Can we predict the behavior of the scoliotic curve after bracing in adolescent idiopathic scoliosis? The prognostic value of apical vertebra rotation

Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 

Can we predict the behavior of the scoliotic curve after bracing in adolescent idiopathic scoliosis? Τhe prognostic value of apical vertebra rotationely treated patients with adolescent idiopathic scoliosis
Eustathios Kenanidis, Theodosios Stamatopoulos, Kleoniki Athanasiadou, Aikaterini Voulgaridou 3, Stavros Pellios, Panagiotis Anagnostis, Michael Potoupnis, Eleftherios Tsiridis 
Spine Deformity, 2020 – DOI: 10.1007/s43390-020-00184-4


We aimed to recognize radiographic and clinical prognostic factors of scoliotic curve behaviour after bracing.


Our prognostic study was based on the 25 years outcomes of a Boston braced AIS cohort between 1978 and 1993 that were previously reported. All patients were followed-up during bracing, at short term and 25 years post-bracing. We evaluated the impact of socio-demographic, clinical and radiological parameters on the loss of curve correction after bracing.


Seventy-seven patients were reevaluated at 25 years post-brace. The mean scoliotic curve was significantly increased after bracing until the 25 years follow-up (p < 0.001). The mean loss of curve correction between the end of bracing and long-term follow-up was independent on the curve type, apical vertebra, premenarcheal status at bracing, time and duration of bracing, Cobb angle before or after bracing. The mean apical vertebral rotation after bracing was significantly related to the loss of curve correction (Spearman ρ = 0.2, p = 0.049). Apical vertebral rotation (Perdriolle method) greater than 20° post-bracing had a three times higher chance of progression > 5° compared with lesser apical vertebral rotation (OR 3.071, CI 0.99–9.51). The rotation of the apical vertebra, type and magnitude of the scoliotic curve after bracing explained 27.4% of the variance in the loss of curve correction post-bracing (R square = 0.274, p < 0.001).


A scoliotic curve is expected to lose some correction after bracing. The apical vertebral rotation post-bracing mainly affected the long-term curve behaviour. Adolescents with apical vertebral rotation greater than 20° after bracing may need further attention.

Level of evidence

Prognostic study, Level II

Extreme long-term outcome of operatively versus conservatively treated patients with adolescent idiopathic scoliosis

Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 

Extreme long-term outcome of operatively versus conservatively treated patients with adolescent idiopathic scoliosis
Mazda Farshad, Lucas Kutschke, Christoph J. Laux, Method Kabelitz, Regula Schüpbach, Thomas Böni& Thorsten Jentzsch  
European Spine Journal 2020 – DOI: 10.1007/s00586-020-06509-1

Purpose: We report on outcomes of surgically versus (vs) non-surgically treated patients with moderate adolescent idiopathic scoliosis (AIS) after minimum of 29 years.

Methods: AIS patients with a follow-up of ≥ 41 years in the surgical group and ≥ 29 years in the non-surgical group were included. Patients were treated surgically for primary curves ≥ 45° vs non-surgically for curves < 45° or refusal of surgery. Groups were matched for age, gender, comorbidities and primary curve severity. Oswestry Disability Index (ODI) was used to measure clinical outcomes and standard radiography to quantify curve severity at final follow-up.

Results: In total, 16 patients (8 within each group, 75% females) with a median age of 14 (interquartile range (IQR) 2) years could be included and were followed up after 46 (IQR 12) years. All matched variables were similar for both groups, including the primary curve Cobb angles of 48° (IQR 17°) (surgical) vs 40° (IQR 19°) (non-surgical); p = 0.17). At final follow-up after a median of 47 (IQR 5) years for the surgical and 39 (IQR 19) years for the non-surgical group (p = 0.43), the ODI was similar for both groups (15 (IQR 13) points (surgical) vs 7 (IQR 15) points (non-surgical); p = 0.17) with, however, a primary curve magnitude lower in the surgical compared to the non-surgical group (38° (IQR 3°) vs 61° (IQR 33°); p = 0.01), respectively.

Conclusion: After around 47 and 39 years, respectively, surgical and non-surgical treatment of moderate AIS showed similar subjective outcomes, but with a relevant smaller curve magnitude with surgical treatment.

Level of evidence: III.

Keywords: Adolescent idiopathic scoliosis; Correction; Long-term; Non-surgical; Surgery.

Friends and brace

Adolescence and bracing are two challenges that can be difficult to face simultaneously. 

In our view, this is perfectly natural and understandable.

Adolescence is usually perceived as a difficult phase during which young people are still immature, tend to be irrational, and struggle to control their emotions. However, research studies focusing on the development of the adolescent brain have recently debunked these myths, allowing adolescence to be understood, from a more modern perspective, as a life stage characterised by numerous possibilities, great creativity, and a desire to experiment.

However, it is also a time of great changes, when youngsters are particularly vulnerable. Their increasing need for freedom and independence sees them looking outside their immediate family; accordingly, friends assume a more and more central role, becoming the basis and starting point for building their self-awareness and personal identity.

At this age, then, finding yourself faced with the prospect of wearing a rigid brace for up to 23/24 hours a day certainly isn’t easy.

A young person who has just been prescribed a brace can experience many different emotions, which vary from individual to individual: some will feel angry, others sad; some may be fearful or feel ashamed.

Shame is an emotion that stems from the fear that others will judge us. What are my friends going to say when they see me in a brace? What will they think if they find out I have scoliosis? 

In adolescence, precisely because this is a time when we are still working out who we are, we can be particularly sensitive to the opinions of others; we want to fit in, and we fear rejection. 

For these reasons, having to wear a brace can be seen as an obstacle to the formation of friendships and early romantic attachments. It becomes a secret to be kept strictly within the family. Some youngsters try to keep their brace hidden under their clothes and avoid physical contact with others, to the point of avoiding those activities in which their brace would have to be exposed, and thus depriving themselves of a whole series of experiences. 

In this way, they become victims of their own secret.

Hiding a brace requires a lot of effort. Is it really the best thing to do?

Even though hiding is a natural and automatic response when we feel ashamed, it is also the most harmful. Instead, the least natural and least automatic (i.e. “telling the truth” and showing yourself) is the most beneficial! When you find out that you have to wear a brace, the best thing to do is to tell your friends and classmates about it immediately. Although this might seem difficult, it is far easier than trying to keep the fact a secret. Start by telling your closest friends, and then gradually share the news with everyone else.

You really have nothing at all to be ashamed of. Quite the opposite: you should be proud of what you are doing in order to have a healthy back!

Authors: Irene Ferrario, psychologist and Antonella Napolitano, physiotherapist

Reliable Skeletal Maturity Assessment for an AIS Patient Cohort: External Validation of the Proximal Humerus Ossification System (PHOS) and Relevant Learning Methodology

Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 

Reliable Skeletal Maturity Assessment for an AIS Patient Cohort: External Validation of the Proximal Humerus Ossification System (PHOS) and Relevant Learning Methodology
Theodor Di Pauli von Treuheim, Don T Li , Christopher Mikhail, Daniel Cataldo, Daniel R Cooperman, Brian G Smith, Baron Lonner 
Spine Deform. 2020 May 8. doi: 10.1007/s43390-020-00105-5

Study design: Validation of classification system.

Objectives: To externally validate the Proximal Humerus Ossification System (PHOS) as a reliable skeletal maturity scoring system and to assess the learning curve associated with teaching the procedure to individuals of varying levels of experience.

Background: Assessment of skeletal maturity is essential for treatment decisions in Adolescent Idiopathic Scoliosis (AIS). PHOS is a five-stage system that uses the proximal humeral physis in assessing skeletal maturity and has been shown to reliably grade skeletal age leading up to and beyond peak growth age (PGA). This system is advantageous in the AIS patient, as it is often captured in standard scoliosis films.

Methods: A medical student, an orthopedic surgery resident (PGY-2), spine fellow, and experienced scoliosis surgeon in his 25th year in practice were given a three-slide PHOS learning module. Each participant rated 100 X-rays on two separate occasions, separated by 1 week. Intra- and inter-observer reliability, as well as cross-institutional reliability, were calculated using intraclass correlation coefficients (ICC) with 95% confidence intervals [CI95].

Results: Average intra-observer reliability ICC between scoring sessions was 0.94 [0.92, 0.96] and inter-observer reliability by level of training were 0.94 [0.91, 0.96], 0.93 [0.9, 0.95], 0.94 [0.91, 0.96], 0.96 [0.94, 0.97] for the medical student, PGY-2, fellow, and attending, respectively. Reliability across institutions was 0.99 [0.98, 0.99]. Combined rating observations (n = 400) showed 82% exact matches, as well as 17% and 1% mismatches by 1 and 2 stages, respectively. Similar to the PHOS developers, we found PHOS stage 3 to occur immediately after PGA.

Conclusion: PHOS is easily learned and employed by raters with varying levels of training. It comprises a five-stage system to reliably measure bone age leading up to PGA and thereafter. This new system relies on visualization of the proximal humerus, which is readily available on standard scoliosis X-rays.

Level of evidence: Level III.

Keywords: Humeral head ossification center; Pediatric growth markers; Scoliosis; Skeletal maturity classification system.

Scoliosis: can it harm the lungs?

Can scoliosis harm the respiratory system? Patients often ask us this question, as it is an aspect that particularly worries them.

The main purpose of the rib cage – we have 12 ribs – is to protect vital organs such as the heart and lungs.

Scoliosis, as we know, takes the form of spinal abnormalities in the three planes of space: the spine presents lateral curvature in the frontal plane, rotates on itself in the horizontal plane, and is shifted forward or back in the sagittal plane, increasing or decreasing lordosis and kyphosis (the spine’s natural curves).
The ribs, being closely linked to the spine, adapt to these abnormalities, and develop changes of their own. This explains why people can be concerned that scoliosis may impair the respiratory function or vital capacity of the lungs.

Let us try and clear up some of these issues, drawing on relevant scientific research data.  

First of all, the latest studies have shown a correlation between impaired lung function and scoliosis only in very severe cases (i.e. curves greater than 80°).

Let us clarify a further point: the alterations of the trunk and rib cage caused by the spinal deformity should not be considered solely from the perspective of the size (in degrees) of the curve; indeed, although this is certainly a significant parameter, it is not the only one. A patient who, despite having severe scoliosis, retains a well-balanced back with regard to other parameters, such as thoracic kyphosis, could have better function than one with less severe curvature of the spine.
As we know, “flat back” (a posture characterised by markedly reduced kyphosis) is a negative consequence of scoliotic curvature of the thoracic spine; this is why, in daily clinical practice and in the construction of braces, we try to avoid this phenomenon, which is also related to reduced lung capacity.

Other important factors that should be evaluated, and not underestimated, are lifestyle and quality of life. Keeping active and doing physical activity designed to improve respiratory fitness can undoubtedly make the difference in terms of maintaining adequate respiratory capacity.
Essentially, the risk of mild or medium scoliosis harming the respiratory system is very low. Meanwhile, in the presence of very severe scoliosis, the size of the curve may not be the only factor determining the correlation with decreased respiratory capacity, since other factors, both anatomical and lifestyle related, can also come into play.  

Studies along these lines are ongoing, their aim being to shed as much light as possible on these aspects, so as to be able to offer patients the best possible treatments, both preventive and conservative.

Interrater reliability of three-dimensional reconstruction of the spine : Low-dose stereoradiography for evaluating bracing in adolescent idiopathic scoliosis

Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 

Interrater reliability of three-dimensional reconstruction of the spine : Low-dose stereoradiography for evaluating bracing in adolescent idiopathic scoliosis.

Almansour H1Pepke W1Rehm J2Bruckner T3Spira D2Akbar M4

Orthopade. 2020 Apr;49(4):350-358. doi: 10.1007/s00132-019-03712-x.


Bracing constitutes the mainstay treatment for mild scoliosis. The 3D reconstruction of the spine using low-dose stereoradiographic imaging (LSI) is increasingly being used to determine the true shape of the deformity and to assess the success of bracing.


The aim of the study was to validate the measurement of 3D spinopelvic parameters and vertebral rotation in the setting of bracing treatment via a reliability study conducted in adherence to the guidelines for reporting reliability and agreement studies (GRRAS).


Full spine stereoradiographs of patients with adolescent idiopathic scoliosis (AIS) who underwent Chêneau bracing were retrospectively analyzed. The 3D reconstruction was performed by two experienced operators in a blinded manner and randomized order. Rotation of every vertebra was computed in the coronal, sagittal and axial planes. Sagittal spinopelvic parameters were evaluated. All measurements were statistically compared to determine agreement of the measurement of brace correction using the intraclass correlation coefficient (ICC).


In this study, 45 patients (81% females) aged 12.5 ± 2 years were included. The mean absolute difference was less than 3.5° for all measured angles, less than 4 mm for sagittal vertical axis (SVA) and less than 1.5 mm for lateral pelvic shift. The ICC was high for all parameters (ICC >0.81). Despite the overall high reliability, the reliability of axial rotation was lower in the upper and middle thoracic spine and the lower lumbar spine.


Brace wearing during full spine LSI acquisition does not affect spinal measurements. The LSI under bracing treatment produces reliable measurements of spinopelvic parameters as well as vertebral rotation. These reproducible 3D data enable spine surgeons to assess the true shape of the deformity, to quantify rotation of each vertebra and enhance the understanding of the efficacy of bracing treatment.

Prevalence of the thoracic scoliosis in children and adolescents candidates for strabismus surgery: results from a 1935-patient cross-sectional study in China.

Every year, the Italian Scoliosis Study Group selects the best published papers on conservative spine treatment from the global scientific literature.
Here is the abstract from one of these papers. 

Prevalence of the thoracic scoliosis in children and adolescents candidates for strabismus surgery: results from a 1935-patient cross-sectional study in China.

Pan XX, Huang CA, Lin JL, Zhang ZJ, Shi YF, Chen BD, Zhang HW, Dai ZY, Yu XP, Wang XY.

Eur Spine J. 2020 Apr;29(4):786-793. doi: 10.1007/s00586-020-06341-7. Epub 2020 Feb 28.


No study so far has paid attention to strabismus-related spinal imbalance. This study aimed to determine the epidemiology of thoracic scoliosis in children and adolescents with strabismus and investigate the association of two diseases.


A cross-sectional study. Study group consists of 1935 consecutive candidates for strabismus surgery (4-18 years); Control group consists of the age- and sex-matched patients with respiratory diseases. All subjects underwent a screening program based on chest plain radiographs using the Cobb method. Their demographic information, clinical variables and results of Cobb angle were recorded and analyzed.


A significantly higher prevalence of thoracic scoliosis (289/1935, 14.94% versus 58/1935, 3.00%) was found in study group compared with control group. Among strabismic patients, the coronal thoracic scoliosis curve mainly distributed in right and in main thoracic (198/289) and in the curves 10°-19° (224/289); Age range 7-9 years (103/1935), female (179/1935) and concomitant exotropia patients (159/851) were more likely to have thoracic scoliosis. According to the logistic regression, thoracic scoliosis had no significant association with age, BMI, duration of illness and onset age (p > 0.05). However, gender, BCVA, type of strabismus and degree of strabismus showed a significant relationship with the prevalence of thoracic scoliosis (p < 0.05).


With a pooled prevalence of 14.94%, strabismus patients showed a great higher risk of developing thoracic scoliosis. Screening for scoliosis in strabismus patients can be helpful to discover a high prevalence of potential coronal scoliosis. More attention should be paid to ophthalmological problems in patients with scoliosis. These slides can be retrieved under Electronic Supplementary Material.

Adolescents with and without idiopathic scoliosis have similar self-reported level of physical activity: a cross-sectional study

Diarbakerli E, Grauers A, Moller H, Abbott A, Gerdhem P

Scoliosis Spinal Disord. 2016 Jul 28;11:17. doi: 10.1186/s13013-016-0082-y. eCollection 2016

BACKGROUND: Little is known about physical activity levels in individuals with idiopathic scoliosis. The aim of this study was to describe the level of physical activity in adolescents with and without idiopathic scoliosis.

METHODS: Two hundred thirty-nine adolescents, median (25th, 75th percentile) age 16.0 (14.4, 17.6) with idiopathic scoliosis and 58 randomly recruited population-based individuals without scoliosis aged 14.6 (12.8, 16.3) participated. The 239 idiopathic scoliosis patients consisted of 88 untreated, 43 previously braced, 36 with ongoing brace-treatment and 72 surgically treated individuals. Main outcome measure was the proportion achieving at least moderate activity level, as estimated by the International Physical Activity Questionnaire short form (IPAQ-SF). Other outcome measures were Metabolic Equivalent Task (MET) minutes/week, time spent sitting, spare time activity level and sporting activities. Statistical analyses were adjusted for age and sex.

RESULTS: The proportion of individuals with scoliosis with moderate activity level was 180 out of 239 (75 %) and for individuals without scoliosis 49 out of 58 (85 %) (p = 0.14). Median MET-minutes/week (25th,75th percentile) was for individuals with scoliosis scoliosis 1977 (840,3777) and for individuals without scoliosis 2120 (887,4598) (p = 0.11). Sporting activities did not differ (p = 0.28). The ongoing brace-treatment group had a significantly higher proportion of individuals categorizing themselves at high spare time activity level compared to the surgically treated and previously braced individuals (p = 0.046). No difference was seen between the treatment groups regarding the proportion achieving moderate activity (p = 0.11) and sporting activities (p = 0.20). Median MET minutes/week was 2160 (794,3797) for the untreated group, 989 (661,2706) for the previously braced group, 2055 (1010, 4026) for the surgery group and 2106 (990,4480) for the ongoing brace-treatment group (p = 0.031).

CONCLUSION: Adolescents with idiopathic scoliosis show similar levels of self-reported physical activity as individuals without idiopathic scoliosis. Bracing and surgery do not appear to inhibit physical activity.

Risk of revision surgery for adult idiopathic scoliosis: a survival analysis of 517 cases over 25 years

Riouallon G, Bouyer B, Wolff S Eur Spine J. 2016 Aug;25(8):2527-34. doi: 10.1007/s00586-016-4505-5. Epub 2016 Mar 10.

Purpose: Little is known about the long-term status of patients operated for spine deformities. The aim of this study was to determine the survival of primary fusion in adult idiopathic scoliosis and identify the risk factors of revision surgery.

METHODS: Adult patients who underwent primary fusion for idiopathic scoliosis between 1983 and 2011 were included in a continuous monocentric retrospective series. Any additional surgery was registered for survival analysis. Survival and follow-up were estimated by the Kaplan-Meier method and an analysis was performed to identify the risk factors of revision surgery.

RESULTS: This series included 447 women (86.5 %) and 70 men (13.5 %) reviewed after a mean follow-up of 7 years (range 0-26.4). Mean age was 44.4 years. Fusion was performed on a median 11 levels (range 3-15); revision rate was 13 % (CI 10-17), 18 % (CI 14-23) and 20 % (CI 16-26) at 5, 10 and 15 years, respectively. Revision surgery was associated with age, anterior release, length of fusion, the inferior limit of fusion, post-operative sagittal balance and junctional kyphosis. The length of fusion (HR 1.13 per vertebrae fused, p = 0.007) and the lower limit of fusion (HR 5.9, p < 0.001) remained independent predictors of revision surgery on multivariate analysis.

CONCLUSION: This series evaluated the risk of revision surgery following spinal fusion for idiopathic scoliosis. Our results show that the risk seemed to increase linearly with a rate of nearly 20 % after 10 years. The length and lower limit of fusion are the main risk factors for revision surgery. Level IV (e.g. case series).

What do astronauts and 80% of the world’s population have in common? A galactic back pain …!

We are talking about that pain that affects, especially between 40 and 50 years, the column between the costal margin and the lower gluteal line. Back pain is, in fact, a pathology that continues to be among the most widespread according to data from the Global Burden Disease Study (2017): the study compared both the major causes of global disabilities over time and the data from 1990 and 2017.

The result? Low back pain maintains the podium in the causes of disability, with particular reference to countries with a high socio-demographic index (since it identifies where the country is located in terms of development by schooling, income and birth rate).

Consequently, there has been no improvement over time in the management capacity of this problem. Most cases still pose a challenge in terms of therapeutic management as their specific cause is unknown (George E. Ehrlich, Bulletin of the World Health Organization 2003; 81: 671-676).

Let’s go back to our spacemen. Because floating in space can be incredible, but unfortunately, half of the astronauts complain of back pain when they return, just like a good part of the rest of the population who pass their time on Earth.
Prolonged exposure to microgravity causes the muscles around the spine to relax and are less “trained” because they are not used. To put it like Luca Parmitano, one of the most famous Italian astronauts, “the spinal column in orbit seems to lengthen”.

In a recent study (Jeannie F. Bailey et al. 2018), the researchers evaluated some anatomical and functional parameters of the spine of some NASA astronauts before and after six months spent in orbit aboard the International Space Station and found that the prolonged exposure to the lack of gravity weakens the muscles that support the astronauts’ back.
“It has been seen that the atrophy of the muscles of the column rather than the protrusion of the intervertebral disc – explains Dr Francesca Di Felice, physician of Isico – is strongly associated with the reduction of lordosis (anterior curve of the column that allows a better distribution of the load to the lower limbs) and with the increase of the stiffness of the column and its weakening. This reduction in muscle strength increases back pain in astronauts once they return to Earth. It is easy to deduce the implications that these results also have for the deconditioned backs of sedentary subjects who live on Earth in gravity: what would happen to the laziest and most sluggish to physical activity would be superimposable to the anatomical and functional alterations recorded for experienced astronauts in a microgravity environment “.