Results of Charleston bracing in skeletally immature patients with idiopathic scoliosis

Previous studies have reported varying success rates with the use of the Charleston brace in idiopathic scoliosis. However, these studies have included patients from multiple centers, those with double curves, and those still undergoing treatment. This article presents the results of Charleston bracing in 42 skeletally immature patients (Risser 0/1) treated at one institution and followed up for a mean of 3.3 years after brace discontinuation. Selection criteria included a diagnosis of idiopathic scoliosis, Risser stage 0 or 1, at least 10 years of age at the time of bracing, female gender, a single curve between 25 degrees and 40 degrees, and no prior treatment. The average age at the time of bracing was 12.5 years (range 10-15) and the average curve was 30.3 degrees (range 25 degrees -40 degrees ). Outcome was considered a failure if the curve had increased more than 5 degrees at last follow-up, if surgical intervention was required, or if there was a change of orthosis during treatment (e.g., Charleston to Boston). In 25 of the 42 patients (60%), the brace was successful in preventing progression of the curve (mean follow-up 3.4 years; range 1.1-11.7). Thoracic curves had the same success as thoracolumbar and lumbar curves. Based on these results, the authors conclude that the Charleston brace is effective in preventing progression of curve. Proper patient selection is important.     

青少年特发性脊柱侧凸患者脊柱柔韧性的影响因素

目的:探讨青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)患者脊柱柔韧性的可能影响因素.方法:选取2006年12月～2008年4月在我院脊柱外科手术治疗的204例AIS患者,男性36例,女性168例,平均年龄15.0岁;平均Cobb角50.1°;平均Risser征3.4度;主弯跨度平均6.8个椎体;主弯顶椎旋转度平均2.0度.摄站立位全脊柱正侧位及仰卧左右侧屈位X线片,计算主弯柔韧性.采用相关分析研究各临床指标与主弯柔韧性的相关性.结果:女性AIS患者的脊柱柔韧性明显高于男性(P<0.05);胸腰弯组和腰弯组AIS患者的脊柱柔韧性显著大于胸弯组(P<0.05),胸腰弯和腰弯组之间无显著性差异(P>0.05).女性AIS患者中的年龄及主弯Cobb角(站立位与侧屈位)均与脊柱柔韧性显著负相关(P<0.05),且胸弯女性AIS患者的月经初潮至手术时间及顶椎旋转度也与脊柱柔韧性显著负相关(P<0.05).男性胸弯AIS患者中侧屈位主弯Cobb角、胸腰弯/腰弯组中主弯Cobb角(站立位与侧屈位)均与脊柱柔韧性显著负相关(P<0.05).主弯跨度及Risser征与脊柱柔韧性均无明显相关性(P>0.05).结论:女性AIS患者脊住柔韧性受年龄、月经初潮至手术时间、主弯Cobb角(站立位与侧屈位)、弯型及顶椎旋转度等因素影响;男性AIS患者的脊柱侧凸柔韧性主要受主弯Cobb角及弯型影响.     

A study of the radiologic predictors of curve flexibility in adolescent idiopathic scoliosis

STUDY DESIGN: A study of flexibility of 101 idiopathic scoliosis antero-posterior radiographs. OBJECTIVE: To discover if there are any parameters on plain antero-posterior radiographs that can predict the flexibility of scoliosis curves. SUMMARY OF BACKGROUND DATA: Previously the flexibility index, generated from fulcrum bending x-rays, has been shown to be an accurate measure of curve stiffness. METHODS: Five postulated predictors of flexibility, measured on 101 immediate preoperative scoliosis radiographs, were compared with the flexibility index generated from fulcrum bending radiographs. Correlation between the 5 parameters and flexibility index was studied. Further analysis was performed to assess the significance of curve location in prediction of flexibility. Linear regression analysis was used. RESULTS: Linear regression including all 5 predictors showed Cobb angle and age to be the only significant predictors of flexibility. When Cobb angle and age were analyzed with location (thoracic, thoracolumbar) this was also found to be a significant factor. CONCLUSIONS: Cobb angle, age, and curve location are useful predictors of flexibility on antero-posterior radiographs. This may aid preoperative planning in the out-patients department.     

幼儿特发性脊柱侧凸研究进展

幼儿时期的脊柱存在很大的生长潜能,因此幼儿期的特发性脊柱侧凸（immature idiopathic scoliosis,immature IS）是临床上的一个诊治难题。若处理不及时可以导致脊柱侧凸进一步加重、发展加快、影响心肺等系统的功能发育。手术干预处理过早则会破坏脊柱的正常生长发育规律,造成脊柱发育不全等。因此充分理解幼儿IS的特点对正确选择治疗时机和方法显得十分重要。本文通过分析最近的相关文献,对幼儿IS的基础和临床研究进展作一综述。     

Evaluating flexibility and predicting curve correction using fulcrum-bending radiographs in Lenke type 2 adolescent idiopathic scoliosis

BackgroundFulcrum-bending (FB) correction is considered to provide the best estimation of main thoracic (MT) curve flexibility and postoperative correction in surgical treatment for adolescent idiopathic scoliosis (AIS). However, few studies evaluated the usefulness of FB radiographs for proximal thoracic (PT) curve. We aimed to perform flexibility assessments using both active side-bending (SB) and FB radiographs and evaluate surgical outcomes after posterior spinal fusion (PSF) for Lenke type 2 AIS.MethodsThis study included 38 consecutive patients with Lenke type 2 AIS who underwent PSF using a pedicle screw construct with a minimum 2-year follow-up. Radiographic parameters, including correction rate, SB and FB flexibility, and FB correction index (FBCI: [correction rate/FB flexibility] × 100), were evaluated preoperatively, immediately after surgery, and at the 2-year follow-up. The clinical outcomes were preoperatively evaluated using the Scoliosis Research Outcomes Instrument-22 and at the follow-up.ResultsAll scoliosis curves significantly improved and shoulder balance shifted toward left shoulder elevation (all comparisons, p < 0.0001). There were significant differences between the SB and FB corrections in the PT and MT curves (p < 0.0001). The magnitudes of the discrepancies between the SB and FB corrections in the PT and MT curves were 11.2° ± 5.2° and 11.6° ± 7.2°, respectively. FB correction did not differ from postoperative Cobb angles correction immediately after surgery or at the 2-year follow-up; the mean FBCIs in the PT and MT curves were 98.8% and 105.5%, respectively. The self-image domain SRS-22 scores had significantly increased at the 2-year follow-up (p < 0.0001).ConclusionsThere were significant differences between the SB and FB corrections, and FB correction tended to approximate the postoperative curve correction (FBCI = 100%) for PT and MT curves in patients with Lenke type 2 AIS. FB flexibility is more reliable than SB flexibility in evaluating actual curve flexibility even for the PT curve.     

Muscle adaptation during distraction osteogenesis in skeletally immature and mature rabbits.

The lack of adaptation of muscle is thought to be a major source of complications during distraction osteogenesis (DO). Although adaptation to DO varies with the regimen (lengthening rate >1 mm/day and increase in bone length >20%) muscle contractures associated with DO may be a function of age. We tested this idea by subjecting skeletally mature and skeletally immature rabbits to an aggressive regimen of DO (1.4 mm/day with a 20% increase in tibial length). By using immunofluorescence to assess the presence of neonatal myosin heavy chain in sections from the tibialis anterior, we observed that the generation of new muscle tissue in response to DO was vigorous in young animals (27% positive fibers), whereas it was more muted in adult animals (9.9% positive fibers). This adaptive response was associated with a pronounced proliferation of myoblasts in the young but not in the mature animals. Adult tibialis anterior subjected to DO showed a 50% loss in tetanic and twitch tension whereas those in young animals did not. This correlated with partial denervation of adult but not young muscle, as judged by morphological criteria. These experiments indicate that adaptation to DO depends not only on mechanical variables but also on skeletal maturity.     

青少年特发性脊柱侧凸术前柔韧性评估方法概述

青少年特发性脊柱侧凸矫形手术的目的是：在融合较短脊柱节段的条件下矫正畸形,阻止畸形进展,得到一个在冠状面和矢状面平衡的躯干。术前柔韧性评估在确定脊柱侧凸的结构性特点、选择手术入路、确定融合节段、预测矫形效果等方面有重要意义。虽然柔韧性作为脊柱侧凸术前常规评估的指标已被广泛使用,但仍存在以下问题：柔韧性的定义模糊,导致很多学者对柔韧性一词的误解和误用;     

Assessment of curve progression in idiopathic scoliosis

In a 5-year prospective study on idiopathic scoliosis, an attempt was made to elucidate the natural history of the disease and to determine which factors contribute to curve progression. A total of 85,622 children were examined for scoliosis in a prospective school screening study carried out in northwestern and central Greece. Curve progression was studied in 839 of the 1,436 children with idiopathic scoliosis of at least 10° detected from the school screening program. Each child was followed clinically and roentgenographically for one to four follow-up visits for a mean of 3.2 years. Progression of the scoliotic curve was recorded in 14.7% of the children. Spontaneous improvement of at least 5° was observed in 27.4% of them, with 80 children (9.5%) demonstrating complete spontaneous resolution. Eighteen percent of the patients remained stable, while the remaining patients demonstrated nonsignificant changes of less than 5° in curve magnitude. A strong association was observed between the incidence of progression and the sex of the child, curve pattern, maturity, and to a lesser extent age and curve magnitude. More specifically, the following were associated with a high risk of curve progression: sex (girls); curve pattern (right thoracic and double curves in girls, and right lumbar curves in boys); maturity (girls before the onset of menses); age (time of pubertal growth spurt); and curve magnitude (≥ 30°). On the other hand, left thoracic curves showed a weak tendency for progression. In conclusion, the findings of the present study strongly suggest that only a small percentage of scoliotic curves will undergo progression. The pattern of the curve according to curve direction and sex of the child was found to be a key indicator of which curves will progress. Received: 4 October 1997 Revised: 10 February 1998 Accepted: 11 March 1998     

Fulcrum像评价青少年特发性脊柱侧凸柔韧性和预测矫形的意义

[目的]前瞻性研究术前支点弯曲(fulcrum)像评价青少年特发性脊柱侧凸(AIS)柔韧性和预测手术矫形效果的价值.[方法]根据入选和排除标准选择2003年10月～2006年8月的AIS患者64例,病例均为单弯(PUMC Ⅰa/Ⅰb/Ⅰc型),根据术前站立正位X像Cobb's角大小分为4组中度胸弯组(20例,40°＜Cobb's≤60°)、重度胸弯组(15例,Cobb's＞60°)、中度腰弯组(17例,35°＜Cobb's≤60°)和重度腰弯组(8例,Cobb's＞60°).各组按PUMC原则接受相同手术方法,均采用第3代节段性内固定系统.测量术前站立全脊柱正位像、fulcrum像及术后正位像的Cobb's角,分析fulcrum像和术后正位像Cobb's角的相关性并计算出fulcrum像侧凸柔韧性和术后侧凸矫正率,所得结果进行统计学分析.[结果]除中度胸弯组fulcrum像柔韧性和手术矫正率相比无显著差异(P=0.141)外,其余组均差异显著;中度胸弯组术后正位像和fulcrum像的Cobb's角相比无显著差异(P=0.094),其余组均差异显著;术后正位像和fulcrum像的Cobb's角呈正相关,但中度腰弯组相关性一般(r=0.525).[结论]Fulcrum只能评价和预测中度胸弯的柔韧性和术后矫正率,现代内固定器械发展尤其是全椎弓根螺钉的应用可获得更好的侧凸矫正率.     

Prospective comparison of flexibility radiographs in adolescent idiopathic scoliosis

STUDY DESIGN: A prospective evaluation of radiographs in patients undergoing anterior spinal fusion or posterior spinal fusion for adolescent idiopathic scoliosis. OBJECTIVE: To determine the most effective preoperative radiographic method for evaluating coronal plane flexibility by comparing preoperative and postoperative correction. SUMMARY OF BACKGROUND DATA: Curve flexibility is traditionally evaluated with side-bending radiographs. Recently, the fulcrum-bending radiograph was shown to provide better correction of thoracic curves undergoing posterior spinal fusion but was not evaluated in thoracolumbar/lumbar curves or in patients undergoing anterior spinal fusion. METHODS: Preoperative coronal radiographs of 46 consecutive patients undergoing spinal fusion for adolescent idiopathic scoliosis obtained while standing, lying supine, side-bending (maximally bending while supine), push-prone (padded bolsters applied to chest wall while prone), and fulcrum-bending (curve apex suspended over a radiolucent fulcrum while lateral) were compared with standing postoperative radiographs. Cobb angles were determined and evaluated for statistical significance. RESULTS: The fulcrum-bending radiograph demonstrated statistically better correction than other preoperative methods for main thoracic curves (P < 0.01) but fell short of demonstrating the correction obtained surgically. There was no statistical difference between side-bending, fulcrum-bending, or postoperative correction for thoracolumbar/lumbar curves (all P values > 0.07). The left side-bending was the most effective method for reducing upper thoracic curves (P < 0.001). There was no difference in the results obtained for curves corrected by anterior spinal fusion or anterior spinal fusion. CONCLUSION: To achieve maximal preoperative correction, thoracic fulcrum-bending radiographs should be obtained for evaluating main thoracic curves, whereas side-bending radiographs should continue to be used for evaluating both upper thoracic and thoracolumbar/lumbar curves.     

Osteoblastoma in the skeletally immature

BACKGROUND: Osteoblastoma is a rare benign and sometimes locally aggressive tumor with peak incidence in the second decade. None of the available series addresses specifically the differences in presentation, management, and outcome between the pediatric and adult patient populations. METHODS: The medical records and radiographs of all children diagnosed with osteoblastoma during a 17-year period were reviewed. We recorded demographic information, time until diagnosis, location, clinical and radiographic characteristics, treatment, complications, and outcome at a minimum 2-year follow-up (range, 2-5 years). RESULTS: Seventeen children met the inclusion criteria. There were 10 boys and 7 girls, with an average age at diagnosis of 11 years (range, 20 months-15 years). The average time delay between onset of symptoms and diagnosis was 6.5 months (range, 2 months-2 years). There were 7 lesions in the lower extremity, 5 in the spine, 4 in the upper extremity, and 1 in the sternum. Pain at the tumor site was present in all cases. Two of the 5 patients with spine lesion had scoliosis. All patients underwent open incisional biopsy with intraoperative frozen section. In 16 cases, this was followed by a 4-step approach (extended curettage, high-speed burring, electrocauterization of cavity wall, and phenol 5% solution). Four of the 5 patients with spine lesions had instrumented posterior spine fusion after tumor removal. Two patients were referred to our institution with recurrent lesion after surgery elsewhere. Only 1 (6%) of 15 children initially treated at our institution had recurrence. All recurrences occurred in children younger than 6 years; all were successfully treated with a 4-step approach. CONCLUSIONS: Osteoblastomas can be successfully treated with a 4-step approach. Children younger than 6 years may have a higher likelihood of recurrence.     

青少年特发性脊柱侧凸生长潜能及侧凸进展风险评估的研究进展

<正>青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)是一种发生于青春发育高峰期的、以女性多见的脊柱畸形,不同国家与地区的AIS发病率波动在1%~4%[1、2]。支具治疗被证明是唯一有效的非手术治疗AIS的策略[3~6],但在严格的支具治疗下,仍有部分患儿最终会因侧凸进展而必须行手术治疗[7、8]。因此,在临床治疗中如能准确评估AIS患儿的侧凸进展风险,则可以根据不同的侧凸进展风险制定不同的治疗策略,从而改善AIS患儿的预     

Maturity assessment and curve progression in girls with idiopathic scoliosis

BACKGROUND: Scoliosis progression during adolescence is closely related to patient maturity. Maturity has various indicators, including chronological age, height and weight changes, and skeletal and sexual maturation. It is not certain which of these indicators correlates most strongly with scoliosis progression. The purpose of the present study was to evaluate various maturity measurements and how they relate to scoliosis progression. METHODS: Physically immature girls with idiopathic scoliosis were evaluated every six months through their growth spurt with serial spinal radiographs; hand skeletal ages; Oxford pelvic scores; Risser sign determinations; height; weight; sexual staging; and serologic studies of the levels of selected growth factors, estradiol, bone-specific alkaline phosphatase, and osteocalcin. These measurements were then correlated with the curve-acceleration phase. RESULTS: The period and pattern of curve acceleration began during Risser stage 0 for all patients. Skeletal maturation scores derived with the use of the Tanner-Whitehouse-III RUS method, particularly those for the metacarpals and phalanges, were superior to all other indicators of maturity. Regression of the scores provided good estimates of maturity relative to the period of curve progression (Pearson r = 0.93). The initiation of this period occurred simultaneously with digital changes from Tanner-Whitehouse-III stage F to G. At this stage, curves also separated into rapid, moderate, and low-acceleration patterns, with specific curve types in the rapid and moderate-acceleration groups. The low-acceleration group was not confined to a specific curve type. CONCLUSIONS: The curve-acceleration phase separates curves into various types of curve progression. The Tanner-Whitehouse-III RUS scores are highly correlated with timing relative to the curve-acceleration phase and provide better maturity determination and prognosis determination during adolescence than the other parameters tested. Accurate skeletal maturity determination should be used as the primary maturity measurement in girls with idiopathic scoliosis.     

The significance of the lumbosacral curve in idiopathic scoliosis

The purpose of this study is to clarify the role of the lumbosacral curve in idiopathic scoliosis from several points of view. Cases with idiopathic scoliosis were radiologically analysed in the frontal plane, in the horizontal plane with CT-scan and in the sagittal plane, and the relationship of these dimensional deformites in the lumbosacral junction was studied. These findings were also contrasted with the severity, the pattern and the chronological changes of the main curve above. From the results it can be said that the lumbosacral curve is not necessarily a compensatory curve, but may play a more positive role in the formation of the curve pattern of the entire spine. Generally, the lumbosacral junction of thoracic scoliosis was less mobile than that of lumbar and double major cases. It was difficult, however, to predict the potential progress of a mild scoliosis from the attitude of the lumbosacral junction.