Scoliosis - Latest Articles

Introduction to the "Scoliosis" Journal Brace Technology Thematic Series: increasing existing knowledge and promoting future developments

Stefano Negrini — 2010-01-28T00:00:00Z

Bracing is the main non-surgical intervention in the treatment of idiopathic scoliosis during growth, in hyperkyphosis (and Scheuermann disease) and occasionally for spondylolisthesis; it can be used in adult scoliosis, in the elderly when pathological curves lead to a forward leaning posture or in adults after traumatic injuries. Bracing can be defined as the application of external corrective forces to the trunk; rigid supports or elastic bands can be used and braces can be custom-made or prefabricated.The state of research in the field of conservative treatment is insufficient and while it can be stated that there is some evidence to support bracing, we must also acknowledge that today we do not have a common and generally accepted knowledge base, and that instead, individual expertise still prevails, giving rise to different schools of thought on brace construction and principles of correction. The only way to improve the knowledge and understanding of brace type and brace function is to establish a single and comprehensive source of information about bracing. This is what the Scoliosis Journal is going to do through the "Brace Technology" Thematic Series, where technical papers coming from the different schools will be published.

A specific scoliosis classification correlating with brace treatment: description and reliability

Manuel Rigo — 2010-01-27T00:00:00Z

Background: Spinal classification systems for scoliosis which were developed to correlate with surgical treatment have historically been used in brace treatment as well. There has previously not been classification systems developed specifically to correlate with brace design and treatment. The purpose of this study is to show the intra- and inter- observer reliability of a new scoliosis classification system correlating with brace treatment. Methods: A novel classification system ("Rigo Classification") was developed in order to define specific principles of correction required for efficacious brace design and fabrication. The classification includes radiological as well as clinical criteria. The radiological criteria are utilized to differentiate five basic types of curvatures including: (I) imbalanced thoracic (or three curves pattern), (II) true double (or four curve pattern), (III) balanced thoracic and false double (non 3 non 4), (IV) single lumbar and (V) single thoracolumbar. In addition to the radiological criteria, the Rigo Classification incorporates the curve pattern according to SRS terminology, the balance/imbalance at the transitional point, and L4-5 counter-tilting. To test the intra-and inter-observer reliability of the Rigo Classification, three observers (1 MD, 1 PT and 1 CPO) measured (and one of them, the MD, re-measured) 51 AP radiographs including all curvature types. Results: The intra-observer Kappa value was 0.87 (acceptance >0.70). The inter-observer Kappa values fluctuated from 0.61 to 0.81 with an average of 0.71 (acceptance > 0.70). Conclusions: A specific scoliosis classification which correlates with brace treatment has been proposed with an acceptable intra-and inter-observer reliability.

The International Research Society of Spinal Deformities (IRSSD) and its contribution to science

Keith Bagnall — 2009-12-22T00:00:00Z

From the time of its initial, informal meetings starting in 1980 to its formal creation in 1990, the IRSSD has met on a bi-annual basis to discuss all aspects of the spine and associated deformities. It has encouraged open discussion on all topics and, in particular, has tried to be the seed-bed for new ideas. The members are spread around the world and include people from all areas of academia as well as the most important people, the patients themselves. Most notably, application of the ideas and results of the research has always been at the forefront of the discussions. This paper was conceived with the idea of evaluating the impact made by the IRSSD over the last 30 years in the various areas and is intended to create discussion for the upcoming meeting in Montreal regarding future focus: "We are lost over the Atlantic Ocean but we are making good time."

Reversal of childhood idiopathic scoliosis in an adult, without surgery: a case report and literature review

William Brooks — 2009-12-15T00:00:00Z

Background: Some patients with mild or moderate thoracic scoliosis (Cobb angle <50-60 degrees) suffer disproportionate impairment of pulmonary function associated with deformities in the sagittal plane and reduced flexibility of the spine and chest cage. Long-term improvement in the clinical signs and symptoms of childhood onset scoliosis in an adult, without surgical intervention, has not been documented previously.Case presentationA diagnosis of thoracic scoliosis (Cobb angle 45 degrees) with pectus excavatum and thoracic hypokyphosis in a female patient (DOB 9/17/52) was made in June 1964. Immediate spinal fusion was strongly recommended, but the patient elected a daily home exercise program taught during a 6-week period of training by a physical therapist. This regime was carried out through 1992, with daily aerobic exercise added in 1974. The Cobb angle of the primary thoracic curvature remained unchanged. Ongoing clinical symptoms included dyspnea at rest and recurrent respiratory infections. A period of multimodal treatment with clinical monitoring and treatment by an osteopathic physician was initiated when the patient was 40 years old. This included deep tissue massage (1992-1996); outpatient psychological therapy (1992-1993); a daily home exercise program focused on mobilization of the chest wall (1992-2005); and manipulative medicine (1994-1995, 1999-2000). Progressive improvement in chest wall excursion, increased thoracic kyphosis, and resolution of long-standing respiratory symptoms occurred concomitant with a >10 degree decrease in Cobb angle magnitude of the primary thoracic curvature. Conclusion: This report documents improved chest wall function and resolution of respiratory symptoms in response to nonsurgical approaches in an adult female, diagnosed at age eleven years with idiopathic scoliosis.

Methodology of evaluation of morphology of the spine and the trunk in idiopathic scoliosis and other spinal deformities - 6th SOSORT consensus paper

Tomasz Kotwicki — 2009-11-26T00:00:00Z

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 studyTo 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.

Tonsillar ectopia in adolescent idiopathic scoliosis: does it play a role in the pathogenesis and prognosis or is it only an incidental finding?

Kasim Abul-Kasim — 2009-11-12T00:00:00Z

Background: There is an ongoing controversy about the significance of tonsillar ectopia among patients with idiopathic scoliosis (IS).AimTo find out if tonsillar ectopia occurs more frequently among patients with IS and if it plays any etiological or prognostic role in IS.Study designRetrospective study. Methods: Retrospective analysis of 155 consecutive spine MRIs (79 patients with IS and 76 controls; aged 7-25 years; 55% were female) with regard to the position of the cerebellar tonsils in relation to foramen magnum and the sagittal diameter of foramen magnum. All images were evaluated independently by two neuroradiologists. Interobserver and intraobserver reliability analysis was performed by calculation of κ-value, intraclass correlation coefficient, and systematic and random errors. The occurrence of tonsillar ectopia among patients with IS and controls was estimated and the association of tonsillar ectopia with different predictors has been tested. Statistical significance was set to P ≤ 0.05. Results: The interobserver and intraobserver agreement with regard to the occurrence of tonsillar ectopia was almost perfect (κ 0.84 and 0.89, respectively). Tonsillar ectopia was found in 37% of patients with IS compared with 13% among controls (p < 0.001 and odds ratio of 3.8, 95% CI 1.7-8.5). The occurrence of tonsillar ectopia was not associated with the severity of scoliotic deformity (p = 0.85), or rapid progression of scoliosis (p = 0.76). Neurological deficit occurs twice as frequently in patients with tonsillar ectopia as in those with no tonsillar ectopia. Two of five patients with tonsillar ectopia showed improvement of their neurological deficit after the surgical correction of scoliosis. Conclusion: As tonsillar ectopia is significantly more frequent among patients with IS and may exhibit some prognostic utility in patients with neurological deficit, we forward the hypothesis that tonsillar ectopia may play a role in the development of the deformity in some patients with IS. However, occurrence of tonsillar ectopia among 13% of controls precludes stating a definitive role of tonsillar ectopia in the pathogenesis of IS. Some patients with IS, tonsillar ectopia and neurological deficit showed neurological improvement following the surgical correction of scoliosis.

Pathogenesis of adolescent idiopathic scoliosis in girls - a double neuro-osseous theory involving disharmony between two nervous systems, somatic and autonomic expressed in the spine and trunk: possible dependency on sympathetic nervous system and hormones with implications for medical therapy

R Geoffrey Burwell — 2009-10-31T00:00:00Z

Anthropometric data from three groups of adolescent girls - preoperative adolescent idiopathic scoliosis (AIS), screened for scoliosis and normals were analysed by comparing skeletal data between higher and lower body mass index subsets. Unexpected findings for each of skeletal maturation, asymmetries and overgrowth are not explained by prevailing theories of AIS pathogenesis. A speculative pathogenetic theory for girls is formulated after surveying evidence including: (1) the thoracospinal concept for right thoracic AIS in girls; (2) the new neuroskeletal biology relating the sympathetic nervous system to bone formation/resorption and bone growth; (3) white adipose tissue storing triglycerides and the adiposity hormone leptin which functions as satiety hormone and sentinel of energy balance to the hypothalamus for long-term adiposity; and (4) central leptin resistance in obesity and possibly in healthy females. The new theory states that AIS in girls results from developmental disharmony expressed in spine and trunk between autonomic and somatic nervous systems. The autonomic component of this double neuro-osseous theory for AIS pathogenesis in girls involves selectively increased sensitivity of the hypothalamus to circulating leptin (genetically-determined up-regulation possibly involving inhibitory or sensitizing intracellular molecules, such as SOC3, PTP-1B and SH2B1 respectively), with asymmetry as an adverse response (hormesis); this asymmetry is routed bilaterally via the sympathetic nervous system to the growing axial skeleton where it may initiate the scoliosis deformity (leptin-hypothalamic-sympathetic nervous system concept = LHS concept). In some younger preoperative AIS girls, the hypothalamic up-regulation to circulating leptin also involves the somatotropic (growth hormone/IGF) axis which exaggerates the sympathetically-induced asymmetric skeletal effects and contributes to curve progression, a concept with therapeutic implications. In the somatic nervous system, dysfunction of a postural mechanism involving the CNS body schema fails to control, or may induce, the spinal deformity of AIS in girls (escalator concept). Biomechanical factors affecting ribs and/or vertebrae and spinal cord during growth may localize AIS to the thoracic spine and contribute to sagittal spinal shape alterations. The developmental disharmony in spine and trunk is compounded by any osteopenia, biomechanical spinal growth modulation, disc degeneration and platelet calmodulin dysfunction. Methods for testing the theory are outlined. Implications are discussed for neuroendocrine dysfunctions, osteopontin, sympathoactivation, medical therapy, Rett and Prader-Willi syndromes, infantile idiopathic scoliosis, and human evolution. AIS pathogenesis in girls is predicated on two putative normal mechanisms involved in trunk growth, each acquired in evolution and unique to humans.

Correction: Assessment of angle velocity in girls with adolescent idiopathic scoliosis

Ferran Escalada — 2009-10-10T00:00:00Z

Correction to Escalada F, Marco E, Duarte E, Muniesa JM, Boza R, Tejero M, Cáceres E. Assessment of angle velocity in girls with adolescent idiopathic scoliosis. Scoliosis 2009; 4:20.

Brace treatment for patients with Scheuermann`s disease - a review of the literature and first experiences with a new brace design

Hans-Rudolf Weiss — 2009-09-29T00:00:00Z

Background: In contemporary literature few have written in detail on the in-brace correction effects of braces used for the treatment of hyperkyphosis. Bradford et al. found their attempts effective, treating Scheuermann's kyphosis with Milwaukee braces, but their report did not specifically focus on in-brace corrections. White and Panjabi's research attempted to correct a curvature of > 50° with the help of distraction forces, but consequently led to a reduction in patient comfort in the application of the Milwaukee brace. In Germany they avoid this by utitlising braces to treat hyperkyphosis that use transverse correction forces instead of distraction forces. Further efforts to reduce brace material have resulted in a special bracing design called kyphologic™ brace. The aim of this review is to present appropriate research to collect and evaluate possible in-brace corrections which have been achieved with brace treatment for hyperkyphosis. This paper introduces new methods of bracing and compares the results of these with other successful bracing concepts.Materials and methods56 adolescents with the diagnosis of thoracic Scheuermann's hyperkyphosis or a thoracic idiopathic hyperkyphosis (22 girls and 34 boys) with an average age of 14 years (12-17 yrs.) were treated with the kyphologic™ brace between May 2007 and December 2008. The average Stagnara angle was 55,6° (43-80). In-brace correction was recorded and compared to the initial angle using the t-test. Results: The average Stagnara angle in the brace was 39°. The average in-brace correction was 16.5° (1-40°). The verage percentage of in-brace correction compared to the initial value was 36%. The differences were significant in the t-test (t = 5.31, p < 0,001). To make these results comparable to other studies, the kyphosis angle of 25° was set to 0 for our sample in order to achieve a norm value adapted (NVA) percentage of in-brace correction. By doing this a correction of 54.1% was achieved. There was no correlation between the percentage of in-brace correction and the age of the patient, but a highly significant correlation between percentage of in-brace correction and the initial Stagnara angle.DiscussionIf we assume that outcome of brace treatment positively correlates with in-brace correction, the treatment should be initiated before the curvature angle exceeds 50 - 55° in a growing adolescent. In scoliosis bracing, if the average in-brace correction equals > 15°, then it is predicted that the result will lead to a final correction. Applying this to hyperkyphosis patients, the average in-brace correction with this brace was also > 15°. We therefore estimated to achieve a favourable outcome using this brace type (once compliance was attained) especially when comparing the correction effects achieved with this new approach to the correction effects reported upon using the Milwaukee brace. The latter brace has been shown to lead to beneficial outcomes in long-term studies with comparable in-brace corrections. Conclusion: Conservative treatment of Scheuermann's hyperkyphosis in international literature is generally regarded as an effective treatment approach. Physiotherapy and bracing are the first-line treatments for this condition.An average in-brace correction of > 15° as was achieved using the kyphologic™ brace predicts a favourable outcome.The kyphologic™ brace leads to in-brace corrections comparable to those of the Milwaukee brace, which has previously been shown to provide beneficial outcome in the long-term.A prospective follow-up study seems desirable before final conclusions can be drawn.Future studies should focus more on thoracolumbar and lumbar curve patterns, because these patterns may predict chronic low back pain in adulthood with reduced quality of life of the patients and high costs with respect to medical care and occupational sickness leave.Surgery according to international literature is rarely necessary in this condition.

Treatment of thoraco-lumbar curves in adolescent females affected by idiopathic scoliosis with a progressive action short brace (PASB): assessment of results according to the SRS committee on bracing and nonoperative management standardization criteria.

Angelo Aulisa — 2009-09-18T00:00:00Z

Background: The effectiveness of conservative treatment of scoliosis is controversial. Some studies suggest that brace is effective in stopping curve progression, whilst others did not report such an effect.The purpose of the present study was to effectiveness of Progressive Action Short Brace (PASB) in the correction of thoraco-lumbar curves, in agreement with the Scoliosis Research Society (SRS) Committee on Bracing and Nonoperative Management Standardisation Criteria. Methods: Fifty adolescent females (mean age 11.8 ± 0.5 years) with thoraco-lumbar curve and a pre-treatment Risser score ranging from 0 to 2 have been enrolled. The minimum duration of follow-up was 24 months (mean: 55.4 ± 44.5 months). Antero-posterior radiographs were used to estimate the curve magnitude (CM) and the torsion of the apical vertebra (TA) at 5 time points: beginning of treatment (t1), one year after the beginning of treatment (t2), intermediate time between t1 and t4 (t3), end of weaning (t4), 2-year minimum follow-up from t4 (t5). Three situations were distinguished: curve correction, curve stabilisation and curve progression.The Kruskal Wallis and Spearman Rank Correlation tests have been used as statistical tests. Results: CM mean value was 29,30 ± 5,16 SD at t1 and 14,67 ± 7,65 SD at t5. TA was 12.70 ± 6,14 SD at t1 and 8,95 ± 5,82 at t5. The variation between measures of Cobb and Perdriolle degrees at t1,2,3,4,5 and between CM t5-t1 and TA t5-t1 were significantly different.Curve correction was accomplished in 94% of patients, whereas a curve stabilisation was obtained in 6% of patients. Conclusion: The PASB, due to its peculiar biomechanical action on vertebral modelling, is highly effective in correcting thoraco-lumbar curves.