Bits and pieces

The Effect of Rigid Versus Flexible Spinal Orthosis on the Clinical Efficacy and Acceptance of the Patients With Adolescent Idiopathic Scoliosis.

Spine. 33(12):1360-1365, May 20, 2008.
Wong, Man Sang PhD *; Cheng, Jack C. Y. MD +; Lam, Tsz Ping FRCS(Ed) +; Ng, Bobby K. W. FRCS(Ed) +; Sin, Sai Wing MPhil ++; Lee-Shum, Sandra L. F. PD [S]; Chow, Daniel H. K. PhD *; Tam, Sandra Y. P. BSc(Hons) *
Study Design. A prospective study on the comparison of the clinical efficacy and patient's acceptance of the 2 orthotic management methods.
Objective. To compare the treatment effectiveness and patients' acceptance of the flexible spinal orthosis, SpineCor with that of the rigid spinal orthosis for the patients with moderate adolescent idiopathic scoliosis.
Summary of Background Data. The patients' acceptance to the rigid spinal orthoses is always a concern as it could greatly affect the clinical outcome. SpineCor is a relatively new design for tackling those inevitable drawbacks found in rigid orthosis. However, there was no study to compare this design with the conventional method regarding their treatment efficacy and the patient's acceptance.
Methods. Forty-three subjects with moderate adolescent idiopathic scoliosis were randomly assigned to the SpineCor group (S group, n = 22) and rigid orthosis group (R group, n = 21). Their survival rate in the first 45 months of intervention was studied. The subjects' acceptance to the orthoses was evaluated by a purpose-designed questionnaire, which was administered in the 3rd, 9th, and 18th months of intervention.
Results. In the study period, there were 68% of the subjects in the S group and 95% of the subjects in the R group did not show curve progression. Significant difference (P = 0.046, by Fisher exact test) in failure rate between the 2 subject groups was found although the 2 groups had similar responses to the questionnaire.

Conclusion. The current study showed that the failure rate of the SpineCor was significantly higher than that of the rigid spinal orthosis, and the patients' acceptance to the SpineCor was comparable to the conventional rigid spinal orthosis. (C) 2008 Lippincott Williams & Wilkins, Inc.

Bits and Pieces

Adolescent Idiopathic Scoliosis Patients Report Increased Pain at Five Years Compared With Two Years After Surgical Treatment.

Health Services Research

Spine. 33(10):1107-1112, May 1, 2008.
Upasani, Vidyadhar V. MD *+; Caltoum, Christine MD +; Petcharaporn, Maty BS +; Bastrom, Tracey P. MA +; Pawelek, Jeff B. BS +; Betz, Randal R. MD ++; Clements, David H. MD [S]; Lenke, Lawrence G. MD [P]; Lowe, Thomas G. MD [//]; Newton, Peter O. MD *+
Study Design. A multicenter study of changes in Scoliosis Research Society (SRS) outcome measures after surgical treatment of adolescent idiopathic scoliosis (AIS).

Objective. To evaluate changes in patient determined outcome measures between 2 and 5 years after AIS surgery.

Summary of Background Data. Current surgical procedures have been shown to improve subjective measures in patients with AIS. At 2-year follow-up, AIS patients reported significant improvement in all 4 preoperative domains of the SRS questionnaire. In addition, the major Cobb angle was shown to be negatively correlated with preoperative scores in the pain, general self-image, and general function domains. Five-year SRS scores have not been evaluated previously.

Methods. A multicenter, prospectively generated database was used to obtain perioperative, radiographic, and SRS-24 outcomes data. The inclusion criteria were: a diagnosis of AIS, surgical treatment (anterior, posterior, or combined), a comprehensive set of radiographic measures, and completed preoperative, 2-year, and 5-year SRS questionnaires. Repeated measures analysis of variance was used to compare changes in patient responses for each of the 7 outcome domains. Univariate analysis of variance was used to compare the change in pain score at 5 years to the level of the lowest instrumented vertebrae and surgical approach. A correlation analysis was used to determine the association between changes in any of the radiographic variables and changes in SRS scores. The data were checked for normality and equal variances, and the level of significance was set at P < 0.01.

Results. Forty-nine patients (42 women, 7 men; 14.2 +/- 2.1 year old; 5.4 +/- 0.6 years follow-up) met the inclusion criteria for this study. Thirty-seven of 49 (76%) of these patients underwent an open or thoracoscopic anterior procedure. SRS-24 scores improved significantly in 3 of the 4 preoperative domains at the 2-year visit. At 5 years postop, a statistically significant decrease in the pain score (4.2 +/- 0.6 to 3.9 +/- 0.9, P = 0.003) and a trend toward worsening scores in 4 other domains was observed; however, Patient Satisfaction scores remained unchanged. Lowest instrumented vertebrae and surgical approach could not be correlated to changes in the pain score. In addition, no correlation was found between changes in any of the 21 radiographic measures evaluated and changes in SRS scores.

Conclusion. There was a statistically significant increase in reported pain from 2 to 5 years after surgical treatment; however, the etiology of worsening pain scores could not be elucidated. Given continued patient satisfaction, the clinical relevance of this small reduction remains unknown. Nevertheless, this observation deserves further evaluation and must be considered in relation to the natural history of this disease.
(C) 2008 Lippincott Williams & Wilkins, Inc.

Bits and Pieces

27The number of idiopathic scoliosis patients in a prospective study of curve progression using a soft brace (SpineCor) versus a Cheneau-derived TLSO during a pubertal growth spurt. The German researches developed a controlled study to compare the brace types. All patients were premenarchal girls. The Cobb angle of 11 of 12 of the soft brace subjects progressed at least 5 percent over 21.5 months, thought when they were switched to the Cheneau brace progression stopped in seven of 10. The 15 control-group subjects in the Cheneau brace showed an average curve progression of 0.2 degrees over 37 months. Weiss HR, Weiss GM. Brace treatment during pubertal growth spurt in girls with idiopathic scoliosis (IS): a prospective trial comparing two different concepts. Pediatr Rehabil 2005;8(3):199-206.

VolumeXIII Number 1/January 2006 Pg. 36

Bits and Pieces

SPINE Volume 22, Number 12, pp 1283-1284
@ 1997, Lippincott-Raven Publishers
. Editorial

To Brace or Not to Brace: The True Value of School Screening
Robert B. Winter, MD, and John E. Lonstein, MD

In 1993, a United States Preventive Services Task Force report was published in the Journal of the American Medical Association. (10,11). The conclusion of this report was that there is "no evidence that school screening for scoliosis is of any value." This opinion was based on the conclusion that, because there was no method of early treatment of any value, early detection was, therefore, useless.
This conclusion was an affront to those of us in the field of scoliosis treatment and management who have tried so hard for so many years to have available a means of early detection (i.e., school screening). Why would we want this early detection if there were no effective method of early treatment?
The truth is that an effective method of early, nonsurgical treatment is available. That method is bracing. We who have had great experience in this field know that bracing can be effective.
How do we know it can be effective? We know because of our own personal experience and also through well documented scientific studies. As an individual deeply involved in scoliosis treatment for the past 32 years, I know bracing can work because I have seen it work.
We clinicians are often ridiculed because of our "clinical experience," because it does not carry the weight of a "prospective randomized clinical trial." If clinical experience was of no value, we physicians would not have aspirin, digitalis, morphine, and penicillin. Can you. imagine the prospective, randomized, double-blinded clinical trial of penicillin by Alexander Fleming? It would have required 100 patients receiving a placebo for their pneumococal pneumonia and 100 more receiving penicillin. When the clinical trial was finished, the 100 treated patients would be alive and well and the 100 "control subjects" dead. The value of penicillin would have been proven, but try rationalizing that to the 100 who died (or to their loved ones).
There have been many studies of bracing in the past, but they were not randomized, controlled, or blinded. They were the typical clinical studies of the 1950s,
From the Minnesota Spine Foundation, Minneapolis and St Paul, Minnesota.
Presented as a speech to the American Academy of Pediatrics. Philadelphia, April 10, 1995.
Acknowledgment date: February 5,1995.
First revision date: September 9. 1996.
Acceptance date: September 20, 1996.

1960s, and 1970s. The results of treatment were reviewed retrospectively. In most of these studies, it was found that, when first placed in a brace, most patients showed a very significant amount of correction. Then, as time went on, there was a subsidence of correction and, finally, as the brace was removed, the curve (on the average) was approximately the same at the end as at the start of treatment. 1.3,7 Because of this, some people chose to interpret such outcomes as showing that the brace had no benefit. Others looked at the same outcomes as showing that curve progression had been prevented. This can be compared to the analogy of the half-full wine glass. The pessimist and the optimist see it in different lights.
One compelling note in these previous studies was
the analysis of the "compliant' versus
"noncompliant" patients. The noncompliant patients always had worse results than the compliant patients. This was actually one of the first clues that part-time (8-12 hours) wearing schedules were less optimal than ''full-time'' (20-hoursplus per day) schedules.
Another obstacle to analysis was the quantity of the
curve being treated. In the major study by Mellencamp and Blount, the average pre-treatment curve was 44°, a curve magnitude we now know to be very difficult for brace treatment. (7)
By the mid 1980s, there was a division in the field of scoliosis brace treatment. There were the "negativists," led by Robert Dickson of Leeds, England, who stated that bracing was of no value whatsoever, and the "positivists," such as Salanova of Toulouse, France, and Lonstein and Wmter of Minneapolis and St. Paul, Minnesota, respectively, who thought the opposite.
The resolution of this conflict had to come from new studies, studies that closely compared the natural history of the disease against the treatment
modalities. The first of these was the paper presented to the Scoliosis Research Society in 1988 by Lonstein and Winter. This study of 1020 patients with adolescent idiopathic scoliosis, all treated with a Milwaukee brace and compared with a natural history, study of 729 patients seen at the same hospitals by the same author (J.E.L.), (5) showed, with statistical certainty (P = 0.0001), that bracing had a positive effect on the natural history of adolescent idiopathic scoliosis. In the critical high-risk group of Risser 0-1 females with thoracic curves of20-40°, there was a

1284 Spine Volume 22 Number 12 1997
failure rate of 43% with bracing, compared with 68% with natural history. This study was finally published in 1994.6
In 1988, Durand and Salanova of Toulouse, France, published a doctoral thesis on the results of Milwaukee brace treatment of 477 patients with adolescent idiopathic scoliosis.² In the highest risk group, the "transpubertal" Risser 0 or I group, a 21 % failure rate was found, compared with the 68% failure rare of natural history (5 years after skeletal maturity).
It is only recently that we have available to us the results of prospective controlled studies. In 1993, at the Scoliosis Research Society meeting in Dublin, Ireland, Nachemson presented the results of the long-term prospective study sponsored by the Scoliosis Research Society. Patients were divided into three groups: 1) natural history (no treatment of any kind), 2) brace treatment of 20 hours minimum per day until the end of growth, and 3) electrical stimulation. The results were analyzed by a Swedish statistical team that was completely unrelated to any treatment method. (8)
The results were conclusive. Electrical stimulation was no different than natural history. Bracing was highly effective compared with natural history.
Finally, in the Journal of Pediatric Orthopaedics in 1995, Fernandez-Filiberti et al (4) of Puerto Rico published the results of 54 complaint brace-treated patients compared with 47 age-, gender-, and curve-matched patients with no treatment. There was a threefold increase in surgery or major curve increase in the control group compared with the brace treated group.
We believe that these latter three studies, all with adequate numbers and control groups, prove beyond a doubt that bracing can be
effective in the nonsurgical management of adolescent idiopathic scoliosis.
All bracing is not the same. All of the published studies proving that bracing can be
effective have involved brace schedules of at least 20 hours per day in the brace plus wearing of the brace on this schedule until the completion of growth (no more height increase, at least 18 months since menarche, and a Risser 4 status). There have been no published studies showing good results with lesser wearing schedules. Common sense would indicate that a brace not on a patient cannot be helping the patient.
Not only is the number of hours per day that the brace is worn important, but also the number of years and the correction achieved in the brace. In an article by Noonan et al, (9) discussing their experience with the Milwaukee brace for adolescent idiopathic scoliosis, they demonstrated results quite inferior to those mentioned earlier. A careful analysis showed a much shorter duration of bracing (an average of 1 year, 8 months versus the 3 years, 8 months of Lonstein and Winter), as well as a very meager correction in the brace (8% for their "failed" group and 20% for their "successful" group versus 30% overall for Lonstein and Winter).
In conclusion, the confusion of the mid 1980s has now been cleared by a multitude of well done clinical studies. The value of bracing is now beyond doubt. Not all patients have a good response to a brace, but that should not deter us from giving the opportunity for a good result to all who are candidates. It is better to have tried and failed than never to have tried at all.
In view of these facts, the U.S. Preventive
Service Task Force should reverse its
stand. They should endorse school screening for scoliosis because early detection can lead to early nonsurgical treatment by bracing. Such brace treatment can significantly lead to fewer major spinal deformities and fewer surgeries. For the U.S. Preventive Services Task Force to endorse a policy that would advocate more surgery at higher costs is untenable in these times.

1. Carr W A, Moe JH, Winter RB, Lonstein JE. Treatment of idiopathic scoliosis in the Milwaukee brace. Long term results. J Bone Joint Surg 1980;62A:599 - 612.
2. Durand H. Faut-il abandonner Ie traitement orthpedique de la scoliose. Doctoral Thesis. Presented at the
University Paul Sabatier, Toulouse, France, October 25, 1988.
3. Edmonson AS, Carlson JM. Follow-up study of Milwaukee brace treatment in patients with idiopathic scoliosis.
Clin Orthop 1977;126:58-61.
4. Fernandez-Filiberti R, Flynn J, Ramirez N, Trautmann M, Alegria M. Effectiveness of TLSO bracing in the conservative treatment of idiopathic scoliosis. J Ped Orthop 1995; 15: 176-81.
5. Lonstein JE, Carlson JM. The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Joint Surg 1984;66A:I061-71.
6. Lonstein JE, Winter RB. The Milwaukee brace for the treatment of adolescent idiopathic scoliosis: A review of 1020 patients. J Bone Joint Surg 1994;76A: 1207-21.
7. Mellenkamp DD, Blount WP, Anderson AJ. Milwaukee brace treatment of idiopathic scoliosis: Late results. Clin Orthop 1977;126:47-57.
8. Nachemson A, Peterson L, and Members of the Brace Study Group of the Scoliosis Research Society. Effectiveness
of treatment with a brace in girls who have adolescent idiopathic scoliosis. J Bone Joint Surg 1995;I77A:815-22.
9. Noonan KJ, Weinstein SL, Jacobson WC, Dolan LA. Use of the Milwaukee brace for progressive idiopathic scoliosis. J Bone Joint Surg 1996;78A:557-67.
10. U.S. Preventive Services Task Force. Screening for adolescent idiopaithic scoliosis: Policy statement. JAMA 1993;269: 2667-72.
11. U.S. Preventive Services Task Force. Screening for adolescent idiopathic scoliosis: Review -article. JAMA 1993;269: 2667-72.
Address requests to
John E. Lonstein, MD Minnesota, Spine Center 60624th Ave. S.
Suite #606
Minneapolis, MN 55454

Bits and pieces

Dynamic Chiropractic
December 4, 1992, Volume 10, Issue 25

Understanding Scoliosis

The past 40 years have offered only insignificant changes in the understanding and treatment of scoliosis. Several previous authors attempted to expand the reader’s clinical knowledge of scoliosis, but no real solution has come forth in the treatment protocol. The Greeks defined scoliosis as a crooked spine(1). Unknown to them, they were some thousand years ahead of time. Most physicians concur with Dr. J.D. Hughes when he described scoliosis as a physical condition rather than a diagnosis(2). In schooling, the physician is limited a few short hours of training on a very complex subject; therefore, the norm for treatment would be to identify, observe and employ treatment protocol which was derived from there own experiences. Physicians have been in a quandary for years as to success in some cases and deterioration in others. The clinical physician must realize that scoliosis is a multifactorial disease and with this knowledge should be properly armed with an arsenal for the treatment of scoliosis.

In this initial article, I will briefly touch upon each know facet of scoliosis, which may enhance the physicians perception of treatment protocol.

The most obvious deformity taught in school was the lateral curvature(3). Various methodologies have been utilized in determining the factor of deformity(4). The most universal method of measurement is the Cobb’s angle of measurement(5). The Cobb’s angle of measurement is lacking in three-dimensional information. With this shortcoming, the treating physician lacks various facts providing a complete comprehension of the severity of the deformity. In the quest to properly treat the lateral deviation, it is essential for vertebral body and its dysfunctional motion in the curved segment of the scoliotic spinal column.(6)

The second most obvious deformity was in vertebral rotation(7). Dr. John H. Moe, n orthopedic surgeon, was one of the first physicians to attempt to describe the amount of rotation from a single dimension x-ray. The methodology evaluates the spinous location in an AP view. As the vertebral body rotates on thickness of he spinous process, it was clinically expressed as a +1. The degree of rotation varied from 3 to 10 degrees. In addition to this, the posterior pedicles were also utilized as a land mark to calculate the rotational deformities. A recent orthopedic article has described that for each +1 quantity, it would clinically be described from 0 to 20 degrees, hence+2 would be from 20 to 40 degrees, and +3 would be from 40 to 60 degrees. With the physicians appreciation for the x-ray beam distortion, one can understand the inaccuracy of the amount of the vertebral rotation and the inability to correlate the x-ray data.

The third deformity, which is very misunderstood, is the muscle imbalances of the scoliotic patient(8). It was once thought that in the concavity of the scoliotic spine, the muscles were very strong; therefore, it was felt that it accentuated the progression of progression of curvature. This theory also displayed that the muscles on the convex side of the spine were stretched and weakened. Recent EMG findings have proven that the convex side displays a more dormant activity level. Studies by Dr. C.S. O’Donnel have also revealed that with proper muscle stimulation, muscles can be rehabilitated.

The forth facet of distortion, which is not readily recognized as a deformity, is a neurological pattern of dysfunction(9). This deformity effects the anatomical performance of standing, locomotion, and comprehension(10). This pattern of dysfunction can be recognized by electromyographic studies. The dysfunction is confirmed by EMG with full range-of-motion: Standing, neutral, right lateral flexion, left lateral flexion, forward flexion, right rotation, left rotation, and extension. This information further enhances the need for a total understanding of the clinical findings.

The fifth deformity is the dysfunctional proprioception of the vestibular and ocular systems. Studies by Dr. R. Herman reveal that the vestibular and ocular systems displayed an inability to correctly react on the upper motor neurons communication of the righting reflex mechanism.(11)

The sixth deformity is a biomechanical imbalance. This deformity effects the body at the microscopic level. This area of distortion reacts upon the cell formation as well as the reproduction of muscle matrix, ligamentous matrix,(12) and nerve tissue(13). This information can be acquired through the tissue analysis. By correcting this imbalance, the scoliotic progression can be controlled and enhance correction.

In reassessment, it becomes apparent that the treating physician must possess a total spectrum of knowledge in scoliosis, with the ability to establish a constant reoccurring treatment protocol for correction. With acquiring a strong knowledge bas of scoliosis, the chiropractic physician can reorganize the infantile stages of the disease and establish early treatment protocol; thereby establishing their profession will display clinical factors answering questions arising from this writing.


1. Stedman’s Medical Dictionary
2. Huges JG: Pediatrics. ed 3 Mosby Co., St. Louis, 1971.
3. Adams W: Lectures on the pathology and treatment of lateral and other forms of curvature of the spine. Churchill & Sons, London, 1865.
4. Perdriolle R, Vidal J: Morphology of scoliosis. Three –dimensional evolution. Orthopedics, 10:909-915, 1987.
5. Cobb Jr: Techniques, after treatment and results of spine fusion for scoliosis. Instructional course lectures 9, Ann Arbor, American Academy of Orthopedic Surgeons, 1952.
6. Patwardhan AG, Burch WH, Meade KP, Vanderby R Jr, and knight GW: A Biomechanical analysis of curve progression and orthotic stabilization in idiopathic scoliosis. J Biomechanical 19: 103-17, 1986.
7. Ohlen G, Aaro S, Bylord P: The sagittal configuration and mobility of the spine in idiopathic scoliosis of the spine, 13: 413, 1988.
8. O’Donnel CS, Bunnell WP, Betz RR, Tipping CR: Electrical stimulation in the treatment of idiopathic scoliosis. Scoliosis Research Society, 1987.
9. Rossini PM, Gigli GL, Marciani MB, et al: Noon-invasive evaluation of input-output characteristics of sensorimotor cerebral areas in healthy humans. Electroencephalogr Clin Neurophysiol, 68:88, 1987.
10. Shichijo F, Gentili F, Tranfeldt E, Niznik G: Neuroanatomical substrate of motor evoked potentials and cerebellar evoked potentials. Poster presentation at the Meeting of the American Academy of Neurosurgery, Toronto, 1988.
11. Herman R, MacEwen GD: Idiopathic scoliosis: Vestibular dysfunction disorder of the CNS. In: Zorab PA, Siegler D, eds. Scoliosis 1979. New York Academic Press, 61-69: 1980.
12. Harris ED, DiSilvestro RA, Balthrop JE: Lysyl Oxidase, a Molecular Target of Copper. Inflammatory Disease and Copper. Sorenson JRJ, Ed: Humana Press, N.J., 1982.
13. Watts DL: Neurological Effects Upon Nutritional Status. Dig. Chiro. Econ. May/June 1991.

Arthur L. Copes, Ph.D.
Baton Rouge, Louiaiana

Bits and pieces

Advanced BioMechanics Orthotics and Prosthetics - Does Scoliosis Bracing Work? Page 1 of 2

Does Scoliosis Bracing Work?

A long-standing and spirited debate among orthopaedic surgeons, family physicians and others in the medical community addresses the value of a spinal brace for limiting the progression of idiopathic scoliosis deformities in adolescents who have not reached skeletal maturity.
While bracing has gained many proponents over the years, the lack of conclusive research to support its effectiveness has led many clinicians to advocate treatment by observation-only, followed by surgery if abnormal spinal curvature should progress to a threatening degree.
The debate rages on, to be sure; however, results of a nine-year project conducted by the Scoliosis Research Society (SRS) now provide the best evidence to date that treatment with a brace is more effective than either observation-only or lateral electrical surface muscle stimulation, which enjoyed a very brief period of popularity in the 1 980s.
Recognizing the inadequacy of existing research, the SRS designed a prospective multi-center, multinational trial involving a well-defined group of patients: girls age 10-15 with adolescent idiopathic scoliosis, a single curve with its apex between the eighth thoracic and first lumbar vertebrae and an average Cobb angle of 25 degrees-35 degrees.
Nineteen physicians representing 10 treatment centers took part in the trial; each participating site adhered to its preferred treatment method. By design, participating physicians were SRS members who either firmly believed in the effectiveness of bracing for scoliosis management or firmly believed bracing to be ineffective and thus managed patients with careful observation until a predetermined increase in curve was observed.
The study design required that each patient’s method of treatment remain consistent throughout and that patients wearing an orthosis do so at least 16 hours in 24. Details of the survey methods and materials are presented in “Effectiveness of Treatment with a Brace in Girls Who Have Adolescent Idiopathic Scoliosis,” published in The Journal of Bone and Joint Surgery, Vol. 77-A, No. 6 (June 1995).
Patients were enrolled over a period of four years; 294 girls were initially included. Subsequently, eight were dropped for insufficient participation (one visit only) or being found in fact not to meet the selection criteria. Another 39 were lost to follow-up, leaving 247 patients who were followed either to maturity (age 16) or treatment failure, defined as an increase of curve of 6 degrees shown on two successive x-rays. Of these, 129 were managed with close observation only, 111 with a spinal orthosis. and 46 with electrical stimulation (see Table 1).
Table 1
‘Observation Only
Spinal Othosis
Originally Enrolled
Lost To Follow Up
Failed Result
The role of a spinal orthosis in treating adolescent idiopathic scoliosis is to prevent the curvature from worsening to the point that spinal fusion surgery becomes necessary, generally concluded to be at 45 degrees. .html 4/17/2002

Advanced BioMechanics Orthotics and Prosthetics - Does Scoliosis Bracing Work? Page 2 of 2
If the curve can be kept under 40 degrees until the subject reaches skeletal maturity, it probably will not progress during adulthood.
In various cases, a scoliotic curve will return to its original, pre-brace magnitude upon cessation of brace wear at skeletal maturity; however, by preventing the curve from increasing further during the rapid growth of adolescence, the orthosis has prevented long-term progression and may well have obviated the need for surgery.
Results of this trial indicate fairly conclusively that use of an orthosis in this very typical scoliosis population is more effective than either observation-only or electrical stimulation. The crude failure rate among patients using an orthosis was 19%, compared to 52% and 56% for observation and stimulation respectively.
A survivorship analysis (“survivors” being subjects who did not experience curve progression of 6 degrees or more) after three and four years of treatment reveals comparable results (see Table 2). The nearly identical rates of success among patients managed with observation-only and electrical stimulation at four years tend to support various other studies showing stimulation to be ineffective.
Table 2
Patients with
less than 6 degrees
curve progression
Observation Only
Spinal Othosis
Electrical Stimulation
At Three Years
At Four Years
74% II
Even in a worst case analysis, in which the 23 in-brace patients lost to follow-up were assumed to have failed treatment, the success rate for the orthosis group was still superior to the other two.
The SRS team acknowledges that, due to the many difficulties associated with a “perfect” study, their research project was not ideal - it was not randomized, nor were the subjects observed independent of the physician managing their care. Nonetheless, they believe that because Milwaukee brace the trial was done prospectively and incorporates a worst-case analysis it generated the most accurate data possible and is superior to previous, retrospective research on the subject.
Their conclusion: “...treatment with a brace is probably 20% more effective than observation alone or electrical stimulation.” Moreover, “The study has also revealed the risk, if the curve is untreated, of 6 degrees or more progression until the patient reaches maturity.”
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Bits and pieces

Bracing Effective for Adolescent Idiopathic Scoliosis
Page 1 of2

Bracing Effective for Ado’escent
Idiopathic Scoliosis
Thomas Renshaw, M.D., pediatric orthopaedic surgeon and scoliosis expert at Yale, finds a very challenging aspect of caring for children with scoliosis is knowing how hard it can be on children and families. “Let’s face it, braces are
limiting and children are self-conscious about them,” explained Dr. Renshaw. The dislike of brace wearing has led some parents to try alternative treatments at have not been proven effective. Major studies
ThomaS Reaahma,MD. completed in the last decade provide solid evidence on what had iken hotly debated for years: should braces be worn; and if so, to what extent?
“Recent studies clearly demonstrate that for progressive curves of 25 to 50 degrees, full-time bracing is the most effective course of action,” he added. Alternatives such as nighttime muscle stimulators and exercises were not found effective. Full-time bracing of more than 21 hours per day is much more effective at stopping the curvature from getting larger than part-time bracing of 16 hours or less. Nighttime-only bracing has also been tried and found less effective.
Endoscopic Surgery Techniques for Scoliosis
Curvatures beyond 50 degrees typically require surgical intervention. Renshaw is now using endoscopic surgery techniques for certain curves. Avoiding a long incision, a series of tiny incisions are made along the side and specially designed instruments are used to remove the disks and insert bone grafts. Recovery time and scarring is minimized while the level of correction is maximized. “In some cases, endoscopic surgery allows us to fuse fewer vertebrae and to correct larger, stiffer curves while obtaining better correction,” he added. Advances in bone graft materials are improving outcomes too. “We employ bone growth enhancers that make the graft stronger and the fusion develop more effectively.”
Resources and Support for Families
The Connecticut Chapter of the Scoliosis Association is a valuable information and support resource for patients with scoliosis and their families. For more information contact Brooke Lyons, national teen spokesperson and president of the state chapter at or 1-800-386-6416.,/new/scoliosis.htm1

Bracing Effective for Adolescent Idiopathic Scoliosis Page 2 of 2
To contact Dr. Thomas Renshaw, call 203- 737-5662 or
thomas.rensha(yal& edu
Scoliosis Treatment Options
Degree of Curvature Treatment Options
Less than 25 degrees Most curves in this range do
not progress; monitoring is
warranted without active
25 to 50 degrees Full-time bracing of 21 or more
hours/day is most effective
treatment in growing children
More than 50 degrees Surgical correction is usually
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Bits and pieces

Influence of an in-patient exercise program on scoliotic curve.

Katharina Schroth Klinik, Spinal Deformities Rehabilitation Center, Sobemheim, Germany.

Weiss HR.
In 107 patients with idiopathic scoliosis radiographs were performed under standard conditions immediately before and immediately after a 4-6 week inpatient exercise program at the Katharina-Schroth Hospital. The average angle of curvature as measured by the Cobb technique was 43.06 degrees (standard deviation = 22.87) before treatment and 38.96 degrees (SD = 23.00 after treatment. An improvement in the curve of 5 degrees or more was found in 43.93% of the patients, 53.27% were unchanged and in 2.8% the curve increased by 5 degrees or more. Altogether the improvements in curvature were highly significant. These results show that even in severe scoliosis the magnitude of the curve can be reduced by a specific rehabilitation program of physiotherapy.
PMID: 1308886 [pubMed - indexed for MEDLINE]

Bits and Pieces

Ann Chir. 1998;52(8):795-800
A Biomechanical Study of New Orthotic Treatment Approaches for the 3D Correction of Scoliosis

Scoliosis is a complex deformity of the spine and rib cage often treated by the Boston brace. The goal of this research is to study the simulation of two new treatment approaches and to compare their results to the Boston brace. A personalized biomechanical model has been used to simulate the treatment on 20 scoliotic teenagers with double curvature. On the first treatment, different forces were applied at the thoracic apex level and the posterior displacement of the rib hump was locked. For the second treatment, an oblique force oriented 45 degrees with respect to the frontal plane was added at the lumbar apex. Following each simulation, geometrical and clinical measurements were calculated and compared to the initial geometry and the Boston brace treatment. Overall, the two new treatment modalities correct the thoracic Cobb angle in the frontal plane while maintaining the normal physiological curvatures in the sagittal plane, move the thoracic plane of maximum deformity towards the sagittal plane and reduce axial rotation and rib hump. In comparison, the Boston brace reduces the Cobb angles in the frontal as well as in the sagittal planes, moves the planes of maximum deformities towards the coronal plane and has no effect on axial rotation and rib hump. This biomechanical study shows force patterns that correct scoliosis more efficiently than the Boston brace. These new treatment approaches must be personalized for each patient and still require clinical evaluation.

BIts and Pieces

Pediatr Rehabil. 2006 Jan-Mar; 9(1):24-30

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 hypercorrection 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 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-Cheneaubrace 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(R) surface topography system, Diers International, Wiesbaden).Results: One patient (Cobb angle 92 degrees) showed no shortterm 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.

Bits and pieces

Is Cobb angle progression a good indicator in adolescent idiopathic scoliosis?

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Delorme S, Labelle H, Aubin CE.
Research Centre, Sainte-Justine Hospital, Montreal, Quebec, Canada.

STUDY DESIGN: A retrospective follow-up study of spine geometry after posterior instrumentation and fusion for adolescent idiopathic scoliosis (AIS). OBJECTIVES: To evaluate 1) if Cobb angle progression is a reliable indicator of the crankshaft phenomenon; 2) if significant growth of the spine can occur after surgery without the development of a crankshaft phenomenon? SUMMARY OF BACKGROUND DATA: Anterior fusion of the spine is often recommended for skeletally immature scoliotic patients to avoid the risk of a crankshaft phenomenon, a long-term loss of curve correction caused by residual growth of the spine combined with the constraints of a posterior fusion. The crankshaft phenomenon is usually assessed indirectly by documenting progression of the Cobb angle on frontal radiographs. Thus far, no study has directly measured the three-dimensional growth of the spine after surgery in AIS. METHODS: Cobb angle, spine length and spine height were obtained from three-dimensional radiographic reconstructions of the spine in 48 adolescent scoliotic patients undergoing posterior instrumentation and fusion. Measurements were done before surgery, after surgery and at skeletal maturity. A significant growth of the spine was defined as a > or = 10 mm increase in spine length, while a significant curve progression was defined as a > or = 10 degrees increase in Cobb angle at skeletal maturity. RESULTS: In the majority of patients (56%), there was no significant change in spinal length or in Cobb angle measurements at an average 2.4 years post surgery. A crankshaft phenomenon was detected in 6 patients (12%) for which significant increases both in spinal length and Cobb angle measurement were found. Significant curve progression without any change in spine length was noted in 9 patients (19%) while an increase in spine length with no evidence of curve progression was present in 6 patients at last follow-up. CONCLUSION: Spinal growth as indicated by an increase in spinal length can be measured in a significant proportion of adolescents with idiopathic scoliosis after posterior instrumentation and fusion. Some of these study participants will develop a crankshaft phenomenon but Cobb angle progression is not a reliable indicator of this complication, since it may occur without any detectable growth of the spine.

PMID: 11884919 [PubMed - indexed for MEDLINE]

Bits and Pieces

Eur Spine Journal 2001 Oct; 10(5):454-7

Corrective surgery for idiopathic scoliosis after heart transplantation.

Ceroni D, Beghetti M, Spahr-Schopfer I, Faundez AA, Kaelin A.

Pediatric Orthopedic Unit, Children’s Hospital, University Hospital Geneva, Switzerland.

Cardiac transplant surgery is being performed with increasing frequency as a treatment for end-stage heart disease. In addition to the well-known post-surgical problems of rejection and infection, these patients may present at a future date with other medical problems which require surgical treatment, including orthopedic pathology. Severe idiopathic scoliosis has been described in association with congenital heart disease, and its surgical treatment poses considerable risks because of heart disease. Spinal fusion in heart transplant recipients involves similar risks due to the particular physiology and pharmacological reactions of the denervated heart. Several cases of cholecystectomy performed in heart transplant recipients have been described, but to our knowledge no orthopedic procedures have been reported in such patients. We report on a 15-year old patient who underwent successful corrective surgery for idiopathic scoliosis 14 months after heart transplant.

PMID: 11718202 [PubMed-in process]

Clin Orthop 1997 Feb;(335):64-72

Spinal instrumentation in the management of adolescent scoliosis.

Bridwell KH.

Washington University School of Medicine, St. Louis, MO 63110, USA.

A multitude of posterior and anterior segmental spinal instrumentation systems are now available for the treatment of idiopathic scoliosis. As a consequence, fixation strategies are more complex than they were with Harrington instrumentation. The newer systems provide better sagittal control and more stable fixation, allowing quicker mobilization of the patient. On thin patients, the bulk of these implants may be a problem. The techniques of fusion and the fusion levels remain constant.

Publication Types
· Review
· Review, tutorial

PMID: 9020207 [PubMed-indexed for MEDLINE]

J Pediatr Orthorp 2001 Nov-Dec; 21
(6): 756-60
Standards in anterior spine surgery in pediatric patients with neuromuscular scoliosis.

Sarwahi V, Sarwark JF, Schafer MF, Backer C, Lee M, King EC, Aminian A, Grayhack JJ.

Children’s Memorial Hospital/Northwestern University Medical School, Chicago, IL, USA

SUMMARY: The authors reviewed 111 patients with neuromuscular disease who underwent anterior spine surgery for correction of scoliosis. An overall complication rate of 44.1% was found, 21.6 major and 22.5% minor. Pulmonary complications were the most common major complications, urinary tract infections the most common minor complications. The rate of complications was greater in patients with cerebral palsy, thoracoabdominal and transthoracic approaches, staged procedures, operative blood loss >1,000 mL, or previous spine surgery. In addition, statistical analysis confirmed that curve magnitude >100 degrees was a risk factor for complications.

PMID: 11675549 [PubMed-in process]