Radiologic findings and curve progression 22 years after treatment for adolescent idiopathic scoliosis: comparison of brace and surgical treatment with matching control group of straight individuals.

Department of Orthopaedics, Sahlgrenska University Hospital, Göteborg University, Sweden.
Spine (Impact Factor: 2.45). 04/2001; 26(5):516-25.
Source: PubMed

ABSTRACT This study is a follow-up investigation for a consecutive series of patients with adolescent idiopathic scoliosis treated between 1968 and 1977. In this series, 156 patients underwent surgery with distraction and fusion using Harrington rods, and 127 were treated with brace.
To determine the long-term outcome in terms of radiologic findings and curve progression at least 20 years after completion of the treatment.
Radiologic appearance is important in comparing the outcome of different treatment options and in evaluating clinical results. Earlier studies have shown a slight increase of the Cobb angle in brace-treated patients with time, but not in fused patients.
Of 283 patients, 252 attended a clinical and radiologic follow-up assessment by an unbiased observer (91% of the surgically treated and 87% of the brace-treated patients). This evaluation included chart reviews, validated questionnaires, clinical examination, and full-length standing frontal and lateral roentgenographs. Curve size was measured by the Cobb method on anteroposterior roentgenograms as well as by sagittal contour and balance on lateral films. The occurrence of any degenerative changes or other complications was noted. An age- and gender-matched control group of 100 individuals was randomly selected and subjected to the same examinations.
The mean follow-up times were 23 years for surgically treated group and 22 years for brace-treated group. The deterioration of the curves was 3.5 degrees for all the surgically treated curves and 7.9 degrees for all the brace-treated curves (P < 0.001). Five patients, all brace-treated, had a curve increase of 20 degrees or more. The overall complication rate after surgery was low: Pseudarthrosis occurred in three patients, and flat back syndrome developed in four patients. Eight of the patients treated with fusion (5.1%) had undergone some additional curve-related surgical procedure. The lumbar lordosis was less in the surgically treated than in the brace-treated patients or the control group (mean, 33 degrees vs 45 degrees and 44 degrees, respectively). Both surgically treated and brace-treated patients had more degenerative disc changes than the control participants (P < 0.001), but no significant differences were found between the scoliosis groups. No statistically significant difference in terms of radiographically detectable degenerative changes in the unfused lumbar discs was found between patients fused below L3 or those fused to L3 and above (P = 0.22). A study on intra- and interobserver measurements of kyphosis, lordosis, and sagittal vertical axis on two films for each patient demonstrated that the repeatability of measuring sagittal plumbline on two different lateral radiographs, with patients moving between radiograms, was unreliable for comparison.
Although more than 20 years had passed since completion of the treatment, most of the curves did not increase. The surgical complication rate was low. Degenerative disc changes were more common in both patient groups than in the control group.

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    ABSTRACT: Postoperative radiographs are routinely obtained following surgery for the correction of scoliosis in pediatric patients. The purpose of this study was to comprehensively evaluate the utility of obtaining routine postoperative radiographs in the management of these patients.METHODS: A total of 1969 clinic notes and corresponding radiographs regarding 451 consecutive patients with scoliosis (age range, ten to eighteen years) who had surgical correction over a ten-year period at a single institution were retrospectively reviewed. Curve etiology, preoperative curve characteristics, and surgical procedures performed were recorded. All postoperative clinic notes and radiographs were reviewed for abnormalities and changes in treatment course. It was then determined whether clinical signs and symptoms and/or abnormal radiographic findings led to a change in treatment course, which was defined as a therapeutic intervention or further diagnostic testing.RESULTS: Of the 451 patients in this study (average age [and standard deviation], 14.7 ± 2.4 years), 72.5% had adolescent idiopathic scoliosis, 23.3% had neuromuscular scoliosis, and 4.2% had other underlying causes of scoliosis. A change in treatment course occurred in the cases of forty-two patients, all of whom had symptomatic findings on postoperative history and physical examination and only fifteen of whom had supportive abnormal findings on postoperative radiographs. Curve etiology and surgical procedures performed had no impact on radiographic utility. A significant increase in utility was seen for radiographs obtained at visits one year or more following surgery compared with those obtained at visits less than one year following surgery (1.7% compared with 0.3%, p = 0.001). The overall sensitivity, specificity, positive predictive value, and negative predictive value of routine postoperative radiographs in guiding treatment course were 35.7%, 98.1%, 28.8%, and 98.6%, respectively.CONCLUSIONS: Routine radiographs provide low utility in guiding the course of treatment for asymptomatic pediatric patients following surgery for scoliosis. The results of this study suggest that patient or caregiver complaints, comorbidities, and clinical suspicion should be considered before obtaining radiographs at postoperative visits in order to minimize radiation exposure in pediatric patients and reduce medical costs without compromising care.LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
    The Journal of Bone and Joint Surgery 07/2014; 96(13):1127-1134. DOI:10.2106/JBJS.L.01357 · 4.31 Impact Factor
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    ABSTRACT: Background Adolescent Idiopathic Scoliosis (AIS) is a three-dimensional deformity of the spine. While AIS can progress during growth and cause a surface deformity, it is usually not symptomatic. However, in adulthood, if the final spinal curvature surpasses a certain critical threshold, the risk of health problems and curve progression is increased. Braces are traditionally recommended to stop curvature progression in some countries and criticized in others. They generally need to be worn full time, with treatment extending over years.Objectives To evaluate the efficacy of bracing in adolescent patients with AIS.Search strategyThe following databases (up to July 2008) were searched with no language limitations: the Cochrane Central Register of Controlled Trials, MEDLINE (from January 1966), EMBASE (from January 1980), CINHAL (from January 1982) and reference lists of articles. An extensive handsearch of the grey literature was also conducted.Selection criteriaRandomised controlled trials and prospective cohort studies comparing braces with no treatment, other treatment, surgery, and different types of braces.Data collection and analysisTwo review authors independently assessed trial quality and extracted data.Main resultsWe included two studies. There was very low quality evidence from one prospective cohort study with 286 girls that a brace curbed curve progression at the end of growth (success rate 74% (95% CI: 52% to 84%)), better than observation (success rate 34% (95% CI:16% to 49%)) and electrical stimulation (success rate 33% (95% CI:12% to 60%)). There is low quality evidence from one RCT with 43 girls that a rigid brace is more successful than an elastic one (SpineCor) at curbing curve progression when measured in Cobb degrees, but there were no significant differences between the two groups in the subjective perception of daily difficulties associated with wearing the brace.Authors' conclusionsThere is very low quality evidence in favour of using braces, making generalization very difficult. Further research could change the actual results and our confidence in them; in the meantime, patients' choices should be informed by multidisciplinary discussion. Future research should focus on short and long-term patient-centred outcomes, in addition to measures such as Cobb angles. RCTs and prospective cohort studies should follow both the Scoliosis Resarch Society (SRS) and Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) criteria for bracing studies.Plain Language SummaryBraces for idiopathic scoliosis in adolescentsScoliosis is a condition where the spine is curved in three dimensions (from the back the spine appears to be shaped like an “s”). It is often idiopathic, or having an unknown cause. The most common type of scoliosis is discovered at 10 years of age or older, and is defined as a curve that measures at least 10° (called a Cobb angle; measured on x-ray). Because of the unknown cause and age of diagnosis, it is called Adolescent idiopathic scoliosis (AIS).While there are usually no symptoms, the appearance of AIS frequently has a negative impact on adolescents. Increased curvature of the spine can present health risks in adulthood and in the elderly. Braces are one intervention that may stop further progression of the curve. They generally need to be worn full time, with treatment lasting for two to four years. However, bracing for this condition is still controversial, and questions remain about how effective it is.This review included two studies; one multicenter international cohort study (a study where treatment groups were defined according to the centre where patients were treated) of 286 girls and a randomised controlled study (an experimental study that randomised the participants to treatment groups) of 43 girls. There is very low quality evidence that braces are more effective than observation (wait-and-see) or electrical stimulation in curbing the increases in the curves of the spine. There is low quality evidence that rigid braces are more effective than a soft, elastic one. Adverse effects of braces were not discussed.Limitations of this review include the sparse data and studies available, and the fact that available studies only included girls (even if there is only one male with scoliosis for every seven females), making it very difficult to generalize the results to males. Due to the very low quality of the evidence in favour of bracing, patients and their parents should regard these results with caution and discuss their treatment options with a multi-professional team.Further research is very likely to change the results and our confidence in them.
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    Scoliosis 10/2014; 9:17. DOI:10.1186/1748-7161-9-17 · 1.31 Impact Factor

Aina J Danielsson