Surgical versus non-surgical interventions in people with adolescent idiopathic scoliosis

Results of Gensingen Bracing in Patients With Adolescent Idiopathic Scoliosis: Retrospective Cross-Sectional Feasibility Study

BACKGROUND

Bracing is an essential part of scoliosis treatment. The standard of brace treatment for patients with scoliosis today is still very variable in terms of brace quality and outcome. The Gensingen brace is a further developed Chêneau brace derivative with individual design, which can be adapted through computer-aided design.

OBJECTIVE

This study aims to generate a template to obtain a database for prospective multicenter studies study to analyze the results of high-corrective asymmetric Gensingen brace treatment for patients with adolescent idiopathic scoliosis (AIS).

METHODS

A template for the database was created, which contains the patients' basic data (age, menarcheal status, Risser Sign, curve pattern, and daily brace wearing time), the Cobb angles of curvature, and the cosmetically relevant angles of trunk rotation (ATR). A retrospective review of medical records of patients with AIS, who met the Scoliosis Research Society's inclusion criteria for brace studies, was performed to test the feasibility of the template. Template items were filled in by the researchers.

RESULTS

Out of 115 patients between 2014 and 2018, the complete data of 33 patients followed up at least 3 months after complete Gensingen brace weaning could be analyzed. The mean age was 12 years, the mean Cobb angle was 33.6°, and the mean Risser value was 0.7 at the beginning of the treatment. The mean improvement in the Cobb angle on in-brace x-ray imaging was -26.1० (80% of in-brace correction). The Cobb angle of the major curvature changed as follows: curve stabilization was achieved in 7 (21.2%) cases, and curve improvement was achieved in 26 (78.8%) cases. None of the patients showed a curve progression. The Cobb angle was significantly reduced in the brace at the end of treatment and at follow-up evaluation (P<.001). ATR improved significantly for thoracic (P<.001) and lumbar curves (P<.001).

CONCLUSIONS

The database proved to be informative in the assessment of radiological and clinical outcome parameters. The example data set we have generated can be a helpful tool for professionals who work in clinics but do not store regular patient data. Especially with regard to different patient collectives worldwide, different results may be achieved with the same standards of care. In addition, the results of this study suggest that above-average correction effects with a full-time brace application lead to significant improvements in the Cobb angle after brace treatment has been completed.

Availability of evidence and comparative effectiveness for surgical versus drug interventions: an overview of systematic reviews and meta-analyses

OBJECTIVES

This study aims to examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons and whether surgery or the drug intervention was favoured.

DESIGN

Systematic review of systematic reviews (umbrella review).

DATA SOURCES

Cochrane Database of Systematic Reviews.

ELIGIBILITY CRITERIA

Systematic reviews attempt to compare surgical to drug interventions.

DATA EXTRACTION

We extracted whether the review found any randomised controlled trials (RCTs) for eligible comparisons. Individual trial results were extracted directly from the systematic review.

SYNTHESIS

The outcomes of each meta-analysis were resynthesised into random-effects meta-analyses. Egger's test and excess significance were assessed.

RESULTS

Overall, 188 systematic reviews intended to compare surgery versus drugs. Only 41 included data from at least one RCT (total, 165 RCTs) and covered a total of 103 different outcomes of various comparisons of surgery versus drugs. A GRADE assessment was performed by the Cochrane reviewers for 87 (83%) outcomes in the reviews, indicating the strength of evidence was high in 4 outcomes (4%), moderate in 22 (21%), low in 27 (26%) and very low in 33 (32%). Based on 95% CIs, the surgical intervention was favoured in 38/103 (37%), and the drugs were favoured in 13/103 (13%) outcomes. Of the outcomes with high GRADE rating, only one showed conclusive superiority in our reanalysis (sphincterotomy was better than medical therapy for anal fissure). Of the 22 outcomes with moderate GRADE rating, 6 (27%) were inconclusive, 14 (64%) were in favour of surgery and 2 (9%) were in favour of drugs. There was no evidence of excess significance.

CONCLUSIONS

Though the relative merits of surgical versus drug interventions are important to know for many diseases, high strength randomised evidence is rare. More randomised trials comparing surgery to drug interventions are needed.

Adolescent Idiopathic Scoliosis Surgery: Postoperative Functional Outcomes at 32 Years Mean Follow-Up

INTRODUCTION

Recent clinical and radiographic studies conducted over short and medium terms have demonstrated positive results in patients undergoing surgery for adolescent idiopathic scoliosis (AIS). However, the absence of long-term data, crucial for comprehending the impact on future quality of life, especially in young patients actively involved in very intense physical activities, remains a gap. This study aims to evaluate long-term functional outcomes in patients who underwent surgery for Adolescent Idiopathic Scoliosis.

MATERIAL AND METHODS

Patients meeting specific criteria (diagnosis of AIS, age at surgery between 12 and 18 years, and follow-up of at least 20 years) were identified from a large spine surgery center database. A questionnaire using "Google Form" assessed various outcomes, including Visual Analog Scale (VAS) back, VAS leg, Short Form 12 score (SF-12), Scoliosis Research Society 22 score (SRS-22), incidence of spine revision surgery, postoperative high demanding activities (work and sport), and possible pregnancies was sent to the enrolled patients. The authors analyzed the results regarding all patients included and, moreover, statistical analysis categorized patients into two groups based on the surgical fusion performed: Group 1 (non-instrumented technique according to Hibbs-Risser) and Group 2 (instrumented tecnique according to Cotrel-Dubousset).

RESULTS

A total of 63 patients (mean age 47.5 years) were included, with a mean follow-up of 31.9 years. Patients were, in mean, 47.5 years old. Group 1 comprised 42 patients, and Group 2 had 21 patients. Revision surgery was required in 19% of patients, predominantly for implant issues in Group 2 (11.9% vs. 33%, p < 0.05). Overall outcomes were favorable: VAS back = 3.5, VAS leg = 2.5, SRS-22 = 3.5, SF-12 Physical Component Summary = 41.1, SF-12 Mental Component Summary = 46.7, with no significant differences between the group 1 and group 2. At 5-years FU, the non-reoperation rate was higher in the non-instrumented group (97.6% vs. 71.4%, p < 0.001). By means of SRS-22, overall satisfaction was 3.7 ± 1.2 on a maximum scale of 5. More than half of women have successfully completed one pregnancy. Most patients (87.3%) maintained regular work activity. Among sport practioners, half returned to the similar preoperative level.

CONCLUSIONS

This study reveals favorable long-term functional results in adolescent idiopathic scoliosis patients after surgical fusion. Mild to moderate back and leg pain were observed, but overall satisfaction, sport participation, and work activity were high. Surgical technique (non-instrumented vs. instrumented) did not significantly impact long-term results, though the instrumented fusion exhibited a higher revision rate.

Barriers and facilitators of physical function, activity, sports and exercise in children and adolescents with spinal pain: a protocol for a systematic review and meta-ethnography

INTRODUCTION

Spinal pain is one of the leading causes of disability, with the incidence of adolescent back pain estimated at 20%. Multiple barriers influence exercise participation in adolescents. However, there remains a lack of literature surrounding patients' choice to exercise, perceived barriers and facilitators of exercise, and their relationship to participant demographics. The aim of this systematic review with meta-ethnography will be to identify the barriers and facilitators of exercise participation among adolescents with thoracic or lower back pain (LBP). The secondary aim will be to identify any trends in barriers and facilitators of exercise between different demographic groups within children or adolescents under 18 years.

METHODS AND ANALYSIS

The seven-phase process identified by Noblit and Hare's meta-ethnography approach will be used. A comprehensive electronic search of databases (AMED, CINAHLplus, EMBASE, MEDLINE, SCOPUS, Nursing & Allied Health, PubMed, PsycINFO, SPORTDiscus, Social Science Database) will be completed during April 2022. Grey literature using reference lists, websites and search engines will also be searched in accordance with Peer Review of Electronic Search Strategies (PRESS) guidelines. Inclusion criteria include: (A) qualitative studies, (B) participants under 18 years experiencing thoracic or LBP, (C) identification of barriers and facilitators of exercise participation in exercise, sports or physical activity and (D) primary research. This systematic review with meta-ethnography review aims to generate theories of behaviours and interpret significance across multiple studies. This process aims to develop future physiotherapeutic behavioural interventions, inform service provision and identify possible future research questions.

ETHICS AND DISSEMINATION

No ethical approval was required due to the nature of using previously published work to form a systematic review paper. This systematic review and meta-ethnography will be disseminated through both conference presentations and journal publications. No funding was received for this review.

PROSPERO REGISTRATION NUMBER

CRD42022314796.

Effectiveness of psychosocial interventions for pediatric patients with scoliosis: a systematic review

Background

Pediatric patients affected by scoliosis have complex psychological and social care needs, and may benefit from psychosocial interventions. We therefore aimed to summarize evidence of the efficacy of psychosocial interventions for this patient population.

Methods

Literature was identified by searching Medline, PsycINFO, Embase, EBSCO Cumulated Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Controlled Trials (CENTRAL) from database inception to 20 March 2022. Articles that evaluated the effectiveness of psychosocial interventions for pediatric patients diagnosed with scoliosis and reported at least one quantitative outcome were included. Article eligibility, data extraction, and quality assessment (using the Cochrane Collaboration's Risk of Bias Tool and Methodological Index for Non-Randomized Studies) were performed by two independent researchers. Findings are presented using narrative synthesis.

Results

We identified ten studies, all of which focused on adolescent idiopathic scoliosis. Studies included a total of 1007 participants, most of whom were female. Three studies focused on patients undergoing bracing, six on patients undergoing spinal surgery, and one on patients broadly. Brace compliance monitoring and counseling were found to significantly improve brace compliance quality and quantity. Proactive mental healthcare delivery by nurses after spinal surgery was similarly found to improve outcomes. Several studies examined the efficacy of brief educational interventions; most did not report clear evidence of their efficacy. The methodological quality of studies was often unclear due to limitations in articles' reporting quality.

Conclusions

Research on the efficacy of psychosocial interventions for pediatric patients with scoliosis is limited, with interventions involving frequent patient-provider interactions showing the most promise. Future clinical and research efforts should focus on developing and testing psychosocial interventions for this patient population, with emphasis on multidisciplinary teams delivering holistic care.

Trial registration number

PROSPERO number CRD42022326957.

Availability of evidence and comparative effectiveness for surgical versus drug interventions: an overview of systematic reviews

Objectives

To examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons, and whether surgery or the drug intervention was favored.

Design

Systematic review of systematic reviews (umbrella review).

Data sources

Cochrane Database of Systematic Reviews (CDSR).

Eligibility criteria and synthesis of results

Using the search term "surg*" in CDSR, we retrieved systematic reviews of surgical interventions. Abstracts were subsequently screened to find systematic reviews that aimed to compare surgical to drug interventions; and then, among them, those that included any randomized controlled trials (RCTs) for such comparisons. Trial results data were extracted manually and synthesized into random-effects meta-analyses.

Results

Overall, 188 systematic reviews intended to compare surgery versus drugs. Only 41 included data from at least one RCT (total, 165 RCTs with data) and covered a total of 103 different outcomes of various comparisons of surgery versus drugs. A GRADE assessment was performed by the Cochrane reviewers for 87 (83%) outcomes in the reviews, indicating the strength of evidence was high in 4 outcomes (4%), moderate in 22 (21%), low in 27 (26%) and very low in 33 (32%). Based on 95% confidence intervals, the surgical intervention was favored in 38/103 (37%), and the drugs were favored in 13/103 (13%) outcomes. Of the outcomes with high GRADE rating, only one showed conclusive superiority (sphincterotomy was better than medical therapy for anal fissure). Of the 22 outcomes with moderate GRADE rating, 6 (27%) were inconclusive, 14 (64%) were in favor of surgery, and 2 (9%) were in favor of drugs.

Conclusions

Though the relative merits of surgical versus drug interventions are important to know for many diseases, high strength randomized evidence is rare. More randomized trials comparing surgery to drug interventions are needed.

Protocol registration

https://osf.io/p9x3j.

The Incidence of Bracing Treatment on Static and Dynamic Baropodometric Parameters in Adolescent Idiopathic Scoliosis

Postural balance is an important but not well-studied concept in the treatment of adolescent scoliosis. The aim of this study was to assess whether conservative treatment with Sforzesco bracing induced negative perturbations on postural stability, as related to static, postural, and dynamic baropodometric indicators. Twelve subjects (12 females, aged 11−16) with moderate AIS, were selected among a group of 97 patients. Inclusion criteria were: (1) confirmed diagnosis of moderate AIS (Cobb angle of 21° to 35° for the primary curve); (2) thoracic or thoracolumbar primary curve; (3) skeletal immaturity with growth cartilage visible on pretreatment radiographs (Risser < 5); (4) chronological age between 11 and 16 years; and (5) Sforzesco bracing treatment. All patients underwent a physical examination and radiological measurements with anteroposterior and lateral scans. Static, postural, and dynamic assessments were performed twice by barefoot patients, with and without Sforzesco bracing. Comparison between demographic, anthropometric, and clinical data highlighted a homogeneity of the sample. We evaluated the point of maximum pressure with and without bracing and found no statistically significant differences (p value = 0.22). In postural measurements, the laterolateral oscillations, anteroposterior oscillations, and average speed of oscillations were evaluated, comparing measurements with and without bracing. There were no statistically significant differences, except for the mean rate of oscillation, which was slightly increased in the recordings with a brace compared to those without a brace, p value = 0.045. Our findings show no statistically significant differences (p > 0.05) in static, postural, and dynamic baropodometric indicators.

Evaluation of Self-Perceived Body Image in Adolescents with Mild Idiopathic Scoliosis

Adolescent idiopathic scoliosis (AIS) is the most prevalent types of scoliosis, affecting up to 3% of children around the world. The progression of AIS can cause alteration in psychological components such as self-perceived body image and self-identity, which negatively affect the teenager quality of life (QoL). The mainly aim of this cross-sectional study is to investigate how mild AIS impacts self-perceived body image in young people. Fifteen participants (mean age = 14.47 ± 2.825) of both sexes (male = 5; female = 10) with a curve magnitude from 10° up to 25° completed the Scoliosis Research Society Patient Questionnaire (SRS-22), the Trunk Appearance Perception Scale (TAPS) and were subject to spinal analysis and photogrammetry. Results display statistical differences between self-perceived body image and other SRS-22 domains (Hotelling t2= 70.29; F(3,12) = 20.08; p < 0.001). Additionally, the regression model, which better explained the self-perceived variability, was fit by function/activity, pain, and mental health domains (F(4,10) = 4.39; p = 0.029; R2 = 0.545). Although AIS was not severe, it negatively affected participants self-perceived body image. More attention in AIS qualify of life is needed, and early treatments could be necessary to prevent psychological impairments self-perception related.

Is self-image, in reference to the gravitational vertical, altered in adolescent idiopathic scoliosis? A multicenter, single-blind, case-control study

PURPOSE

Adolescent idiopathic scoliosis (AIS) is associated with perturbation of orthostatic postural control. In humans, orthostatic postural control is organized around the gravitational vertical (GV). Perception of the GV involves a bottom-up process (central integration of multisensorial information) and a top-down process that uses cognitive mechanisms relying on body image. This study hypothesized that AIS would be associated with an erroneous central representation of verticality. The objective was to demonstrate an altered top-down process of sense of verticality in AIS.

METHODS

This multicenter, single-blind, case-control study evaluated 63 adolescent girls with AIS divided into two groups (major AIS (n = 31) and minor AIS (n = 32)) and 30 matched non-scoliotic adolescents. Participants scored their perception of trunk appearance in an upright position using a pictographic scale. The outcome measure was the difference between perception score and real trunk deformity.

RESULTS

Participants with major AIS presented with misperception of their trunk appearance in an upright position when compared with those with minor AIS or controls.

CONCLUSION

Adolescents with major AIS underestimate their trunk deformity in an upright position. This suggests an altered representation of body image, affecting top-down control of sense of verticality.

Guidelines for the conservative treatment of spinal deformities - Questionnaire for a Delphi consensus

Background

Spinal deformity is the oldest disease known to humankind. Many types of treatment methods, including both conservative and surgical, are in use.

Objective

We aimed to validate a published guideline protocol based on the conservative treatment of spinal deformities.

Method

A modified Delphi technique was used with a questionnaire sent out to professionals worldwide regarding the conservative treatment of spinal deformities.

Results

Our study was completed after two rounds. A strong level of agreement of 80% and more (consensus cut-off point) was achieved in most questions in the first round. Some statements were below this margin, and they were sent to the participants via email in the second round for re-evaluation. Consensus was achieved in almost all of the statements in the second round. Only two items did not reach the cut-off point but were close to this value.

Conclusion

This proposed Guideline Protocol was approved by the participants using the Delphi method and can be used as a valid tool for the conservative treatment of spinal deformities.

Clinical implications

A conservative treatment guideline in spinal deformity management, will provide consistency in treatment and will facilitate comparability with surgery. It will be useful in determining the cost-effectiveness of treatment and in choosing the right patient for the right method of treatment. This guideline might help in this context, and may also create a systematic method for clinicians to use as a reference in both research and clinical practice.

Conservative treatment of a scoliosis patient after two heart surgeries in early childhood - A case report

Introduction

This is a case report of a juvenile female patient with scoliosis following two heart surgeries for congenital heart disease (CHD).

Patient presentation, management and outcome

Initially, the premenarchial female was 9 years old and had a Tanner stage 2–3 with a single thoracic curve of 65° Cobb. Because of the high risk for progression, immediate brace treatment was proposed as the father declined surgery. The patient received intensive treatment according to the Schroth Best Practice® programme and a Gensingen Brace® designed for large thoracic curves. Over the 18 months following the initial visit, she received two additional braces. As a result, the progression of the main curve was prevented. The patient continues to maintain an improved cosmetic result and is currently at a Risser 2.

Conclusion

Surgery performed for CHD in rare cases may lead to stiff spinal deformity as a consequence of that surgery. Progression of a severe and stiff curve was prevented during the most vulnerable phase of the pubertal growth spurt with an improved clinical result. Therefore, we assume that the patient may have a normal life in adulthood with minor restrictions only. Supported by pattern-specific high correction exercises and braces, these typical single thoracic curves can be re-compensated to a more balanced appearance, less prone to progression in adulthood.

Clinical implications

Because of the relative high risks of spinal fusion and the long-term unknowns of such an intervention, high-impact conservative treatment should be implemented first before surgical correction is considered.

Is there an indication for surgery in patients with spinal deformities? - A critical appraisal

Background

High-quality evidence exists to support physiotherapy and brace treatment for scoliosis and other spinal deformities. However, according to previous systematic reviews, it seems that no evidence exists for surgery. Nevertheless, the number of research articles focussing on spinal surgery highly exceeds the number of articles focussing on conservative treatment.

Objective

The purpose of this study is to conduct an updated search for systematic reviews providing high-quality evidence for spinal surgery in patients with spinal deformities.

Method

A narrative review including PubMed and the Cochrane database was conducted on April 12, 2020, with the following search terms: (1) spinal deformities, surgery, systematic review and outcome; (2) kyphosis, surgery, systematic review and outcome; (3) Scheuermann's disease, surgery, systematic review and outcome, and (4) scoliosis, surgery, systematic review and outcome.

Results

No reviews containing prospective controlled or randomised controlled studies were found providing evidence for surgery.

Conclusions

A general indication for spine surgery just based on the Cobb angle is not given. In view of the long-term unknown variables and the possible long-term complications of such treatment, a surgical indication for patients with spinal deformities must be reviewed on an individual basis and considered carefully. A current systematic review appears necessary in order to be able to draw final conclusions on the indication for surgery in patients with spinal deformities.

Clinical implications

In view of the increasing number of surgeons with an affiliation to industry, the indication for surgery needs to be given by independent conservative specialists for spinal deformities in order to provide an objective recommendation.

Design, reliability, and validity of a portable electronic device based on ergonomics for early screening of adolescent scoliosis

BACKGROUND/OBJECTIVE

The reported incidence of scoliosis among adolescents in China differs according to screening method owing to the lack of uniformity and limitations of certain techniques. We aimed to design, develop, and validate a non-invasive, accurate, portable, fast, and automated tool that would enable the measurement and storage of data during scoliosis screening.

METHODS

We designed a new portable electronic scoliosis screening device (PESSD)-for the identification of adolescent scoliosis based on ergonomics theory. The device measured the axial deflection angle of the trunk of the human body using a built-in angle sensor. Data obtained using the PESSD, a traditional scoliometer manual ruler, and X-ray measurement of the Cobb angle were compared.

RESULTS

The PESSD exhibited more sensitive detection of small-angle scoliosis and improved repeatability compared with the scoliometer. The data obtained using the PESSD showed good correlation with Cobb angle data measured from X-ray images. All patients who were indicated to be positive for scoliosis using the PESSD were found to have clinically identifiable scoliosis from X-ray examination.

CONCLUSIONS

The PESSD may be able to achieve early detection of scoliosis in adolescents. It is non-invasive, highly precise, portable, easy to use, and offers automated data storage and traceability. This study is a pilot or preliminary validation study. With further, more in depth studies, the PESSD has excellent potential for transformation into an effective tool for use in large-scale screening programs for adolescent scoliosis in schools and communities.

THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE

This article is about designing a new portable electronic scoliosis screening device based on ergonomics theory. Because there are currently no uniform screening methods and standards, the results in this article could facilitate the adoption of a uniform screening tool into large-scale screening programs for adolescent scoliosis in schools and communities, preliminary examination in hospitals, and self-testing at home after parent training.

Reliability of the original Lehnert-Schroth (LS) scoliosis classification in physiotherapy practice

[Purpose] The foundations of the scoliosis specific and evidence-based physiotherapy program according to Schroth is the original the Lehnert-Schroth (LS) classification which is still in use today. The purpose of this paper is to test the reliability of the LS classification system, using clinical and radiological images of scoliosis patients as classified by specialist experienced clinicians. [Participants and Methods] A list of 40 pictures of X-Rays and a list of 40 clinical pictures (all posterior trunk images) of patients with idiopathic scoliosis were provided by the second author. Three specialist professional physiotherapists or orthotists rated all clinical and radiological pictures according to these two patterns of the LS classification. [Results] The intra-observer Kappa value was 0.90 (clinical) and 1.00 (x-rays). The inter-observer Kappa values at average was 0.65 (clinical) and 0.71 (x-rays). [Conclusion] For the application of classifying the patients when prescribing postural advice and exercises from the Schroth program the LS-classification seems an easy to use and highly reliable tool. This test demonstrated sufficient reliability with respect to the x-rays, but the tests of the clinical pictures alone, demonstrated fair levels of reliability, which indicates that it is an appropriate tool for physiotherapists when an x-ray is not available.

Efficacy of bracing in skeletally immature patients with moderate-severe idiopathic scoliosis curves between 40° and 60°

STUDY DESIGN

Retrospective case-series.

OBJECTIVES

To evaluate the outcomes of bracing in skeletally immature patients with moderate-severe idiopathic scoliosis (IS) curves ≥ 40°.

BACKGROUND

In contrast to prior beliefs, the recent studies have reported successful outcomes with brace treatment may occur in some patients with moderate-severe scoliosis ≥ 40°. Despite other encouraging case-series, non-operative treatment is rarely attempted and the efficacy of bracing large curves remains uncertain.

METHODS

100 skeletally immature children (mean 11.8 ± 2.36 years; range 6.1-16.5) with IS ≥ 40° were identified. 80 were adolescent IS (80%) and 20 juvenile IS (20%). The Risser plus score was used to evaluate skeletal maturity. 66 children were Risser 0 (66%). SRS-SOSORT outcome guidelines were used: > 5° progression, stabilization between - 5° and 5° and, > 5° improvement.

RESULTS

Mean initial Cobb was 45° ± 3.9° (range 40°-59°), with in-brace and  % correction of 30° ± 8.7° (range 7°-48°) and 34 ± 17.5% (range 2-84%), respectively. 57 progressed (57%), 32 stabilized (32%), and 11 improved (11%) after a median of 1.8 years (IQR 1.2-2.9). Open triradiate cartilage at presentation (p = 0.005) and less in-brace correction (p = 0.009) were associated with progression. 58 children (58%) underwent surgery after a mean of 3.0 years (range 0.7-7.3). Surgical patients were younger (11.2 vs. 12.7 years; p = 0.003), more often Risser 0 (79% vs. 48%; p < 0.001); however, presented with similar curves (45° vs. 44°; p = 0.31). Open triradiate cartilage at presentation (OR 15.3; 95% CI 4.3-54.6; p < 0.001) and less in-brace correction (p = 0.03) increased the likelihood of surgery. All 20 JIS patients avoided temporary growth rods, with 18 (90%) eventually requiring surgery.

CONCLUSION

Non-operative treatment was successful in 42% of children. Risk factors for surgery were younger age, open triradiates, and less in-brace correction. Bracing can be effective in delaying surgery until skeletal maturity in patients with curves ≥ 40°. Patients should be counseled on the risks and benefits of bracing and surgery.

LEVEL OF EVIDENCE

Level IV.

Adolescent idiopathic scoliosis: evaluating perioperative back pain through a simultaneous morphological and biomechanical approach

Background

Adolescent idiopathic scoliosis (AIS) has been associated with diminished postural stability and a greater prevalence of back pain. Currently, the literature is lacking information on the effect of spinal fusion on both postural stability and its association with back pain. Our objectives were to evaluate the postsurgical effect of spinal morphological changes on static standing balance and assess the influence of these alterations on reported pain throughout the perioperative period.

Methods

Twenty consecutive AIS patients schedule to undergo spinal fusion surgery were recruited and followed prospectively at the Shriners Hospitals for Children-Canada. Data was collected at the preoperative, 6 weeks and 6 months postoperative visits. Spinal morphology data was collected through 3D reconstructed simultaneous standing biplanar radiographs using the SterEOS software. Postural balance was assessed through Moticon© sensor insoles and analyzed through their software. The data was simultaneously collected as part of the Global Biomechanical and morphological Assessment. Pain was evaluated through self-reported questionnaires.

Results

Morphological curve parameters were significantly reduced after surgery. Balance parameters did not change significantly throughout the perioperative period with the exception of the Center of Pressure of the left foot medial/lateral transient shift (P = 0.017) at 6 weeks. Of note, preoperative balance parameters were associated with the degree of right thoracic Cobb angles (P = 0.029 R = 0.528). Pain scores significantly improved 6 weeks and 6 months after the surgery. Pain intensity diminished in the thoracic and lumbar spine but worsen in the neck region at the 6 weeks and 6 months postoperative time points (P = 0.044). Greater residual Cobb angle difference between Mid thoracic and Thoracolumbar/Lumbar curves was associated with greater pain severity at 6 weeks postop (P < 0.005). In addition, greater residual thoracic deformity was associated with significant pain severity 6 months after surgery (P < 0.05).

Conclusions

Improved spinal morphology of postsurgical AIS patients has no significant impact on their static standing balance. Suggesting that other factors apart from the spinal morphology may contribute to AIS patients’ balance during stance. Although balance did not influence pain severity, spinal morphology and its correction appear to have influenced the intensity and location of back pain.

Extreme long-term outcome of operatively versus conservatively treated patients with adolescent idiopathic scoliosis

PURPOSE

We report on outcomes of surgically versus (vs) non-surgically treated patients with moderate adolescent idiopathic scoliosis (AIS) after minimum of 29 years.

METHODS

AIS patients with a follow-up of  ≥ 41 years in the surgical group and  ≥ 29 years in the non-surgical group were included. Patients were treated surgically for primary curves  ≥ 45° vs non-surgically for curves  < 45° or refusal of surgery. Groups were matched for age, gender, comorbidities and primary curve severity. Oswestry Disability Index (ODI) was used to measure clinical outcomes and standard radiography to quantify curve severity at final follow-up.

RESULTS

In total, 16 patients (8 within each group, 75% females) with a median age of 14 (interquartile range (IQR) 2) years could be included and were followed up after 46 (IQR 12) years. All matched variables were similar for both groups, including the primary curve Cobb angles of 48° (IQR 17°) (surgical) vs 40° (IQR 19°) (non-surgical); p = 0.17). At final follow-up after a median of 47 (IQR 5) years for the surgical and 39 (IQR 19) years for the non-surgical group (p = 0.43), the ODI was similar for both groups (15 (IQR 13) points (surgical) vs 7 (IQR 15) points (non-surgical); p = 0.17) with, however, a primary curve magnitude lower in the surgical compared to the non-surgical group (38° (IQR 3°) vs 61° (IQR 33°); p = 0.01), respectively.

CONCLUSION

After around 47 and 39 years, respectively, surgical and non-surgical treatment of moderate AIS showed similar subjective outcomes, but with a relevant smaller curve magnitude with surgical treatment.

LEVEL OF EVIDENCE

III.

First end-result of a prospective cohort with AIS treated with a CAD Chêneau style brace

[Purpose] Specific exercises and brace treatment are the two evidence-based modes of treatment for patients with scoliosis. The purpose of this paper is to present the first end-results from a prospective cohort that commenced treatment in 2011 with a CAD based Chêneau derivate and is then compared to the published results achieved with the Boston Brace. [Participants and Methods] Inclusion criteria for the study, refers to the SRS inclusion criteria on bracing, except the range of Cobb angles which was extended to curvatures of up to 45°. Twenty-eight patients were weaned from their CAD Chêneau style brace. The results of this cohort have been compared with the BRAIST study by Weinstein et al. with the help of the Z-test. [Results] A success rate of 92.9% has been achieved. This was compared to the success rate of 72% in the BRAIST study. The differences were highly significant in the Z-test. [Conclusion] The results achieved with the GBW are significantly and better than the results achieved with the Boston brace. Therefore, the standards for bracing should be reviewed with the results that symmetric compression with Boston bracing is not as successful, when compared to asymmetric high correction bracing results, which allow a standardized classification-based corrective approach.

Bracing In The Treatment Of Adolescent Idiopathic Scoliosis: Evidence To Date

Brace effectiveness for adolescent idiopathic scoliosis was controversial until recent studies provided high quality of evidence that bracing can decrease likelihood of progression and need for operative treatment. Very low evidence exists regarding bracing over 40^ο and adult degenerative scoliosis. Initial in-brace correction and compliance seem to be the most important predictive factors for successful treatment outcome. However, the amount of correction and adherence to wearing hours have not been established yet. Moderate evidence suggests that thoracic and double curves, and curves over 30^ο at an early growth stage have more risk for failure. High and low body mass index scores are also associated with low successful rates. CAD/CAM braces have shown better initial correction and are more comfortable than conventional plaster cast braces. For a curve at high risk of progression, rigid and day-time braces are significantly more effective than soft or night-time braces. No safe conclusion on effectiveness can be drawn while comparing symmetrical and asymmetrical brace designs. The addition of physiotherapeutic scoliosis-specific exercises in brace treatment can provide better outcomes and is recommended, when possible. Despite the growing evidence for brace effectiveness, there is still an imperative need for future high methodological quality studies to be conducted.

Review of scoliosis-specific exercise methods used to correct adolescent idiopathic scoliosis

Background

Adolescent idiopathic scoliosis (AIS) refers to a spinal curvature of an unknown origin diagnosed in otherwise healthy children. A conservative treatment approach includes physiotherapy scoliosis-specific exercises (PSSE) with or without corrective bracing in preventing further spinal column deviation. However, several PSSE types have been developed to facilitate a positive patient outcome and/or preclude surgical remediation. Based on other reviews, there has been insufficient evidence published on the efficacy of PSSEs. In addition, the superiority of PSSE over no intervention or compared to other exercise modes has yet to be determined.

Methods

A comprehensive search of AIS literature, inception through February 2018, was conducted to reveal relevant PSSE articles. Only studies using commonly reported PSSEs were included. Examined databases included PubMed, Scopus, CINAHL Complete, and Physiotherapy Evidence Database (PEDro). Google Scholar search engine was also examined. Article types included randomized or clinical control trials. All articles were published in English or were of English translation. Search parameters were collectively defined by the reviewers and subsequently used to determine included studies. Individual PSSE study methodology quality was determined by the PEDro scale. Effect sizes (Hedge’s g) and their 95% confidence intervals were calculated for Cobb angle between group changes.

Results

Of the initial 24 articles recovered only eight (33%) met the established search criteria. Patient ages from these sources ranged from 11.4–16.2 including both males and females. Examined papers included two Schroth method and six specifying the Scientific Exercise Approach to Scoliosis (SEAS) method. All articles demonstrated positive between group effect sizes for PSSEs. There were no studies that compared one PSSE to another. Determined PEDro scores indicated an overall moderate quality of these studies.

Conclusions

There is insufficient evidence to suggest that both Schroth and SEAS methods can effectively improve Cobb angles in patients with AIS compared to no intervention. There is limited evidence that the SEAS method is more effective at reducing Cobb angles compared to traditional exercises in treating AIS. Overall, this review revealed a noticeable lack of contemporary studies that could be used in answering our questions. Evidence-based medicine (EBM) supplies clinicians with verifiable results from well-designed and managed research studies. Consequently, more and varied studies of higher quality are needed before any definitive determination can be made as to the effectiveness of any PSSE let alone the one offering better patient outcomes.

Correlations between Malocclusion and Postural Anomalies in Children with Mixed Dentition

The aim of this study was to investigate the possible relationship between malocclusion and body posture anomalies. The original sample involved 127 children (45 males and 82 females) with mixed dentition. Clinical examination of oral cavity was performed by an orthodontist, who recorded molar and canine relationship, cross-bite, lower middle-line deviation, and centric relation (CR) considering mono or bilateral contacts in CR. Orthopedic examination of the body posture was clinically carried out by an orthopedist who detected anomalies such as scoliosis, false scoliosis or paramorphism, kyphosis and lordosis. Of the 127 subjects of the sample, 18 children were orthopedically normal, 80 patients had false scoliosis, 22 scoliosis and 7 showed kyphosis. In our study, we don't consider the 7 patients with kyphosis for the exiguity of the sample; so, our analysis was performed on 120 children (42 males and 78 females). The results obtained revealed that the cross-bite was more frequent when scoliosis became worse. We also found that the relationship between left cross-bite and contralateral side of deviation of the curve of the spine in subjects with scoliosis is statistically significant (p = 0.002). Furthermore, the relationship between lower midline and contralateral side of deviation of the curve of the spine in patients with false scoliosis is statistically significant (p = 0.003). In conclusion, it seems that posture anomalies are correlated to cross-bite and mandible abnormal position.

The creation of a national coalition to target adolescent idiopathic scoliosis: a meeting report

In this report, we document the discussions and recommendations of a national conference designed to create a coalition to tackle adolescent idiopathic scoliosis (AIS) held on June 6 and 7, 2017 in Hamilton, ON, Canada. The goal of the establishment of this coalition is to join the efforts of patients, parents, physicians, researchers and other stakeholders to identify stakeholders' perspectives and to categorize gaps in knowledge and target further AIS research and clinical care priorities. The participants' main priorities included focus on shared decision making regarding clinical and research priorities between the stakeholders on the clinical, research and policy sides with patients and families. In addition, improvements in the dissemination of information via digital platforms and identification of cost-effective screening strategies that may help early identification and intervention were also recognized as a priority. Commitment was reached to form a national coalition to understand the determinants of this condition and enhance patient outcomes through improved clinical care and research efforts.

Body height loss characterizes camptocormia in Parkinson's disease

Axial deformities such as camptocormia or Pisa syndrome in people with Parkinson's disease (PwP) are poorly understood. The scarcity of information may result from the shortage of reliable and responsive evaluation instruments. We evaluated the body height loss (BHL) as a new measure for PwP with axial deformities. 50 PwP with axial deformity defined by an UPDRS item 28 value of at least 2 were included in this mono-center study. We measured body height while lying supine and after 1 min of standing, providing a percentage value of BHL, and compared this measure to other clinical variables. BHL depended on the Hoehn and Yahr clinical stage and correlated with clinical scales for function and mobility, but not with timely measures of the axial disorder such as age at diagnosis or duration of disease. ANOVA showed that only lumbar flexion explained the variability of BHL (F = 21.0, p < 0.0001), but not kyphosis (F = 0.4, p = 0.74) or lateroflexion (F = 0.6, p = 0.6). Re-test reliability of BHL was good with к = 0.76 (p < 0.0001). BHL resulted from the lumbar spine and the hip joint and not from the thoracic spine or lateroflexion. This observation conforms to the concept of upper-type and lower-type camptocormia with only the latter leading to a BHL. The assessment of the BHL is shown to be a well defined, easy to perform, and reliable measure for the clinical evaluation of lower-type camptocormia.

Management of Spinal Deformities and Evidence of Treatment Effectiveness

INTRODUCTION

The review evaluates the up-to-date evidence for the treatment of spinal deformities, including scoliosis and hyperkyphosis in adolescents and adults.

MATERIAL AND METHODS

The PubMed database was searched for review articles, prospective controlled trials and randomized controlled trials related to the treatment of spinal deformities. Articles on syndromic scoliosis were excluded and so were the articles on hyperkyphosis of the spine with causes other than Scheuermann's disease and osteoporosis. Articles on conservative and surgical treatments of idiopathic scoliosis, adult scoliosis and hyperkyphosis were also included. For retrospective papers, only studies with a follow up period exceeding 10 years were included.

RESULTS

The review showed that early-onset idiopathic scoliosis has a worse outcome than late-onset idiopathic scoliosis, which is rather benign. Patients with AIS function well as adults; they have no more health problems when compared to patients without scoliosis, other than a slight increase in back pain and aesthetic concern. Conservative treatment of adolescent idiopathic scoliosis (AIS) using physiotherapeutic scoliosis-specific exercises (PSSE), specifically PSSR and rigid bracing was supported by level I evidence. Yet to date, there is no high quality evidence (RCT`s) demonstrating that surgical treatment is superior to conservative treatment for the management of AIS. For adult scoliosis, there are only a few studies on the effectiveness of PSSEs and a conclusion cannot as yet be drawn.For hyperkyphosis, there is no high-quality evidence for physiotherapy, bracing or surgery for the treatment of adolescents and adults. However, bracing has been found to reduce thoracic hyperkyphosis, ranging from 55 to 80° in adolescents. In patients over the age of 60, bracing improves the balance score, and reduces spinal deformity and pain. Surgery is indicated in adolescents and adults in the presence of progression of kyphosis, refractory pain and loss of balance.

DISCUSSION

The available evidence reviewed has suggested that different approaches are needed towards the management of different spinal deformities. Specific exercises should be prescribed in children and adolescents with a Cobb angle in excess of 15°. In progressive curves, they should be used in conjunction with bracing. Clarity regarding differences and similarities is given as to what makes PSSE and PSSR specific exercises. As AIS is relatively benign in nature, conservative treatment should be tried when the curve is at a surgical threshold, before surgery is considered. Similarly, bracing and exercises should be prescribed for patients with hyperkyphosis, particularly when the lumbar spine is afflicted. Surgery should be considered only when the symptoms cannot be managed conservatively.

CONCLUSION

There is at present high quality evidence in support of the conservative treatment of AIS. The current evidence supports the use of PSSE, especially those using PSSR, together with bracing in the treatment of AIS. In view of the lack of medical consequences in adults with AIS, conservative treatment should be considered for curves exceeding the formerly assumed range of conservative indications.There is, however a lack of evidence in support of any treatment of choice for hyperkyphosis in adolescents and spinal deformities in adults. Yet, conservative treatment should be considered first. Yet to date, there is no high quality evidence (RCT`s) demonstrating that surgical treatment is superior to conservative treatment for the management of AIS and hyperkyphosis. Additionally, surgery needs to be considered with caution, as it is associated with a number of long-term complications.

Imaging in the Diagnosis and Monitoring of Children with Idiopathic Scoliosis

The paper reviews the current imaging methods in the diagnosis and monitoring of patients with adolescent idiopathic scoliosis. Radiography is generally used in the initial diagnosis of the condition. Postero-anterior erect full spine radiograph is generally prescribed, and is supplemented by lateral full spine radiograph when indicated. To reduce the radiation hazard, only the area of interest should be exposed, and follow-up radiographs should be taken with as few projections as possible. When available, EOS® stereoradiography should be used. The radiation of the microdose protocol is 45 times less than that of the conventional radiography. Surface topography offers another approach to monitoring changes of curvatures in AIS patients. Recently, 3D ultrasound has been found to be able to measure the Cobb angle accurately. Yet, it is still in the early developmental stages. The inherent intrinsic and external limitations of the imaging system need to be resolved before it can be widely used clinically. For AIS patients with atypical presentation, computed tomography (CT) and/or magnetic resonance imaging (MRI) may be required to assess for any underlying pathology. As CT is associated with a high radiation dose, it is playing a diminishing role in the management of scoliosis, and is replaced by MRI, which is also used for pre-operative planning of scoliosis. The different imaging methods have their limitations. The EOS® stereoradiography is expensive and is not commonly available. The surface topography does not enable measurement of Cobb angle, particularly when the patient is in-brace. The 3D ultrasound scanning has inherent intrinsic technical limitation and cannot be used in all subjects. Radiography, however, enables diagnosis and monitoring of the adolescent idiopathic scoliosis (AIS). It is thus the gold standard in the evaluation and management of scoliosis curves.

A Prospective Cohort Study of AIS Patients with 40° and More Treated with a Gensingen Brace (GBW): Preliminary Results

Introduction:

There is a growing resistance from patients and their families to spinal fusion surgery for scoliosis. Due to inconclusive evidence that surgery has a long-term effect on scoliosis and/or improves the quality of life for patients with scoliosis, there is a need to extend the conservative perspective of treatment to patients with curvatures greater than 40 degrees. For that reason, a prospective cohort study was initiated to determine the effectiveness of the Gensingen brace (a Cheneau-style TLSO) in preventing progression in skeletally immature patients.

Materials and Methods:

Since 2011, fifty-five patients have been enrolled in this prospective cohort study. This report includes the mid-term results of twenty-five of these patients, who have a minimum follow-up of 18 months and an average follow-up of 30.4 months (SD 9.2). The twenty-five patients had the following characteristics at the start of treatment: Cobb angle: 49° (SD 8.4; 40º-71º); 12.4 years old (SD 0.82); Risser: 0.84 (SD 0.94; 0-2). A z-test was used to compare the success rate in this cohort to the success rate in the prospective braced cohort from BrAIST.

Results:

After follow-up, the average Cobb angle was 44.2° (SD 12.9). Two patients progressed, 12 patients were able to achieve halted progression, and eleven patients improved. Angle of trunk rotation (ATR) decreased from 12.2 to 10.1 degrees in the thoracic spine (p = 0.11) while the ATR decreased from 4.7 to 3.6 degrees in the lumbar spine (p = 0.0074). When comparing the success rate of the BrAIST cohort with the success rate of patients in this cohort, the difference was statistically significant (z = -3.041; p = 0.01).

Conclusion:

Conservative brace treatment using the Gensingen brace was successful in 92% of cases of patients with AIS of 40 degrees and higher. This is a significant improvement compared to the results attained in the BrAIST study (72%). Reduction of the ATR shows that postural improvement is also possible.

Quality of life in adolescent patients with idiopathic scoliosis after brace treatment: A meta-analysis

BACKGROUND

Whether brace-treated adolescents with idiopathic scoliosis (AIS) have improved quality of life (QoL) is still unknown. Thus, we conducted a meta-analysis to compare the QoL of brace-treated AIS patients with untreated AIS patients. The pain, self-image/appearance, mental health, function/activity, satisfaction with management, total score without satisfaction, and total score of patients were used to measure the QoL after the intervention.

METHODS

Multiple electronic databases including PubMed, Web of Science, and Embase were searched for all years up to June 30, 2016. Articles in English that used the Scoliosis Research Society-22 (SRS-22) or a modified version of the SRS-22 questionnaire to evaluate the QoL differences between brace-treated AIS patients and untreated AIS patients were included in the meta-analysis. The Newcastle-Ottawa Scale was used in the quality of literature evaluation. The pooled standardized mean difference (SMD) with its corresponding 95% confidence interval (CI) for each parameter was computed. Egger test and Begg test were used to test for publication bias.

RESULTS

The SRS-22 or a modified SRS-22 questionnaire was used to evaluate the QoL after surgery. There was no significant difference in pain (SMD = 0.123, 95% CI: -0.101 to 0.347, P = .282), self-image/appearance (SMD = 0.108, 95% CI: -0.116 to 0.332, P = .334), mental health (SMD = 0.031, 95% CI: -0.130 to 0.201, P = .365), function/activity (SMD = 0.202, 95% CI: -0.022 to 0.425, P = .077), and total score without satisfaction (SMD = 0.123, 95% CI: -0.232 to 0.478, P = .497) between the untreated (observation) and brace-treated AIS patients, whereas a significant difference was observed in satisfaction with management (SMD = 0.393, 95% CI: 0.127-0.659, P = .004) and total score (SMD = 0.312, 95% CI: 0.054-0.571, P = .018) between the 2 groups.

CONCLUSION

Our meta-analysis indicated that brace-treated AIS patients had a higher QoL. However, further analysis could not be performed because of insufficient data, such that we were unable to make subgroup analysis of QoL for different types of AIS and the therapeutic methods chosen by brace-treated AIS patients.

Scoliosis in adulthood-a case with untreated early onset scoliosis presenting at the age of 76 years

[Purpose] Untreated early-onset scoliosis may eventually progress to more than 90° after growth, cause severe health problems, and increase chance of mortality. Therefore, surgical intervention is often indicated prior to the development of a life-threatening deformity. This case report aims to reveal how a 76-year-old male patient with curves exceeding 110° is functioning with minimal difficulty. [Subject and Methods] The patient, who has never had surgical intervention for scoliosis, can perform his everyday activities. His curves were 111° thoracic and 118° lumbar when he presented at the author’s office in January 2015. [Results] The patient reported that he rarely needs a physician and participates in endurance sports like jogging. Despite this, the patient recognizes his restrictive ventilation disorder (shortness of breath) when he is inactive. The patient complained of shortness of breath and cosmetic concerns. [Conclusion] The current guidelines indicate that early-onset scoliosis should be operated at a young age; however, this protocol is not supported by high-quality evidence. Notably, patients with curvatures exceeding 100° after puberty may have a reasonable quality of life when they lead an active life with regular participation in endurance sports and physical rehabilitation.

Long-Term Effects of Untreated Adolescent Idiopathic Scoliosis: A Review of the Literature

Currently, adolescent idiopathic scoliosis (AIS) is principally regarded as benign, but some researchers have cited serious or extreme effects, including severe pain, cardiopulmonary compromise, social isolation, and even early death. Therefore, exploration of the long-term effects of AIS, the most common type of idiopathic scoliosis, is warranted. The purpose of this review was to examine the long-term studies on the natural history of AIS and/or reviews concerning the long-term effects of untreated AIS. A PubMed search was conducted using the key words idiopathic scoliosis, long-term effects and idiopathic scoliosis, natural history. For further analysis, references cited in those studies were reviewed for additional, related evidence not retrieved in the initial PubMed search. A review of the pertinent bibliography showed that older natural history studies did not distinguish between late-onset scoliosis (referred to in this paper as AIS) and early-onset scoliosis (EOS). The more recent studies offer such important distinction and reach to the general conclusion that untreated AIS does not lead to severe consequences with respect to signs and symptoms of scoliosis. It is possible that earlier studies may have included patient populations with EOS, leading to the perception of untreated scoliosis as having an unusually high morbidity rate. Studies on the long-term effects of AIS that specifically excluded EOS patients conclude that AIS is a benign disorder. This indicates that for research and reporting purposes, it is important to distinguishing between AIS and EOS. This will allow the practitioner and patient and their families to decide on an optimal treatment plan based on the most appropriate prognosis.

Minimally invasive surgery in the treatment of adolescent idiopathic scoliosis: A literature review and meta-analysis

BACKGROUND CONTEXT

Spinal fusion surgery for scoliosis can be performed using a traditional open approach, or by following a minimally invasive approach. Minimally invasive surgery (MIS) is associated with theoretical advantages, such as reduced blood loss and a shorter hospital stay, yet there is no consensus in the literature with regard to the best treatment approach for adolescent idiopathic scoliosis (AIS).

PURPOSE

To assess the clinical outcomes of patients with AIS treated with either an open or minimally invasive approach.

STUDY DESIGN

Systematic review and meta-analysis of English-language studies for the treatment of adolescent idiopathic scoliosis.

PATIENT SAMPLE

Pooled results from level 1 and 2 studies.

METHODS

We carried out a systematic literature search of EMBASE and MEDLINE, identifying studies investigating MIS in the treatment of AIS. Percentages of curvature correction were pooled and analysed.

RESULTS

The literature search returned 50 articles, of which we determined 4 studies to be relevant. The pooled percentage curve correction across these groups was 62.05% for the MIS group and 70% for the open surgery group. Although these data are significant (p = 0.001), the available studies are of variable quality, and sample sizes small.

CONCLUSIONS

Patients with adolescent idiopathic scoliosis can be managed with either a traditional open approach or a minimally invasive approach. The data suggests that open surgery offers an advantage in terms of curve correction, compared to minimally invasive surgery, however more investigation (in the form of robust randomized control trials) is needed before conclusive clinical suggestions can be recommended.

Adolescent idiopathic scoliosis and back pain

This broad narrative review addresses the relationship between adolescent idiopathic scoliosis (AIS) and back pain. AIS can be responsible for low back pain, particularly major cases. However, a linear relationship between back pain and the magnitude of the deformity cannot be expected for any individual patient. A large number of juvenile patients can remain pain-free. The long-term prognosis is rather benign for many cases and thus a tailored approach to the individual patient seems mandatory. The level of evidence available does not allow stringent recommendations for any of the disorders included in this review.

Effect of surgical correction of adolescent idiopathic scoliosis on the quality of life: a prospective study with a minimum 5-year follow-up

PURPOSE

To prospectively evaluate the quality of life (QoL), functionality, and body image of subjects who had undergone surgery for adolescent idiopathic scoliosis (AIS) 5-12 years previously, and to identify the outcome predictors.

METHODS

The sample consisted of 87 patients for whom follow-up data were available out of a series of 91 patients who had surgery for AIS between 2002 and 2009. We assessed the preoperative, 1-year postoperative, and 5-year or more postoperative SF-36 and SRS-23 questionnaire scores. Longitudinal clinical and radiographic data also were evaluated. Changes in the patient-oriented outcomes were compared with age and sex-adjusted normative values. A multiple regression analysis was used to identify possible outcome predictors.

RESULTS

Preoperatively, patients had impaired QoL, functionality, and body image compared to age- and sex-matched healthy controls. Surgery led to significant improvement of the SF-36 and SRS scores at the one-year and final control date, but the final scores on SF-36's physical indexes were lower than control subjects' scores. No clinically relevant differences with the normative values were detected in the final SRS scores. The height of the residual rib hump negatively predicted the total SRS and self-image scores; a more caudal level of fusion correlated with more postoperative pain.

CONCLUSIONS

Patients who underwent surgery for AIS a minimum of 5 years earlier had impaired self-reported physical QoL compared to control subjects, but they nevertheless performed better than before their surgery. Greater size of the residual hump and greater distal extension of the fusion area are negatively correlated with final self reported outcome.

[Fusion in adolescent idiopathic scoliosis : Anterior, posterior or combined? One-stage or two-stage?]

Scoliosis is a complex, three-dimensional spinal deformity with various causes. Adolescent idiopathic scoliosis (AIS) is the most common form. Surgical treatment is indicated for curves greater than 45-50° meaured using the Cobb method. We can distinguish among posterior, anterior or combined surgical procedures. Today, the posterior, transpedicular approach has revolutionized scoliosis surgery. This review gives an overview of current surgical options in scoliosis treatment.

Are current scoliosis school screening recommendations evidence-based and up to date? A best evidence synthesis umbrella review

PURPOSE

Recommendations addressing school screening for adolescents with idiopathic scoliosis are contradictory. Consequently a critical evaluation of the methodological quality of available systematic reviews, including those upon which these recommendations are based, was conducted.

METHODS

Articles meeting the minimal criteria to be considered a systematic review were included for a best evidence synthesis, umbrella review of secondary studies. The primary outcome measure was "any recommendation addressing the continuation, or not, of school screening programs". Multiple general bibliographic databases, guideline registries, as well as websites of institutions were searched. The AMSTAR tool was used to critically appraise the methodology of included reviews. Venn diagrams were created to examine potential overlaps across included papers within different reviews.

RESULTS

Six reviews undertaken between 2002 and 2011, scored as moderate to low quality, were included. The 2012 US Preventive Services Task Force recommendation against screening was found to be based on an outdated (2004) low-quality review, whilst two higher quality and more recent (2009 and 2010) reviews support the continuation of school screening programs.

CONCLUSIONS

As the existing recommendations supporting screening are based on moderate quality evidence whilst the recommendations against screening are based on low-quality evidence, the latter recommendations appear to be both unconvincing and methodologically invalid.