Idiopathic scoliosis: clinical guidelines

List of Abbreviations

ALT – alanine aminotransferase

AST – aspartate aminotransferase

VAS – Borg visual analogue scale

CI – confidence interval

IS – idiopathic scoliosis

KOMOT – computer optical spine topography

CT – computed tomography

PT – physical therapy

MRI – magnetic resonance imaging

Hip – hip joint

TPF — transpedicular fixation,

US – ultrasound examination

PRM – physical and rehabilitation medicine

PTL – physical therapy treatment

ECG – electrocardiography

PSO – Pedicle Subtraction Osteotomy

SOSORT – The International Society on Scoliosis Orthopaedic and Rehabilitation Treatment

SPO – Smith-Petersen Osteotomy

SRS – Scoliosis Research Society

VCR – Vertebral Column Resection

Terms and Definitions

Adams test (Adams, English physician) — asymmetry of paraspinal tissues in a patient with spinal deformity, detected during examination in a forward bend position.

Apical vertebra — the most horizontally positioned, most rotated, most displaced from the central sacral line, and most deformed vertebra of the scoliotic curve.

Trunk balance (compensation) — clinically: location of the midpoint of the occipital bone over the sacrum and the shoulder girdles over the hip joints in the vertical plane; radiographically: a situation where the sum of all angular deviations of the spine in one direction equals the sum of all deviations in the opposite direction.

Ventral angle of kyphosis — the angle formed by the intersection of lines tangent to the anterior surface of the vertebral bodies of the upper and lower limbs of kyphosis.

Secondary curve — a structural scoliotic deformity, smaller than the primary one, but usually more mobile.

Hyperkyphosis — exceeding the limits of normal parameters of the thoracic spine in the sagittal plane (>40°).

Hypokyphosis — flattening of thoracic kyphosis beyond the lower limit of its normal parameters (<20°), but without the formation of thoracic lordosis.

Hypoplasia — congenital underdevelopment of anatomical structures or organs.

Gibbus — a sharp-peaked angular kyphosis.

Vertebral growth zones:

a) vertebral body endplates — ensure the growth of the vertebral body in height and width;

c) growth zones of the spinous, transverse, and articular processes determine the growth of the posterior elements of the vertebra;

c) the cartilaginous plate located between the vertebral body and the pedicle (neurocentral cartilage) plays a decisive role in the formation of the spinal canal. Normally, all growth zones develop harmoniously.

Idiopathic scoliosis — a structural three-plane spinal deformity of undetermined origin.

Measurement of the scoliotic curve (Cobb method) — The upper and lower end vertebrae are identified. Perpendiculars are drawn to the cranial endplate of the upper vertebra and the caudal endplate of the lower vertebra. The intersection of these lines forms the scoliotic curve angle. If the endplates are poorly visualized, lines drawn through the upper or lower points of the pedicles can be used.

Mobility index — calculated by subtracting the percentage of correction of the thoracic curve (ratio of Cobb angles in the standing position and during side-bending) from the percentage of correction of the lumbar curve.

Infantile scoliosis — a spinal deformity developing in the first 4 years of life.

Kyphosis — an alteration in the shape of a spinal segment in the sagittal plane resulting in a deformity with a posteriorly directed convexity; abnormal kyphosis.

Kyphotic scoliosis — scoliosis with such a pronounced rotational component that the lateral tilt of the rotated vertebra mimics kyphosis.

Kyphoscoliosis — a combination of scoliotic deformity with true hyperkyphosis. Rotational deformity combined with apparent kyphosis should not be designated by this term.

Compensatory curve — a scoliotic curvature of the spine, which may be structural, located cranially and/or caudally to the main curve, and helps maintain trunk balance. If a compensatory curve initially shows no signs of being structural, it acquires them over time. Despite this, it remains compensatory—that is, a reaction of the body aimed at preserving and maintaining spinal balance. The terms "secondary curve" and "compensatory curve" are synonyms.

End vertebrae of the curve:

a) the most cranial vertebra in the curve, whose upper endplate is maximally tilted toward the concavity of the curvature,

b) the most caudal vertebra in the curve, whose lower endplate is maximally tilted toward the convexity of the curvature.

Determined on standing spondylograms. In the presence of two curves, one end vertebra may be shared by both curves. The end vertebra may coincide with the neutral vertebra. Usually, the intervertebral discs adjacent to the end vertebra are "open" in opposite directions.

Curve correctability — determined by subtracting the Cobb angle value in the side-bending position from the value of the same angle in the standing position.

Myelodysplasia (Lat. *Myelodysplasia*; myelo- + dysplasia) — a general term for spinal cord developmental anomalies.

Myelopathy (Lat. *myelopathia*; myelo- + Gk. *pathos* suffering, disease) — a general term for acquired pathological conditions of the spinal cord.

Non-structural curve — a scoliotic deformity without signs of structural changes. It corrects completely, up to hypercorrection, in the side-bending position.

Neutralized disc — a disc in which the right and left differential changes most uniformly during lateral bending.

Neutral vertebra — on a standing coronal spondylogram, it is located at or near the end of the curve and is in a state of minimal rotation. It is usually located adjacent to the neutralized disc.

Primary curve — one of two or three structural deformations that appeared first, thus differing from a secondary or compensatory curve. When two structural curves of equal magnitude are present, determining the primary one can be very difficult, if at all possible. When two structural curves of unequal magnitude are present, it can generally be considered that the one with the greater Cobb angle is the primary one. In Western literature, the terms «major» and «minor» curve are more frequently used.

Pelvic tilt — deviation of the pelvis from the horizontal plane in the frontal plane. Fixed tilts can be accompanied by the development of contractures proximal and distal to the pelvis. Scolioses caused by pelvic tilt due to limb length discrepancy are never structural.

Junctional kyphosis — kyphotic deformity in the thoracolumbar junction of the spine. Normally, the Th12-L2 segment is straight or slightly lordotic (3° measured by Cobb). Therefore, any kyphosis in this area is considered pathological, which must be taken into account when planning corrective intervention, especially in King type II deformities.

Platyspondyly (platyspondylia; platy- + Greek basis base) — a uniform decrease in the height of the vertebral body (flattening), accompanied by an increase in its horizontal dimension.

Vertebral growth plates — cartilaginous plates located on the cranial and caudal endplates of the vertebral body. They provide for the height growth of the vertebral body.

Rachischisis (rhachischisis; rhachi- + Greek schisis splitting) — a severe form of neural tube closure defect of the spinal canal combined with a skin defect and exposure of the spinal cord.

Scoliosis (scoliosis curvature) — curvature of the spine in the frontal plane.

Scoliotic disease — lateral curvature of the spine with mandatory rotation of the vertebral bodies (torsion), a characteristic feature of which is the progression of the deformity associated with the age and growth of the child.

Spina bifida — failure of closure of the spinal canal due to impaired fusion of the vertebral arches (spina bifida posterior) or bodies (spina bifida anterior).

Spina bifida aperta (open cleft spinous process) — one of the synonyms for the general designation of congenital neural tube defects — combined developmental anomalies of the spinal canal, spinal cord, and its meninges: meningomyeloceles, lipomyelomeningoceles, and rachischisis.

Spina bifida occulta (hidden cleft spinous process) — failure of fusion of the vertebral arches not accompanied by the formation of a spinal hernia.

Spondylocostal dysostosis — a combined developmental anomaly: a combination of congenital spinal deformity and severe chest malformations, most commonly rib synostosis or agenesis.

Central sacral line — drawn through the center of the sacrum perpendicular to the horizontal line connecting the iliac crests.

Stable vertebra — the vertebra that is most symmetrically divided into two parts by the central sacral line.

Structural curve — a segment of the spinal column with lateral deviation and loss of normal intersegmental mobility. Radiographically, it does not correct completely in the side-bending position toward the convexity, and signs of torsion appear.

Risser sign — ossification of the iliac crest epiphyses begins in the region of the anterior superior iliac spine and proceeds in a dorsal direction toward the posterior superior iliac spine over an average period of two years. According to Risser, the iliac crest is divided into 4 parts, and the stages of the process are as follows: Risser-0 (no epiphyseal shadow), Risser-1 (ossification within 25% of the crest), Risser-2 (ossification within 50% of the crest), Risser-3 (ossification within 75% of the crest), Risser-4 (complete ossification of the crest), Risser-5 (fusion of the epiphysis and the iliac bone body). Risser-4 corresponds to the completion of spinal column growth.

Torsion — plays a major role in the mechanogenesis of scoliotic deformity and consists of two elements. The first is the displacement of the vertebra in three planes: anterior or posterior tilt (sagittal plane), lateral displacement (frontal plane), rotation (horizontal plane). The second is the three-dimensional deformation of the vertebra itself: anterior or posterior wedging of the vertebral body (sagittal plane), lateral wedging (frontal plane), deviation of the vertebral body toward the convexity of the curve and the posterior elements toward the concavity (horizontal plane). Torsion involves all vertebrae of the structural curve, reaching its maximum at the apex of the deformity.

Traction myelopathy — impairment of spinal cord function of ischemic origin, occurring under the tensile action on the spine: excessive flexion, extension, or instrumental traction.

Crankshaft phenomenon — after posterior spinal arthrodesis in a child during active growth, the formed bony block causes the posterior elements of the vertebrae to stop growing, while the vertebral bodies continue. Because the growth of the vertebral bodies is limited, the vertebrae begin to rotate toward the convexity of the deformity, with the mass of the dorsal block acting as the axis around which rotation occurs. The ongoing rotation produces a clinical and radiological effect of increased scoliotic deformity. The extent of rotation increases as it approaches the apex of the scoliotic curve, which led Dubousset to use the term "crankshaft".

Fractional curve — a compensatory counter-curve that appears incomplete because it transitions into a straight line. The single horizontal vertebra of this curve is the most cranial or most caudal.

Juvenile scoliosis — a spinal deformity developing from the age of four until the onset of puberty.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Idiopathic scoliosis (IS) — a polygenically inherited complex three-dimensional twisting deformity of the spine.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

To date, the cause of scoliosis remains a topic of discussion. Often, when it is impossible to identify the cause of the spinal deformity, a diagnosis of so-called IS is made, i.e., scoliosis caused by an unknown etiology. The difficulty in resolving etiological issues is also explained by the fact that in some cases scoliosis manifests as an independent disease, while in others it appears as a symptom of another condition with a well-known origin.

The lack of clear concepts regarding the onset of the disease and the complexity of systematizing existing data become apparent when comparing the classifications of various authors.

The region of the spine where lateral curvature with vertebral rotation around the longitudinal axis has occurred is called the primary curvature arc or primary curve. Sometimes it is called the main or major curve. The primary curve represents the zone of the spinal disease. Beyond its boundaries, the spine may be anatomically and functionally healthy.

The change in the position of the vertebrae — turning around the longitudinal axis of the spine — is called rotation. The change in the shape and internal structure of the vertebrae is called torsion (twisting). Rotation and torsion develop simultaneously and are interrelated by a common genesis (origin), which is why some authors combine them under the general name of rotation, while others use torsion.

During the formation of scoliosis, not one, but two (or three) primary curves may appear. Such spinal curvatures are termed complex — double or triple S-shaped scoliosis.

Scoliosis is considered right-sided if the convexity of the primary curve (primary curvature arc) is directed to the right, and left-sided if it is directed to the left.

In balanced (compensated) scoliosis, the shoulder girdles are positioned directly above the pelvis, and the pelvis above the feet. If these correct relationships are disrupted and the shoulder girdles are not positioned over the pelvis, nor the pelvis over the feet, scoliosis is considered decompensated.

Spinal growth is a dynamic process that varies depending on age. Ultrasonography confirms the explosive nature of intrauterine spinal growth. After birth, it decreases but remains very high until the age of 2, then slows down and plateaus from 2 to 10 years of age. During puberty, hormonal surges stimulate a sharp acceleration in growth. This phase lasts for 3 years. Accelerated progression of scoliosis is typically observed precisely during this period.

Postnatal spinal growth in quantitative terms was most precisely determined by A. DiMeglio [1]. Average parameters for each segment and region of the spine, as well as the relative contribution of the head and pelvis to sitting height, were determined, and the sitting-to-standing height ratio was calculated.

In a newborn, this is 60%, and after growth completion — 53%. In patients with scoliosis due to trunk deformity, this ratio changes. First, there is a loss due to the lateral deviation of the spine. This loss increases with the Cobb angle and the number of segments in the curve. This loss can be calculated using a simple trigonometric formula. Second, the growth of the vertebrae slows down due to asymmetric pressure on the growth plates (Hueter-Volkmann law). All of this has been well documented. Winter R.B. [2] proposed a simple method for calculating potential spinal shortening — the "shortening formula". It is based on the fact that each segment grows by 0.7 mm per year, and growth ceases at 14 years of age in girls and 16 years of age in boys.

The Scoliosis Research Society (SRS) confirms the diagnosis of "scoliosis" at Cobb angle values ≥10º and discernible axial rotation. Maximum axial rotation is determined at the apical vertebra. Nevertheless, structural scoliosis can be detected at a Cobb angle of less than 10º with a high potential for progression [17, 25, 26].

Progression is more frequently observed in girls during the pubertal growth spurt (peak height velocity). Untreated, severe trunk deformities can develop, negatively affecting the volume and functional biomechanics of the chest, exercise capacity, general patient condition and working capacity, as well as impairing the quality of life.

1.3 Epidemiology of the Disease or Condition

Screening studies show that scoliotic spinal deformities are detected in 4–9% of school-age children, with active progression of the pathology in 15–25% of cases and the development of severe disabling forms in half of them [3]. The prevalence of IS with a Cobb angle >10° in Russia corresponds to the global trend and is 1.3% according to various authors [21]. Modern domestic population studies on the described nosology are lacking.

1.4 Features of Coding the Disease or Condition

M41 — Scoliosis

M41.0 — Infantile idiopathic scoliosis

M41.1 — Juvenile idiopathic scoliosis

M41.2 — Other idiopathic scoliosis

M41.3 — Thoracogenic scoliosis

M41.8 — Other forms of scoliosis

M41.9 — Scoliosis, unspecified

When formulating the diagnosis, it is necessary to consider: the presence of complications, the course (progressive, non-progressive), changes in trunk balance (compensated, decompensated), mobility, side, localization, anatomical type, severity of deformity (grades I–IV according to V.D. Chaklin's classification) [4], the stage of skeletal growth maturity according to Risser and Sadofyeva tests, and concomitant orthopedic pathology (deformities of the chest, limbs, etc.).

1.5 Classification of the disease or condition

Depending on the age at which the spinal curvature is first detected, the Scoliosis Research Society (SRS) expert group led by Goldstein L.A. [5] classifies IS as follows. Each form differs from the others not only in the age of detection, but also in the pattern of progression, prognosis, and treatment methods applied, which allows each of them to be regarded, with a certain degree of convention, as an independent nosological entity.

I. Idiopathic

A. Infantile (0 to 3 years):

1. self-resolving;

2. progressive.

B. Juvenile or early-onset scoliosis (from 3 to 10 years).

C. Adolescent (over 10 years old).

At least nine options for the localization of the main curve with and without counter-curves can be distinguished. Moreover, each type of deformity has more or less fixed location points for the end and apical vertebrae, which must be considered when planning surgical intervention.

Classification of scoliosis (magnitude of deformity) mentioned in the literature [4] has become most widespread in our country:

Grade I — 0-10º;

Grade II — 11-25º;

Grade III — 26-40º;

Grade IV — > 41º

Classification of idiopathic scoliosis (deformation types) [6]

1. Single upper thoracic curve:

   • Level of the upper end vertebra — C7, Th1, or Th2;

   • Level of the apical vertebra — thoracic.

2. Single thoracic curve:

   • Level of the upper end vertebra — Th4, Th5, or Th6;

   • Level of the apical vertebra — Th8, Th9;

   • Level of the lower end vertebra — Th11, Th12, L1, or L2.

3. Single thoracolumbar curve:

   • Level of the upper end vertebra — Th8, Th9, or Th10;

   • Level of the apical vertebra — Th12 or L1;

   • Level of the lower end vertebra — L3.

4. Single lumbar curve:

   • Level of the upper end vertebra — Th11, Th12, L1;

   • Level of the apical vertebra — L2 or L3;

   • Level of the lower end vertebra — L4 or L5.

5. Thoracic curve with lumbar counter-curve

   • Thoracic curve:

     • Level of the upper end vertebra — Th4 or Th5;

     • Level of the apical vertebra — Th8.

   • Lumbar counter-curve:

     • Level of the upper end vertebra — Th12;

     • Level of the apical vertebra — L1, L2;

     • Level of the lower end vertebra — L4 or L5.

6. Two primary curves: thoracic and lumbar

   • Thoracic curve:

     • Level of the upper end vertebra — Th4, Th5, or Th6;

     • Apical vertebra level: Th7 or Th8;

     • Lower end vertebra level: Th10, Th11, Th12.

   • Lumbar curve:

     • Upper end vertebra level: Th11 or Th12;

     • Apical vertebra level: L1 or L2;

     • Lower end vertebra level: L4 (rarely).

7. Two primary curves: thoracic and thoracolumbar

   • Thoracic curve:

     • Upper end vertebra level: Th4;

     • Apical vertebra level: Th6 or Th7;

     • Lower end vertebra level: Th9 or Th10.

   • Thoracolumbar curve:

     • Upper end vertebra level: Th9, Th10;

     • Apical vertebra level: Th12, L1;

     • Level of the lower end vertebra — L3.

8. Double thoracic curve

   • Upper thoracic curve:

     • Upper end vertebra level: Th1, Th2;

     • Apical vertebra level: Th3, Th4;

     • Lower end vertebra level: Th5, Th6.

   • Lower thoracic curve:

     • Upper end vertebra level: Th5, Th6;

     • Apical vertebra level: Th8, Th9, Th10, Th11, Th12;

     • Lower end vertebra level: Th11, Th12, L1, L2.

9. Multiple curves [6]

Type 1A (right or left) — structural thoracic and lumbar curves, with the lumbar curve being larger and/or less mobile, with the apex at the L1-2 disc level or distal to it (9.9%).

Type 1B (right or left) — structural thoracic and thoracolumbar curves, with the thoracolumbar curve being larger and/or less mobile, with the apex at the Th12, L1 vertebra or Th12-L1 disc level (7.2%).

Type 2A (right or left) — structural thoracic and lumbar curves, with the thoracic curve being larger and/or less mobile, and the apex of the lumbar curve located at the L1-2 disc level or distal to it (18.8%).

Type 2B (right or left) — structural thoracic and thoracolumbar curves, with the thoracic curve being larger and/or less mobile, and the apex of the thoracolumbar curve located at the Th12, L1 vertebra or Th12-L1 disc level (4.2%).

Type 3 (right or left) — single structural thoracic curve with the apex at the level of the Th7, Th8, or Th9 vertebral body; the existence of a small number of upper thoracic scolioses, most commonly left-sided, should be taken into account (26.4%).

Type 4 (right or left) — single structural thoracic curve with the apex located more caudally than in Type 3 (usually the Th10 or Th11 vertebral bodies), with L2 or L3 being the lower end vertebra and the Th4 vertebral body tilted within the curve (2.3%).

Type 5 (right or left) — two structural thoracic curves, Th1 or Th2 vertebrae tilted in the upper curve, both apices in the thoracic spine (3.4%).

Type 6 (right or left) — single thoracolumbar curve with the apex at the level of the Th12, L1 vertebra or Th12-L1 disc (17.0%).

Type 7 (right or left) — single lumbar curve with the apex from the L1-2 to L4-5 disc level (8.2%).

Type 8 (right or left) — three curves, the side of the scoliosis is determined by the side of the largest of the three (2.2%).

Type 9 — more than three curves (maximum of four in the author's study), some of which are non-structural and small in size (0.2%).

Lenke et al. (2001) [6] proposed a new classification of IS, identifying six deformity types, and introduced two modifiers to characterize the lumbar curve and the sagittal profile of the thoracic spine: lumbar (A, B, or C) and thoracic (–, N, or +).

The deformity type (from I to VI) is determined in accordance with the Scoliosis Research Society (SRS) recommendations. Thoracic scolioses (apex of deformity located between the Th2 vertebral body and the Th11–Th12 intervertebral disc) include proximal or upper thoracic (apex at the level of Th3, Th4, Th5 vertebrae) and main (apex between the Th6 vertebral body and the Th11–Th12 disc). The apex of thoracolumbar scoliosis is located between the cranial endplate of the Th12 vertebra and the caudal endplate of the L1 vertebra. Lumbar scolioses have their apex between the L1–L2 disc and the caudal endplate of the L4 vertebral body. A scoliotic curve is considered structural if there is a loss of normal mobility, with signs of torsional changes of the bodies, and, depending on the magnitude of the Cobb angle, it is designated as primary (major) or secondary. A secondary curve can be either structural or non-structural.

For ease of use of the classification, specific characteristics of structural curves were introduced.

A structural upper thoracic curve in side-bending has a Cobb angle of at least 25° (regardless of the presence or absence of Th1 vertebral body tilt) and/or kyphosis of at least 20° from Th1 to Th5. The primary thoracic structural curve also maintains a minimum Cobb angle of 25° in side-bending and/or thoracolumbar kyphosis of at least 20° at the Th10-L2 vertebral levels.

A structural lumbar (thoracolumbar) curve is characterized by the same mobility parameters in the side-bending position and/or the presence of kyphosis of at least 20° at the Th10–L2 levels, even if the sagittal curve is the result of rotation rather than true kyphosis. Any secondary curve is considered structural if the listed characteristics are present. Lenke et al. [6] believe that when planning surgery, only primary and structural secondary curves should be included in the fusion zone.

Type I deformity: the main thoracic curve is structural, while the upper thoracic or lumbar (thoracolumbar) counter-curve is non-structural.

Type II deformity: two structural thoracic curves, while the lumbar (thoracolumbar) counter-curve is non-structural.

Type III deformity: two structural curves — primary thoracic and lumbar (thoracolumbar), upper thoracic counter-curve is non-structural; the thoracic curve is greater than, equal to, or less than the lumbar (thoracolumbar) by no more than 5°.

Type IV deformity: three structural curves — two thoracic and lumbar (thoracolumbar), with either of the latter two being primary.

Type V deformity: structural lumbar (thoracolumbar) curve, with more proximally located curves being non-structural.

Type VI deformity: the main curve is lumbar (thoracolumbar) and at least 5° larger than the thoracic curve, with both being structural; the proximal upper thoracic counter-curve is non-structural.

If the difference between the thoracic and lumbar curves is less than 5°, the scoliosis is classified as Type III, IV, or V deformity based on structural characteristics. Types III (primary curve is thoracic) and VI (primary curve is lumbar or thoracolumbar) must always be distinguished. If the magnitude of these two curves is equal, the thoracic curve is considered primary.

Lumbar modifiers (A, B, C). When planning surgery, it is necessary to assess the lumbar curve, as it affects both spinal balance and proximally located curves. Based on the relationship of the central sacral vertical line to the lumbar curve on the posteroanterior radiograph, Lenke et al. [6] identified three types of lumbar scoliotic deformities. The central sacral vertical line divides the cranial surface of the sacrum strictly in half and is perpendicular to the horizontal. Pelvic tilt with a leg length discrepancy of less than 2 cm is not taken into account unless it is the cause of spinal deformity progression. In such cases, as well as if leg shortening is greater than 2 cm, it must be corrected during radiography. The central sacral vertical line is continued cranially, and whichever lumbar or lower thoracic vertebra is divided most precisely in half by this line is considered stable. If an intervertebral disc is divided into two equal parts, the vertebra located caudal to this disc is considered stable. The apex of the lumbar (thoracolumbar) curve is considered to be the vertebra or disc located most horizontally and displaced to the greatest extent in the lateral direction.

Modifier A is used in cases where the central sacral vertical line passes between the pedicles of the lumbar vertebrae up to the level of the stable vertebra. Such scoliosis must have its apex at the Th11-12 disc level or more cranially, meaning Modifier A is used only in thoracic scolioses (Types I–IV), but not in lumbar and thoracolumbar scolioses (Types V–VI). Similarly, it is not used in cases where the central sacral vertical line passes through the medial edge of the apical vertebra pedicle shadow.

Modifier B is used if, due to the deviation of the lumbar spine from the midline, the central sacral vertical line touches the apex of the lumbar curve between the medial edge of the apical vertebra pedicle shadow and the lateral edge of its body (or bodies, if the apex is at the disc level). Such scolioses, as in the case of Modifier A, belong to Types I–IV. Modifier B is also used in cases where there is doubt as to whether the central sacral vertical line touches the lateral edge of the apical vertebral body.

Modifier C is used when the central sacral vertical line lies completely medial to the lateral border of the apical vertebra of the lumbar (thoracolumbar) curve. Such scoliosis can have a primary thoracic, lumbar, or thoracolumbar curve. In doubtful cases, when the central sacral vertical line does not completely clear the endplate of the apical vertebra, modifier B is used.

Modifier C can be used in any thoracic scoliosis (types I–IV) and must be used in types V and VI (lumbar and thoracolumbar scoliosis). All three modifiers can be used in the postoperative period to assess the position of the lumbar spine.

Sagittal thoracic modifiers (–, N, +). The sagittal contour of the thoracic spine must be taken into account when planning surgical intervention. For a more precise definition of the six types of scoliosis, Lenke et al. [6] proposed using special modifiers. The authors proceeded from the assumption that the average normal thoracic kyphosis (Th1–Th12) is 30°, ranging from 10° to 40°. In IS, the thoracic spine tends to flatten the kyphosis and even form lordosis. Modifiers are determined by measuring the sagittal contour of the Th5–Th12 vertebrae with the patient standing. In the presence of kyphosis less than 10° (hypokyphosis), the "–" modifier is used; from 10° to 40°, the N modifier; and for a deformation greater than 40° (hyperkyphosis), the "+" modifier.

Thus, by classifying the scoliotic deformity into one of the 6 types and determining the necessary lumbar and thoracic modifiers for the given case, scoliosis can be classified compactly, for example: 1A–; 1AN; 6CN, and so on.

Structural characteristics of the deformity in the sagittal plane play a very important role in the Lenke et al. [6] system as they determine the extent of the spinal fusion zone.

Hyperkyphosis of the upper thoracic and thoracolumbar regions and rigidity demonstrated in the side-bending position are important characteristics of so-called secondary curves.

The extent of thoracic spinal fusion in type I–IV deformities depends on the increase in kyphosis in the upper thoracic or thoracolumbar regions. In types V and VI scoliosis, the primary curve is lumbar (thoracolumbar); the thoracic compensatory curve is non-structural in type V and structural in type VI.

Lumbar modifier A indicates that the lumbar curve is minimal or absent altogether, whereas modifier B indicates the presence of a mild or moderate lumbar curve. Such lumbar deformities are difficult to classify using the King et al. [7] system (historical classification), and they have to be assigned to type II or III deformities based on the presence of a lumbar curve on standing and side-bending spine radiographs.

Lenke et al. [6] suggest that in the presence of modifiers A or B, the lumbar curve should not be fused unless there is kyphosis greater than 20° in the thoracolumbar spine. Scoliosis with lumbar modifier C was previously classified according to King et al. [7] as type I, II, or sometimes V deformity, which included all double, triple, lumbar, and thoracolumbar scoliosis curves. In such scoliosis, the lumbar curve often requires inclusion in the fusion area. However, in patients with type 1C or 2C deformities, selective thoracic fusion can be performed, the extent of which preserves lumbar spine balance.

The sagittal thoracic modifier is necessary to assess the state of the thoracic spine in terms of surgical planning, choice of approach and instrumentation type, correction of cosmetic defects, and normalization of lung function in patients with thoracic hypokyphosis or lordosis. One of the drawbacks of the King et al. [7] system is the lack of capability to analyze deformity in the sagittal plane.

Selective thoracic fusion for type I deformities with any lumbar modifier, classified according to King et al. [7] as type II or III, when using segmental instrumentation often leads to trunk imbalance. However, this surgery is feasible if the following conditions are met: the lumbar curve on side-bending is less than 25°, there is no thoracolumbar kyphosis, and the thoracic spine is more rotated than the lumbar spine. These criteria allowed Lenke et al. [6] to perform selective thoracic fusion in 114 out of 126 patients with type I deformity.

Type IIA deformities (with any thoracic modifiers) include, in addition to the main thoracic curve, a structural upper thoracic and a non-structural lumbar (thoracolumbar) compensatory curve. Any structural thoracic or lumbar curve can have a structural upper thoracic compensatory curve (deformation greater than 25° on side-bending and increased upper thoracic kyphosis).

Structural upper thoracic curves in type IIB scoliosis have the same characteristics. Unlike the King et al. [7] classification, the identification of type IIC makes it possible to consider the upper thoracic and lumbar components of the deformity separately. In the material of Lenke et al. [6], out of 56 patients with type II scoliosis, 50 underwent spinal fusion spanning the primary thoracic curve and the upper thoracic compensatory curve.

Type IIIA and IIIB deformities (with any thoracic modifiers) are relatively rare and contain two primary curves—thoracic and lumbar (thoracolumbar). The lumbar component of such a deformity is always structural in the frontal and sagittal planes, even if the curve deviates slightly from the midline. In type IIIC scoliosis, this deviation is always significant, so both curves should be included in the fusion block. Lenke et al. [6] operated on 58 patients with type III deformities and in 56 cases fused both the thoracic and lumbar (thoracolumbar) curves.

Triple scoliosis of types IVA and IVB (with any thoracic modifiers) contains three structural curves: upper thoracic, thoracic, and lumbar (thoracolumbar), with the latter two being larger than the first. The lumbar curve is not completely displaced from the midline, but if the thoracic curve is pronounced, the lumbar curve shows signs of structural characteristics. In type IVC deformities, the deviation of the lumbar curve from the midline is significant, as would be expected. Out of eight patients with type IV deformities operated on by Lenke et al. [6], all three structural curves had to be fused in six cases.

Lumbar (thoracolumbar) scoliosis is classified as type VC if it has a non-structural thoracic compensatory curve, and as type VIC if the thoracic counter-curve shows structural features. In any case, only structural curves are subjected to fusion.

1.6 Clinical presentation of the disease or condition

The main clinical manifestation of the disease is the presence of spinal deformity, which may be accompanied by the following clinical signs:

• presence of a unilateral prominence in the form of a rib hump at the level of the thoracic or thoracolumbar region and concavity on the opposite side in the position of lumbar flexion — Adams sign (W. Adams);

• presence of a prominence in the form of a muscle ridge — Schulthess-Chaklin sign (W. Schulthess) on one side at the level of the lumbar region and concavity on the opposite side;

• asymmetry of neck contours;

• asymmetry of the spatial arrangement of the shoulder girdles;

• asymmetry of waist triangles;

• "sign of disappearance of the waist triangle in the lumbar region on the side of the deformity curve" according to A. Lorenz;

• asymmetry of scapular positioning;

• "scapular position sign" according to I. A. Movshovich;

• asymmetric arrangement of the iliac crests and gluteal regions;

• asymmetry of the Michaelis rhombus;

• asymmetry of clavicle positioning, "clavicular shortening" sign according to I. A. Movshovich;

• asymmetry of the shape and location of the mammary glands;

• arc-like arrangement of vertebral spinous processes;

• fixed change in the shape of the sagittal profile of the spine in variants of physiological curve flattening or the "doll" sign according to A. Lorenz;

• externally determined truncation of the torso;

• detectable "functional sign of the spinal extensor muscles".

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition based on:

1. anamnestic data – established spinal deformity in a close relative or suspected presence thereof;

2. physical examination data – signs of spinal deformity detected in the frontal or sagittal planes;

3. laboratory tests – in case of suspected secondary nature of the deformity, exclusion of a systemic disease based on genetic testing data;

4. instrumental examination – spinal deformity confirmed by instrumental diagnostic methods.

2.1 Complaints and Anamnesis

Comments: There are usually two main complaints: a cosmetic defect associated with spinal and chest deformity, and pain syndrome, and it is not at all necessary for the patient to present both complaints. During the initial conversation with the patient, they may be absent altogether. It should be taken into account that the patient's self-assessment of their appearance is extremely variable. A relatively small scoliotic deformity of 40-45º according to Cobb can cause a young female patient unimaginable moral suffering, which she and her parents cannot speak of without tears. At the same time, patients with 90º scoliosis often believe that their appearance is quite acceptable and does not need any correction. From the anamnesis, it is necessary to find out at what age and by whom the spinal deformity was first noticed, whether the patient's parents consulted a doctor, whether treatment was carried out, what kind of treatment, and what the effect was. In particular, it is advisable to find out whether attempts were made to correct the shape of the spinal column using manual therapy methods [RS3], and whether such an intervention led to the appearance of pain and accelerated progression of the deformity.

It is extremely important to review the patient's available medical documentation, especially in cases where there is an indication of previous surgical treatment. It is necessary to try to find out what the dynamics of deformity progression were and what age coincided with the peaks of this progression. It is very interesting, although from a practical point of view often of little significance, whether there are other family members with spinal deformities, who specifically they are, and whether surgical treatment was performed. It is also important to inquire about the condition of pelvic organ function.

Finally, since the vast majority of patients with spinal deformities are girls, it is necessary to clarify at what age menstruation first started (if it has already occurred) and whether a normal menstrual cycle has been established. The latter circumstance is very important from the standpoint of the prognosis of the pathological process, as it characterizes the degree of development of the organism and, in particular, the musculoskeletal system. Often the teenager does not focus on the pain syndrome and only upon targeted questioning specifies that the back hurts. It is important to find out when the pain first appeared, in what situations it intensifies or disappears, and in which part of the spine it is localized. Most often, pain occurs at the apex of the deformity or in the lower lumbar spine. Frequently, especially in patients over 20 years of age, the pain syndrome dominates and is the main reason prompting them to consult a doctor and raise the issue of surgical intervention. It is necessary to find out if the patient is troubled by shortness of breath, when it was first noted, under what exertion it occurs, and whether it intensifies over years.

2.2 Physical Examination

Comments: The recommended assessment of the patient's orthopedic status according to various data [6, 12, 21] includes the evaluation of:

• frontal and sagittal spinal balance;

• spinal mobility using the traction test;

• compensation of pelvic tilt;

• pain according to the VAS (if present).

Examination of the patient by a trauma surgeon and orthopedist is one of the most important elements of the examination. It must be carried out with all thoroughness and properly documented. This ensures methodological uniformity, allowing the comparison of examination results obtained at various times and, in particular, in the pre- and postoperative periods. The proposed examination scheme (status localis) has been used for many years in the clinics of the Republican Center for Spinal Pathology (Novosibirsk) and, despite its seeming cumbersomeness, allows for a quick and complete documentation of the results of the patient's examination by a trauma surgeon and orthopedist [12].

It must be emphasized, although it seems self-evident, that the examination should not be limited only to the spine; the entire musculoskeletal system of the patient must be examined. For more than 100 years, one of the simplest and most widespread diagnostic techniques for spinal deformity has been the Adams test. Its technique is as follows. The patient stands facing the doctor and bends forward, touching the floor with their fingers, while the surface of the back is positioned in a plane close to horizontal. The doctor's gaze is directed in the same plane, which makes it possible to detect the slightest asymmetries of the right and left halves of the dorsal surface of the patient's torso.

2.3 Laboratory Diagnostics

Comments. During outpatient and inpatient conservative treatment, laboratory tests are prescribed in accordance with the clinical manifestations of vertebral and extravertebral pathology present [11, 12, 21].

2.4 Instrumental Diagnostics

Comments: The basis of the instrumental examination of a patient with spinal deformity is radiation diagnostics. Images in the anteroposterior projection are performed annually for spinal curvatures of less than 15−20°, and every 6 months for curvatures greater than 20° until skeletal maturity. An interval of more than 1 year between radiographs increases the likelihood that the progression of scoliosis will go unnoticed. After skeletal maturity, the decision on the need for radiography is made again, based on clinical evaluation [11, 12, 21].

Comments: It is necessary to take into account the frequent combination of spinal deformities, especially congenital ones, with pathology of the urinary system elements. Ultrasound examination of the kidneys and retrograde ureteropyelography provide sufficient information that can influence the decision of the trauma surgeon and orthopedist when planning surgical intervention. Double-contrast radiography of the stomach and duodenum, and contrast radiography of the small intestine are performed strictly according to indications. Such an indication may be, for example, compression of the duodenum by a vessel with the development of cast syndrome.

Comments: Spondylograms taken in the supine position are uninformative because the absence of body weight on the spinal deformity leads to a reduction of the latter due to the partial elimination of the so-called functional component. The thoracic and lumbar spine must be fully captured on the spondylograms — from the Th1 to the S1 vertebra. It is highly desirable that all vertebrae along this length are captured on a single film. The current gold standard is spine X-ray telemetry, i.e., digital radiography of the entire spine capturing the skull, pelvis, and proximal femurs in slot mode (or step mode). Otherwise, spondylograms of different spinal regions have to be glued together with transparent tape to obtain a complete picture.

X-ray analysis: The following qualitative and quantitative data are determined from the obtained radiographs:

• type of scoliotic deformity;

• anatomic type of scoliotic deformity (reflected in the Classification section);

• deformation parameters characterizing spinal involvement in three planes;

• status of spinal growth and bone maturity as one of the leading background factors for predicting the natural course of the deformity.

Type of scoliotic deformity. Determined by the causal factor of the orthopedic pathology:

1. Deformities caused by congenital anomalies of the spine, rib cage, sternum, as well as systemic congenital diseases, which is confirmed on radiographs by corresponding structural and morphological data.

2. Curvatures resulting from past injuries and diseases of the spine and chest, as well as various surgical interventions.

3. Changes in spinal shape due to neuro-orthopedic pathology (various forms of cerebral palsy and myopathies, spinal cord diseases, etc.).

4. Curvatures associated with age-related degenerative-dystrophic changes in the spine (osteochondrosis, osteoporosis, etc.).

5. Spinal deformities classified as an independent nosology — idiopathic scoliosis.

Next, the type of scoliotic deformity (see classification in Chapter II) is determined by the apex location, convexity side, boundaries, and finally, measurements are performed to characterize the deformity quantitatively.

Scoliosis is a three-dimensional spinal deformity, therefore the magnitudes of the scoliotic (frontal plane), kyphotic or lordotic (sagittal plane), and rotational (horizontal plane) components of the deformity are measured.

Frontal plane.

Determination of the magnitude of the scoliotic deformation component worldwide is performed in accordance with the method of J.R. Cobb, described in 1948 [8]. The first stage is the localization of the end vertebrae of the scoliotic curve. All vertebrae included in the curve, except the apical one, are tilted either toward the concavity of the deformity (cranial to the apical vertebra) or toward its convexity (caudal to the apical vertebra).

The apical vertebra is located horizontally. When the apex of the deformity is located not at the vertebral body but at the intervertebral space, all vertebrae are tilted. The end vertebra is defined as the last of the tilted vertebrae. If the endplates of two vertebrae at the end of the curve are strictly parallel to each other, the one located farther from the apex is considered the end vertebra. In the transitional zone between the primary and compensatory curves, the intervertebral space caudal to the end vertebra may be bounded by parallel endplates. In other cases, the lower end vertebra of the cranial curve may simultaneously be the upper end vertebra of the caudal counter-curve. The second stage of the Cobb method: drawing straight lines on the spondylogram at the intersection of which the target angle is formed. The first line is drawn strictly along the cranial endplate of the upper end vertebra, and the second along the caudal endplate of the lower end vertebra. In cases where the endplates are poorly visualized due to anatomical features or postoperative changes, it is permissible to draw these lines through the upper or lower edges of the pedicle shadows. Their intersection within a standard film is possible only in severe scoliotic deformities; in other cases, the lines intersect outside the film, and to measure the angle of the scoliotic curve, it is necessary to construct perpendiculars to both lines. According to the laws of geometry, the angle at the intersection of these perpendiculars will also characterize the magnitude of the scoliotic curve. The third stage is measuring the obtained angle and recording the result on the radiograph and in the medical history.

Sagittal plane. The magnitude of thoracic kyphosis and lumbar lordosis is also determined in accordance with the Cobb method. However, there are specific features dictated by the nature of the pathology. If a profile spondylogram of a patient with scoliosis is examined, regardless of its etiology, it is necessary to measure the magnitude of the curvature of the entire thoracic spine — from Th1 to Th12. This is not always feasible, as the upper thoracic vertebrae on a profile spondylogram are usually obscured by the shadow of the humeral heads. Measurement from Th4 to Th12 is quite acceptable. It is important that all measurements in a given patient are performed at the same levels, otherwise it will be impossible to reliably assess noted changes — an increase or decrease in kyphosis. Straight lines are drawn through the cranial endplate of the upper end vertebra and the caudal endplate of the lower end vertebra, forming an angle at their intersection that characterizes the magnitude of the deformity. For small kyphoses, the lines intersect outside the radiograph, and in such cases, as when measuring the scoliotic curve, perpendiculars to the main lines should be constructed and the deformation angle determined at their intersection point. When documenting the results, it is advisable to designate kyphotic deformity with a "+" sign and lordotic with a "–" sign. As for measuring lumbar lordosis parameters, its magnitude is measured from the L1 to the S1 vertebra. A special situation arises in the case of a sharp-peaked or gentle kyphosis with the development of compensatory counter-curves in the sagittal plane; for example, in congenital kyphotic deformities. The end vertebrae are determined using the same principle as in scoliosis — it is necessary to find the cranial and caudal vertebrae most tilted toward the concavity of the deformity, i.e., ventrally. It is clear that using standard Th1 (Th4) and Th12 as end vertebrae will lead to severe distortion of the result. Both overview and functional spondylograms are measured using a standardized technique with the same reference points.

Horizontal plane

Deformity of the spinal column in the horizontal plane, i.e., rotation of the vertebrae around the vertical axis, is the main component of the mechanogenesis of IS. It is maximally expressed at the level of the apical vertebra and progressively decreases toward both end vertebrae of the curve. The most prominent radiographic manifestation of rotation is the change in the position of the shadows of the pedicles of the apical vertebra on the frontal spondylogram. Normally, in the absence of rotation, these shadows are located symmetrically relative to the midline of the vertebral body and its lateral contours. The degree of rotation is determined from 0 to IV. Grade 0 rotation practically corresponds to the norm, when the pedicle shadows are symmetrical and located at equal distances from the lateral endplates of the vertebral body. In Grade I rotation, the pedicle on the convex side of the scoliotic curve shifts toward the concavity and occupies a position asymmetric relative to the corresponding endplate and the opposite pedicle. In Grade III rotation, the pedicle corresponding to the convex side of the deformity is located in the projection of the middle of the vertebral body shadow, whereas in Grade II rotation, it occupies an intermediate position between Grades I and III. The extreme degree of rotation (IV) is characterized by the displacement of the convex-side pedicle shadow beyond the midline of the vertebral body — closer to the medial lateral endplate. A more precise determination of the degree of rotation is provided by a technique involving a special ruler — a torsiometer. First, the largest vertical diameter of the shadow of the pedicle corresponding to the convex side of the deformity (B) should be determined. Next, points (A and A1) located at the height of the "waist" of the vertebral body medially and laterally are marked. The torsiometer is applied to the spondylogram in such a way that points A and A1 are located at the edges of the ruler. It remains to determine which of the torsiometer scale lines coincides with the maximum vertical diameter of the pedicle shadow (B). If developmental anomalies of the vertebrae and ribs are detected, their identification and localization are necessary. All vertebrae — both complete and supernumerary — should be numbered in the craniocaudal direction, the nature of the anomaly determined, and the correspondence of the ribs to the vertebrae and hemivertebrae clarified; in case of rib synostosis, which ones are blocked. Numbering of the vertebrae is mandatory not only in the presence of congenital anomalies, but absolutely in all cases, specifically in the craniocaudal direction. Neglecting this rule will inevitably lead to errors in planning and performing surgical intervention. For example, the presence of a transitional L6 vertebra must be taken into account when determining the lower boundary of the spinal fusion zone, otherwise there is a risk of postoperative trunk imbalance or early pain syndrome.

Comments: Radiographs with lateral bending are performed with the patient in the supine position. Bending is performed actively by the patient separately toward the convexity of the primary and compensatory curves. For example, if there is a right thoracic curve with a left lumbar counter-curve, the patient must actively bend the thoracic spine to the right as much as possible, and the lumbar spine to the left. Both spinal radiographs are carefully marked. The second option for studying spinal mobility in scoliosis is traction spinal radiographs. The patient lies supine, and two technicians apply traction — by the lower legs and using a Glisson loop. The image is taken at the moment of maximum traction. Both methods (lateral bending and traction) should not be considered mutually exclusive.

Lateral spine radiography with functional tests is performed when it is necessary to determine the degree of mobility of a kyphotic deformity. The patient is placed supine, and a sandbag 10 cm high and 15-20 cm wide is placed under the apex of the kyphosis. It is important for the patient to relax fully. If it is necessary to determine the degree of spinal mobility in the presence of hyperlordosis, the image is taken in active maximum flexion. Lumbar spine radiography with functional tests in flexion and extension is performed to clarify the condition of the lumbar intervertebral discs when planning the extent of the arthrodesis zone in a patient with scoliosis.

Special projections

Oblique projections (right and left in 3/4) are used to assess the pars interarticularis of the lumbar vertebral arch in cases of spondylolysis or spondylolisthesis. In the thoracic spine, oblique projections help to more accurately assess the condition of the bone mass after spinal arthrodesis surgery. So-called targeted spinal radiographs make it possible to clarify local anatomical features of the motion segment of the spine. In the presence of anomalies of the lumbosacral spine, the Ferguson view is used. With the patient supine, the X-ray tube is angled cranially (30° for men and 35° for women), with the beam passing in the plane of the L5-S1 disc, making the anatomical features of this joint clearly visible. These radiographs should be performed with very good reasons, as pelvic irradiation is relatively high. In severe scoliotic deformities (usually greater than 100°), the standard anteroposterior projection does not allow for the evaluation of the true curve magnitude due to pronounced vertebral rotation. A deformity in the sagittal plane occurs, which externally looks like kyphosis, although it is not, as it is the result of rotation. If the rotation is "eliminated", the scoliotic curve will appear larger than it does on the anteroposterior radiograph. The radiograph thus displays the true scoliotic deformity. In patients with scoliosis, tangential radiography of the rib hump is routinely performed. The patient bends forward, and the beam is directed along the plane of the back, resulting in a radiograph reflecting the shape of the ribs at the apex of the hump and the mutual arrangement of the ribs on the right and left halves of the rib cage. Rib hump radiography is performed before corrective spine surgery or thoracoplasty, as well as in the postoperative period to assess the achieved result. The method can be replaced by axial computed tomography of the trunk.

Comments: CT is used to diagnose congenital, traumatic, and degenerative spinal canal stenoses, and to determine the degree of spinal cord compression. CT provides an axial image, demonstrates the relationship between soft tissue and bone structures, and detects minor changes in the density of the studied structures. When examining the skeletal system, CT makes it possible to detail changes in bone tissue structure and calculate the parameters of the implantable metal hardware. When cervical spine pathology is suspected, following radiography, CT allows for the verification of the pathology [11, 12, 21, 28].

Comments: With regard to the spine, MRI makes it possible to assess the condition of the intervertebral discs and the contents of the spinal canal. An additional advantage of MRI is that the anatomical structure of interest can be studied in any plane. MRI should be a routine method in a specialized vertebrology clinic.

In adolescent idiopathic scoliosis, especially advanced cases, it is important to know the position of the dural sac relative to the spinal canal walls at the apex of the deformity. In all cases of juvenile scoliosis, in extensive left-sided idiopathic deformities, and with the slightest manifestations of neurological deficit, examination of the spinal canal contents is mandatory. The same applies to congenital spinal deformities, given the high percentage of coexisting extraspinal and intraspinal developmental anomalies (diastematomyelia, etc.). If a patient presents with clinical signs of spinal cord compression, MRI helps to clarify its cause, which is relatively straightforward in cases of "pure" kyphosis. A large scoliotic component complicates the picture, and in these cases, combining MRI with myelography is useful. As an independent imaging method, myelography is most often used when magnetic resonance imaging is unavailable.

Comments: In 1994, the Novosibirsk Research Institute of Traumatology and Orthopedics (NNIITO) developed the method of computer-based optical topography (KOMOT), based on fringe projection and spatial phase detection, and performed the first domestic computer-based optical topography of the spine, which provides non-contact, remote determination of the shape of the dorsal surface of the patient's trunk based on fringe projection and computer processing of digital images [8,12].

During the examination, the patient stands with their back to a television camera and a projector located to the side of it. The projector projects an image of a system of rectilinear equidistant stripes onto the dorsal surface of the patient's trunk, the shape of which changes proportionally to the relief of the surface being examined. The television camera captures this image and inputs it digitally into a computer. The method is non-invasive, completely harmless to the patient, yet highly informative. Designed for screening large populations, this method of quantitative sciascopic evaluation has proven extremely effective in assessing the results of surgical correction of spinal deformities of various etiologies. The described advantages also make it possible to recommend it for assessing the severity of adolescent idiopathic scoliosis using remote digital technologies (telemedicine medical information systems).

If a biomechanical laboratory or 3D motion video analysis systems are available, they allow for additional objective evaluation of the result of spinal correction in terms of the normalization of locomotor function and the restoration of trunk balance.

2.5 Other Procedures

Comments: The problem of evaluating the outcomes of surgical treatment for spinal deformities rests on the difficulty of establishing criteria that objectively reflect the outcomes of a condition that is simultaneously psychosomatic and somatopsychic—scoliosis. Evaluating surgical outcomes, especially in the long term, helps to identify the most effective treatment methods and determine the causes of unsuccessful outcomes.

The SRS questionnaire (Appendix G2) was developed to evaluate and compare the outcomes of surgical treatment in patients with scoliotic spinal deformity. It also makes it possible to isolate the parameters that have the greatest impact on patient satisfaction with treatment outcomes.

The use of the SRS questionnaire in recent years is universally regarded as a standard component of postoperative evaluation in patients with spinal deformities of various etiologies. The main advantage of the method is the ability to compare results obtained using different endocorrectors or the same instrumentation used in different clinics. However, a review of the literature did not reveal any studies comparing questionnaire results with methods other than radiography. Questionnaires are not used in the preoperative period.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Conservative Treatment

Comments: Conservative medical treatment and physical therapy are not of independent significance in the treatment of spinal deformities and are used in complex rehabilitation or as symptomatic treatment. The goals of conservative treatment are to:

• curb the worsening of spinal deformity in the early stages and thus even avoid surgical treatment;

• prevent further progression of the deformity, external respiration and cardiovascular function disorders, providing a favorable background for surgical treatment;

• become part of the "lifestyle" for operated patients and patients with spinal deformity for whom surgical treatment is not indicated.

Physiotherapy exercise (PE) includes exercise complexes for: strengthening trunk muscles; developing movement coordination; correcting and/or stabilizing deformity curves; developing respiratory endurance; recovery after physical exertion.

Additional physical activity includes: swimming (mastering the technique of classic styles); adaptive physical education. The patient must disciplinedly exercise 2–3 times a day with a total time of 1.5 to 3 hours. Physical therapy is mastered by the patient as a way of life [16, 17, 22, 23, 24].

The protocol of the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) [26] recommends using the progression coefficient and progression rate in patients with a Cobb angle greater than 20 degrees to determine conservative treatment tactics in children of different age groups, as presented in Appendix G1.

Currently, one of the most convenient methods for assessing the probability of progression is the Lonstein formula and graph shown in Appendix A3.1.

Comments: The Cheneau-type corrective brace design has found widespread use, which makes it possible to increase treatment efficiency, reducing the number of patients requiring surgical treatment and the percentage of disability in spinal deformities in children; it has a number of advantages:

• application of correcting forces simultaneously in three planes — frontal, sagittal, and horizontal, which prevents the redistribution of deformity from one plane to another; action on the rotational component of the deformity with an asymmetric derotating load;

• localized application of corrective efforts to the apex and base of the deformity, making it possible to correct even the "shortest" scoliotic curves; elimination of the upper support's pressure on the shoulder girdle, cervical spine, and skull, thereby avoiding complications such as lower jaw deformity, degenerative changes in the cervical spine, etc.; the overall dimensions of the brace practically do not restrict the patient's motor activity; ease of use by the patient (can be put on and taken off by a preschool-aged child without outside help).

Indications for the use of a corrective brace:

1. Idiopathic progressive scoliosis of grade II, III with skeletal growth maturity indices according to Sadofyeva S0-SIV and Risser R0-RIV for active corrective action on the deformity, to restrain the development of the deformity until the age of skeletal maturation and subsequent single-stage surgical treatment; presence of a progressive scoliotic spinal deformity measuring 20 degrees or more by Cobb measurement with incomplete bone growth of the patient [16,24, 28, 29].

2. Presence of concomitant genetic diseases and syndromes (Marfan, Ehlers-Danlos, neurofibromatosis, etc.).

Contraindications for the use of the brace:

1. Chronic somatic diseases in the stage of decompensation;

2. Infectious diseases;

3. Skin pathology at the sites of contact with the brace;

4. Neurological pathology with motor disorders;

5. Mental disorders in the acute stage.

Before prescribing the brace, an examination by an orthopedic traumatologist is performed, along with an X-ray examination of the spine in 2 standard standing projections including the lower cervical or upper thoracic spine (depending on technical capabilities) and mandatory visualization of the iliac wings, and optical computer topography of the spine (optional). The procedure for putting on the brace is strictly regulated.

The brace is worn round-the-clock and is removed for hygiene procedures and therapeutic treatments for no more than 40-50 minutes at a time. Thus, the patient stays in the brace for at least 20 hours a day.

Conditions for brace therapy:

• Daily physical therapy exercises;

• Comprehensive rehabilitation courses 2-3 times a year;

• Compliance with the rules of brace treatment [27, 28, 29]:

• Adaptation period (2-3 weeks) until reaching a wear time of 21 hours/day;

• X-ray in the brace after 6 weeks – evaluation of correction in the brace, adjustment of the brace if necessary;

• Follow-up examination after 3 months;

• X-ray control in the brace every 6-12 months depending on the course of the pathology as prescribed by the orthopedic traumatologist;

• Strict adherence to the brace-wearing regimen;

• Periodic examinations by an orthopedic traumatologist with anthropometry at least once every 4 months.

Possible complications of brace therapy:

1. Formation of macerations and pustules at strap chafing sites, resolved by temporarily suspending brace therapy and applying a dressing if skin integrity is compromised;

2. Occurrence of pain in the ribs and sternum due to inadequate load, which is resolved by reducing the load;

3. Decrease in forced vital capacity, compensated by prescribing additional physical therapy exercises and breathing exercises.

According to recent randomized studies [26, 36], the Rigo classification, which combines topographic and radiological criteria, is the most promising for use in the practice of conservative treatment. This classification was developed in accordance with the specific principles of deformity correction required for the design and manufacture of a corrective brace, as shown in Appendix A3.

3.2 Surgical Treatment

Comments: The decision regarding surgical treatment requires an individualized approach that takes into account the goal of the surgery, the effectiveness of conservative treatment, the risk of the upcoming intervention, and potential postoperative complications. The main task is to select the most rational technologies for surgical treatment and anesthetic management. In some cases, based on preoperative examination data, a postponement of or refusal to perform surgery will be required.

Surgical treatment technologies for idiopathic scoliosis in patients of different age groups depend not only on the age of detection, but also on the nature of the clinical course and prognosis.

Indications for elective surgical treatment of idiopathic scoliosis:

• Malignantly progressing forms of idiopathic scoliosis in children in the first decade of life.

• Progressing forms of idiopathic scoliosis in adolescents with a Cobb angle of 40° or greater.

• Idiopathic scoliosis with a Cobb angle of 40° or greater in adolescents with a pronounced cosmetic defect and trunk imbalance.

• Idiopathic scoliosis in patients older than 20 years with a deformity of 40° or greater according to Cobb, a cosmetic defect, pain syndrome, and impaired cardiopulmonary function.

• Complaints of a cosmetic defect in patients older than 20 years with a residual rib hump or deformity of 25°–40° according to Cobb.

An absolute contraindication to elective surgical treatment is:

• severe general condition of the patient caused by impaired function of vital organs and systems (decompensation of the cardiovascular system,

• absence of respiratory reserves with a decrease in vital capacity (VC) and forced vital capacity (FVC) of more than 70% of the age norm).

Relative contraindications to surgical treatment are acute (chronic) diseases or severe congenital malformations of internal organs requiring preliminary surgical correction or drug therapy:

• acute infectious and parasitic diseases;

• cardiac pathology (congenital heart defects with hemodynamic disorders, complex heart rhythm disorders); chronic diseases of the respiratory system and congenital malformations of the respiratory organs;

• liver diseases (acute hepatitis, chronic hepatitis in the stage of marked process activity);

• blood diseases (thrombocytopenia, thrombocytopathy, severe anemia);

• kidney diseases with symptoms of renal failure; — thyroid diseases (hyperthyroidism, hypothyroidism); — parathyroid diseases (hypoparathyroidism); — adrenal pathology;

• oncological diseases;

• other pathological conditions.

Previous single-stage and multi-stage spine surgeries, especially those involving bone grafting with the formation of an extensive bone block (both dorsal and ventral) and surgeries complicated by suppuration, are also a relative contraindication.

Correction of spinal deformity can be performed using differentiated surgical tactics in children with high growth potential (the first 10 years of life).

Comment: Anterior and anterior-posterior options of spinal arthrodesis and spondylosynthesis may be used [30].

It is possible to use an anterior approach for spinal correction; however, according to meta-analyses in the world literature, no significant difference has been found between the use of anterior and dorsal interventions [31].

For patients with high axial growth potential, the use of dynamic correction techniques (Dual Growing Rods, VEPTR, and their analogues) has been described [32, 33]. Staged distractions of growth-control systems according to the Skaggs classification (2014) should be performed on average every 6–12 months, depending on the age and degree of deformity progression [33]. An absolute indication for rib-vertebral distraction using the VEPTR technique is thoracic insufficiency syndrome [34].

To reduce the need for reoperation, a magnetically controlled growing rod technique has recently been actively used as an alternative to traditional growing rods that require sequential surgical lengthenings, which is clinically and economically effective in the long term [33, 35].

3.3 Other Treatment

3.3.1 Surgical antibiotic prophylaxis

• When performing surgical treatment in patients with idiopathic scoliosis, it is recommended to administer surgical antibiotic prophylaxis (SAP) for surgical site infection with a single preoperative dose of an antibacterial drug to reduce the risk of infectious complications [96, 97].

GRL CLEL 5Grade of Recommendation C (Level of Evidence 5).

Comments. In accordance with international clinical guidelines for the prevention of surgical site infection [96, 98] the goal of SAP is to achieve bactericidal concentrations of the antibacterial drug in tissues exposed to microbial contamination during surgery to prevent surgical site infections. The need for SAP is determined by the surgical wound class of the upcoming operation: SAP is not required for "clean" surgical wounds not involving the implantation of orthopedic implants and metal structures. SAP should be administered for clean-contaminated and contaminated surgical wounds, as well as for "clean" surgical wounds involving the installation of orthopedic implants and metal structures. For infected ("dirty") wounds, SAP is not indicated; antibiotic therapy is performed instead.

• In patients with idiopathic scoliosis, it is recommended to use first- and second-generation cephalosporins (cefazolin**, cefuroxime**) as the primary drugs for surgical antibiotic prophylaxis in trauma and orthopedic surgeries, and glycopeptide antibiotics (vancomycin**), lincosamides (#clindamycin**) as an alternative in case of beta-lactam antibiotic intolerance [96].

GRC CLEL 5Grade of Recommendation C (Level of Evidence 5)

Comments. For patients with an unremarkable allergy history and without significant risk factors for methicillin-resistant Staphylococcus aureus carriage, first- and second-generation cephalosporins (cefazolin**, cefuroxime**) are used for SAP, administered intravenously 30 to 60 minutes before skin incision. In case of beta-lactam antibiotic intolerance, a combination of vancomycin** with one of the fluoroquinolones (ciprofloxacin**, #levofloxacin**) should be prescribed, administered for at least 60 minutes starting the intravenous infusion 2 hours before the incision, or #clindamycin** should be used. In the presence of significant risk factors for methicillin-resistant Staphylococcus aureus (MRS) carriage, the SAP regimen should include an antibiotic with anti-MRS activity (vancomycin**) [96]. In most cases, a single preoperative dose of the antibiotic is sufficient for effective prevention. For prolonged procedures or massive blood loss, an additional intraoperative dose of the antibiotic should be administered (the estimated time of intraoperative administration is two half-lives after the preoperative dose). Administering an antibiotic after wound closure in the operating room is inappropriate, even in the presence of inserted drains [96].

Single doses of main antibacterial drugs for surgical site infection (SSI) prophylaxis in adult traumatology and orthopedics: cefazolin** 2 g (for patients with a weight ≥120 kg — 3 g), cefuroxime** 1.5 g, #clindamycin** 900 mg, vancomycin** 15 mg/kg as a slow IV infusion, ciprofloxacin** 400 mg, #levofloxacin** 500 mg [96].

Single doses for children should be calculated based on actual weight: cefazolin** 30 mg/kg, cefuroxime** 50 mg/kg, #clindamycin 10 mg/kg, vancomycin** 15 mg/kg; the use of fluoroquinolones during the period of musculoskeletal system development is contraindicated due to the risk of arthropathy [96, 129, 130].

• In the surgical treatment of patients with idiopathic scoliosis, it is recommended to perform antibiotic prophylaxis of the surgical site infection for no more than 24 hours [99].

GCR CLEL 5Level of recommendation evidence C (level of data reliability 5).

Comments. In accordance with the regulatory documentation in force in the Russian Federation (SanPiN 3.3686-21) and clinical guidelines [99] to achieve an effective concentration of the antibacterial drug in tissues and blood serum at the time of skin incision, antibiotics for surgical site infection prophylaxis should be administered intravenously 30 to 60 minutes before the skin incision, or within 2 hours before the incision when using vancomycin**. The maximum duration of prophylactic antibiotic administration should not exceed 24 hours after the end of surgery. In most cases, a single dose of antibiotic is sufficient for effective prophylaxis. Additional doses should be administered during prolonged procedures when the half-life of the administered antibiotic elapses from the moment of preoperative administration, creating a risk of antibiotic concentration dropping below the bactericidal level and increasing the risk of SSI.

3.3.2. Pain management

• For adequate pain management in patients with idiopathic scoliosis after surgical treatment, it is recommended to use multimodal analgesia, which may include non-steroidal anti-inflammatory and antirheumatic drugs (ATC group code: M01A), paracetamol**, gabapentinoids (ATC group code: N02BF), and immediate-release opioids, taking into account age restrictions in the instructions for medical use; if multimodal analgesia cannot be prescribed, monomodal analgesia should be used [100–102].

GCR ALOE 2Grade of Recommendation A (Level of Evidence – 2)

Comments: It is necessary to ensure adequate analgesia for the patient prior to any manipulations and throughout the entire treatment period, the duration of which varies significantly depending on the chosen management strategy. When providing analgesia in a hospital setting, it is essential to take into account the prescriptions made at the emergency medical care stage.

Among pharmacological strategies, the currently accepted standard is the use of multimodal analgesia (MMA), which involves the use of several analgesic drugs (opioid and non-opioid) with different mechanisms of action and non-pharmacological interventions aimed at affecting peripheral and/or central parts of the nervous system [103]. This combination allows for more effective pain relief by enhancing the effects of various drugs, which in most cases leads to a reduction in the frequency of prescriptions and/or doses of opioid analgesics. Thus, MMA improves the risk profile of each drug while providing synergistic pain control using different drug classes. Postoperative MMA may include psychotherapy, physical therapy, NSAIDs, paracetamol**, gabapentinoids, regional anesthesia (single injection or placement of peripheral nerve catheters), local injections, and opioids [101, 104].

In modern scientific literature, authors emphasize the use of the lowest effective doses of opioids for the shortest possible period of time, avoiding extended-release opioids. As an adjunct during MMA, a single perioperative dose of #dexamethasone** can be used, which provides significant pain reduction [100].

It must be remembered that the duration of parenteral administration of most NSAIDs (ketorolac**, ketoprofen**, diclofenac**) is limited to two days, which requires timely switching of the patient to oral administration, changing the drug, or coordinating further use with the medical commission. The specific choice of local anesthesia method and medicinal products is made by the attending physician individually in accordance with the patient's characteristics, local protocols, and the equipment of the medical organization.

When prescribing analgesic therapy to children, a single dose should be chosen taking into account the child's weight and age. Preference should be given to analgesics with oral or rectal routes of administration, avoiding intramuscular injections. When choosing analgesics for MMA, it should be considered that perioperative use of #pregabalin** in children undergoing posterior instrumented spinal fusion does not reduce postoperative opioid consumption [106].

Recommended analgesic drugs are listed in Appendix A3.3-3.4.

Comments: according to a systematic review with meta-analysis by Bas JL. et al., which included 4 randomized controlled trials involving 196 adolescent patients, #gabapentin was shown to be effective in reducing pain syndrome and reducing the need for opioid prescriptions during the first 48 hours [93].

• Opioids (ATC code: N02A), for example, tramadol**, tapentadol, are recommended for the relief of unbearable, highly intense postoperative pain when it cannot be managed by other means [87, 95].

GRC CLEL 5Grade of Recommendation C (Level of Evidence 5)

3.3.3. Prevention of venous thromboembolic events

Comments: To assess individual VTE risk, it is advisable to use the Caprini scale (Appendix G3). Recommended doses, frequency, and route of administration of anticoagulants for high-risk VTE prophylaxis during conservative treatment and in the preoperative period are presented in Appendix A3.5.

• In patients with a high risk of bleeding, it is recommended to apply mechanical thromboprophylaxis before surgery, and to delay the first administration of a low molecular weight heparin from the heparin group (ATC code B01AB) until hemostasis is achieved (12–24 hours postoperatively) [108, 109, 110].

GCR BLOCE 2Grade of Recommendation B (Level of Evidence 2).

Comments: When prescribing anticoagulants and other antithrombotic drugs, time intervals between the administration of drugs from these groups and the performance of neuraxial blockade or catheter removal must be taken into account (Appendix A3.6).

• In the case of admission of a patient with restricted mobility, including due to hemi- and tetraparesis/-paralysis, it is recommended to initiate pharmacological VTE prophylaxis in the preoperative period [111].

GRC CLEL 5Grade of Recommendation C (Level of Evidence 5)

• When performing pharmacological VTE prophylaxis in children, it is recommended to consider the use of #enoxaparin sodium** or heparin sodium** [113].

GRC CLEL 5Grade of Recommendation C (Level of Evidence 5)

Comments: In pediatric practice, there is no standardized and validated risk assessment tool for thromboprophylaxis [114]. All hospitalized patients older than 6 months should be screened for both bleeding risk and VTE risk within 24 hours of hospitalization [115], and periodically during their hospital stay (every 48–72 hours) [116, 117, 118].

3.3.4. Blood-conserving technologies

Comments: A systematic review evaluated the effect of tranexamic acid on the need for blood transfusion and blood loss volume in patients undergoing spine surgery [107]. The review included an analysis of 11 randomized controlled trials involving 644 patients who underwent various types of spinal surgeries, including spinal fusion, decompressive laminectomy with spinal fusion, cervical laminoplasty, adolescent scoliosis correction surgery, and surgery for degenerative spinal instability with stenosis. The use of tranexamic acid compared to placebo or no treatment was associated with a reduced need for blood transfusion. In the analysis of 11 studies involving 504 patients, the relative risk was 0.67 (95% CI: 0.54–0.83). The use of tranexamic acid led to a decrease in intraoperative blood loss by an average of 219.03 ml (95% CI: 321.67 ml to 116.38 ml), postoperative blood loss by 119.15 ml (95% CI: 140.76 ml to 97.54 ml), and total blood loss by 202.07 ml (95% CI: 229.25 ml to 104.88 ml).

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Comment: establishing a rehabilitation diagnosis using the ICF is central to rehabilitation planning [54–56].

Comments: a systematic review with meta-analysis by Ceballos-Laita L. et al. analyzed the results of 6 randomized controlled trials involving 144 patients with idiopathic scoliosis. The results of the systematic review demonstrated efficacy in reducing the Cobb angle, trunk rotation angle, and improving quality of life compared to other conservative rehabilitation methods for patients with idiopathic scoliosis or compared to no intervention [45]. In a systematic review with meta-analysis by Dimitrijević V. et al., the results of 10 randomized controlled trials were analyzed; the data obtained indicate moderate to high efficacy of Schroth method exercises in reducing the Cobb angle and trunk rotation angle, as well as improving quality of life [60]. According to a systematic review with meta-analysis by Dimitrijević V. et al., which included 13 randomized controlled trials evaluating the efficacy of Schroth method exercises combined with or separate from spinal stabilization exercises, it was shown that Schroth exercises combined with spinal stabilization exercises are effective in reducing the Cobb angle, trunk rotation angle, and improving quality of life. Subgroup analysis showed that the Schroth method is more effective than spinal stabilization exercises [61]. In a study by Rrecaj-Malaj S. et al. involving 69 adolescents with idiopathic scoliosis aged 10–17 years with a Cobb angle of 10–45°, it was shown that a combination of Schroth method exercises and Pilates has a positive effect on the Cobb angle, trunk rotation angle, active range of motion of the trunk, and quality of life, regardless of the use of bracing. The first stage lasted 2 weeks in a rehabilitation center and consisted of daily 60-minute exercises, followed by home-based exercises following the same program for 10 weeks. After re-evaluation, patients continued the second part of daily exercises for 2 weeks in a rehabilitation center, followed by the same home rehabilitation program for 10 weeks [59].

Comments: during corrective brace treatment, it is recommended to perform contact or highly dynamic physical exercises with caution [2, 30]. Patients with scoliosis at high risk of progression are recommended to avoid competitive activities that heavily mobilize the spine [16, 66, 67].

Comments: back extension exercises reduce thoracic kyphosis, which can destabilize the thoracic spine, increase its tendency to lateral flexion and rotation, and increase spinal curvature [68]. Patients with idiopathic scoliosis, especially those with double curves, should avoid lateral flexion exercises [69]. Lateral flexion to one side reduces one curve but increases the other. Flexion exercises have been found to cause the progression of scoliosis in many cases [69]. There is also evidence that rotational exercises increase the rib hump [69].

Comments: a systematic review by López-Torres O. et al., which included 17 randomized controlled trials, showed that myofascial release is effective in reducing the severity of idiopathic scoliosis and pain intensity [70]. Manual therapy methods such as myofascial release and spinal manipulative techniques are potentially effective in the treatment of idiopathic scoliosis when combined with other rehabilitation methods [71]. It should be noted that two systematic reviews with meta-analysis showed that evidence regarding the effectiveness of manual therapy in idiopathic scoliosis is insufficient [72, 73].

Comments: a retrospective study by Wang HY. et al., which included 262 patients, demonstrated that reflexology combined with massage is effective after surgical interventions for idiopathic scoliosis [50].

Comments: In the early postoperative period (7–14 days after radical spine surgeries), rehabilitation measures are carried out to achieve early motor activation of the patient, relieve pain, and stimulate reparative processes in the wound defect area.

Recovery of motor activity begins on the first day with breathing exercises and passive exercises in bed. Verticalization and gait restoration measures can be carried out using special therapeutic exercises, verticalizers, and subsequently, balance systems.

In the late postoperative period (from 2 to 8 weeks after radical spine surgeries), the goal of rehabilitation measures is the full restoration of motor activity, the formation of the muscular corset, and the stimulation of metabolic processes in the spinal tissues to prevent the recurrence of pain.

The leading role in this period belongs to exercise therapy aimed at strengthening the muscles of the back, interscapular region, abdominal wall, and buttocks, forming correct posture skills and movement stereotypes, as well as providing post-isometric muscle relaxation. Specialized exercise therapy is supplemented with sessions on specialized exercise equipment. Exercise therapy is combined with physical therapy methods that help strengthen the muscular corset.

Rehabilitation measures in the late postoperative period are carried out on an outpatient basis or in a sanatorium setting.

In the long-term postoperative period, it is recommended to avoid significant spinal loads (prolonged sitting, standing, walking, heavy lifting, torso bending and twisting, and contact sports) [47, 57, 58].

5. Prevention and Dispensary Observation

Comment: In case of active progressive development of the deformity and the absence of a positive effect from treatment within a year, the patient is referred to a specialized medical institution to clarify the clinical diagnosis, coordinate further treatment tactics, and, if necessary, decide on the advisability of surgical treatment.

Comments: With the progression of untreated spinal deformity, there is a high risk of developing early degenerative-dystrophic changes in the spine, respiratory failure, pain syndrome, neurological complications, and deterioration of somatic status up to profound disability.

6. Organization of Medical Care

Indications for hospital admission to a medical organization:

1. Presence of a verified outpatient scoliotic spinal deformity with a Cobb angle greater than 40°.

2. Deformities of any severity that provoke the onset and/or progression of neurological spinal symptoms.

3. The fact of seeking medical care for the specified disease, with complaints of scoliotic spinal deformity and/or pain syndrome caused by the specified disease.

Indications for patient discharge from a medical organization

1. Achieved improvement regarding deformity correction and sagittal balance, and reduction of the pre-treatment pain syndrome.

2. Absence or, if they occur, resolution of septic, inflammatory, and other complications caused by the treatment.

3. Patient mobilization (verticalization), ability to perform self-care.

Conservative treatment of IS, depending on the magnitude of the scoliotic deformity and the patient's age, should be carried out in medical institutions of various levels (hospital - intensive rehabilitation, hospital day care, outpatient clinic day care, outpatient monitoring, sanatorium-resort treatment).

7. Additional Information

Potential complications of surgical treatment:

Complications arising in operated patients may require re-operation. They can be divided into three groups:

• complications associated with the use of implants;

• complications from surgical manipulations not associated with the use of implants;

• infectious complications.

The following types of complications are most frequently anticipated:

1. Dural tear, postoperative cerebrospinal fluid (CSF) leakage. The method of preventing postoperative CSF leakage is meticulous dural closure at the final stage of the surgery. If leakage occurs in the early postoperative period, delayed skin sutures are applied, and their removal is delayed until a reliable scar is formed. If these measures are ineffective, re-operation is performed to carefully seal the CSF spaces. Lumbar drainage may be performed to divert CSF in the first few days after dural injury and the onset of CSF leakage.

2. Mild neurological complications (plexitis, neuritis, etc.) require conservative treatment.

3. Worsening of limb paresis, hypoesthesia, and urinary retention may rarely occur (less than 1%) due to the following reasons:

   • Impaired spinal cord circulation at the conus-epiconus level. To avoid spinal cord circulatory disorders in the postoperative period, the patient requires constant monitoring of hemodynamic parameters (blood pressure, heart rate) and minimal traction of the nerve root and dural sac. If hemodynamic changes occur, medical correction is required.

   • Epidural hematoma. Prevention of hematoma formation is meticulous hemostasis during surgery. The method of eliminating a formed hematoma causing spinal cord root compression is re-operation to remove the hematoma and achieve more thorough hemostasis.

4. Implant-related complications.

   • Screw malposition and migration of interbody spinal stabilization implants. In these complications, the management strategy is dictated by the severity of clinical and radiological manifestations. Some situations require revision surgery for decompression and restoration of the desired segmental relationship under fixation. The method of preventing these complications is the selection of adequate implant sizes, intraoperative X-ray or CT control, and CT control of implanted medical device positions in the early postoperative period.

   • Instability of the implanted system. This includes rod fractures, hook displacement, and fractures of supporting bone structures. The complication requires re-operation to restore the system. Hooks are re-implanted at the same or adjacent level, rod integrity is restored using connectors, and lost correction is restored.

   • Pedicle fracture due to the insertion of an improperly sized screw. The method of correction is re-implantation of screws into another adjacent vertebra, allowing for reliable subsequent fixation.

   • Rod fractures are especially dangerous during the period up to 4–5 months after surgery, when bone union has not yet occurred. Destabilization of the spinal fixation construct can lead to secondary spinal deformity, worsening of neurological deficits, and chronic pain syndrome.

5. Infectious complications at the surgical site. Management options:

   • antibiotic therapy based on pathogen susceptibility testing;

   • surgical revision and debridement of the surgical site.

   • The decision to retain the implant is made on an individual basis.

6. Hematoma resulting from ongoing bleeding or ineffective postoperative wound drainage. Management options: evacuation of the hematoma; in case of ongoing bleeding, wound revision and hemostasis.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Belyaev Anatoly Fedorovich, D.Sc. (Med.), Professor, Professor of the Institute of Clinical Neurology and Rehabilitative Medicine, Pacific State Medical University of the Russian Ministry of Health, Honored Doctor of Russia, Director of the Primorsky Institute of Vertebroneurology and Manual Medicine, Chief Specialist in Medical Rehabilitation for the Far Eastern Federal District, Vladivostok.

2. Buylova Tatyana Valentinovna, D.Sc. (Med.), Associate Professor, Head of the Department of Medical Rehabilitation and Neurology, Institute of Clinical Medicine, National Research Lobachevsky State University of Nizhny Novgorod, Professor of the Department of Medical Rehabilitation, Privolzhsky Research Medical University of the Russian Ministry of Health, Chief Specialist in Medical Rehabilitation for the Volga Federal District, Nizhny Novgorod.

3. Vasyura Alexander Sergeevich — Trauma and Orthopedic Surgeon and Neurosurgeon at the Pediatric Orthopedic Department, Senior Researcher at the Pediatric and Adolescent Vertebrology Research Department, Ya.L. Tsivyan Novosibirsk Research Institute of Traumatology and Orthopedics of the Russian Ministry of Health, Candidate of Medical Sciences (Ph.D.), Vice-President of the Interregional Public Organization "Association of Spinal Surgeons".

4. Vetrile Marchel Stepanovich — Deputy Director for Science, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov, Ph.D. (Med.), Trauma and Orthopedic Surgeon, member of the Association of Trauma Surgeons and Orthopedists (ATOR).

5. Vissarionov Sergey Valentinovich — Trauma and Orthopedic Surgeon, Neurosurgeon, Director of the H. Turner National Medical Research Center for Children's Orthopedics and Trauma, Doctor of Medical Sciences, Professor, Corresponding Member of the RAS, member of the Interregional Public Organization "Association of Spinal Surgeons".

6. Kazmin Arkady Ivanovich — Ph.D. (Med.), Trauma and Orthopedic Surgeon at Department No. 7, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, member of ATOR.

7. Kokushin Dmitry Nikolaevich — Ph.D. (Med.), Senior Researcher at the Department of Spinal Pathology and Neurosurgery, H. Turner National Medical Research Center for Children's Orthopedics and Trauma of the Russian Ministry of Health, member of the Interregional Public Organization "Association of Spinal Surgeons".

8. Kolesov Sergey Vasilievich — Trauma and Orthopedic Surgeon and Neurosurgeon, Head of Traumatology and Orthopedics Department No. 7 (Spinal Pathology), National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, Professor, Doctor of Medical Sciences, Vice-President of the Interregional Public Organization "Association of Spinal Surgeons".

9. Mikhailovsky Mikhail Vitalievich — Trauma and Orthopedic Surgeon and Neurosurgeon, Chief Researcher at the Pediatric and Adolescent Vertebrology Research Department, Ya.L. Tsivyan Novosibirsk Research Institute of Traumatology and Orthopedics of the Russian Ministry of Health, Doctor of Medical Sciences, Professor, member of the Interregional Public Organization "Association of Spinal Surgeons".

10. Novikov Vyacheslav Viktorovich — Trauma and Orthopedic Surgeon and Neurosurgeon, Head of the Pediatric and Adolescent Vertebrology Research Department, Ya.L. Tsivyan Novosibirsk Research Institute of Traumatology and Orthopedics of the Russian Ministry of Health, Doctor of Medical Sciences, member of the Interregional Public Organization "Association of Spinal Surgeons".

11. Otdelenov Vitaly Alexandrovich, Ph.D. (Med.), Head of the Department of Rational Pharmacotherapy and Drug Supply Analysis, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, Moscow

12. Ryabykh Sergey Olegovich — D.Sc. (Med.), Deputy Director for Scientific Work, Academician Yu.E. Veltischev Research Institute of Pediatrics and Children's Surgery, Pirogov Russian National Research Medical University of the Russian Ministry of Health, member of the Association of Spinal Surgeons.

13. Tesakova Daria Dmitrievna — Ph.D. (Med.), Head of the Department of International Cooperation and External Relations, Management for the Implementation of Functions of the National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, Associate Professor at the Department of Traumatology and Orthopedics, Russian Medical Academy of Continuous Professional Education (RMAPO), member of ATOR.

14. Filatov Egor Yurievich — Orthopedic and Trauma Surgeon, Vertebrologist, Ilizarov National Medical Research Center for Traumatology and Orthopedics of the Russian Ministry of Health.

15. Sheyko Gennady Evgenyevich, Associate Professor, Ph.D. (Med.), Associate Professor at the Department of Medical Rehabilitation, Privolzhsky Research Medical University of the Russian Ministry of Health, Head of the Early Medical Rehabilitation Department, University Clinic of the Privolzhsky Research Medical University of the Russian Ministry of Health, Nizhny Novgorod

Conflict of interest.

The working group for the drafting of clinical guidelines for idiopathic scoliosis has no conflicts of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

• neurologists;

• neurosurgeons; trauma and orthopedic surgeons; pediatric surgeons; general surgeons;

• pediatricians;

• district pediatricians; general practitioners (family physicians);

• district general practitioners;

• general practitioners (family physicians); physical therapy doctors;

• specialists in medical prevention and medical rehabilitation.

Stages of evaluating the levels of evidence and grades of recommendation:

1. Definition of search and selection criteria for publications on clinical trials (CT) regarding the efficacy and/or safety of the medical intervention described in the recommendation statement.

2. Systematic search and selection of CT publications in accordance with the previously defined criteria.

Systematic search and selection of clinical trial publications:

The evidence base for the recommendations consisted of publications retrieved via information retrieval in the following databases: Central Scientific Medical Library (CSML) "Russian Medicine", MEDLINE (US NLM), and COCHRANE Library; scientific electronic libraries eLibrary.ru and "CyberLeninka"; as well as on the Internet using Yandex, Google, and Google Scholar search engines, by reviewing leading specialized peer-reviewed domestic medical journals on the subject and treatment guidelines for fractures from the international Association for Osteosynthesis AO/ASIF.

Table 1.Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Scale for grading levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Appendix A3.1. Lonstein's formula and graph

Currently, one of the most convenient methods for assessing the probability of progression is the Lonstein formula and graph. The formula includes the Cobb angle of the most pronounced curve, the Risser sign, and the patient's age. This formula determines the progression factor, after which the probability of progression is determined using the graph presented below. Based on the probability of progression, a set of recommended therapeutic measures is determined. Thus, if the probability of progression is less than 40%, regular follow-up examinations of the patient may be sufficient. If the probability of progression is between 40% and 50%, the addition of therapeutic exercises is mandatory. If the probability of progression exceeds 50%, intensive rehabilitation is recommended, which includes not only performing therapeutic exercises at home, but also intensive courses of special exercises under the supervision of an experienced specialist. If it exceeds 60%, brace treatment is mandatory added to the intensive rehabilitation. These indicators are recommendatory in nature, and the final choice of treatment method remains with the attending physician and the team of specialists observing the specific patient [26, 36].

Appendix A3.2. Rigo classification for the design and manufacture of a corrective brace

The most promising classification for use in conservative treatment practice is the Rigo classification, which combines topographic and radiological criteria. This classification was developed in accordance with the specific principles of deformity correction required for the design and manufacture of a corrective brace. According to this classification, clinically there are 4 variants of deformity: with 3 curves; with 4 curves; a variant defined by the authors as "non-3 non-4 curves"; a variant with an isolated lumbar or thoracolumbar curve. The clinical diagnosis must be confirmed and expanded by a standing anteroposterior X-ray examination of the spine. Based on radiological data, several subtypes are distinguished within each deformity variant. Thus, the basic 3-curve deformity variant is subdivided into 3 subtypes A1, A2, A3, depending on the lumbar spine configuration. The 4-curve variant is divided into 2 subtypes B1, B2, depending on the thoracic configuration. The "non-3 non-4" variant is also divided into two subtypes C1, C2, depending on the lumbar configuration. Isolated curve variants are designated as E1 for the lumbar curve variant and E2 for the thoracolumbar variant. Additionally, for variants A, B, and C, a D modifier can be introduced, which is assigned in the presence of a upper thoracic curve [26, 36].

Radiological criteria are determined by the following factors:

1. Curve pattern according to SRS terminology: single structural upper thoracic curve; single structural thoracic curve; single structural thoracolumbar curve; single structural lumbar curve; structural thoracic, compensatory lumbar curves; structural thoracic and lumbar curves; structural thoracic and thoracolumbar curves; two structural thoracic curves; structural and non-structural thoracic curves. The apex localization determines its name: Th 3-5 – upper thoracic, Th2 – Th11-12 disc – thoracic, Th12-L1 – thoracolumbar, L1-2 disc – L4 – lumbar, L4-5 – S1 disc – lumbosacral.

2. Position of the transitional point (TP) between the thoracic curve and the lumbar or thoracolumbar curve relative to the central sacral vertical line. The transitional point can be balanced (on the central sacral line) or imbalanced (outside the central sacral line).

3. Position of Th1 relative to the central sacral line. Th1 can be balanced or shifted towards the convexity or concavity of the thoracic curve.

4. Position of L4 in the frontal plane and its relationship with L5. L4 can be horizontal, or tilted towards the convexity or concavity of the thoracic curve. In the presence of a lumbar curve (whether structural or non-structural), L4 is tilted towards the concavity of the thoracic curve. L5 can be tilted in the same direction and by the same magnitude; in this case, it is defined as a negative L5-4 counter-tilt. A positive L5-4 counter-tilt is defined when L5 is tilted in the same direction as L4, but by a lesser number of degrees, thereby forming a compensatory lumbosacral curve. In other words, a negative counter-tilt denotes a situation where the lower endplate of L4 is parallel to the upper endplate of L5. In the presence of a thoracolumbar curve, a positive counter-tilt can simultaneously be determined at the L4-3 and L5-4 levels.

5. Any of the curve patterns described in paragraph 1 may be accompanied by a primary or secondary (iatrogenic – caused by previous brace treatment) upper thoracic curve. The presence of an upper thoracic curve is defined as the D modifier.

A1	A2	A3
Clinical criteria
Pelvis shifted towards the concavity of the thoracic curve Trunk shifted towards the convexity of the thoracic curve Rib hump prolonged into the lumbar region	Pelvis shifted towards the concavity of the thoracic curve Trunk shifted towards the convexity of the thoracic curve Pronounced rib hump / lumbar prominence absent or minimally pronounced	Pelvis shifted towards the concavity of the thoracic curve Trunk shifted towards the convexity of the thoracic curve Pronounced rib hump / lumbar prominence pronounced
Radiological criteria
Prolonged thoracic curve TP shifted towards the convexity of the thoracic curve Th1 shifted towards the convexity of the thoracic curve L4 is horizontal or tilted towards the convexity of the thoracic curve	Thoracic / lumbar curve is absent or minimal and functional in nature TP shifted towards the convexity of the thoracic curve Th1 shifted towards the convexity of the thoracic curve, L4 is horizontal	Thoracic curve / lumbar curve is absent or minimal and functional in nature TP shifted towards the convexity of the thoracic curve Th1 shifted towards the convexity of the thoracic curve, L4 is horizontal

B1	B2
Clinical signs:
Pelvis shifted towards the convexity of the thoracic curve Trunk shifted towards the concavity of the thoracic curve Noticeable rib hump and lumbar or thoracolumbar prominence	Pelvis shifted towards the convexity of the thoracic curve Trunk shifted towards the concavity of the thoracic curve Noticeable thoracolumbar prominence with mild rib bulging
Radiological criteria
Double thoracic and lumbar curves or thoracic and thoracolumbar curves TP shifted towards the concavity of the thoracic curve Th1 shifted towards the concavity of the thoracic curve Positive L5-4 counter-tilt	Primary thoracolumbar curve combined with a lesser degree thoracic curve TP shifted towards the concavity of the thoracic curve Th1 shifted towards the concavity of the thoracic curve Positive L5-4 counter-tilt (often positive L4-3 counter-tilt)

C1	C2
Clinical signs:
Pelvis not shifted Trunk balanced Noticeable rib hump with a straightened lumbar spine	Pelvis not shifted Trunk balanced Noticeable rib hump with a noticeable lumbar prominence
Radiological criteria
Thoracic curve, lumbar spine intact TP is on the central sacral line Th1 is on the central sacral line	Primary thoracic curve combined with a lesser degree lumbar curve TP is on the central sacral line Th1 is on the central sacral line Negative L5-4 counter-tilt

E1	E2
Clinical features
Pelvis shifted towards the concavity of the lumbar curve Trunk shifted towards the convexity of the lumbar curve Noticeable lumbar prominence in the absence of a rib hump	Pelvis shifted towards the concavity of the thoracolumbar curve Trunk shifted towards the convexity of the thoracolumbar curve Noticeable thoracolumbar prominence in the absence of a rib hump
Radiological criteria
Lumbar curve, thoracic curve absent TP shifted towards the convexity of the lumbar curve Th1 shifted towards the convexity of the lumbar curve	Thoracolumbar curve, thoracic curve absent TP shifted towards the convexity of the thoracolumbar curve Th1 shifted towards the convexity of the thoracolumbar curve

Appendix A3.3. Pain management guidelines for major musculoskeletal trauma (surgical interventions for long bone fracture fixation or complex articular fracture, extensive soft tissue trauma, major surgery, etc.) in adults

The table presents analgesic medications and their dosing regimens in accordance with the Clinical Practice Guideline for Acute Musculoskeletal Trauma Pain Management [103].

Appendix A3.4. Recommendations for postoperative analgesia in children

¹ In children under 12 years of age, morphine** is preferred if opioid analgesics need to be prescribed, as the use of tramadol** is associated with a higher risk of adverse reactions [126, 127].

² Use in children is not recommended because its metabolite accumulates in the body and provokes seizures with repeated use [128].

Appendix A3.5 Recommended dosing regimen of low molecular weight heparins for the prophylaxis of high-risk VTE in orthopedic surgery in adult patients at high risk of VTE

Appendix A3.6. Risk factors for bleeding in children from 6 months to 18 years [116, 117, 133]

Notes:

• If the patient meets at least one "NOT recommended" criterion, avoid pharmacoprophylaxis, as the risk outweighs the benefit.

• If the patient has at least one relative contraindication criterion, consider withholding pharmacoprophylaxis.

• Consider consulting a hematologist if the patient is at high risk of VTE with a high bleeding risk [117].

• Uncontrolled hypertension is defined as systolic or diastolic blood pressure above the 95th percentile for age, height, and sex [116].

• Coagulopathy is defined as INR > 1.5, aPTT > 44 s, fibrinogen < 100 g/dL, or platelets < 50,000/μL.

Appendix A3.7. VTE risk factors in children aged 6 months to 18 years [133, 134]

Notes:

• Reduced mobility is defined as a decrease in mobility compared to baseline or the inability to participate in physical therapy.

• Central venous access device is defined as a non-tunneled catheter, tunneled catheter, or central venous catheter.

• A massive burn is defined as a burn involving more than 50% of the body surface area.

• Major surgical interventions include operations lasting more than 45 minutes.

• Critically ill patients are defined as those admitted to an intensive care unit or critical care unit (requiring inotropic support, mechanical ventilation).

• Thrombophilic conditions include antithrombin defects, protein C or S deficiency, Factor V Leiden, or prothrombin gene mutation.

• Active malignancy is defined as receiving chemotherapy/radiation therapy within the preceding 6 months.

• Active inflammatory disease includes Kawasaki disease, inflammatory bowel disease, systemic lupus erythematosus, or nephrotic syndrome.

• Estrogen therapy includes oral contraceptives, estrogen replacement therapy, or use within the past 2 weeks.

• Obesity is defined as a BMI above the 95th percentile for age.

Key:

Low VTE risk:

• No altered mobility and 0-1 risk factors

Moderate VTE risk:

• No mobility impairment and 2-3 risk factors

• Altered mobility and 0-1 other risk factors

High VTE risk:

• No mobility impairment and ≥4 risk factors

• Altered mobility and ≥2 other risk factors

Thromboprophylaxis recommendation

Appendix B. Physician Action Algorithms

Appendix B1. Management algorithm for patients with spinal deformities at the primary care level

Appendix B2. Management algorithm for patients at the specialized primary care level

Appendix B3. Management algorithm for patients receiving specialized, including high-tech, medical care

Appendix C. Patient Information

1. Postoperative rehabilitation. The early rehabilitation period lasts approximately 1-3 months. During this time, the patient gradually returns to usual activities. The pace and characteristics of the rehabilitation period are individual for each person. Each patient should increase the load relying on their own feelings. During the recovery process, there may be periods of improvement and worsening, which are expected and should not cause anxiety.

2. Postoperative sutures. In most cases, the patient is discharged after the healing of sutures by primary intention. This means that a "crust" forms on the surface of the suture, under which a narrow linear scar develops. Daily suture care is performed according to the attending physician's prescriptions. After the "crust" detaches, the scar does not require treatment. Scars usually form within 1 month. It is recommended to wear cotton or knitwear clothing that does not irritate the skin in the area of the postoperative suture. It is extremely undesirable to touch the suture with hands (treatment is performed with cotton swabs); expose the suture to water or moisture. Until complete healing, visiting saunas and bathhouses is not recommended. For showering, you can independently apply a waterproof dressing to the suture; do not tear off the "crusts" until the scar forms;

3. Psycho-emotional changes. In some cases, the following phenomena may be observed after discharge:

   • Emotional instability, irritability, tearfulness; depressed mood, pessimistic view of the future; reluctance to do anything, rapid fatigue; sleep disturbance.

   • These manifestations are a natural body reaction to "surgical stress" and resolve as the general condition improves without any treatment. In rare cases (when the condition causes pronounced discomfort), it is recommended to consult a psychotherapist or the attending physician. To stabilize the emotional background, it is useful to maintain an active regime alternating with rest, and to listen to or watch relaxation music and video programs. If falling asleep is difficult, it is advisable to switch to another activity (listen to music, read, walk) until sleepiness occurs, ventilate the room, and then return to bed. The body needs some time to restore sleep. In case of prolonged sleep disturbance, consultation with a neurologist is recommended.

4. Pain. Pain in the cervical, thoracic, or lumbar spine is possible. This pain may occur or increase after physical exertion or prolonged walking. This is a common phenomenon and should not cause anxiety. Medications prescribed by the attending physician, relaxation exercises, and light massage are acceptable. If the pain becomes pronounced, prolonged, and radiates to the arms or legs, it is recommended to consult a local neurologist, having mandatory consultation with the attending physician.

5. The way home. You can travel home by car, bus, train, or airplane. As a rule, transportation is carried out in a prone or lateral position. In a car, you can ride in the back seat or the reclined front passenger seat.

   • On the train, transportation is carried out on the lower berth of a compartment (the necessary certificate can be obtained from the senior ward nurse).

   • On a bus or airplane, it is best to recline the seat back or use several vacant seats. At the airport, you must have your discharge summary and X-ray with you.

6. Orthopedic regimen. Prolonged standing should be avoided. Lifting and carrying heavy objects (no more than 3 kg), seasonal agricultural work, general physical education, jumping, and hanging on a pull-up bar are excluded. Sitting until fatigue occurs is not recommended for the first 6 months after surgery; body bending, flexing, and lifting legs should be avoided. To pick up an item lying on the floor, you need to squat slightly, keeping your torso straight. For comfortable shoe donning, you should make a stand and use outside help. Sleeping on a semi-rigid bed with a small pillow is recommended. For going to bed and using the toilet, conditions similar to hospital ones must be created (handrails, stands, supports).

7. Stair walking. Going up and down stairs requires significantly more effort than walking on a flat surface. You should go up and down stairs using the step-to method with stops for rest, holding onto the handrails.

8. Posture. Posture is the habitual body position of a standing person. Posture characteristics are determined by the position of the head, shoulder girdle, spinal curves, shape of the chest and abdomen, pelvic tilt, and position of the lower extremities. Posture maintenance is ensured by the tension of the muscles of the neck, shoulder girdle, torso, pelvic girdle, and legs. You should stand so that the load is evenly distributed on both legs. It is necessary to monitor the correct position of the torso (shoulders should be at the same level, the back should be straightened, shoulder blades pulled back). For this, training in front of a mirror with visual self-correction, periodic monitoring of the torso position against a wall, and maintaining the correct position while walking are used.

9. Footwear. Wearing shoes with high heels (more than 3 cm) is not recommended. Shoes should be comfortable and follow the normal shape of the foot arch.

10. Housework. At the initial stage, you will only be able to do light housework, such as dusting and helping with cooking. Gradually, the amount of housework can be increased. Work requiring physical effort should be avoided.

11. Studies. After surgery, individual education is recommended. It is necessary to warn the head of the educational institution about the surgery. When studying at home, proper organization of the workplace is required: the table height must be selected correctly, and the light source must be sufficiently bright. Classes can be conducted lying down, standing, or kneeling. You need to learn how to do homework quickly and efficiently. If fatigue appears, take a break. At school or university, classes should be conducted in a similar position. If fatigue appears, it is better to ask to be excused from classes and rest in a lying position.

12. Profession. It is undesirable to choose a profession associated with prolonged standing and heavy lifting.

13. Nutrition. A proper dietary regimen is important during the recovery period. It is advisable to avoid fried and fatty foods, as well as to reduce the intake of salty foods, sweets, and organ meats. Body weight should correspond to height. Mealtimes should be consistent. Excessive food intake should be avoided. Nutrition should be diverse, wholesome, and vitamin-rich.

14. Physical activity. Any physical activity, except for walking, may be permitted only after consulting the attending physician. Physical loads should be increased gradually, moving from light exercises to more complex ones. Swimming in a pool is recommended no earlier than 3 months after surgery (at least 2 times a week). Sports involving the risk of falls and trauma are not recommended.

15. Further follow-up and control examination. After discharge, you should make an appointment with an orthopedic traumatologist, general practitioner (district therapist), and neurologist. You must bring the discharge summary to the appointment. Physical therapy and massage can be performed in local outpatient settings. A set of exercises can be obtained from the hospital physical therapy doctor. No earlier than 3 months later, courses of back muscle massage are possible without manual therapy and without touching the 3 cm postoperative scar. Massage is performed according to indications for prolonged fatigue and unpleasant sensations or pain that do not disappear in a lying position. You need to practice breathing exercises.

    Physiotherapy is not recommended during the first 6 months after surgery. A follow-up examination to assess treatment efficacy is performed at 6 months, 1 year, and 2 years postoperatively. To do this, you need to book an appointment in advance at the outpatient clinic reception desk using the phone number listed in your discharge summary!

16. Disability. Regarding the paperwork for establishing (extending) disability, contact your attending physician (the metal implant is installed for life and removed only for medical reasons).

If you have any questions related to the surgery, do not hesitate to contact your attending physician directly.

Each patient returns to their usual level of activity at their own individual pace. You should not compare yourself with other patients.

Standing should be alternated with rest. You should not walk to the point of fatigue.

Pain in the area of postoperative sutures may persist for some time. Listen to the radio or music to distract yourself, or get up and walk around a bit, and then try to fall asleep again. Frequent mood swings are characteristic of the recovery period and resolve over time.

Patients should perform trunk self-correction exercises in front of a mirror and breathing exercises.

It is important to inform every physician you consult that you have undergone spinal surgery. Recommendations and treatment methods proposed on an outpatient basis must be coordinated with your attending physician.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Protocol of the International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT)

Russian title: Protocol of the International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT).

Original title (if applicable): SOSORT guidelines.

Source (official developer website): [22,23,24,25,26].

Type: protocol

Purpose: calculation of the progression coefficient in patients with a Cobb angle greater than 20 degrees to determine conservative treatment tactics in children across different age groups.

Content:

Progression coefficient = Cobb angle – (Risser stage 3) / chronological age.

Key (interpretation):

With a progression coefficient value of:

• less than 1.4, patient monitoring is recommended,

• 1.4–1.6, intensive physical therapy sessions,

• greater than 1.6, intensive inpatient rehabilitation, treatment using bracing.

Children "without signs of maturity" with a curve magnitude of:

• <15⁰ are monitored at intervals of 6–12 months;

• 15–20⁰ receive physical therapy courses with 3-month breaks;

• 20–25⁰ receive physical therapy with part-time bracing (16 hours).

Children and adolescents with Risser 0–3 at a progression coefficient of:

• up to 1.6, observation and physical therapy;

• 1.6 to 2.0, intensive inpatient rehabilitation using full-time bracing;

• greater than 2: inpatient intensive rehabilitation, full-time bracing (21–22 hours).

Adolescents with Risser 4:

• 20–35⁰: intensive inpatient rehabilitation using physical therapy;

• greater than 35⁰: bracing.

Adolescents with Risser 4–5, newly diagnosed case:

• 25–35⁰: intensive inpatient rehabilitation using physical therapy;

• greater than 35⁰: bracing for "cosmetic" purposes.

Children and adolescents with scoliosis and chronic pain: inpatient intensive rehabilitation, use of bracing with confirmed positive effect.

Appendix G2. Scoliosis Research Society 22-Item Questionnaire (SRS-22)

Russian title: Scoliosis Research Society 22-Item Questionnaire (SRS-22).

Original title: Scoliosis Research Society Outcomes Instrument-22.

Source (official developer website): https://www.srs.org/Research/Patient-Outcome-Questionnaires;

publication with validation in children [18] (for the SRS-24 questionnaire, which is an earlier version of the SRS-22 questionnaire [19]; validation studies of the Russian-language version of SRS-22 in children have not been published), publication with validation in adults [20].

Source of the Russian-language version: [20].

Type: questionnaire

Purpose: assessment of the patient's subjective state and quality of life

Content:

Patient's full name: _______________________________ Date of birth: ____________________

Date of completion: ______________ Have you had spinal surgery and when: _______________

Instructions: We have carefully evaluated the condition of your back. It is important that you answer all questions independently. Please circle the single most appropriate answer option for each question.

1. How would you describe the amount of pain you have experienced in the past 6 months?

5 – none; 4 – mild; 3 – moderate; 2 – moderate to severe; 1 – severe.

2. How would you describe the amount of pain you have experienced in the past month?

5 – none; 4 – mild; 3 – moderate; 2 – moderate to severe; 1 – severe.

3. Have you been a very nervous person in the past 6 months?

5 – none of the time; 4 – a little bit of the time; 3 – some of the time; 2 – a good bit of the time; 1 – all of the time.

4. How would you feel if you had to spend the rest of your life with the appearance of your back as it is now?

5 – very satisfied; 4 – somewhat satisfied; 3 – neither satisfied nor dissatisfied; 2 – somewhat dissatisfied; 1 – very dissatisfied.

5. What is your level of daily activity?

1 – bedridden; 2 – mostly inactive; 3 – light work and light sports;

4 – moderate work and moderate sports; 5 – full activity without restrictions.

6. How do you look in clothes?

5 – very well; 4 – well; 3 – satisfactory; 2 – poorly; 1 – very poorly.

7. In the past 6 months, have you felt downhearted and blue, with nothing able to cheer you up?

1 – very often; 2 – often; 3 – sometimes; 4 – rarely; 5 – never.

8. Do you experience back pain at rest?

1 – very often; 2 – often; 3 – sometimes; 4 – rarely; 5 – never.

9. What is your level of work/study performance?

5 – 100% of normal; 4 – 75% of normal; 3 – 50% of normal; 2 – 25% of normal; 1 – 0% of normal.

10. What does your trunk look like, excluding the head and limbs?

5 – very well; 4 – well; 3 – satisfactory; 2 – poorly; 1 – very poorly.

11. How often and what medications do you take to reduce back pain?

5 – none; 4 – pain relievers weekly or less often; 3 – pain relievers daily;

2 – strong pain relievers weekly or less often (tramadol, tramal);

1 – strong pain relievers daily (tramadol, tramal).

12. Does your spine limit you in housework?

5 – never; 4 – rarely; 3 – sometimes; 2 – often; 1 – very often.

13. Have you felt calm and peaceful in the past 6 months?

5 – all of the time; 4 – a good bit of the time; 3 – some of the time; 2 – a little bit of the time; 1 – none of the time.

14. Do you think your condition affects your relationship with loved ones?

5 – no; 4 – slightly; 3 – insignificantly; 2 – moderately; 1 – severely.

15. Do you and/or your family experience financial difficulties due to the condition of your spine?

1 – severe; 2 – moderate; 3 – minor; 4 – slight; 5 – no.

16. Over the past 6 months, have you felt depressed or downcast?

5 – never; 4 – rarely; 3 – sometimes; 2 – often; 1 – very often.

17. Have you taken sick leave due to back pain (if working)?

Was your working capacity in daily activities limited due to back problems?

5 – 0 days; 4 – 1 day; 3 – 5–10 days; 2 – 10–14 days; 1 – more than 14 days.

18. Does your back condition restrict you from meeting with family/friends?

5 – never; 4 – rarely; 3 – sometimes; 2 – often; 1 – very often.

19. Do you consider yourself attractive at present?

5 – yes, very; 4 – yes, somewhat; 3 – neither yes nor no; 2 – no, not really; 1 – absolutely not.

20. Have you felt happy over the past 6 months?

1 – never; 2 – a little bit of the time; 3 – some of the time; 4 – a good bit of the time; 5 – all of the time.

21. Are you satisfied with the outcome of your spinal treatment?

5 – very satisfied; 4 – satisfied; 3 – neither yes nor no; 2 – dissatisfied; 1 – very dissatisfied.

22. Would you undergo the same treatment again given the same back condition?

5 – definitely yes; 4 – maybe yes; 3 – not sure; 2 – maybe no; 1 – definitely no.

Scoring key for the SRS-22 questionnaire

• Unanswered questions should be excluded from the sum of answered questions.

• Remove questions with more than one answer.

• The domain (subject area) cannot be assessed if fewer than three questions are answered.

Appendix G3. Caprini Risk Assessment Model for Venous Thromboembolism

Russian title: Caprini risk assessment model for venous thromboembolism.

Original title: Caprini Score for Venous Thromboembolism

Source: Lobastov K.V., Barinov V.E., Schastlivtsev I.V., Laberko L.A. Caprini score as a tool for individual risk stratification of postoperative venous thromboembolism in high-risk group. Pirogov Russian Journal of Surgery. 2014; (12):16-23.

Type: scale

Purpose: assessment of venous thromboembolism risk

Content:

1 point

Age 41–60 years

Lower extremity edema

Varicose veins

Body mass index over 25 kg/m2

Minor surgery

Sepsis (< 1 month)

Severe pulmonary disease (including pneumonia < 1 month)

Oral contraceptive use, hormone replacement therapy

Pregnancy and postpartum period (< 1 month)

History of unexplained stillbirths, spontaneous abortions (≥3),

Premature birth with preeclampsia or intrauterine growth restriction

Acute myocardial infarction

Chronic heart failure (< 1 month)

Bed rest in a non-surgical patient

History of inflammatory bowel disease

History of major surgery (< 1 month)

Chronic obstructive pulmonary disease

2 points

Age 61–74 years

Arthroscopic surgery

Malignant neoplasm105

Laparoscopic surgery (duration > 45 min)

Bed rest > 72 h

Limb immobilization (< 1 month)

Central venous catheterization

Major surgery (duration > 45 min)

3 points

Age > 75 years

Personal history of VTE

Family history of VTE

Factor V Leiden mutation

Prothrombin G20210A mutation

Hyperhomocysteinemia

Heparin-induced thrombocytopenia

Elevated anticardiolipin antibodies

Lupus anticoagulant

5 points

Stroke (< 1 month)

Multiple trauma (< 1 month)

Major joint arthroplasty

Femur and lower leg fractures (< 1 month)

Spinal cord injury/paralysis (< 1 month)

Interpretation: Depending on the total score obtained from the patient's history and examination, the patient is assigned to one of the risk groups:

• low risk: 0 - 1 point;

• moderate risk: 2 points;

• high risk: 3 - 4 points;

• very high risk: 5 points or more.