Douglas Hedden

A comparative study of TLSO, Charleston, and Milwaukee braces for idiopathic scoliosis

Study Design. Retrospective cohort study. Objective. To determine which of TLSO, Charleston, or Milwaukee bracing best prevents curve progression and surgery in adolescent idiopathic scoliosis. Summary of Background Data. Bracing has been shown to prevent curve progression in idiopathic scoliosis, when compared with no treatment. However, there is little literature available comparing the effectiveness of different brace designs. Methods. One hundred seventy patients who completed brace treatment for adolescent idiopathic scoliosis between 1988 and 1995 were studied. Forty‐five thoracolumbosacral orthoses, 95 Charleston braces, and 35 Milwaukee braces were used. Thoracolumbosacral orthoses and Charleston braces were used on comparable curves, whereas Milwaukee braces were used in a sub‐group in which the other brace designs were considered inappropriate. Evaluated were the absolute increase in curve severity, the percentage of curves that progressed beyond 6° and 10° thresholds, and the percentage of patients who underwent surgery. Results. Age, Risser stage, curve size, and time braced and observed did not differ among groups. Mean progression of the curve during bracing was 1.1° with thoracolumbosacral orthosis, 6.5° with the Charleston brace, and 6.3° with the Milwaukee brace (P = 0.012; analysis of variance). Proportion of patients with more than 10° of curve progression was 14% with thoracolumbosacral orthosis, 28% with the Charleston brace, and 43% with the Milwaukee brace (P = 0.017; chi‐square). The proportion of patients who underwent surgery was 18% with thoracolumbosacral orthosis, 31% with the Charleston brace, and 23% with the Milwaukee brace (P = 0.26; chi‐square). Conclusions. The thoracolumbosacral orthosis was superior at preventing curve progression in adolescent idiopathic scoliosis.

Parents' and patients' perceptions of postoperative appearance in adolescent idiopathic scoliosis.

Study Design. A cross-sectional evaluation of patients after surgery for adolescent idiopathic scoliosis (AIS). Objectives. To determine the agreement between patients’ and parents’ perceptions of the patient’s postoperative appearance and to compare those perceptions with physical and radiographic measures of deformity. Summary of Background Data. Improving cosmesis is an important aim of surgery. Patients’ appearances may influence their evaluation of its outcome. Methods. Physical and radiographic data were collected 2 years after surgery for 128 patients with AIS. Patients and parents independently rated shoulder blades, shoulders, waist, and overall appearance. Additionally, patients completed the Quality of Life Profile for Spinal Disorders (QLPSD). Agreement was evaluated with the weighted kappa statistic ranging between 0 and 1 where higher values indicate better agreement. Results. Fair to moderate agreement was found between patient and parent ratings of the patient’s shoulder blades (kappa = 0.39; 95% confidence interval [CI], 0.29–0.48), shoulders (kappa = 0.38; 95% CI, 0.26–0.50), waist (kappa = 0.45; 95% CI, 0.25–0.55), and overall appearance (kappa = 0.22; 95% CI, 0.04–0.40). Patients rated the appearance of their waist (P = 0.013) and overall appearance (P = 0.039) significantly worse than their parents. Patients’ perceptions of their overall appearance had higher correlations with the body image subscale score (r = 0.45, P = 0.000) and the total quality of life score on the QLPSD (r = 0.37, P = 0.000) than did parents’ perceptions of those same measures (r = 0.21, P = 0.025; and r = 0.08, P = 0.369, respectively). Conclusions. Radiographic and physical measures of deformity do not correlate well with patients’ and parents’ perceptions of appearance. Patients and parents do not strongly agree on the cosmetic outcome of AIS surgery. Therefore, given that the adolescents themselves undergo the surgery, patients’ assessments of their deformity, rather than radiographic measures or parents’ assessments, should play a major role in the evaluation of surgical success.

The use of bone scan to investigate back pain in children and adolescents.

Children with back pain frequently undergo detailed investigation because of the perception that a high percentage will have a treatable spinal condition. The purposes of this study was (i) to determine the percentage of children with disabling back pain presenting to our institution who had a diagnosis (i.e., to explain their back pain), (ii) to evaluate the clinical markers that should alert clinicians to underlying pathology, (iii) and to determine the prognosis of children with back pain and no specific diagnosis. This study was a retrospective analysis of consecutive children undergoing single-photon emission computed tomography for a primary complaint of back pain. Data collection included chart review, radiographic analysis, and clinical follow-up with the Roland and Morris scale for pain and disability. Two hundred and seventeen patients with an average age of 13 years (range, 2.7–17.7) were reviewed on average 4.4 years after presentation (range, 1.1–7.2 years). One hundred and seventy children (78.3%) had no specific diagnosis to explain their back pain, 15 children (6.9%) had spondylosis, 10 children (4.6%) had tumor, and the remaining 22 children (10.1%) had various diagnoses including infection, Scheuermanns kyphosis, herniated disc, kidney disease, facet arthritis, degenerative disc disease, congenital anomalies, and tethered cord. Factors associated with positive diagnoses were constant pain and male gender. Night pain, constant pain, and duration of symptoms <3 months were associated with the diagnosis of a tumor. Although the majority of children presenting with persistent back pain had no demonstrable cause, of 132 contactable patients 94 (71%) had persisting pain at the time of clinical follow-up. In conclusion, the majority of children with disabling back pain has no demonstrable cause and the majority will continue to have pain years after initial presentation.

Superior Mesenteric Artery Syndrome Following Spinal Deformity Correction

BACKGROUND Superior mesenteric artery syndrome is a known complication associated with the correction of spinal deformity. Recent investigations of this disorder have focused on patient height and weight. We are not aware of any published study examining the degree of deformity, type of curve, or magnitude of correction, and to our knowledge all of the reported literature on this syndrome lacks control data. The purpose of this study was to examine the relationship between the correction of spinal deformity and the development of superior mesenteric artery syndrome in patients with scoliosis. Our hypothesis was that greater correction of spinal deformity would increase the risk of the development of superior mesenteric artery syndrome. METHODS A case-control study was performed over a five-year period. The primary outcome measure was the development of superior mesenteric artery syndrome. The predictor variables that were considered included demographic characteristics; preoperative height, weight, and body mass index; aspects of the deformity, including curve magnitude, Lenke curve classification, and correction; and operative factors, including surgical approach, estimated blood loss, and the presence of operative hypotension. RESULTS A review of the records on 364 surgical procedures for scoliosis identified seventeen cases of superior mesenteric artery syndrome. Thirty-four subjects who had had surgery for scoliosis but no superior mesenteric artery syndrome were randomly selected as controls. Eight of the seventeen subjects with superior mesenteric artery syndrome had undergone a two-stage procedure (compared with one of the thirty-four controls, p < 0.001), nine of the seventeen had had combined anterior and posterior procedures (compared with two of the thirty-four controls, p < 0.001), and seven of the seventeen had had a thoracoplasty (compared with two of the thirty-four controls, p < 0.001). No significant differences were noted between the groups with regard to demographic factors. Compared with the controls, the patients in whom superior mesenteric artery syndrome developed were shorter (by a mean of 7.1 cm, p = 0.03), weighed less (by a mean of 11.5 kg, p = 0.001), had a lower body mass index (p = 0.003), had a greater minimal thoracic curve magnitude achieved by bending (a mean of 12 degrees greater [45 degrees for subjects with superior mesenteric artery syndrome and 33 degrees for controls], p = 0.015), had a lower percent correction of the thoracic curve on bending (a mean of 11% lower, p = 0.025), and had more lumbar lateralization (88%, compared with 61% in the control group, had a Lenke lumbar modifier of B or C instead of A, p = 0.008). Multivariate logistic regression analysis identified a staged procedure (odds ratio, 31.0), the lumbar modifier (odds ratio, 9.06), body mass index (odds ratio, 7.75), and thoracic stiffness (odds ratio, 6.67) as the most predictive of the development of superior mesenteric artery syndrome. CONCLUSIONS Preoperative identification of the risk factors described above in conjunction with preoperative nutritional maximization should be considered in order to limit the prevalence of superior mesenteric artery syndrome in patients undergoing surgical correction of spinal deformity.

Improvement in quality of life following surgery for adolescent idiopathic scoliosis

Study Design. We used the Climent Quality of Life for Spinal Deformities Scale prospectively in a nonrandomized prospective comparative cohort of operative versus observational management of adolescent idiopathic scoliosis. Objective. To compare the change in disease-specific quality of life associated with operating on adolescents with idiopathic scoliosis, to the change in disease-specific quality of life among observed scoliosis patients with a similar 2-year follow-up period. Summary of Background Data. The immediate effect of scoliosis surgery on quality of life from a patient perspective has not been properly documented but should play a role in the patient’s decision to operate. Methods. At a single tertiary referral children’s hospital spinal clinic, 119 patients undergoing scoliosis surgery and 42 patients undergoing observation only for scoliosis were enrolled in a prospective study, including preoperative and postoperative spine-specific quality of life. Change in quality of life after 2 years of follow-up among operated versus observed patients (adjusted for baseline quality of life) was used to estimate the short-term benefit of scoliosis surgery. Results. The operated group experienced an increase in quality of life of 4.3 points (95% confidence interval, 0.69–7.88) on the 115-point Climent scale. Although statistically significant, this increase was lower than the 5.5-point cutoff we had defined a priori as clinically significant. Conclusion. Scoliosis surgery results in a small increase in spine-related quality of life at 2 years. This increase is of questionable clinical significance. Decisions to operate on adolescents with scoliosis should acknowledge modest expectations about short-term gains in quality of life.

An objective measurement of brace usage for the treatment of adolescent idiopathic scoliosis.

Effectiveness of orthotic treatment for scoliosis depends on how much time and how well the orthosis is worn. Questionnaires and clinical judgment are subjective methods to wear compliance. Even though using a temperature sensor can objectively record how long the orthosis has been used, it may not be able to answer the orthosis effectiveness without knowing the wear tightness. Custom made thoracolumbosacral orthoses (TLSO) were instrumented with low power wireless data acquisition systems to measure the time and loads imposed by the pressure pad during daily activities. Force measurements were recorded at 1 sample/min and the system was able to record data up to 4 months without patient-involvement. Ten subjects (9F, 1M), age between 9 and 13.5 years, average 11.6±1.3 years, who prescribed a new TLSO and full-time brace wear were took part in this study over 4.4±1.0 months. Long-term logging of loads within a spinal orthosis is a reliable method to measure compliance objectively. The monthly quantity of brace wear ranged from 33% to 82%, average 60.0±4.3%. The monthly average loads imposed by the pressure pads varied from 39% to 78% relative to the reference level, average 64.3±4.6%. There was a statistically significant decrease in force, but increase in wear time over the period after the brace fitting session. This information may help to better understand the effectiveness of bracing and to predict the brace treatment outcomes.

Intra- and Inter-rater Reliability of Coronal Curvature Measurement for Adolescent Idiopathic Scoliosis Using Ultrasonic Imaging Method—A Pilot Study

STUDY DESIGN Retrospective reliability study of the coronal curvature measurement on ultrasound (US) imaging in adolescent idiopathic scoliosis (AIS). OBJECTIVES To determine the intra- and inter-rater reliability and validity of the coronal curvature measurements obtained from US images. SUMMARY OF BACKGROUND DATA Cobb angle measurements on radiographs are the usual method to diagnose and monitor the progression of scoliosis. Repeated ionizing radiation exposure is a frequent concern of patients and their families. Use of US imaging method to measure coronal curvature in children who have idiopathic scoliosis has not been clinically validated. METHODS The researchers scanned 26 subjects using a medical 3-dimensional US system. Spinal radiographs were obtained on the same day from the local scoliosis clinic. Three raters used the center of lamina method to measure the coronal curvature on the US images twice 1 week apart. The raters also measured the Cobb angle on the radiographs twice. Intra- and inter-rater reliability of the coronal curvature measurement from the US images was analyzed using intra-class correlation coefficients. The correlation coefficient of the US coronal curvature measurements was compared with the Cobb angles. RESULTS The intra-class correlation coefficient (2,1) values of intra- and inter-rater reliability on the US method were greater than 0.80. Standard error of measurement on both of the intra- and inter-rater US methods was less than 2.8°. The correlation coefficient between the US and radiographic methods ranged between 0.78 and 0.84 among 3 raters. CONCLUSIONS The US method illustrated substantial intra- and inter-rater reliability. The measurement difference between radiography and the US method was within the range of clinically acceptable error (5°). The US method may be considered a radiation-free alternative to assess children with scoliosis of mild to moderate severity.

Improvement on the Accuracy and Reliability of Ultrasound Coronal Curvature Measurement on Adolescent Idiopathic Scoliosis With the Aid of Previous Radiographs.

Study design. Retrospective study of the coronal curvature measurement on ultrasound (US) images with the aid of previous radiographs. Objective. To compare the reliability and accuracy of the coronal curvature measurements from US images on children who have adolescent idiopathic scoliosis (AIS) with and without the knowledge of previous radiographs. Summary of Background Data. Using US imaging technique to measure coronal curvature on children with AIS has demonstrated high intra- and interrater reliabilities. However, the selection of end-vertebrae and the measurement difference between radiography and the US method were only moderately reliable. Methods. Two raters measured the coronal curvatures from 65 AIS standing US spine images, without (measured one time) and with the aid of previous standing radiographs (measured two times). The intra- and interrater reliability, the correlation and the difference between the radiographic and US measurements, and the error index of the end-vertebrae selection were assessed. Results. Overall, 109 curves were investigated. The intraclass correlation coefficients (ICC) of intra- and interrater reliability of the US coronal curvature measurement with the aid of previous radiographs (AOR) were 0.95 and 0.91, respectively. In comparison with the radiographic measurements, the correlation of AOR method (R2) was 0.90 and the MAD was 2.8°; the corresponding results of the US measurement without the AOR (blinded US method) were 0.73° and 4.8°, respectively. The average error index on end-vertebral selection improved 43% with the AOR. Conclusion. The AOR method significantly improved reliability and accuracy of the spinal curvature measurement on US images compared with the blinded US method (P<0.001). It indicates that US standing images with the AOR can be used as a reliable and accurate nonionizing imaging method to monitor children with AIS. Level of Evidence: 3

Effect of Schroth exercises on curve characteristics and clinical outcomes in adolescent idiopathic scoliosis: protocol for a multicentre randomised controlled trial

INTRODUCTION The promising results of Schroth scoliosis-specific exercises for adolescent idiopathic scoliosis found in low-quality studies will be strengthened by confirmation in a randomised controlled trial. RESEARCH QUESTIONS 1. Are Schroth exercises combined with standard care for 6 months more effective than standard care alone in improving radiographic and clinical outcomes for adolescents with idiopathic scoliosis? 2. Will the outcomes of the control group (who will be offered Schroth therapy delayed by 6 months) improve after 6 months of Schroth therapy? 3. Are the effects maintained 6 months after discontinuing the supervised intervention? DESIGN This is an assessor-blinded and statistician-blinded randomised controlled trial with transfer of the controls to the exercise group after 6 months. PARTICIPANTS AND SETTING Two hundred and fifty-eight consecutive adolescents with idiopathic scoliosis, aged 10 to 16 years, treated with or without a brace, with curves between 10 and 45 deg Cobb and Risser sign ≤ 3 will be recruited from three scoliosis clinics. INTERVENTION Combined with standard care, the Schroth group will receive five individual training sessions, followed by weekly group classes and daily home exercises for 6 months. CONTROL Controls will only receive standard care consisting of observation or bracing, and will be offered Schroth therapy 6 months later. MEASUREMENTS Curve severity (Cobb angle) and vertebral rotation will be assessed from radiographs at baseline, 6 and 12 months. Secondary clinical outcomes (back muscle endurance, surface topography measures of posture, and self-reported perceived spinal appearance and quality of life) will be assessed at baseline, and every 3 months until 1-year follow-up. ANALYSIS Data will be analysed using intention-to-treat linear mixed models. DISCUSSION The results will demonstrate whether Schroth exercises combined with standard of care can improve outcomes in adolescents with idiopathic scoliosis. This study has potential to influence clinical practice worldwide, where exercises are not routinely prescribed for adolescents with idiopathic scoliosis.

Management themes in congenital scoliosis.

Congenital spinal deformities are among the most difficult deformities to treat. They are a challenge both from a decision-making and a technical point of view. Many deformities do not require any treatment short of investigation and observation, but, at their worst, they will challenge the surgeon technically and cognitively. The variety of combinations of congenital deformities seems limitless and therefore makes the prediction about what will happen with growth very difficult. In this article, the principles of nonoperative and operative management will be discussed. Observation is appropriate when the natural history suggests that the curve will not worsen to an extent that will lead to a clinically important deformity. This has been discussed elsewhere in this symposium and will not be further discussed here. The other form of nonoperative management is bracing. Bracing plays a very limited role in the management of congenital scoliosis, especially as a primary form of treatment1. It is often added as a supplement to surgical treatment. Bracing is sometimes used to control secondary curves when the primary congenital curve has not been treated surgically. Occasionally the noncongenital curve progresses on its own and will respond to bracing. Bracing may also be used to prevent progression of a secondary curve that is causing balance problems. The surgical management of a congenital spinal deformity can be divided into two categories. There are procedures that prevent further deformity and those that correct the present deformity. In the latter type, there are techniques that correct the curve gradually and those that correct the curve acutely. Fusion in situ is the classic example of a procedure that prevents further deformity. Convex anterior and posterior hemiarthrodesis allows gradual correction, while hemivertebra excision and osteotomy allow acute correction. As a guiding principle, it is safe to say that it is …