What imaging does my AIS patient need? A multi-group survey of provider preferences

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Jenny L Zheng, Ying Li, Grant Hogue, Megan Johnson, Jason B Anari, Maia D Regan, Keith D Baldwin 

Spine Deform. 2024 Nov 4. doi: 10.1007/s43390-024-00995-9. Online ahead of print.

Abstract

Introduction: Adolescent idiopathic scoliosis (AIS) is a common diagnosis managed by pediatric orthopedic surgeons with nonoperative radiographic monitoring representing a cornerstone of treatment. Differences in practices and techniques for obtaining radiographic studies contribute to variation, cost of care, and hamper data aggregation. We surveyed several large organizations dedicated to children’s orthopedics or scoliosis care to obtain a consensus for radiographic evaluation of AIS.

Methods: A REDCap-based survey was developed across four institutions and beta-tested by staff and fellows from a single institution. The finalized survey was distributed to members of POSNA, PSSG, and SOSORT, and shared on social media. Participants were asked to rank the importance of various datapoints in radiographic assessment of the spinal deformity, skeletal maturity, and study indications during initial, subsequent, preoperative, and final office visits for AIS. Response rate for the overall group was 26%.

Results: Cobb angle was considered the most important (> 94%) radiographic index across all time points. For positioning, 46% of respondents favored arms bent touching clavicles as the ideal positioning for X-rays, and another 24% favored arms down with palms forward (Table 2). The majority of respondents obtain lateral X-rays at the first visit (99%) and at the preoperative visit (70%). At the preoperative visit, sagittal contour (86%), apex location (85%), and Lenke classification (73%) were considered important factors to record. Flexibility studies are primarily obtained at the preoperative visit (89%) and 81% of respondents prefer bending films as the flexibility technique of choice. Regarding measures of skeletal maturity, Sanders bone age was considered to be the most important by over 70% of respondents across initial, subsequent, preoperative and brace wean visits (Fig. 2). MRIs were obtained routinely by 34% of respondents and only when the patient had a concerning symptom or finding for 67% of respondents.

Conclusions: Despite large variations in radiographic examination of AIS, large areas of agreement were found. It is important to establish standards for positioning patients, evaluating skeletal maturity, and obtaining assessments including lateral views, flexibility studies, and advanced imaging. Establishing common practices for radiographic evaluation of AIS will allow for less variation in care and for critical questions to be answered through registry formation and large multicenter data collection.

Significance: This study establishes current practitioner opinion on the radiographic evaluation of the AIS patient. Minimum data sets are useful for data aggregation and answering research questions in the face of data variability.

Level of evidence: Level V.

Keywords: Adolescent idiopathic scoliosis; Imaging; Nonoperative; Radiography; Survey.

https://pubmed.ncbi.nlm.nih.gov/39495401/

Intelligenza artificiale: quale rivoluzione nel trattamento riabilitativo?

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L’Intelligenza Artificiale (IA) sta trasformando il modo in cui i medici affrontano la riabilitazione, offrendo strumenti innovativi che migliorano la qualità dei trattamenti. In ISICO siamo sempre più impegnati a esplorare come l’IA possa supportare il lavoro clinico quotidiano e contribuire a decisioni terapeutiche sempre più personalizzate.
Ne abbiamo parlato con il dr. Francesco Negrini, fisiatra specialista di ISICO, autore nel 2023 della ricerca su AI e riabilitazione che si è aggiudicata il SOSORT AWARD (Developing a new tool for scoliosis screening in a tertiary specialistic setting using artificial intelligence: a retrospective study on 10,813 patients: 2023 SOSORT award winner). Negrini ha di recente presentato un’altra relazione su IA e progetti di utilizzo nella riabilitazione dello Stroke. 

Quali sono gli ambiti principali in cui l’IA può essere utilizzata nella riabilitazione?
L’IA è incredibilmente versatile. Può essere difatti applicata in molte fasi del processo medico: dalla diagnosi, attraverso l’analisi automatizzata di immagini radiografiche o RM per identificare patologie con maggiore precisione, alla prognosi, con previsioni sui risultati dei trattamenti, fino alla  personalizzazione dei trattamenti, per determinare il percorso terapeutico più efficace basato sui dati del paziente e al monitoraggio continuo, così da valutare in tempo reale i progressi del paziente per adattare il trattamento. In ISICO, per esempio, stiamo studiando come l’IA possa supportare la personalizzazione del trattamento. Con questa tecnologia si potrebbero analizzare la storia naturale del paziente e le probabilità di successo nell’utilizzo di un corsetto rispetto a un altro, fornendo al medico strumenti decisionali più accurati.

Ci può fare un esempio concreto di come ISICO sta utilizzando l’IA?
Un esempio significativo è la ricerca premiata con il SOSORT Award 2023, pubblicata recentemente. Lo studio ha dimostrato come l’analisi dei dati clinici attraverso tecniche avanzate possa migliorare la comprensione della scoliosi e dei suoi trattamenti. Un altro possibile utilizzo riguarda la diagnosi della lombalgia, dove l’IA può analizzare immagini radiografiche per identificare eziologie che altrimenti potrebbero sfuggire all’occhio umano. Questo approccio sfrutta la maggiore potenza di calcolo disponibile oggi, che permette di processare grandi quantità di dati in modo rapido e accurato.

Come l’IA potrebbe cambiare la gestione delle patologie vertebrali in futuro?
Ci sono tre aree chiave in cui vediamo un enorme potenziale: screening e diagnosi precoce che significa rilevare la scoliosi o altre condizioni in una fase iniziale, migliorando gli esiti del trattamento; personalizzazione dei corsetti, ossia utilizzare i dati raccolti nei centri clinici per prevedere quale tipo di corsetto sarà più efficace per un determinato paziente; monitoraggio dei risultati, così da tracciare l’andamento della terapia e adattarla in base ai progressi osservati, migliorando l’efficacia del trattamento.

Cosa rende l’AI un alleato così prezioso per i clinici?
L’IA amplifica le capacità del clinico, fornendo informazioni più dettagliate e aiutandolo a prendere decisioni basate sui dati. Tuttavia, come sottolineiamo sempre in ISICO, il rapporto medico-paziente rimane centrale. L’IA non sostituisce l’esperienza e l’empatia del medico; piuttosto offre strumenti che migliorano il lavoro umano.

Qual è il futuro dell’IA in medicina riabilitativa?
Credo che vedremo un’integrazione sempre più stretta. In ISICO ci stiamo muovendo in questa direzione, esplorando come utilizzare l’IA per migliorare i risultati terapeutici e rendere la riabilitazione più mirata. Siamo solo all’inizio, ma le possibilità sono enormi, soprattutto se riusciamo a combinare il meglio della tecnologia con la preziosa competenza umana.

Scientific Exercise Approach to Scoliosis in Adolescents With Mild Idiopathic Scoliosis: A Controlled Clinical Trial

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Gözde Yagcı, Halil Gökhan Demirkıran 

J Manipulative Physiol Ther. 2024 Oct 14:S0161-4754(24)00053-8.doi:10.1016/j.jmpt.2024.08.015

Abstract

Objective: This study aimed to investigate the effectiveness of Scientific Exercise Approach to Scoliosis (SEAS) protocol for patients with mild adolescent idiopathic scoliosis (AIS).

Method: (A controlled clinical trial) This preliminary study included 32 patients with AIS, aged 10 to 16 years, with Cobb angles ranging from 12° to 25°. The participants were divided into 2 groups: the SEAS group (n = 21) and standard care (n = 11). We assessed Cobb angles via radiographs, axial trunk rotation using the Adams test, spinal deformity from various perspectives with the Spinal Appearance Questionnaire (SAQ), and health-related quality of life with the Scoliosis Research Society-22 (SRS-22) questionnaire, both before and after 1 year of treatment.

Results: Repeated measure-ANOVA revealed significant group x time interactions for various parameters: Cobb angle (F1,30 = 35.757; P < .001), axial trunk rotation (F1,30 = 39.595; P < .001), SAQ appearance domain for the physiotherapist (F1,30 = 53.943; P < .001), SAQ appearance (F1,30= 14.054; P = .001), expectations (F1,30 = 9.103; P = .005) domains, the total score (F1,30 = 23.574; P < .001) for the child, and the SAQ appearance domain for the parent (F1,29 = 5.412; P = .027). There were no significant differences in SRS-22 scores between the 2 groups. The success rates for the SEAS group and the standard care group were 100% and 72.7%, respectively.

Conclusion: After 1 year, the group of patients with mild AIS who received the SEAS method showed greater improvements in the Cobb angle, axial trunk rotation, and spinal appearance than those who received standard care. This preliminary study suggests that larger trials should be completed.

Keywords: Body; Exercise Therapy; Physical Appearance; Quality of Life; Scoliosis.

https://pubmed.ncbi.nlm.nih.gov/39412452/

Scoliosis X-rays: Why We No Longer Use Old Protections

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The use of protective devices intended to shield the foetus and gonads of the patient during X-ray imaging should be discontinued as a routine practice since it can compromise its benefits. This recommendation, published in April 2019 by the American Association of Physicists in Medicine AAPM represents a historic change.

Why, after more than 70 years of gonadal protection, have we reached this conclusion?
Let’s take a closer look. At ISICO, this topic is particularly important to us because we need to visualise the spine to offer the best therapies for scoliosis and assess its progress properly. Thus, while we reduce requests as much as possible, it’s almost always necessary to prescribe complete spine X-rays in one projection (either frontal or lateral) at least once a year.

Why This Change? There Are Two Reasons:

  1. Minimal or No Benefits from Protections
    Current scientific evidence shows that these protections provide minimal or no health benefits to patients. In the past, it was believed that radiation could damage reproductive cells, potentially harming future offspring. However, it has been discovered that reproductive cells are much less sensitive to radiation than previously thought, and there is no evidence that the very low doses currently used in diagnostic imaging can harm reproductive cells or the foetus. Radiation is not harmful to the foetus, even when a radiographic exam on a pregnant patient is necessary and indispensable.
  2. Negative Impact on Exam Effectiveness
    The protective equipment can obscure anatomy or significant pathologies or produce artefacts that require repeating the exam, thereby substantially increasing the dose. Additionally, most modern X-ray equipment can automatically adjust the amount of radiation used based on the body region being examined. Lead-equivalent individual protection in the field of view could lead to a significant and unjustified increase in the patient’s dose. These technological advancements have made patient shielding a practice that introduces more risks than benefits.

In line with this evidence, at ISICO, we discourage using these protections as they could potentially be harmful.

Prognostic model development for risk of curve progression in adolescent idiopathic scoliosis: a prospective cohort study of 127 patients

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Marlene Dufvenberg, Anastasios Charalampidis, Elias Diarbakerli, Birgitta Öberg , Hans Tropp, Anna Aspberg Ahl, Daphne Wezenberg, Henrik Hedevik, Hans Möller, Paul Gerdhem, Allan Abbott

Acta Ortho. 2024 Sep 13:95:536-544.doi: 10.2340/17453674.2024.41911

Abstract

Background and purpose: The study’s purpose was to develop and internally validate a prognostic survival model exploring baseline variables for adolescent idiopathic scoliosis curve progression.

Methods: A longitudinal prognostic cohort analysis was performed on trial data (n = 135) including girls and boys, Cobb angle 25-40°, aged 9-17 years, remaining growth > 1 year, and previously untreated. Prognostic outcome was defined as curve progression of Cobb angle of > 6° prior to skeletal maturity. 34 candidate prognostic variables were tested. Time-to-event was measured with 6-month intervals. Cox proportional hazards regression survival model (CoxPH) was used for model development and validation in comparison with machine learning models (66.6/33.3 train/test data set). The models were adjusted for treatment exposure.

Results: The final primary prognostic model included 127 patients, predicting progress with acceptable discriminative ability (concordance = 0.79, 95% confidence interval [CI] 0.72-0.86). Significant prognostic risk factors were Risser stage of 0 (HR 4.6, CI 2.1-10.1, P < 0.001), larger major curve Cobb angle (HRstandardized 1.5, CI 1.1-2.0, P = 0.005), and higher score on patient-reported pictorial Spinal Appearance Questionnaire (pSAQ) (HRstandardized 1.4, CI 1.0-1.9, P = 0.04). Treatment exposure, entered as a covariate adjustment, contributed significantly to the final model (HR 3.1, CI 1.5-6.0, P = 0.001). Sensitivity analysis displayed that CoxPH maintained acceptable discriminative ability (AUC 0.79, CI 0.65-0.93) in comparison with machine learning algorithms.

Conclusion: The prognostic model (Risser stage, Cobb angle, pSAQ, and menarche) predicted curve progression of > 6° Cobb angle with acceptable discriminative ability. Adding patient report of the pSAQ may be of clinical importance for the prognosis of curve progression.

https://pubmed.ncbi.nlm.nih.gov/39287215/

The application of machine learning methods for predicting the progression of adolescent idiopathic scoliosis: a systematic review

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Lening Li, Man-Sang Wong 

Skeletal Radiol. 2024 Aug;53(8):1517-1528.doi: 10.1007/s00256-024-04592-9. Epub 2024 Feb 21.

Abstract

Predicting curve progression during the initial visit is pivotal in the disease management of patients with adolescent idiopathic scoliosis (AIS)-identifying patients at high risk of progression is essential for timely and proactive interventions. Both radiological and clinical factors have been investigated as predictors of curve progression. With the evolution of machine learning technologies, the integration of multidimensional information now enables precise predictions of curve progression. This review focuses on the application of machine learning methods to predict AIS curve progression, analyzing 15 selected studies that utilize various machine learning models and the risk factors employed for predictions. Key findings indicate that machine learning models can provide higher precision in predictions compared to traditional methods, and their implementation could lead to more personalized patient management. However, due to the model interpretability and data complexity, more comprehensive and multi-center studies are needed to transition from research to clinical practice.

Keywords: Adolescent idiopathic scoliosis; Machine learning; Prediction.

https://pubmed.ncbi.nlm.nih.gov/39118179/

Distances and angles in standing long-leg radiographs: comparing conventional radiography, digital radiography, and EOS

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Christof Birkenmaier, Louise Levrard , Carolin Melcher , Bernd Wegener, Jens Ricke, Boris M Holzapfel, Andrea Baur-Melnyk , Dirk Mehrens 

Skeletal Radiol. 2024 Aug;53(8):1517-1528.doi: 10.1007/s00256-024-04592-9. Epub 2024 Feb 21.

Abstract

Objective: Distances and angles measured from long-leg radiographs (LLR) are important for surgical decision-making. However, projectional radiography suffers from distortion, potentially generating differences between measurement and true anatomical dimension. These phenomena are not uniform between conventional radiography (CR) digital radiography (DR) and fan-beam technology (EOS). We aimed to identify differences between these modalities in an experimental setup.

Materials and methods: A hemiskeleton was stabilized using an external fixator in neutral, valgus and varus knee alignment. Ten images were acquired for each alignment and each modality: one CR setup, two different DR systems, and an EOS. A total of 1680 measurements were acquired and analyzed.

Results: We observed great differences for dimensions and angles between the 4 modalities. Femoral head diameter measurements varied in the range of > 5 mm depending on the modality, with EOS being the closest to the true anatomical dimension. With functional leg length, a difference of 8.7% was observed between CR and EOS and with the EOS system being precise in the vertical dimension on physical-technical grounds, this demonstrates significant projectional magnification with CR-LLR. The horizontal distance between the medial malleoli varied by 20 mm between CR and DR, equating to 21% of the mean.

Conclusions: Projectional distortion resulting in variations approaching 21% of the mean indicate, that our confidence on measurements from standing LLR may not be justified. It appears likely that among the tested equipment, EOS-generated images are closest to the true anatomical situation most of the time.

Keywords: Cone-beam; Conventional radiography; Digital radiography; Distortion; EOS; Fan-beam; Lower extremity; Projectional distortion; Slot-scanner; Valgus; Varus.

https://pubmed.ncbi.nlm.nih.gov/38378861/

Immediate vs Gradual Brace Weaning Protocols in Adolescent Idiopathic Scoliosis: A Randomized Clinical Trial

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Prudence Wing Hang Cheung, Oi Kiu Olivia Chan, Hao Wu, Marcus Kin Long Lai, Lester Po Kwan Wong, Shiyu Tang, Jason Pui Yin Cheung 

JAMA Pediatr. 2024 Jul 1;178(7):657-668.doi: 10.1001/jamapediatrics.2024.1484

Abstract

Importance: Lack of evidence and consensus for brace weaning protocol in adolescent idiopathic scoliosis (AIS) results in clinicians prescribing gradual weaning in the hope of avoiding curve deterioration after weaning. However, gradual weaning contributes to prolonged brace wear, which can affect spinal stiffness and health-related quality of life (HRQoL).

Objective: To determine whether gradual weaning results in better curve magnitude and truncal balance maintenance after brace weaning vs immediate brace removal for patients with AIS.

Design, setting, and participants: This was an open-labeled randomized clinical trial commenced in April 2017 with 24-month follow-up completed in January 2023. Outcome assessors were masked to weaning protocol assigned. The study took place at a territory-wide tertiary scoliosis clinic serving the largest number of referrals in the local population. Patients with AIS ready to wean off of brace wear were eligible (402 were screened; 33 were excluded [15 for <18 hours/day of brace-wear compliance before weaning, 11 were treated with Milwaukee brace, and 7 declined to participate]; and 369 were included), and those who were treated with a custom molded thoracolumbosacral orthosis and had reached skeletal maturity were consecutively recruited.

Interventions: Patients were randomized to gradual weaning protocol (n = 176) with an additional 6 months of nighttime wear before completely stopping or immediate weaning protocol (n = 193) with immediate brace removal at recruitment.

Main outcomes and measures: Changes in major curve Cobb angle and truncal balance from the time of weaning to 6-month, 12-month, and 24-month follow-up. HRQoL was also assessed using the refined Scoliosis Research Society 22-item and EuroQol 5-dimension questionnaires.

Results: A total of 369 patients (mean [SD] age, 14.9 [1.1] years; 304 [83.4%] girls) were randomized with 284 (77.0%) completing 24-month longitudinal follow-up. Immediate and gradual weaning groups had no significant differences in change of major Cobb angle at postweaning 6-month (difference, -0.6°; 95% CI, -1.4 to 0.2; P = .17), 12-month (difference, -0.3°; 95% CI, -1.2 to 0.6; P = .47), and 24-month (difference, -0.3°; 95% CI, -1.2 to 0.7; P = .60) follow-up. The number of curve progression, nonprogression, and rebound cases were comparable (χ22 = 2.123; P = .35). Postweaning changes in truncal balance and HRQoL demonstrated no significant differences between groups.

Conclusions: Gradual weaning did not demonstrate superiority to immediate weaning with predefined criteria of Cobb angle and truncal balance maintenance and HRQoL after brace weaning. Gradual and immediate weaning achieved very similar maintenance of brace outcomes in AIS. We therefore recommend the consideration of immediate brace weaning, which aims to benefit patients with earlier time for increased exercises and activity level.

Trial registration: ClinicalTrials.gov Identifier: NCT03329716.

https://pubmed.ncbi.nlm.nih.gov/38829664/

Development of a Motion-Based Video Game for Postural Training: A Feasibility Study on Older Adults With Adult Degenerative Scoliosis

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Frances K W Wan, Alex T H Mak, Claire W Y Chung, Joanne Y

EEE Trans Neural Syst Rehabil Eng. 2024:32:2106-2113. doi: 10.1109/TNSRE.2024.3398029 Epub 2024 Jun 7

Abstract

Forward sagittal alignment affects physical performance, is associated with pain and impacts the health-related quality of life of the elderly. Interventions that help seniors to improve sagittal balance are needed to inhibit the progression of pain and disability.

A motion-sensing video game (active game) is developed in this study to monitor sitting and standing postures in real-time and facilitate the postural learning process by using optical sensors to measure body movement and a video game to provide visual feedback.
Ten female subjects (mean age: 60.0 ± 5.2 years old; mean BMI: 21.4 ± 1.9) with adult degenerative scoliosis (mean major Cobb’s angle: 38.1° ± 22.7°) participate in a 6-week postural training programme with three one-hour postural training sessions a week.
Eleven body alignment measurements of their perceived “ideal” sitting and standing postures are obtained before and after each training session to evaluate the effectiveness of postural learning with the game.
The participants learn to sit and stand with increased sagittal alignment with a raised chest and more retracted head position. The forward shift of their head and upper body is significantly reduced after each training session.
Although this immediate effect only partially sustained after the 6-week program, the participants learned to adjust their shoulder and pelvis level for a better lateral alignment in standing.
The proposed postural training system, which is presented as a gameplay with real-time visual feedback, can effectively help players to improve their postures.
This pilot feasibility study explores the development and initial assessment of a motion-based video game designed for postural training in older adults with adult degenerative scoliosis, and demonstrates the usability and benefits of active gameplay in motor training.

https://pubmed.ncbi.nlm.nih.gov/38717877/

Modular Italian Brace works just as well as the Sforzesco

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A modular brace that has the same practicality and comfort of wearing and the same proven effectiveness, even on the most severe curves, of the Sforzesco corset but with significantly reduced costs. It is the Modular Italian Brace (MIB), the latest corset developed by our institute, after the Sforzesco and the Sforzesco Free Plevis.
Its effectiveness is demonstrated by the data of one of our studies recently published in the Journal of Clinical Medicine, The New Modular Sforzesco Brace (Modular Italian Brace) Is as Effective as the Classical One: A Retrospective Controlled Study from a Prospective Cohort. “A research of considerable importance,” comments Dr. Francesco Negrini, physiatrist and author of the study. “We recently developed a new Sforzesco brace based on modularity (the Modular Italian Brace—MI brace) that could allow standardisation, facilitating global expertise diffusion, increased modifiability and adaptability, and cost savings due to longer brace life”.

We remind you that the Sforzesco brace is a very rigid push-up brace effective in adolescent idiopathic scoliosis (AIS), which revolutionised rehabilitation treatment years ago by replacing the cast but guaranteeing the same results. Recently, the “Free Pelvis” (FP) innovation has been introduced. It consists of semi-rigid material on the pelvis connected to the main rigid body of the brace on the trunk.
It was found that it does not change the in-brace and short-term results of classical very rigid braces and, consequently, can be safely applied.

The MI brace, even if built in a different way, keeps the main characteristic of the Sf brace, that is, the overall symmetry (with some asymmetries inserted in specific areas). In fact, it is the symmetry that allowed the development of the MI brace, where it is possible to recreate the asymmetrical needs of the SF brace through internal pads.

The MIB can be built and fully personalised directly for the patient, modifying the classical procedures of brace construction through CAD-CAM or casting. Moreover, the MIB can be continuously adapted during treatment, giving full adaptability to the patient during changes due to growth or treatment.

The MIB is an evolution of the SF-FP. The two braces share the semi-rigid material on the pelvis, a novelty that improves comfort and patient acceptability. On the other hand, Sf FP is built in a more traditional way, without the MIB modularity and the possibility to adapt the brace during treatment. With Sf FP, if the patient changes due to growth, the brace must be changed altogether.

“The braces considered in this paper share the same action; the question is if they also share the same results. We aimed to compare the short-term results of the two braces,” explains Dr. Negrini. “We compared in this retrospective study 231 patients with scoliosis, between 10 and 16 years old, 53 treated with a MI brace, and 178 treated with a Sforzesco brace. Both braces reduced the Cobb angle (−6◦ out-of-brace; −16◦ in-brace) without differences between groups. The results of the present study suggest that the SfB and MIB can have similar positive short-term results on moderate-to-moderate, moderate-to-severe, and severe curve brace treatment with modular braces. that could lead to easier diffusion worldwide, even where there are reduced economic means and expertise in brace treatment. Before suggesting a generalised use of the MIB as a first-line rigid brace treatment, the results should be confirmed in studies with longer follow-ups”.