Important articles
1. Analysis and simulation of progressive adolescent scoliosis by biomechanical growth modulation
3. Differential diagnosis of back pain in adult scoliosis (non operated patients)
8. Indications for conservative management of scoliosis (guidelines)
9. European Braces for Conservative Scoliosis Treatment
13. Radiological and cosmetic improvement 2 years after brace weaning—a case report
14. Rate of complications in scoliosis surgery – a systematic review of the Pub Med literature
15. "Rehabilitation schools for scoliosis" thematic series: describing the methods and results
17. Spinal deformities rehabilitation - state of the art review
18. The method of Katharina Schroth - history, principles and current development
19. Treatment of the congenital scoliosis by Cheneau brace: 2 year follow-up
Analysis and simulation of progressive adolescent scoliosis by biomechanical growth modulation
Scoliosis is thought to progress during growth because spinal deformity produces asymmetrical spinal loading, generating asymmetrical growth, etc. in a ‘vicious cycle.’ The aim of this study was to test quantitatively whether calculated loading asymmetry of a spine with scoliosis, together with measured bone growth sensitivity to altered compression, can explain the observed rate of scoliosis progression in the coronal plane during adolescent growth.
The simulated spinal geometry represented a lumbar scoliosis of different initial magnitudes, averaged and scaled from measurements of 15 patients’ radiographs. Level-specific stresses acting on the vertebrae were estimated for each of 11 external loading directions (‘efforts’) from published values of spinal loading asymmetry. These calculations assumed a physiologically plausible muscle activation strategy. The rate of vertebral growth was obtained from published reports of growth of the spine. The distribution of growth across vertebrae was modulated according to published values of growth sensitivity to stress. Mechanically modulated growth of a spine having an initial 13° Cobb scoliosis at age 11 with the spine subjected to an unweighted combination of eleven loading conditions (different effort direction and magnitude) was predicted to progress during growth. The overall shape of the curve was retained. The averaged final lumbar spinal curve magnitude was 32° Cobb at age 16 years for the lower magnitude of effort (that produced compressive stress averaging 0.48 MPa at the curve apex) and it was 38° Cobb when the higher magnitudes of efforts (that produced compressive stress averaging 0.81 MPa at the apex). An initial curve of 26° progressed to 46°and 56°, respectively. The calculated stresses on growth plates were within the range of those measured by intradiscal pressures in typical daily activities. These analyses predicted that a substantial component of scoliosis progression during growth is biomechanically mediated.
The rationale for conservative management of scoliosis during skeletal growth assumes a biomechanical mode of deformity progression (Hueter- Volkmann principle). The present study provides a quantitative basis for this previously qualitative hypothesis. The findings suggest that an important difference between progressive and non-progressive scoliosis might lie in the differing muscle activation strategies adopted by individuals, leading to the possibility of improved prognosis and conservative or less invasive interventions...read more
Brace treatment for patients with Scheuermann's disease - a review of the literature and first experiences with a new brace design
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 methods
56 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.Discussion
If 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...read more
Differential diagnosis of back pain in adult scoliosis (non operated patients)
The relationship between back pain and scoliosis is not clear. Old long-term follow-up studies reported no greater incidence or degree of back pain in adult scoliosis than in normal population when matched for age and sex. At the end of the seventies studies were contradictories. While Fowles et al (1978) concluded that untreated scoliosis could be considered as a disabling disease in the adult particularly after the age of 30, Nachemson (1979) reported a minimal risk of disabling back pain in adult patients with lumbar curves stating that ‘whether severe low back pain occurs more often in adults who have lumbar curves than in those whose spines are straight is open to question’. Later, in 1981, Weinstein et al found that backache was more common in scoliosis patients than in the general population with no relation between back pain and the presence of osteoarthritic changes. Kostuik and Ventivoglio (1981) reported a similar incidence of low back pain (59%) in subjects with lumbar or thoracolumbar curves and normal population. However, they found a correlation between back pain and severity of the curve especially for curves of more than 45°, while patients with no pain tended to have smaller curves. Jackson et al (1983) confirmed that incidence was comparable between adult scoliosis and general population but severity was greater in scoliotic patients. They found that patients with lumbar curve had more pain. Compensatory lumbosacral curves were most painful and disabling. The controversy about how well or bad scoliosis population do it (pain and function) during adult life still continued during the nineties and while the results from the Ste-Justine Adolescent Idiopathic Scoliosis Cohort Study suggested that back pain is responsible for a considerable amount of disability and handicap in later life, the revisited sample from Weinstein et al, showed that untreated late onset idiopathic scoliosis causes little physical impairment other than back pain and cosmetic concerns, with these patients being productive and functional at high level at 50-year follow up. In agreement with the Ste-Justine’s study, Schwab F et al (2003) studied the effect of scoliosis in the self-perception of health and showed that patients in this study averaged scores (SF-36) much lower than the norm from both the general US population in all 8 categories and the US population for ages 55-64 in 7 out of 8 categories of the SF-36 questionnaire. Whether or not idiopathic scoliosis developed during growth will alter health related quality of life later and how conservative and/or surgical treatment will change its natural history is something needing further research, however, from a practical point of view, here the question is not that but how scoliosis condition affects the diagnose, prognosis and management of adult patients suffering from chronic back pain...read more
Discrepancy in clinical versus radiological parameters describing deformity due to brace treatment for moderate idiopathic scoliosis
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...read more
Effect of conservative management on the prevalence of surgery in patients with adolescent idiopathic scoliosis
STUDY DESIGN
Retrospective analysis of outcome in terms of prevalence of surgery for adolescent idiopathic scoliosis in patients receiving conservative management.
OBJECTIVES
To determine whether a centre with an active policy of conservative management has fewer patients who eventually undergo surgery for adolescent idiopathic scoliosis than a centre where the practice is non-intervention.
BACKGROUND DATA
The efficacy of orthoses for the treatment of idiopathic scoliosis was called into question in a recent publication. Because the prevalence of surgery in an untreated group of patients (28.1%) was not significantly different from that in a braced group (22.4%), the authors concluded that bracing appears to make no difference. Based on prior experience, this conclusion is questioned.
METHODS
Since 1991, bracing and physical therapy have been recommended for children with adolescent idiopathic scoliosis at a centre in Barcelona, Spain. The scoliosis database was searched for patients with adolescent idiopathic scoliosis who were at least 15 years of age at last review and who had adequate documentation of the Cobb angle. The prevalence of surgery was compared with that of published data from a centre where the practice is non-intervention.
RESULTS
From a total of 106 braced cases out of which 97 were followed up, six cases (5.6%) ultimately underwent spinal fusion. A worst case analysis, which assumes that all nine cases that were lost to follow-up had operations, brings the uppermost number of cases that could have undergone spinal fusion to 15 (14.1%). Either percentage is significant statistically when compared to the 28.1% reported surgeries from the centre with the policy of non-intervention.
CONCLUSIONS
If conservative management does reduce the proportion of children with adolescent idiopathic scoliosis that require surgery, it can be said to provide a real and meaningful advantage to both the patients and the community. It is contended that conservative methods of treatment should never be ruled out from scoliosis management, because they can and do offer a viable alternative to those patients who cannot or will not opt for surgical treatment...read more
Effectiveness of Chêneau brace treatment for idiopathic scoliosis: prospective study in 79 patients followed to skeletal maturity
Background
Progressive idiopathic scoliosis can negatively influence the development and functioning of 2-3% of adolescents, with health consequences and economic costs, placing the disease in the centre of interest of the developmental medicine. The aim of this study was to evaluate the effectiveness of Chêneau brace in the management of idiopathic scoliosis.
Methods
A prospective observational study according to SOSORT and SRS recommendations comprised 79 patients (58 girls and 21 boys) with progressive idiopathic scoliosis, treated with Chêneau brace and physiotherapy, with initial Cobb angle between 20 and 45 degrees, no previous brace treatment, Risser 4 or more at the final evaluation and minimum one year follow-up after weaning the brace. Achieving 50° of Cobb angle was considered surgical recommendation.
Results
At follow-up 20 patients (25.3%) improved, 18 patients (22.8%) were stable, 31 patients (39.2%) progressed below 50 degrees and 10 patients (12.7%) progressed beyond 50 degrees (2 of these 10 patients progressed beyond 60 degrees). Progression concerned the younger and less skeletally mature patients.
Conclusion
Conservative treatment with Chêneau orthosis and physiotherapy was effective in halting scoliosis progression in 48.1% of patients. The results of this study suggest that bracing is effective in reducing the incidence of surgery in comparison with natural history...read more
Guidelines on "Standards of management of idiopathic scoliosis with corrective braces in everyday clinics and in clinical research": SOSORT Consensus 2008
Background
Reported failure rates,(defined based on percentage of cases progressing to surgery) of corrective bracing for idiopathic scoliosis are highly variable. This may be due to the quality of the brace itself, but also of the patient care during treatment. The latter is sometimes neglected, even though it is considered a main determinant of good results among conservative experts of SOSORT. The aim of this paper was to develop and verify the Consensus on management of scoliosis patients treated with braces.
Methods
We followed a Delphi process in four steps, distributing and gradually changing according to the results 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 Athens Meeting with a Meeting Questionnaire (MQ). We set a 90% agreement as the minimum to be reached.
Results
We had a 71% response rate to PMQ, and 66.7% to MQ. Since the PMQ we had a good agreement (no answers below 72% – 70.2% over 90%). With the MQ the agreement consistently increased for all the answers previously below 90% (no answers below 83%, 75% over 90%). With increasing experience in bracing all numerical criteria tended to become more strict. We finally produced a set of 14 recommendations, grouped in 6 Domains (Experience/competence, Behaviours, Prescription, Construction, Brace Check, Follow-up).
Conclusion
The Consensus permits establishment of recommendations concerning the standards of management of idiopathic scoliosis with bracing, with the aim to increase efficacy and compliance to treatment. The SOSORT recommends to professionals engaged in patient care to follow the guidelines of this Consensus in their clinical practice. The SOSORT criteria should also be followed in clinical research studies to achieve a minimum quality of care. If the aim is to verify the efficacy of bracing these criteria should be companions of the methodological research criteria for bracing proposed by other societies...read more
Indications for conservative management of scoliosis (guidelines)
Abstract
This guideline has been discussed by the SOSORT guideline committee prior to the SOSORT consensus meeting in Milan, January 2005 and published in its first version on the SOSORT homepage: http://www.sosort.org/meetings.php webcite. After the meeting it again has been discussed by the members of the SOSORT guideline committee to establish the final 2005 version submitted to Scoliosis, the official Journal of the society, in December 2005.
Definition
Scoliosis is defined as a lateral curvature of the spine with torsion of the spine and chest as well as a disturbance of the sagittal profile [2].
Etiology
Idiopathic scoliosis is the most common of all forms of lateral deviation of the spine. By definition, it is a lateral curvature of the spine in an otherwise healthy child, for which a currently recognizable cause has not been found. Less common but better defined etiologies of the disorder include scoliosis of neuromuscular origin, congenital scoliosis, scoliosis in neurofibromatosis, and mesenchymal disorders like Marfan's syndrome [3]...read more
European Braces for Conservative Scoliosis Treatment
Several published articles suggest that an untreated progressive idiopathic scoliosis (IS) curve may present a poor prognosis into adulthood including back pain, pulmonary compromise, cor pulmonale, psychosocial effects, and even death [Rowe 1998, Danielsson et al 2006, Danielsson et al. 2007, Weinstein et al. 1981, Weinstein and Ponsetty 1983, Weinstein et al 2003]. Bracing, even though it hasn’t gained complete acceptance, has been the basis of non-operative treatment for IS for nearly 60 years, [Negrini et al. 2009, 2010a,b, Schiller et al. 2010]. The majority of publications in the peer review literature refer to braces used in North America, [Schiller et al 2010], and there is a lack of systematic examination of the braces commonly used in Europe. The aim of this report, based on peer review publications on the issue, is to concisely describe the European braces which are widely used, focusing on their history, design rationale, indications, biomechanics, outcomes and comparison between them. Cheneau Brace, the two Cheneau derivative braces, namely the Rigo System Cheneau and the ScoliOlogiC® “Chêneau light”, the Lyonnaise Brace, the Dynamic Derotating Brace (DDB) the TriaC brace, the Sforzesco brace and the Progressive Action Short Brace PASB will be described...read more
Scoliosis Rehabilitation
Historically the treatment options for Adolescent Idiopathic Scoliosis (AIS), the most common form of scoliosis are; exercises; braces and surgery. Methods and modules of rehabilitation are described in more detail within this review. Out-patient physiotherapy (PT), In-patient rehabilitation and correct braces used in the rehabilitation of patients with scoliosis should be pattern specific as described to be current ‘Best Practice’. Evidence has been gained to support conservative scoliosis management on level Ib / IIa: One short-term RCT exists to support out-patient PT, a prospective controlled study was found to support Scoliosis In-patient Rehabilitation. One prospective multi-centre study, a long-term prospective controlled study and a meta-analysis have been found to support bracing. No controlled study, neither short, mid nor long-term, was found to reveal any substantial evidence to support surgery as a treatment for this condition.
In the case of scoliosis and pain certain programs of physiotherapy and bracing are applied, a description of which is included within this paper.
Scoliosis rehabilitation, unlike surgery, aims to improve the signs and symptoms of scoliosis. Not only curve magnitude, but also functional impairment like reduced general mobility and reduced vital capacity can be improved upon by physical methods. Back pain cannot be regarded as a consequence of scoliosis, however there is evidence that this can be improved by a specialised rehabilitation program and specific bracing technology.
Not only an improved physical, but also an improved psychosocial outcome can be achieved by utilising current standards of scoliosis rehabilitation, which have been described as being the current ‘Best Practice’...read more
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
Abstract
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...read more
Physical exercises in the treatment of idiopathic scoliosis at risk of brace treatment – SOSORT consensus paper 2005
Background
Based on a recognized need for research to examine the premise that nonsurgical approaches can be used effectively to treat signs and symptoms of scoliosis, a scientific society on scoliosis orthopaedic and rehabilitation treatment (SOSORT) was established in Barcelona in 2004. SOSORT has a primary goal of implementing multidisciplinary research to develop quantitative, objective data to address the role of conservative therapies in the treatment of scoliosis. This international working group of clinicians and scientists specializing in treatment of scoliosis met in Milan, Italy in January 2005.
Methods
As a baseline for developing a consensus for language and goals for proposed multicenter clinical studies, we developed questionnaires to examine current beliefs, before and after the meeting, regarding (1) the aims of physical exercises; (2) standards of treatment; and (3) the impact of such treatment performed by specialists in the field.
Results
The responses to the questionnaires show that, in principle, specialists in scoliosis physiotherapy do not disagree and that several features can be regarded, currently, as standard features in the rehabilitation of scoliosis patients. These features include autocorrection in 3D, training in ADL, stabilizing the corrected posture, and patient education...read more
Radiological and cosmetic improvement 2 years after brace weaning—a case report
In the early international literature, up to now only very few cases are reported with adolescent idiopathic scoliosis (AIS) and a significant improvement of Cobb angle after conservative management. In the recent literature the possibility of an improvement of Cobb angle at skeletal maturity after brace treatment is mentioned no more. The application of physiotherapy and braces is widely rejected while the standards of conservative measures differ greatly worldwide. So it seems necessary more than ever to present the possibility of successful conservative measures nowadays. More detailed case reports with long-term follow-up using defined protocols are needed to provide appropriate standards for replication by others. The purpose of this presentation is to demonstrate the possibility of significant improvement of curvature angle and cosmesis after the application of long-term physiotherapy and brace treatment in a girl with a curve of more than 50° where spontaneous resolving is not usual. A pre-menarchial girl (although being Risser 2) with a Cobb angle of 53° was treated by exercises and curve-specific bracing for more than 3 years. Two years after the start of the weaning period, the Cobb angle was 36° with a marked and stable cosmetic improvement at the age of 18 years. This case report shows that conservative treatment can improve both cosmesis and curvature in immature patients with AIS. The results of such treatment is appreciated by the patients because of the significant reduction of the truncal deformity as documented by surface topography...read more
Rate of complications in scoliosis surgery – a systematic review of the Pub Med literature
Background
Spinal fusion surgery is currently recommended when curve magnitude exceeds 40–45 degrees. Early attempts at spinal fusion surgery which were aimed to leave the patients with a mild residual deformity, failed to meet such expectations. These aims have since been revised to the more modest goals of preventing progression, restoring 'acceptability' of the clinical deformity and reducing curvature.
In view of the fact that there is no evidence that health related signs and symptoms of scoliosis can be altered by spinal fusion in the long-term, a clear medical indication for this treatment cannot be derived. Knowledge concerning the rate of complications of scoliosis surgery may enable us to establish a cost/benefit relation of this intervention and to improve the standard of the information and advice given to patients. It is also hoped that this study will help to answer questions in relation to the limiting choice between the risks of surgery and the "wait and see – observation only until surgery might be recommended", strategy widely used. The purpose of this review is to present the actual data available on the rate of complications in scoliosis surgery.
Materials and methods
Search strategy for identification of studies; Pub Med and the SOSORT scoliosis library, limited to English language and bibliographies of all reviewed articles. The search strategy included the terms; 'scoliosis'; 'rate of complications'; 'spine surgery'; 'scoliosis surgery'; 'spondylodesis'; 'spinal instrumentation' and 'spine fusion'.
Results
The electronic search carried out on the 1st February 2008 with the key words "scoliosis", "surgery", "complications" revealed 2590 titles, which not necessarily attributed to our quest for the term "rate of complications". 287 titles were found when the term "rate of complications" was used as a key word. Rates of complication varied between 0 and 89% depending on the aetiology of the entity investigated. Long-term rates of complications have not yet been reported upon.
Conclusion
Scoliosis surgery has a varying but high rate of complications. A medical indication for this treatment cannot be established in view of the lack of evidence. The rate of complications may even be higher than reported. Long-term risks of scoliosis surgery have not yet been reported upon in research. Mandatory reporting for all spinal implants in a standardized way using a spreadsheet list of all recognised complications to reveal a 2-year, 5-year, 10-year and 20-year rate of complications should be established. Trials with untreated control groups in the field of scoliosis raise ethical issues, as the control group could be exposed to the risks of undergoing such surgery...read more
"Rehabilitation schools for scoliosis" thematic series: describing the methods and results
Abstract
The Scoliosis Rehabilitation model begins with the correct diagnosis and evaluation of the patient, to make treatment decisions oriented to the patient. The treatment is based on observation, education, scoliosis specific exercises, and bracing. The state of research in the field of conservative treatment is insufficient. There is some evidence supporting scoliosis specific exercises as a part of the rehabilitation treatment, however, the evidence is poor and the different methods are not known by most of the scientific community. The only way to improve the knowledge and understanding of the different physiotherapy methodologies (specific exercises), integrated into the whole rehabilitation program, is to establish a single and comprehensive source of information about it. This is what the SCOLIOSIS Journal is going to do through the "Rehabilitation Schools for Scoliosis" Thematic Series, where technical papers coming from the different schools will be published...read more
'SOSORT consensus paper on brace action: TLSO biomechanics of correction (investigating the rationale for force vector selection)'
Background
The effectiveness of orthotic treatment continues to be controversial in international medical literature due to differences in the reported results and conclusions of various studies. Heterogeneity of the samples has been suggested as a reason for conflicting results. Besides the obvious theoretical differences between the brace concepts, the variability in the technical factors can also explain the contradictory results between same brace types. This paper will investigate the degree of variability among responses of scoliosis specialists from the Brace Study Ground of the International Society on Scoliosis Orthopedic and Rehabilitation Treatment SOSORT. Ultimately, this information could be a foundation for establishing a consensus and framework for future prospective controlled studies.
Methods
A preliminary questionnaire on the topic of 'brace action' relative to the theory of three-dimensional scoliosis correction and brace treatment was developed and circulated to specialists interested in the conservative treatment of adolescent idiopathic scoliosis. A particular case was presented (main thoracic curve with minor lumbar). Several key points emerged and were used to develop a second questionnaire which was discussed and full filed after the SOSORT consensus meeting (Milano, Italy, January 2005).
Results
Twenty-one questionnaires were completed. The Chêneau brace was the most frequently recommended. The importance of the three point system mechanism was stressed. Options about proper pad placement on the thoracic convexity were divided 50% for the pad reaching or involving the apical vertebra and 50% for the pad acting caudal to the apical vertebra. There was agreement about the direction of the vector force, 85% selecting a 'dorso lateral to ventro medial' direction but about the shape of the pad to produce such a force. Principles related to three-dimensional correction achieved high consensus (80%–85%), but suggested methods of correction were quite diverse.
Conclusion
This study reveals that among participating SOSORT specialists there continues to be a strongly held and conflicting if not a contentious opinion regarding brace design and treatment. If the goal of a 'treatment consensus' is realistic and achievable, significantly more effort will be required to reconcile these differences...read more
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...read more
The method of Katharina Schroth - history, principles and current development
Katharina Schroth, born February 22nd 1894 in Dresden Germany, was suffering from a moderate scoliosis herself and underwent treatment with a steel brace at the age of 16 years before she decided to develop a more functional approach of treatment for herself.
Inspired by a balloon, she tried to correct by breathing away the deformities of her own trunk by inflating the concavities of her body selectively in front of a mirror. She also tried to ‚mirror' the deformity, by overcorrecting with the help of certain pattern specific corrective movements. She recognized that postural control can only be achieved by changing postural perception.
From 1921 this new form of treatment with specific postural correction, correction of breathing patterns and correction of postural perception was performed with rehabilitation times of 3 months in her own little institute in Meissen and in the late 30's and early 40's she was supported by her daughter, Christa Schroth.
After World War II, Katharina Schroth and her daughter moved to West Germany to open a new little institute in Sobernheim, which constantly grew to a clinic with more than 150 in-patients at a time, treated as a rule for 6 weeks. In the 80's this institute was renamed to ‚Katharina Schroth Klinik'. At this time the first studies were carried out and the patient series for the first prospective controlled trial was derived from the patient samples of 1989-1991.
Content, rehabilitation times and patients meanwhile have changed, and braces have been developed to offer highest treatment security.
Therefore today, bracing in the patient at risk has to be regarded as the primary treatment. We have been able to reduce the training times by adapting the old techniques and introducing new forms of postural education (sagittal correction, ADL correction and experiential learning) whilst the programme is still based on the original approaches of the 3-dimensional treatment according to Katharina Schroth, namely specific postural correction, correction of breathing patterns and correction of postural perception...read more
Treatment of the congenital scoliosis by Cheneau brace: 2 year follow-up
Background
The treatment of congenital spinal deformities is a real challenge. The modern standard of treatment includes surgical interventions intended to correct or fuse the spine. In some cases, such an approach is impossible because of severe comorbidities. We hypothesized that a Cheneau brace might be effective in young patients with congenital spinal deformity. This paper is a continuation of our previous study.
Objective
The objective of this study was to study Cheneau brace treatment results in patients with congenital spinal deformities during 2-years follow-up.
Materials and methods
We investigated 7 patients with congenital formation failure. 2 patients had wedge vertebra, and 5 patients had hemivertebra. They were treated utilitizing the Cheneau brace from 2007 to 2009. The mean age at the beginning of treatment was 5.6 years (range 2-9 years). A full-time regimen was prescribed for all the patients.
Outcome
We observed a significant improvement of Cobb angle, wedge angle, and Cheneau index after 1 year of bracing treatment. After 2 years, radiographic data did not change dramatically, but slightly improved (Table 1).
Conclusion
We conclude that Cheneau brace active correction principles provide correction and control of congenital spinal deformities...read more
Vertebral deformity corrected by bracing: retrospective selected case series of 10 scoliosis patients treated with a RSC Brace
Background
Bracing can prevent curve progression in Idiopathic Scoliosis. Compliance and in-brace correction predict the end result. Part time, full time or even night time bracing may result in excellent in-brace correction. This is associated with a progressive correction of the spinal and trunk deformity as well as a correction of the vertebral deformity. This 10 patient series demonstrates a clear correction of the vertebral, spinal and trunk deformity.
Materials and methods
Retrospective selected case series of 10 patients (8 F, 2 M) diagnosed with IS, with a minimum age of 5 years and a maximum of 13, all of them treated with a RSC brace. Curve pattern: 7 thoracic, 1 thoracic double major and 2 thoracolumbar. Minimum observation time was 1 year and 3 months and maximum 5 years 5 months. Mean Cobb angle was 36° (25°–47°). All the patients showed an in-brace correction in their first brace > 45%.
Results and conclusion
Results are presented case by case. After a minimum of 1 year of observation all the patients showed a correction of the vertebral wedging in the apex ≥ 50%. Four patients have finished the treatment, and they maintain a correction of the main curve higher than 10°. All the patients showed a marked correction of the trunk asymmetry. Some case reports have shown that correction of the vertebral deformity is possible. A retrospective series of selected cases demonstrate that this phenomenon is not rare. These results support the 'vicious cycle model'...read more
Wedged vertebrae normalization in congenital scoliosis due to application of external forces by brace
Objective
It is well documented that congenital scoliosis patients suffering defects of segmentation, like unilateral unsegmented bars, need early surgical treatment, as the deformity will malignantly progress [1]. Other similar cases having defects of formation such as hemivertebrae (nonincarcerated, semincarcerated, or incarcerated) receive a variety of treatments ranging from observation to brace treatment or surgical intervention [2]. The aim is to highlight the fact that, in selected congenital scoliosis patients, the smaller side of blocks and wedged vertebrae can be expanded due to brace treatment.
Study design
Presentation of the long-term follow-up of two congenital scoliotics with blocks and hemivertebrae, conservatively treated.
Materials and methods
The first patient is a boy (born on 30 October 1985). He was eleven years of age when he initially attended the scoliosis clinic with a L3 incarcerated hemivertebra, with a Cobb angle L2–L4 of 21 degrees. Due to surface deformity and anticipation of a possible progression of the scoliotic curve, conservative treatment with a modified Boston Brace was commenced, with regular clinical and radiographic followup. The second patient is a girl (born on 30 September 1985). She was six years of age when she initially with an abnormal block, a congenital wedge vertebra Th5–6 and 23° of Cobb angle. She received a nearly typical Chêneau brace.
Results
Long-term follow-up revealed that wedged vertebrae were sufficiently normalized in both patients, that no further treatment was needed.
Conclusion
Wedge deformed vertebrae can be straightened by brace. Other types of vertebral deformations, including idiopathic scoliosis and Scheuermann's disease often show wedge deformed vertebrae and can also be straightened by brace, although this fact seems to be generally not acknowledged...read more
Why do we treat adolescent idiopathic scoliosis? What we want to obtain and to avoid for our patients. SOSORT 2005 Consensus paper
Background
Medicine is a scientific art: once science is not clear, choices are made according to individual and collective beliefs that should be better understood. This is particularly true in a field like adolescent idiopathic scoliosis, where currently does not exist definitive scientific evidence on the efficacy either of conservative or of surgical treatments.
Aim of the study
To verify the philosophical choices on the final outcome of a group of people believing and engaged in a conservative treatment of idiopathic scoliosis.
Methods
We performed a multifaceted study that included a bibliometric analysis, a questionnaire, and a careful Consensus reaching procedure between experts in the conservative treatment of scoliosis (SOSORT members).
Results
The Consensus reaching procedure has shown to be useful: answers changed in a statistically significant way, and 9 new outcome criteria were included. The most important final outcomes were considered Aesthetics (100%), Quality of life and Disability (more than 90%), while more than 80% of preferences went to Back Pain, Psychological well-being, Progression in adulthood, Breathing function, Scoliosis Cobb degrees (radiographic lateral flexion), Needs of further treatments in adulthood.
Discussion
In the literature prevail outcome criteria driven by the contingent treatment needs or the possibility to have measurement systems (even if it seems that usual clinical and radiographic methods are given much more importance than more complex Disability or Quality of Life instruments). SOSORT members give importance to a wide range of outcome criteria, in which clinical and radiographic issues have the lowest importance.
Conclusion
We treat our patients for what they need for their future (Breathing function, Needs of further treatments in adulthood, Progression in adulthood), and their present too (Aesthetics, Disability, Quality of life). Technical matters, such as rib hump or radiographic lateral alignment and rotation, but not lateral flexion, are secondary outcomes and only instrumental to previously reported primary outcomes. We advocate a multidimensional, comprehensive evaluation of scoliosis patients, to gather all necessary data for a complete therapeutic approach, that goes beyond x-rays to reach the person and the family...read more