The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) produced its first guidelines in 2005 and renewed them in 2011. Recently published high-quality clinical trials on the effect of conservative treatment approaches (braces and exercises) for idiopathic scoliosis prompted us to update the last guidelines’ version. The objective was to align the guidelines with the new scientific evidence to assure faster knowledge transfer into clinical practice of conservative treatment for idiopathic scoliosis (CTIS). Physicians, researchers and allied health practitioners working in the area of CTIS were involved in the development of the 2016 guidelines. Multiple literature reviews reviewing the evidence on CTIS (assessment, bracing, physiotherapy, physiotherapeutic scoliosis-specific exercises (PSSE) and other CTIS) were conducted. Documents, recommendations and practical approach flow charts were developed using a Delphi procedure. The process was completed with the Consensus Session held during the first combined SOSORT/IRSSD Meeting held in Banff, Canada, in May 2016. The contents of the new 2016 guidelines include the following: background on idiopathic scoliosis, description of CTIS approaches for various populations with flow-charts for clinical practice, as well as literature reviews and recommendations on assessment, bracing, PSSE and other CTIS. The present guidelines include a total of 68 recommendations divided into following topics: bracing (n = 25), PSSE to prevent scoliosis progression during growth (n = 12), PSSE during brace treatment and surgical therapy (n = 6), other conservative treatments (n = 2), respiratory function and exercises (n = 3), general sport activities (n = 6); and assessment (n = 14). According to the agreed strength and level of evidence rating scale, there were 2 recommendations on bracing and 1 recommendation on PSSE that reached level of recommendation “I” and level of evidence “II”. Three recommendations reached strength of recommendation A based on the level of evidence I (2 for bracing and one for assessment); 39 recommendations reached strength of recommendation B (20 for bracing, 13 for PSSE, and 6 for assessment).The number of paper for each level of evidence for each treatment is shown in Table 8. The 2016 SOSORT guidelines were developed based on the current evidence on CTIS. Over the last 5 years, high-quality evidence has started to emerge, particularly in the areas of efficacy of bracing (one large multicentre trial) and PSSE (three single-centre randomized controlled trials). Several grade A recommendations were presented. Despite the growing high-quality evidence, the heterogeneity of the study protocols limits generalizability of the recommendations. There is a need for standardization of research methods of conservative treatment effectiveness, as recognized by SOSORT and the Scoliosis Research Society (SRS) non-operative management Committee.

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2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth.

Current population studies characterize idiopathic scoliosis as a single-gene disorder that follows the patterns of mendelian genetics, including variable penetrance and heterogeneity. The role of melatonin and calmodulin in the development of idiopathic scoliosis is likely secondary, with indirect effects on growth mechanisms. Reported abnormalities of connective tissue, skeletal muscle, platelets, the spinal column, and the rib cage are all thought to be secondary to the deformity itself. Although no consistent neurological abnormalities have been identified in patients with idiopathic scoliosis, it is possible that a defect in processing by the central nervous system affects the growing spine. The true etiology of idiopathic scoliosis remains unknown; however, it appears to be multifactorial.

Etiology of idiopathic scoliosis: current trends in research.

The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT), that produced its first Guidelines in 2005, felt the need to revise them and increase their scientific quality. The aim is to offer to all professionals and their patients an evidence-based updated review of the actual evidence on conservative treatment of idiopathic scoliosis (CTIS). All types of professionals (specialty physicians, and allied health professionals) engaged in CTIS have been involved together with a methodologist and a patient representative. A review of all the relevant literature and of the existing Guidelines have been performed. Documents, recommendations, and practical approach flow charts have been developed according to a Delphi procedure. A methodological and practical review has been made, and a final Consensus Session was held during the 2011 Barcelona SOSORT Meeting. The contents of the document are: methodology; generalities on idiopathic scoliosis; approach to CTIS in different patients, with practical flow-charts; literature review and recommendations on assessment, bracing, physiotherapy, Physiotherapeutic Specific Exercises (PSE) and other CTIS. Sixty-five recommendations have been given, divided in the following topics: Bracing (20 recommendations), PSE to prevent scoliosis progression during growth (8), PSE during brace treatment and surgical therapy (5), Other conservative treatments (3), Respiratory function and exercises (3), Sports activities (6), Assessment (20). No recommendations reached a Strength of Evidence level I; 2 were level II; 7 level III; and 20 level IV; through the Consensus procedure 26 reached level V and 10 level VI. The Strength of Recommendations was Grade A for 13, B for 49 and C for 3; none had grade D. These Guidelines have been a big effort of SOSORT to paint the actual situation of CTIS, starting from the evidence, and filling all the gray areas using a scientific method. According to results, it is possible to understand the lack of research in general on CTIS. SOSORT invites researchers to join, and clinicians to develop good research strategies to allow in the future to support or refute these recommendations according to new and stronger evidence.

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2011 SOSORT guidelines: Orthopaedic and Rehabilitation treatment of idiopathic scoliosis during growth

Study Design. The authors developed a rat-tail model to investigate the hypothesis that vertebral wedging during growth in progressive spinal deformities results from asymmetric loading in a vicious cycle. Objectives. To document growth curves with axial compression or distraction applied to tail vertebrae to determine whether compression laod slow growth and distraction accelerates it. Summary of Background Data. Progression of skeletal deformity during growth is believed to be governed by the Hueter-Volkmann law, but there is conflicting evidence to support this idea. Methods. Twenty-eight 6-week-old Sprague-Dawley rats were assigned to one of three groups : compression loading, distraction loading, or sham (apparatus applied without loading). Under general anesthesia, two 0.7-mm diameter stainless steel percutaneous pins were used to transfix each of two vertebrae. The pins were glued to 25-mm diameter external ring fixators. Springs (load rate, 35 g/mm) were installed on three stainless steel threaded rods that were passed through holes in each ring and compressed with nuts to apply compression or distraction forces between 25-75% of bodyweight. Vertebral growth rates in μm/day were measured by digitizing the length of the vertebrae images in radiographs taken 0, 1, 3, 5, 7, and 9 weeks later. Results. The loaded vertebrae grew at 68% of control rate for compressed vertebrae and at 114% for distracted vertebrae. (Difference statistically significant, P<0.01 by analysis of variance). For the compressed vertebrae, the pinned vertebrae, which were loaded at one of their two growth cartilages, grew at a reduced rate (85%), although this effect was not apparent for the distraction animals. Conclusions. The findings confirm that vertebral growth is modulated by loading, according to the Hueter-Volkmann principle. The quantification of this relationship will permit more rational design of conservative treatment of spinal deformity during the adolescent growth spurt.

Mechanical modulation of vertebral body growth. Implications for scoliosis progression.

Study design A retrospective study investigated the sagittal alignment in adolescent idiopathic scoliosis (AIS). Objective To evaluate the sagittal alignment of the spine and pelvis in adolescent idiopathic scoliosis on the basis of curve type. Summary of background data The relation between the spine and pelvis highly influences the sagittal balance in adults. However, the sagittal alignment of the spine and pelvis in adolescent idiopathic scoliosis is poorly defined in the literature. Methods Five sagittal parameters were evaluated on lateral radiographs of 160 patients with adolescent idiopathic scoliosis: thoracic kyphosis, lumbar lordosis, sacral slope, pelvic tilt, and pelvic incidence. The patients were classified according to their coronal curve type. Analysis of variance was used to compare the parameters between the curve types, and Pearson coefficients were used to investigate the relation between all parameters (alpha = 0.05). Results The thoracic kyphosis was significantly lower for King I, II, and III curves than for lumbar curves. The lumbar lordosis was higher for lumbar curves, although not significantly. No significant change between the groups was observed for the sacral slope, pelvic tilt, or pelvic incidence. The pelvic incidence was significantly correlated with the lumbar lordosis, sacral slope, and pelvic tilt for all the groups. The lumbar lordosis was strongly related to the sacral slope in all cases, but not with the thoracic kyphosis, except in the case of thoracolumbar curves. Conclusions Thoracic kyphosis depended mostly on the spinal deformity, whereas lumbar lordosis was influenced mainly by the pelvic configuration. The scoliotic curve type was not associated with a specific pattern of sagittal pelvic morphology and balance. The pelvic incidence found in this study was significantly higher than that reported in the literature for normal adolescents. The role of the pelvic incidence in the pathogenesis of adolescent idiopathic scoliosis needs to be explored in a longitudinal study involving patients with adolescent idiopathic scoliosis and normal adolescents.

Sagittal plane analysis of the spine and pelvis in adolescent idiopathic scoliosis according to the coronal curve type.

The development of structural skeletal changes was evaluated on 132 anteroposterior radiographs of spines from three scoliotic groups with a Cobb angle of up to 30 degrees and a reference control group. Significant wedging of the vertebral bodies and disks at the coronal plane was registered in-curves with a Cobb angle of 4 degrees or more. Asymmetry of the rib-vertebra angle was found in curves with a Cobb angle of 8 degrees or more and was most pronounced in the cranial part of the curves. The early simultaneous occurrence of vertebral and disk wedging suggests the involvement of an extraspinal factor rather than growth disturbance of the vertebral body or of the disk in the early pathomechanism of scoliosis.

Radiographic changes at the coronal plane in early scoliosis.

Sagittal configuration of the spine and growth of the posterior elements in early scoliosis.

One CT-scan at the central part of the vertebral body of the apical vertebra of 32 patients with right convex thoracic idiopathic scoliosis and one CT-scan of either T8 or T9 of 22 normal subjects are included in this study. The position of the aorta in relation to the apical vertebra of the scoliotic patients and the corresponding vertebra of the normal subjects was determined at the horizontal plane. The mean lateral translation of the aorta in relation to the mid axis of the vertebral body increased from 19.7±4.3 mm in the normal group to 26.4±4.1 mm in the scoliotic group (p = 0.0001). In the normal group the aorta was located 41.7±8.6 mm in front of a perpendicular line to the mid axis of the vertebral body and in the scoliotic group this distance was reduced to 30.0±9.0 mm making the position of the aorta more posterior in the scoliotic group (p = 0.0001). This was in accordance with a decreased mean kyphosis-lordosis index from 0.53 ± 0.06 in the normal group to 0.46±0.07 in the scoliotic group (p−0.01). The position of the aorta, also expressed as the angle formed between the aorta and the vertebral body, the “aorto-vertebral angle”, was increased from 24.4°±6.9° in the normal group to 41.4°±8.4° aorto-vertebral angle did not change significantly with increasing Cobb angle (p = 0.26) but was positively correlated to the vertebral rotation (p = 0.0001). An estimation of the length of the intercostal arteries revealed a significantly greater R (right)/L (left) index in the scoliotic patients 1.18±0.11 than in the normal subjects 1.08±0.06 (p−0.0003). It is concluded that the rotation and the anterior displacement of the vertebral body in scoliosis result in a deviation of the aorta along the left (concave) side of the vertebral body to a more posterior position relative to the vertebral body with a possible increased length of the intercostal artery on the right (convex) side.

The position of the aorta in relation to the vertebra in patients with idiopathic thoracic scoliosis.

Rotation in the horizontal plane of vertebra T8, T9 or T10 was determined on CT scans of 25 male and 25 female patients with normal spines. The pedicle length was measured using a new method, and the right/left pedicle length index was calculated. In 38 (76%) of the patients there was vertebral rotation to the right with a mean Cobb angle of 3.0 degrees, and in 4 (8%) rotation to the left, mean Cobb angle 2.2 degrees (P < 0.01). In 8 (16%) there was no measurable rotation. The pedicle length index was greater than 1.05 in 9 subjects, between 0.95 and 1.05 in 16 and less than 0.95 in 25, indicating a predominance of longer pedicles on the left side. In 21 out of the 38 patients with vertebral rotation to the right, the left pedicle was longer than the right one (P < 0.01). The results indicate that the normal spine is afflicted with a vertebral rotation to the right in association with a longer pedicle on the left. The significance of these observations for the pathogenesis of idiopathic scoliosis remain uncertain.

Vertebral rotation and pedicle length asymmetry in the normal adult spine.

Computed tomography (CT) scans are widely used for quantification of the morphology of the vertebral body and of the changes of the thoracic cage in the horizontal plane in scoliosis. So far, however, no method exists for precise quantification of the parameters of the posterior elements. We present a method for quantification on the basis of CT scans of different parameters of the morphology of both the vertebral body and posterior elements in the horizontal plane. The precision and accuracy of the method were estimated in a model study by CT scanning of a normal and a scoliotic vertebra in different, controlled, tilted positions. Moreover, in a clinical study CT scans of 19 thoracic vertebrae from non-scoliotic subjects and the apex vertebra from 40 scoliotic subjects were selected to test the applicability of the method to clinical studies. The intra- and interobserver variation of the measurements was analysed. The angle between the longitudinal axis of the vertebral body and that of the whole vertebra was used to evaluate the asymmetry of the vertebral body. The right to left pedicle width index, the right to left hemi-canal width index and the index of transverse process angles related to the axis of the vertebra were used to quantify the asymmetry of the posterior elements. The results indicate that, except for the pedicle width index, the variables under study were not significantly influenced by a 5° or 10° tilt ventrally, dorsally, or laterally of either the normal or the scoliotic vertebra. Hence, the method can be satisfactorily applied to longitudinal group comparisons. However, its use in longitudinal studies of individual patients is questionable.

B. Xiong

Papers

Radiographic changes at the coronal plane in early scoliosis.

Sagittal configuration of the spine and growth of the posterior elements in early scoliosis.

The position of the aorta in relation to the vertebra in patients with idiopathic thoracic scoliosis.

Vertebral rotation and pedicle length asymmetry in the normal adult spine.

Horizontal plane morphometry of normal and scoliotic vertebrae. A methodological study.