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Early-onset spinal deformity (EOSD) is characterised by detection of spinal deformity (scoliosis, kyphosis or multi-planar) in children at aged less than five years. The common causes could be classified under congenital, neuromuscular, syndromic and idiopathic etiologies. Early treatment is paramount in preventing rigid, severe and progressive deformities that can cause pulmonary compromise. The inability of lungs and thoracic cage to support normal ventilation at rest constitutes the pathophysiology in manifestation of thoracic insufficiency syndrome (TIS). The treatment options have evolved from observation, serial casting, bracing to surgery. Early definitive spinal fusion is now obsolete and contra-indicated for EOSD. Growing rods (submuscular or subfascial) continues to be the standard of care in treating these challenging deformities. Vertebral expandable prosthetic titanium rib (VEPTR) continues to be an attractive option for TIS but is fraught with high complication rate. I hereby present a theme on EOSD with a set of thirty three peer reviewed indexed publications and one surgical patent in treating such challenging conditions highlighting my original contribution as Consultant spinal surgeon spanning over two decades. My pioneering and ground-breaking research that has shaped the surgical management of EOSD and helped define 'standard of care' is presented. My novel and innovative concept of treating EOSD using magnet driven growing rod (MdGR) along with its preliminary results is discussed. MdGRs are an attractive alternative in eliminating need for repetitive anaesthesia facilitating normal cognitive development in comparison to growing rods (CGRs). They also improve pulmonary function in neuromuscular scoliosis. A brief one page summary of all my indexed publications with comments on originality and how they contributed to spinal surgery is enclosed at the end of each chapter. My current research update on MdGR project at Royal National Orthopaedic Hospital (Stanmore), my surgical patent National institute of clinical excellence (NICE) position statement on MdGRs and clinical guidance documents are attached appendices I - III.

Scoliosis is a three dimensional deformity in which the spine deviates from the normal sagittal and coronal position in upright posture and becomes fixed in an unbalanced posture. The aetiology is poorly understood, however the spinal deformity is a problematic developmental process, the outcome of which can be altered with appropriate intervention. There is some evidence in the literature that scoliosis is reversible. Asymmetric loading is the driving force for development and progression of curvatures. Progression of curvatures is related to growth potential, magnitude of the curve and bone age. Curves that are not managed result in signs and symptoms of pain, deformity, pulmonary dysfunction and psychological distress. For many cases that end up in surgery, spinal fusion fails to address the significant clinical symptoms of spinal deformity. The complications of surgery are high. There is controversy as to whether conservative management of wearing a brace and exercises are effective in stabilising the curve. Past studies have shown that exercises alone do not improve the curve. Studies have also shown that a brace only prevents progression of the curve and the efficiency of the brace is not clear. Guidelines for brace wearing have not been given in the literature. High correction bracing has however been shown to have favourable outcomes when patients are compliant. The aim of this study was therefore to determine the effect of compliance to the RSC brace and a specific exercise programme on idiopathic scoliosis curvature. Further objectives were to determine factors affecting compliance to the treatment protocol. The quality of life and psychological traits of compliant subjects and non compliant subjects during the study were established and compared. To achieve these objectives a pre test /post test study design was used with a post study comparison between subjects who complied with the management and those who did not comply. Fifty one subjects, girls aged 12-16 years were drawn from a private physiotherapy practice in Randburg, South Africa referred by different orthopaedic surgeons. Cobb angles were between 20-50 degrees and subjects had no prior treatment. Subjects were divided into two groups after the brace and exercise interventions were complete and when weaning out of the brace had begun. Subjects were allocated to the two groups according to their compliance. The compliant group was defined as those subjects who wore the brace 20 or more hours a day and exercised three or more times per week. The non-compliant group were those subjects who wore the brace less than 20 hours a day and exercised less than three times per week. The study was terminated the day the subjects started weaning out of the brace. The two study groups were compared with respect to the Cobb angle, kyphotic and lordotic angle, apical vertebral rotation, scoliometer measures, peak flow, quality of life and personality traits. The subjects in both groups were well matched at baseline. The compliant group, who wore the brace 21.5 hours per day and exercised four times a week, significantly improved in all measures compared to non compliant subjects, who wore the brace 12 hours per day, exercised 1.7 times a week and significantly deteriorated. The non compliant group followed the natural history of progression of IS curvatures. The major Cobb angles in the compliant group improved 10.19° (±5.5) and deteriorated 5.52°(±4.3) in the non compliant group. Compliant subjects had a significantly better quality of life than the non compliant subjects. Vitality, physical functioning, self esteem, bodily pain, school activity and general health perception, emotional function were significantly better in the compliant group compared to the non compliant group. The compliant group were significantly more emotionally mature, stable and realistic than the non compliant group. In conclusion good compliance to a conservative treatment programme of the RSC brace and a specific regime of exercises resulted in a significant improvement in curvatures, poor compliance resulted in progression/deterioration. A poorer quality of life in the non compliant group possibly was caused by personality traits of the group, being more emotionally immature and unstable. Possibly different personality traits have different psychosocial coping mechanisms and when put in a stressful situation, result in different levels of compliance. A personality trait questionnaire is recommended on subjects initially, to predict compliance and then to include psychological support if required. This conservative treatment programme can be offered to patients all over South Africa and Africa. The patients only have to visit the physiotherapist and brace technician once a month and in some cases every three months. Further studies are required on the long term effects of this conservative treatment programme. Scoliosis is a complex condition of the developing child, and their psychosocial coping mechanisms need further research to improve compliance.

This thesis presents an experimental study of a bovine vertebra using transmission and pulse-echo methods and a preliminary investigation to guide a screw insertion into a pedicle using TomoScan phased array unit. The results show the cancellous bone has higher attenuation than the cortical bone for 1.0-5.0 MHz. The optimal frequencies for imaging are found to be 3.5 and 5.0 MHz. When the sample is filled with water with the cancellous core removed, all reflections from the layers and screw are visible; however when the core is present, only reflections from the top cortex are identifiable. For the preliminary study, size and placement of the transducer array are important. When the ultrasound beam is normal to the pedicle surface, echoes from the pedicle layers and the steel bit are strong; otherwise, signals are weak and not even identifiable. Larger aperture size will enhance the signal-to-noise ratio but deteriorate lateral resolution.

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Current scoliosis corrective surgeries may include the use of multiple instrumentation devices including screws, wires, nuts, and rods. The instrumentation in most cases is implemented in its native form. However, the instrumentation rods must be contoured to a desired shape prior to fixation to the spine. The contouring of the instrumentation rod is currently performed manually and may require significant time for completion. This results in an increase of operation time and reduced accuracy of the instrumentation rod. The feasibility of automating the contouring process was studied to determine if the time required to contour a rod could be reduced and if the accuracy of the rod could be improved. This study built upon a previous effort to construct a prototype that would automate the manufacture of spinal instrumentation rods. The Spinal Instrumentation Bending Prototype (SIBP) focused on ease of use, time of manufacture, and accuracy. In order to complete the manufacturing process, the current SIBP uses a set of three dimensional control points that represent the desired contour of the rod. These control points are translated into manufacturing inputs that control the SIBP. The control application for the SIBP contains local and global feedback routines that correct for any manufacturing errors. A comparative study was made between the SIBP and an experienced orthopedic surgeon to determine the level of bending accuracy improvement. / Master of Science

by Tang Shengping. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2002. / Includes bibliographical references (p. 217-244). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Mode of access: World Wide Web. / Abstracts in English and Chinese.

published_or_final_version / Orthopaedic Surgery / Doctoral / Doctor of Philosophy

published_or_final_version / abstract / Medicine / Master / Doctor of Medicine