Angelos Kaspiris

A review of the trunk surface metrics used as Scoliosis and other deformities evaluation indices

BackgroundAlthough scoliosis is characterized by lateral deviation of the spine, a 3D deformation actually is responsible for geometric and morphologic changes in the trunk and rib cage. In a vast related medical literature, one can find quite a few scoliosis evaluation indices, which are based on back surface data and are generally measured along three planes. Regardless the large number of such indices, the literature is lacking a coherent presentation of the underlying metrics, the involved anatomic surface landmarks, the definition of planes and the definition of the related body axes. In addition, the long list of proposed scoliotic indices is rarely presented in cross-reference to each other. This creates a possibility of misunderstandings and sometimes irrational or even wrong use of these indices by the medical society.Materials and methodsIt is hoped that the current work contributes in clearing up the issue and gives rise to innovative ideas on how to assess the surface metrics in scoliosis. In particular, this paper presents a thorough study on the scoliosis evaluation indices, proposed by the medical society.ResultsMore specifically, the referred indices are classified, according to the type of asymmetry they measure, according to the plane they refer to, according to the importance, and relevance or the level of scientific consensus they enjoy.ConclusionsSurface metrics have very little correlation to Cobb angle measurements. Indices measured on different planes do not correlate to each other. Different indices exhibit quite diverging characteristics in terms of observer-induced errors, accuracy, sensitivity and specificity. Complicated positioning of the patient and ambiguous anatomical landmarks are the major error sources, which cause observer variations. Principles that should be followed when an index is proposed are presented.

Nonspecific Low Back Pain During Childhood A Retrospective Epidemiological Study of Risk Factors

Objectives:In contrast to what was believed in the past, nonspecific low back pain is a fairly frequent condition in children, whose pathophysiology remains unclear as yet. Although many factors have been implicated in its development, results are often contradictory. Methods:Our study aims to examine most of the reasons investigated in the international literature, as well as the previously unexamined impact of passive smoking in its clinical appearance. It is a retrospective study that investigates the symptom of nonspecific low back pain during a 12-month period before the visit of children to our department. The research included 692 children aged 7.5 to 14 years. The data were collected using a semi-structured questionnaire, which included a mix of open and closed questions, followed by physical examination during their visit. Results:A total of 153 children were considered to present nonspecific low back pain during the previous year. The determinant factors appear to be greater age, the male sex, larger height, increased weight, dissatisfaction with school chairs, the clinical presentation of back pain in at least 1 parent, and coexisting anatomic orthopedic conditions. On the contrary, the weight of the school bag, the way in which it was carried and participation in sports, as well as the time spent by children in front of the TV or PC playing video or play station games, did not appear to have a statistically significant correlation with its appearance. In general, passive smoking does not appear to be a risk factor (P[r] = 0.341), and does not seem to play a leading role in the etiology of the condition. Furthermore, even the heaviness of parental smoking (over 20 cigarettes a day) does not seem to alter the appearance of the disease. The effect of nonspecific low back pain in childrens activities was measured using Hannover Functional Ability and Rolland Morris questionnaires, appropriately modified to childhood, where he found a moderate or severe restriction of activity in 23.52% (score >5) and 19.61% (score >6), respectively. Conclusions:The data analysis shows that nonspecific low back pain in children is a benign disorder with an unknown pathophysiological mechanism. Many anthropometric characteristics and environmental factors are implicated, but to a different degree each time. Passive smoking as well as the heaviness thereof does not appeal to play in important role in its clinical presentation. Further investigation is deemed necessary to determine the existence of other risk factors, as well as the level of their participation in the conditions pathophysiology.

Historical overview of spinal deformities in ancient Greece

Little is known about the history of spinal deformities in ancient Greece. The present study summarizes what we know today for diagnosis and management of spinal deformities in ancient Greece, mainly from the medical treatises of Hippocrates and Galen. Hippocrates, through accurate observation and logical reasoning was led to accurate conclusions firstly for the structure of the spine and secondly for its diseases. He introduced the terms kyphosis and scoliosis and wrote in depth about diagnosis and treatment of kyphosis and less about scoliosis. The innovation of the board, the application of axial traction and even the principle of trans-abdominal correction for correction of spinal deformities have their origin in Hippocrates. Galen, who lived nearly five centuries later impressively described scoliosis, lordosis and kyphosis, provided aetiologic implications and used the same principles with Hippocrates for their management, while his studies influenced medical practice on spinal deformities for more than 1500 years.

Relatively lower body mass index is associated with an excess of severe truncal asymmetry in healthy adolescents: Do white adipose tissue, leptin, hypothalamus and sympathetic nervous system influence truncal growth asymmetry?

BackgroundIn healthy adolescents normal back shape asymmetry, here termed truncal asymmetry (TA), is evaluated by higher and lower subsets of BMI. The study was initiated after research on girls with adolescent idiopathic scoliosis (AIS) showed that higher and lower BMI subsets discriminated patterns of skeletal maturation and asymmetry unexplained by existing theories of pathogenesis leading to a new interpretation which has therapeutic implications (double neuro-osseous theory).Methods5953 adolescents age 11–17 years (boys 2939, girls 3014) were examined in a school screening program in two standard positions, standing forward bending (FB) and sitting FB. The sitting FB position is thought to reveal intrinsic TA free from back humps induced by any leg-length inequality. TA was measured in both positions using a Pruijs scoliometer as angle of trunk inclinations (ATIs) across the back at each of three spinal regions, thoracic, thoracolumbar and lumbar. Abnormality of ATIs was defined as being outside 2 standard deviations for each age group, gender, position and spinal region, and termed severe TA.ResultsIn the sitting FB position after correcting for age,relatively lower BMIs are statistically associated with a greater number of severe TAs than with relatively higher BMIs in both girls (thoracolumbar region) and boys (thoracolumbar and lumbar regions).The relative frequency of severe TAs is significantly higher in girls than boys for each of the right thoracic (56.76%) and thoracolumbar (58.82%) regions (p = 0.006, 0.006, respectively). After correcting for age, smaller BMIs are associated with more severe TAs in boys and girls.DiscussionBMI is a surrogate measure for body fat and circulating leptin levels. The finding that girls with relatively lower BMI have significantly later menarche, and a significant excess of TAs, suggests a relation to energy homeostasis through the hypothalamus. The hypothesis we suggest for the pathogenesis of severe TA in girls and boys has the same mechanism as that proposed recently for AIS girls, namely: severe TAs are initiated by a genetically-determined selectively increased hypothalamic sensitivity (up-regulation, i.e. increased sensitivity) to leptin with asymmetry as an adverse response to stress (hormesis), mediated bilaterally mainly to the growing trunk via the sympathetic nervous system (leptin-hypothalamic-sympathetic nervous system (LHS) concept). The putative autonomic dysfunction is thought to be increased by any lower circulating leptin levels associated with relatively lower BMIs. Sympathetic nervous system activation with asymmetry leads to asymmetries in ribs and/or vertebrae producing severe TA when beyond the capacity of postural mechanisms of the somatic nervous system to control the shape distortion of the trunk. A test of this hypothesis testing skin sympathetic responses, as in the Rett syndrome, is suggested.

Growing pains in children: epidemiological analysis in a Mediterranean population.

OBJECTIVES Recurrent lower limb pains (growing pains) constitute the most frequent cause of musculoskeletal pain in children. Despite the fact that the international literature has presented numerous cases over the years, which have led to various hypotheses and theories, the disorders exact nature and aetiology remain unclear. METHODS Our study aims to examine both the epidemiological profile of the children affected by the disorder and the measures taken by parents or medical specialists for their management. In addition, we tried to link the existing theories with the findings of our study, to ascertain whether these were verified by the epidemiological findings. This retrospective study investigated the appearance of lower limbs in the 12-month period before the visit of the children to our department. The study included a total of 532 children, aged 4-12, while the data were collected through semi-structured interviews including a mix of open and closed questions. RESULTS One hundred and thirty of these children presented growing pains, meeting Petersens criteria. The frequency of the disorder was 24.5%. Most times, they appeared after intensive physical exercise, while their development was not linked to the childrens BMI. The main therapeutic approach used by parents was massaging the painful lower limbs and, to a lesser extent, the administration of anti-inflammatory agents. CONCLUSIONS The data analysis proves that this is a benign disorder with an unknown pathophysiological mechanism. In addition, their presence is not strongly related to anatomic or orthopaedic disorders, a fact opposing anatomical theory. On the contrary, their appearance after intensive physical exercise at a percentage of up to 78.5% leads us to hypothesise that it is a lower local extremity overuse syndrome, which seems in accordance with many experimental data in international literature.

Trunk asymmetry in juveniles

BackgroundTrunk asymmetry (TA) is a common phenomenon in children, but its incidence in juveniles is not known. The present cross sectional study reports TA in normal juveniles and provides data which describe the evolution of TA from early childhood to adolescence.Materials and methodsThe scoliometer readings in both standing and sitting forward bending position (FBP) of 3301 children, (1645 boys, and 1656 girls) aged from 3 to 9 years old were studied. TA was quantified by measuring angle of trunk rotation (ATR) and children were categorized as symmetric (ATR = 0°), mild asymmetric (ATR 1° – 6°) and severely asymmetric (ATR ≥ 7°). The difference of TA between standing and sitting FBP as well as differences between boys and girls in frequency of TA were also calculated. The scoliometer readings were analyzed by age to reveal at which age the juvenile pattern of TA changes into the adolescent one.Results74.2% of boys and 77% of girls were symmetric (ATR = 0°) in the thoracic region in standing FBP, while 82.7% of boys and 84.1% of girls were symmetric in the thoracic region in sitting FBP. Juvenile girls are more symmetric than boys but severe TA was found almost the same between the two genders. A significant reduction in the frequency of mild TA from standing into sitting FBP, in all the examined regions in both boys and girls was found, but in severe TA this reduction is very small. Analysing scoliometer readings by age it appears that significant TA changes take place between 8–9 years of age for boys and between 6–7 and 8–9 years for girls. TA in boys is changing into the adolescent pattern at a later age than in girls.ConclusionJuveniles were found more symmetric than adolescents, who were studied previously in a different study. Furthermore, juvenile girls were found more symmetric than boys. Juvenile TA pattern seems to be in accordance with the higher incidence of juvenile idiopathic scoliosis in boys. Furthermore, severe TA, which could be correlated with a scoliotic curve, was found to be more common to the left side. The present report provides information about the variability of back morphology in normal juveniles. The amount of TA in children is the indicator for referral and further orthopaedic assessment if a spinal curve is detected, but can also be used as a baseline for further research on idiopathic scoliosis aetiology.

Surgical and conservative treatment of patients with congenital scoliosis: α search for long-term results

BackgroundIn view of the limited data available on the conservative treatment of patients with congenital scoliosis (CS), early surgery is suggested in mild cases with formation failures. Patients with segmentation failures will not benefit from conservative treatment. The purpose of this review is to identify the mid- or long-term results of spinal fusion surgery in patients with congenital scoliosis.MethodsRetrospective and prospective studies were included, reporting on the outcome of surgery in patients with congenital scoliosis. Studies concerning a small numbers of cases treated conservatively were included too. We analyzed mid-term (5 to 7 years) and long-term results (7 years or more), both as regards the maintenance of the correction of scoliosis and the safety of instrumentation, the early and late complications of surgery and their effect on quality of life.ResultsA small number of studies of surgically treated patients were found, contained follow-up periods of 4-6 years that in the most cases, skeletal maturity was not yet reached, and few with follow-up of 36-44 years. The results of bracing in children with congenital scoliosis, mainly in cases with failure of formation, were also studied.DiscussionSpinal surgery in patients with congenital scoliosis is regarded in short as a safe procedure and should be performed. On the other hand, early and late complications are also described, concerning not only intraoperative and immediate postoperative problems, but also the safety and efficacy of the spinal instrumentation and the possibility of developing neurological disorders and the long-term effect these may have on both lung function and the quality of life of children.ConclusionsFew cases indicate the long-term results of surgical techniques, in the natural progression of scoliosis. Similarly, few cases have been reported on the influence of conservative treatment.In conclusion, patients with segmentation failures should be treated surgically early, according to the rate of deformity formation and certainly before the pubertal growth spurt to try to avoid cor- pulmonale, even though there is lack of evidence for that in the long-term. Furthermore, in patients with formation failures, further investigation is needed to document where a conservative approach would be necessary.

Congenital scoliosis in monozygotic twins: case report and review of possible factors contributing to its development

BackgroundThe exact etiology of congenital scoliosis remains unknown as yet. It seems that its development may be influenced by both genetic predisposition and environmental factors, at varying degrees. International bibliography features few cases of monozygotic twins with congenital scoliosis. The aim of this study is to report a case in monozygotic twins and review the literature relating to the description of similar cases as well as the pathophysiological mechanism involved in its development.MethodsClinical examination and simple X-rays revealed scoliosis of differing degrees and types in male monozygotic twins with moderate mental retardation and dyslalia.ResultsCongenital scoliosis identified in both twins. In the first, this was manifested as left thoracic scoliosis, with Cobb angle of 34 degrees while in the second as left thoracolumbar scoliosis with Cobb angle of 10 degrees. Both were found to suffer from incarcerated hemivertebrae.ConclusionAccording to both its clinical identification and severity and to its course, not only the genetic but the environmental factors seem to play a leading role in the appearance of the condition.

Expression of matrix metalloproteinase-1 (MMP-1) in Wistar rat's intervertebral disc after experimentally induced scoliotic deformity.

IntroductionA scoliotic deformity on intervertebral discs may accelerate degeneration at a molecular level with the production of metalloproteinases (MMPs). In the present experimental study we evaluated the presence of MMP-1 immunohistochemically after application of asymmetric forces in a rat intervertebral disc and the impact of the degree of the deformity on MMP-1 expression.Material-MethodThirty female Wistar rats (aged 2 months old, weighted 200 ± 10 grams) were used. All animals were age, weight and height matched. A mini Ilizarov external fixator was applied at the base of a rat tail under anaesthesia in order to create a scoliotic deformity of the intervertebral disc between the 9th and 10th vertebrae. Rats were divided into three groups according to the degree of the deformity. In group I, the deformity was 10°, in group II 30° and in group III 50°. The rats were killed 35 days after surgery. The discs were removed along with the neighbouring vertebral bodies, prepared histologically and stained immunohistochemically. Immunopositivity of discs cells for MMP-1 was determined using a semi-quantitative scored system.ResultsMMP-1 immunopositivity was detected in disc cells of annulus fibrosus of all intervertebral disc specimens examined. The percentage of MMP-1 positive disc cells in annulus fibrosus in group I, II and III were 20%, 43% and 75%, respectively. MMP-1 positivity was significantly correlated with the degree of the deformity (p < 0,001). An increase of chondrocyte-like disc cells was observed in the outer annulus fibrosus and at the margin of the intervertebral disc adjacent to the vertebral end plates. The difference in the proportion of MMP-1 positive disc cells between the convex and the concave side was statistically not significant in group I (p = 0,6), in group II this difference was statistically significant (p < 0,01). In group III the concave side showed a remarkable reduction in the number of discs cells and a severe degeneration of matrix microstructure.ConclusionThe present study showed that an experimentally induced scoliotic deformity on a rat tail intervertebral disc results in over-expression of MMP-1, which is dependent on the degree of the deformity and follows a dissimilar distribution between the convex and the concave side.

Range of variation of genu valgum and association with anthropometric characteristics and physical activity: comparison between children aged 3-9 years.

The lower limbs of children aged 3–9 years present varying knock-knee deformities that have a direct impact on the diversification of the load-bearing axis of the valgus limb and on the modification of gait kinematics. The purpose of our study was to establish the reference values of knee alignment in a Greek population and whether this is linked to a change in the physical activity of children depending on the severity of the genu valgum. Using a clinical method, we measured both the tibiofemoral (TF) angle and the intermalleolar (IM) distance of the lower extremities of normal children. Subsequently, forms of the Netherlands Physical Activity Questionnaire (NPAQ) for young children and the Baecke questionnaire on habitual physical activity, modified especially for children, were completed by the parents. We examined both the development of the TF angle and the IM distance in relation to age and the degree of restriction of physical activity in relation to the severity of the genu valgum. We analysed 316 unaffected lower extremities in children aged 3–9 years. The average value of the TF angle starts around 7° at the age of 3 years and gradually decreases to 4° at the age of 7–8 years. The average value of the IM distance ranges over 3.5 cm at the age of 3 years and progressively decreases to 2 cm at the age of 7–8 years. Physical activity appears to be influenced by sex and the severity of the genu valgum. We provide age-specific values for limb alignment and joint orientation of the lower extremity in children aged 3–9 years. A statistical correlation between all indexes (sport, leisure time and total) of the Baecke and the NPAQs and measurements of genu valgum was noted depending on the severity of the valgus deformity. The level of evidence is the level II Prognostic Study.