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The Influence of Lumbar Modifiers on Functional and Radiological Outcomes in the Brace Treatment of Lenke Type 1 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. 

The Influence of Lumbar Modifiers on Functional and Radiological Outcomes in the Brace Treatment of Lenke Type 1 Adolescent Idiopathic Scoliosis
Alkan Bayrak, Altug Duramaz, Alican Koluman, Burak Belen , Vedat Öztürk 
PMID: 33233010 DOI: 10.1055/a-1269-0000

Abstract

Background Brace treatment prevents the progression of scoliosis and reduces surgical treatment rates. However, the efficacy of brace treatment varies depending on the patientʼs age, gender, curve magnitude and type, structure of the curve, and patient compliance at the beginning of treatment.

Methods Between January 2009 and April 2015, 106 Lenke type 1 AIS consecutive patients (69 females, 37 males) who were treated with a brace were examined in three groups according to Lenke classification lumbar modifiers. The patients were evaluated at pre-bracing and 1 and 2 years after bracing. The Scoliosis Research Society 22 (SRS-22) and Oswestry Disability Index (ODI) were used for functional evaluation. Radiological evaluation revealed the Cobb angle, thoracic kyphosis angle, lumbar lordosis angle, trunk shift, shoulder asymmetry, and body height difference.

Results Functional and radiological evaluation showed a statistically significant improvement in Lenke 1A, 1B, and 1C at 1 and 2 years after bracing compared to the pre-bracing (p = 0.000, p = 0.000, and p = 0.000, respectively). Lenke 1C had the best ODI score and followed by decreasing values of 1B and 1A respectively (p = 0.009). Lenke 1B had the best SRS-22 score and the mean scores of 1A and 1C were equal (p = 0.017). There was no significant difference between the groups in the parameters other than the trunk shift in radiological evaluation (p = 0.043).

Conclusions Significant improvement was observed in all types of lumbar modifiers at the end of the 2nd year compared to pre-bracing. The best improvement in the ODI score was in the 1C modifier, whereas the best improvement in the SRS-22 score was in the 1B modifier. The type of lumbar modifier should be directly taken into consideration before starting brace treatment in Lenke type 1 AIS.

Level of evidence Level III, retrospective study

https://pubmed.ncbi.nlm.nih.gov/33233010/

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/

ISICO Telemedicine described in a recently published article

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ISICO’s use of the telemedicine approach during the COVID-19 emergency and the data collected in relation to that experience are the focus of a new article by our team, Feasibility and acceptability of telemedicine to substitute outpatient rehabilitation services in the COVID-19 emergency in Italy: an observational everyday clinical-life study, which has just been published in Archives of Physical Medicine and Rehabilitation.

“This is a hugely important publication,” remarks Prof. Stefano Negrini, scientific director of ISICO, “as it testifies to the work done by ISICO right at the beginning of the COVID-19 crisis when, in our daily clinical work, we switched to the telemedicine modality in order to avoid having to interrupt the care and treatment of many of our patients”.

Here are a few figures: the article examines data collected over a 15-day telemedicine period, during which 325 teleconsulations and 882 telephysiotherapy sessions were provided. Instead, over the entire lockdown period, the remote sessions numbered 3,231 in total, i.e. 2317 telephysiotherapy sessions and 914 teleconsulations. These are impressive numbers, especially if we consider the high level of patient satisfaction recorded (2.8/3).

ISICO has longstanding experience in caring for and monitoring young scoliosis patients (children and adolescents) living all over Italy and also abroad. Precisely for this reason, i.e. in order to find a way of allowing farther-flung patients to travel to the centre less often, it has already experimented with various telemedicine tools. 

In fact, over the years, ISICO patients, some even living in other continents (such as Australia and the USA), have been able to follow long-term treatment programmes, thanks to the availability of online consultations.

Therefore, our temporary recourse to online consultations and treatments following the COVID outbreak and during the subsequent lockdown did not constitute a completely new experience, but rather a speeding up of a process that was already under way. 

“This strategy aims to decrease the heavy impact on the health systems and allow hospitalisation and intensive care of the huge number of patients in need, thereby reducing the overall mortality” explains Prof. Negrini. But “the COVID-19 emergency is hitting hard not only infected patients, but also all the others. In many countries, outpatient services have been fully closed due to the need for physicians to treat COVID-19 patients, and also to reduce the risk of infection linked to travelling. This has left outpatients are on their own and mostly self-managing. This is not acceptable for diseases that can still show sudden, important progressions, even in the space of a few months, and it is even less acceptable in children.”

How did telemedicine at ISICO work? The telemedicine services consisted of teleconsultations and telephysiotherapy sessions, which lasted as long as usual interventions. They were delivered using free teleconference apps, caregivers were actively involved, and interviews and counseling were performed as usual. 
Teleconsultations included standard, but adapted, measurements and evaluations by video and using photographs and videos prepared according to specific tutorials and sent in beforehand.  During telephysiotherapy sessions, new sets of exercises were defined and recorded as usual.

In the article, we considered 3 phases: the first covers the usual services delivered, over a period of  30 working days (January 7th to February 23rd), prior to the discovery of the spread of COVID-19 the second phase (February 24th to March 14th) was the one in which COVID-19 began to impact  on our usual services, but before we started using the telemedicine approach; finally the last data analysed refer to the 15 working days from our introduction of exclusively Telemedicine consultations (starting from March 16th)

What came out of the study?

That “Telemedicine is feasible and allows us to keep on providing outpatient services that meet with patients’ satisfaction. In the current pandemic,” Prof. Negrini concludes, “telemedicine has been shown to be effective in specific areas of care, particularly where technology is involved. To our knowledge there are no published results about the application of telemedicine to patients with spinal deformities,” and the publication of this article shows that “this strategy can provide a viable alternative to closure of many outpatient services”.

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

Active self correction and stabilization: an Isico letter to the editor

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It has just been published a letter to the editor  “The active self-correction component of scoliosis-specific exercises has results in the long term, while the stabilization component is sufficient in the short term” in the scientific journal Prosthetics and Orthotics International. 

“This is a comment to the study “Core stabilization exercises versus scoliosis-specific exercises in moderate idiopathic scoliosis treatment” –explains dr. Alessandra Negrini, Isico physiotherapist and author of the letter – the authors of the research compared two groups included Scientific Exercises Approach to Scoliosis (SEAS) and core stabilization. Scoliosis-specific exercise schools like SEAS include two main components: active self-correction (ASC) and stabilization. Consequently, a common intervention was provided to the two groups (stabilization) in this study, while the SEAS group also received ASC”.

Follow-up X-rays were taken after only 4 months. According to the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT)/Scoliosis Research Society (SRS) criteria, these results should be classified as a very short-term assessment. No significant difference was found between the two interventions. The patients were more adherent to the brace than to the exercise therapy. “Unfortunately, the authors did not mention if there was a difference in the adherence to bracing between the groups: this variable is expected to impact the results more than the type of exercises -adds dr. Negrini – Experts agree that stabilization exercises are more important during the first treatment phase (when the brace maintains for many hours every day the alignment of the spine and exercises are aimed to counteract muscle impairment). Exercises in ASC are more important in maintaining the obtained results when the brace weaning phase starts, when the patients should live sustaining in correction their spine without the brace support”. 

It is important for the future to determine when to start ASC: immediately (even if it could add nothing to stabilization) or when weaning starts (when it could be too late)?

The full letter: https://pubmed.ncbi.nlm.nih.gov/32524898/

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/

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/

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