an ICC of 0.59 which was likely due to the incomplete visibility of the femoral heads in few radiographs. Among ASD patients, from pre to postoperative, PI-LL significantly decreased from 18° to 5°, PT significantly decreased from 26° to 19°, L1-S1 LL significantly increased from 37° to 47°, L4-S1 LL significantly increased from 28° to 31°, GT significantly decreased from 37° to 25°, SVA significantly decreased from 120 mm to 64 mm, and total GAP score significantly decreased from 8 to 6. For the 32 patients with long term data, the GAP score changed significantly from 9 to 6 to 7 at one year follow up. Of the 32 patients, 14 patients experienced a worsened score at the one year follow up. Among AIS patients, PI-LL increased from 0° to 3°, PT remained 13°, L1-S1 LL decreased from 56° to 53°, L4-S1 LL significantly decreased from 37° to 31°, GT increased from 14° to 16°, SVA decreased from 25 mm to 28 mm, and total GAP score increased from 3 to 4. For the 19 with long term data, the GAP score changed significantly from 3 to 3 to 2 and 2 patients experienced a worsened score at the one year follow up. DISCUSSION: The patient population showed a slight improvement in GAP score among both ASD and AIS groups. The improvement is more pronounced when evaluating with the SRS-Schwab Classification. The GAP score does not emphasize the same radiographic parameters and therefore does not correlate well with the SRS-Schwab Classification. Many patients also experienced a worsened GAP score by the one year follow up which can be attributed to the adjacent superior or inferior region (PJK), thoracolumbar region (construct failure), or compensation at the pelvis through hip flexion. Additionally, GAP is potentially oversensitive to measurement error and rounding differences. Thus, the utility of the GAP score in evaluating spinal deformity patients is questionable and requires further adjustment and evaluation based on prospective studies.

Background: Adolescents need to develop health literacy skills to participate in making decisions about their health care. Organizational health literacy facilitates patient understanding of health information, care access, and self-management. Methods: A literature review and qualitative case study were conducted to explore adolescent health literacy within an organizational context of an adolescent scoliosis program. Results: Adolescent health literacy is more nuanced than numeracy and reading levels. Yet, little is known about how organizations (including clinicians) support adolescent health literacy. Interviews with health care professionals in a pediatric tertiary hospital related health literacy to scoliosis patient education but did not address other factors associated with adolescents’ ability to navigate health systems. Organizational documents did not adequately support healthcare professionals in promoting the health literacy of adolescent scoliosis patients. Conclusion: Organizational supports are needed to build health literacy capacity amongst adolescents receiving scoliosis care and clinicians need help to leverage the supports that are in place.

Scoliosis is a common skeletal condition in which a curvature forms along the coronal plane of the spine. Although scoliosis has been long recognized, its pathophysiology and best mode of treatment are still debated. Currently, definitive diagnosis of scoliosis and its progression are performed through anterior-posterior (AP) radiographs by measuring the angle of coronal curvature, referred to as Cobb angle. Cobb angle measurements can be performed by Deep Learning algorithms and are currently being investigated as a possible diagnostic tool for clinicians. This thesis focuses on the role of Deep Learning in the diagnosis and treatment of Scoliosis and proposes a study design using the algorithms to continue to better understand and classify the disease.