https://www.ipd.gu.se/digitalAssets/1252/1252566_Artikel_sept_Aina_Lancet_2_.pdf

Adolescent idiopathic scoliosis.

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.

/pdf/2016-sosort-guidelines-orthopaedic-and-rehabilitation-wd47whqefo.pdf

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

Adolescent idiopathic scoliosis (AIS) is the most common form of structural spinal deformities that have a radiological lateral Cobb angle - a measure of spinal curvature - of ≥10(°). AIS affects between 1% and 4% of adolescents in the early stages of puberty and is more common in young women than in young men. The condition occurs in otherwise healthy individuals and currently has no recognizable cause. In the past few decades, considerable progress has been made towards understanding the clinical patterns and the three-dimensional pathoanatomy of AIS. Advances in biomechanics and technology and their clinical application, supported by limited evidence-based research, have led to improvements in the safety and outcomes of surgical and non-surgical treatments. However, the definite aetiology and aetiopathogenetic mechanisms that underlie AIS are still unclear. Thus, at present, both the prevention of AIS and the treatment of its direct underlying cause are not possible.

Developmental stability reflects the ability of a genotype to undergo stable development of a phenotype under given environmental conditions. Deviations from developmental stability arise from the disruptive effects of a wide range of environmental and genetic stresses, and such deviations are usually measured in terms of fluctuating asymmetry and phenodeviants. Fluctuating asymmetry is the most sensitive indicator of the ability to cope with stresses during ontogeny. There is considerable evidence that developmental stability, and especially fluctuating asymmetry, is a useful measure of phenotypic and genetic quality, because it covaries negatively with performance in multiple fitness domains in many species, including humans. It is proposed that developmental stability is an important marker of human health. Our goal is to initiate formally the integration of the sciences of evolutionary biology, developmental biology and medicine. We believe that this integrative framework provides a significant addition to the growing field of Darwinian medicine. The literature linking developmental stability and disease in humans is reviewed. Recent biological theoretical treatments pertaining to developmental stability are applied to a range of human health issues such as genetic diseases, ageing and survival, subfertility, abortion, child maltreatment by parents, cancer, infectious diseases, physiological and mental health, and physical attractiveness as a health certification.

Developmental stability, disease and medicine.

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 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.

Mammary asymmetry was estimated visually by different investigators in three series of scoliotic girls and in three control groups. The breasts of each girl were classified as being equal in size or as being obviously different in size, note being made of which breast was the larger. Breast asymmetr

The symmetry of the breasts in normal and scoliotic girls.

A new method for the measurement of scoliotic curves in antero-posterior (AP) radiographs is presented, in which the centre of the surface image of the vertebral bodies of the apical and two end vertebrae of the curvature are defined on the basis of geometric principles. Measurements using the Cobb, the Ferguson, and the new method were performed on ten AP radiographs from each of three groups of young patients with right convex thoracic idiopathic scoliosis with Cobb angles of between 7 and 15 degrees, 16 and 45 degrees and 46 and 80 degrees, respectively. Measurements using the Cobb method yielded significantly higher values than measurements using either the Ferguson method or the new method. In curves with Cobb angles of between 7 and 15 degrees, the values using Ferguson's method were significantly lower than those using the new method; the difference increased significantly in curves with a Cobb angle of 16 degrees or more. The level of significance of the intra- and interobserver differences between the new, the Cobb and the Ferguson methods was significantly higher in curves with a Cobb angle of 16 degrees or more. It is argued that measures of the scoliotic angle obtained by the new method are of greater clinical relevance than those obtained by the two other methods. Unlike the Cobb method, the new method takes into consideration the translation of the apical vertebra in relation to the end vertebrae and not only the tilt of the end vertebrae of the curve. As compared to the Ferguson method, the new method is based on standardised geometric principles, and is not influenced by changes in the shape of the vertebral body. Moreover, the repeatability of the new method is greater than that of both the Cobb method and the Ferguson method. Therefore, it is believed that the new method provides a more accurate measure of the scoliotic curve than do the two other methods, and it is to be preferred over the other two methods in longitudinal evaluation of the development of the curve.

Accuracy and applicability of measurement of the scoliotic angle at the frontal plane by Cobb's method, by Ferguson's method and by a new method

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.

J. Sevastik

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 symmetry of the breasts in normal and scoliotic girls.

Accuracy and applicability of measurement of the scoliotic angle at the frontal plane by Cobb's method, by Ferguson's method and by a new method

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