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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/

Sforzesco in-brace corrections visible with EOS images

The aim of our study “The three-dimensional analysis of the Sforzesco brace correction ”, published by Scoliosis and Spinal Disorders, is to analyse the Sforzesco Brace correction, through all the parameters provided by Eos 3D imaging system. This is a cross-sectional study from a prospective database started in March 2003.
The study took into account 16 AIS girls (mean age 14.01) in Sforzesco brace treatment, with EOS x-rays, at start, in brace after one month and out of brace after the first four months of treatment
One of the major revolutions in the field of adolescent idiopathic scoliosis during the past 10 years is the development of 3D imaging devices in standing position, such as EOS Imaging – explains dr. Sabrina Donzelli, physiatrist of Isico and one of the authors of the study –  Through the 3D reconstructions produced by dedicated user-friendly software, it is possible to calculate and visualise a series of regional and local parameters characterising the spinal deformity. This new technology allows the clinician to deepen the direct effect of braces in all three spatial planes”.
Brace efficacy can play a role in determining the final outcome of a treatment. In recent years, braces have become really three dimensional, adding a detorsion action and addressing the whole shape of the trunk and its deformity. 
Different braces can act in different ways and may act in one plane more than in the other. Therefore, personalised prescription of the brace can optimise treatment.
According to the results, the Sforzesco brace has its strongest influence on the middle of the spine in the axial plane, while the Torsion Index cannot be considered an index of brace correction.
The three-dimensional elongation effect, which is typical of the Sforzesco brace, can be responsible for the main effect focused on the middle part of the spine and seen in the axial plane.
The main limitation of this study is a very small sample size, associated with a large heterogeneity of data which threaten the internal validity of the study. The lack of distinction in curve types, magnitude, bone maturity and age is a threaten for the external validity too, but “of course this preliminary study gives some interesting insight into the mechanism of the Sforzesco brace action and it suggests that EOS imaging could be very useful also to improve the immediate in-brace correction“.

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/

The criteria for evaluation of aesthetics in scoliosis

Our study “Construct validity of the Trunk Aesthetic Clinical Evaluation (TRACE) in young people with idiopathic scoliosis” has recently been published by the journal Annals of Physical and Rehabilitation Medicine.

The aim of this study? Scientifically validate the criteria of evaluation of aesthetics in scoliosis.

Indeed, we recall that aesthetics is recognized as a main outcome in idiopathic scoliosis (IS) treatment, but to date, there are no standard criteria for physicians’ evaluation.

Trunk Aesthetic Clinical Evaluation (TRACE) is a simple 12-point ordinal scale to quantify symmetry as a proxy of aesthetics. TRACE is already diffused worldwide and has been used in clinical research.

” In our study, that included 1553 participants (1334 females, mean age 13 years old), we aimed to validate TRACE and improve it with Rasch analysis – explains prof. Stefano Negrini, Scientific Director of Isico – the statistical technique allows to make more precise measurements.
Let’s take the temperature measurement as an example: is it hot, warm, medium, or a little cold? With this type of analysis we develop a real thermometer, obtaining a numerical data. The same criterion is applied to the measurement of the aesthetics, reliably and effectively, as well as objective because it derives from external observation and not simply from what the patient reports “.


The TRACE ordinal scale has been converted into a Rasch-consistent, interval-level measure of trunk aesthetics in IS patients and can be used to compare different populations.

TRACE can be used as an outcome measure and in everyday clinical evaluation of IS, even if new developments of the scale are advised – ends prof. Negrini – It is an objective tool, the only one up to now in the literature. The benchmark for the aesthetics in scoliosis which we want to improve more and more with use”