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Current methods for treating and diagnosing spinal deformities caused by scoliosis are both surgically intensive and rarely allow for complete correction. This is mainly due to the fact that the diagnostic techniques used are rough estimates made by angles defined by observations of 2-D radiographs. By utilizing the latest software, our research is based on designing a tool that creates a 3-D representation of the spine. When creating a three-dimensional spinal model, it becomes possible to determine local curvature and local torsion values at each specific vertebrae. By manipulating these values at discrete locations on the spine, one can generate "virtual" spines in a three-dimensional environment. The Scoliosis Learning Tool includes algorithmic steps that determine the Lenke Classification of the "virtual" spines. The Lenke Classification is the most commonly accepted method for diagnosing spinal deformities. This patient building program will produce a group of spines with random values for curvature, torsion and initial spinal orientation. An algorithm within the software determines the Lenke Classification of each, and discards any curves that appear unnatural. By defining a metric that places an emphasis on certain geometric similarities, the software is able to define diameters of classification groups and separations between different classification groups. In turn it is possible to determine minor to major differences between spines within the same classification. In doing so, the opportunity exists to possibly find an undiscovered deformity that had previously fallen under another classification category. / Master of Science

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.

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Background: The global burden of osteoporosis includes considerable numbers of fractures, morbidity, mortality and expenses, due mainly to vertebral, hip and forearm fractures. Underdiagnosis and undertreatment are common. Several studies have shown decreased health-related quality of life (HRQOL) after osteoporotic fracture, but there is a lack of data from long-term follow-up studies, particularly regarding vertebral fractures, which are often overlooked despite patients reporting symptoms. Aim: The overall aim of this thesis was to evaluate the usefulness of a recent low-energy fracture as index event in a case-finding strategy for osteoporosis and to describe and analyse long-term HRQOL in postmenopausal women with osteoporotic fracture. The specific aims were to describe bone mineral density and risk factors in women 55-75 years of age with a recent low-energy fracture (I), estimate the impact of osteoporotic fractures on HRQOL in women three months and two years after a forearm, proximal humerus, vertebral or hip fracture (II), investigate the changes and long-term impact of vertebral or hip fracture on HRQOL in women prospectively between two and seven years after the inclusion fracture (III), and describe how HRQOL and daily life had been affected in women with vertebral fracture several years after diagnosis (IV). Design and methods: Data were collected from southern Sweden between 1998 and 2008. A total of 303 women were included in Study I, and this group served as the basis for Studies II (n=303), III (n=67), and IV (n=10). A cross-sectional observational, case-control design (I), and a prospective longitudinal observational design (II-III) were used. In Study IV a qualitative inductive approach with interviews was used and data were analysed using a qualitative conventional content analysis. Results: The type of recent fracture and number of previous fractures are important information for finding the most osteoporotic women in terms of severity (I). Hip and vertebral fractures in particular have a significantly larger impact on HRQOL evaluated using the SF-36 than do humerus and forearm fractures, both during the three months after fracture and two years later, compared between the different fracture groups and the reference population (II). Women who had a vertebral fracture as inclusion fracture had remaining pronounced reduction of HRQOL at seven years. At the mean age of 75.5 years (±4.6 SD), the prevalence of vertebral fracture suggests more negative long-term impact on HRQOL, more severe osteoporosis and a poorer prognosis than a hip fracture does, and this effect may have been underestimated in the past (III). Study IV demonstrates that the women’s HRQOL and daily life have been strongly affected by the long-term impact of the vertebral fracture several years after diagnosis. The women strive to maintain their independence by trying to manage different types of symptoms and consequences in different ways. Conclusions and implications: Type and number of fractures should be taken into account in the case-finding strategy for osteoporosis in postmenopausal women between 55 and 75 years of age. The long-term reduction of HRQOL in postmenopausal women (age span 55-75 yr) with vertebral fracture emerged clearly, compared to women with other types of osteoporotic fractures and references in this thesis. The results ought to be taken into consideration when developing guidelines for more effective fracture prevention and treatment, including non-pharmacological intervention for women with osteoporotic fractures, with highest priority placed on vertebral fractures and multiple fractures, to increase or maintain HRQOL.

Les déformations rachidiennes se réfèrent aux patients avec une courbure anormal de la colonne vertébrale qui ont terminé leur croissance. Par leur prévalence, leur impact clinique, et le taux relativement élevé d'échecs chirurgicaux, elles représentent un défi thérapeutique. La recherche a permis de démontrer que la préservation ou la restauration de l'alignement, sont des éléments clé du traitement chirurgical. L'objectif de cette thèse était d'analyser le traitement des patients avec DR, avec un intérêt particulier pour la restauration de l'alignement sagittal et l'évaluation musculaire. Fondé sur une analyse rétrospective d'une base de données multicentriques, les deux premiers articles présentent une évaluation du traitement chirurgical en termes d'efficacité clinique et de réalignement radiographique. Les écarts entre la planification préopératoire et l'exécution opérationnelle ont aussi été étudiés avec une collecte de données prospectives, et ont mis en évidence la nécessité de mieux comprendre le rôle des muscles dans le maintien de la posture. Par conséquent, deux protocoles pour la caractérisation des principaux muscles impliqués dans l'alignement sagittal ont été validés. Les deux méthodes sont basées sur la segmentation manuelle d'acquisition IRM spécifique (méthode de Dixon) afin d'obtenir l'infiltration graisseuse en plus du volume musculaire. Une des méthodes permet d'obtenir la reconstruction 3D des muscles et donc de générer des modèles musculo-squelettiques personnalisés. L'autre ouvre la voie à une pratique clinique car nécessite seulement la segmentation de quatre coupes pour obtenir une évaluation des principaux groupes musculaires. Enfin, à partir de la première méthode, le système musculaire de patients avec DR a été décrit. / Adult spinal deformity(ASD) refers to abnormal curvatures of the spine in patients who have completed their growth. Due to its prevalence, clinical impact, and the relatively high rate of surgical failures, they represent a therapeutic challenge. Research has been able to demonstrate that the preservation or the restoration of the sagittal alignment, are key objectives of surgical treatment. The objective of this thesis is to analyze the treatment of ASD patients, with particular interest in restoration of sagittal alignment and to develop tools to assess the spino-pelvic musculature of ASD patients. Based on an analysis of a multicenter database, the first two articles present an evaluation of the surgical treatment in term of clinical effectiveness and radiographic realignment. In addition, the discrepancies between surgical preoperative planning and operative execution have been studied with a prospective data collection, and have highlighted the necessity to understand better the role of the muscles in the maintaining of the posture. Therefore two methods for the characterization of the muscles involved in the sagittal alignment have been validated. Both methods are based on manual segmentation of specific MRI acquisition (Dixon methods) in order to obtain precise fat infiltration quantification in addition to muscular volume. One method permits to obtain 3D reconstruction able to generate patient–specific musculoskeletal model. The other one open the path to a clinical purpose, because necessitate only segmentation of four slices to obtain an relevant evaluation of the muscular system. Finally, thanks to the first protocol the muscular system of ASD patients have been described.

No description available.