[3-dimensional surface measurement of spinal deformities with video rasterstereography]

Influence of Lateral Sitting Wedges on the Rasterstereographically Measured Scoliosis Angle in Patients Aged 10-18 Years with Adolescent Idiopathic Scoliosis

Adolescent idiopathic scoliosis (AIS) is a three-dimensional axial deviation of the spine diagnosed in adolescence. Despite a long daily sitting duration, there are no studies on whether scoliosis can be positively influenced by sitting on a seat wedge. For the prospective study, 99 patients with AIS were measured with the DIERS formetric III 4D average, in a standing position, on a level seat and with three differently inclined seat wedges (3°, 6° and 9°). The rasterstereographic parameters 'scoliosis angle' and 'lateral deviation RMS' were analysed. The side (ipsilateral/contralateral) on which the optimal correcting wedge was located in relation to the lumbar/thoraco-lumbar convexity was investigated. It was found that the greatest possible correction of scoliosis occurred with a clustering in wedges with an elevation on the ipsilateral side of the convexity. This clustering was significantly different from a uniform distribution (p < 0.001; chi-square = 35.697 (scoliosis angle); chi-square = 54.727 (lateral deviation RMS)). It should be taken into account that the effect of lateral seat wedges differs for individual types of scoliosis and degrees of severity. The possibility of having a positive effect on scoliosis while sitting holds great potential, which is worth investigating in follow-up studies.

Reference values and functional descriptions of transverse plane spinal dynamics during gait based on surface topography

Spinal dynamics during gait have been of interest in research for many decades. Based on respective previous investigations, the pelvis is generally expected to be maximally forward rotated on the side of the reference leg at the beginning of each gait cycle and to reach its maximum counterrotation approximately at the end of the reference leg's stance phase. The pelvic-upper-thoracic-spine coordination converges towards an anti-phase movement pattern in high velocities during ambulation. The vertebral bodies around the seventh thoracic vertebra are considered to be an area of transition during human ambulation where no or at least little rotary motion can be observed. The respective cranial and caudal vertebrae meanwhile are expected to rotate conversely around this spinal point of intersection. However, these previous assumptions are based on scarce existing research, whereby only isolated vertebrae have been analyzed contemporaneously. Due to huge methodological differences in data capturing approaches, the results are additionally hardly comparable to each other and involved measurement procedures are often not implementable in clinical routines. Furthermore, none of the above-mentioned methods provided reference data for spinal motion during gait based on an appropriate number of healthy participants. Hence, the aim of this study was to present such reference data for spinal rotary motion of every vertebral body from C7 down to L4 and the pelvis derived from surface topographic back shape analyses in a cohort of 201 healthy participants walking on a treadmill at a given walking speed of 5 km/h. Additionally, the spine's functional movement behavior during gait should be described in the transverse plane based on data derived from this noninvasive, clinically suitable measurement approach and, in conclusion, the results shall be compared against those of previous research findings derived from other measurement techniques. Contrary to the previous functional understanding, the area of the mid-thoracic spine was found to demonstrate the largest amplitude of rotary motion of all investigated vertebrae and revealed an approximately counterrotated movement behavior compared to the rotary motion of the pelvis. In both directions, spinal rotation during gait seemed to be initiated by the pelvis. The overlying vertebrae followed in succession in the sense of an ongoing movement. Therefore, the point of intersection was not statically located in a specific anatomical section of the spine. Instead, it was found to be dynamic, ascending from one vertebra to the next from caudal to cranial in dependence of the pelvis's rotation initiation.

Standard reference values of the upper body posture in healthy male adults aged between 51 and 60 years in Germany

Comparative values are essential for the classification of orthopedic abnormalities and the assessment of a necessary therapy. At present, reference values for the upper body posture for healthy, male adults exist for the age groups of 18-35, 31-40 and 41-50 years. However, corresponding data on the decade of 51 to 60 year-old healthy men are still lacking. 23 parameters of the upper body posture were analyzed in 102 healthy male participants aged 51-60 (55.36 ± 2.78) years. The average height was 180.76 ± 7.81 cm with a weight of 88.22 ± 14.57 kg. The calculated BMI was 26.96 ± 3.92 kg/m2. In the habitual, upright position, the bare upper body was scanned three-dimensionally using video raster stereography. Mean or median values, confidence intervals, tolerance ranges and group comparisons, as well as correlations of BMI and physical activity, were calculated for all parameters. The spinal column parameters exhibited a good exploration of the frontal plane in the habitual standing position. In the sagittal plane, a slight, ventral inclination of the trunk with an increased kyphosis angle of the thoracic spine and increased thoracic bending angle was observed. The parameters of the pelvis showed a pronounced symmetry with deviations from the 0° axis within the measurement error margin of 1 mm/1°. The scapula height together with the scapula angles of the right and left side described a slightly elevated position of the left shoulder compared to the right side. The upper body posture is influenced by parameters of age, height, weight and BMI. Primarily there are significant correlations to measurements of trunk lengths D (age: p ≤ 0.02, rho = -0.23; height: p ≤ 0.001, rho = 0.58; weight: p ≤ 0.001, rho = 0.33), trunk lengths S (age: p ≤ 0.01, rho = -0.27; height: p ≤ 0.001, rho = 0.58; weight: p ≤ 0.001, rho = 0.32), pelvic distance (height: p ≤ 0.01, rho = 0.26; weight: p ≤ 0.001, rho = 0.32; BMI: p ≤ 0.03, rho = 0.22) and scapula distance (weight: p ≤ 0.001, rho = .32; BMI: p ≤ 0.01, rho = 0.27), but also to sagittal parameters of trunk decline (weight: p ≤ 0.001, rho = -0.29; BMI: p ≤ 0.01, rho = -0.24), thoracic bending angle (height: p ≤ 0.01, rho = 0.27) and kyphosis angle (BMI: p ≤ 0.03, rho = 0.21). The upper body posture of healthy men between the ages of 51 and 60 years was axially almost aligned and balanced. With the findings of this investigation and the reference values obtained, suitable comparative values for use in clinical practice and for further scientific studies with the same experimental set-up have been established.

Acute Effects of Self-Correction on Spine Deviation and Balance in Adolescent Girls with Idiopathic Scoliosis

Background: Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of spine and trunk with a higher incidence in girls. AIS alters and reduces postural control and balance. Self-correction movement (SCM) is a well-known non-invasive approach to ameliorate spine curve in AIS subjects. We aimed to evaluate the effects of SCM on the spine and on the balance of adolescents with AIS with a new non-invasive instrumentation. Methods: A total of 38 girls with AIS were recruited. To evaluate the acute effects of SCM and the oscillations of center of pressure (COP), we used LiDAR technology combined with a stabilometric platform to evaluate both changes in spinal curves and balance at the same time. Two tests were carried out simultaneously using the two instruments: before the execution of SCM, in the spontaneously assumed position of each subject (SP) and after the execution of SCM, during the achieved position (SC). Sway area, COP medio-lateral and antero-posterior directions, eccentricity of the ellipse and vertebral lateral deviation were recorded. The two conditions were compared with a Wilcoxon signed-rank test. Results: In general, all measures showed lower values in SC condition (p < 0.05), except the variation along the Y axis. Conclusions: Thanks to objective measured data, the therapists observed real-time changes during the performance of SCM, appreciating its efficacy on curve correction.

Using INTEGRATE-HTA for the assessment of videorasterstereography in idiopathic scoliosis

OBJECTIVE

For the assessment of videorasterstereography compared with radiography for monitoring idiopathic scoliosis, new tools given by the INTEGRATE-HTA methodology were included within the frame set by the authority. In contrast to the usual linear approach by covering the single domains' safety and efficacy, costs, and ethical, legal, socio-cultural and organizational issues (ELSOI) separately, the methodology is based on the assumption of interactions of different aspects of the domains. From the very beginning, these interactions are captured systematically using various tools and are repeatedly discussed with stakeholders.

METHODS

Relevant databases were systematically searched for studies and question catalogues were processed in order to be able to search for specific aspects in orienting bibliographic research. An initial logic model was developed and successively expanded. A synoptic table showing multiple mapping of aspects to domains, a complexity checklist, and a semantic complex highlighting the socio-cultural impact of the disease were newly developed.

RESULTS

Four diagnostic studies with high risk of bias were included. For the clinical outcome, Cobb angle standard deviations up to 8.2 degrees and average measurement differences up to 8.8 degrees were determined. These differences in measurement accuracy correspond to those observed for purely radiographic measurements in other studies. In addition to freedom from radiation as the greatest advantage, there were clear arguments in favor of videorasterstereography when considering ELSOI, for example less harm.

CONCLUSIONS

Using INTEGRATE-HTA contributes to identify interactions between domains and to significantly expand the perspective on a technology. It improves patient-centered understanding and facilitates discussions.

Relationship between back posture and early orthodontic treatment in children

Background

The purpose of this study was to analyze the relationship between body posture and sagittal dental overjet in children before and after early orthodontic treatment with removable functional orthodontic appliances.

Methods

Angle Class II patients (mean age 8.2 ± 1.2 years; 29 males and 25 females) with a distinctly enlarged overjet (> 9 mm) were retrospectively examined regarding body posture parameters before and after early orthodontic treatment. In addition, changes in overjet were investigated with the aid of plaster models. Forms of transverse dysgnathism (crossbite, lateral malocclusions) and open bite cases were excluded. Body posture parameters kyphosis, lordosis, surface rotation, pelvic tilt, pelvic torsion and trunk imbalance were analyzed by means of rasterstereographical photogrammetry to determine, if the orthodontic overjet correction is associated with specific changes in posture patterns.

Results

In nearly all patients an overjet correction and an improvement regarding all body posture and back parameters could be noted after early orthodontic treatment. Overjet reduction (− 3.9 mm ± 2.1 mm) and pelvic torsion (− 1.28° ± 0,44°) were significantly (p < 0.05) and moderately correlated (R = 0.338) with no significant associations found for the other posture and back parameters (p > 0.05).

Conclusion

Overjet reduction during early orthodontic treatment may be associated with a detectable effect on pelvic torsion.

The Value of Video Rasterstereography in the Detection of Alterations in Posture as a Marker of Pain Relief after Targeted Infiltrations of the Lumbar Spine

BACKGROUND

Targeted infiltrations to the lumbar spine are used to identify the correct scope for surgery in patients with chronic lumbar back pain (CLBP) and multi-segmental pathologies, where radiologic imaging and clinical presentation do not match. Conclusions from that method have so far been based on individual statements of pain relief. The main principle for the infiltrations is the assumption that by locally administering an analgesic agent to possible surgical target areas, the effect of surgery can be temporarily simulated. The aim was to investigate the use of rasterstereographic posture measurements to substantiate reported pain reduction after infiltrations.

METHODS

In this case-control study (Level II), rasterstereography was performed on 57 patients and 28 reference subjects to evaluate changes in posture during 1 week of injections under fluoroscopic guidance and correlated with changes in the Numeric Pain Rating Scale (NRS). Statistical analysis was performed with SPSS (α = .05, two-sided) and presented in the form of box, scatter, and Bland-Altman plots.

RESULTS AND CONCLUSION

The CLBP patients' trunk inclination (median 6°) and absolute lateral tilt were significantly increased (p < .01 each) compared to the reference group. No significant difference was observed for trunk length, kyphotic/lordotic angle, or lateral deviation. During infiltration, no significant difference in posture could be observed. A subgroup analysis of patients reporting the highest pain improvement indicated no significant difference. No correlation was observed with pain improvement reported by the patients during injections. Subsequent rasterstereography does not seem to be able to verify results of injections in the diagnostics of lumbar spine pathologies, as patients' reported pain relief does not correlate with a relevant alteration in posture. The short-term effect of the targeted infiltrations may not suffice to change false posture being developed over years.

Meta-analysis of the validity and reliability of rasterstereographic measurements of spinal posture

OBJECTIVE

We provide a meta-analysis for clinicians and researchers regarding reliability and validity of rasterstereographic measurement of the spinal posture.

METHOD

A comprehensive PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) literature search identified 19 eligible studies evaluating reliability and validity of static rasterstereographic measurements in healthy subjects and patients with different spinal pathologies.

RESULTS

Our meta-analysis suggests that rasterstereography is a reliable and valid instrument to assess spinal posture parameters, especially thoracic kyphosis, lumbar lordosis, and scoliosis, reliability overall effect sizes rs > .91, ps < .001, validity overall effect sizes rs > 70, ps < .001, when compared to traditional radiological imaging techniques. Validity is higher in scoliosis patients compared with healthy controls. Limitations are a lack of reported statistics of the included studies and small sample sizes.

CONCLUSION

The first meta-analysis on reliability and validity of rasterstereography shows satisfactory results. Rasterstereography thus presents a reliable and valid alternative to classic radiological imaging technique to assess and evaluate spinal posture in patients with spinal pathologies. Further studies are needed, focusing on the measurement properties of both static and dynamic rasterstereographic measurements.

Rasterstereographic Analysis of Lateral Shift in Patients with Lumbar Disc Herniation: A Case Control Study

Objective

Detection of a lateral shift (LS) in patients with diagnosed disc herniation compared to healthy controls.

Summary of Background Data

A specific lateral shift (LS) pattern is observed in patients with disc herniation and low back pain, as shown in earlier studies.

Methods

Rasterstereography (RS) was used to investigate the LS. Thirty-nine patients with lumbar disc herniation diagnosed by radiological assessment and low back pain and/or leg pain (mean age 48.2 years, mean BMI 28.5, 28 males and 11 females) and 36 healthy controls (mean age 47.4 years, mean BMI 25.7, 25 males and 11 females) were analysed. LS, pelvic tilt, pelvic inclination, lordotic angle, and trunk torsion were assessed.

Results

The patient group showed a nonsignificant increase in LS, that is, 5.6 mm compared to the healthy controls with 5.0 mm (p = 0.693). However, significant differences were found between groups regarding pelvic tilt in degrees (patients 5.9°, healthy controls 2.0°; p = 0.016), trunk torsion (patients 7.5°, controls 4.5°; p = 0.017), and lordotic angle (patients 27.5°, healthy controls 32.7°; p = 0.022). The correlation between pain intensity and the FFbH-R amounted 0.804 (p = < 0.01), and that between pain intensity and the pain disability index was 0.785 (p < 0.01).

Discussion

Although some studies have illustrated LS with disc herniation and low back pain, the present findings demonstrate no significant increase in LS in the patient group compared to healthy controls.

Conclusion

The patients with lumbar disc herniation did not demonstrate an increased LS compared to healthy controls. Other parameters like pelvic tilt and inclination seemed to be more suitable to identify changes in posture measured by RS in patients with low back pain or disc herniation.

Using video rasterstereography and treadmill gait analysis as a tool for evaluating postoperative outcome after lumbar spinal fusion

BACKGROUND

The rise in the number of patients with lumbar back pain has led to an increase in the number of spinal surgeries. To avoid unfavorable outcomes, high accuracy and reliability of indication for surgery are essential. This requires critical evaluation of postoperative outcomes with its two key dimensions pain and function. While imaging findings give details about the technical dimension of the intervention, they are prone to high inter-/intra-observer variability, with limited relation to functional outcomes. Pain improvement can be directly asked from patients or documented by questionnaires. There is abundant literature on postoperative function based on questionnaires, but quantifiable data such as gait or posture analysis are scarce. Highprecision measurement tools are available and easy to implement in a clinician's work routine.

OBJECTIVE

This study evaluates whether lumbar fusion surgery changes gait and postural variables and how these changes are related to patients' descriptions of alterations in their levels of pain.

METHODS

Back profiles and gait analyses were measured by video rasterstereography and treadmill gait analysis. Measurements were recorded before surgery, at discharge, after 3 months in a longitudinal (n = 30), and after 12 months in a cross-sectional group (n = 29). A reference group was formed (n = 28). The improvement on the Numeric Pain Rating Scale was documented and compared with changes in gait and posture.

RESULTS

A significant reduction in kyphotic (52-43°, p = 0.014) and lordotic (28-11°, p < 0.001) angles was observed. The values again increased after 3 months, with a significant reduction in cadence (98-91 steps/min, p = 0.006). While improvements in pain were also obtained by surgery (p < 0.001), no clear correlation could be detected between 3-month alleviation in pain and changes in kyphotic/lordotic angle or cadence.

CONCLUSIONS

Although both methods offer high-precision measurement, changes in gait and posture were not related with the patients' reported pain relief after lumbar fusion surgery.

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.

Non-radiographic methods of measuring global sagittal balance: a systematic review

Background

Global sagittal balance, describing the vertical alignment of the spine, is an important factor in the non-operative and operative management of back pain. However, the typical gold standard method of assessment, radiography, requires exposure to radiation and increased cost, making it unsuitable for repeated use. Non-radiologic methods of assessment are available, but their reliability and validity in the current literature have not been systematically assessed. Therefore, the aim of this systematic review was to synthesise and evaluate the reliability and validity of non-radiographic methods of assessing global sagittal balance.

Methods

Five electronic databases were searched and methodology evaluated by two independent reviewers using the13-item, reliability and validity, Brink and Louw critical appraisal tool.

Results

Fourteen articles describing six methodologies were identified from 3940 records. The six non-radiographic methodologies were biophotogrammetry, plumbline, surface topography, infra-red motion analysis, spinal mouse and ultrasound. Construct validity was evaluated for surface topography (R = 0.49 and R = 0.68, p < 0.001), infra-red motion-analysis (ICC = 0.81) and plumbline testing (ICC = 0.83). Reliability ranged from moderate (ICC = 0.67) for spinal mouse to very high for surface topography (Cronbach α = 0.985). Measures of agreement ranged from 0.9 mm (plumbline) to 22.94 mm (infra-red motion-analysis). Variability in study populations, reporting parameters and statistics prevented a meta-analysis.

Conclusions

The reliability and validity of the non-radiographic methods of measuring global sagittal balance was reported within 14 identified articles. Based on this limited evidence, non-radiographic methods appear to have moderate to very high reliability and limited to three methodologies, moderate to high validity. The overall quality and methodological approaches of the included articles were highly variable. Further research should focus on the validity of non-radiographic methods with a greater adherence to reporting actual and clinically relevant measures of agreement.

Biomechanics of the osteoporotic spine, pain, and principles of training

INTRODUCTION

A fracture is a clinical manifestation of osteoporosis and is one of the main causes of functional limitations and chronic pain in patients with osteoporosis. Muscle and coordination training are recommended to the patients as general measures. We inquired whether sling training is better than traditional physiotherapy in relieving pain and improving abilities of daily living.

METHODS

Fifty patients with osteoporosis were divided into two groups. Group A performed conventional physiotherapy, while Group B performed sling training exercises. Data were collected before and after the intervention and after 3 months. The registered parameters were stamina, posture, and pain. Posture, torques, and the associated strength of spinal muscles were studied in a biomechanical model in order to estimate the forces acting on the spine. Furthermore, the factors that exerted a positive impact on the success of therapy were registered.

RESULTS

Forty-four patients (88%) completed the study. Positive effects of the training were noted in both groups, but significantly better effects were observed in the group that performed sling training. A reduction of pain independent of the number of fractures, significantly reduced torques, and reduced muscle strength were registered.

CONCLUSIONS

Specific training programs helped to increase muscle strength and straightening the back thereby reducing the force needed on a permanent basis and decreasing torque in the spine. Sling training was more effective in that than traditional physiotherapy.

Influence of proprioceptive insoles on spinal curvature in patients with slight idiopathic scoliosis

PURPOSE

Proprioceptive insoles are known to influence the functions of posture and gait by modulations of the sensory structures at the sole of the foot. Literature has shown that they could improve the position of the upper-body in patients with postural complaints of the musculoskeletal system. The aim of this study was to evaluate the influence of proprioceptive insoles on the spinal curvature in patients with slight idiopathic scoliosis.

PATIENTS AND METHODS

Eighteen patients were included in this prospective, single-centre, randomized study. All patients needed to have a relevant growth potential and suffered from a slight idiopathic scoliosis. Two groups were used, where group 1 performed physiotherapy twice a week, whereas group 2 was additionally supplied with proprioceptive insoles. Patients underwent three-dimensional rasterstereography for back-shape analysis. Furthermore, a conventional x-ray imaging of the spine was performed at the beginning and 1 year later to document the curvatures.

RESULTS

There was no statistical difference in the Cobb angles, and in almost all parameters of the rasterstereography, there was no statistically significant change between and within both groups.

CONCLUSION

According to the results of this study, there was no evidence of any statistical significant effect of proprioceptive insoles on spinal curvature in patients with slight idiopathic scoliosis.

The Validity of Rasterstereography: A Systematic Review

To investigate and monitor the progression of scoliosis and other spinal deformities in patients following idiopathic scoliosis (IS), non-invasive and radiation-free techniques are recommended because of the need for repeated radiographs. In a clinical setting, spine parameters can be quickly, cheaply and easily assessed using rasterstereography (RS). To assess the validity of the radiation-free technique RS based on surface topography compared with radiographs. MEDLINE, the Cochrane Library and EMBASE were systematically searched for studies which investigate the validity of rasterstereography compared with x-ray measurements. Studies published between January 1, 1990 and July 31, 2013 in English, German and French were included. Studies dealing with magnetic resonance imaging were excluded. Twelve studies with 570 patients were included; these articles were published between 1990 and 2013. The majority of studies investigated patients with IS, but other spinal pathologies included were thoracic hyperkyphosis and Scheuermann’s disease. With regard to the quality assessment criteria for the included studies, three out of twelve studies were evaluated using a twelve point scale and two used a scale with eleven points. We conclude that RS facilitates clinical practice by analysing the spinal column. It is completely radiation-free and could help to monitor scoliosis progression.

The effect of simulating a leg-length discrepancy on pelvic position and spinal posture

[Purpose] The purpose of this study was to examine how a leg-length discrepancy contributes to the pelvic position and spinal posture. [Subjects and Methods] A total of 20 subjects (10 males, 10 females) were examined during different artificially created leg-length inequalities (0–4 cm) using a platform. The pelvic tilt and torsion and the sagittal deviation of the spine were measured using the rasterstereographic device formetric 4D. [Results] Changes in platform height led to an increase in pelvic tilt and torsion, while no changes in the spinal posture were found with the different simulated leg-length inequalities. [Conclusion] Our study showed that a leg-length discrepancy may cause pelvic deviation and torsion, but may not lead to kyphosis and lordosis. Therefore, we consider that an artificially created leg-length discrepancy has a greater effect on pelvic position than spine position.

Assessing kyphosis with SpineScan: another attempt to reduce our dependence on radiography

BACKGROUND CONTEXT

Kyphosis management is mainly conservative, with annual examinations to assess angular progression. This includes physical examination and usually long spine X-rays, notorious for ionizing radiation. Several nonradiological instruments have been devised for this, but none have become popular. SpineScan, a programmed digital inclinometer, has been proved effective for screening kyphoscoliosis.

PURPOSE

The aim of this study was to assess the accuracy of SpineScan in monitoring kyphosis.

STUDY DESIGN/SETTING

Prospective, observational, diagnostic accuracy study.

PATIENT SAMPLE

Twenty-eight subjects examined for kyphosis, with recent full-length lateral spine X-rays.

METHODS

Each subject was examined by two examiners. The technique involved the subject standing with arms flexed to 90° and then sliding the SpineScan from just below C7 to L2. Maximum X-ray kyphotic Cobb angle was compared with the SpineScan result. The study was institutional review board approved, and all patients signed an informed consent.

RESULTS

The mean Cobb angle of the 28 subjects on radiography was 51° ± 15°. The mean SpineScan angle of all trials of all examiners was 54° ± 12°. The difference between the two measurements was significantly different from zero (3.2° ± 9.4°, p<.0001) and not normally distributed. The difference was significantly affected by the Cobb angle, examiner, and interaction between Cobb and examiner (statistical significance for all p<.0001). Ninety-five percent confidence intervals for all examiners ranged between -16° and 22° and for separate examiners between -25° and 32°, far above the 5° preplanned error level.

CONCLUSIONS

The results demonstrated that there is significant error in monitoring kyphosis with SpineScan. Even for a more modest indication including replacing radiography with SpineScan on alternate visits, the measurement was not accurate enough. Future research is necessary to find a nonradiographic method of kyphosis follow-up, possibly using a digitalized modification of one of the described instruments.

Influence of non-traumatic thoracic and lumbar vertebral fractures on sagittal spine alignment assessed by radiation-free spinometry

Due to missing indications for specific diagnostics, the majority of non-symptomatic vertebral fractures are not diagnosed. This study shows the ability of radiation-free spinometry to assess sagittal spine parameters to raise suspicion for new non-traumatic thoracic and lumbar vertebral fractures and indicate specific diagnostics.

INTRODUCTION

The primary aim of this study was to investigate the accuracy of radiation-free spinometry to predict new non-traumatic vertebral fractures (VF) by the assessment of thoracic kyphosis (TK), lumbar lordosis (LL), and trunk inclination.

METHODS

Three hundred sixty-one patients (278 females and 83 males; age, 67.0 ± 8.6 years) were enrolled. In 86 women and 24 men, at least one non-traumatic VF was confirmed by radiography, MRI, and/or CT. Spinometry (video rasterstereography) was used to assess TK, LL, and trunk inclination. Receiver operating characteristic (ROC) and multivariate logistic regression analyses were performed to test the influence of age, sex, number, location, and grade of fractures on sagittal spine alignment.

RESULTS

TK, LL, and trunk inclination were associated with advancing age (p < 0.05). Patients with prevalent thoracic and lumbar VFs showed increased TK (p < 0.001), decreased LL (p < 0.001), and increased trunk inclination (p < 0.001) in comparison to patients without VFs. ROC analysis revealed that the combination of TK and LL presented with the best predictive accuracy to raise suspicion for new grade 2 or grade 3 VFs in the thoracic and the lumbar spine (AUC, 0.752-0.771). Odds ratio (OR) showed an increased risk for VFs with increased TK (OR, 1.05-1.11; p < 0.001) and LL (1.05-1.07; p < 0.001) in specified regions of interest. A TK <50° (sensitivity, 88-100 %; specificity, 23-25 %) and LL (78-92 %; 24-27 %) were considered as appropriate cutoffs for future screening.

CONCLUSION

Spinometry showed better predictive accuracy than historical height loss. Severe changes of TK and LL may help to raise suspicion of new VFs radiation-free and indicate proper diagnostics, such as radiographs, MRI, or CT.

The effect of simulating leg length inequality on spinal posture and pelvic position: a dynamic rasterstereographic analysis

INTRODUCTION

Leg length inequalities (LLI) are a common finding. Rasterstereography offers a non-invasive, contact-free and reliable method to detect the effects of LLIs on spinal posture and pelvic position.

MATERIALS AND METHODS

A total of 115 subjects were rasterstereographically examined during different artificially created leg length inequalities (5-15 mm) using a platform. The pelvic obliquity and torsion and the lateral and frontal deviation of the spine, as well as the surface rotation, were measured.

RESULTS

Changes in platform height led to an increase of the pelvic tilt and torsion. Only minor changes in the spinal posture were found by different simulated leg length inequalities.

CONCLUSIONS

Our study showed that there was a correlation between an artificial leg length inequality up to 15 mm and pelvic tilt or torsion, but only minor changes in the spinal posture were measured. Further studies should investigate the effects of greater leg length inequalities on spine and pelvis.

Patient evaluation in idiopathic scoliosis: Radiographic assessment, trunk deformity and back asymmetry

Progressive adolescent idiopathic scoliosis (AIS) produces specific signs and symptoms, including trunk and spinal deformity and imbalance, impairment of breathing function, pain, progression during adult life, and psychological problems, as a whole resulting in an alteration of the health-related quality of life. A scoliosis-specific rehabilitation program attempts to prevent, improve, or minimize these signs and symptoms by using exercises and braces as the main tools in the rehabilitation treatment. Patient evaluation is an essential point in the decision-making process and determines the selection of the specific exercises and the specifications of the brace design. However, this article is not addressed to scoliosis management. In this present article, a complete definition and discussion of radiological aspects, such as the Cobb angle, axial rotation, curve pattern classifications, and sagittal configuration, follow a short description of the three-dimensional nature of AIS. The relationship between AIS and growth is also discussed. There is also a section dedicated to the assessment of trunk deformity and back asymmetry. Other important clinical aspects, such as pain and disability, changes in other regions of the body, muscular balance, breathing function, and health-related quality of life, are not discussed in this present article.

Reliability and validity of 4D rasterstereography under dynamic conditions

Purpose of this study was to evaluate the reliability and validity of 4D rasterstereography under dynamic conditions. Therefore simulated anatomical fixed points on a wooden plate were measured during different movements. Seven different motion patterns in all three angles of space were evaluated. The simulated parameter trunk length was measured with an accuracy of 3.58 mm (SD±3.29 mm) and the dimple distance was detected with an accuracy of 0.88 mm (SD±1.04 mm). With this rasterstereographic prototype it is possible to examine dynamically the spinal posture with adequate accuracy.

The rasterstereographic-dynamic analysis of posture in adolescents using a modified Matthiass test

The Matthiass posture test is a clinical test to detect posture changes in children and adolescents. Aim of this study was to objectify this test using a dynamic rasterstereographic measuring device. We examined 31 healthy athletes during a modified Matthiass test with a dynamic rasterstereographic measuring system. Hereby the trunk inclination, kyphosis and lordosis angle were measured. The trunk inclination decreased by about 50% of the basic value just by raising the arms. Additional weight loads of only 5% body weight (bw) resulted in significant changes of the posture (lordosis and kyphosis angle) during this test. With this rasterstereographic measuring device it seems to be possible to determine spinal posture changes under dynamic conditions. The results suggest that additional weights of 5% bw during the Matthias-test are enough to create significant deviations in posture parameters, even in healthy subjects.

Improving excellence in scoliosis rehabilitation: A controlled study of matched pairs

OBJECTIVES

Physiotherapy programmes so far mainly address the lateral deformity of scoliosis, a few aim at the correction of rotation and only very few address the sagittal profile. Meanwhile, there is evidence that correction forces applied in the sagittal plane are also able to correct the scoliotic deformity in the coronal and frontal planes. So it should be possible to improve excellence in scoliosis rehabilitation by the implementation of exercises to correct the sagittal deformity in scoliosis patients. An exercise programme (physio-logic exercises) aiming at a physiologic sagittal profile was developed to add to the programme applied at the centre or to replace certain exercises or exercising positions.

MATERIAL AND METHODS

To test the hypothesis that physio-logic exercises improve the outcome of Scoliosis Intensive Rehabilitation (SIR), the following study design was chosen: Prospective controlled trial of pairs of patients with idiopathic scoliosis matched by sex, age, Cobb angle and curve pattern. There were 18 patients in the treatment group (SIR + physio-logic exercises) and 18 patients in the control group (SIR only), all in matched pairs. Average Cobb angle in the treatment group was 34.5 degrees (SD 7.8) Cobb angle in the control group was 31.6 degrees (SD 5.8). Age in the treatment group was at average 15.3 years (SD 1.1) and in the control group 14.7 years (SD 1.3). Thirteen of the 18 patients in either group had a brace. Outcome parameter: average lateral deviation (mm), average surface rotation ( degrees ) and maximum Kyphosis angle ( degrees ) as evaluated with the help of surface topography (Formetric-system).

RESULTS

Lateral deviation (mm) decreased significantly after the performance of the physio-logic programme and highly significantly in the physio-logic ADL posture; however, it was not significant after completion of the whole rehabilitation programme (2.3 vs 0.3 mm in the controls). Surface rotation improved at average 1.2 degrees in the treatment group and 0.8 degrees in the controls while Kyphosis angle did not improve in both groups.

DISCUSSION

The physio-logic programme has to be regarded as a useful 'add on' to Scoliosis Rehabilitation with regards to the lateral deviation of the scoliotic trunk. A longitudinal controlled study is necessary to evaluate the long-term effect of the the physio-logic programme also with the help of X-rays.

Raster stereography versus radiography in the long-term follow-up of idiopathic scoliosis

STUDY DESIGN

Raster-stereographic and radiographic evaluation of idiopathic scoliosis without braces in a retrospective longitudinal long-term follow-up study.

OBJECTIVE

To investigate the reliability and accuracy of raster stereography in comparison with radiography as the gold standard, using a longitudinal long-term study design in idiopathic scoliosis, to reduce the number of radiographs required during follow-up in scoliosis patients.

SUMMARY OF BACKGROUND DATA

It has been confirmed that raster stereography produces reliable data in patients with conservatively and surgically treated idiopathic scoliosis, up to a Cobb angle of 80 degrees. This means that the method can be used to replace radiography during the follow-up in these patients. However, no data have yet been published on the use of raster stereography in a longitudinal setting during a long-term follow-up period in comparison with radiography as the gold standard.

METHODS

Raster stereographs and digitized anterior-posterior radiographs of 16 patients with idiopathic scoliosis were studied retrospectively in a longitudinal study design, with a mean follow-up period of 8 years (range 3 to 10 y). Lateral vertebral deviation and vertebral rotation were measured between C7 and L4 using raster stereography and radiography, compared with Cobb angles, and correlated.

RESULTS

During the follow-up period, the Cobb angle increased on average by 13 degrees. The progression of lateral vertebral deviation measured using both techniques, and that of vertebral rotation measured with radiography, was greater than that of the Cobb angle, whereas that of raster-stereographic vertebral rotation was lower. However, there was an excellent correlation between the raster-stereographic and radiographic progression of these parameters (R2 >or=0.5). The mean difference between raster stereographs and radiographs was 3.21 mm for lateral vertebral deviation and 2.45 degrees for vertebral rotation.

CONCLUSIONS

Using the parameters of lateral vertebral deviation and vertebral rotation, raster stereography accurately reflects the radiographically measured progression of idiopathic scoliosis during the long-term follow-up, but these parameters are not directly comparable with the Cobb angle. In the follow-up of scoliosis patients, the authors would recommend a raster-stereographic examination every 3 to 6 months and a radiographic examination every 12 to 18 months only, provided that raster stereography does not show rapid deterioration of the scoliosis. The patient's radiation exposure can be reduced using this approach.

Acupucture in the treatment of scoliosis - a single blind controlled pilot study

Background

Today, acupuncture therapy is commonly used for pain control throughout the world, although the putative mechanisms are still unclear. A Pub Med search for the key words "Acupuncture" and "Scoliosis" reveals 3 papers only, not containing any results of studies designed for the treatment of scoliosis with the help of acupuncture. Because of this lack of trials especially designed for the treatment of scoliosis this pilot study has been performed.

Methods

24 girls undergoing in-patient rehabilitation, 14 – 16 years of age (at average 15,1 years, SD 0,74) with the diagnosis of an Adolescent Idiopathic Scoliosis (AIS) have agreed to take part in this controlled single blind crossover study. Average Cobb angle was 33 degrees (SD 9,2) ranging from 16 to 49 degrees. 10 of the girls had a thoracic, one a lumbar, 7 a double major and 6 a thoracolumbar curve pattern. The patients have been scanned with the Formetric^® surface topography measurement system before and after lying on the left side [L], before and after sham acupuncture [S] and before and after real acupuncture [R].

Results

For the whole group of patients no significant changes have been found during lying, sham acupuncture or real acupuncture. There were no differences between the patient groups with different curve pattern. In the explorative subgroup analysis of Patients with curvatures from 16 to 35 degrees, however significant changes in surface rotation have been found after R intervention as well as a strong differences in lateral deviation while in the L or S intervention no real changes have been achieved.

Conclusion

One session with real (verum) acupuncture seems to have an influence on the deformity of scoliosis patients with no more than 35 degrees. The findings during verum acupuncture clearly are different to sham acupuncture or just lying, while in the whole group of patients also including patients with curvatures of more than 35 degrees no obvious changes have been found. The results of this study justify further investigation of the effect of acupuncture in the treatment of patients with scoliosis.

Sagittal counter forces (SCF) in the treatment of idiopathic scoliosis: a preliminary report

BACKGROUND

In patients with idiopathic scoliosis (IS), reduced thoracic kyphosis and reduced lumbar lordosis frequently occur in correlation with the lateral spinal curvature. Normalization of the sagittal profile and hyper-correction of the deviation in frontal and coronal plane are the main issues of the latest concept of bracing. The purpose of this study was to investigate the influence of of sagittal counter forces (SCF) on the scoliotic deformity.

STUDY DESIGN

A case series of four patients with IS treated with two braces designed to improve the sagittal profile (Rigo-System-Chêneau-brace and with a sagittal counter force brace, SCF-brace).

METHODS

The short-term effect (30 min) of both braces was evaluated using surface topography (Formetric surface topography system, Diers International, Wiesbaden).

RESULTS

One patient (Cobb angle 92 degrees ) showed no short-term correction in the frontal and coronal planes; others (Cobb angles between 39 and 48 degrees ) exhibited valuable correction in frontal and coronal planes. There was no short-term correction in the sagittal plane for either brace.

CONCLUSION

The application of sagittal counter forces (SCF) seems to have similar short-term effects as 3D correction and should be addressed more in future concepts of scoliosis bracing.

Dysgnathia, orthognathic surgery and spinal posture

The aim of this study was to evaluate the spine by video rasterstereography before and after orthognathic surgery. Twenty-nine patients (17 patients with a skeletal class III, 7 patients with a skeletal class II, and 5 patients with mandibular asymmetry) were evaluated preoperatively and 1 year postoperatively. Video rasterstereography is a method of back surface measurement and shape analysis using the moire topography. Orthognathic surgery in cases of class III and asymmetry did not lead to significant changes in body posture. In class II patients it led to some changes in body posture, but without orthopaedic consequences. It is concluded that orthognathic surgery causes minimal or no change in body posture.

Spontaneous correction and derotation of secondary curves after selective anterior fusion of idiopathic scoliosis

STUDY DESIGN

Clinical, rasterstereographic, and radiographic evaluation of spontaneous vertebral derotation of secondary curves in idiopathic scoliosis following selective anterior correction and fusion of the primary curve.

OBJECTIVE

To quantify spontaneous vertebral derotation in secondary curves after selective anterior correction with attention to cosmetic outcome.

SUMMARY OF BACKGROUND DATA

While the derotational effect of anterior instrumentation techniques on the instrumented curve is well understood, there is a paucity on data of the rotational behavior of the noninstrumented secondary curves.

METHODS

A total of 43 patients with idiopathic scoliosis (16 with thoracic curves in group 1 and 27 with thoracolumbar/lumbar curves in group 2) underwent selective anterior instrumentation. Vertebral rotation was analyzed before surgery and, on average, 20 months after surgery using digital radiometric rotation analysis, back shape analysis with rasterstereography, and scoliometer measurement.

RESULTS

In Group 1, there was a significant spontaneous vertebral derotation of the secondary lumbar curves by 14.2% (range from 12.7 degrees to 10.9 degrees) in the digital radiometric rotation analysis, surface derotation amounted to 49% (range from 9.6 degrees to 4.9 degrees) in the rasterstereography, and to 70% in the clinical scoliometer measurement (range from 8.0 degrees to 2.4 degrees ). In group 2, there was an increase of rotation of the noninstrumented secondary thoracic curves by 30% (range from 5.0 degrees to 6.5 degrees ) in digital radiometry, by 32.9% in the rasterstereography (range from 8.5 degrees to 11.3 degrees), and a 28.3% increase in scoliometer measurement (range from 6.0 degrees to 7.7 degrees).

CONCLUSION

Selective anterior instrumentation and fusion of primary thoracic curves results in satisfactory spontaneous vertebral and high surface derotation of the secondary lumbar curves. However, in primary thoracolumbar or lumbar curves, an increase of both vertebral and surface rotation of the secondary thoracic curve was noted. This increase can impair cosmetic outcome.

The influence of right anterolateral thoracotomy in prepubescent female patients on late breast development and on the incidence of scoliosis

BACKGROUND

It is assumed that a right anterolateral thoracotomy for correction of simple congenital cardiac defects (ie, atrial septal defect) achieves more favorable cosmetic results than a standard median sternotomy.

METHODS

Ninety-five patients, 72 with right anterolateral thoracotomy and 23 with median sternotomy, who had corrective transatrial operations when they were younger than 12 years of age were contacted by questionnaire. The mean follow-up time was 23.1 years. Of these, 61 patients (46 thoracotomy and 15 sternotomy) were investigated clinically. Volume differences of the breasts were measured by 3-dimensional surface scanning. By using photographs of the upper chest, breast symmetry was described by an index. The degree of scoliosis was measured by clinical examination.

RESULTS

According to the questionnaire analysis, 76% (thoracotomy group) versus 39% (sternotomy group) thought that the cosmetic result was excellent (P =.008). Breast volume measurement showed a volume difference greater than 20% (left side larger than right) in 55% (thoracotomy) versus 0% (sternotomy). With our index, asymmetry in the lower part of the right breast occurred in 61% (thoracotomy) versus 0% (sternotomy; P <.001). A total of 6.6% of the patients had scoliosis, without any differences between groups.

CONCLUSIONS

Because our long-term follow-up in prepubescent female patients after right anterolateral thoracotomy revealed significantly impaired unilateral breast development, we propose to abandon right anterolateral thoracotomy in this subgroup of patients, although the subjective satisfaction with the cosmetic result was high. To avoid potential damage of future breast tissue, other surgical approaches, such as right posterior thoracotomy, should be considered. According to the orthopedic investigation, the surgical approach does not cause a higher rate of scoliosis.

Rasterstereographic back shape analysis in idiopathic scoliosis after posterior correction and fusion

OBJECTIVE

To determine the accuracy of rasterstereographic three-dimensional back surface analysis and reconstruction of the spine in idiopathic scoliosis treated by posterior correction and fusion.

DESIGN

Prospective imaging study of 25 patients with idiopathic scoliosis who underwent posterior correction and fusion and were followed for one year.

BACKGROUND

In an earlier study published in this journal rasterstereography has proved to be an accurate imaging modality for quantifying the changes in the three-dimensional shape of the spine and posterior rib cage after anterior correction and fusion. Goal of the present study was to determine the accuracy for the more common posterior correction and fusion with attention paid to the presence of the posterior implants and scarring.

METHODS

Twenty-five patients with idiopathic scoliosis with maximum Cobb angles of 78 degrees were examined by rasterstereography and radiography. Seventy-one anterior-posterior radiographs were digitised. Twenty-four were preoperative and 47 postoperative radiographs. Rasterstereographic and radiographic curves were compared by best-fit superimposition. Root-mean-square differences were calculated as parameters of accuracy.

RESULTS

The accuracy of rasterstereography in severe idiopathic scoliosis with Cobb angles between 48 degrees and 78 degrees was satisfactory with root-mean-square differences of 5.8 mm for the lateral deviation and 4.8 degrees for vertebral rotation. Following posterior correction the accuracy was good. The root-mean-square difference was 4.5 mm for the lateral deviation and 4.3 degrees for vertebral rotation.

CONCLUSION

The accuracy obtained for posteriorly-operated scolioses between 50 degrees and 80 degrees was similar to the findings for scolioses operated via anterior approach, as well as those with curves up to 50 degrees Cobb angle. Therefore rasterstereography can be used postoperatively to reduce the number of radiographs and radiation exposure. Additionally, the method provides an objective quantification of the postoperative improvement in the cosmesis of the back shape.

RELEVANCE

In the treatment of severe idiopathic scoliosis rasterstereography provides both a considerable reduction of X-rays and an objective documentation of the cosmesis before after scoliosis surgery.

Rasterstereographic back shape analysis in idiopathic scoliosis after anterior correction and fusion

OBJECTIVE

To determine the accuracy of rasterstereographic three-dimensional back surface analysis and reconstruction of the spine in cases of severe idiopathic scoliosis treated by anterior correction and fusion.

DESIGN

Comparison of digitized radiographic curves and rasterstereographic curves by best fit superimposition and calculation of root mean square differences as parameters of similarity.

BACKGROUND

Rasterstereography has been proven to be accurate in scoliosis up to 50 degrees Cobb angle. Since 1989 the device is in clinical routine use for non-operatively treated patients and reduces the need for otherwise indispensable radiographs significantly.

METHODS

Fifty two patients with severe idiopathic scoliosis with Cobb angles up to 88 degrees were examined rasterstereographically and radiographically. Forty eight pre-operative anterior-posterior radiographs and 101 post-operative anterior-posterior radiographs were digitized. Radiographic and rasterstereographic curves were compared and the root mean square differences were calculated as parameters of precision of rasterstereographic reconstruction.

RESULTS

Accuracy of rasterstereography in idiopathic scoliosis with Cobb angles between 50 degrees and 88 degrees is satisfactory. The root mean square difference of the radiographic and rasterstereographic curves was 6.4 mm for lateral deviation and 4.5 degrees for vertebral rotation. After anterior scoliosis surgery the precision of the device is good. The root mean square difference for lateral deviation was 3.4 mm and 3.2 degrees for rotation. Considering both groups an average root mean square of 4.7 mm and 3.7 degrees was calculated.

CONCLUSIONS

Accuracy in severe scoliosis up to 88 degrees Cobb angle was satisfactory. The results of this first evaluation of surgically treated severe scoliosis showed a good accuracy after anterior surgery. The system can be used for post-operative follow up examinations and may reduce the number of X-rays considerably. In contrast to radiography, CT or MRI rasterstereography provides an objective quantification and documentation of the post-operative cosmetic improvement of the back shape in standing posture. RELEVANCE STATEMENT: Based on the findings of this study rasterstereography in future enables both objective quantification of cosmetic improvement and significant reduction of X-rays in idiopathic scoliosis with Cobb angles higher than 50 degrees before and after anterior surgical correction and fusion.