Study design This study is a retrospective review of the initial enrollment data from a prospective multicentered study of adult spinal deformity. Objectives The purpose of this study is to correlate radiographic measures of deformity with patient-based outcome measures in adult scoliosis. Summary of background data Prior studies of adult scoliosis have attempted to correlate radiographic appearance and clinical symptoms, but it has proven difficult to predict health status based on radiographic measures of deformity alone. The ability to correlate radiographic measures of deformity with symptoms would be useful for decision-making and surgical planning. Methods The study correlates radiographic measures of deformity with scores on the Short Form-12, Scoliosis Research Society-29, and Oswestry profiles. Radiographic evaluation was performed according to an established positioning protocol for anteroposterior and lateral 36-inch standing radiographs. Radiographic parameters studied were curve type, curve location, curve magnitude, coronal balance, sagittal balance, apical rotation, and rotatory subluxation. Results The 298 patients studied include 172 with no prior surgery and 126 who had undergone prior spine fusion. Positive sagittal balance was the most reliable predictor of clinical symptoms in both patient groups. Thoracolumbar and lumbar curves generated less favorable scores than thoracic curves in both patient groups. Significant coronal imbalance of greater than 4 cm was associated with deterioration in pain and function scores for unoperated patients but not in patients with previous surgery. Conclusions This study suggests that restoration of a more normal sagittal balance is the critical goal for any reconstructive spine surgery. The study suggests that magnitude of coronal deformity and extent of coronal correction are less critical parameters.

Correlation of radiographic parameters and clinical symptoms in adult scoliosis

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

Adolescent idiopathic scoliosis.

A B S T R AC T METHODS We conducted a multicenter study that included patients with typical indications for bracing due to their age, skeletal immaturity, and degree of scoliosis. Both a ran- domized cohort and a preference cohort were enrolled. Of 242 patients included in the analysis, 116 were randomly assigned to bracing or observation, and 126 chose between bracing and observation. Patients in the bracing group were instructed to wear the brace at least 18 hours per day. The primary outcomes were curve progres- sion to 50 degrees or more (treatment failure) and skeletal maturity without this de- gree of curve progression (treatment success). RESULTS The trial was stopped early owing to the efficacy of bracing. In an analysis that in- cluded both the randomized and preference cohorts, the rate of treatment success was 72% after bracing, as compared with 48% after observation (propensity-score- adjusted odds ratio for treatment success, 1.93; 95% confidence interval (CI), 1.08 to 3.46). In the intention-to-treat analysis, the rate of treatment success was 75% among patients randomly assigned to bracing, as compared with 42% among those ran- domly assigned to observation (odds ratio, 4.11; 95% CI, 1.85 to 9.16). There was a significant positive association between hours of brace wear and rate of treatment success (P<0.001). CONCLUSIONS Bracing significantly decreased the progression of high-risk curves to the threshold for surgery in patients with adolescent idiopathic scoliosis. The benefit increased with longer hours of brace wear. (Funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and others; BRAIST ClinicalTrials.gov number, NCT00448448.)

/pdf/effects-of-bracing-in-adolescents-with-idiopathic-scoliosis-2qpv1sza6q.pdf

Effects of bracing in adolescents with idiopathic scoliosis

A new method for the treatment of scoliosis is described in which a metal system of rods and hooks is implanted, and distraction and compression forces applied, to correct the curve and stabilize the treated segments in the corrected position by skeletal fixation. The technique and principles of this method of treatment and a summary of the preliminary results are given.

JBJS classics: Treatment of scoliosis: Correction and internal fixation by spine instrumentation

Adolescent idiopathic scoliosis is a common disease with an overall prevalence of 0.47–5.2 % in the current literature. The female to male ratio ranges from 1.5:1 to 3:1 and increases substantially with increasing age. In particular, the prevalence of curves with higher Cobb angles is substantially higher in girls than in boys: The female to male ratio rises from 1.4:1 in curves from 10° to 20° up to 7.2:1 in curves >40°. Curve pattern and prevalence of scoliosis is not only influenced by gender, but also by genetic factors and age of onset. These data obtained from school screening programs have to be interpreted with caution, since methods and cohorts of the different studies are not comparable as age groups of the cohorts and diagnostic criteria differ substantially. We do need data from studies with clear standards of diagnostic criteria and study protocols that are comparable to each other.

https://online.boneandjoint.org.uk/doi/pdf/10.1007/s11832-012-0457-4

Epidemiology of adolescent idiopathic scoliosis

ContextPrevious long-term studies of idiopathic scoliosis have included patients
with other etiologies, leading to the erroneous conclusion that all types
of idiopathic scoliosis inevitably end in disability. Late-onset idiopathic
scoliosis (LIS) is a distinct entity with a unique natural history.ObjectiveTo present the outcomes related to health and function in untreated
patients with LIS.Design, Setting, and PatientsProspective natural history study performed at a midwestern university
with outpatient evaluation of patients who presented between 1932 and 1948.
At 50-year follow-up, which began in 1992, 117 untreated patients were compared
with 62 age- and sex-matched volunteers. The patients' mean age was 66 years
(range, 54-80 years).Main Outcome MeasuresMortality, back pain, pulmonary symptoms, general function, depression,
and body image.ResultsThe estimated probability of survival was approximately 0.55 (95% confidence
interval [CI], 0.47-0.63) compared with 0.57 expected for the general population.
There was no significant difference in the demographic characteristics of
the 2 groups. Twenty-two (22%) of 98 patients complained of shortness of breath
during everyday activities compared with 8 (15%) of 53 controls. An increased
risk of shortness of breath was also associated with the combination of a
Cobb angle greater than 80° and a thoracic apex (adjusted odds ratio,
9.75; 95% CI, 1.15-82.98). Sixty-six (61%) of 109 patients reported chronic
back pain compared with 22 (35%) of 62 controls (P =
.003). However, of those with pain, 48 (68%) of 71 patients and 12 (71%) of
17 controls reported only little or moderate back pain.ConclusionsUntreated adults with LIS are productive and functional at a high level
at 50-year follow-up. Untreated LIS causes little physical impairment other
than back pain and cosmetic concerns.

/pdf/health-and-function-of-patients-with-untreated-idiopathic-4scgnvdoyg.pdf

Health and function of patients with untreated idiopathic scoliosis: a 50-year natural history study.

Objectives. The purpose of this study was to evaluate the efficacy of the Ponseti method in reducing extensive corrective surgery rates for congenital idiopathic clubfoot. Methods. Consecutive case series were conducted from January 1991 through December 2001. A total of 157 patients (256 clubfeet) were evaluated. All patients were treated by serial manipulation and casting as described by Ponseti. Main outcome measures included initial correction of the deformity, extensive corrective surgery rate, and relapses. Results. Clubfoot correction was obtained in all but 3 patients (98%). Ninety percent of patients required ≤5 casts for correction. Average time for full correction of the deformity was 20 days (range: 14–24 days). Only 4 (2.5%) patients required extensive corrective surgery. There were 17 (11%) relapses. Relapses were unrelated to age at presentation, previous unsuccessful treatment, or severity of the deformity (as measured by the number of Ponseti casts needed for correction). Relapses were related to noncompliance with the foot-abduction brace. Four patients (2.5%) underwent an anterior tibial tendon transfer to prevent further relapses. Conclusions. The Ponseti method is a safe and effective treatment for congenital idiopathic clubfoot and radically decreases the need for extensive corrective surgery. This technique can be used in children up to 2 years of age even after previous unsuccessful nonsurgical treatment.

Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method.

STUDY DESIGN : Systematic review of clinical studies. OBJECTIVES : To develop a pooled estimate of the prevalence of surgery after observation and after brace treatment in patients with adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA : Critical analysis of the studies evaluating bracing in AIS yields limited evidence concerning the effect of TLSOs on curve progression, rate of surgery, and the burden of suffering associated with AIS. Many patients choose bracing without an evidence-based estimate of their risk of surgery relative to no treatment. Therefore, such an estimate is needed to promote informed decision-making. METHODS : Multiple electronic databases were searched using the key words "adolescent idiopathic scoliosis," "observation," "orthotics," "surgery," and "bracing." The search was limited to the English language. Studies were included if observation or a TLSO was evaluated and if the sample closely matched the current indications for bracing (skeletal immaturity, age <15 years, Cobb angle between 20 degrees and 45 degrees ). One reviewer (L.A.D) selected the articles and abstracted the data, including research design, type of brace, minimum follow-up, and surgical rate. Additional data concerning inclusion criteria and risk factors for surgery included gender, Risser, age and Cobb angle at brace initiation, curve type, and dose (hours of recommended brace wear). RESULTS : Eighteen studies were included (observation = 3, bracing = 15). All were Level III or IV clinical series. Despite some uniformity in surgical indications, the surgical rates were extremely variable, ranging from 1 surgery of 72 patients (1%) to 51 of 120 patients (43%) after bracing, and from 2 surgeries of 15 patients (13%) to 18 of 47 patients (28%) after observation. When pooled, the bracing surgical rate was 23% compared with 22% in the observation group. Pooled estimates for surgical rate by type of brace, curve type, Cobb angle, Risser sign, and dose were also calculated. CONCLUSION : Comparing the pooled rates for these two interventions shows no clear advantage of either approach. Based on the evidence presented here, one cannot recommend one approach over the other to prevent the need for surgery in AIS. This recommendation carries a grade of D, indicating that the use of bracing relative to observation is supported by "troublingly inconsistent or inconclusive studies of any level." The decision to brace for AIS is often difficult for clinicians and families. An evidence-based estimate of the risk of surgery will provide additional information to use as they weigh the costs and benefits of bracing.

Lori A. Dolan

Papers

Adolescent idiopathic scoliosis.

Effects of bracing in adolescents with idiopathic scoliosis

Health and function of patients with untreated idiopathic scoliosis: a 50-year natural history study.

Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method.

Surgical rates after observation and bracing for adolescent idiopathic scoliosis: an evidence-based review.