7th SOSORT consensus paper: conservative treatment of idiopathic & Scheuermann's kyphosis

Abstract

Thoracic hyperkyphosis is a frequent problem and can impact greatly on patient's quality of life during adolescence. This condition can be idiopathic or secondary to Scheuermann disease, a disease disturbing vertebral growth. To date, there is no sound scientific data available on the management of this condition. Some studies discuss the effects of bracing, however no guidelines, protocols or indication's of treatment for this condition were found. The aim of this paper was to develop and verify the consensus on managing thoracic hyperkyphosis patients treated with braces and/or physiotherapy.

Methods

The Delphi process was utilised in four steps gradually modified according to the results of a set of recommendations: we involved the SOSORT Board twice, then all SOSORT members twice, with a Pre-Meeting Questionnaire (PMQ), and during a Consensus Session at the SOSORT Lyon Meeting with a Meeting Questionnaire (MQ).

Results

There was an unanimous agreement on the general efficacy of bracing and physiotherapy for this condition. Most experts suggested the use of 4-5 point bracing systems, however there was some controversy with regards to physiotherapeutic aims and modalities.

Conclusion

The SOSORT panel of experts suggest the use of rigid braces and physiotherapy to correct thoracic hyperkyphosis during adolescence. The evaluation of specific braces and physiotherapy techniques has been recommended.     

A review of the trunk surface metrics used as Scoliosis and other deformities evaluation indices

Background

Although scoliosis is characterized by lateral deviation of the spine, a 3D deformation actually is responsible for geometric and morphologic changes in the trunk and rib cage. In a vast related medical literature, one can find quite a few scoliosis evaluation indices, which are based on back surface data and are generally measured along three planes. Regardless the large number of such indices, the literature is lacking a coherent presentation of the underlying metrics, the involved anatomic surface landmarks, the definition of planes and the definition of the related body axes. In addition, the long list of proposed scoliotic indices is rarely presented in cross-reference to each other. This creates a possibility of misunderstandings and sometimes irrational or even wrong use of these indices by the medical society.

Materials and methods

It is hoped that the current work contributes in clearing up the issue and gives rise to innovative ideas on how to assess the surface metrics in scoliosis. In particular, this paper presents a thorough study on the scoliosis evaluation indices, proposed by the medical society.

Results

More specifically, the referred indices are classified, according to the type of asymmetry they measure, according to the plane they refer to, according to the importance, and relevance or the level of scientific consensus they enjoy.

Conclusions

Surface metrics have very little correlation to Cobb angle measurements. Indices measured on different planes do not correlate to each other. Different indices exhibit quite diverging characteristics in terms of observer-induced errors, accuracy, sensitivity and specificity. Complicated positioning of the patient and ambiguous anatomical landmarks are the major error sources, which cause observer variations. Principles that should be followed when an index is proposed are presented.     

Effectiveness of complete conservative treatment for adolescent idiopathic scoliosis (bracing and exercises) based on SOSORT management criteria: results according to the SRS criteria for bracing studies - SOSORT Award 2009 Winner

Background

The SRS criteria give the methodological reference framework for the presentation of bracing results, while the SOSORT criteria give the clinical reference framework for an appropriate bracing treatment. The two have not been combined in a study until now. Our aim was to verify the efficacy of a complete, conservative treatment of Adolescent Idiopathic Scoliosis (AIS)according to the best methodological and management criteria defined in the literature.

Methods

Study Design. Retrospective study. Population. We included all AIS patients respecting the SRS inclusion criteria (age 10 years or older; Risser test 0-2; Cobb degrees 25-40°; no prior treatment; less than one year post-menarchal) who had reached the end of treatment since our institute database start in 2003. Thus we had 44 females and four males, with an age of 12.8 ± 1.6 at the commencement of the study. Methods. According to individual needs, two patients have been treated with Risser casts followed by Lyon brace, 40 with Lyon or SPoRT braces (14 for 23 hours per day, 23 for 21 h/d, and seven for 18 h/d at start), and two with exercises only (1 male, 1 female): these were excluded from further analysis. Outcome criteria. SRS (unchanged; worsened 6° or more; over 45° at the end of treatment; surgically treated; two years' follow-up); clinical (ATR, Aesthetic Index, plumbline distances); radiographic (Cobb degrees); and ISICO (optimal; minimal). Statistics. Paired ANOVA and t-test, Tukey-Kramer and chi-square test.

Results

Median reported compliance during the 4.2 ± 1.4 treatment years was 90% (range 5-106%). No patient progressed beyond 45°, nor was any patient fused, and this remained true at the two-year follow-up for the 85% that reached it. Only two patients (4%) worsened, both with single thoracic curve, 25-30° Cobb and Risser 0 at the start. We found statistically significant reductions of the scoliosis curvatures (-7.1°): thoracic (-7.3°), thoracolumbar (-8.4°) and lumbar (-7.8°), but not double major. Statistically significant improvements have also been found for aesthetics and ATR.

Conclusion

Respecting also SOSORT management criteria and thus increasing compliance, the results of conservative treatment were much better than what had previously been reported in the literature using SRS criteria only.     

Tridimensional evaluation and optimization of the orthotic treatment of adolescent idiopathic scoliosis

Adolescent idiopathic scoliosis involves complex tridimensional deformities of the spine, rib cage and pelvis. Moderate curves generally are treated using an orthosis. This paper presents different studies performed over the last fifteen years related to the biomechanical evaluation and optimization of the orthopedic treatment of scoliotic deformities. Patient specific 3D models of the spine, pelvis and rib cage are computed from calibrated radiographs, and are used to calculate 2D and 3D clinical indices. The torso shape is acquired using surface topography. With such internal and external 3D models, the efficacy of the most frequently used orthoses can be analyzed and new treatments can be developed. Pressures generated by a brace on the patient's trunk were measured using a flexible matrix of pressure sensors and displayed over the patient's internal geometry in order to analyze the brace efficacy. Patient specific finite element models have been developed, including the osseo-ligamentous structures as well as the muscles, the neuro-control, trunk growth and its adaptation to the stress. These models were used to analyze the effects of the Boston brace. The electro-myographic activity also was measured to analyze the < active > correction mechanisms. Adjustment techniques and software are used to help the orthotists with real time feedback when the brace is being fabricated and adjusted to the patient. Residual growth potential is also being added to the computer model to simulate the long term effect of a brace. The improvement of the orthotic treatments of scoliotic deformities is very encouraging. The exploitation of such tools is expected to allow reaching optimal treatment personalized to each patient. double dagger.     

Trunk appearance perception scale for physicians (TAPS-Phy) - a valid and reliable tool to rate trunk deformity in idiopathic scoliosis

Background

Evaluation of trunk deformity by physicians in patients with idiopathic scoliosis (IS) has been considered an important part of clinical practice. Different methods to quantify the severity of trunk deformity by external observation have been reported. A valid tool to evaluate patients’ perception of trunk deformity, the Trunk Appearance Perception Scale (TAPS), is hereby validated for use by physicians (TAPS-Phy).

Methods

Cross-sectional study of patients with non-surgically treated IS. Patients were prospectively recruited. On the day of the visit, a posterior-anterior radiograph in standard position and clinical photographs in three different views (anterior, posterior and forward bending position) were obtained. Patients also completed a TAPS questionnaire (TAPS-Pat). Three different observers scored the TAPS questionnaire (TAPS-Phy), based on the digital photographs previously obtained, twice a week. The angle of trunk inclination (ATRI) was also measured on digital photographs. Inter and intra-rater reliability was calculated through weighted kappa coefficient. External validity was tested by the Spearman correlation coefficient between the TAPS-Phy score and the scoliosis magnitude determined using the magnitude of the largest curve (MLC), ATRI, and TAPS-Pat.

Results

Fifty two patients (46 women; mean age 16.6 years) were included. The average curve magnitude of the major curve was 44°. Mean scores of TAPS-Phy for the three evaluators ranged from 3.4 to 3.5. No differences between the three means were found. TAPS-Phy showed good internal consistency (Cronbach’s alpha coefficient 0.84). Inter-observer reliability ranged from slight to substantial (0.14 to 0.63); intra-observer reliability ranged from 0.35 to 0.99. Correlation between TAPS-Phy and ATRI (r?=??0.54 to ?0.75), MLC (r?=??0.47 to ?0.6) and TAPS-Pat (r?=?0.29 to 0.34) were statistically significant (p?<?0.01).

Conclusions

TAPS-Phy is a valid and reliable scale to rate a physician’s impression of the severity of the deformity in patients with idiopathic scoliosis and can be useful in routine clinical records.

     

Conservative treatment of idiopathic scoliosis according to FITS concept: presentation of the method and preliminary, short term radiological and clinical results based on SOSORT and SRS criteria

Background

Conservative scoliosis therapy according to the FITS Concept is applied as a unique treatment or in combination with corrective bracing. The aim of the study was to present author's method of diagnosis and therapy for idiopathic scoliosis FITS-Functional Individual Therapy of Scoliosis and to analyze the early results of FITS therapy in a series of consecutive patients.

Methods

The analysis comprised separately: (1) single structural thoracic, thoracolumbar or lumbar curves and (2) double structural scoliosis-thoracic and thoracolumbar or lumbar curves. The Cobb angle and Risser sign were analyzed at the initial stage and at the 2.8-year follow-up. The percentage of patients improved (defined as decrease of Cobb angle of more than 5 degrees), stable (+/- 5 degrees), and progressed (increase of Cobb angle of more than 5 degrees) was calculated. The clinical assessment comprised: the Angle of Trunk Rotation (ATR) initial and follow-up value, the plumb line imbalance, the scapulae level and the distance from the apical spinous process of the primary curve to the plumb line.

Results

In the Group A: (1) in single structural scoliosis 50,0% of patients improved, 46,2% were stable and 3,8% progressed, while (2) in double scoliosis 50,0% of patients improved, 30,8% were stable and 19,2% progressed. In the Group B: (1) in single scoliosis 20,0% of patients improved, 80,0% were stable, no patient progressed, while (2) in double scoliosis 28,1% of patients improved, 46,9% were stable and 25,0% progressed.

Conclusion

Best results were obtained in 10-25 degrees scoliosis which is a good indication to start therapy before more structural changes within the spine establish.     

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

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.     

Melatonin the "light of night" in human biology and adolescent idiopathic scoliosis

Melatonin "the light of night" is secreted from the pineal gland principally at night. The hormone is involved in sleep regulation, as well as in a number of other cyclical bodily activities and circadian rhythm in humans. Melatonin is exclusively involved in signalling the 'time of day' and 'time of year' (hence considered to help both clock and calendar functions) to all tissues and is thus considered to be the body's chronological pacemaker or 'Zeitgeber'. The last decades melatonin has been used as a therapeutic chemical in a large spectrum of diseases, mainly in sleep disturbances and tumours and may play a role in the biologic regulation of mood, affective disorders, cardiovascular system, reproduction and aging. There are few papers regarding melatonin and its role in adolescent idiopathic scoliosis (AIS). Melatonin may play a role in the pathogenesis of scoliosis (neuroendocrine hypothesis) but at present, the data available cannot clearly support this hypothesis. Uncertainties and doubts still surround the role of melatonin in human physiology and pathophysiology and future research is needed.     

Taxonomic significance of spine morphology in the echinoid genera Diadema and Echinothrix

Abstract. The spine morphology of all established species of Diadema and Echinothrix, including 2 color morphs of E. calamaris, were examined externally and internally via transverse sectioning to identify diagnostic species features and to assess the morphological relationship between species. Forty‐nine different morphological characters were measured and analysed using ordination by multi‐dimensional scaling (MDS) and cluster analysis. Specimens of Diadema paucispinum and D. setosum had very distinct spine structures. In D. paucispinum, the spines were more robust than those of other species of Diadema. This was evident in the spine's internal structure, with large, closely packed solid wedges, a small axial cavity, and rings of trabeculae throughout the spine's length. The spines in D. setosum were distinctive because of their length in relation to test size and the reduced flaring of their verticillations. The spines of other members of this genus were very similar to each other. Without careful sectioning, the spines from specimens of D. antillarum, D. ascensionis, D. mexicanum and D. savignyi were difficult to differentiate. The internal structures of spines for each species did, however, possess a combination of features that differentiated the species. Such features included the shape, orientation, and number of solid wedges, the presence or absence of spokes and rings of trabeculae between the solid wedges, and the presence or absence of tissue within the axial cavity. Individuals of Diadema palmeri also had spines morphologically similar to other species, however, the red pigmentation of these spines (in life and when preserved) made them easily distinguishable. The spine structures of the 2 species of Echinothrix were starkly different, while the white and brown color morphs of E. calamaris had morphologically distinctive ambulacral and interambulacral spines. The blunt, open‐tipped interambulacral spines, with reticular tissue present in the axial cavity of the white color morph, were easily distinguished from the pointed, closed‐tipped spines, with a hollow axial cavity found in the brown color morph. Such differences indicate that the brown color morph is either a subspecies or a separate species. Taken together the data show that each species has significant morphological differences in the structure of the spines. It is evident from our data that spine morphology is a useful tool to differentiate these commonly confused species.     

Constraining spine stability levels in an optimization model leads to the prediction of trunk muscle cocontraction and improved spine compression force estimates

A major limitation of optimization models of the spine has been the inability to accurately predict trunk muscle co-activity. Antagonist muscle activity is thought to be necessary to maintain adequate levels of spine stability but, in turn, creates increased loading on the spine. It is thus hypothesized that the CNS attempts to optimize the relationship between spine loading and spine stability in determining muscular activation patterns. This study presents an optimization model of the spine in which stability was constrained to target levels predicted from regression equations of independent loading variables. Objective functions were set to either minimize the sum of the cubed muscle forces or minimize the sum of the squared intervertebral forces at the L4-L5 disc level. Results demonstrate that the inclusion of stability constraints in optimization simulations produced realistic predictions of antagonist muscle activity and predictions of spine compression levels that agree more closely with EMG-based estimates, compared to simulations in which stability was unconstrained. It was concluded that spinal stability is a vital consideration for the CNS when dictating trunk muscle recruitment patterns.     

The lateral dental lamina and the enamel niche. 6th and last paper on the embryology of human teeth]

Up to the cap-stage the lateral enamel strand extends from the dental lamina to the tip of the tongue-like projection of the enamel organ, forming there a swelling. It does not reach the free margin of the enamel organ at the bell-stage. The lateral enamel strand gradually becomes smaller in regard to the tooth germ, changing its relative position to the mesial half of the latter, and finally degenerates. In the molar germ, as the epithelial tongue-like projection at the cap-stage increases in length to become an interradical process, the lateral enamel strand extends as a crest on the buccal interradical process. The direction of the lateral enamel strand is inverse in the maxillary molar germs.     

The role of dendritic spine morphology in the compartmentalization and delivery of surface receptors

Since AMPA receptors are major molecular players in both short- and long-term plasticity, it is important to identify the time-scales of and factors affecting the lateral diffusion of AMPARs on the dendrite surface. Using a mathematical model, we study how the dendritic spine morphology affects two processes: (1) compartmentalization of the surface receptors in a single spine to retain local chemistry and (2) the delivery of receptors to the post-synaptic density (PSD) of spines via lateral diffusion following insertion onto the dendrite shaft. Computing the mean first passage time (MFPT) of surface receptors on a sample of real spine morphologies revealed that a constricted neck and bulbous head serve to compartmentalize receptors, consistent with previous works. The residence time of a Brownian diffusing receptor on the membrane of a single spine was computed to be ～ 5 s. We found that the location of the PSD corresponds to the location at which the maximum MFPT occurs, the position that maximizes the residence time of a diffusing receptor. Meanwhile, the same geometric features of the spine that compartmentalize receptors inhibit the recruitment of AMPARs via lateral diffusion from dendrite insertion sites. Spines with narrow necks will trap a smaller fraction of diffusing receptors in the their PSD when considering competition for receptors between the spines, suggesting that ideal geometrical features involve a tradeoff depending on the intent of compartmentalizing the current receptor pool or recruiting new AMPARs in the PSD. The ultimate distribution of receptors among the spine PSDs by lateral diffusion from the dendrite shaft is an interplay between the insertion location and the shape and locations of both the spines and their PSDs. The time-scale for delivery of receptors to the PSD of spines via lateral diffusion was computed to be ～ 60 s.     

Patient-specific finite element model of the spine and spinal cord to assess the neurological impact of scoliosis correction: preliminary application on two cases with and without intraoperative neurological complications

Scoliosis is a 3D deformation of the spine and rib cage. For severe cases, surgery with spine instrumentation is required to restore a balanced spine curvature. This surgical procedure may represent a neurological risk for the patient, especially during corrective maneuvers. This study aimed to computationally simulate the surgical instrumentation maneuvers on a patient-specific biomechanical model of the spine and spinal cord to assess and predict potential damage to the spinal cord and spinal nerves. A detailed finite element model (FEM) of the spine and spinal cord of a healthy subject was used as reference geometry. The FEM was personalized to the geometry of the patient using a 3D biplanar radiographic reconstruction technique and 3D dual kriging. Step by step surgical instrumentation maneuvers were simulated in order to assess the neurological risk associated to each maneuver. The surgical simulation methodology implemented was divided into two parts. First, a global multi-body simulation was used to extract the 3D displacement of six vertebral landmarks, which were then introduced as boundary conditions into the personalized FEM in order to reproduce the surgical procedure. The results of the FEM simulation for two cases were compared to published values on spinal cord neurological functional threshold. The efficiency of the reported method was checked considering one patient with neurological complications detected during surgery and one control patient. This comparison study showed that the patient-specific hybrid model reproduced successfully the biomechanics of neurological injury during scoliosis correction maneuvers.