Skeletally Immature Patients With Adolescent Idiopathic Scoliosis Curves 15°-24° Are at High Risk for Progression

Outcomes for nighttime bracing in adolescent idiopathic scoliosis based on brace wear adherence

BACKGROUND

This study determined brace wear adherence for patients treated with nighttime braces and evaluated the effect of brace adherence on curve progression.

METHODS

One hundred twenty-two patients with AIS ages 10-16 years, Risser stages 0-2, major curves 20°-40° treated with Providence nighttime braces prescribed to be worn at least 8 h per night were prospectively enrolled and followed until skeletal maturity or surgery. Brace adherence was measured using iButton temperature sensors after 3 months of brace initiation and at brace discharge.

RESULTS

Curve types were single thoracolumbar/lumbar (62%, n = 76), double (36%, n = 44), and single thoracic (2%, n = 2). Brace adherence averaged 7.8 ± 2.3 h after 3 months (98% adherence) and 6.7 ± 2.6 h at brace discharge (84% adherence). Curves that progressed ≥ 6° had decreased brace adherence than non-progressive curves after 3 months (7.0 h vs. 8.1 h, p = 0.010) and at brace discharge (5.9 h vs. 7.1 h, p = 0.017). Multivariate logistic regression analysis showed that increased hours of brace wear [odds ratio (OR) 1.23, 95% confidence interval (CI) 1.06-1.46], single curves (OR 3.11, 95% CI 1.35-7.53), and curves < 25° (OR 2.61, 95% CI 1.12-6.44) were associated with non-progression at brace discharge.

CONCLUSIONS

Patients treated with nighttime bracing have a high rate of brace adherence. Lack of curve progression is associated with increased brace wear. Nighttime bracing is effective at limiting curve progression in AIS single thoracolumbar/lumbar and double curves.

LEVEL OF EVIDENCE

Prognostic Level 2.

Using the Proximal Femur Maturity Index at Brace Initiation for Adolescent Idiopathic Scoliosis Predicts Curve Progression Risk

BACKGROUND

The Proximal Femur Maturity Index (PFMI) can be used to assess skeletal maturity on existing whole-spine radiographs without additional radiation. However, the relationship between the PFMI at the initiation of bracing for adolescent idiopathic scoliosis (AIS) and subsequent curve progression remains unknown. This study aimed to investigate the relationship between the PFMI and curve progression, and the predictability of risks to adulthood curve progression and surgical thresholds based on the PFMI grade at brace initiation.

METHODS

This was a prospective study of 202 patients with AIS who were prescribed underarm bracing according to the Scoliosis Research Society criteria and had good brace-wear compliance. The patients were followed from brace initiation until complete skeletal maturity. Longitudinal data on the coronal Cobb angle and skeletal maturity assessments using Risser staging, Sanders staging, the distal radius and ulna classification, and the PFMI were collected. Each patient was assessed on whether the major curve progressed to ≥40° (adulthood deterioration) and ≥50° (the surgical threshold). Logistic regressions were used to predict probabilities of curve progression to the 2 thresholds, adjusted for factors that were significant in univariate analyses.

RESULTS

The PFMI correlated with the other skeletal maturity indices (r s [Spearman rank correlation] = 0.60 to 0.72, p < 0.001 for all). The pre-brace PFMI grade correlated with progression to ≥40° (r rb [rank-biserial correlation] = -0.30, p < 0.001) and to ≥50° (r rb = -0.20, p = 0.005). Based on regression models (p < 0.001) adjusted for the pre-brace major Cobb angle and curve type, brace initiation at PFMI grades 2 and 3 for a curve of ≥30° had predicted risks of 30% (95% confidence interval [CI], 4% to 55%) and 12% (95% CI, 7% to 17%), respectively, for progression to the surgical threshold. Brace initiation at PFMI grade 5 had 0% progression risk.

CONCLUSIONS

The PFMI can be used for predicting curve progression and prognosticating brace outcomes in AIS. Patients with brace initiation at PFMI grade 4 for a curve of <30° or at grade 5 were unlikely to progress to the adulthood deterioration or surgical threshold. In comparison, skeletally immature patients initiating bracing at a PFMI grade of ≤3 for a major curve of ≥30° had a higher risk of progression despite compliant brace wear.

LEVEL OF EVIDENCE

Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

The Clinical and Imaging Outcome of the Tandem Growing Rod Technique in Early-Onset Scoliosis With the Proximal Upper Thoracic Curve Progression: A Modified Technique of Growing Rod

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The orthopaedic ability of traditional GR for severe EOS is limited. The proximal upper thoracic curve may progress during the lengthening procedure, which may lead to coronal imbalance and inhibit the longitudinal growth of the spine. In this retrospective cohort study, we investigated the clinical outcome of tandem GR.

METHODS

We modified the traditional technique by using two groups of GR devices to control the major and the proximal upper thoracic curve, connected the two groups of GR in series, and named it tandem GR. The clinical and imaging outcomes of the new technique were evaluated and compared with traditional technique.

RESULTS

Twenty one patients were enrolled in the tandem GR group, and 30 patients were treated with traditional GR as the control. The baseline parameters were consistent between the two groups. In the tandem GR group, the secondary curve progressed from 24.9 ± 3.9° to 31.4 ± 3.2° (P = .006) in the procedure with the traditional GR and improved to 18.4 ± 4.5° (P = .001) after the switch. Meanwhile, the clavicular angle aggravated from 1.6 ± 1.0° to 2.6 ± .7° (P = .041), and improved to 1.7 ± .8° after changed to the tandem GR (P = .033). At the final of the follow-up, the secondary curve was higher in the control group (27.1 ± 8.3° vs 18.4 ± 4.5°, P = .034), the clavicle angle was 2.4 ± 1.1° in control and 1.7 ± .8° in the tandem GR group (P = .028), the T1-S1 height was 28.2 ± 4.8 cm in the control and 33.3 ± 3.0 cm in the tandem GR group (P = .027). The average growth rate was 1.0 ± .3 cm/year in the control and 1.2 ± .4 cm/year in the tandem GR group (P = .046).

CONCLUSION

Tandem GR can effectively improve the proximal upper thoracic curve progression during the treatment of EOS. Compared with the traditional GR, tandem GR can achieve better curve correction, better shoulder balance, and retains more capacity for longitudinal spine growth.

Effect of sling exercise combined with Schroth therapy on adolescents with mild idiopathic scoliosis: A twelve-week randomized controlled trial

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is the most common structural deformity of the spine during adolescence, which could cause varying degrees of physical and mental damage to patients. Schroth therapy and sling exercise are widely used in the treatment of patients with AIS currently, and have shown the significant therapeutic effect relatively.

OBJECTIVE

To observe the efficacy of sling exercise combined with Schroth therapy on adolescents with mild idiopathic scoliosis (MIS).

METHODS

Sixty patients with AIS were randomly divided into the Schroth+sling group (n= 31) and the Schroth group (n= 29). Patients in both groups received Schroth therapy, and sling exercise was added in the Schroth+sling group. Before and after 12 weeks of treatment, the Cobb angle, angle of trunk rotation (ATR), Scoliosis Research Society-22 (SRS-22) scale score and averaged electromyography (AEMG) of bilateral paraspinal muscles were evaluated.

RESULTS

After the treatment, Cobb angle, ATR in both groups were decreased compared with those before (P< 0.001), and the decrease in the Schroth+sling group was more obvious (P< 0.05). The AEMG of bilateral paraspinal muscles and the total score, posture, mental health of SRS-22 of the two groups improved compared with those before treatment (P< 0.05), and the Schroth+sling group had a significant improvement than the Schroth group (P< 0.05).

CONCLUSION

Schroth therapy improved the degree of scoliosis, torticollis, quality of life, and bilateral paraspinal strength on adolescents with mild idiopathic scoliosis. The effect was more pronounced when the sling exercise was included in the treatment regimens.

Early brace treatment for idiopathic scoliosis may change the paradigm to improve curves

PURPOSE

This study evaluated whether early brace treatment of curves < 25° decreased the prevalence of curve progression and surgery.

METHODS

In a retrospective review, patients with idiopathic scoliosis Risser stages 0 to 2 braced at < 25° were followed until brace discontinuation, skeletal maturity, or surgery. Patients with predominantly primary thoracolumbar/lumbar curves were prescribed nighttime braces (NTB) and thoracic curves were prescribed fulltime braces (FTB). Comparisons were made for TLSO type (NTB vs. FTB) and triradiate cartilage (TRC) status (open vs. closed) at brace prescription.

RESULTS

283 patients were included, 81% who were Risser stage 0 with curves averaging 21.8° ± 2.1° at brace prescription. The average curve change was 2.4° ± 11.2°. Curves improved ≥ 6° in 23% of patients. Patients who were not skeletally mature at brace discontinuation (n = 39) had lower Cobb angles (16.7° vs. 23.9°, p < 0.001), better curve improvement (- 4.7° vs. 2.1°, p < 0.001), and were braced for a shorter period of time (1.8 years vs. 2.3 years, p = 0.011) than those who were skeletally mature at brace discontinuation (n = 239). Only 7% of patients in NTB and 8% of patients in FTB with open TRC required surgery. The numbers needed to treat to prevent surgery in patients in FTB with open TRC was calculated to be 4.

CONCLUSION

Early brace treatment (Cobb < 25° and open TRC) may not only reduce curve progression and the need for surgical treatment but may also result in curve improvement, thus challenging the paradigm that the goal of bracing is merely to stop curve progression.

LEVEL OF EVIDENCE

3-retrospective cohort study.

News in paediatric orthopaedic surgery: an overview of the latest advances in paediatric orthopaedics and traumatology (2020-2023)

PURPOSE

We propose to survey - even if arbitrarily - the publications in paediatric orthopaedics and traumatology that have had the greatest impact on the specialty during the period extending from the beginning of the COVID-19 pandemic in December 2020 and the end of all health restrictions in March 2023.

METHODS

Only studies with a high level of evidence or clinical relevance were selected. We briefly discussed the results and conclusions of these quality articles to situate them in relation to the existing literature and current practice.

RESULTS

Publications are presented by dividing traumatology and orthopaedics whose publications are further subdivided according to anatomical districts; articles concerning neuro-orthopaedics, tumours, and infections were presented separately while sports medicine is jointly presented with knee-related articles.

CONCLUSIONS

Despite the difficulties encountered during the global COVID-19 pandemic (2020-2023), orthopaedic and trauma specialists, including paediatric orthopaedic surgeons, have maintained a high level of scientific output, in terms of quantity and quality of production.

The Addition of Daytime Physiotherapeutic Scoliosis-specific Exercises to Adolescent Idiopathic Scoliosis Nighttime Bracing Reduces Curve Progression

BACKGROUND

The effectiveness of physiotherapeutic scoliosis-specific exercises (PSSE) in addition to nighttime bracing compared with nighttime bracing alone is unknown. The purpose of this prospective comparative study was to evaluate the effectiveness of PSSE in skeletally immature patients with adolescent idiopathic scoliosis treated with nighttime bracing (PSSE group) compared with the standard of care of nighttime bracing alone (control group).

METHODS

Patients with adolescent idiopathic scoliosis thoracolumbar or lumbar primary curves <35 degrees at Risser stage 0 who wore a Providence brace were prospectively enrolled into the PSSE or control group. A temperature sensor recorded the number of hours of brace wear. The PSSE group was instructed in the Schroth-based physical therapy method and a home exercise program for at least 15 minutes per day, 5 days per week, for 1 year.

RESULTS

Seventy-four patients (37 PSSE, 37 controls) were followed until the final visit of skeletal maturity or surgery. The PSSE and control groups had similar baseline Cobb angles (24 vs. 25 degrees) and average hours of brace wear (8.0 vs. 7.3 h). The PSSE group had no change in curve magnitude at the final visit compared with curve progression in the control group (1 vs. 7 degrees, P <0.01). Furthermore, the PSSE group had a lower rate of curve progression >5 degrees at the final visit (14% vs. 43%, P <0.01). The PSSE group also had less conversion to full-time bracing after 1 year (5% vs. 24%, P =0.046), but differences were no longer significant at the final visit (14% vs. 27%).

CONCLUSIONS

In this prospective series of patients in nighttime Providence braces, the addition of Schroth-based physical therapy reduced curve progression after 1 year and at skeletal maturity. These findings can educate motivated families interested in PSSE.

LEVEL OF EVIDENCE

Level II.

A United States multi-site randomized control trial of Schroth-based therapy in adolescents with mild idiopathic scoliosis

PURPOSE

The purpose of this study was to determine the feasibility and efficacy of a United States multi-site randomized control trial (RCT) of the Schroth-based therapy program in Risser 0 patients with mild adolescent idiopathic scoliosis (AIS) curves.

METHODS

Six sites enrolled 98 Risser 0 patients with single AIS curves between 12° and 24°. Patients were randomized to Exercise:Control group in a 2:1 ratio. Exercise group patients were instructed on the Schroth-based method and a home exercise program of 75 min/week for 1 year.

RESULTS

Enrollment across 6 institutions averaged 2.2 patients per month over 45 months. Patient attrition was 42% after 1 year (41/98) and 52% after 2 years (51/98). Exercise group patients were significantly younger (11.6 vs 12.5 years) without differences in the baseline Cobb angle (16.2° vs 17.1°). Self-reported exercise adherence averaged 82% at 6 months and 63% at 1 year (n = 35). A significantly lower frequency of patients was braced in the Exercise group after 1 year (26% vs 55%, p = 0.03) but not after 2 years (48% vs 63%, p = 0.31). Curve magnitude changes between groups were not significant after 1 and 2 years.

CONCLUSION

Performing a multi-site RCT for mild AIS in the United States is challenging with slow enrollment and high attrition. Young patients with small curves have difficulty adhering to the intensive demands of Schroth-based therapy.

LEVEL OF EVIDENCE

II.

Adolescent Idiopathic Scoliosis for Pediatric Providers

Adolescent idiopathic scoliosis occurs in 2% to 3% of the adolescent population, affecting people between ages 10 and 16 years. Scoliosis onset is usually earlier in girls than in boys-generally occurring between ages 10 and 14 years for girls and 12 and 16 years for boys. The cause of idiopathic scoliosis is unknown. It is probably multifactorial. Much of the research on the etiology has focused on connective tissue abnormalities, nutritional deficiency, and genetic factors. [Pediatr Ann. 2022;51(9):e364-e369.].

Scoliosis and Prognosis-a systematic review regarding patient-specific and radiological predictive factors for curve progression

INTRODUCTION

Idiopathic scoliosis, defined as a > 10° curvature of the spine in the frontal plane, is one of the most common spinal deformities. Age, initial curve magnitude and other parameters define whether a scoliotic deformity will progress or not. Still, their interactions and amounts of individual contribution are not fully elaborated and were the aim of this systematic review.

METHODS

A systematic literature search was conducted in the common databases using MESH terms, searching for predictive factors of curve progression in adolescent idiopathic scoliosis ("adolescent idiopathic scoliosis" OR "ais" OR "idiopathic scoliosis") AND ("predictive factors" OR "progression" OR "curve progression" OR "prediction" OR "prognosis"). The identified and analysed factors of each study were rated to design a top five scale of the most relevant factors.

RESULTS

Twenty-eight investigations with 8255 patients were identified by literature search. Patient-specific risk factors for curve progression from initial curve were age (at diagnosis < 13 years), family history, bone mineral status (< 110 mg/cm³ in quantitative CT) and height velocity (7-8 cm/year, peak 11.6 ± 1.4 years). Relevant radiological criteria indicating curve progression included skeletal maturity, marked by Risser stages (Risser < 1) or Sanders Maturity Scale (SMS < 5), the initial extent of the Cobb angle (> 25° progression) and curve location (thoracic single or double curve).

DISCUSSION

This systematic review summarised the current state of knowledge as the basis for creation of patient-specific algorithms regarding a risk calculation for a progressive scoliotic deformity. Curve magnitude is the most relevant predictive factor, followed by status of skeletal maturity and curve location.

Intervention versus Observation in Mild Idiopathic Scoliosis in Skeletally Immature Patients

Introduction:

Observation is the treatment of choice for idiopathic scoliosis with Cobb angles between 15 degrees - 20 degrees in growing children. This passive approach does not address the anxiety of the patient and the stress of the parents. In this paper, we attempt to identify skeletally immature patients with mild scoliosis curvatures that are more at risk of progression and propose possible intervention for this group of subjects.

Methods:

The literature was searched in Pubmed, and additional references were searched manually in the literature.

Results:

Many studies have shown that low serum 25[OH]D level, bone mineral density (BMD), and body mass index (BMI) are related to the curve severity or progression of the curve.

We suggest that skeletally immature patients (< Risser 2) with mild curves be divided into two groups, viz. Group O (observation) with a lower risk of progression, and Group I (intervention) with a higher risk of curvature progression. We propose early intervention for the latter group.

It is suggested that pre-menarcheal, skeletally immature patients with mild idiopathic scoliosis, and low vitamin D, BMD, and BMI should be treated. Also, asymmetric foot biomechanics should be addressed, although nutrition and foot orthoses are regarded to have no role in the management of idiopathic scoliosis. The outcome of early intervention may be utterly different from late treatment when the curvature becomes more structural, and the patient more skeletally mature.

Conclusion:

Research is required to prove if the intervention is clinically indicated.