Curve Progression In Patients Research Articles

Anterior Scoliosis Correction in Immature Patients with Idiopathic Scoliosis

The current standard of care for skeletally immature patients with progressive scoliosis measuring >25° is a thoracolumbosacral orthosis. Recent evidence has established the efficacy of bracing in halting curve progression in patients with curves measuring 20°-40°. However, issues surrounding psychosocial impact, compliance, and the efficacy of bracing in larger curves remain. In patients with significant growth remaining, anterior growth modulation surgery has been established as a unique and promising alternative. Using a patient׳s remaining growth, vertebral body stapling and vertebral body tethering (VBT) exert compressive forces along the convexity of the deformity to wield control over coronal curvatures. Extensive preclinical studies have established the biomechanical foundation for stapling and tethering, and while clinical reports are still few, initial data have shown these procedures to be a promising treatment option in select patients. Vertebral body stapling is best employed for smaller, more flexible curves in younger patients, primarily as an alternative to bracing (thoracic curves

Spinal growth velocity versus height velocity in predicting curve progression in peri-pubertal girls with idiopathic scoliosis.

BackgroundHeight velocity (HV) is traditionally used to monitor the residual growth potential in idiopathic scoliosis (IS). The temporal timing of rapid increase in standing height often does not match exactly that of the increase in spine height. The purposes of this study were to analyze the correlation between change of angle velocity (AV) vs the changes of spinal growth velocity (SGV) and HV, and the associated predictive value on curve progression in IS.MethodsPre-pubertal IS girls with single curve receiving standardized bracing treatment followed longitudinally with documented curve progression >5° were retrospectively reviewed. The age, standing height, Cobb angle (main curve), spinal length, Risser sign, HV, SGV and AV at each visit were measured and calculated. The visit with the highest AV value of each patient was selected for the final analysis and correlated with the corresponding peak height velocity (PHV) and peak spinal growth velocity (PSGV).ResultsSixty-two IS girls were reviewed. Chi-square test revealed PSGV contributed more to the highest AV than PHV (P = 0.001). Pearson correlation analysis demonstrated that AV was correlated with SGV (r = 0.454, P < 0.001) and HV (r = 0.280, P = 0.027). Multiple linear regression analysis showed that high AV was better predicted by higher SGV (B = 0.321, P = 0.007) rather than higher HV (B = 0.259, P = 0.362) (R = 0.467).ConclusionsVariations of spinal growth velocity exerted more direct influence over changes in angle velocity as compared with height velocity. High spinal growth velocity predisposed to more rapid curve progression in patients with idiopathic scoliosis.

An Independent Evaluation of the Validity of a DNA-Based Prognostic Test for Adolescent Idiopathic Scoliosis.

ScoliScore is a DNA-based prognostic test, designed and used to help to predict the risk of curve progression in patients with adolescent idiopathic scoliosis. The role of this test in clinical practice remains unclear as the published results of the ScoliScore have not been validated independently. The purpose of this study was to determine if the ScoliScore effectively predicted the risk of curve progression in patients with mild and moderate adolescent idiopathic scoliosis in two urban academic medical centers. One hundred and twenty-six patients with adolescent idiopathic scoliosis who met inclusion criteria at two centers were administered the ScoliScore test. Two groups were created: a progression group (those who had a Cobb angle of >40° or those who had undergone surgical fusion) and a non-progression group (those who had skeletal maturity without curve progression to 40°). ScoliScore values and risk levels were compared between the two groups. The negative predictive value was calculated for low-risk scores and the positive predictive value was calculated for high-risk scores. There was no significant difference (p = 0.706) in the mean ScoliScore (and standard deviation) between patients with curve progression (107 ± 55 points) and those without curve progression (102 ± 62 points). There was also no significant difference (p = 0.399) in curve progression between patients with high-risk scores (26.7%) and those with low-risk scores (12.9%). The positive predictive value of the test was 0.27 (95% confidence interval, 0.09 to 0.55), and the negative predictive value was 0.87 (95% confidence interval, 0.69 to 0.96). ScoliScores and rates of progression were not affected by brace-wear. ScoliScores did not differ between patients with and without curve progression, and the negative and positive predictive values were lower in our study than in the previously published validation study by the developers of the test. This may be due to differences in our test population, genetic variability, or failure of patients in the non-progression group to follow up.

Significance of peak height velocity as a predictive factor for curve progression in patients with idiopathic scoliosis.

BackgroundMuch attention has been paid to peak height velocity (PHV) as a possible predictor of curve progression in patients with idiopathic scoliosis (IS). The aim of this study was to analyze the relationship between the magnitude of the Cobb angle at PHV and scoliosis progression, defined as having surgery prior to skeletal maturity in female patients with IS.MethodsA retrospective review identified 56 skeletally immature female IS patients who were followed until maturity. The mean age and the mean pubertal status at the initial visit were 10 years and 24 months before menarche respectively, with a follow-up period of 5 years. They were divided into two groups: non-surgery group (NS) and surgery group (S), depending on their treatment method in use at the final follow-up visit. Surgery group was defined as an ultimately having surgery due to Cobb angle greater than 45 degrees prior to skeletal maturity regardless of conservative management. Height measurements were recorded at each visit; height velocity was calculated as the height change, in cm, divided by the time interval, in years. The PHV, chronological age at PHV (APHV), height at PHV (HPHV), and final height (FH) were determined for each group. In patients with Cobb angle greater than 30 degrees, the corrected height was calculated by Kono formula and corrected height velocity values were provided. The sensitivity, specificity, and area under the curve (AUC) of the receiver-operating -characteristic (ROC) analysis were calculated to predict spinal curve progression for various Cobb-angle cutoff values at PHV.ResultsThe corrected PHV had a mean value of 8.5 and 8.9 cm/year in the NS-group and S-group, respectively. The APHV was 11.9 and 11 years, the corrected HPHV was 152.9, and 149.3 cm, and the corrected FH was 159.9 and 159.3 cm, respectively. When a Cobb angle of 31.5 degrees was at PHV, ROC analysis revealed 78% sensitivity, 82% specificity, and an AUC of 0.93, acceptable values for curve progression in patients with IS.ConclusionsThese findings indicate that 31.5 degrees of spinal curvature when patients are at PHV is a significant predictive indicator for progression of the curve to a magnitude requiring surgery. We suggest that the curve-progression risk assessment in patients with IS should include PHV, along with measures of skeletal and non-skeletal maturities.

Significance of peak height velocity as a predictive factor for curve progression in patients with idiopathic scoliosis

Significance of peak height velocity as a predictive factor for curve progression in patients with idiopathic scoliosis

Review of current technologies and methods supplementing brace treatment in adolescent idiopathic scoliosis

To report on the current technologies and methods supplementing brace treatment in adolescent idiopathic scoliosis. A comprehensive literature review was performed to determine the effectiveness of bracing, to report on imaging techniques that can assist in the assessment of bracing, to understand the roles of the biomechanical treatment concepts on bracing and to address the importance of the quality of life of the brace wearers. The effectiveness of bracing still remains controversial. Many technologies are still in development to improve the bracing process and quantify the effects of bracing. Imaging techniques with decreased or no radiation are promising in providing more frequent data on curve progression for patients. Computer-assisted design models have been used for both fitting and manufacturing the brace to patient contours. Ultrasound has been developed as a new means of diagnosing scoliosis and determining the effects of a brace on a patient's spine in real time. The brace treatment outcomes are correlated to the quantity and the quality of brace usage. Compliance monitors and force sensors have been developed to track the quality of brace usage. Improvements to brace wear also require consideration of patient quality of life. Surveys have been developed to describe the effects of family influence and self-image on bracing effectiveness of patient quality of life. Bracing remains a highly qualitative process, relying on the empirical judgment of the physicians and orthotists, along with buy-in with the patient. The suggested improvements will help to push bracing into a more evidence-based practice.

Quantitative Ultrasound for Predicting Curve Progression in Adolescent Idiopathic Scoliosis: A Prospective Cohort Study of 294 Cases Followed-Up Beyond Skeletal Maturity

Adolescent idiopathic scoliosis (AIS) is prevalent among adolescents and can carry significant morbidities. We evaluated the use of quantitative ultrasound (QUS) for predicting curve progression in patients with AIS. We recruited 294 girls with AIS at a mean age of 13.4 years, and they were prospectively followed beyond skeletal maturity for curve progression. We recorded 3 calcaneal QUS measurements at baseline, namely broadband ultrasound attenuation (BUA), velocity of sound (VOS), and stiffness index (SI). Logistic regression analysis indicated that SI, age, menarchal status, and Cobb angle were significant prognostic factors to be included in the final prediction model. The adjusted odds ratio of curve progression for Z-score of SI≦0 was 2.00 (95% CI: 1.08–3.71). The area under the ROC curve was 0.831 (95% CI: 0.785–0.877). The results of this study indicate that SI was an independent and significant prognostic factor for AIS and could be considered in addition to other prognostic factors when estimating the risk for curve progression and planning treatment for patients with AIS.

Brace Wear Control of Curve Progression in Adolescent Idiopathic Scoliosis

The efficacy of brace treatment for patients with adolescent idiopathic scoliosis remains controversial, and effectiveness remains unproven. We accurately measured the number of hours of brace wear for patients with this condition to determine if increased wear correlated with lack of curve progression. Of 126 patients with adolescent idiopathic scoliosis curves measuring between 25 degrees and 45 degrees , 100 completed a prospective study in which they were managed with a Boston brace fitted with a heat sensor that measured the exact number of hours of brace wear. Orthopaedic teams prescribed either sixteen or twenty-three hours of brace wear and were blinded to the wear data. At the completion of treatment, the number of hours of brace wear were compared with the frequency of curve progression of > or =6 degrees and with curve progression requiring surgery. The total number of hours of brace wear correlated with the lack of curve progression. This effect was most significant in patients who were at Risser stage 0 (p = 0.0003) or Risser stage 1 (p = 0.07) at the beginning of treatment and in patients with an open triradiate cartilage at the beginning of treatment. Logistic regression analyses showed a "dose-response" curve in which the greater number of hours of brace wear correlated with lack of curve progression. Brace wear to school and immediately afterward was most successful. Curves did not progress in 82% of patients who wore the brace more than twelve hours per day, compared with only 31% of those who wore the brace fewer than seven hours per day (p = 0.0005). The number of hours of brace wear also correlated inversely with the need for surgical treatment (p = 0.0005). The number of hours of wear were similar for the patients who were advised to wear the brace sixteen or twenty-three hours daily. The Boston brace is an effective means of controlling curve progression in patients with adolescent idiopathic scoliosis when worn for more than twelve hours per day.

Orthotic Management in Adolescent Idiopathic Scoliosis

In this issue, we are publishing 2 articles that have used the new Scoliosis Research Society (SRS) guidelines for inclusion and assessment of brace studies in adolescent idiopathic scoliosis. The guidelines are a product of the SRS Committee on Bracing and Nonoperative Management and are designed to establish standardized reporting parameters for subjects and measures for use in determining effective treatment. Such guides will allow for meaningful comparisons in future studies. The SRS inclusion criteria for bracing studies are diagnosis of adolescent idiopathic scoliosis, age of 10 years or older when the orthosis was fabricated, skeletal immaturity (Risser sign 0, 1, or 2), primary curve between 25 and 40 degrees, absence of previous treatment, and, if female, either premenarcheal or less than 1 year past menarche. All patients are to be included regardless of whether or not they were found to be compliant with their treatment regimen (intent to treat). The new SRS assessment of effectiveness criteria includes (1) the percentage of patients who had 5 degrees or less of curve progression, (2) the percentage of patients who had 6 degrees or more of curve progression at maturity, (3) the percentage of patients whose curve progressed beyond 45 degrees, and (4) the percentage of patients who had surgery recommended or performed. A minimum of 2 years of follow-up beyond skeletal maturity was required to complete a successful brace treatment. It is also recommended that all studies be stratified according to curve magnitude and type. We have embraced these guidelines and expect them to be used in future submissions to the Journal of Pediatric Orthopaedics of studies on brace management of adolescent idiopathic scoliosis. The lack of standardized inclusion and assessment criteria has recently led the US Preventive Health Task Force to recommend against school screening for early diagnosis for scoliosis. The rationale is a documented lack of evidence that there is an effective nonoperative treatment option to prevent curve progression in patients with mild curves. We think that this is a grievous error and may lead to a greater number of patients presenting late with more severe curves. Abandoning early diagnosis will limit any chance of nonoperative treatment and will result in greater risk associated with a larger number of children requiring complex surgical procedures for correction. However, it is also a challenge for pediatric orthopaedic surgeons to seek evidence-based proof that orthotic management is a statistically significant effective treatment for mild but progressive curves. These 2 articles share similar inclusion criteria and comparable results in curves of 25 to 35 degrees at the time of initiation of brace management. The thoracolumbar sacral orthosis and Providence orthosis were less successful in preventing progression in the larger curves and in reducing the need for surgery. However, the SpineCor orthosis demonstrated better results in this group. The exact reasons remain unclear. These 2 articles should serve as encouragement to future investigators to perform level 1 evidencebased research on this important question.

The Associated Effects of Untreated Unilateral Hip Dislocation in Cerebral Palsy Scoliosis

The presence of a unilateral hip dislocation in children with cerebral palsy (CP) may cause problems with sitting imbalance, pressure ulcers, and hip pain. There is a dynamic interplay between hip dislocation, pelvic obliquity (PO), and scoliosis. The effect of an untreated unilateral hip dislocation on the rate of curve progression of CP scoliosis has not been defined in the literature. The purpose of this study is to investigate the effect of unilateral hip dislocation on PO and the rate of curve progression in children with spastic quadriplegic CP. Patients with spastic quadriplegic CP who had spine radiographs at the time of initial presentation with scoliosis and at the latest follow-up were evaluated. Twenty-three children with spastic CP who had an untreated unilateral hip dislocation and scoliosis constituted the study group. The control group consisted of 83 quadriplegic CP patients with scoliosis and well-located hips. The rate of curve progression, incidence of PO, and the rate of PO progression at follow-up were compared between the 2 groups. The mean ages of patients with a unilateral dislocation and with well-located hips at initial radiograph were 10.4 and 10.5 years, respectively. The mean follow-up was 3.5 years. The mean rate of scoliosis curve progression in patients with a unilateral hip dislocation was 12.9 degrees per year. In the control group, the mean progression rate was 12.2 degrees per year. The incidence of PO at follow-up was 74% in scoliotic patients with a dislocation and 63% in scoliotic patients with normal hips. Using repeated-measures analysis of variance, unilateral hip dislocation was found to have no significant effect on scoliosis progression; however, progression of PO was significantly increased in the hip dislocation group (P < 0.05). Pelvic obliquity was corrected after posterior spinal fusion to the sacrum with pelvic fixation, without reducing the hip(s) at the same surgery. Unilateral hip dislocation causes a significant increase of PO but does not affect the rate of scoliosis curve progression.

Decreased Orthotic Effectiveness in Overweight Patients with Adolescent Idiopathic Scoliosis

Many studies have demonstrated that orthotic treatment is effective for the prevention of curve progression in patients with adolescent idiopathic scoliosis. However, the effect of being overweight on the outcome of orthotic treatment has not been reported. The purpose of the present study was to determine whether orthotic treatment of adolescent idiopathic scoliosis is less successful for patients who are overweight than it is for those who are not overweight. A ten-year multicenter retrospective review of patients in whom adolescent idiopathic scoliosis had been treated with a Boston or a custom-molded thoracolumbosacral orthosis was performed. The inclusion criteria were no previous treatment, skeletal immaturity (a Risser sign of 0, 1, or 2), a curve of 25 degrees to 40 degrees at the time of orthotic initiation, and follow-up to skeletal maturity. Patients were divided into two groups according to body habitus, with overweight patients defined as those with a body mass index in the eighty-fifth percentile or greater. Curve progression was compared between the two groups. Successful orthotic treatment was defined as no more than a 5 degrees increase in the primary curve from the start of orthotic wear to skeletal maturity. Absolute curve progression to 45 degrees or greater also was considered to be an adverse outcome. Two hundred and seventy-six consecutive patients from two institutions were analyzed, and thirty-one patients were considered to be overweight. The mean curve progression was 9.6 degrees +/- 7.3 degrees for the patients who were overweight, compared with 3.6 degrees +/- 9.4 degrees for those who were not overweight (p < 0.01). Overweight patients were 3.1 times more likely to have an unsuccessful result than those who were not overweight. Curve progression to 45 degrees or greater occurred in fourteen (45%) of the thirty-one patients who were overweight, compared with sixty-nine (28%) of the 245 patients who were not overweight. The results of the present study suggest that overweight patients with adolescent idiopathic scoliosis will have greater curve progression and less successful results following orthotic treatment than those who are not overweight. The ability of an orthosis to transmit corrective forces to the spine through the ribs and soft tissue may be compromised in overweight patients. This factor should be taken into consideration when making treatment decisions. Additional study is warranted to determine a threshold effect.