The three-dimensional easy morphological (3-DEMO) classification of scoliosis – Part III, correlation with clinical classification and parameters

Background

The shape of the torso in patients with idiopathic scoliosis is considered to reflect the shape of the vertebral column, however the direct correlation between parameters describing clinical deformity and those characterizing radiological curvature was reported to be weak. It is not clear if the management proposed for scoliosis (physiotherapy, brace, surgery) affects equally the shape of the axial skeleton and the surface of the body. The aim of the study was to compare clinical deformity of (1) idiopathic scoliosis girls being under brace treatment for radiological curves of 25 to 40 degrees and (2) non treated scoliotic girls matched for age and Cobb angle.

Methods

Cross-sectional study of 24 girls wearing the brace versus 26 girls without brace treatment, matched for age and Cobb angle. Hypothesis: Patients wearing the brace for more than 6 months, when comparing to patients without brace, may present different external morphology of the trunk, in spite of having similar Cobb angle. Material. Inclusion criteria: girls, idiopathic scoliosis, growing age (10–16 years), Cobb angle minimum 25°, maximum 40°. The braced group consisted of girls wearing a TLSO brace (Cheneau) for more than 6 months with minimum of 16 hours per day. The non-braced group consisted of girls first seen for their spinal deformity, previously not treated. The groups presented similar curve pattern. Methods. Scoliometer exam: angle of trunk rotation at three levels of the spine: upper thoracic, main thoracic, lumbar or thoracolumbar. The maximal angle was noted at each level and the sum of three levels was calculated. Posterior trunk symmetry index (POTSI) and Hump Sum were measured using surface topography.

Results

Cobb angle was 34.9° ± 4.8° in braced and 32.7° ± 4.9° in un-braced patients (difference not significant). The age was 14.1 ± 1.6 years in braced patients and 13.1 ± 1.9 years in un-braced group (p = 0.046). The value of angle of trunk rotation in the main curvature was 8.4° ± 2.7°in braced and 11.4° ± 2.7° in un-braced patients (difference extremely significant, p = 0.0003). The value of the sum of angles of trunk rotation at three levels of the trunk was 12.8° ± 4.6° in braced and 16.5° ± 3.8° in un-braced patients (difference very significant, p = 0.0038). The POTSI did not differ significantly between the groups (p = 0.78), the Hump Sum values were not quite different (p = 0.07).

Conclusion

(1) Adolescent girls wearing the brace for idiopathic scoliosis of 25 to 40 degrees of Cobb angle, reveal smaller clinical rotational deformity of their back than non-treated girls having similar radiological deformity. (2) evaluation of the results of treatment for idiopathic scoliosis should consider parameters describing both clinical and radiological deformity.     

The direct cost of "Thriasio" school screening program

Background

Adolescent girls treated with a brace for scoliosis are submitted to prolonged stress related to both the disease and the therapy. Currently proposed quality of life questionnaires are focused on the outcome of therapy. Bad Sobernheim Stress Questionnaire (BSSQ) enables monitoring of patients being under treatment with a brace or exercises. The aim of the study was to assess the stress level in conservatively managed scoliotic girls using BSSQ.

Materials and methods

111 girls, aged 14,2 ± 2,2 years, mean Cobb angle of the primary curve 42,8° ± 17,0° and mean Bunnell angle of 11,4° ± 4,5° were examined with two versions of BSSQ (Deformity and Brace). The analysis considered the type of treatment, curve location, correlation of the total score with age, Cobb angle and Bunnell rotation angle.

Results

The BSSQ Deformity revealed the median of 17 points in patients managed with exercises (from 4 to 24 points), 18 in patients managed with a brace (from 8 to 24 points) and 12 in patients before surgery (from 3 to 21 points). Braced patients who completed both questionnaires (n = 50) revealed significantly higher score with BSSQ Deformity (median = 18) comparing to BSSQ Brace (median = 9). There was a correlation between the total score of BSSQ Deformity and the Cobb angle (r = -0,34), Bunnell primary curve rotation (r = -0,34) and Bunnell sum of rotation (r = -0,33) but not with the age of patients.

Conclusion

Scoliotic adolescents managed with exercises and brace suffered little stress from the deformity. The brace increased the level of stress over the stress induced by the deformity. The stress level correlated with clinical deformity (Bunnell angle), radiological deformity (Cobb angle) and the type of treatment (exercises, bracing, surgery). Bad Sobernheim Stress Questionnaires are simple and helpful in the management of girls treated conservatively for idiopathic scoliosis.     

Effect of an elongation bending derotation brace on the infantile or juvenile scoliosis

Background

A wide variety of braces are commercially available designed for the adolescent idiopathic scoliosis (AIS), but very few braces for infantile scoliosis (IS) or juvenile scoliosis (JS). The goals of this study were: 1) to briefly introduce an elongation bending derotation brace (EBDB) in the treatment of IS or JS; 2) to investigate changes of Cobb angles in the AP view of X-ray between in and out of the EBDB at 0, 3, 6, 9, and 12 months; 3) to compare differences of Cobb angles (out of brace) in 3, 6, 9, and12 month with the baseline; 4) to investigate changes (out of brace) in JS and IS groups separately.

Methods

Thirty-eight patients with IS or JS were recruited retrospectively for this study. Spinal manipulation was performed using a stockinet. This was done simultaneously with a surface topography scan. The procedure was done in the operating room for IS, or in a clinical setting for JS. The brace was edited and fabricated using CAD/CAM method. Radiographs were recorded in and out of bracing approximately every 3 months from baseline to 12 months. A linear mixed effects model was used to compare in and out of bracing, and out of brace Cobb angle change over the 12 month period.

Results

Overall, 37.5% of curves are corrected and 37.5% stabilized after 12 months (Thoracic curves 48% correction, 19% stabilization; thoracolumbar curves 33% correction, 56% stabilization and lumbar curves 29% correction, 50% stabilization). The juvenile group had 25.7% correction and 42.9% stabilization, while the infantile group had 50% correction and 32.1% stabilization. There was a significant Cobb angle in-brace reduction in the thoracic (11°), thoracolumbar (12°), and lumbar (12°) (p?<?0.001). There was no statistically significant change in out of brace Cobb angle from baseline to month 12 (p?>?0.05). No patients required surgery within the 12 month span.

Conclusions

This study describes a new clinical protocol in the development of the EBDB. Short-term results show brace is effective in preventing IS or JS curve progression over a 12 month span.

     

School screening for scoliosis: can surface topography replace examination with scoliometer?

Background

Although most idiopathic scoliosis patients subject to conservative treatment in daily clinical practice, there have been no ideal methods to evaluate the spinal flexibility for the patients who are scheduled the brace treatment. The purpose of this study was to investigate the value of hanging total spine x-ray to estimate the indicative correction angle by brace wearing in idiopathic scoliosis patients.

Methods

One hundred seventy-six consecutive patients with idiopathic scoliosis who were newly prescribed the Osaka Medical College (OMC) brace were studied. The study included 14 boys and 162 girls with a mean age of 13 years and 1 month. The type of curves consisted of 62 thoracic, 23 thoracolumbar, 22 lumbar, 42 double major, 14 double thoracic, and 13 triple curve pattern. We compared the Cobb angles on initial brace wearing (BA) and in hanging position (HA). Of those, 108 patients who had main thoracic curves were selected and evaluated the corrective ability of OMC brace. These subjects were divided into three groups according to the relation between BA and HA (BA < HA group, BA = HA group, and BA > HA group), and then, maturity was compared among them.

Results

The average Cobb angle in upright position (UA) of all cases was 31.0 ± 7.8°. The average BA and HA of all cases were 20.3 ± 9.5° and 21.1 ± 8.4°, respectively. The average chronological age was lowest in BA < HA group. And also, maturity in BA < HA group was the lowest among each of them. The rate of BA < HA cases were decreased as the Risser stage of the patients were progressed.

Conclusions

The use of hanging total spine x-ray served as a useful tool to estimate the degree of correction possible curve within the OMC brace for main thoracic curve in idiopathic scoliosis. Maturity had some influence on the correlation between HA and BA. Namely, in immature patients, HA tended to be larger than BA. In contrast, in mature patients, HA had a tendency to be smaller than BA. With consideration for spinal flexibility based on maturity, in mature patients, larger BA than HA may be allowed. However, in immature patients, smaller BA than HA should be aimed.     

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.     

The three dimensional analysis of the Sforzesco brace correction

Background

Scoliosis is a three dimensional deformity, and brace correction should be 3D too. There is a lack of knowledge of the effect of braces, particularly in the sagittal and transverse plane. The aim of this study is to analyse the Sforzesco Brace correction, through all the parameters provided by Eos 3D imaging system.

Method

Design: This is a cross sectional study from a prospective database started in March 2003.Participants: 16 AIS girls (mean age 14.01) in Sforzesco brace treatment, with EOS x-rays, at start, in brace after 1 month and out of brace after the first 4 months of treatment. Outcome measures: All the parameters and the Torsio-Index obtained from 3D Eos System, in and out of brace, in the three planes. Statistical analysis: the variability of the parameters and the mean differences were analyzed and compared using paired T test. ANOVA was used for multiple comparisons. Critical P value was set at 0.05.

Results

In the comparison of in-brace vs start of treatment, the mean Cobb angle changed significantly from 36.44 +/? 4 to 28.99?+??3.9° (p?=?0.01). Significant changes in all the sagittal parameters were found (p?=?0.02). In the axial plane, the Torsio Index changed significantly in-brace for thoracolumbar and lumbar curves (P?<?0.05). The analysis of the single vertebral tilt demonstrated that the effect of the brace is mostly concentrated at specific segments: T4-T5, T10-T12, L1 and L5 in the axial plane and T3-T6 and T10-L1 in the frontal plane.

Conclusion

The Sforzesco brace mostly modifies the middle of the spine and preserves the sagittal balance. The single vertebral orientation in each plane should be considered together with the typically used values to assess brace effect.

     

Segmental correction of adolescent idiopathic scoliosis by all-screw fixation method in adolescents and young adults. minimum 5 years follow-up with SF-36 questionnaire

Background

In our institution, the fixation technique in treating idiopathic scoliosis was shifted from hybrid fixation to the all-screw method beginning in 2000. We conducted this study to assess the intermediate -term outcome of all-screw method in treating adolescent idiopathic scoliosis (AIS).

Methods

Forty-nine consecutive patients were retrospectively included with minimum of 5-year follow-up (mean, 6.1; range, 5.1-7.3 years). The average age of surgery was 18.5 ± 5.0 years. We assessed radiographic measurements at preoperative (Preop), postoperative (PO) and final follow-up (FFU) period. Curve correction rate, correction loss rate, complications, accuracy of pedicle screws and SF-36 scores were analyzed.

Results

The average major curve was corrected from 58.0 ± 13.0° Preop to 16.0 ± 9.0° PO(p < 0.0001), and increased to 18.4 ± 8.6°(p = 0.12) FFU. This revealed a 72.7% correction rate and a correction loss of 2.4° (3.92%). The thoracic kyphosis decreased little at FFU (22 ± 12° to 20 ± 6°, (p = 0.25)). Apical vertebral rotation decreased from 2.1 ± 0.8 PreOP to 0.8 ± 0.8 at FFU (Nash-Moe grading, p < 0.01). Among total 831 pedicle screws, 56 (6.7%) were found to be malpositioned. Compared with 2069 age-matched Taiwanese, SF-36 scores showed inferior result in 2 variables: physical function and role physical.

Conclusion

Follow-up more than 5 years, the authors suggest that all-screw method is an efficient and safe method.     

Manual therapy as a conservative treatment for adolescent idiopathic scoliosis: a systematic review

Background

Studies on adolescent idiopathic scoliosis have well documented the differences between natural history of male and female patients. There are also differences in responses to nonoperative treatment, but the results of operative treatment in male patients compared with females have not been widely reported. Only few studies had compared the outcomes of operative treatment between male and female patients with different results.

Methods

We retrospectively reviewed the outcome of 150 (112 girls and 38 boys) consecutive patients with diagnosis of adolescent idiopathic scoliosis who were managed surgically between May 1996 and September 2005. Next, male radiographic parameters were compared with female ones pre- and postoperatively. Then, a subgroup of 38 matched girls was compared regarding the age, curve type, curve magnitude, and the instrumentation we used.

Results

In comparing male patients with unmatched girls, the boys had greater mean age (17.3 ± 2.3 vs. 16.3 ± 2.9; p = 0.049), greater primary curve (71.4 ± 21.3° vs. 62.7 ± 17.5°; p = 0.013), less flexibility (30.1 ± 13.5% vs. 40.3 ± 17.8%; p = 0.01), and less correction percentage (51.3 ± 12.9% vs. 58.8 ± 16.5%; p = 0/013). The loss of correction was comparable between the two groups. In the matched comparison, the flexibility in boys was less than girls (30.1 ± 13.5% vs. 38.1 ± 17.5%; p = 0.027). Also, the boys had a smaller correction percentage compared to the girls, but this finding was not statistically significant.

Conclusion

There was similar distribution curve pattern between male and female patients with AIS. Males had more rigid primary curves compared to females but a similar degree of postoperative scoliosis correction. Male AIS patients were older at the time of surgery. These preoperative gender differences, however; did not compromise the radiological outcomes of surgical treatment and the results were comparable between the genders.     

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.     

A reliability and validity study for Scolioscan: a radiation-free scoliosis assessment system using 3D ultrasound imaging

Background

Radiographic evaluation for patients with scoliosis using Cobb method is the current gold standard, but radiography has radiation hazards. Several groups have recently demonstrated the feasibility of using 3D ultrasound for the evaluation of scoliosis. Ultrasound imaging is radiation-free, comparatively more accessible, and inexpensive. However, a reliable and valid 3D ultrasound system ready for clinical scoliosis assessment has not yet been reported. Scolioscan is a newly developed system targeted for scoliosis assessment in clinics by using coronal images of spine generated by a 3D ultrasound volume projection imaging method. The aim of this study is to test the reliability of spine deformity measurement of Scolioscan and its validity compared to the gold standard Cobb angle measurements from radiography in adolescent idiopathic scoliosis (AIS) patients.

Methods

Prospective study divided into two stages: 1) Investigation of intra- and inter- reliability between two operators for acquiring images using Scolioscan and among three raters for measuring spinal curves from those images; 2) Correlation between the Cobb angle obtained from radiography by a medical doctor and the spine curve angle obtained using Scolioscan (Scolioscan angle). The raters for ultrasound images and the doctors for evaluating radiographic images were mutually blinded. The two stages of tests involved 20 (80 % females, total of 26 angles, age of 16.4?±?2.7 years, and Cobb angle of 27.6?±?11.8°) and 49 (69 % female, 73 angles, 15.8?±?2.7 years and 24.8?±?9.7°) AIS patients, respectively. Intra-class correlation coefficients (ICC) and Bland-Altman plots and root-mean-square differences (RMS) were employed to determine correlations, which interpreted based on defined criteria.

Results

We demonstrated a very good intra-rater and intra-operator reliability for Scolioscan angle measurement with ICC larger than 0.94 and 0.88, respectively. Very good inter-rater and inter-operator reliability was also demonstrated, with both ICC larger than 0.87. For the thoracic deformity measurement, the RMS were 2.5 and 3.3° in the intra- and inter-operator tests, and 1.5 and 3.6° in the intra- and inter-rater tests, respectively. The RMS differences were 3.1, 3.1, 1.6, 3.7° in the intra- and inter-operator and intra- and inter-rater tests, respectively, for the lumbar angle measurement. Moderate to strong correlations (R²?>?0.72) were observed between the Scolioscan angles and Cobb angles for both the thoracic and lumbar regions. It was noted that the Scolioscan angle slightly underestimated the spinal deformity in comparison with Cobb angle, and an overall regression equation y?=?1.1797x (R²?=?0.76) could be used to translate the Scolioscan angle (x) to Cobb angle (y) for this group of patients. The RMS difference between Scolioscan angle and Cobb angle was 4.7 and 6.2°, with and without the correlation using the overall regression equation.

Conclusions

We showed that Scolioscan is reliable for measuring coronal deformity for patients with AIS and appears promising in screening large numbers of patients, for progress monitoring, and evaluation of treatment outcomes. Due to it being radiation-free and relatively low-cost, Scolioscan has potential to be widely implemented and may contribute to reducing radiation dose during serial monitoring.

     

Retrospective analysis of idiopathic scoliosis medical records coming from one out-patient clinic for compatibility with Scoliosis Research Society criteria for brace treatment studies

Background

First author attempted to analyse medical records of patients with idiopathic scoliosis for compliance with the Scoliosis Research Society brace studies criteria. A retrospective analysis of medical records of 2705 girls treated from 1989 to 2002 was carried out.

Methods

Age, Cobb, Risser and menarchal status were analyzed for compliance with the Scoliosis Research Society brace studies criteria: a) age ≥10 years, b) Risser 0–2, c) 25–40° Cobb angle, d) no earlier treatment, e) patients before first menses or not more than one year from first menses.

Results

It has been found that 183 girls out of 2705 were ≥10 years old and in the range 25–40° Cobb angle. One hundred two out of 2705 patients revealed eligible for brace effectiveness study according to SRS 2005 criteria. 120 out of 2705 patients revealed eligible for brace brace effectiveness study according to SRS-SOSORT 2014 criteria.

Conclusion

The excluded patients revealed too old or with too significant Cobb angles. This indicates the changing criteria for scoliosis brace treatment over the time. Direct comparison of current results of brace treatment with historical series of cases turns out to be very difficult.

     

The flying buttress construct for posterior spinopelvic fixation: a technical note

Background

School screening for adolescent idiopathic scoliosis (AIS) is discussed. The aim of the present study was to describe the point prevalence of AIS and to evaluate the effectiveness of school screening in 12-year- old children.

Methods

Community nurses and physical therapists in the Southern Health region of Norway including about 12000 school children aged 12 years were invited to participate. All participating community nurses and physical therapists fulfilled an educational course to improve their knowledge about AIS and learn the screening procedure including the Adam Forward Bending Test and measurement of gibbus using a scoliometer.

Results

Sub-regions including 4000 school children participated. The prevalence of idiopathic scoliosis defined as a positive Adam Forward Bending Test, gibbus > 7° and primary major curve on radiographs > 10°, was 0.55%. Five children (0.13%) had a major curve > 20°. Bracing was not indicated in any child; all children were post menarche; four had Risser sign of 4, and one with Risser 1 did not have curve progression > 5° at later follow-up. In one of these 5 children however, the major curve progressed to 45° within 7 months after screening and the girl was operated.

Conclusion

The point prevalence of AIS in 12- year old children is in agreement or slightly lower than previous studies. The screening model employed demonstrates acceptable sensitivity and specificity and low referral rates. Screening at the age of 12 years only was not effective for detecting patients with indication for brace treatment.     

Real time noninvasive assessment of external trunk geometry during surgical correction of adolescent idiopathic scoliosis

Study design

Retrospective study.

Objective

To evaluate the radiological results of fusion with segmental pedicle screw fixation in juvenile idiopathic scoliosis with a minimum 5-year follow-up.

Summary of background data

Progression of spinal deformity after posterior instrumentation and fusion in immature patients has been reported by several authors. Segmental pedicle screw fixation has been shown to be effective in controlling both coronal and sagittal plane deformities. However, there is no long term study of fusion with segmental pedicle screw fixation in these group of patients.

Methods

Seven patients with juvenile idiopathic scoliosis treated by segmental pedicle screw fixation and fusion were analyzed. The average age of the patients was 7.4 years (range 5–9 years) at the time of the operation. All the patients were followed up 5 years or more (range 5–8 years) and were all Risser V at the most recent follow up. Three dimensional reconstruction of the radiographs was obtained and 3DStudio Max software was used for combining, evaluating and modifying the technical data derived from both 2d and 3d scan data.

Results

The preoperative thoracic curve of 56 ± 15° was corrected to 24 ± 17° (57% correction) at the latest follow-up. The lumbar curve of 43 ± 14° was corrected to 23 ± 6° (46% correction) at the latest follow-up. The preoperative thoracic kyphosis of 37 ± 13° and the lumbar lordosis of 33 ± 13° were changed to 27 ± 13° and 42 ± 21°, respectively at the latest follow-up. None of the patients showed coronal decompensation at the latest follow-up. Four patients had no evidence of crankshaft phenomenon. In two patients slight increase in Cobb angle at the instrumented segments with a significant increase in AVR suggesting crankshaft phenomenon was seen. One patient had a curve increase in both instrumented and non instrumented segments due to incorrect strategy.

Conclusion

In juvenile idiopathic curves of Risser 0 patients with open triradiate cartilages, routine combined anterior fusion to prevent crankshaft may not be warranted by posterior segmental pedicle screw instrumentation.     

Right ventricular function impaired in children and adolescents with severe idiopathic scoliosis

Background

Although it is speculated that scoliosis may induce cardiac dysfunction, there is no report about evaluation of cardiac function, especially right cardiac function in patients with scoliosis. Therefore, we evaluated right ventricular function in idiopathic scoliotic patients with mild to severe curves and compared them with healthy children and adolescents matched in age, then explored relationship between scoliosis and right ventricular function.

Methods

Thirty-seven patients diagnosed with idiopathic scoliosis with a mean age of 16y/o (range, 8-25y/o) and an average spine curve of 77.5°Cobb (range, 30-157°) were studied by echocardiography. TAD was obtained using M-mode echocardiography. Similar examination was performed in a control group of 17 healthy individuals in matched-age. According to the different curve degree, all patients were divided into 3 groups (mild, moderate and severe). Comparison was done among the groups and the relationship between TAD and spine curve of Cobb was analyzed.

Results

Patients with severe scoliosis showed depressed TAD. There was good correlation between TAD and spine curve of Cobb.

Conclusions

Patients with severe scoliosis showed a significant lower right ventricular systolic function.     

Magnetic resonance imaging of the erector spinae muscles in Duchenne muscular dystrophy: implication for scoliotic deformities

Background

In patients with structural idiopathic scoliosis the body asymmetries involve the pelvis and the lower limbs; they are included in many theories debating the pathogenesis of idiopathic scoliosis.

Methods

Hip joint range of motion was studied in 158 adolescent girls, aged 10–18 years (mean 14.2 ± 2.0) with structural idiopathic scoliosis of 20–83° of Cobb angle (mean 43.0° ± 14.5°) and compared to 57 controls, sex and age matched. Hip range of rotation was examined in prone position, the pelvis level controlled with an inclinometer; hip adduction was tested in five different positions.

Results

In girls with structural scoliosis the symmetry of hip rotation was less frequent (p = 0.0047), the difference between left and right hip range of internal rotation was significantly higher (p = 0.0013), and the static rotational offset of the pelvis, calculated from the mid-points of rotation, revealed significantly greater (p = 0.0092) than in healthy controls. The detected asymmetries comprised no limitation of hip range of motion, but a transposition of the sector of motion, mainly towards internal rotation in one hip and external rotation in the opposite hip. The data failed to demonstrate the curve type, the Cobb angle, the angle of trunk rotation or the curve progression factor to be related to the hip joint asymmetrical range of motion.

Conclusion

Numerous asymmetries around the hip were detected, most of them were expressed equally in scoliotics and in controls. Pathogenic implications concern producing a "torsional offset" of muscles patterns of activation around the spine in adolescent girls with structural idiopathic scoliosis during gait.     

The transformation of spinal curvature into spinal deformity: pathological processes and implications for treatment

Background

Chêneau-Brace treatment of a certain standard reduces the rate of surgery, prevents progression and in a certain patient population leads to marked improvement of Cobb angle and cosmetic appearance. During the last two years a patient refusing surgery with a double major curvature of initially 60° showed a clear cosmetic improvement and a clear radiological progression at the same time. The findings of this patient have been reviewed in order to find out how cosmetic appearance and Cobb angle can develop differently.

Methods

The patient entered conservative treatment at the age of 13 years, premenarchial with Tanner II and a Cobb angle of 60° thoracic and 59° lumbar. The angle of trunk rotation (ATR; Scoliometer) was 13° thoracic and 13° lumbar. We have documented the findings of this patient (Surface topography, ATR, Cobb angles and angles of vertebral rotation (according to Raimondi) during the treatment period (27 Month) until 2 years after the onset of menarche.

Results

After a treatment time of 27 Month the Cobb angle increased to 74° thoracic and 65° lumbar. The angles of vertebral rotation according to Raimondi increased slightly from 26° thoracic and 28° lumbar to 30° thoracic and 28° lumbar. The ATR improved to 12° thoracic and 5° lumbar while Lateral deviation improved from 22,4 mm to 4,6 mm and average surface rotation improved from 10,6° to 6°. In the X-rays a reduction of decompensation was visible. The patient felt comfortable with the cosmetic result.

Conclusion

Conservative treatment may improve cosmetic appearance while the curve progresses radiologically. This could be explained by assuming that (1) the Rigo Chêneau brace is able to improve cosmetic appearance by changing the shape of the thorax when the curve itself is too stiff to be corrected by a brace, that (2) reduction of decompensation leads to significant cosmetical improvements or (3) that the patient gained weight and therefore the deformation is masked. However, the weight the patient gained cannot explain the cosmetical improvement in this case. Conservative treatment with a certain standard of quality seems a viable alternative for patients with Cobb angles of > 60° when surgical treatment is refused. Specialists in scoliosis management should be aware of the fact that curve progression can occur even if the clinical measurements show an improvement.     

The utility of superficial abdominal reflex in the initial diagnosis of scoliosis: a retrospective review of clinical characteristics of scoliosis with syringomyelia

Background

The incidence of spinal deformity in children with Prader-Willi syndrome (PWS) is high, with 86% of these patients found to have a significant structural scoliosis; however, there are very few case reports describing surgical treatment for this deformity.

Methods

The authors reviewed a case series consisting of 6 patients who underwent spine surgery for scoliosis. Children's mean age at index surgery was 12 years and 10 months (range, 10 to 15 yrs). Clinical evaluation revealed the typical phenotypic features of the PWS in all of the patients; 4 subjects had a karyotype confirmation of PWS. Major structural curves showed preoperative mean Cobb angles of 80.8° (range, 65° to 96°). Hybrid instrumentation with sublaminar wires, hooks and screws was used in the first 2 patients, while the remaining 4 were treated with titanium pedicle screw constructs.

Results

The mean clinical and radiological follow-up was 3 years and 10 months (range, 2 years to 9 years). Major complication rate was 50%. One patient who developed a major intraoperative complication (paraparesis) prevented spinal fusion to be obtained: the neurologic deficit resolved completely after instrumentation removal. Solid arthrodesis and deformity correction in both coronal and sagittal plane was, however, achieved in the other 5 cases and no significant curve progression was observed at follow-up. Another major short-term complication was encountered 3 months after surgery in a patient who experienced the detachment of a distally located rod and required correction through revision surgery and caudal extension by one level. Cervico-thoracic kyphosis was seen in 1 patient who did not require revision surgery.

Conclusions

Spine reconstructive surgery in patients with PWS is rare and highly demanding. The best method of reconstruction is posterior multilevel pedicle screw fixation. Moreover, even with modern techniques, the risk of complications is still high. These new techniques, however, have shown to improve the postoperative course by allowing for immediate mobilization without any brace or cast. The use of the growing rod techniques, requiring repeated surgeries, should be carefully evaluated in each single case.