Impact of growth hormone treatment on scoliosis development and progression: analysis of 1128 patients with idiopathic short stature

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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. 

Impact of growth hormone treatment on scoliosis development and progression: analysis of 1128 patients with idiopathic short stature
Se-Jun Park , Keun-Ho Lee , Chong-Suh Lee , Ki-Tack Kim , Jun Hyuk Jang , Dae Hun Shin , Min Sun Kim , Jiyeon Kim , Sung Yoon Cho , Dong-Kyu Jin 
PMID: 33180047DOI: 10.1515/jpem-2020-0393

Abstract

Objectives
The purpose of this study was to evaluate the impact of recombinant human growth hormone (rhGH) on the development and progression of scoliosis in patients with idiopathic short stature (ISS).
Methods
Patients with ISS who underwent rhGH treatment from 1997 to 2017 and were followed up for scoliosis screening with serial radiographic examination were included. For assessing scoliosis development, patients who did not have scoliosis at the time of rhGH treatment were included and followed up to determine whether de novo scoliosis developed during the treatment. For evaluating scoliosis progression, patients who already had scoliosis were analyzed. Univariate and multivariate Cox regression analyses of demographic and radiographic variables were performed to determine the related factors in the development and progression of scoliosis.
Results
For assessing scoliosis development, 1093 patients were included. The average duration of rhGH treatment was about 2 years. De novo scoliosis developed in 32 patients (3.7%). The analysis revealed that sex (p=0.016) and chronological age (p=0.048) were statistically significant factors associated with scoliosis development. However, no relationship was observed between scoliosis development and rhGH treatment types or duration. Among 67 patients who already had scoliosis at the time of rhGH treatment, 11 (16.4%) showed scoliosis progression. However, the rhGH types and duration also did not affect scoliosis progression.
Conclusions
De novo scoliosis developed in 3.7% and scoliosis progressed in 16.4% of the patients during rhGH treatment. However, scoliosis development or progression was not affected by the types or duration of rhGH treatment in patients with ISS.

https://pubmed.ncbi.nlm.nih.gov/33180047/

Quality of life of adolescent idiopathic scoliosis patients under brace treatment: a brief communication of literature review

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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. 

Quality of life of adolescent idiopathic scoliosis patients under brace treatment: a brief communication of literature review
Huan Wang, Daniel Tetteroo, J J Chris Arts, Panos Markopoulos, Keita Ito 
Qual Life Res. 2020 Oct 24. doi: 10.1007/s11136-020-02671-7

Purpose: To identify the life domains that are most frequently reported to be affected in scoliosis patients undergoing brace treatment.

Methods: A search within the PubMed database was conducted and a total of 60 publications were selected. We classified the studies based on the methods used to measure patients’ quality of life (QoL) and categorized the life domains reported to be affected.

Results: Self-image/body configuration was the most reported affected domain of patients’ QoL, identified in 32 papers, whilst mental health/stress was the second most reported affected domain. Mental health was identified in 11 papers, and 11 papers using the BSSQ questionnaire reported medium stress amongst their participants. Vitality was the third most reported affected domain, identified in 12 papers.

Conclusions: Our review indicates that scoliotic adolescents treated with bracing suffer in their quality of life most from psychological burdens. To improve these patients’ life quality, more attention should be focussed on supporting their mental health.

Keywords: Adolescent idiopathic scoliosis; Brace treatment; Quality of life; Self-image.

https://pubmed.ncbi.nlm.nih.gov/33098493/

Pelvic rotation parameters related to in-brace correction in patients with idiopathic scoliosis

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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. 

Pelvic rotation parameters related to in-brace correction in patients with idiopathic scoliosis
Kepeng Li, Jun Miao, Jingan Zhang

September 2020, European Journal of Medical Research 25(1):41

Background

To identify the pelvic parameters affecting in-brace correction (IBC) in patients with idiopathic scoliosis (IS).

Methods

Patients with IS receiving Chêneau brace treatment in our scoliosis center from January 2019 to November 2019 were retrospectively analyzed. Pelvic rotation parameters, including pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), L/R ratio, were collected. Other radiographic data, such as Risser sign, coronal and sagittal balance, curve location, kyphosis, lordosis of each patient were also recorded to analyze their correlations with IBC. Correlation analyses were performed to identify the classified variables influencing IBC. The principal component analysis was used to extract common factors of radiographic parameters to eliminate interaction effects. The linear regression equation was established using principal components, the variables influencing IBC were identified.

Results

A cohort of 44 patients with IS (36 girls and 8 boys) were included in the present study. The mean IBC was 49.87% (range, 3%–100%). IBC of lumbar IS was negatively correlated with apical rotate factor (ARF, B = –0.385), mainly consisted of pelvic coronal plane rotation (PCPR, 0.449), Cobb angle (CA, 0.575), apical vertebral rotation (AVR, 0.918), and pelvic rotate factor (PRF, B = –0.387), mainly consisted of PT (0.861), PI (0.728), PCPR (–0.570). The regression equation of lumbar IS had statistical significance (F = 6.500, P = 0.005, R2 = 0.317), whereas statistically significance was not found in the regression equation of thoracic IS (F = 2.913, P = 0.106). The remaining parameters were not related to IBC.

Conclusions

For lumbar IS, ARF and PRF have negative effects on IBC, coronal and sagittal rotation of the pelvis is related to IBC.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7495828/

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

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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

Purpose

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

Methods

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.

Results

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).

Conclusion

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

https://link.springer.com/article/10.1007%2Fs43390-020-00184-4

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

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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.

https://pubmed.ncbi.nlm.nih.gov/32588235/

Friends and brace

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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

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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.

https://pubmed.ncbi.nlm.nih.gov/32385841/

Scoliosis: can it harm the lungs?

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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

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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 H1, Pepke W1, Rehm J2, Bruckner T3, Spira D2, Akbar M4

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

BACKGROUND 

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.

OBJECTIVE 

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).

MATERIAL AND METHODS 

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).

RESULTS 

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.

CONCLUSION

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.

 https://www.ncbi.nlm.nih.gov/pubmed/30899991

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

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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.

PURPOSE 

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.

METHODS AND DESIGN

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.

RESULTS 

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).

CONCLUSIONS

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.