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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

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

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/

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.

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

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.

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.

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.