title: Vertebral rotation and thoracic torsion in adolescent idiopathic scoliosis: what is the best radiographic correlate?
abstract: BACKGROUND
  As a result of the increased appreciation of the three-dimensional nature of scoliosis and modern spinal instrumentation's improved corrective capabilities, there has been renewed interest in the correction and measurement of vertebral rotation. Computed tomography (CT), the gold standard for accuracy, is limited in its clinical utility owing to cost, radiation exposure, and the effects of postural changes on scoliosis curves and vertebral rotation. Consequently, the Perdriolle and Nash-Moe techniques remain the standard measurements for providing a reasonable estimate of pre- and postoperative vertebral rotation because of their simplicity. However, these techniques have considerable interobserver variability, and pedicle screw instrumentation obscures the landmarks necessary for utilizing these techniques for postoperative vertebral rotation assessment. The purpose of the present study was to assess the utility of alternate radiographic measures to assess vertebral rotation and thoracic torsion when compared with conventional measures on pre- and postoperative radiographs and CT evaluation.
  
  
  METHODS
  We reviewed the preoperative, immediate postoperative, and final follow-up radiographs, as well as the pre- and postoperative CT scans, of 19 patients (average age 15 years, 6 months) with Lenke 1 curves (average 55 degrees , range 47-66 degrees ), all treated with anterior spinal fusion. Coronal and sagittal Cobb angles as well as vertebral rotation (Perdriolle and Nash-Moe) at the superior uninstrumented, superior instrumented, apical, inferior instrumented, and inferior uninstrumented vertebrae were measured on all films, and vertebral rotation was assessed on the CT scans by a previously described method. Additionally, several measures of thoracic torsion (as a proxy for vertebral rotation and overall deformity improvement) were assessed. These included the rib-vertebral angle difference (RVAD), apical rib hump prominence (RH), apical vertebral body-rib ratio (AVB-R), and apical rib spread difference (ARSD).
  
  
  RESULTS
  The postoperative main thoracic curve averaged 26 degrees (range 16-39 degrees , 52% correction) and 29 degrees (range 22-40 degrees , 47% correction) at final follow-up. For apical derotation, the postoperative CT improved from -11.5 degrees to -6.6 degrees and correlated significantly with the Cobb main thoracic curves (42% correction, r = 0.48, P = 0.003). There was weakly positive, but statistically significant, correlation between the pre- and postoperative CT scans and the corresponding Perdriolle and Nash-Moe measures of segmental rotation (r = 0.32-0.40, all P < 0.0001). The RVAD demonstrated poor correlation with the main thoracic curve values and correction, Perdriolle rotation and correction, and CT rotation and correction (r = -0.22-0.37, all P > 0.20). The apical RH demonstrated good correlation with the main thoracic curve (r = 0.65, P < 0.0001), apical Perdriolle rotation (r = 0.57, P < 0.0001), and CT apical rotation (r = 0.53, P = 0.002). We also found moderate correlation between the AVB-R and the main thoracic Cobb, apical Perdriolle, and CT (r = 0.57, 0.59, and 0.49, respectively; all P < 0.005). Similar relationships were found with the ARSD (r = 0.51, 0.47, and 0.43, respectively; all P < 0.02).
  
  
  CONCLUSIONS
  The RH, AVB-R, and the ARSD-measures of thoracic torsion-demonstrated moderate to good overall correlation with the main thoracic curve Cobb angles, apical Perdriolle rotation, and apical CT rotation. These should be useful as clinical measures for assessing three-dimensional deformity correction on plane radiographs, especially for the intraoperative evaluation of vertebral derotation and thoracic symmetry restoration.
authors.affiliation: Spine Surgery, Department of Orthopaedics and Rehabilitation, Walter Reed Army Medical Center, Washington, DC 20307, USA. Timothy.Kuklo@na.amedd.army.mil
authors.forename: Timothy R
authors.initials: TR
authors.lastname: Kuklo
authors.forename: Benjamin K
authors.initials: BK
authors.lastname: Potter
authors.forename: Lawrence G
authors.initials: LG
authors.lastname: Lenke
mesh_terms: D000293:Adolescent; D000328:Adult; D001863:Bone Screws; D002648:Child; D005260:Female; D006801:Humans; D016268:Internal Fixators; D008297:Male; D015588:Observer Variation; D011859:Radiography / Q000379:methods* / Q000592:standards; D015203:Reproducibility of Results; D012272:Ribs / Q000000981:diagnostic imaging* / Q000473:pathology; D012399:Rotation / Q000009:adverse effects; D012600:Scoliosis / Q000000981:diagnostic imaging* / Q000473:pathology; D013123:Spinal Fusion / Q000295:instrumentation; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging* / Q000473:pathology; D014057:Tomography, X-Ray Computed / Q000592:standards; D014102:Torsion Abnormality / Q000000981:diagnostic imaging; D016896:Treatment Outcome