Search

Background: The North American non-surgical standard of care for adolescent idiopathic scoliosis (AIS) includes observation and bracing, but not exercises. Schroth physiotherapeutic scoliosis-specific exercises (PSSE) showed promise in several studies of suboptimal methodology. The Scoliosis Research Society calls for rigorous studies supporting the role of exercises before including it as a treatment recommendation for scoliosis., Objectives: To determine the effect of a six-month Schroth PSSE intervention added to standard of care (Experimental group) on the Cobb angle compared to standard of care alone (Control group) in patients with AIS., Methods: Fifty patients with AIS aged 10-18 years, with curves of 10°-45° and Risser grade 0-5 were recruited from a single pediatric scoliosis clinic and randomized to the Experimental or Control group. Outcomes included the change in the Cobb angles of the Largest Curve and Sum of Curves from baseline to six months. The intervention consisted of a 30-45 minute daily home program and weekly supervised sessions. Intention-to-treat and per protocol linear mixed effects model analyses are reported., Results: In the intention-to-treat analysis, after six months, the Schroth group had significantly smaller Largest Curve than controls (-3.5°, 95% CI -1.1° to -5.9°, p = 0.006). Likewise, the between-group difference in the square root of the Sum of Curves was -0.40°, (95% CI -0.03° to -0.8°, p = 0.046), suggesting that an average patient with 51.2° at baseline, will have a 49.3° Sum of Curves at six months in the Schroth group, and 55.1° in the control group with the difference between groups increasing with severity. Per protocol analyses produced similar, but larger differences: Largest Curve = -4.1° (95% CI -1.7° to -6.5°, p = 0.002) and [Formula: see text] (95% CI -0.8 to 0.2, p = 0.006)., Conclusion: Schroth PSSE added to the standard of care were superior compared to standard of care alone for reducing the curve severity in patients with AIS., Trial Registration: NCT01610908., Competing Interests: The authors have declared that no competing interests exist.

Study Design: Retrospective study of the coronal curvature measurement on ultrasound (US) images with the aid of previous radiographs., Objective: To compare the reliability and accuracy of the coronal curvature measurements from US images on children who have adolescent idiopathic scoliosis (AIS) with and without the knowledge of previous radiographs., Summary of Background Data: Using US imaging technique to measure coronal curvature on children with AIS has demonstrated high intra- and interrater reliabilities. However, the selection of end-vertebrae and the measurement difference between radiography and the US method were only moderately reliable., Methods: Two raters measured the coronal curvatures from 65 AIS standing US spine images, without (measured one time) and with the aid of previous standing radiographs (measured two times). The intra- and interrater reliability, the correlation and the difference between the radiographic and US measurements, and the error index of the end-vertebrae selection were assessed., Results: Overall, 109 curves were investigated. The intraclass correlation coefficients (ICC) of intra- and interrater reliability of the US coronal curvature measurement with the aid of previous radiographs (AOR) were 0.95 and 0.91, respectively. In comparison with the radiographic measurements, the correlation of AOR method (R) was 0.90 and the MAD was 2.8°; the corresponding results of the US measurement without the AOR (blinded US method) were 0.73° and 4.8°, respectively. The average error index on end-vertebral selection improved 43% with the AOR., Conclusion: The AOR method significantly improved reliability and accuracy of the spinal curvature measurement on US images compared with the blinded US method (P<0.001). It indicates that US standing images with the AOR can be used as a reliable and accurate nonionizing imaging method to monitor children with AIS., Level of Evidence: 3.

Purpose: To determine the reliability of a prognostic curve progression model and the role of the quantity and quality of brace wear for adolescent idiopathic scoliosis (AIS) brace treatment., Methods: To develop a curve progression model for full-time AIS brace treatment, 20 AIS subjects (Group 1) prescribed full-time thoracolumbar sacral orthosis (TLSO) were monitored and followed for 2 years beyond maturity. The developed curve progression model was: curve progression (in degrees) = 33 + 0.11 × Peterson risk (%) - 0.07 in-brace correction (%) - 0.45 × quality (%) - 0.48 × quantity (%) + 0.0062 × quantity × quality. To validate the model, 40 new (test) subjects (Group 2) who met the same inclusion criteria and used the same type of monitors, were monitored and followed for 2 years after bracing., Results: For the 40 test subjects (Group 2), the average in-brace correction was 40 ± 22 %. The average quantity and quality of the brace wear were 56 ± 19 and 55 ± 17 %, respectively. Twelve subjects (30 %) progressed of which 10 subjects (25 %) required surgery and 28 subjects (70 %) showed no progression. The accuracy of the model to determine which patients would progress was 88 % (35/40) which was better than the Peterson's risk model (68 %; 26/40) alone. Patients who had the combined quantity times the quality over a threshold 43 % had a success treatment rate of 95 %., Conclusions: This study showed the prognostic model of brace treatment outcome on AIS patients treated with full-time TLSO was reliable. Both the quantity and quality of the brace wear were important factors in achieving successful brace treatment.

Purpose: The objectives of this preliminary study were to assess the reliability and accuracy of ultrasound (US) for measuring coronal curvature with and without the aid of a previous radiograph, and to evaluate the ability of US to detect curve progression in adolescent idiopathic scoliosis (AIS) patients., Methods: Four raters measured 20 AIS US images twice at one-week intervals. Intra-rater reliability and correlation with radiograph were investigated with (rater 1) and without (raters 2-4) the aid of a previous radiograph. The center of lamina (COL) method was used to approximate the Cobb angle., Results: Thirty-six curves were identified. All raters showed high intra-rater reliability (ICC[2,1] >0.80). With the aid of a previous radiograph, rater 1 showed higher correlation with radiograph (ICC[2,1] = 0.86), better standard error of measurement (SEM = 2.2°), and improved error index of selecting end-vertebrae (EI = 1.34), but no statistical improvement of intra-rater reliability (p > 0.05). For rater 2-4, the range of the ICC[2,1] values between US and radiograph measurements, the SEM value, and the range of the EI values were 0.70°-0.72°, 3.3°, and 1.65°-2.36°, respectively. Specificity and sensitivity of US for detecting curve progression were 0.91 and 0.83, respectively., Conclusions: Using a previous radiograph as a measurement aid helped the user to measure coronal curvature from US images, and improved the accuracy of end-vertebrae selection. US showed high sensitivity and specificity for detecting curve progression, indicating that US may be a suitable, radiation-free alternative for monitoring patients with AIS who have mild or moderate curves.

The outcomes of brace treatment for scoliosis depend on how the brace is used. Simply prescribing a brace does not mean it will be worn properly. A smart brace has been developed to control the brace wear tightness with the expectation that appropriately worn braces will improve outcomes. Twelve brace candidates (10F; 2M) agreed to participate into this study and were randomly divided into 2 groups. The smart brace group used the smart brace for the first year, and then wore the standard brace for the following year. The standard rigid brace group wore their TLSO for 2 years. Both groups were followed for 3 years after they finished the brace treatment. The smart brace group showed better quality of brace wear, wearing their brace at the prescribed tightness level a higher proportion of time than the standard brace group. All subjects in the smart brace group had successful outcomes, Cobb angle changed less than 5°, whereas 2/6 subjects in the standard brace group had unsuccessful bracing. One had 7° increment and 1 underwent surgery. The smart brace group also reported that the smart brace was more comfortable to wear than the standard rigid brace.

Bracing is the most commonly used non-surgical treatment for adolescent idiopathic scoliosis (AIS) and requires an extensive commitment on the part of the patient and family. However, demonstrating efficacy of brace treatment for AIS has been hampered by the lack of compressive information about wear characteristics. The first 6 months is considered a critical time to evaluate whether AIS patients will commit to the treatment and may predict the treatment outcome. The characteristics of brace wear can assist clinicians to provide better support and aid long term compliance with treatment. This study describes the first 6 month brace wear characteristics in 15 AIS patients (12F;3M) who were prescribed full-time brace wear. There was a statistically significant increase in wear time (p = 0.02) after brace fitting and the brace wear tightness stabilized after month 4. The force at the major pressure pad area continuously decreased after month 2. A moderate correlation was found between the (quantity * quality) of the brace wear at month 6 and the change of Cobb angle (first out of brace - pre brace) (r2 = 0.47). The more time that the brace was worn and the higher proportion of time worn at the prescribed tightness or above improves the likelihood of a better treatment result.

Study Design: Development of a computer-aided Cobb measurement method and evaluation of its reliability., Objectives: To reduce the variability of Cobb angle measurement by developing the computer-aided method and to investigate if the developed method is sensitive to observer skill levels or experiences., Summary of Background Data: Therapeutic decisions for scoliosis heavily rely on the Cobb angle measured from consecutive radiographs. The manual Cobb measurement is subject to human errors. The observer error is 3 to 10 degrees resulted from different end-vertebrae selection and/or manually drawing variable best-fit lines to the endplates of the end-vertebrae., Methods: A fussy Hough transform technique was used to develop a computer-aided method to detect the vertebral endplates. The Cobb angle, upper end-vertebra, and lower end-vertebra were then measured automatically. The computer-aided method was tested twice by each of 3 observers in 84 posteroanterior radiographs from patients with adolescent idiopathic scoliosis. The intraobserver and interobserver errors were analyzed., Results: Both the intraobserver and interobserver reliability analyses resulted in the intraclass correlation coefficients higher than 0.9 for the Cobb angle. The average intraobserver and interobserver errors were less than 3 degree for the Cobb angle, and less than 0.3 levels for both the upper and lower end-vertebral identification. There were no significant differences in the measurement variability between groups of curve location (thoracic, thoracolumbar, and lumbar), curve direction (right and left), curve magnitude (curves less than 25 degree, between 25 and 45 degrees, and more than 45 degree), and observer experience (experienced observer and inexperienced observers)., Conclusions: Compared with the documented results, variability of the Cobb measurement is reduced by using the developed computer-aided method. This method can help orthopedic surgeons measure the Cobb angle more reliably during scoliosis clinics.

In order to reduce the observer variability in radiographic scoliosis assessment, a computer-aided system was developed. The system semi-automatically measured the Cobb angle and vertebral rotation on posteroanterior radiographs based on Hough transform and snake model, respectively. Both algorithms were integrated with the shape priors to improve the performance. The system was tested twice by each of three observers. The intraobserver and interobserver reliability analyses resulted in the intraclass correlation coefficients higher than 0.9 and 0.8 for Cobb measurement on 70 radiographs and rotation measurement on 156 vertebrae, respectively. Both the Cobb and rotation measurements resulted in the average intraobserver and interobserver errors less than 2 degrees and 3 degrees , respectively. There were no significant differences in the measurement variability between groups of curve location, curve magnitude, observer experience, and vertebra location. Compared with the documented results, measurement variability is reduced by using the developed system. This system can help orthopedic surgeons assess scoliosis more reliably.

Scoliosis surgery involves the insertion of screws and/or hooks into selected vertebrae to secure a pre-bent rod placed along the concave side of the spine. Usually conventional x-rays will be taken before the surgery to plan the alignment and positioning of the pedicle screws. However, reports state that perforation rate range from 6% to 54%. A misalignment of a pedicle screw can potentially cause permanent neurological spinal cord injury or even a life-threatening vascular injury. Because of the importance of positioning and aligning of pedicle screws, we are working on an ultrasound method to guide the insertion of pedicle screws in real time. A pulse-echo immersion experiment was set up to study how well the edges of cortical bone could be detected using a bovine spinous process in-vitro. Two ultrasound frequencies (3.5 MHz and 5.0 MHz) were considered in this study. This preliminary study shows that ultrasound is able to penetrate cortical bone and reflect back from the outer boundary. All interfaces are clearly identified for both frequencies. Strong reflection signals are obtained when the beam is normal to the interface. Derived thickness values from the reflections are comparable with those from micro-CT image. The 5.0 MHz ultrasound frequency provided better resolution than the 3.0 MHz frequency.

To reduce variability of Cobb angle measurement for scoliosis assessment, a computerized method was developed. This method automatically measured the Cobb angle on spinal posteroanterior radiographs after the brightness and the contrast of the image were adjusted, and the top and bottom of the vertebrae were selected. The automated process started with the edge detection of the vertebra by Canny edge detector. After that, the fuzzy Hough transform was used to find line structures in the vertebral edge images. The lines that fitted to the endplates of vertebrae were identified by selecting peaks in Hough space under the vertebral shape constraints. The Cobb angle was then calculated according to the directions of these lines. A total of 76 radiographs were respectively analyzed by an experienced surgeon using the manual measurement method and by two examiners using the proposed method twice. Intraclass correlation coefficients (ICC) showed high agreement between automatic and manual measurements (ICCs > 0.95). The mean absolute differences between automatic and manual measurements were less than 5 degrees . In the interobserver analyses, ICCs were higher than 0.95, and mean absolute differences were less than 5 degrees . In the intraobserver analyses, ICCs were 0.985 and 0.978, respectively, for each examiner, and mean absolute differences were less than 3 degrees . These results demonstrated the validity and reliability of the proposed method.

Choosing the most suitable treatment for scoliosis relies heavily on accurate and reproducible Cobb angle measurement from successive radiographs. The objective is to reduce variability of Cobb angle measurement by reducing user intervention and bias. Custom software to increase automation of the Cobb angle measurement from posteroanterior radiographs was developed using active shape models. Validity and reliability of the automated system against a manual and semiautomated measurement method was conducted by two examiners each performing measurements on three occasions from a test set (N = 22). A training set (N = 47) of radiographs representative of curves seen in a scoliosis clinic was used to train the software to recognize vertebrae from T4 to L4. Images with a maximum Cobb angle between 20 degrees and 50 degrees , excluding surgical cases, were selected for training and test sets. Automated Cobb angles were calculated using best-fit slopes of the detected vertebrae endplates. Intraclass correlation coefficient (ICC) and standard error of measurement (SEM) showed high intraexaminer (ICC > 0.90, SEM 2 degrees -3 degrees ) and interexaminer (ICC > 0.82, SEM 2 degrees -4 degrees ), but poor intermethod reliability (ICC = 0.30, SEM 8 degrees -9 degrees ). The automated method underestimated large curves. The reliability improved (ICC = 0.70, SEM 4 degrees -5 degrees ) with exclusion of the four largest curves (>40 degrees ) in the test set. The automated method was reliable for moderate-sized curves, and did detect vertebrae in larger curves with a modified training set of larger curves.

Adolescent idiopathic scoliosis (AIS) presents as an abnormal curvature of spine with vertebral rotation. It may impact the patient for their entire life. Approximately 0.25% of adolescents will require treatment. Brace treatment is the most commonly used non-surgical treatment for AIS. Its goal is stop the progression and maintain the curve at an acceptable level through the high risk growth phase of adolescence. However, its effectiveness is controversial and the actual biomechanical action of the brace is not fully understood. Recently, the Scoliosis Research society (SRS) created a standard criterion for AIS brace studies. However, to evaluate the effectiveness of the brace treatment, the spine flexibility, in brace correction and patient's compliance should also be included in a study. Although bracing has been used for more than 50 years, there are still many unknowns. How much wear time per day is needed for an optimum treatment outcome? How much brace tightness is optimal? What is the best weaning protocol? What is the best method to determine the curve flexibility? How much in-brace correction is needed to obtain good results? Without accurate and precise methods to objectively measure or answer the above questions, it is misleading to state whether or not brace treatment is effective. Therefore, a lot of research is still required before one can answer the effectiveness of the brace treatment.

Study Design: Retrospective cross-sectional assessment of the reproducibility and reliability of radiographic parameters., Objective: To measure the intra-examiner and interexaminer reproducibility and reliability of salient radiographic features., Summary of Background Data: The management and treatment of adolescent idiopathic scoliosis (AIS) depends on accurate and reproducible radiographic measurements of the deformity., Methods: Ten sets of radiographs were randomly selected from a sample of patients with AIS, with initial curves between 20 degrees and 45 degrees. Fourteen measures of the deformity were measured from posteroanterior and lateral radiographs by 2 examiners, and were repeated 5 times at intervals of 3-5 days. Intra-examiner and interexaminer differences were examined. The parameters include measures of curve size, spinal imbalance, sagittal kyphosis and alignment, maximum apical vertebral rotation, T1 tilt, spondylolysis/spondylolisthesis, and skeletal age., Results: Intra-examiner reproducibility was generally excellent for parameters measured from the posteroanterior radiographs but only fair to good for parameters from the lateral radiographs, in which some landmarks were not clearly visible. Of the 13 parameters observed, 7 had excellent interobserver reliability., Conclusions: The measurements from the lateral radiograph were less reproducible and reliable and, thus, may not add value to the assessment of AIS. Taking additional measures encourages a systematic and comprehensive assessment of spinal radiographs.

Study Design: A retrospective cross-sectional review studied the posteroanterior and lateral bending radiographs of 26 preoperative patients with thoracic major adolescent idiopathic scoliosis., Objective: To characterize the relation of vertebral axial rotation, apparent vertebral wedging, and disc wedging with lateral bending in patients with severe adolescent idiopathic scoliosis., Summary of Background Data: Lateral bending radiographs are used commonly in surgical planning to assess the flexibility of the spine and to establish the placement of instrumentation. However, their use in the assessment of motion in the axial plane has not been clearly established., Methods: Data were collected retrospectively from 26 subjects immediately before spinal surgery. All the subjects had adolescent idiopathic scoliosis with right thoracic major curves. Axial rotation, vertebral wedging, and disc wedging were measured from T4 to L4 on left and right supine bending and standing posteroanterior radiographs. The apexes of the major and minor curves, the neutral vertebrae, and the Cobb angles were recorded., Results: No significant differences in axial rotation were found at the thoracic apex, neutral vertebrae, or lumbar apex in response to lateral bending. Most of the wedging occurs in the disc, and is maximal at the apex of the curve. The total amount of wedging was higher in more severe curves., Conclusions: Lateral bending does not improve axial rotation in severe scoliosis (scoliosis for which surgical correction is advised). Structural changes including disc and vertebral wedging may be responsible for the lack of rotational correction of the scoliotic spine. Lack of axial flexibility in the thoracic region may hamper surgical attempts to correct the deformities of the trunk.

The outcomes of brace treatment for scoliosis depend on how the brace is used. Simply prescribing a brace does not mean it will be worn properly. A smart brace has been developed to control the brace wear tightness with the expectation that appropriately worn braces will improve outcomes. Twelve brace candidates (10F; 2M) agreed to participate into this study and were randomly divided into 2 groups. The smart brace group used the smart brace for the first year, and then wore the standard brace for the following year. The standard rigid brace group wore their TLSO for 2 years. Both groups were followed for 3 years after they finished the brace treatment. The smart brace group showed better quality of brace wear, wearing their brace at the prescribed tightness level a higher proportion of time than the standard brace group. All subjects in the smart brace group had successful outcomes, Cobb angle changed less than 5°, whereas 2/6 subjects in the standard brace group had unsuccessful bracing. One had 7° increment and 1 underwent surgery. The smart brace group also reported that the smart brace was more comfortable to wear than the standard rigid brace. [ABSTRACT FROM AUTHOR]

Bracing is the most commonly used non-surgical treatment for adolescent idiopathic scoliosis (AIS) and requires an extensive commitment on the part of the patient and family. However, demonstrating efficacy of brace treatment for AIS has been hampered by the lack of compressive information about wear characteristics. The first 6 months is considered a critical time to evaluate whether AIS patients will commit to the treatment and may predict the treatment outcome. The characteristics of brace wear can assist clinicians to provide better support and aid long term compliance with treatment. This study describes the first 6 month brace wear characteristics in 15 AIS patients (12F;3M) who were prescribed full-time brace wear. There was a statistically significant increase in wear time (p = 0.02) after brace fitting and the brace wear tightness stabilized after month 4. The force at the major pressure pad area continuously decreased after month 2. A moderate correlation was found between the (quantity * quality) of the brace wear at month 6 and the change of Cobb angle (first out of brace - pre brace) (r2 = 0.47). The more time that the brace was worn and the higher proportion of time worn at the prescribed tightness or above improves the likelihood of a better treatment result. [ABSTRACT FROM AUTHOR]

To reduce variability of Cobb angle measurement for scoliosis assessment, a computerized method was developed. This method automatically measured the Cobb angle on spinal posteroanterior radiographs after the brightness and the contrast of the image were adjusted, and the top and bottom of the vertebrae were selected. The automated process started with the edge detection of the vertebra by Canny edge detector. After that, the fuzzy Hough transform was used to find line structures in the vertebral edge images. The lines that fitted to the endplates of vertebrae were identified by selecting peaks in Hough space under the vertebral shape constraints. The Cobb angle was then calculated according to the directions of these lines. A total of 76 radiographs were respectively analyzed by an experienced surgeon using the manual measurement method and by two examiners using the proposed method twice. Intraclass correlation coefficients (ICC) showed high agreement between automatic and manual measurements (ICCs > 0.95). The mean absolute differences between automatic and manual measurements were less than 5°. In the interobserver analyses, ICCs were higher than 0.95, and mean absolute differences were less than 5°. In the intraobserver analyses, ICCs were 0.985 and 0.978, respectively, for each examiner, and mean absolute differences were less than 3°. These results demonstrated the validity and reliability of the proposed method. [ABSTRACT FROM AUTHOR]

Adolescent idiopathic scoliosis (AIS) presents as an abnormal curvature of spine with vertebral rotation. It may impact the patient for their entire life. Approximately 0.25% of adolescents will require treatment. Brace treatment is the most commonly used non-surgical treatment for AIS. Its goal is stop the progression and maintain the curve at an acceptable level through the high risk growth phase of adolescence. However, its effectiveness is controversial and the actual biomechanical action of the brace is not fully understood. Recently, the Scoliosis Research society (SRS) created a standard criterion for AIS brace studies. However, to evaluate the effectiveness of the brace treatment, the spine flexibility, in brace correction and patient's compliance should also be included in a study. Although bracing has been used for more than 50 years, there are still many unknowns. How much wear time per day is needed for an optimum treatment outcome? How much brace tightness is optimal? What is the best weaning protocol? What is the best method to determine the curve flexibility? How much in-brace correction is needed to obtain good results? Without accurate and precise methods to objectively measure or answer the above questions, it is misleading to state whether or not brace treatment is effective. Therefore, a lot of research is still required before one can answer the effectiveness of the brace treatment. [ABSTRACT FROM AUTHOR]

An abstract of the article "Brace treatment for adolescent idiopathic scoliosis-Protocols of the Canadian Spinal Deformity Study Group Surgeons," by Douglas L. Hill and colleagues is presented.