Predicting success or failure of brace treatment for adolescents with idiopathic scoliosis

Clinical Decision Support System Used in Spinal Disorders: Scoping Review

BACKGROUND

Spinal disorders are highly prevalent worldwide with high socioeconomic costs. This cost is associated with the demand for treatment and productivity loss, prompting the exploration of technologies to improve patient outcomes. Clinical decision support systems (CDSSs) are computerized systems that are increasingly used to facilitate safe and efficient health care. Their applications range in depth and can be found across health care specialties.

OBJECTIVE

This scoping review aims to explore the use of CDSSs in patients with spinal disorders.

METHODS

We used the Joanna Briggs Institute methodological guidance for this scoping review and reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) statement. Databases, including PubMed, Embase, Cochrane, CINAHL, Web of Science, Scopus, ProQuest, and PsycINFO, were searched from inception until October 11, 2022. The included studies examined the use of digitalized CDSSs in patients with spinal disorders.

RESULTS

A total of 4 major CDSS functions were identified from 31 studies: preventing unnecessary imaging (n=8, 26%), aiding diagnosis (n=6, 19%), aiding prognosis (n=11, 35%), and recommending treatment options (n=6, 20%). Most studies used the knowledge-based system. Logistic regression was the most commonly used method, followed by decision tree algorithms. The use of CDSSs to aid in the management of spinal disorders was generally accepted over the threat to physicians' clinical decision-making autonomy.

CONCLUSIONS

Although the effectiveness was frequently evaluated by examining the agreement between the decisions made by the CDSSs and the health care providers, comparing the CDSS recommendations with actual clinical outcomes would be preferable. In addition, future studies on CDSS development should focus on system integration, considering end user's needs and preferences, and external validation and impact studies to assess effectiveness and generalizability.

TRIAL REGISTRATION

OSF Registries osf.io/dyz3f; https://osf.io/dyz3f.

A feasibility study of application of purpose-design frame and 3-D clinical ultrasound in assessment and design of spinal orthoses for adolescent idiopathic scoliosis

BACKGROUND

The immediate in-orthosis correction of adolescent idiopathic scoliosis (AIS) is a useful prognostic parameter for the long-term orthotic treatment outcome. The 3-D clinical ultrasound technique is considered a noninvasive alternative to assess scoliotic deformities that could be applied in the orthotic treatment of AIS.

OBJECTIVE

This study aimed to investigate the feasibility of a purpose-design assessment frame in estimating biomechanical effects of the controlling pads of a spinal orthosis under the guidance of the ultrasound system.

METHODS

Twenty-six subjects with AIS were recruited and arranged to position inside the assessment frame, and controlling pads were applied strategically while the scoliotic deformities were assessed by clinical ultrasound to obtain at least 30% curvature correction, and the body shape was then captured using a computer-aided design and computer-aided manufacture system, and spinal orthoses were subsequently fabricated. The preorthosis and immediate in-orthosis coronal and sagittal X-rays were used for comparison.

RESULTS

X-ray assessments showed that the mean coronal Cobb angle and lumbar lordosis of the subjects from the preorthosis to immediate in-orthosis visits decreased significantly ( p < 0.05) from 29.6° to 16.6°, and from 47.2° to 35.3°, respectively.

CONCLUSIONS

This feasibility study showed that the proposed method would have a good potential to improve orthotic treatment outcome in a documented approach that should be considered for implementation into routine clinical practice aiming to reduce the chance of deformity deterioration leading to surgical intervention. However, a controlled group study is required to compare the results.

Predicting curve progression for adolescent idiopathic scoliosis using random forest model

Background

Adolescent Idiopathic Scoliosis (AIS) is a three-dimensional (3D) spinal deformity characterized by coronal curvature and rotational deformity. Predicting curve progression is important for the selection and timing of treatment. Although there is a consensus in the literature regarding prognostic factors associated with curve progression, the order of importance, as well as the combination of factors that are most predictive of curve progression is unknown.

Objectives

(1) create an ordered list of prognostic factors that most contribute to curve progression, and (2) develop and validate a Machine Learning (ML) model to predict the final major Cobb angle in AIS patients.

Methods

193 AIS patients were selected for the current study. Preoperative PA, lateral and lateral bending radiographs were retrospectively obtained from the Shriners Hospitals for Children. Demographic and radiographic features, previously reported to be associated with curve progression, were collected. Sequential Backward Floating Selection (SBFS) was used to select a subset of the most predictive features. Based on the performance of several machine learning methods, a Random Forest (RF) regressor model was used to provide the importance rank of prognostic features and to predict the final major Cobb angle.

Results

The seven most predictive prognostic features in the order of importance were initial major Cobb angle, flexibility, initial lumbar lordosis angle, initial thoracic kyphosis angle, age at last visit, number of levels involved, and Risser "+" stage at the first visit. The RF model predicted the final major Cobb angle with a Mean Absolute Error (MAE) of 4.64 degrees.

Conclusion

A RF model was developed and validated to identify the most important prognostic features for curve progression and predict the final major Cobb angle. It is possible to predict the final major Cobb angle value within 5 degrees error from 2D radiographic features. Such methods could be directly applied to guide intervention timing and optimization for AIS treatment.

Predictive Factors on Initial in-brace Correction in Idiopathic Scoliosis: A Systematic Review

STUDY DESIGN

Systematic literature review.

OBJECTIVE

The aim of this study was to systematically review the literature and provide an overview of reported predictive factors on initial in-brace correction in patients with idiopathic scoliosis (IS).

SUMMARY OF BACKGROUND DATA

Brace therapy is the best proven non-surgical treatment for IS. There is strong evidence that lack of initial in-brace correction is associated with brace treatment failure. To improve initial in-brace corrections and subsequently long-term brace treatment success, knowledge about factors influencing initial in-brace correction is a prerequisite.

METHODS

A systematic literature search was performed in Pubmed, Embase, Web-of-Science, Scopus, Cinahl, and Cochrane in November 2020. Studies which reported factors influencing initial in-brace correction in IS patients treated with brace therapy were considered eligible for inclusion.

RESULTS

Of the 4562 potentially eligible articles identified, 28 studies fulfilled the inclusion criteria and were included in this systematic review. Nine studies (32%) were classified as high quality studies and the remaining 19 studies (68%) as low quality. Thirty-four different reported factors were collected from the included studies. Strong evidence was found for increased curve flexibility as favorable predictive factor for initial in-brace correction. Moderate evidence was found for thoracolumbar or lumbar curve pattern as favourable predictive factor, and double major curve pattern as unfavourable predictive factor for initial in-brace correction. Also moderate evidence was found that there is no significant difference on initial in-brace correction between computer-aided design and manufacturing systems (CAD/CAM) braces with or without finite element models (FEM) simulation, and braces fabricated using the conventional plaster-cast.

CONCLUSION

The results of this systematic review indicate that increased curve flexibility is strongly associated with increased initial in-brace correction.Level of Evidence: 1.

Predictors for long-term curve progression after Boston brace treatment of idiopathic scoliosis

BACKGROUND

Identifying factors that predict successful bracing in patients with idiopathic scoliosis may help planning treatment.

AIM

To assess predictors for long-term curve progression and health-related quality of life after Boston brace treatment.

DESIGN

Observational retrospective cohort study with analysis of brace treated patients followed from start until at least 10 years after treatment.

SETTING

Patients recruited from the country's entire population consecutively treated at the National Hospital.

POPULATION

365 patients (339 girls/26 boys) with idiopathic scoliosis. Mean (SD) chronological age/bone age at start bracing was 13.2 (1.9)/12.6 (1.9) years. The primary major curve measured 33.2 (7.4°), and the major levels were thoracic (N.=248), thoracolumbar (N.=78) and lumbar (N.=39). Mean bracing time was 2.8 (1.5) years. Long-term follow-up was in average 23.3 (4.1) years after weaning with a mean major curve of 33.0 (13.1°). Successful treatment was defined as a stable primary curve with progression ≤5°, and secondary the SRS-22 questionnaire assessed quality of life.

METHODS

We applied linear or logistic regression with backward elimination. Internal validation was assessed by bootstrapping. Twelve variables were included in the prediction models: age, bone age, scoliosis in close family, major curve size, level, shape, flexibility and in-brace redressement, compliance, curve magnitude after 1 year, treatment time and quality of life (SRS-22).

RESULTS

290 patients (79%) had rated good compliance using the brace >20 hours daily. Treatment failure was observed in 65 patients (18%), and 27 of them were operated. The best baseline predictors were age and brace redressement. During treatment compliance, major curve after 1 year, and treatment time were the best predictors, while thoracic major curve, curve size at start bracing and scoliosis in close family also contributed to the final model. The model's ability to predict quality of life was low.

CONCLUSIONS

The best predictors for a long-term success were good redressement and compliance, unchanged or reduced major curve after one year and short treatment time.

CLINICAL REHABILITATION IMPACT

Predictors at baseline and during early treatment can help identifying patients who benefit from bracing.

The development of a novel knowledge-based weaning algorithm using pulmonary parameters: a simulation study

Weaning is important for patients and clinicians who have to determine correct weaning time so that patients do not become addicted to the ventilator. There are already some predictors developed, such as the rapid shallow breathing index (RSBI), the pressure time index (PTI), and Jabour weaning index. Many important dimensions of weaning are sometimes ignored by these predictors. This is an attempt to develop a knowledge-based weaning process via fuzzy logic that eliminates the disadvantages of the present predictors. Sixteen vital parameters listed in published literature have been used to determine the weaning decisions in the developed system. Since there are considered to be too many individual parameters in it, related parameters were grouped together to determine acid-base balance, adequate oxygenation, adequate pulmonary function, hemodynamic stability, and the psychological status of the patients. To test the performance of the developed algorithm, 20 clinical scenarios were generated using Monte Carlo simulations and the Gaussian distribution method. The developed knowledge-based algorithm and RSBI predictor were applied to the generated scenarios. Finally, a clinician evaluated each clinical scenario independently. The Student's t test was used to show the statistical differences between the developed weaning algorithm, RSBI, and the clinician's evaluation. According to the results obtained, there were no statistical differences between the proposed methods and the clinician evaluations.

Efficacy of nighttime brace in preventing progression of idiopathic scoliosis of less than 25°

INTRODUCTION

The objective of the present study was to assess, at skeletal maturity, the efficacy of non-operative treatment by isolated nighttime brace in the prevention of progression of progressive idiopathic scoliosis of less than 25°.

HYPOTHESIS

Isolated nighttime brace treatment is effective in the prevention of progression of mild progressive idiopathic scoliosis (Cobb<25°).

MATERIAL AND METHODS

A single-center retrospective study included 142 patients managed by nighttime brace for progressive idiopathic scoliosis with Cobb angle<25°, with assessment at skeletal maturity. Mean Cobb angle at start of treatment was 15.5° (range, 10-25°). Mean values for Cobb angle and sagittal parameters before treatment and at skeletal maturity were compared on Student t-test. Change in Cobb angle over time was also analyzed.

RESULTS

Mean Cobb angle at skeletal maturity was 16.3°, showing significant increase over baseline (15.5°; P=0.04), although the difference was less than the uncertainty of measurement (±6°). In baseline Risser 0 or 1, mean change in Cobb angle at skeletal maturity (16.2°) was not significant (P=0.1). Cobb angle diminished in 26 cases (18%), increased in 24 (17%) and was unchanged in 92 (65%).

CONCLUSION

The present study confirmed the efficacy of non-operative treatment by nighttime brace in mild progressive idiopathic scoliosis (<25°) in a large majority of cases. A nighttime brace thus seems to be an effective option for the treatment of adolescent scoliosis, ensuring a safe curve of around 20°.

LEVEL OF EVIDENCE

Level IV, retrospective study.