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Tian Cheng, Elisabet Einarsdottir, Juha Kere, and Paul Gerdhem


  • Idiopathic scoliosis is the most common spinal deformity and affects 1–3% of children and adolescents. Idiopathic scoliosis may run in families and the purpose of this systematic review was to describe the degree of heritability.


  • We searched Medline, Web of Science and EMBASE for family and twin studies reporting heritability estimates for idiopathic scoliosis, or studies from which heritability estimates could be calculated. Reference lists were screened for additional papers. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The protocol was registered at PROSPERO (registration number: CRD42022307329).


  • The literature search identified 1134 reports. After full-text screening, nine eligible reports were included for data extraction. Seven were twin studies containing between 5 and 526 pairs, and two were family studies with 1149 and 2732 individuals, respectively. Quality was ‘good’ in four studies and ‘fair’ in five studies. In general, studies with radiograph-confirmed diagnosis reported higher heritability estimates than studies with self-reported diagnosis. Population-based twin studies reported lower heritability estimates than clinic-based twin studies. Family-based studies reported higher heritability estimates than twin studies. Pairwise concordance for scoliosis ranged from 0.11 to 1.00 in monozygotic twins and from 0 to 1.0 in dizygotic twins. A meta-analysis of three studies resulted in a narrow sense heritability estimate of 0.57 (95% CI: 0.29–0.86).


  • Twin and family studies indicate a hereditary component in idiopathic scoliosis, but study heterogeneity is large, and the degree of the heritability is uncertain. Nevertheless, known genetic variants associated with idiopathic scoliosis can still only explain a minor part of heritability.

Jie Xiang, Weibo Zhao, Xiao Luo, Zhenghua Hong, and Hua Luo

  • Spontaneous spinal subdural hematoma (SSDH) is a rare and dangerous intraspinal hematoma that usually occurs in the thoracic vertebra. The influence of early cardiovascular changes secondary to spinal cord injury is an important emergent issue.

  • Herein, we report a case of a middle-aged woman with clinical manifestations of back pain and motion and sensory disturbances below the level of spinal cord compression. During the disease course, she also developed changes indicative of myocardial injury, such as tachycardia, markedly increased concentrations of brain natriuretic peptide and cardiac troponin I, and a decreased left ventricular ejection fraction, which were consistent with the diagnosis of Takotsubo cardiomyopathy (TTC). After the administration of supportive therapies, the symptoms of myocardial injury rapidly resolved. With the absorption of SSDH, the symptoms and clinical signs were alleviated. We also reviewed the literature on cases of concomitant SSDH and TTC.

  • This rare case broadens the symptom spectrum of SSDH and highlights the need for clinicians to be aware of concomitant SSDH and TTC. Initial conservative treatment is a viable option for SSDH with concomitant TTC. However, urgent surgery may be a better option if the SSDH progressively enlarges and causes spinal cord compression.

Amer Sebaaly, Mohammad Daher, Bendy Salameh, Ali Ghoul, Samuel George, and Sami Roukoz

  • Congenital scoliosis (CS) is a spinal deformity resulting from underlying spinal malformations with an incidence of 0.5–1/1000 births.

  • CS makes up 10% of scoliotic deformities, of which 25% do not progress, 25% progress mildly and 50% need treatment depending on the age, curve characteristics and magnitude and type of anomaly.

  • CS is associated with non-vertebral anomalies (genitourinary, musculoskeletal, cardiac, ribs anomalies, etc.) and intraspinal anomalies (syrinx and tethered cord).

  • Imaging should include whole spine X-rays, CT scanner with reconstruction to better delineate the vertebral anomalies and MRI to visualize the neural elements.

  • Treatment of CS in the majority of cases is non-surgical and relies on fusion techniques (in situ fusion and hemiepiphysiodeis), resection techniques (hemiverterba resection), and growth-friendly techniques (distraction and instrumentation without fusion).

Mariam S Alharbi

  • The aim of the study was to conduct a literature review on growth hormone therapy in short-stature patients with kyphoscoliosis.

  • The search strategy was performed in which all the relevant papers published in 20 years were included on Pub Med, Central, and Google scholar by using keywords short stature, growth hormones, adverse events of growth hormones in kyphoscoliosis, safety.

  • The study investigation supports the idea that giving human growth hormone (HGH) to a diverse population of short-statured children does not enhance the occurrence of scoliosis.

  • Patients on HGH therapy for progressing scoliosis had syndromes in which scoliosis was more prevalent in an age-matched group. Short stature attributed to progressive growth failure is prevalent in all mucopolysaccharidosis (MPS) disorders, as per the existing research on growth and growth hormone in MPS.

  • MPS should be explored in children who are being tested for short stature since growth failure might be the presenting symptom.

Junbo He, Tingkui Wu, Chen Ding, Beiyu Wang, Ying Hong, and Hao Liu

  • Anterior cervical surgery (ACS) owes its development to various pioneering individuals whose revolutionary works form key advances and guide current medical decisions. This bibliometric study aimed to identify, analyse and visualize the main features of the most-cited papers in ACS.

  • The citation count for the top 100 most-cited articles ranged from 148 to 1,197, and citations per year ranged from 3.1 to 89.8. The articles were published from 1958 to 2016, with the 2000s being the most active decade. There was an inverse correlation between the average citations per year since publication and article age.

  • The oldest as well as most-cited two articles were both published in 1958 by Smith and Robinson, and Cloward, respectively. In their studies, the authors individually described the technique of anterior cervical discectomy with fusion (ACDF).

  • The most popular keywords were: ‘fusion’ (22), ‘spine’ (20), ‘cervical spine’ (16), ‘complications’ (15), ‘arthrodesis’ (13), ‘interbody fusion’ (13), ‘bone morphogenetic protein’ (13), and ‘radiculopathy’ (12).

  • ACDF was the most frequent surgical procedure (80%), while cervical disc arthroplasty is of gradual greater impact.

  • The surgical techniques of ACDF have remained unaltered for over 60 years. More attempts are needed to promote its development.

Cite this article: EFORT Open Rev 2021;6:1203-1213. DOI: 10.1302/2058-5241.6.210074

Juan I. Cirillo Totera, José G. Fleiderman Valenzuela, Jorge A. Garrido Arancibia, Samuel T. Pantoja Contreras, Lyonel Beaulieu Lalanne, and Facundo L. Alvarez-Lemos

  • Adequate sagittal balance (SB) is essential to maintain an upright, efficient, and painless posture. It has been shown that sagittal profile alterations affect quality of life of patients with a similar or even greater impact than chronic disease.

  • Evaluation of the SB has gained much relevance in recent years, with recognition of its importance in the evaluation of spinal pathology.

  • This review summarizes the basic principles of SB, aiming to obtain a practical, simple and understandable evaluation of the sagittal profile of a patient.

  • SB is a dynamic process that involves a varying degree of energy expenditure. Distinguishing between a balanced, compensated imbalance or decompensated imbalanced patient, is relevant to diagnosis and therapeutic decision-making.

Cite this article: EFORT Open Rev 2021;6:1193-1202. DOI: 10.1302/2058-5241.6.210062

Eduardo Moreira Pinto, Artur Teixeira, Ricardo Frada, Pedro Atilano, and António Miranda

  • Adjacent segment pathology (ASP) is a major cause of disability, and the recognition of the surgical risk factors associated with the development of this condition is essential for its prevention.

  • Different surgical approaches, from decompression without fusion to non-instrumented and instrumented fusion, have distinct contributions to the development of ASP.

  • Although motion-preservation procedures could reduce the prevalence of ASP, these are also associated with a higher percentage of complications.

  • Several risk factors associated with previous surgery, namely the chosen surgical approach and anatomical dissection, the choice of interbody fusion, the increment and length of the fusion, and the restoration of sagittal alignment, may influence the development of ASP.

Cite this article: EFORT Open Rev 2021;6:966-972. DOI: 10.1302/2058-5241.6.210050

Wai Weng Yoon and Jonathan Koch

  • In all levels of disc herniations the absolute surgical indications include deteriorating neurological deficits with myelopathy or cauda equina syndrome. However, this review summarized the relative indications for surgery in each level.

  • In cervical disc herniation (CDH), the indications for surgery consist of six months of persisting symptoms, not responding to conservative treatment. However, high-quality studies are lacking, and a randomized controlled trial is now underway to clarify the indications.

  • In thoracic disc herniation (TDH), the indications for surgery comprise failure of conservative measures and/or worsening neurological symptoms. Moreover, giant calcified thoracic disc herniations or myelopathy signs on magnetic resonance imaging, even in the absence of neurological symptoms, may benefit from surgical treatment as a preventive measure.

  • In lumbar disc herniation (LDH), the indications for surgery include imaging confirmation of LDH, consistent with clinical findings, and failure to improve after six weeks of conservative care.

Cite this article: EFORT Open Rev 2021;6:526-530. DOI: 10.1302/2058-5241.6.210020

Spyridon Sioutis, Lampros Reppas, Achilles Bekos, Eleftheria Soulioti, Theodosis Saranteas, Dimitrios Koulalis, Georgios Sapkas, and Andreas F. Mavrogenis

  • Echinococcosis or hydatid disease affecting the spine is an uncommon manifestation of Echinococcus granulosus infection of the spine.

  • More commonly found in endemic areas, it causes significant morbidity and mortality as it grows slowly and produces symptoms mainly by compressing the spinal cord.

  • As diagnostic methods are non-specific, diagnosis and management are usually delayed until the disease is advanced, thereby therapy is usually unlikely.

  • Treatment is usually surgical, aiming at cyst excision, spinal cord decompression and spinal stabilization.

  • This article summarizes the clinical findings of echinococcosis of the spine, discusses the specific laboratory and diagnostic findings, lists the current treatment options, and reviews the patients’ outcomes.

  • The aim is to prompt clinicians to be aware of the possibility of echinococcosis as a possible diagnosis in endemic areas.

Cite this article: EFORT Open Rev 2021;6:288-296. DOI: 10.1302/2058-5241.6.200130

Kaustubh Ahuja, Syed Ifthekar, Samarth Mittal, Gagandeep Yadav, Bhaskar Sarkar, and Pankaj Kandwal

  • Over the years, a number of authors have used different working definitions of instability in tuberculosis of the spine (TB spine). However, no clear consensus exists to define instability in TB spine. The current systematic review addresses the question ‘What defines instability in TB spine’?

  • A comprehensive medical literature search was carried out to identify all the studies which defined instability in the setting of spinal TB. The extracted data included the clinical, X-ray and CT or MRI-based definitions.

  • The current review identified lesser age, junctional region of the spine, mechanical pain and ‘instability catch’, kyphotic deformity above 40 degrees, pan-vertebral or bilateral facetal involvement and multifocal contiguous disease involving more than three vertebrae as predictors for spinal instability in the dorso-lumbar spine.

  • Cervical kyphosis more than 30 degrees and facetal or pan-vertebral involvement were found to be the factors used to define instability in subaxial cervical spine.

  • With respect to C1–C2 TB spine, migration of the tip of the odontoid above the McRae or McGregor line or anterior translation of C1 over C2 were considered as determinants for instability.

  • Although definitive conclusions could not be drawn due to lack of adequate evidence, the authors identified factors which may contribute towards instability in TB spine.

Cite this article: EFORT Open Rev 2021;6:202-210. DOI: 10.1302/2058-5241.6.200113