Curve progression in idiopathic scoliosis.
01 Apr 1983-Journal of Bone and Joint Surgery, American Volume (J Bone Joint Surg Am)-Vol. 65, Iss: 4, pp 447-455
TL;DR: Curves that measured between 50 and 75 degrees at skeletal maturity, particularly thoracic curves, progressed the most and Translatory shifts played an important role in curve progression.
Abstract: One hundred and thirty-three curves in 102 patients who were followed for an average of 40.5 years were evaluated to quantitate curve progression after skeletal maturity and for prognostic factors leading to curve progression. Sixty-eight per cent of the curves progressed after skeletal maturity. In general, curves that were less than 30 degrees at skeletal maturity tended not to progress regardless of curve pattern. In thoracic curves the Cobb angle, apical vertebral rotation, and the Mehta angle were important prognostic factors. In lumbar curves the degree of apical vertebral rotation, the Cobb angle, the direction of the curve, and the relationship of the fifth lumbar vertebra to the intercrest line were of prognostic value. Translatory shifts played an important role in curve progression. Curves that measured between 50 and 75 degrees at skeletal maturity, particularly thoracic curves, progressed the most.
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TL;DR: Adolescent idiopathic scoliosis affects 1-3% of children in the at-risk population of those aged 10-16 years and the aetiopathogensis of this disorder remains unknown, with misinformation about its natural history.
970 citations
TL;DR: Bracing significantly decreased the progression of high-risk curves to the threshold for surgery in patients with adolescent idiopathic scoliosis and the benefit increased with longer hours of brace wear.
Abstract: 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.)
771 citations
TL;DR: Untreated adults with LIS are productive and functional at a high level at 50-year follow-up and cause little physical impairment other than back pain and cosmetic concerns.
Abstract: 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.
619 citations
TL;DR: In the most completely studied series to date, at 20 to 28 years follow-up both braced and operated patients had similar, significant, and clinically meaningful reduced function and increased pain compared to non-scoliotic controls, however, their function and pain scores were much closer to normal than patient groups with other, more serious conditions.
Abstract: Adolescent idiopathic scoliosis is a lifetime, probably systemic condition of unknown cause, resulting in a spinal curve or curves of ten degrees or more in about 2.5% of most populations. However, in only about 0.25% does the curve progress to the point that treatment is warranted. Untreated, adolescent idiopathic scoliosis does not increase mortality rate, even though on rare occasions it can progress to the >100° range and cause premature death. The rate of shortness of breath is not increased, although patients with 50° curves at maturity or 80° curves during adulthood are at increased risk of developing shortness of breath. Compared to non-scoliotic controls, most patients with untreated adolescent idiopathic scoliosis function at or near normal levels. They do have increased pain prevalence and may or may not have increased pain severity. Self-image is often decreased. Mental health is usually not affected. Social function, including marriage and childbearing may be affected, but only at the threshold of relatively larger curves. Non-operative treatment consists of bracing for curves of 25° to 35° or 40° in patients with one to two years or more of growth remaining. Curve progression of ≥ 6° is 20 to 40% more likely with observation than with bracing. Operative treatment consists of instrumentation and arthrodesis to realign and stabilize the most affected portion of the spine. Lasting curve improvement of approximately 40% is usually achieved. In the most completely studied series to date, at 20 to 28 years follow-up both braced and operated patients had similar, significant, and clinically meaningful reduced function and increased pain compared to non-scoliotic controls. However, their function and pain scores were much closer to normal than patient groups with other, more serious conditions. Risks associated with treatment include temporary decrease in self-image in braced patients. Operated patients face the usual risks of major surgery, a 6 to 29% chance of requiring reoperation, and the remote possibility of developing a pain management problem. Knowledge of adolescent idiopathic scoliosis natural history and long-term treatment effects is and will always remain somewhat incomplete. However, enough is know to provide patients and parents the information needed to make informed decisions about management options.
515 citations
The Chinese University of Hong Kong1, Utrecht University2, University of Gothenburg3, Sahlgrenska University Hospital4, Washington University in St. Louis5, University of Hong Kong6, Université de Montréal7, University of California, San Diego8, Boston Children's Hospital9, University of Vermont10, University of Iowa11, Nottingham University Hospitals NHS Trust12
TL;DR: Both the prevention of AIS and the treatment of its direct underlying cause are not possible, because the definite aetiology and aetiopathogenetic mechanisms that underlie AIS are still unclear.
Abstract: 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.
440 citations
References
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TL;DR: A simplified method of describing vertebral rotation is proposed, which correlates the amount or percentage of convex pedicle displacement seen on roentgenograms with the approximate degrees of rotation present in that vertebra.
Abstract: The problem of roentgenographic evaluations of vertebral rotations has been studied using upper thoracic, thoracic, and lumbar segments of a normal spine which were marked with wires and which then had roentgenograms made in known increments of rotation. The results showed a definite difference between a grading system based upon the position of the spinous process and a system based on the position of the pedicle located on the convex side of the curve. The pedicle technique proved to have definite merit in its case of application over a wide range of rotation and its over-all consistecy of values evens when applied to the scoliotic spine.
As an additional part of the study, the approximate range of degrees of rotation represented by each grade of rotation was determined.
Finally, by combining the two parts of this study, we were able to propose a simplified method of describing vertebral rotation, which correlates the amount or percentage of convex pedicle displacement seen on roentgenograms with the approximate degrees of rotation present in that vertebra.
584 citations
01 Jan 1981
TL;DR: Two hundred and nineteen patients with untreated adolescent idiopathic scoliosis who were seen at the University of Iowa between 1932 and 1948 were studied, and recent information was available on 194 of the patients.
Abstract: Two hundred and nineteen patients with untreated adolescent idiopathic scoliosis who were seen at the University of Iowa between 1932 and 1948 were studied, and recent information was available on 194 of the patients. The mortality rate was 15 per cent. Backache was somewhat more common in these pa- tients than in the general population, although it was never disabling. The backache was unrelated to the presence of osteoarthritic changes on roentgenograms. Many curves continued to progress slightly in adult life, particularly thoracic curves that had reached be- tween 50 and 80 degrees at skeletal maturity. The lum- bar components of combined curves between 50 and 74 degrees also tended to progress. Pulmonary function was affected only in patients with thoracic curves.
428 citations
TL;DR: A prospective study was carried out of the incidence and natural history of adolescent idiopathic scoliosis in 26,947 students, finding that spontaneous improvement of the curve occurred in 3 per cent and was seen more frequently in curves milder than 11 degrees.
Abstract: A prospective study was carried out of the incidence and natural history of adolescent idiopathic scoliosis in 26,947 students. Data were obtained on 1,122 students with idiopathic scoliosis. The incidence of idiopathic scoliosis was 4.5 per cent. The female-to-male ratio was 1.25:1.0 over-all, but the ratio varied directly with the severity of the curve--that is, 1:1 for curves of 6 to 10 degrees, and 5.4:1 for curves of more than 20 degrees. Progression of the curve was determined by a two-year follow-up of 603 patients. Progression was observed in 6.8 per cent of the students and in 15.4 per cent of the skeletally immature girls with scoliosis of more than 10 degrees at the initial examination. In 20 per cent of the skeletally immature children with curves of 20 degrees at the initial examination, there was no progression. Spontaneous improvement of the curve occurred in 3 per cent and was seen more frequently in curves milder than 11 degrees. Treatment was required in 2.75 students per 1,000 screened.
420 citations
TL;DR: A study of serial radiographs of 138 children with infantile scoliosis starting under the age of two years has resulted in a method of early differentiation between resolving and progressive curves.
Abstract: 1. A study of serial radiographs of 138 children with infantile scoliosis starting under the age of two years has resulted in a method of early differentiation between resolving and progressive curves. 2. The method involves careful measurement of the rib-vertebra angles at the apex of the curve and observation of the relationship of the head of the rib to the body of the vertebra as seen in antero-posterior radiographs. 3. The influence of the infantile growth spurt upon progressive curves is examined and the importance of early diagnosis and treatment is stressed.
295 citations
TL;DR: It is significant that thoracic primary curves are commonly severe and the early onset of this curve accentuates this feature.
Abstract: The evolution of an idiopathic scoliosis is determined by the site of the primary curve and by the age of onset. It is significant that thoracic primary curves are commonly severe and the early onset of this curve accentuates this feature. Early operation based on prognosis is practised but sufficient time has not yet elapsed to justify any conclusions.
215 citations