Department of Pediatric Orthopaedics, University of Medical Sciences, Poznan, Poland
ISICO (Italian Scientific Spine Institute), Milan, Italy
Department of Orthopaedics and Traumatology, "Tzanio" General Hospital of Piraeus, Piraeus, Greece
Instituto Èlena Salvá, Barcelona, Spain
Department of Orthopaedic Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
Department of Rehabilitation, Medical University of Silesia, Katowice, Poland
Abstract
Background
Comprehensive evaluation of the morphology of the spine and of the whole body is essential in order to correctly manage patients suffering from progressive idiopathic scoliosis. Although methodology of clinical and radiological examination is well described in manuals of orthopaedics, there is deficit of data which clinical and radiological parameters are considered in everyday practise. Recently, an increasing tendency to extend scoliosis examination beyond the measure of the Cobb angle can be observed, reflecting a more patient-oriented approach. Such evaluation often involves surface parameters, aesthetics, function and quality of life.
Aim of the study
To investigate current recommendations of experts on methodology of evaluation of the patient with spinal deformity, essentially idiopathic scoliosis.
Methods
Structured Delphi procedure for collecting and processing knowledge from a group of experts with a series of questionnaires and controlled opinion feedback was performed. Experience and opinions of the professionals - physicians and physiotherapists managing scoliosis patients - were studied. According to Delphi method a Meeting Questionnaire (MQ) has been developed, resulting from a preliminary Pre-Meeting Questionnaire (PMQ) which had been previously discussed and approved on line. The MQ was circulated among the SOSORT experts during Consensus Session on "Measurements" which took place at the Annual Meeting of the Society, totally 23 panellists being engaged. Clinical, radiological and surface topography parameters were checked for agreement.
Results
90% agreement or more was reached in 35 items and superior than 75% agreement was reached in further 25 items. An evaluation form was proposed to be used by clinicians and researchers.
Conclusion
The consensus was reached on evaluation of the morphology of the patient with idiopathic scoliosis, comprising clinical, radiological and, to less extend, surface topography assessment. Considering the variety of parameters indicated by the panellists, the Cobb angle, yet the gold standard, can be seen neither as the unique nor the only decisive parameter in the management of patients with idiopathic scoliosis.
Background
Before a therapeutic intervention of any clinical condition, careful evaluation of the disorder should be performed. In the case of idiopathic scoliosis, the deformation of the body is usually (and superficially) identified with the disease itself, because the underlying pathomechanisms remain obscure
A typical clinical examination consists of inspection, palpation, percussion and auscultation, the two latter not involved in scoliosis patients. Moreover, the appraisal of the patient's morphology can be made both for static and dynamic conditions (during gait). Traditionally, the clinical exam of scoliosis is static and includes the assessment of the asymmetries of the shoulders, scapulae, flanks, hips, the plumb line exam, trunk imbalance, disturbances in sagittal curvatures and rotational phenomena (rib prominence, lumbar prominence),
Although every manual of orthopaedics tends to present a comprehensive view of the clinical and radiological examination of scoliosis, there is a deficiency of data about the methods which are currently used in everyday practise by the professionals and about the parameters considered important. An increasing tendency to extend the examination beyond the assessment of the Cobb angle is observed, reflecting a more patient-oriented approach to spinal deformities
Subjective observation made by SOSORT members on insufficient skills and knowledge of medical students and residents concerning scoliosis examination was another impulse to undertake this study.
The purpose of this study was to conduct a systematic analysis
Methods
The typical steps
Pre-Meeting Questionnaire. the first version of the consensus questionnaire.
Click here for file
Meeting Questionnaire. the final version of the consensus questionnaire.
Click here for file
The development and refinement of the questionnaire aimed to select the domains of primary importance for patient evaluation. The final questionnaire (MQ) consisted of five section: (1) general, (2) clinical examination, (3) radiological examination, (4) surface topography examination, (5) respondent's demographic data. The clinical examination comprised seven domains composed of 36 items (numbers of items in brackets): anthropometry (10 items), maturation (3), lower limbs discrepancy (4), trunk balance (3), sagittal plane (1), rib prominence (9), aesthetics (6). The radiological examination comprised twelve domains (79 items): patient positioning (12 items), cassette size (3), views (11), radiation protection (5), frontal plane parameters (6), rotation assessment (7), sagittal plane parameters (7), bone age (3), logistics (5), schedule (16), in-brace radiograph (2), follow-up (3). Surface topography examination comprised nine domains (72 items): hardware (5 items), patient positioning (5), views (3), logistics (13), anatomic landmarks (10), general and frontal plane parameters (17), sagittal plane parameters (8), transverse plane parameters (8) and pelvis (3). The final questionnaire is available as Additional File
Questions were constructed to collect the participants' opinion on the usefulness of each particular parameter. The possible answers were as follows: 3 - always recommended; 2 - I use and recommend to use when it's needed; 1 - I don't use but it could be useful; 0 - never and I think it's not useful. In the Results section of this paper the score is presented as follows: Highest priority (3), Recommended (2), Acceptable (1) or Not recommended (0). Comments and complementary information could be freely provided at the end of each section. Each question was analyzed for agreement. The agreement for recommendation to use a particular parameter was calculated as the sum of the percentage of answers "always recommended (3)" and "I use and recommend to use when needed (2)" to the total number of participants who answered the question. SOSORT Scoliosis Evaluation Form was constructed with all items that received 75% of agreement or more and did not received more than 10% of "not recommended" answers while items that received 90% agreement or more were bolded as recommended for systematic use. SOSORT Scoliosis Evaluation Form is presented in Additional File
Proposal for SOSORT Scoliosis Evaluation Form. evaluation form for scoliosis recommended by the authors.
Click here for file
Results
Twenty-three filled-up MQ were collected during the Consensus Session. The respondents were 11 physicians, 10 physiotherapists and 1 orthotist; one person did not reveal the profession. Among the physicians there were six physiatrists specialized in conservative scoliosis treatment and five orthopaedic surgeons with experience in conservative management. Most respondents work in a team specialized in scoliosis management, composed most often of physician (physiatrist or orthopaedic surgeon), physiotherapist and orthotist. Half of the respondents see more than 10 scoliosis patients per week (table
Characteristics of the respondents to the MQ (N = 23)
number
%
Profession
Physician -- specialist in rehabilitation
6
26
Physician -- orthopaedic surgeon
5
22
Physiotherapist
10
43
Orthotist
1
4
Unknown
1
4
Institution
Public health system
6
26
Private sector
12
52
Both public and private
4
17
Not answered
1
4
Scoliosis team (MD + PT + CPO)
Team work
15
65
Alone
5
22
Not answered
3
13
Number of patients with scoliosis evaluated per week
1 or less
1
4
2 -- 5
3
13
6 -- 10
5
22
11 or more
12
52
Not answered
2
8
MQ -- Meeting Questionnaire, MD -- physician, PT -- physiotherapist, CPO -- orthotists
The priority of methods of the assessment of the trunk morphology is reported in Table
Priority of methods of assessment of the trunk morphology, N = 23
Method of assessment
High Prior
Rec
Acc
Not Rec
Not Ans
Clinical
19
2
1
0
1
Radiological
6
15
1
0
1
Surface topography
3
9
7
1
3
Photography
4
13
2
1
3
CT, MRI, US, Therm.
0
9
5
3
6
High Prior -highest priority, Rec - recommended, Acc -- acceptable, Not Rec - not recommended, Not Ans -- not answered, CT -- computer tomography, MRI -- magnetic resonance imaging, US -- ultrasounds, Therm. -- thermography;
Comments: (1) video filming is useful.
Clinical examination
The data concerning clinical examination are presented in tables
General anthropometry (% of indications)
Parameter
N
High Prior
Rec
Acc
Not Rec
%
of Agreement
Weight
22
59.1
18.2
22.7
0.0
77.3
Height
23
82.6
13.0
4.3
0.0
95.6
Sitting height
23
26.1
34.8
30.4
8.7
60.9
Peak height velocity
23
34.8
26.1
39.1
0.0
60.9
Arms span
23
21.7
21.7
34.8
21.7
43.4
Growth charts
23
26.1
30.4
34.8
8.7
56.5
Longitudinal graph
19
15.8
21.1
47.4
15.8
36.9
N -number of answers, High Prior -highest priority, Rec-recommended, Acc -- acceptable, Not Rec -not recommended
Maturation data in girls (% of indications)
Parameter
N
High Prior
Rec
Acc
Not Rec
%
of Agreement
Breast development
(Tanner scale
20
30.0
30.0
35.0
5.0
60.0
Pubic hair development (Tanner scale)
21
9.5
28.6
47.6
14.3
38.1
Menarche
21
95.2
0.0
4.8
0.0
95.2
N -number of answers, High Prior -highest priority, Rec - recommended, Acc -- acceptable, Not Rec -not recommended;
Comments: (1) stability of menses is a sign to be observed.
Measurement of lower limbs discrepancy (% of indications)
Parameter
N
High Prior
Rec
Acc
Not Rec
%
of Agreement
Lower limbs length assessment is necessary
19
78.8
15.8
5.3
0.0
94.7
ASIS level in standing position
23
65.2
26.1
8.7
0.0
91.3
PSIS level in standing position
22
63.6
9.1
22.7
4.5
72.7
ASIS -- malleolous in supine position
21
42.9
33.3
14.3
9.5
76.2
N -number of answers, High Prior -highest priority, Rec - recommended, Acc -- acceptable,
Not Rec -not recommended, ASIS -- anterior superior iliac spine. PSIS -- posterior superior iliac spine;
Comments: (1) assess the axis of lower limbs. (2) make the measures from the navel. (3) stretch hamstrings on the side of thoracic hump. (4) use sacral bone level in full bend. (5) measure distance trochanter-foot in side lying. (6) use shoe lift to level pelvis. (7) use iliac crests.
Plumb line examination (% of indications)
Parameter
N
High Prior
Rec
Acc
Not Rec
%
of Agreement
C7 plumb line
23
60.9
13.0
26.1
0.0
73.9
Axillary plumb line
21
23.8
4.8
66.7
4.8
28.6
Sagittal plumb line
22
31.8
9.1
50.0
9.1
40.9
N -number of answers, High Prior -highest priority, Rec-recommended, Acc -- acceptable, Not Rec -not recommended;
Comment: (1) use inclinometer instead of plumb line for sagittal plane.
Assessment of the transverse plane deformity (% of indications)
Parameter
N
High Prior
Rec
Acc
Not Rec
%
of Agreement
Standing forward bending position
23
82.6
8.7
4.3
4.3
91.3
Sitting forward bending position
22
59.1
9.1
31.8
0.0
68.2
Prone position
20
15.0
10.0
55.0
20.0
25.0
Scoliometer ATR measure main curve
22
95.0
0.0
4.5
0.0
95.0
Scoliometer ATR measure upper compensatory curve
21
85.7
0.0
14.3
0.0
85.7
Scoliometer ATR measure lower compensatory curve
22
90.9
0.0
9.1
0.0
90.9
Rib prominence measured in cm with a ruler
22
40.9
13.6
40.9
4.5
54.5
N -number of answers, High Prior -highest priority, Rec-recommended, Acc-- acceptable,
Not Rec -not recommended, ATR -- angle of trunk rotation (synonym ATI -- angle of trunk inclination);
Comment: (1) measure sacral bone rotation.
47.8% of respondents systematically note information about aesthetics, further 21.7% recommend it, totally 69.5% of agreement for recommendation. 43.5% only had a systematic way of noting aesthetics. Aesthetic Index and TRACE index
Radiological examination
The data are presented in tables
Positioning of the patient (% of indications)
Parameter
N
High Prior
Rec
Acc
Not Rec
%
of Agreement
Standing
23
95.7
4.3
0.0
0.0
100
Sitting
12
0.0
8.3
58.3
33.3
8.3
Supine
12
0.0
25.0
41.7
33.3
25.0
Prone
12
0.0
0.0
58.3
41.7
0.0
Spontaneous
19
78.9
10.5
10.5
0.0
89.4
Corrected
13
38.5
15.4
30.8
15.4
53.9
N -number of answers, High Prior -highest priority, Rec-recommended, Acc -- acceptable, Not Rec -not recommended;
Comment: (1) spontaneous should be neutral. every-day posture. not totally relaxed.
Position of upper limbs for lateral radiography (% of indications)
Parameter
N
High Prior
Rec
Acc
Not Rec
%
of Agreement
Along the trunk
18
44.4
0.0
11.1
44.4
44.4
Crossed on the chest
14
14.3
21.4
42.9
21.4
35.7
Reposed on a support
14
42.9
0.0
28.6
28.6
42.9
N -number of answers, High Prior -highest priority, Rec-recommended, Acc -- acceptable, Not Rec -not recommended;
Comments: (1) upper limbs bent. fingers on clavicles. (2) upper limbs bent 20 cm forward. (3) upper limbs in 45° anterior flexion.
Cassette size and radiological views (% of indications)
Parameter
N
High Prior
Rec
Acc
Not Rec
%
of Agreement
Long cassette
20
60.0
40.0
0.0
0.0
100.0
Standard cassette
15
20.0
46.7
13.3
20.0
66.7
Small cassette
9
0.0
0.0
22.2
77.8
0.0
Antero-posterior view
19
47.4
21.1
5.3
26.3
68.5
Postero-anterior view
16
62.5
31.3
6.3
0.0
93.8
Lateral view systematically
16
6.2
6.2
50.0
37.5
12.5
Lateral at start of treatment
20
75.0
20.0
5.0
0.0
95.0
Lateral at final visit
17
29.0
17.6
41.2
11.8
46.6
Oblique view of Stagnara
16
0.0
12.5
50.0
37.0
12.5
Side bending
17
0.0
41.2
23.5
35.3
41.2
Supine traction
16
0.0
12.5
37.5
50.0
12.5
Axial for rib prominence
15
0.0
13.3
20.0
66.7
13.3
Wrist bone age
16
6.3
50.0
18.8
25.0
56.3
N -number of answers, High Prior -highest priority, Rec-recommended, Acc -- acceptable,
Not Rec -not recommended.
Radiation protection (% of indications)
Parameter
N
High Prior
Rec
Acc
Not Rec
%
of Agreement
Gonads
19
94.7
5.3
0.0
0.0
100.0
Breast
15
40.0
33.3
6.7
20.0
73.3
Thyroid
15
6.7
26.7
46.7
20.0
33.4
N -number of answers, High Prior -highest priority, Rec-recommended, Acc -- acceptable,
Not Rec -not recommended.
Radiological parameters recommended for systematic use (% of indications)
Parameter
N
High Prior
Rec
Acc
Not Rec
%
of Agreement
Cobb angle
22
100.0
0.0
0.0
0.0
100.0
Fergusson angle
15
0.0
6.7
46.7
46.7
6.7
C7 shift
20
35.0
25.0
35.0
5.0
60.0
Apical vertebra transposition
19
21.1
21.1
47.4
10.5
42.2
Nash and Moe rotation
15
13.3
6.7
33.3
46.7
20.0
Drerup rotation
12
0.0
0.0
66.7
33.3
0.0
Perdriolle rotation
19
36.8
42.1
15.8
5.3
78.9
Raimondi rotation
15
40.0
20.0
26.7
13.3
60.0
Mehta rib vertebra angle
16
12.5
31.3
50.0
6.3
43.8
Segmental rib vertebra angle
13
7.7
7.7
61.5
23.1
15.4
Th4-Th12 sagittal Cobb
22
50.0
40.9
9.1
0.0
90.9
L1-L5 sagittal Cobb
22
45.5
45.5
9.1
0.0
91.0
Lumbo-sacral L5-S1 angle
19
10.5
47.4
42.1
0.0
57.9
Double rib contour sign
17
5.9
29.4
58.8
5.9
35.3
Sacral slope
18
16.7
27.8
55.6
0.0
44.5
Pelvic incidence
18
22.2
27.8
50.0
0.0
50.0
Risser sign
21
90.5
9.5
0.0
0.0
100.0
Triradiate cartilage closure
16
18.8
12.5
56.3
12.5
31.3
N -number of answers, High Prior -highest priority, Rec - recommended, Acc -- acceptable, Not Rec -not recommended;
Comments - additional parameters to be used systematically: (1) imbalance of transitional point. (2) transitional point to CSL. (3) sagittal segmental evaluation. (4) restricted kyphosis angle
Where the X-ray should be made? (% of indications)
Parameter
N
High Prior
Rec
Acc
Not Rec
%
of Agreement
At any X office of patient's choice
15
26.7
20.0
33.3
20.0
46.7
At indicated X-ray office only
19
57.9
26.3
10.5
5.3
84.2
N -number of answers, High Prior -highest priority, Rec - recommended, Acc -- acceptable,
Not Rec -not recommended
Schedule for X-ray examination (% of indications)
Parameter
N
High Prior
Rec
Acc
Not Rec
%
of Agreement
First visit
Always
14
21.4
21.4
21.4
35.7
42.8
Only if clinically suspected
18
83.3
11.1
5.6
0.0
94.4
Intervals while management with observation
3 months
14
7.1
21.4
35.7
36.7
28.5
6 months
17
29.4
47.1
5.9
17.6
76.5
12 months
16
62.5
25.0
6.3
6.3
87.5
Other
7
28.6
14.3
14.3
42.9
42.9
Intervals while management with physiotherapy
3 months
14
7.1
21.4
21.4
50.0
28.5
6 months
17
23.5
29.4
17.6
29.4
52.9
12 months
16
50.0
31.3
6.3
12.5
81.3
Other
7
14.3
14.3
28.6
42.9
28.6
Intervals while management with brace
3 months
15
20.0
33.3
6.7
40.0
53.3
6 months
16
31.3
43.8
0.0
25.0
75.1
12 months
13
61.5
23.1
7.7
7.7
84.6
Other
4
25.0
25.0
25.0
25.0
50.0
Comments: (1) in puberty 6 months. (2) depends on suspected growth rate. (3) depends on child age. (4) 6 months at 11-13 years. 12 months at 13-15 years. (5) when clinical progression. (6) every 4 months.
N -number of answers, High Prior -highest priority, Rec-recommended, Acc -- acceptable,
Not Rec -not recommended.
Type of radiograph performed during brace treatment (% of indications)
Parameter
N
High Prior
Rec
Acc
Not Rec
%
of Agreement
In brace
19
68.4
15.8
15.8
0.0
84.2
Out of brace
17
58.8
29.4
11.8
0.0
88.2
N -number of answers, High Prior -highest priority, Rec - recommended, Acc -- acceptable,
Not Rec -not recommended.
Follow-up considered the outcome of brace treatment (% of indications)
Parameter
N
High Prior
Rec
Acc
Not Rec
%
of Agreement
1 year after completion of treatment
15
60.0
33.3
6.7
0.0
93.3
2 years after completion of treatment
14
85.7
0.0
14.3
0.0
85.7
N -number of answers, High Prior -highest priority, Rec - recommended, Acc -- acceptable,
Not Rec -not recommended;
Comment: (1) 6 months.
The respondents were asked who should perform the radiological measurements, having: (1) the treating person, (2) the radiologist or (3) other person as answer option. All but two physicians (N = 9) highly recommended the measurements done by the treating physician (expert) and they excluded the radiologist. The two remaining accorded the measures to be done by the radiologist. The non-physician responders divided in opinions equally between the radiologist and the treating physician but never indicated themselves.
Surface topography examination
The number of participants to this section was eleven, six were physicians and five were physiotherapists. The remaining respondents declared to be not enough experienced with surface topography to answer the questionnaire. The equipment used was basically raster stereography method (Formetric, Orten, CQ, other), Auscan, Goals and classical Moire. No respondent revealed being used the Quantec system or ISIS technique. The data is presented in tables
Logistics of surface topography examination (% of indications)
Parameter
N
High Prior
Rec
Acc
Not Rec
%
of Agreement
Availability of the hardware
At the practise
19
68.4
15.8
15.8
0.0
84.2
Out of practise but easily accessible
17
58.8
29.4
11.8
0.0
88.2
Who performs surface topography examination
Physician
7
14.3
0.0
14.3
71.4
14.3
Physiotherapist
8
62.5
12.5
12.5
12.5
75.0
Technician
7
14.3
0.0
14.3
71.4
14.3
Nurse
6
16.7
0.0
16.7
66.7
16.7
Who treats surface images and performs measurements
Physician
8
25.0
12.5
12.5
50.0
37.5
Physiotherapist
8
62.5
12.5
12.5
12.5
75.0
Technician
6
0.0
0.0
16.7
83.3
0.0
Nurse
6
0.0
0.0
16.7
83.3
0.0
Final interpretation of surface topography exam is basically on
Images created
8
75.0
12.5
0.0
12.5
87.5
Values of parameters
10
90.0
10.0
0.0
0.0
100.0
N -number of answers, High Prior -highest priority, Rec - recommended, Acc -- acceptable,
Not Rec -not recommended.
Positioning of the patient for surface topography (% of indications)
Parameter
N
High Prior
Rec
Acc
Not Rec
%
of Agreement
Position
Standing upright
11
100.0
0.0
0.0
0.0
100.0
Standing forward bent
7
28.6
14.3
28.6
28.6
42.9
Sitting upright
7
14.3
14.3
42.9
28.6
28.6
Sitting forward bent
8
12.5
25.0
37.5
25.0
37.5
View
Back
10
100.0
0.0
0.0
0.0
100.0
Front
7
14.3
14.3
28.6
42.9
28.3
N -number of answers, High Prior -highest priority, Rec-recommended, Acc -- acceptable,
Not Rec -not recommended;
Comments: (1) movements performed: autocorrection. side bending. (2) left and right bending.
(3) three-dimensional view.
Anatomic surface landmarks to be taken into consideration systematically (% of indications).
Parameter
N
High Prior
Rec
Acc
Not Rec
%
of Agreement
Spinous processes
10
90.0
10.0
0.0
0.0
100.0
Posterior iliac spines
10
90.0
10.0
0.0
0.0
100.0
Rib prominence
8
87.5
0.0
0.0
12.5
87.5
Occiput
7
42.9
0.0
14.3
42.9
42.9
Neck
7
71.4
14.3
0.0
14.3
85.7
Shoulders
10
80.0
20.0
0.0
0.0
100.0
Scapulae
9
77.8
11.1
0.0
11.1
88.9
Waist
8
62.5
12.5
12.5
12.5
75.0
Coccyx
8
62.5
12.5
12.5
12.5
75.0
N -number of answers, High Prior -highest priority, Rec-recommended, Acc -- acceptable,
Not Rec -not recommended
Comment: (1) heels systematically.
Surface parameters recommended for systematic use (% of indications)
Parameter
N
High Prior
Rec
Acc
Not Rec
%
of Agreement
General
Spine length (curve line)
9
88.9
11.1
0.0
0.0
100.0
Spine height: C7-S1 distance
9
55.6
11.1
11.1
22.2
66.7
Measures of main curve only
8
37.5
0.0
12.5
50.0
37.5
Measures of main and secondary curves
8
100.0
0.0
0.0
0.0
100.0
Body axis definition
Analogous to radiological VCSL
7
100.0
0.0
0.0
0.0
100.0
C7-S1 line
7
85.7
0.0
14.3
0.0
85.7
Frontal plane analysis
C7 shift
8
62.5
0.0
12.5
25.0
62.5
Curve angle
8
75.0
0.0
0.0
25.0
75.0
Apex distance from body axis
7
71.4
0.0
0.0
28.6
71.4
Frontal plane body asymmetry
Shoulders
9
66.7
0.0
0.0
33.3
66.7
Scapulae
9
66.7
0.0
0.0
33.3
66.7
Waist
8
50.0
0.0
12.5
37.5
50.0
Special indices
POTSI index
7
28.6
0.0
0.0
71.4
28.6
Weiss index
7
14.3
14.3
14.3
57.1
28.6
Sagittal plane analysis
Relation of C7 to S1
8
87.5
12.5
0.0
0.0
100.0
Cervical lordosis
9
77.8
22.2
0.0
0.0
100.0
Thoracic kyphosis
9
100.0
0.0
0.0
0.0
100.0
Lumbar lordosis
9
100.0
0.0
0.0
0.0
100.0
Segmental analysis
6
50.0
0.0
50.0
0.0
50.0
Limits of kyphosis and lordosis indicated
Automatically by software
7
85.7
14.3
0.0
0.0
100.0
Manually by examinator
6
33.3
33.3
0.0
33.3
66.6
Transverse plane analysis
Trunk rotation main curve
8
100.0
0.0
0.0
0.0
100.0
Trunk rotation compensatory curves
8
100.0
0.0
0.0
0.0
100.0
Hump Sum
7
42.9
42.9
14.3
0.0
85.8
DAPI index
5
0.0
0.0
80.0
20.0
0.0
Levels to measure surface rotation indicated
Automatically by software
6
83.3
0.0
16.7
0.0
83.3
Manually by examinator
6
50.0
16.7
0.0
33.3
66.7
Pelvis
PSIS height
7
100.0
0.0
0.0
0.0
100.0
PSIS depth (distance from the camera)
7
71.4
0.0
0.0
28.6
71.4
Manual correction of patient position to achieve pelvis level at PSIS
7
42.9
14.3
14.3
28.6
57.2
N -number of answers, High Prior -highest priority, Rec-recommended, Acc -- acceptable,
Not Rec -not recommended, VCSL -- vertical central sacral line. PSIS -- posterior superior iliac spines.
Discussion
The general opinion (table
Maturation (table
It is recognized that progression of structural scoliotic curvature takes place essentially during the periods of rapid spinal growth
To calculate the peak height velocity it is necessary to dispose of the patient's height noted at regular intervals of 6 months, at least 3 times. The value of 9 cm/year (occurring in average 12 years chronological age in girls) was reported to be a good predictor for curve progression, better than Risser sign or menarche
Lower limbs discrepancy (table
Assessment of the length of the lower limbs was recommended by the participants, essentially in standing position with anterior superior iliac spines (ASIS) as reference points. It was reported that the position of ASIS is sensitive to intra-pelvic distortion due to nutation/counter-nutation movements of the hemipelvis
Plumb line exam (table
The examination with the plumb line has entered the classics of scoliosis measurements
Transverse plane of deformity (table
The recommendation was made to measure the angle of trunk rotation (ATR, synonym ATI - angle of trunk inclination,
Examination of trunk asymmetries with a scoliometer performed in sitting position seems to be useful when detecting small deformities, for example for the purpose of scoliosis screening. Grivas reported higher percentage of symmetric children when examined in sitting versus standing position
Assessment of the height of rib prominence in Adams test can be practiced without scoliometer, with the use of a simple ruler. The measurement error was estimated +/- 2 mm
Sagittal plane
The Meeting Questionnaire did not approach deeply the issue of clinical assessment of sagittal balance (one question only). The sagittal plane assessment was the main topic of the 2009 SOSORT Annual Meeting in Lyon
Radiological examination
There is a clear recommendation for standing position to make spinal radiographs. The posture should be neutral, spontaneous which means not actively corrected on one hand and not totally relaxed on the other hand (table
Parameters for systematic use
Among the parameters for systematic use, the Cobb angle and the Risser sign got 100% of recommendations, followed by sagittal thoracic and lumbar Cobb angles (over 90%). Perdriolle method revealed the most recommended for measuring the vertebral axial rotation (78.9%). It is understandable that other radiological measures got less indications, as this question was constructed to reveal the parameters considered in a systematic way in clinical practise. The Questionnaire did not precise whether the original
Surface topography
Petit et al. stated: "Because surgeons are so familiar with Cobb angle measurements on radiograph, the introduction of new surface shape measures whose meaning may not be readily apparent to clinicians has been difficult"
In last three decades we observed a dynamic development of the equipment and software for surface measurements. The International Research Society on Spinal Deformities (IRSSD) started in the 80 s of last century as working group for Moire Topography, Surface Topography and 3 Dimensional Spinal Deformity. Current technical capabilities offer reliable and precise surface measurements. Unfortunately, clinicians apparently did not take advantage of the technique. The reason does not seem to be the lack of consensus. Also, in this study, a good consensus for surface measurements was achieved, as good as for clinical and radiological exams.
Searching for relationship between radiological Cobb angle and surface parameters with making presumption that the higher correlation with Cobb angle, the better the surface technique may be one of the reason that introduced the surface topography in a blind alley. In fact, Cobb angle is nothing more than a shadow of two limit vertebrae. It is not clear what would be the rationale to expect that so constructed angle should highly correlate with any of the surface describing parameters. James presented photos of four girls with 70° curvature each to demonstrate the variations in external shape of the back
Gold standard parameters for surface topography wait to be named. It is also a challenge for producers of surface topography equipment to unify the parameters in order to let the users speak the same language. In our opinion, surface topography seems still have a chance to work in service of patients if additional effort in order to standardize the examination is done.
Conclusion
This paper is the 6th SOSORT Consensus Paper. Previously, the role of physical exercises
According to the results obtained the authors prepared "Proposal for SOSORT Scoliosis Evaluation Form" (Apendix 3). It is offered as proposal to professionals taking care of the patients with idiopathic scoliosis. It is supposed to serve as a guideline for clinicians and a tool for patients to check the course of the disease. It was based on the Consensus, completed according to the authors' experience and may be further developed with new parameters to perform high quality clinical research studies.
This study addresses the issue of scoliosis evaluation and emphasizes the need for correct methodological assessment of the shape of the spine and the whole body. Hence, it should be stressed that methodology limited to Cobb angle analysis seems to be particularly misleading. Moreover, the authors would like to underline that describing such a complex condition with exclusively morphology-related parameters is superficial. Morphology alone cannot substitute the assessment of the impaired function as well as of the quality of life.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
T.K. - study design, collecting data, data analysis and interpretation, manuscript drafting S.N., T.B.G., M.R., T.M., J.D., F.Z. - data analysis and interpretation, manuscript revision All authors read and approved the final manuscript.
Acknowledgements
We thank Dr. Nachiappan Chockalingam for language assistance.