title: Post-operative shoulder imbalance in adolescent idiopathic scoliosis: a study of clinical photographs.
abstract: METHODS
  Retrospective observational study.
  
  
  OBJECTIVE
  To assess what features determine post-operative shoulder asymmetry in Adolescent Idiopathic Scoliosis (AIS).
  
  
  BACKGROUND
  Shoulder balance is one of the major determinants of the cosmetic outcomes of AIS surgery. Yet, other than level of the shoulders we are not clear what parameters are to be measured to assess torso symmetry. This study looks at the various features that might affect the appearance of the shoulder region.
  
  
  METHODS
  The records of 157 operated cases of AIS were retrospectively reviewed. Eight patients with documented post-operative shoulder asymmetry and were dissatisfied with their cosmetic outcomes were selected for the study. Their clinical photographs alone were studied. Three regions- the base of the neck, the shoulder and upper arm region- were analysed separately. Four measures each for the neck and shoulder and two for the arms were documented. No statistical tools were employed since the numbers were quite small but consensus was obtained between two Consultant Orthopaedic surgeons regarding the cosmetic impact of each parameter.
  
  
  RESULTS
  The neck and the shoulder appeared independent determinants of cosmesis of the proximal trunk. The base of neck symmetry seemed to be dependent on four features viz. centralization of the neck, neck tilt, trapezius angle and base of neck angle. The appearance of the shoulder itself depended on its level, axillary fold level, scapular level and the scapular prominence. The upper arm parameters appeared less critical in determining the cosmetic impact.
  
  
  CONCLUSIONS
  Proximal trunk symmetry in AIS depends on the symmetry of the base of the neck and shoulder regions. The level of the shoulders, axillary folds along with the base of neck angle, Trapezius angle appear to be key determinants of symmetry.
authors.affiliation: Orthopaedics, Khoula Hospital, Mina al Fahal, Muscat, Sultanate of Oman.
authors.forename: K Venugopal
authors.initials: KV
authors.lastname: Menon
authors.affiliation: Department of Neurosurgery, RIPAS Hospital, Bandar Seri Begawan, Brunei Darussalam.
authors.forename: Haroon M
authors.initials: HM
authors.lastname: Pillay
authors.affiliation: Department of Neurosurgery, RIPAS Hospital, Bandar Seri Begawan, Brunei Darussalam.
authors.forename: Anbuselvam
authors.initials: A
authors.lastname: M
authors.affiliation: Sparsh Hospital, Bangalore, India.
authors.forename: Naveen
authors.initials: N
authors.lastname: Tahasildar
authors.affiliation: Amrita Institute of Medical Sciences, Cochin, Kerala India.
authors.forename: Renjit Kumar
authors.initials: RK
authors.lastname: J
keywords: Adolescent Idiopathic Scoliosis; Clinical photograph; Neck symmetry; Shoulder balance; Torso symmetry; Trunk balance