A new brace treatment similar for adolescent scoliosis and kyphosis based on restoration of thoracolumbar lordosis. Radiological and subjective clinical results after at least one year of treatment

Study design

A prospective treatment study with a new brace was conducted Objective. To evaluate radiological and subjective clinical results after one year conservative brace treatment with pressure onto lordosis at the thoracolumbar joint in children with scoliosis and kyphosis.

Summary of background data

Conservative brace treatment of adolescent scoliosis is not proven to be effective in terms of lasting correction. Conservative treatment in kyphotic deformities may lead to satisfactory correction. None of the brace or casting techniques is based on sagittal forces only applied at the thoracolumbar spine (TLI= thoracolumbar lordotic intervention). Previously we showed in patients with scoliosis after forced lordosis at the thoracolumbar spine a radiological instantaneous reduction in both coronal curves of double major scoliosis.

Methods

A consecutive series of 91 children with adolescent scoliosis and kyphosis were treated with a modified symmetric 30 degrees Boston brace to ensure only forced lordosis at the thoracolumbar spine. Scoliosis was defined with a Cobb angle of at least one of the curves [greater than or equal to] 25 degrees and kyphosis with or without a curve <25 degrees in the coronal plane. Standing radiographs were made i) at start, ii) in brace at beginning and iii) after one year treatment without brace.

Results

Before treatment start ??in brace?? radiographs showed a strong reduction of the Cobb angles in different curves in kyphosis and scoliosis groups (sagittal n = 5 all p < 0.001, pelvic obliquity p < 0.001). After one year of brace treatment in scoliosis and kyphosis group the measurements on radiographs made without brace revealed an improvement in 3 Cobb angles each.

Conclusion

Conservative treatment using thoracolumbar lordotic intervention in scoliotic and kyphotic deformities in adolescence demonstrates a marked improvement after one year also in clinical and postural criteria. An effect not obtained with current brace techniques.     

Sphingosine 1-phosphate differentially regulates proliferation of C2C12 reserve cells and myoblasts

Scoliosis is a condition that involves an abnormal curvature and deformity of the spinal vertebrae. The genetic background and key gene for congenital scoliosis in humans are still poorly understood. Ishibashi rats (ISR) have congenital malformation of the lumbar vertebrae leading to kyphoscoliosis similar to that seen in humans. To understand the pathogenesis of congenital scoliosis, we have studied the abnormality of vertebral formation and the associated gene expression in ISR. Almost all ISR showed kyphosis or scoliosis of the lumbar vertebrae. In ISR with severe kyphosis, some vertebral disks were missing and some vertebral bodies were fused. Of the ISR, 27% showed hemi-lumbarization of lumbar and sacral vertebrae. Homeotic transformation of the first sacral vertebra into the seventh lumbar vertebra and the resultant loss of the fourth sacral vertebra were seen in half of the ISR. We also found unilateral fusions and deformities of primary ossification centers of the lumbar vertebral column in fetal ISR. Moreover, we observed that the expression levels of Hox10 and Hox11 paralogs in lumbo-sacral transitional areas of ISR were extremely low compared with those of normal rats. These results suggest that fusion of primary ossification centers in lumbar vertebrae in the embryonic period causes scoliosis and kyphosis and that Hox genes are involved in the occurrence of homeotic transformation in lumbo-sacral vertebrae of congenital kyphoscoliotic ISR.     

Musculoskeletal deformities following treatment of Wilms' tumour.

Wilms'' tumour is one of the most common neoplasms of infancy and childhood. Current treatment regimens result in a cure rate of about 80% for localized tumours but may also cause musculoskeletal deformities. Assessment of 21 patients previously treated for Wilms'' tumour showed that all had flank atrophy on the treated side. Radiologic abnormalities included asymmetry of vertebral bodies, vertebral end-plate irregularities, scoliosis, kyphosis, platyspondyly and hypoplasia of the ilium. Although the vertebral changes following radiotherapy for Wilms'' tumour are present from an early age and the potential is great for an increase in spinal deformity with growth, few spinal curves progress past 20 degree. Since one cannot predict which curves will progress, all such patients need careful orthopedic follow-up until skeletal maturity is achieved.     

Kyphectomy for severe kyphosis with pyogenic spondylitis associated with myelomeningocele: a case report

Cavernous hemangioma consists mainly of congenital vascular malformations present before birth and gradually increasing in size with skeletal growth. A small number of patients with cavernous hemangioma develop scoliosis, and surgical treatment for the scoliosis in such cases has not been reported to date. Here we report a 12-year-old male patient with severe progressive scoliosis due to a huge subcutaneous cavernous hemangioma, who underwent posterior correction and fusion surgery. Upon referral to our department, radiographs revealed a scoliosis of 85° at T6-L1 and a kyphosis of 58° at T4-T10. CT and MR images revealed a huge hemangioma extending from the subcutaneous region to the paraspinal muscles and the retroperitoneal space and invading the spinal canal. Posterior correction and fusion surgery using pedicle screws between T2 and L3 were performed. Massive hemorrhage from the hemangioma occurred during the surgery, with intraoperative blood loss reaching 2800 ml. The scoliosis was corrected to 59°, and the kyphosis to 45° after surgery. Seven hours after surgery, the patient suffered from hypovolemic shock and disseminated intravascular coagulation due to postoperative hemorrhage from the hemangioma. The patient developed sensory and conduction aphasia caused by cerebral hypoxia during the shock on the day of the surgery. At present, two years after the surgery, although the patient has completely recovered from the aphasia. This case illustrates that, in correction surgery for scoliosis due to huge subcutaneous cavernous hemangioma, intraoperative and postoperative intensive care for hemodynamics should be performed, since massive hemorrhage can occur during the postoperative period as well as the intraoperative period.     

Kyphectomy for severe kyphosis with pyogenic spondylitis associated with myelomeningocele: a case report

A 32-year-old woman was referred to our hospital for a refractory ulcer on her back. She had a history of myelomeningocele with spina bifida that was treated surgically at birth. The ulcer was located at the apex of the kyphosis. An X-ray film revealed a kyphosis of 154° between L1 and 3 and a scoliosis of 60° between T11 and L5. Computed tomography, magnetic resonance imaging and laboratory data indicated the presence of a pyogenic spondylitis at L2/3. To correct the kyphosis and remove the infected vertebrae together with the skin ulcer, kyphectomy was performed. Pedicle screws were inserted from T8 to T12 and from L4 to S1. The dural sac was transected and ligated at L2, followed by total kyphectomy of the L1-L3 vertebrae. The spinal column was reconstructed by approximating the ventral wall of the T12 vertebral body and the cranial endplate of the L4 vertebra. Postoperatively, the kyphosis was corrected to 61° and the scoliosis was corrected to 22°. In the present case, we treated the skin ulcer and pyogenic spondylitis successfully by kyphectomy, thereby, preventing recurrence of the ulcer and infection, and simultaneously obtaining sufficient correction of the spinal deformity.     

CT and radiographic analysis of sagittal profile changes following thoracoscopic anterior scoliosis surgery

ABSTRACT: BACKGROUND: Previous studies report an increase in thoracic kyphosis after anterior approaches and a flattening of sagittal contours following posterior approaches. Difficulties with measuring sagittal parameters on radiographs are avoided with reformatted sagittal CT reconstructions due to the superior endplate clarity afforded by this imaging modality. METHODS: A prospective study of 30 Lenke 1 adolescent idiopathic scoliosis (AIS) patients receiving selective thoracoscopic anterior spinal fusion (TASF) was performed. Participants had ethically approved low dose CT scans at minimum 24 months after surgery in addition to their standard care following surgery. The change in sagittal contours on supine CT was compared to standing radiographic measurements of the same patients and with previous studies. Inter-observer variability was assessed as well as whether hypokyphotic and normokyphotic patient groups responded differently to the thoracoscopic anterior approach. RESULTS: Mean T5-12 kyphosis Cobb angle increased by 11.8 degrees and lumbar lordosis increased by 5.9 degrees on standing radiographs two years after surgery. By comparison, CT measurements of kyphosis and lordosis increased by 12.3 degrees and 7.0 degrees respectively. 95% confidence intervals for inter-observer variability of sagittal contour measurements on supine CT ranged between 5-8 degrees. TASF had a slightly greater corrective effect on patients who were hypokyphotic before surgery compared with those who were normokyphotic. CONCLUSIONS: Restoration of sagittal profile is an important goal of scoliosis surgery, but reliable measurement with radiographs suffers from poor endplate clarity. TASF significantly improves thoracic kyphosis and lumbar lordosis while preserving proximal and distal junctional alignment in thoracic AIS patients. Supine CT allows greater endplate clarity for sagittal Cobb measurements and linear relationships were found between supine CT and standing radiographic measurements. In this study, improvements in sagittal kyphosis and lordosis following surgery were in agreement with prior anterior surgery studies, and add to the current evidence suggesting that anterior correction is more capable than posterior approaches of addressing the sagittal component of both the instrumented and adjacent non instrumented segments following surgical correction of progressive Lenke 1 idiopathic scoliosis.     

Finite element simulation of spinal deformities correction by in situ contouring technique

Biomechanical models have been proposed in order to simulate the surgical correction of spinal deformities. With these models, different surgical correction techniques have been examined: distraction and rod rotation. The purpose of this study was to simulate another surgical correction technique: the in situ contouring technique. In this way, a comprehensive three-dimensional Finite Element (FE) model with patient-specific geometry and patient-specific mechanical properties was used. The simulation of the surgery took into account elasto-plastic behavior of the rod and multiple moments loading and unloading representing the surgical maneuvers. The simulations of two clinical cases of hyperkyphosis and scoliosis were coherent with the surgeon's experience. Moreover, the results of simulation were compared to post-operative 3D measurements. The mean differences were under 5 degrees for vertebral rotations and 5 mm for spinal lines. These simulations open the way for future predictive tools for surgical planning.     

Finite element simulation of spinal deformities correction by in situ contouring technique

Biomechanical models have been proposed in order to simulate the surgical correction of spinal deformities. With these models, different surgical correction techniques have been examined: distraction and rod rotation. The purpose of this study was to simulate another surgical correction technique: the in situ contouring technique. In this way, a comprehensive three-dimensional Finite Element (FE) model with patient-specific geometry and patient-specific mechanical properties was used. The simulation of the surgery took into account elasto–plastic behavior of the rod and multiple moments loading and unloading representing the surgical maneuvers. The simulations of two clinical cases of hyperkyphosis and scoliosis were coherent with the surgeon's experience. Moreover, the results of simulation were compared to post-operative 3D measurements. The mean differences were under 5° for vertebral rotations and 5 mm for spinal lines. These simulations open the way for future predictive tools for surgical planning.     

Optimization of skeletal configuration: studies of scoliosis correction biomechanics

A scheme for optimizing configurations in models of skeletal structures is presented. Use of the scheme is illustrated through determination of biomechanically optimal correction of a right-thoracic scoliosis by passive brace and active muscle forces. The locations and magnitudes of the passive brace forces, and the trunk muscle groups and their corresponding contraction intensity magnitudes that would optimally correct the geometric deformities of the spine were determined. The results suggest that, from a biomechanical viewpoint, both brace and muscle forces are capable of substantial correction of a model thoracic scoliosis. However, comparison of model results with long-term clinical results suggests that even under optimal conditions it is unlikely that scoliosis can be fully corrected by passive brace forces or active muscle contractions.     

Halo pelvic traction appliance for spinal deformities

The halo pelvic traction appliance, which has been used extensively for the correction of kyphotic and scoliotic spinal deformities, is described in detail. The appliance has been made more versatile to accommodate all shapes of spinal and pelvic deformities. Remarkable results have been achieved by this highly efficient controlled form of distraction which is carefully prescribed under medical supervision. Specifications of the appliance are given to suit a complete range of sizes and weights of patients. Also is included a novel method of measuring the applied tensile distracting force between the skull and pelvis.     

Induced abortion--a historical outline

An historical review of the use of induced abortion is presented, beginning with early eras. The Chinese were the 1st to record the practice of induced abortion, with this operation being administered to royal concubines recorded at 500-515 B.C. Induced abortion was not used in ancient Greece, either for criminal or ethical reason. However, the ancient Greeks did utilize compulsory abortion for serious economic indications, as a means of controlling natural growth. Greek medical, gyneoclogigcal instruments for adminsitering abortions were described by Hippocrates. The Greek moral attitudes on abortion were largely adopted by the Romans, which were later altered by the appearance of Christianity and new ethical ideas. These ideas dominated European attitudes, along with the Church of Rome, limiting induced abortion to cases where the life of the mother was threatened. This attitude has existed until the present century, when these moral ideas are being challanged seriously for the 1st time in modern history.     

Spinal curvature of cultured Japanese mackerel Scomber japonicus associated with a brain myxosporean, Myxobolus acanthogobii

Skeletal deformities were found in the cultured Japanese mackerel Scomber japonicus. External and radiographical observations showed the deformed fish to exhibit a dorso-ventral spinal curvature (kyphosis) without fracture or dislocation of the vertebrae. Numerous myxosporean cysts, ca. 0.3 to 1.0 mm in diameter, formed in the 4th ventricle, the cavity of the optic tectum, the surface of the olfactory lobe and bulb, the optic lobe and the inferior lobe of the brain. Spore morphology and molecular analysis of the small subunit ribosomal RNA gene sequence identified the myxosporean parasite as Myxobolus acanthogobii, a parasite which also causes scoliosis in yellowtail Seriola quinqeradiata. Histopathological observation showed that the myxosporean cysts were encapsulated within the host's collagenous layer although some had disintegrated to disperse mature spores into the cranial cavity. Occasionally, lymphocytic infiltration and local granulomatous inflammation were found to be associated with spore dispersion.     

Use of a cytogenetic method for buccal epithelium study, and a method of laser correlation spectrometry for health disturbances monitoring in children

Buccal epithelium cytogenetic disturbances were studied in schoolchildren from Moscow schools, a country school (Novgorod region) and a Moscow boarding school for chindren with musculoskeletal diseases (scoliosis and kyphosis). The minimal mean frequency of cells with karyorrhexis were revealed in children from an ecologically pure Novgorod region. Moscow schoolchildren demonstrated more than 13-fold higher level of this parameter. Children with spinal deformities had an intermediate frequency. Cells with karyolysis minimal mean frequency were observed in Moscow pupils. Children from Novgorod demonstrated a statistically valid higher level of this parameter, and the maximum was reached in Moscow boarding school. No difference between these groups was revealed in a study of the mean frequency of binucleated cells, cells with pyknosis, cells with micronuclei, or "broken eggs" incidence. Laser correlation spectrometry (LCS) method was used for parallel studies. It was shown that the distribution of spectra in Moscow pupils and in children with spinal deformities differs from that in children living in ecologically pure region. Normal spectra prevailed in pupils of country school, who demonstrated, in addition, high levels of anabolic and low levels of catabolic type metabolism. The examined Moscow schoolchildren demonstrated almost the same incidence of normal spectra. They differed from the country children by statistically valid reduction of anabolic type spectra, and by increased levels of catabolic type spectra. Young patients with spinal deformities demonstrated the maximum incidence of catabolic type spectra. The authors suggest the availability of a qualitative correlation between both the monitoring methods used in this study. It was shown that children living in unfavorable conditions and patients with musculoskeletal diseases manifested an enhanced incidence of buccal epithelium cells with karyorrhexis and karyolysis, as well as higher levels of catabolic type spectra accompanied by reduction of normal and anabolic type spectra.     

Spinal deformities rehabilitation - state of the art review

Background

Medical rehabilitation aims at an improvement in function, capacity and participation. For the rehabilitation of spinal deformities, the goal is to maintain function and prevent secondary symptoms in the short- and long-term. In patients with scoliosis, predictable signs and symptoms include pain and reduced pulmonary function.

Materials and methods

A Pub Med review was completed in order to reveal substantial evidence for inpatient rehabilitation as performed in Germany. No evidence has been found in general to support claims for actual inpatient rehabilitation programmes as used today. Nevertheless, as there is some evidence that inpatient rehabilitation may be beneficial to patients with spinal deformities complicated by certain additional conditions, the body of evidence there is for conservative treatment of spinal deformities has been reviewed in order to allow suggestions for outpatient conservative treatment and inpatient rehabilitation.

Discussion

Today, for both children and adolescents, we are able to offer intensive rehabilitation programmes lasting three to five days, which enable the patients to acquire the skills necessary to prevent postures fostering scoliosis in everyday life without missing too much of school teaching subjects at home. The secondary functional impairments adult scoliosis patients might have, as in the opinion of the author, still today require the time of 3-4 weeks in the clinical in-patient setting. Time to address psychosocial as well as somatic limitations, namely chronic pains and cardiorespiratory malfunction is needed to preserve the patients working capability in the long-term.

Conclusion

Outpatient treatment/rehabilitation is sufficient for adolescents with spinal deformities. Inpatient rehabilitation is recommended for patients with spinal deformities and pain or severe restrictive ventilation disorder.     

Teleosts as models for human vertebral stability and deformity

Vertebral development is a dynamic and complicated process, and defects can be caused by a variety of influences. Spinal curvature with no known cause (idiopathic scoliosis) affects 2-3% of the human population. In order to understand the etiology and pathogenesis of complex human skeletal defects such as idiopathic scoliosis, multiple models must be used to study all of the factors affecting vertebral stability and deformity. Although fish and humans have many of the same types of offenses to vertebral integrity, they have been overlooked as a resource for study. The most common morphological deformity reported for fish are those that occur during the development of the spinal system, and as with humans, curvature is a common morphological consequence. Here we review spinal curvature in teleosts and suggest that they are an unexploited resource for understanding the basic elements of vertebral stability, deformity, development and genetics. Fish can be a value to vertebral research because they are tractable, have a diversity of non-induced vertebral deformities, and substantial genomic resources. Current animal models lack non-induced deformities and the experimental tractability necessary for genetic studies. The fact that fish are free of an appendicular skeleton should allow for analysis of basic spinal integrity without the biomechanical constraints observed in quadrupedal and bipedal models. To illustrate the point we review human idiopathic scoliosis and the potential contribution teleosts can make for the identification of causes, risk factors, and treatment options.     

Aetiology of skeletal deformities in the Zebra Danio fish (Bruchydanio rerio, Hamilton-Buchanan)

Laboratory bred Zebra Danio ( Brachydanio rerio , Hamilton-Buchanan) tropical fish are prone to skeletal deformities resembling scoliosis and lordosis. This condition appears related to diet and has been studied by breeding from different broods of fish for three generations. Two broods bred using two commercially available tropical flaked foods developed severe spinal curvature three to six weeks post-hatching. A third brood of fish fed exclusively on live food did not develop any deformity. The results demonstrate that a dietary factor is responsible for the deformities and that the Zebra Danio is especially susceptible to this factor as other species breed normally when fed the same commercial diet. Analysis of the diets showed no deficiency in either ascorbic acid (Vitamin C) or tryptophan, deficiency of either being associated with scoliosis and lordosis in fish. The analysis did show, however, a relationship between the lead content of the diet and the incidence of deformities. Lead has previously been implicated in skeletal deformities in second and third generation Brook trout, Salvelinus fontinalis.