Asssociation Between Suppressor Of Cytokine Signaling-3Gene Polymorphism And Susceptibility Of Adolescent Idiopathic Scoliosis And Radiographic Evaluation Of AIS

Chapter1Asssociation between suppressor of cytokine signaling-3gene polymorphism and susceptibility of adolescent idiopathic scoliosisObjective To explore whether the SOCS3gene polymorphisms are associated with the susceptibility, abnormal growth pattern of adolescent idiopathic scoliosis (AIS).Methods398AIS girls aged10to18years old were enrolled, and367age-matched healthy girls were recruited as controls. The diagnosis was confirmed clinically and radiologically. Onlypatients who had Cobb angleslarger than20°were included in this study. Anthropometric parameters including body weight, height and body mass index (BMI) were measured for AIS girls. Rs4969198was selected as a tagSNP to cover all of the relatedpolymorphisms on SOCS3that are based on the recentlyreleased HapMap data.Genotyping was performed usingPCR-based Invader assay with the probe sets designed and synthesized by Third Wave. The genotyping results were read with an ABI PRISM7900HT sequence detection system (Applied Biosystems, Foster City, CA). Twentypercent of the samples were selected randomly to validate the reproducibility of the genotyping results. Rs4969198was successfully genotyped. No significant difference of genotype frequencies from the HWE test was noted for the AIS patients or the normal controls. Neither the genotype nor the allele frequencies of rs49691968weresignificantly different between the AIS patients and the normal controls. A subgroup of322skeletally mature AIS patients who did not received bracing or any otherconservative treatment previously were analyzed to define the contribution of rs4969168on curve severity, body height, body weight and BMI. By one-way ANOVA test, rs4969168was not found to be associated with the curve severity of scoliosis and body height.AIS patients with AA genotype had significantly higher body weight and BMI than the patients with AG and GG genotype (P=0.014)Conclusion The SOCS3gene polymorphisms are not associated with the occurrence of AIS, but the SNP polymorphism (rs4969168) is associated with abnormal growth pattern of AIS, indicating that SOCS3gene might be a disease-modifying gene of AIS. Chapter2(section1) Comparison of the aorta impingement risks between thoracolumbar/lumbar curves with different convexities in Adolescent Idiopathic Scoliosis:A Computed Tomography StudyObjective:To compare the positions of the aorta relative to vertebral bodies and the potential risk of the aorta impingement for pedicle screw (PS) placement between right-sided and left-sided thoracolumbar/lumbar curves of adolescent idiopathic scoliosis (AIS).Methods:Thirty-nine AIS patients with a main thoracolumbar or lumbar curve were recruited. The Lenke’s classification was type5C in all patients. According to the convexity of the thoracolumbar or lumbar curves, the patients were divided into either group R or Group L. The patients in Group R had a main right-sided thoracolumbar/lumbar curve, and the patients in Group L had a main left-sided thoracolumbar/lumbar curve. Axial CT images from T12to L4at the midvertebral body level were obtained to evaluate Aorta-vertebra angle (a), Vertebral rotation angle (β), Lefty safety distance (LSD) and Right safety distance (RSD). The risks of the aorta impingement from T12to L4were calculated, and then compared between the two groups.Results:The a increased from T12through L4in Group R while increased from T12through L1, and then decreased from L1through L4in Group L. The (3decreased from T12through L4in both groups. The LSD constantly increased from T12through L4in Group R while increased from T12through L3, and then decreased from L3through L4in Group L. The RSD increased from T12through L3, and the decreased from L3through L4in both groups. With the increment of the lengths of the simulated screws, the aorta impingement risks were constantly elevated at all levels in both groups. The aorta was at a high risk of impingement from left PS regardless of the diameters of the simulated screws in Group R (80%to100%at T12and53.3%to100%at L1). In Group L, the aorta was completely safe when using35mm (0at all levels) PS and at high risks of the aorta impingement on the right side from45mm PSs (31.8%to72.7%). In all, the risks of the aorta impingement were mainly from left PS in Group R and from right PS in Group L, and the risk of the aorta impingement from PS placement was generally higher in right thoracolumbar or lumbar curves when compared with that of the left.Conclusions:The present study illustrated different changed positions of the aorta relative to vertebrae between thoracolumbar/lumbar curves with different convexities. In right-sided curve, the risks of the aorta impingement were mainly from left PS while in left-sided curves, from right PS. The aorta was more proximal to entry points in right-sided lumbar curve when compared with left-sided curve; thus placing PS carries more risks in right-sided thoracolumbar/lumbar curve. Surgeons should be more cautious when placing PSs on the concave sides of T12and L1vertebrae of right-sided thoracolumbar/lumbar curves. Chapter2(section2) Indication for preoperative MRI of Neural axis abnormalities in patients with presumed thoracolumbar/lumbar idiopathic scoliosisObjective The purpose of this study was to investigate the incidence of neural axis abnormalities in patients with presumed "idiopathic" thoracolumbar or lumbar scoliosis by magnetic resonance imaging (MRI) and try to determine which clinical and radiographic characteristics correlate with neural axis abnormalities on MRI in these patients.Methods The database of a single spinal deformity center was retrospectively reviewed to identify all patients with a primary diagnosis of IS between January2003and August2011. A total of446patients with main thoracolumbar or lumbar curves were identified. Radiographic parameters including main curve Cobb angles, location of curve apex, span of main curve, thoracic kyphosis (T5-T12), thoracolumbar junction kyphosis (T10-L2), lumbar lordosis (L1-S1) and sagittal and coronal balance were measured.Results Neural axis abnormalities were detected in35(7.8%) patients. For patients with neural axis abnormalities, a higher proportion of male gender and long thoracolumbar curves presented. In these patients, the mean age was smaller and the mean Cobb angle of main curve was larger. Greater thoracic kyphosis (≥30°) was more frequently found in those with neural axis abnormalities. The incidences of thoracolumbar junction hyperkyphosis were similar between two groups (P>0.05). There was no difference between two groups as to lumbar lordosis and coronal and sagittal balance.Conclusion We recommend the routine use of MRI in the patients with one or more of the following characteristics:right curves, long curve span, apex at thoracolumbar spine and hyperthoracic kyphosis. Chapter2(section3) A comparison of reliability analysis for the measurement of Cobb angle using digital inclinometer versus traditional manual methodObjective:To evaluate the intra-and interobserver reliability for Cobb angle measurement using iPhone and compare it with that of manual methodMethods:Fifty posteroanterior radiographs of adolescent idiopathic scoliosis (AIS) patients with thoracic scoliosis were used for the standard Cobb method of measurement (manual set) and the smartphone aided Cobb method of measurement. Four spinal surgeons measured the Cobb angle with the use of both the manual method and iPhone. The measurement time was recorded for every measurement. The intraclass correlation coefficient (ICC) two-way mixed model on absolute agreement was used to analyze measurement reliability. Summary statistics from analyses-of-variance calculations were used to provide95%prediction limits for the error in measurements. Paired-t test was employed to compare the time consumed for the measurement between both sets.Results:The intraobserver ICC was excellent in the iPhone set and in the manual set. The interobserver ICC was excellent in the iPhone set and in the manual set.Both the intraobserver ICC and interobserver ICC were better in the iPhone set than in the manual set. The mean Cobb angle of all measured X-rays was28.9degrees and the mean difference between two measurements was2.6degrees in the manual set whilethe mean Cobb angle of all measured X-rays was28.8degrees and the mean difference between two measurements was1.4degrees in the iPhone set.The mean time consumed was13.4S (range:8.6S-18.4S) for the iPhone set while38.2S (range:30.1S-46.4S) for the manual set, and the mean time consumed for the iPhone set was significantly shorter than that of the manual set.(P<0.05)Conclusion:iPhone method for the measurement of Cobb angle showed excellent reliability and efficiency that could help surgeons make decisions of the diagnosis and treatment of scoliosis more accurately and efficiently. So it is suggested to popularize the use of this method in clinical practice. Chapter3(section1) Validation of the Simplified Chinese Version of the Core Outcome Measures Index (COMI)Objective:To translate the Core Outcome Measures Index (COMI) into Simplified Chinese and then validate it for Mainland Chinese people with low back pain (LBP).Methods:120consecutive patients with LBP>3months who visited our outpatient from December2011to March2012were asked to complete a questionnaire booklet including:(1) the Roland Morris disability (questionnaire RMQ)1;(2) the Short Form Health Survey (SF-36)2;(3) the Oswestry Disability Index (ODI)3;(4) visual analog scale (VAS) measure of pain, and (5) COMI. These patients were also asked to complete a second COMI questionnaire and a transition question (5-point Likert scale: better, a little better, no change, a little worse, worse), and to mail back the second COMI questionnaire within1month.Results:The floor effects for the COMI items ranged from5.8%to12.5%. High values (28.3%,27.5%,25.8%) were found for symptom-specific quality of life, social and work disability. As to the ceiling effects, social and work disabilities were relatively high,17.5%and24.2%, respectively. For other items, the values ranged from0to14.2%. Neither floor nor ceiling effects have been found for the COMI summary score. Excellent correlations were found between the COMI pain scores and VAS scores (Rho=0.89) and between the COMI pain and the SF-36bodily pain domain (Rho=0.84). Other individual items and summary scores showed a very good correlation (Rho=0.54-0.72) with corresponding questionnaires except "symptom-specific well-being"(0.31-0.45). One-way repeated measures ANOVA was used to determine the intraclass correlation coefficient (ICC). The ICC for the COMI whole score was0.91(95%CI0.85-0.94), and0.81-0.86for the two pain scores (back and leg). The "minimum detectable change"(MDC95%) for the COMI summary score was1.91points. No significant difference in the mean values was found for the repeated scores of individual items and summary score.Conclusion The Simplified Chinese version of COMI showed good psychometric properties and reliability. This concise questionnaire is suitable for the widespread use in Mainland China. Chapter3(section2) Gender differences of Scoliosis Research Society-22scores in adolescent idiopathic scoliosisObjective:To compare differences of SRS-22scores between male and female AIS patients.Methods:From October2007to April2009,296AIS patients (62males,236females) from7spine centers completed Simplified Chinese edition of SRS-22questionnaire. The average age of the patients was15.7years old (range,12to20years old), and the average Cobb angle was52.8°(range,21°to106°). Of62male patients,34were from urban areas and28rural areas. Among236female patients,132were from urban areas and104rural areas. A comparison was conducted1in terms of age, Cobb angle, the ratio of urban population to rural population, and the scores of all domains and the subtotal scores of SRS-22questionnaire between male and female patients.Results:There was no difference of age, Cobb angle and the ratio of urban population to rural population between male and female patients (p>0.05). The average scores of four domains in male patients were as follows:function/activity (18.5), pain (22.3), self-image (16.7), mental health (18.8) and the subtotal scores was76.3; and in female patients, the scores were as follows:function/activity (16.0), pain (16.7), self-image (15.2), mental health (17.3) and the subtotal scores (76.3). The scores of four domains and subtotal scores of SRS-22questionnaire were significantly higher in male patients when compared with female patients (p<0.05)Conclusion:Gender difference should be taken into the consideration when estimating the quality of life in AIS patients by means of SRS-22questionnaire. The quality of life in male patients with AIS was better than that of female patients. The results of this study were different from those of others, which may be largely attributed to the social and cultural factors.