James V. Raso

Development and Initial Validation of a Risk Score for Predicting In-Hospital and 1-Year Mortality in Patients With Hip Fractures†

Our objectives were to better define the rates and determinants of in‐hospital and 1‐year mortality after hip fracture. We studied a population‐based cohort of 3981 hip fracture patients. Using multivariable regression methods, we identified risk factors for mortality (older age, male sex, long‐term care residence, 10 prefracture co‐morbidities) and calculated a hip fracture‐specific score that could accurately predict or risk‐adjust in‐hospital and 1‐year mortality. Our methods, after further validation, may be useful for comparing outcomes across hospitals or regions.

The Production of Scoliosis After Pinealectomy in Young Chickens, Rats, and Hamsters

STUDY DESIGN This study involved weekly radiographic examination of pinealectomized rats, hamsters, and chickens to observe the development of scoliosis. OBJECTIVES To determine whether pinealectomy produces scoliosis in animals more closely related phylogenetically to humans than to chickens, namely rats and hamsters, which are representative of mammals. SUMMARY OF BACKGROUND DATA Pinealectomy in 3-day-old chickens has consistently resulted in the development of scoliosis with many characteristics similar to those seen in patients with adolescent idiopathic scoliosis. It has not been determined whether this phenomenon is restricted solely to chickens or is applicable to other animals, especially those more closely related to humans. METHODS The pineal gland was removed from young rats, hamsters, and chickens. All animals underwent radiography weekly to detect the development of any scoliosis. Weight and length measurements were also taken weekly, and serum melatonin levels were determined at the time the animals were killed. RESULTS Scoliosis was not observed in either the rats or the hamsters. In contrast, scoliosis developed in 10 of 21 chickens. Serum melatonin levels in all pinealectomized animals were zero. CONCLUSIONS In contrast to the chickens, pinealectomy does not seem to cause scoliosis in either young rats or hamsters. The reasons for this discrepancy may include differences in the physiology and spinal morphology of the rat and hamster in comparison with the chicken. In the pinealectomized chickens, the results also suggest that future scoliosis development might be indicated by a significant increase in size when they are compared with pinealectomized chickens that do not develop scoliosis. Such differences in growth rates also distinguish patients with adolescent idiopathic scoliosis.

Characterization of the scoliosis that develops after pinealectomy in the chicken and comparison with adolescent idiopathic scoliosis in humans

Study Design. The characteristics of the scoliosis that develops after pinealectomy in young chickens were determined from weekly posteroanterior radiographs. These data were compared with similar data collected from human patients with adolescent idiopathic scoliosis. Objectives. To characterize the scoliosis produced in young chickens after pinealectomy and to compare these characteristics with those seen in human patients with adolescent idiopathic scoliosis. Summary of Background Data. Although it has been recognized that pinealectomy produces scoliosis in chickens, the characteristics of these curves have never been well described other than by simple visual descriptions. Methods. The characteristics of the scoliosis produced in chickens after pinealectomy done 3 days after hatching were measured from radiographs taken at weekly intervals. These characteristics were compared with similar data collected from human patients with adolescent idiopathic scoliosis. Results. Similarities included development of single and double curves, degree of curvature, stability of the curve, numbers of vertebrae involved, direction of rotation, and progression characteristics. Differences included wedged vertebrae in the chickens, in conjunction with curve development and increased variability in vertebrae involved. Conclusions. There are many similarities in the development of scoliosis in young chickens after pinealectomy and in children with adolescent idiopathic scoliosis. The few differences might be related to the different biomechanical properties associated with the spine in the two species.

Intra-observer Reproducibility and Interobserver Reliability of the Radiographic Parameters in the Spinal Deformity Study Group's AIS Radiographic Measurement Manual

Study Design. Retrospective cross-sectional assessment of the reproducibility and reliability of radiographic parameters. Objective. To measure the intra-examiner and interexaminer reproducibility and reliability of salient radiographic features. Summary of Background Data. The management and treatment of adolescent idiopathic scoliosis (AIS) depends on accurate and reproducible radiographic measurements of the deformity. Methods. Ten sets of radiographs were randomly selected from a sample of patients with AIS, with initial curves between 20° and 45°. Fourteen measures of the deformity were measured from posteroanterior and lateral radiographs by 2 examiners, and were repeated 5 times at intervals of 3–5 days. Intra-examiner and interexaminer differences were examined. The parameters include measures of curve size, spinal imbalance, sagittal kyphosis and alignment, maximum apical vertebral rotation, T1 tilt, spondylolysis/spondylolisthesis, and skeletal age. Results. Intra-examiner reproducibility was generally excellent for parameters measured from the posteroanterior radiographs but only fair to good for parameters from the lateral radiographs, in which some landmarks were not clearly visible. Of the 13 parameters observed, 7 had excellent interobserver reliability. Conclusions. The measurements from the lateral radiograph were less reproducible and reliable and, thus, may not add value to the assessment of AIS. Taking additional measures encourages a systematic and comprehensive assessment of spinal radiographs.

Validity and Reliability of Active Shape Models for the Estimation of Cobb Angle in Patients with Adolescent Idiopathic Scoliosis

Choosing the most suitable treatment for scoliosis relies heavily on accurate and reproducible Cobb angle measurement from successive radiographs. The objective is to reduce variability of Cobb angle measurement by reducing user intervention and bias. Custom software to increase automation of the Cobb angle measurement from posteroanterior radiographs was developed using active shape models. Validity and reliability of the automated system against a manual and semiautomated measurement method was conducted by two examiners each performing measurements on three occasions from a test set (N = 22). A training set (N = 47) of radiographs representative of curves seen in a scoliosis clinic was used to train the software to recognize vertebrae from T4 to L4. Images with a maximum Cobb angle between 20° and 50°, excluding surgical cases, were selected for training and test sets. Automated Cobb angles were calculated using best-fit slopes of the detected vertebrae endplates. Intraclass correlation coefficient (ICC) and standard error of measurement (SEM) showed high intraexaminer (ICC > 0.90, SEM 2°–3°) and interexaminer (ICC > 0.82, SEM 2°–4°), but poor intermethod reliability (ICC = 0.30, SEM 8°–9°). The automated method underestimated large curves. The reliability improved (ICC = 0.70, SEM 4°–5°) with exclusion of the four largest curves (>40°) in the test set. The automated method was reliable for moderate-sized curves, and did detect vertebrae in larger curves with a modified training set of larger curves.

Automatic Cobb Measurement of Scoliosis Based on Fuzzy Hough Transform with Vertebral Shape Prior

To reduce variability of Cobb angle measurement for scoliosis assessment, a computerized method was developed. This method automatically measured the Cobb angle on spinal posteroanterior radiographs after the brightness and the contrast of the image were adjusted, and the top and bottom of the vertebrae were selected. The automated process started with the edge detection of the vertebra by Canny edge detector. After that, the fuzzy Hough transform was used to find line structures in the vertebral edge images. The lines that fitted to the endplates of vertebrae were identified by selecting peaks in Hough space under the vertebral shape constraints. The Cobb angle was then calculated according to the directions of these lines. A total of 76 radiographs were respectively analyzed by an experienced surgeon using the manual measurement method and by two examiners using the proposed method twice. Intraclass correlation coefficients (ICC) showed high agreement between automatic and manual measurements (ICCs > 0.95). The mean absolute differences between automatic and manual measurements were less than 5°. In the interobserver analyses, ICCs were higher than 0.95, and mean absolute differences were less than 5°. In the intraobserver analyses, ICCs were 0.985 and 0.978, respectively, for each examiner, and mean absolute differences were less than 3°. These results demonstrated the validity and reliability of the proposed method.

A computer-aided Cobb angle measurement method and its reliability.

Study Design Development of a computer-aided Cobb measurement method and evaluation of its reliability. Objectives To reduce the variability of Cobb angle measurement by developing the computer-aided method and to investigate if the developed method is sensitive to observer skill levels or experiences. Summary of Background Data Therapeutic decisions for scoliosis heavily rely on the Cobb angle measured from consecutive radiographs. The manual Cobb measurement is subject to human errors. The observer error is 3 to 10 degrees resulted from different end-vertebrae selection and/or manually drawing variable best-fit lines to the endplates of the end-vertebrae. Methods A fussy Hough transform technique was used to develop a computer-aided method to detect the vertebral endplates. The Cobb angle, upper end-vertebra, and lower end-vertebra were then measured automatically. The computer-aided method was tested twice by each of 3 observers in 84 posteroanterior radiographs from patients with adolescent idiopathic scoliosis. The intraobserver and interobserver errors were analyzed. Results Both the intraobserver and interobserver reliability analyses resulted in the intraclass correlation coefficients higher than 0.9 for the Cobb angle. The average intraobserver and interobserver errors were less than 3 degree for the Cobb angle, and less than 0.3 levels for both the upper and lower end-vertebral identification. There were no significant differences in the measurement variability between groups of curve location (thoracic, thoracolumbar, and lumbar), curve direction (right and left), curve magnitude (curves less than 25 degree, between 25 and 45 degrees, and more than 45 degree), and observer experience (experienced observer and inexperienced observers). Conclusions Compared with the documented results, variability of the Cobb measurement is reduced by using the developed computer-aided method. This method can help orthopedic surgeons measure the Cobb angle more reliably during scoliosis clinics.

Quantitative Morphology of the Lateral Ligaments of the Spine: Assessment of Their Importance in Maintaining Lateral Stability

Study Design This study used human cadaveric material to examine the three-dimensional morphology and biomechanics of the superior and lateral costotransverse ligaments and the intertransverse ligament of the spine. Objectives To provide descriptive and quantitative data on the morphology of the lateral ligaments of the spine and to assess their importance in maintaining lateral stability, especially regarding the pathogenesis of idiopathic scoliosis. Summary of Background Data Ligaments have been reported as being able to stabilize the spine by mechanical constraint and by neurologic feed-back. Midline spinal ligaments have been well studied but do not appear to be effective in maintaining lateral stability because of their sites of attachment. Lateral ligaments of the spine have not been adequately documented in the literature. Methods The morphology, sites of attachment, and dimensions of the superior costotransverse ligament, lateral costotransverse ligament, and intertransverse ligament from thoracic level 7 to thoracic level 10 were determined on 32 human cadavers. Results The intertransverse ligament was found not to be a true ligament. The lateral costotransverse ligament was a true ligament but did not have the characteristics appropriate for involvement in lateral stability. The superior costotransverse ligament also was a true ligament and had all of the characteristics appropriate for involvement in the active lateral balancing of the spine. Conclusions In contrast to the midline ligaments of the spine, the superior costotransverse ligament perhaps is the most important ligament for active lateral balancing of the spine and warrants further study, particularly regarding the development of idiopathic scoliosis.

Thoracic Lordosis in Idiopathic Scoliosis

Lordosis, a significant aspect of thoracic scoliosis, is difficult to assess with routine clinical radiographs. Computerized analysis of 138 sets of standardized anteroposterior and lateral radiographs served to elicit the three-dimensional structure of scoliosis. Spinal curvatures in the usual anatomic planes and in the sagittal and frontal planes of the apical vertebrae were measured. Lordosis was present in 35% of curves greater than or equal to 40 degrees and in 50% of curves greater than 49 degrees. Lordosis may be a contraindication for brace treatment.

Computer-aided assessment of scoliosis on posteroanterior radiographs

In order to reduce the observer variability in radiographic scoliosis assessment, a computer-aided system was developed. The system semi-automatically measured the Cobb angle and vertebral rotation on posteroanterior radiographs based on Hough transform and snake model, respectively. Both algorithms were integrated with the shape priors to improve the performance. The system was tested twice by each of three observers. The intraobserver and interobserver reliability analyses resulted in the intraclass correlation coefficients higher than 0.9 and 0.8 for Cobb measurement on 70 radiographs and rotation measurement on 156 vertebrae, respectively. Both the Cobb and rotation measurements resulted in the average intraobserver and interobserver errors less than 2° and 3°, respectively. There were no significant differences in the measurement variability between groups of curve location, curve magnitude, observer experience, and vertebra location. Compared with the documented results, measurement variability is reduced by using the developed system. This system can help orthopedic surgeons assess scoliosis more reliably.