Orthosis. Cobb angle between 25º - 45º. Immature skeleton (Risser 0).

A 13-year-old female, with no relevant history, with menarche 3 months ago, followed since the age of 10 years by idiopathic scoliosis that has worsened. In the physical examination she presents a hump of 7 degrees in the Adams test and in the scoliogram a thoracolumbar curve T4-L1 of 35 degrees of Cobb and a Risser 0. The correct attitude to take will be:

Recommend swimming and revision in three months.

Refer to physiotherapy for spine elastification.

The natural history of idiopathic scoliosis.

Background. The natural history of idiopathic scoliosis is a crucial issue in the planning and assessment of different treatment methods. This article presents the evaluation of scoliotic deformity in immature patients who have been in observation without any treatment. Material and methods. 159 patients (128 girls, 31 boys) were examined between 1971 and 2002. Skoliosis was diagnosed at a mean age of 6 years 4 months (range 2.1-8.10), and observation was concluded at a mean age of 16 years 11 months (range 14.6-20.3). The mean follow-up was 10 years 5 months. The prognostic factors analyzed were: age, sex, Cobb angle, Mehta angle, apical vertebral rotation, specific rotation, Risser test. The progression and regression of curvature was analyzed in different biological age periods, and was measured by calculating the difference in the Cobb angle on successive x-rays divided by the interval between x-rays. Results. The mean progression of curvature before age 5 was 5.7 degrees per year; in the 6-10 age bracket, 2.3 degrees per year; in the 11-15 age bracket, 7.4 degrees per year; in the >15 age bracket, 0.3 degrees per year. The mean progression for patients with Risser 1 was 8.8 degrees per year; Risser 2, 7.3 degrees per year; Risser 3, 5.1 per year; Risser 4, 2.1 degrees per year; Risser 5, 0.3 degrees per year. Conclusions. The progression of curvature in idiopathic scoliosis is variable, and is influenced by age. Knowledge of the natural history of idiopathic scoliosis is a crucial tool in predicting the development of spinal curvature. The Risser test and biological age are the only effective predictors of progression.

Effectiveness of brace treatment for adolescent idiopathic scoliosis.

Effectiveness of brace treatment for adolescent idiopathic scoliosis (AIS) was demonstrated by the BrAIST study in 2013. Objectives of this study were to confirm its effectiveness by analyzing our results and to clarify the factors affecting the results of the treatment. According to the Scoliosis Research Society AIS brace studies standardization criteria, patients with age 10 years or older, Risser 0 to II, less than 1 year post-menarche, curve magnitude 25 to 40 degrees before brace treatment and who received no prior treatment were included in the study. At skeletal maturity, the rate of the patients whose curve was stabilized, exceeded 45 degrees, and who were recommended or underwent surgery were investigated. Additionally, initial correction rate by the brace and factors affecting the results were investigated. A total of 33 patients (27 females and 6 males) could be followed-up until their skeletal maturity and included in the analysis. An average age was 11.9 years, average Cobb angle was 30.8°, and Risser sign was 0 in 13 patients, I in 5, and II in 15 patients before treatment. There were 13 thoracic curves, 14 thoracolumbar or lumbar curves, and 6 double curves. Initial correction rate by the brace was 53.8% for the total curves. In terms of curve pattern, 34.4% for thoracic curve, 73.9% for thoracolumbar or lumbar curve, and 48.8% for double curve. After an average follow-up period of 33 months, 8 patients improved in more than 6 degrees, change of 17 patients were within 6 degrees, and 8 progressed in more than 6 degrees. Therefore, totally, 76% (25/33) of the curves were stabilized by the treatment. Four curves (12%) exceeded 45 degrees and one patient (3%) underwent surgery. Our results were better than the reported natural history. Factors that affected the results were hump degree before treatment and initial correction rate by the brace. 76% of the curve with AIS could be stabilized by brace treatment. Brace treatment was effective for treatment of AIS. Factors affecting the results were hump degrees and initial correction rate.

[The Schroth scoliosis-specific back school--initial results of a prospective follow-up study].

The prospective study reported here was instituted in 1987 to obtain more detailed data on the efficacy of scoliosis-specific spinal rehabilitation after Schroth. Inclusion criteria were 1) idiopathic scoliosis, 2) Risser stage < 4, 3) no treatment with corset or electrical stimulation, 4) first examination between 1 and 3 years postoperatively, 5) usable total X-rays taken with the patient standing not more than 6 months prior to admission. A total of 181 scoliosis patients with an average age of 12.76 years and an average Cobb angle of 27 degrees were included in the study. The average Risser's sign was 1.4 and the average follow-up period was 33 months. No cases of relative progression (annual increase in curvature of 5 degrees or more) were observed. For the purpose of comparison with the spontaneous course, the patients were grouped by age and severity of scoliosis. Both the absence of any relative progression as well as direct comparison of the development of scoliosis under therapy with the spontaneous course confirmed the efficacy of the stationary rehabilitation programme notably in cases with poor prognosis, i.e. with large scoliosis angles and unfavourable curvatures.

Effectiveness of the Charleston night-time bending brace in the treatment of adolescent idiopathic scoliosis.

Part-time or night-time bracing has been introduced to address the poor compliance and psychological burden of full-time bracing. The results of various bracing methods vary, however, due to a lack of consistent inclusion criteria and definitions of brace effectiveness. We have evaluated the effectiveness of the Charleston night-time bending brace in the treatment of adolescent idiopathic scoliosis based on the new standardized criteria proposed by the Scoliosis Research Society. To be included in this study, patients met the following criteria proposed by the Scoliosis Research Society: diagnosis of adolescent idiopathic scoliosis, age 10 years and older when the orthosis was prescribed, Risser 0-2, a primary curve magnitude of 25 to 40 degrees, and no prior treatment. A total of 95 patients (87 girls, 8 boys) were included. At skeletal maturity, 80 patients (84.2%) had 5 degrees or less curve progression and 15 (15.8%) had 6 degrees or more progression. Seven patients (7.8%) were recommended to undergo or underwent surgery before skeletal maturity. Eleven patients (12.6%) progressed beyond 45 degrees. According to these 3 criteria, the Charleston night-time brace was successful in 74 patients (77.9%). Depending on curve type, we observed success rates of 78.3% (47/60) for double, 71.4% (15/21) for thoracic, 83.3% (5/6) for thoracolumbar, and 87.5% (7/8) for lumbar curves. Success rates of 80.0% (36/45) and 76.0% (38/50) were observed in patients with curve magnitudes at bracing of 25 to 30 degrees and 31 to 40 degrees, respectively. Patients with high apex curves had a 67.6% (23/34) success rate, and those with low apex curves had 83.0% (39/47) success rate. Brace success rates among patients with initial Risser signs of 0, 1, and 2 were 68.8% (22/32), 80.6% (25/31), and 84.4% (27/32), respectively. Compared with the results of previous natural history and conventional brace study, the Charleston night-time bending brace is effective for the treatment of adolescent idiopathic scoliosis. Level VI.

Preliminary results and worst-case analysis of in patient scoliosis rehabilitation.

The purpose of this study was to assess the effectiveness of a scoliosis-specific rehabilitation programme as it is carried out in the Katharina Schroth Spinal Deformities Rehabilitation Center. Physiotherapy in the treatment of scoliosis patients is still regarded as ineffective since the study by the American Orthopedic Association in 1941, which showed that general exercises could not influence the natural history of scoliosis. However, specific exercise programmes were not known in the USA at that time. This preliminary study started in 1989 with the following inclusion criteria: (1) diagnosis of idiopathic scoliosis; (2) risser sign < 4; (3) no treatment other than physiotherapy; (4) first control after 1-3 years during repeated in patient treatment; (5) standing AP radiograph taken not more than 6 months before the first in patient treatment. A total of 181 scoliosis patients, with an average age of 12.7 years and an average angle of curvature of 27% according to Cobb, were included in this study. The average risser sign was 1.4, the average follow-up 33 months. The Cobb angle of the major curve was measured in a standardized way. The results of our preliminary study were compared to natural history as known from literature. For the worst-case analysis additionally a questionnaire was sent to the non-repeaters treated at our centre at the same time (1989 and 1990) as the patient sample described above, taking into account the same inclusion criteria for this patient sample except point 4. Results showed that progression as usually defined (increase in curvature of 5 degrees or more per year) has not been found in the preliminary study. The patient sample of this study was divided into different age groups and different groups of curve magnitude, for comparison with other studies. Additional to the patient sample of the preliminary study, 116 of the patients from the years 1989 and 1990 fulfilled the inclusion criteria of the preliminary study with the exception of point 4. These patients formed the questionnaire sample for the worst-case analysis showing that the progression rate of the 181 patients from the preliminary study and the 116 patients of the questionnaire sample together was still better than natural history even if all drop-outs were considered to be failures. The fact that there was no relative progression in our patients sample treated solely by physiotherapy (preliminary study), seems to show the effectiveness of the inpatient rehabilitation programme even in cases with a bad prognosis, severe angles of curvature and unfavourable curvature patterns. A worst-case analysis does not prevent this conclusion, even if all dropouts from the non-repeaters group were considered as failures.

Mild angle early onset idiopathic scoliosis children avoid progression under FITS method (Functional Individual Therapy of Scoliosis).

Physiotherapy for stabilization of idiopathic scoliosis angle in growing children remains controversial. Notably, little data on effectiveness of physiotherapy in children with Early Onset Idiopathic Scoliosis (EOIS) has been published.The aim of this study was to check results of FITS physiotherapy in a group of children with EOIS.The charts of the patients archived in a prospectively collected database were retrospectively reviewed. The inclusion criteria were:diagnosis of EOIS based on spine radiography, age below 10 years, both girls and boys, Cobb angle between 118 and 308, Risser zero, FITS therapy, no other treatment (bracing), and a follow-up at least 2 years from the initiation of the treatment. The criterion for curve progression were as follows: the Cobb angle increase of 68 or more, for curve stabilization; the Cobb angle was 58 comparing to the initial radiograph,for curve correction; and the Cobb angle decrease of 68 or more at the final follow-up radiograph.There were 41 children with EOIS, 36 girls and 5 boys, mean age 7.71.3 years (range 4 to 9 years) who started FITS therapy. The curve pattern was single thoracic (5 children), single thoracolumbar (22 children) or double thoracic/thoracolumbar (14 children), totally 55 structural curvatures. The minimum follow-up was 2 years after initiation of the FITS treatment, maximum was 16 years, mean 4.8 years). At follow-up the mean age was 12.53.4 years. Out of 41 children, 10 passed pubertal growth spurt at the final follow-up and 31 were still immature and continued FITS therapy. Out of 41 children, 27 improved, 13 were stable, and one progressed. Out of 55 structural curves, 32 improved, 22 were stable and one progressed. For the 55 structural curves, the Cobb angle significantly decreased from 18.085.48 at first assessment to 12.586.38 at last evaluation,p<0.0001, paired t-test. The angle of trunk rotation decreased significantly from 4.782.98 to 3.282.58 at last evaluation, p<0.0001,paired t-test.FITS physiotherapy was effective in preventing curve progression in children with EOIS. Final postpubertal follow-up data is needed.

[Primary correction of scoliosis with the Wilmington corset].

As part of our study, the effectiveness and patient's acceptance of the Wilmington-brace is to be evaluated. The effectiveness can be documented with the help of the primary correction achieved, especially in light of the fact, that the primary correction and the long-term results are directly dependant upon one another. We examined a total of 52 patients with an idiopathic scoliosis treated in a thermoplast brace. The group consisted of 38 female and 14 male patients (average age 11.6 years). The angulation was measured with the help of the Cobb-angle and the rotation with the method described by Nash and Moe. The skeletal age was classified according to Risser's-sign. The angle determinations were carried out at three separate points in time--at first presentation, prior to bracing and four to six weeks following bracing. The patients presented with an average angulation of 31 degrees. The average correction achieved in the Wilmington-brace was 41%. This corresponds to a correction of 13 degrees. The best primary correction (45%) was obtained in the thoracolumbar spine. Those patients with the smallest deformity at the onset of treatment showed the best results. The scoliosis with a large primary deformity and a marked rotation of the vertebral bodies responded poorly to correction. Advanced age or skeletal maturity were also limiting factors. Physical therapy had a positive influence on the amount of primary correction obtained. The Wilmington-brace (thermoplast) allows for a good primary correction of idiopathic scoliosis. The simplicity of application and the low production costs are also positive attributes.

Effectiveness of complete conservative treatment for adolescent idiopathic scoliosis (bracing and exercises) based on SOSORT management criteria: results according to the SRS criteria for bracing studies - SOSORT Award 2009 Winner.

The SRS criteria give the methodological reference framework for the presentation of bracing results, while the SOSORT criteria give the clinical reference framework for an appropriate bracing treatment. The two have not been combined in a study until now. Our aim was to verify the efficacy of a complete, conservative treatment of Adolescent Idiopathic Scoliosis (AIS)according to the best methodological and management criteria defined in the literature. Study Design. Retrospective study. Population. We included all AIS patients respecting the SRS inclusion criteria (age 10 years or older; Risser test 0-2; Cobb degrees 25-40 degrees ; no prior treatment; less than one year post-menarchal) who had reached the end of treatment since our institute database start in 2003. Thus we had 44 females and four males, with an age of 12.8 +/- 1.6 at the commencement of the study. Methods. According to individual needs, two patients have been treated with Risser casts followed by Lyon brace, 40 with Lyon or SPoRT braces (14 for 23 hours per day, 23 for 21 h/d, and seven for 18 h/d at start), and two with exercises only (1 male, 1 female): these were excluded from further analysis. Outcome criteria. SRS (unchanged; worsened 6 degrees or more; over 45 degrees at the end of treatment; surgically treated; two years' follow-up); clinical (ATR, Aesthetic Index, plumbline distances); radiographic (Cobb degrees); and ISICO (optimal; minimal). Statistics. Paired ANOVA and t-test, Tukey-Kramer and chi-square test. Median reported compliance during the 4.2 +/- 1.4 treatment years was 90% (range 5-106%). No patient progressed beyond 45 degrees , nor was any patient fused, and this remained true at the two-year follow-up for the 85% that reached it. Only two patients (4%) worsened, both with single thoracic curve, 25-30 degrees Cobb and Risser 0 at the start. We found statistically significant reductions of the scoliosis curvatures (-7.1 degrees ): thoracic (-7.3 degrees ), thoracolumbar (-8.4 degrees ) and lumbar (-7.8 degrees ), but not double major. Statistically significant improvements have also been found for aesthetics and ATR. Respecting also SOSORT management criteria and thus increasing compliance, the results of conservative treatment were much better than what had previously been reported in the literature using SRS criteria only.

Low rate of surgery in juvenile idiopathic scoliosis treated with a complete and tailored conservative approach: end-growth results from a retrospective cohort.

The main distinctive aspect of Juvenile Idiopathic Scoliosis (JIS) with respect to Adolescent Idiopathic Scoliosis (AIS) is the high risk of severe deformity and surgery. Approximately 70% of curves in patients with JIS progress and ultimately require surgery. There are presently very few studies with long-term follow-up of JIS and even fewer looking specifically at bracing Purpose To verify the effectiveness of a complete conservative treatment, including bracing and exercises, for JIS. Retrospective cohort observational study nested in a clinical prospective database of consecutive outpatients. Patient Sample Inclusion criteria: JIS, no previous treatment, all consecutive radiographies available from treatment start to end of growth (Risser sign 3). We found 30 patients, 27 females, 10 JIS type 1; mean age at first diagnosis was 7.8 +/-1.5 and mean treatment lasted 5.8 years. Cobb degrees 24.4+/-10 degrees, with 7 cases >30 degrees, and 2 > 45degrees. Outcome Measures Physiological measures. Radiographic and clinical data. Treatment (exercises alone, or elastic-rigid-highly rigid braces plus exercises) was tailored and continuously changed according to Cobb degrees, individual preferences, anthropometric characteristics, pubertal spurt, remaining growth, rotation, hump, lumbar curve take-off, and imbalance. The SOSORT Guidelines for patients' management have been followed. Funding and Conflict of Interest: no. 33.3% (95% Confidence Interval 16.4-50.2%) of patients worsened over the years. At the end of growth, 6.6% (0-15.5%) had surgical deformities (>45degrees). We observed a good correction in the first years of treatment until pubertal growth spurt, when progression was usually noted and treatment changed increasing corrective forces (hours or rigidity of bracing). 23 cases were followed up until they had two consecutive radiographies showing Risser sign 5 and showed stability. Conservative treatment initiated already in childhood may favorably change the natural history of JIS with the aim of reaching a curve as far as possible from surgical thresholds. Observation, physical exercises, braces can be useful tools in the hand of physicians, but they must be carefully utilized by a deep knowledge of JIS.

A comparison of thoracolumbosacral orthoses and SpineCor treatment of adolescent idiopathic scoliosis patients using the Scoliosis Research Society standardized criteria.

SpineCor is a relatively new bracing system that uses dynamic bracing concepts in the treatment of adolescent idiopathic scoliosis (AIS). Limited data are available regarding its effectiveness. This study compared treatment outcomes of 2 groups of AIS patients treated via either a conventional rigid thoracolumbosacral orthoses (TLSO) or a SpineCor nonrigid orthosis. We identified 2 scoliosis patient cohorts: 35 patients treated with a TLSO and 32 patients treated with a SpineCor orthosis. All patients included in these groups conformed with the Scoliosis Research Society (SRS) standardized criteria for AIS bracing: (1) Risser < or =2, (2) curve magnitude 25 to 40 degrees, (3) age > or =10 years. Outcomes were SRS standardized with failure being defined as curve progression > or =6 degrees, or ever exceeding 45 degrees, or having surgery recommended before skeletal maturity. All patients were followed through the completion of brace treatment or attainment of other treatment end points. The Yates corrected chi test and unpaired t test were used for data analysis. The 35 patients (32 girls, 3 boys) in the TLSO group had an average age of 13 years (range: 11.1-16.8) and an average primary curve magnitude of 33 degrees (range: 25-40 degrees). Follow-up averaged 2 years (range: 8-61 m) from the beginning of brace treatment. The 32 patients (28 girls, 4 boys) in the SpineCor group had an average age of 13 years (range: 11-15.2) and an average primary curve magnitude of 31 degrees (range: 25-40 degrees). Follow-up for this group averaged 2 years and 6 months (range: 13-73 mo) from the beginning of brace treatment. No significant difference (P=0.75) was found using the more strict outcome measure (< or =5-degree curve progression) as the success rates were 60% (21/35) for TLSO and 53% (17/32) for SpineCor. Similarly, no significant difference (P=0.62) was found using the more liberal outcome measure (never reached 45 degrees) as the success rates were 80% (28/35) for TLSO and 72% (23/32) for SpineCor. We were unable to identify any significant differences in brace treatment outcomes when comparing TLSO and SpineCor treated patients.

Management of scoliosis

Surgery is indicated by the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) at 45 degrees to 50 degrees and by the Scoliosis Research Society (SRS) at a Cobb angle of 45 degrees. SOSORT uses the 45-degree to 50-degree threshold as a result of the well-documented, plus or minus five degrees measurement error that can occur while measuring Cobb angles. Scoliosis braces are usually comfortable for the patient, especially when it is well designed and fit; also after the 7- to 10-day break-in period. A well fit and functioning scoliosis brace provides comfort when it is supporting the deformity and redirecting the body into a more corrected and normal physiological position. The Scoliosis Research Society's recommendations for bracing include curves progressing to larger than 25°, curves presenting between 30 and 45°, Risser sign 0, 1, or 2 (an X-ray measurement of a pelvic growth area), and less than six months from the onset of menses in girls.

[Results of brace treatment in idiopathic scoliosis--evaluation of the patients treated for over 2 years or those who completed the treatment].

The results of the brace treatment (Milwaukee brace, Thoraco-Lumbo-Sacral-Orthosis, Boston-Milwaukee brace) were studied in 509 patients with idiopathic scoliosis, who were braces for an average of 3 years and 3 months ranging from 2 to 10 years. Of these patients, 60 were followed up for about 24 months after the brace was discontinued. The distribution of these patients according to curve pattern was as follows: 319 had thoracic curve; 78 had lumbar curve (combining lumbar and thoracolumbar curves together as one group); and 112 had double major curve. The findings are summarized and conclusions were drawn as follows. 1. The best correction was obtained within a year after the initiation of bracing, followed by a gradual loss of correction. 2. There was a significant difference between the final correction rate and the best correction rate in the brace. 3. In the patients with ages ranging from 11 to 14 years and with curves of 30 degrees or less at the beginning of brace treatment, the curves were maintained within 30 degrees at the final stage. 4. Those patients who cooperated well in wearing their braces had a smaller loss of correction at the final stage. 5. In 63 per cent of the cases who showed progression in the brace, iliac apophysis did not appear at the beginning of brace treatment. 6. Moiré topography was used for the analysis of cosmesis and it was shown to be a valuable method of three dimensional evaluation. 7. In 60 patients who were followed up for 24 months on average after the brace was discontinued, the curves had improved an average of 1.6 degrees at the time of their last check up.

Bracing can reduce high degree curves and improve aesthetics immediately after the end of growth. Final results of a retrospective case series.

Recently it has been shown that idiopathic scoliosis (IS) curves can be reduced with bracing, and it has been proposed that this could be useful in non-surgically treated high degree curves even after Risser 3. Moreover, bracing has been shown to be able to improve aesthetics, and this could be another reason to treat some patients with cosmetic needs. Our aim is to preliminary check if results can be obtained in IS patients after Risser 3. Design. Retrospective uncontrolled cohort study. Inclusion criteria. All IS patients treated on a voluntary basis for aesthetic reasons and/or for curve reduction; Risser 4-5 at start; end of treatment reached. Population. 34 females and 2 males, age 16.2±1.6 years, Cobb angle 27.6°±8.9°. Treatment. Lyon or SPoRT braces 18 to 24 hours/day, specific SEAS exercises, rapid weaning (2-3 hours every 6 months). Outcome criteria: SRS (unchanged; worsened over 6°; over 45° at the end of treatment; surgically treated), radiographic and clinical. Statistics. ANOVA and chi-test. The reported compliance during the 2.8 ± 1.1 treatment years was 95.1%, while residual growth was 0.9 ± 1.1 cm. Improvements were found in 39% of this cohort, (46% in curves over 30°). Only 1 patient progressed 6°. We found highly statistically significant reductions of maximal (-4.4°), thoracic (-6.0°) and thoracolumbar (-6.6°) curves. Statistically significant improvements were found for Aesthetic Index. Before 20 years of age, even in skeletally mature patients, it is possible to reach radiographic and aesthetic improvements, although not as good as during growth. Correction is based on bone growth, but ligaments and neuromuscular control of posture can also be involved.

Treatment of thoraco-lumbar curves in adolescent females affected by idiopathic scoliosis with a progressive action short brace (PASB): assessment of results according to the SRS committee on bracing and nonoperative management standardization criteria.

The effectiveness of conservative treatment of scoliosis is controversial. Some studies suggest that brace is effective in stopping curve progression, whilst others did not report such an effect.The purpose of the present study was to effectiveness of Progressive Action Short Brace (PASB) in the correction of thoraco-lumbar curves, in agreement with the Scoliosis Research Society (SRS) Committee on Bracing and Nonoperative Management Standardisation Criteria. Fifty adolescent females (mean age 11.8 +/- 0.5 years) with thoraco-lumbar curve and a pre-treatment Risser score ranging from 0 to 2 have been enrolled. The minimum duration of follow-up was 24 months (mean: 55.4 +/- 44.5 months). Antero-posterior radiographs were used to estimate the curve magnitude (CM) and the torsion of the apical vertebra (TA) at 5 time points: beginning of treatment (t1), one year after the beginning of treatment (t2), intermediate time between t1 and t4 (t3), end of weaning (t4), 2-year minimum follow-up from t4 (t5). Three situations were distinguished: curve correction, curve stabilisation and curve progression.The Kruskal Wallis and Spearman Rank Correlation tests have been used as statistical tests. CM mean value was 29,30 +/- 5,16 SD at t1 and 14,67 +/- 7,65 SD at t5. TA was 12.70 +/- 6,14 SD at t1 and 8,95 +/- 5,82 at t5. The variation between measures of Cobb and Perdriolle degrees at t1,2,3,4,5 and between CM t5-t1 and TA t5-t1 were significantly different.Curve correction was accomplished in 94% of patients, whereas a curve stabilisation was obtained in 6% of patients. The PASB, due to its peculiar biomechanical action on vertebral modelling, is highly effective in correcting thoraco-lumbar curves.

Scoliosis detection, patient characteristics, referral patterns and treatment in the absence of a screening program in Norway.

Early diagnosis of idiopathic scoliosis allows for observation and timely initiation of brace treatment in order to halt progression. School scoliosis screening programs were abolished in Norway in 1994 for lack of evidence that the programs improved outcome and for the costs involved. The consequences of this decision are discussed. To describe the detection, patient characteristics, referral patterns and treatment of idiopathic scoliosis at a scoliosis clinic during the period 2003-2011, when there was no screening and to compare treatment modalities to the period 1976-1988 when screening was performed. Patient demographics, age at detection, family history, clinical and radiological charts of consecutive patients referred for scoliosis evaluation during the period 2003-2011, were prospectively registered. Patients were recruited from a catchment area of about 500000 teenagers. Maturity was estimated according to Risser sign and menarcheal status. Severity of pain was recorded by a verbal 5-point scale from no pain to pain at all times. Physical and neurological examinations were conducted. The detector and patient characteristics were recorded. Referral patterns of orthopedic surgeons at local hospitals and other health care providers were recorded. Patient data was obtained by spine surgeons. Treatment modalities in the current period were compared to the period 1976-1988. We registered 752 patients with late onset juvenile and adolescent idiopathic scoliosis from 2003-2011. There were 644 (86%) girls and 108 (14%) boys. Mean age at detection was 14.6 (7-19) years. Sixty percent had Risser sign ≥ 3, whilst 74% were post menarche with a mean age at menarche of 13.2 years. Thirty-one percent had a family history of scoliosis. The mean major curve at first consultation at our clinic was 38° (10°-95°). About 40% had a major curve >40°. Seventy-one percent were detected by patients, close relatives, and friends. Orthopaedic surgeons referred 61% of the patients. The mean duration from detection to the first consultation was 20(0-27) months. The proportion of the average number of patients braced each year was 68% during the period with screening compared to 38% in the period without screening, while the proportion for those operated was 32% and 62%, respectively ( p=0.002, OR 3.5, (95%CI 1.6 to 7.5). In the absence of scoliosis screening, lay persons most often detect scoliosis. Many patients presented with a mean Cobb angle approaching the upper limit for brace treatment indications. The frequency of brace treatment has been reduced and surgery is increased during the recent period without screening compared with the period in the past when screening was still conducted.

Scoliosis

For example, a person who is still growing with a 17° Cobb angle and significant thoracic rotation or flatback could be considered for nighttime bracing. On the opposite end of the growth spectrum, a 29° Cobb angle and a Risser sign three or four might not need to be braced because the potential for progression is reduced. The Scoliosis Research Society's recommendations for bracing include curves progressing to larger than 25°, curves presenting between 30 and 45°, Risser sign 0, 1, or 2 (an X-ray measurement of a pelvic growth area), and less than six months from the onset of menses in girls. Scoliosis braces are usually comfortable, especially when well designed and well fitted, also after the 7- to 10-day break-in period. A well fitted and functioning scoliosis brace provides comfort when it is supporting the deformity and redirecting the body into a more corrected and normal physiological position.

Does Risser Casting for Adolescent Idiopathic Scoliosis Still Have a Role in the Treatment of Curves Larger Than 40°? A Case Control Study with Bracing.

<bBackground</b: The most common conservative treatment for Adolescent Idiopathic Scoliosis (AIS) is bracing. However, several papers questioned the effectiveness of bracing for curves between 40° and 50° Cobb: the effectiveness in preventing curve progression could be as low as 35%. Seriate casting is considered a standard approach in early onset scoliosis; however, in the setting of AIS, cast treatment is seldom utilized, with only few studies reporting on its effectiveness. <bAim of the study:</b The main aim of the study is to determine whether a seriate casting with Risser casts associated with bracing is more effective in preventing curve progression than bracing alone in curves larger than 40°. Furthermore, the secondary endpoints were: (1) is there a difference in effectiveness of casting between Thoracic (T) and Thoracolumbar/Lumbar (TL/L) curves? (2) Does the 'in cast' correction predicts the treatment outcome? (3) What is the effect on thoracic kyphosis of casting? <bMethods</b: This is a retrospective monocentric case-control study; through an Institutional Database search we identified all the patients treated at our institution between 1 January 2017 and 31 December 2020, with a diagnosis of AIS, Risser grade between 0 and 4 at the beginning of the treatment, at least one curve above 40° Cobb and treatment with either seriate Risser casting and bracing (Study Group, SG) or bracing alone (Control Group, CG). Standing full spine X-rays in AP and LL are obtained before and after the cast treatment; only AP standing full spine X-rays 'in-cast' are obtained for each cast made. Patients were stratified according to the curve behavior at the end of treatment (Risser 5): progression was defined as ≥6° increase in the curve magnitude or fusion needed; stabilization is defined as a change in curve by ±5°; and improvement was defined as ≥6° reduction in the curve. <bResults</b: For the final analysis, 55 compliant patients (12 M, 43 F, mean age 13.5 ± 1.6) were included in the SG and 27 (4 M, 23 F, mean age 13.6 ± 1.6) in the CG. Eight (14.5%) patients in the SG failed the conservative treatment while 14 (51.3%) failed in the CG. Consequently, the Relative Risk for progression in the Efficacy Analysis was 1.8 (95% CI 1, 3-2.6, <ip</i = 0.001), and the Number Needed to Treat was 2,4. No significant difference was found between the T and TL/L curves concerning the 'progressive' endpoint (z-score 0.263, <ip</i = 0.79). The mean percentage of 'in cast' curve reduction was 40.1 ± 15.2%; no significant correlation was found between the percentage of correction and the outcome (Spearman Correlation Coefficient 0.18). Finally, no significant differences between baseline and end of FU TK were found (32° ± 16.2 vs. 29.6 ± 15.8, <ip</i = ns). <bDiscussion:</b Seriate Risser casting for AIS with larger curves (&gt;40° Cobb) is effective in reducing curve progression when compared with full time bracing alone in treatment compliant patients. The treatment is equally effective in controlling T and TL/L curves; furthermore, a slight but non-significant decrease in TK was observed in patients treated with casting. This type of treatment should be considered for AIS patients who present with large curves to potentially reduce the percentage of surgical cases. <bShort Abstract</b: The aim of the study is to determine whether seriate Risser casting associated with bracing is more effective in preventing curve progression than bracing alone in curves larger than 40°. This is a retrospective monocentric case-control study; we identified all the patients treated at our institution with a diagnosis of AIS, Risser grade 0-4 at the beginning of the treatment, at least one curve above 40° Cobb (35° if treated with bracing alone) and treatment with either seriate Risser casting and bracing (Study Group, SG) or bracing alone (Control Group, CG). Fifty-five patients (12 M, 43 F, mean age 13.5 ± 1.6) were included in the SG and 30 (5 M, 25 F, mean age 13.9 ± 1.7) in the CG. Eight (14,5%) patients in the SG failed the conservative treatment while fifteen (50%) failed in the CG. Consequently, the Relative Risk for progression in the Efficacy Analysis was 1.8 (95% CI 1.3-2.6, <ip</i = 0.001), and the Number Needed to Treat was 2,4. Seriate Risser casting for AIS with larger curves (&gt;40°) is effective in reducing curve progression when compared with full time bracing alone. This type of treatment should be considered for AIS patients who present with large curves.

Effectiveness of Chêneau brace treatment for idiopathic scoliosis: prospective study in 79 patients followed to skeletal maturity.

Progressive idiopathic scoliosis can negatively influence the development and functioning of 2-3% of adolescents, with health consequences and economic costs, placing the disease in the centre of interest of the developmental medicine. The aim of this study was to evaluate the effectiveness of Chêneau brace in the management of idiopathic scoliosis. A prospective observational study according to SOSORT and SRS recommendations comprised 79 patients (58 girls and 21 boys) with progressive idiopathic scoliosis, treated with Chêneau brace and physiotherapy, with initial Cobb angle between 20 and 45 degrees, no previous brace treatment, Risser 4 or more at the final evaluation and minimum one year follow-up after weaning the brace. Achieving 50° of Cobb angle was considered surgical recommendation. At follow-up 20 patients (25.3%) improved, 18 patients (22.8%) were stable, 31 patients (39.2%) progressed below 50 degrees and 10 patients (12.7%) progressed beyond 50 degrees (2 of these 10 patients progressed beyond 60 degrees). Progression concerned the younger and less skeletally mature patients. Conservative treatment with Chêneau orthosis and physiotherapy was effective in halting scoliosis progression in 48.1% of patients. The results of this study suggest that bracing is effective in reducing the incidence of surgery in comparison with natural history.

Three-dimensional action of Chêneau brace on thoracolumbar scoliosis.

We treated 18 girls for idiopathic thoracolumbar scoliosis with Chêneau brace. The apex of the curve was at Th12 or at L1 or at the disc Th12/L1. The initial Cobb angle varied from 21 to 42 degrees, mean 28. The follow up period was of 2 years and 6 months on the average. We noted the rib hump height on Adams' forward bending test. We measured Cobb angle, apical vertebra transposition and apical vertebra rotation (according to Perdriolle method) on antero-posterior standing radiograms before the treatment had started and at the moment of the best correction. We digitized antero-posterior and lateral standing radiograms with sonic digitizer GP-9 and we prepared computed reconstruction of the transversal plane of the spine with Hecquet and Graf's software RACHIS 91TM. The best clinical and radiological correction was achieved after 3 to 8 months of treatment (mean 5,5 months). We considered it as the fitting period and we analysed the correction achieved at that moment and at last follow-up. Cobb angle in brace ranged from 0 to 18 degrees, mean 9 degrees. The correction of apical vertebra transposition ranged from 51% to 100%, mean 80%. The correction of apical vertebra rotation ranged from 0% to 100%, mean 52%. The correction of rib hump ranged from 0 to 100%, mean 42%. Normal sagittal contour was established in 15 patients. important correction was present in each of the three planes.

Anterior spinal fusion versus posterior spinal fusion for moderate lumbar/thoracolumbar adolescent idiopathic scoliosis: a prospective study.

A prospective study. Comparison study of radiologic and clinical outcomes, efficiency, and cost between anterior spinal fusion (ASF) and posterior spine fusion (PSF) in surgical treatment of moderate lumbar/thoracolumbar adolescent idiopathic scoliosis (AIS). ASF and PSF indicated for lumbar and thoracolumbar adolescent idiopathic scoliosis surgical treatment have respective advantages and disadvantages. However, up until today, a related prospective AIS comparative study has rarely been reported. Thirty-two cases in this prospective study with patients enrolled in either method A or B alternately in a sequence were divided into 2 groups. Group A underwent ASF with single solid rod and single screw constructs, and group B underwent PSF with segmental total pedicle screw system. Inclusion criteria were: (1) AIS diagnosis; (2) diagnosis classification as Lenke5CN type; (3) Cobb angles 35 degrees-60 degrees on anteroposterior view radiographs. Exclusion criteria were: (1) a history of spinal surgery; (2) age younger than 10 years; (3) Risser sign 0 degree; (4) lumbar/thoracolumbar kyphosis. All patients were observed with 2-year minimum follow-up (24-46 months). Clinical and radiologic outcomes of both groups A and B were analyzed. Statistical t test or Mann-Whitney U test demonstrated no significant difference in preoperative age (P = 0.380), Risser sign (P = 0.733), magnitude (P = 0.936), flexibility (P = 0.815), apical vertebra rotation (AVR, P = 0.756), and apical vertebra translation (AVT, P = 0.355) of the lumbar/thoracolumbar curves, trunk shift (TS, P = 0.448), sagittal kyphosis from T5-T12 (P = 0.792) and sagittal lordosis from L1-L5 (P = 0.299). Average coronal correction of thoracolumbar/lumbar curves was 83% after surgery and 77% at follow-up in group A and 87% after surgery and 82% at follow-up in group B (P = 0.236 and P = 0.138). No significant differences were observed regarding correction of sagittal alignment, TS, AVT, AVR and hospitalization days on last follow-up between both groups (P > 0.05). No pseudarthrosis, reoperation, neurologic complications, infection, and no other problems were observed. Excellent clinical fusion results were present in all patients on their last follow-up. However, significant differences were evident in group A in regards to reduced operative time (P = 0.046), reduced estimated blood loss (P = 0.003), decreased blood transfusion (P = 0.006), reduced implants cost and hospitalization expenses (P = 0.000). Additionally, group A had shorter fusion levels than group B (p50 = 4 vs. p50 = 5, P = 0.003). ASF versus PSF comparison in treating moderate lumbar/thoracolumbar AIS did not show significant differences in regards to safety or efficacy but demonstrated shorter fusion levels, reduced surgical trauma and costs in ASF.

Progression in scoliosis. A 360 degrees change in 75 years.

With the proliferation of school screening programs for spinal deformity, attention has been directed to methods of scoliosis evaluation and follow-up that avoid serial x-ray exposure. An historical review of the scoliosis literature prior to the extensive use of x-ray in scoliosis care has demonstrated much that is now being "rediscovered." By 1900, screening for spinal deformity in the schools had been instituted, pertinent findings of the physical examination in patients with scoliosis had been well described, and early natural history information had been obtained regarding the behavior of small curves and curves associated with thoracic lordosis. Recordings of surface contours and rib humps, using inclinometers, lead rulers, and other measuring devices, were used to assess the progression of curves. Low contour braces were widely available. Although our orthopaedic forefathers had many erroneous ideas, a perusal of the early orthopaedic writings from around the turn of the century has shown how little is "new" (other than changes in material and spinal instrumentation techniques) from what was recognized 75 years ago.

Anterior instrumentation (dual screws single rod system) for the surgical treatment of idiopathic scoliosis in the lumbar area: a prospective study on 33 adolescents and young adults, based on a new system of classification.

The choice of anterior instrumentation in the treatment of lumbar scoliosis in adolescents and young adults is not a new topic for the authors. The first results achieved using the Dwyer surgical modality were reported by one of the authors followed by the results achieved using Zielke (VDS) instrumentation. Today, new techniques and new instrumentations have been developed that challenge the instrumentation choices. Here we describe how the new system of classification of scoliotic curves we developed has been used as a basis for treating idiopathic scoliosis in lumbar area in adolescents and young adults using an anterior approach. A prospective study was carried out between 1998 and 2010 at two hospital centers on 33 adolescents and young adult with idiopathic lumbar scoliosis involving curves of three kinds, on whom surgical treatment was performed using a single solid rod. Topography of curves: our system of classification includes curves corresponding to the following three type of scoliosis: Type K I: double thoracic and lumbar curves (lumbar predominant) scoliosis (17 cases) mean age 16 years all female patients. Mean Cobb angle of lumbar curve 41°. Mean Cobb angle of thoracic curve 28°. The lumbar curve was left hand convex in 15 cases and right hand convex in 2 cases. Horizontal tilting of L4 mean value 22°. C7 offset mean value 3 cm. Type K IV A: unbalanced thoracolumbar scoliosis (13 cases) mean age 17 years, ten female patients and three male patients. Mean Cobb angle of thoracolumbar curve 39°. The thoracolumbar curve was left hand convex 4 times and right hand convex 9 times. Horizontal tilting of L4 mean value 18°. C 7 offset mean value 2.5 cm. Type K VI A: real lumbar (three cases). Age: 17, 15 and 13 years; all female patients. Cobb angle of the lumbar curve 66°, 29° and 70° (all LH convex). Horizontal tilting of L4: 40°, 20° and 46°. C 7 offset: 7 cm, 1 cm and 4 cm. Surgical instrumentation: We used the EUROS AZUR anterior instrumentation for all the procedures. Cages have been used on five patients at the lower stages. Number of vertebrae instrumented: mean five vertebrae. The patients did not wear postoperative orthosis. Mean duration of procedure: 3 h 50 min. Mean blood loss: 350 cm(3). Type K I scoliosis (17 cases): Mean follow-up: 6 years. Correction of the lumbar curve Cobb angle: the mean angle has been corrected from 41° to 21°. Number of vertebrae instrumented: 4:6 times and 5:11 times. Correction of the upper thoracic curve Cobb angle: mean angle corrected from 28° to 19°. Correction of L4 horizontal tilting: mean residual was 7°. Correction of C 7 offset: mean 0.7 cm. Type K IV A scoliosis (13 cases): mean follow-up: 4 years. Correction of the lumbar curve Cobb angle: the mean angle has been corrected from 39° to 16°. Mean number of instrumented vertebrae: 5 (4:4 times, 5:6 times and 6:3 times.) Correction of L4 horizontal tilting: mean residual 5°. Correction of C 7 offset: mean 0.7 cm. Type K VI A scoliosis (three cases): mean follow-up: 7, 2 and 4 years; Correction of the lumbar curve Cobb angle: the angles have been corrected from 66° to 15°, from 29° to 11° and from 70° to 28°. Number of instrumented vertebrae: 5, 4 and 6. Correction of L4 horizontal tilting: residual tilting of 8°, 7° and 17°. Correction of C 7 offset: 1 cm, 0 cm and 1 cm. There has been no report early or late septic or vascular or neurological complications. Instrumentation failure: there were three cases of screw breakage, all occurred on the lowest implant. Revision surgery was undertaken in both cases, only the last plate needed to be replaced and the rod could be kept without any other modification of the construct. In both cases, fusion has been achieved without any loss of correction. The mean loss of correction of the main curve was 2.5° for the three series. Anterior instrumentation of lumbar idiopathic scoliosis gives highly satisfactory morphological and functional results, since the lumbar musculature is spared and the instrumentation placed at the apex of the curvature has selective effects. Despite our preference and that of other surgeons throughout the world for anterior instrumentation, we are still a minority in comparison with the users of posterior instrumentation. There are several reasons for this reticence, including surgeons' training and ideas about pedicular screw fixation, but the main reason has been the lack of a sufficiently exact system of classification. Previous comparative studies between the anterior and posterior approaches have been biased by the use of an excessively restrictive mode of classification (lumbar/thoracolumbar) of the curves. Real lumbar scoliosis, unbalanced thoracolumbar scoliosis and thoracic and lumbar double curve (lumbar predominant) scoliosis should be properly defined before being compared.

Management of scoliosis

Indications for Scoliosis Bracing: Scoliosis professionals determine the proper bracing method for a patient after a complete clinical evaluation. The patient’s growth potential, age, maturity, and scoliosis (Cobb angle, rotation, and sagittal profile) are also considered. Immature patients who present with Cobb angles less than 20 degrees should be closely monitored and proactively treated based on their risk of progression as surgery can be prevented with early intervention of conservative treatment. Immature patients who present with Cobb angles of 20 degrees to 29 degrees should be braced according to the risk of progression by considering age, Cobb angle increase over a six-month period, Risser sign, and clinical presentation. Immature patients who present with Cobb angles greater than 30 degrees should be braced. However, these are guidelines and not every patient will fit into this table. For example, an immature patient with a 17-degree Cobb angle and significant thoracic

SpineCor vs. natural history - explanation of the results obtained using a simple biomechanical model.

In the recent peer reviewed literature the SpineCor is described as an effective method of treatment for patients with scoliosis. However until recently no prospective controlled end-result study is presented comparing the results obtained with this soft brace to natural history. The objective was to determine whether the results obtained by the use of the SpineCor are better than natural history during pubertal growth spurt. The method employed prospective comparison of the survival rates of SpineCor treatment vs. natural history with respect to curve progression during pubertal growth spurt. 12 Patients with Cobb angles between 16 and 32 degrees (at average 21 degrees) during pubertal growth spurt are presented as a case series treated with the SpineCor. Survival rate of this sample is described and compared to natural history (SRS brace study 1995). All girls treated in both studies were at risk for being progressive with the first clinical signs of maturation (Tanner 2-3). During the pubertal growth spurt most of the patients (11/12) with SpineCor progressed clinically and radiologically as well (at least 5 degrees). Progression could be stopped changing SpineCor to the Chêneau brace in most of the sample described (7/10). The avarage Cobb angle at the start of treatment with the SpineCor was 21.3 degrees, after an average observation time of 21.5 months 31 degrees. At 24 months of treatment time 33% of the patients with the SpineCor where still under treatment with their original bracing concept, at 72 months follow-up time 8 % of the patients with the SpineCor survived with respect to curvature progression. Survival proportion in the SpineCor sample, though was 0.08, while in the natural history cohort it was 0.34. The SpineCor treatment during pubertal growth spurt seems to lead to a worse outcome than observation only. The use of a simple biomechanical model explains that in the brace the compression forces exceed the lateral forces used for the corrective movement. Therefore SpineCor does not seem to be indicated as a treatment during pubertal growth spurt.

Management of scoliosis

Bracing is most effective when the patient has bone growth remaining (is skeletally immature) and should aim to both prevent progression of the curve (prevent progression to surgery), as well as reduce the scoliosis curve. Reduction of the curve is important as the natural history of idiopathic scoliosis suggests it can continue to progress at a rate ~1 degree per year in adulthood, while the treatment results of bracing have been shown to hold over >15 years. In some cases with juveniles, bracing has reduced curves significantly, going from a 40 degrees (of the curve, mentioned in length above.) out of the brace to 18 degrees in it. Braces are sometimes prescribed for adults to relieve pain related to scoliosis. Bracing involves fitting the patient with a device that covers the torso; in some cases, it extends to the neck. The most commonly used brace is a TLSO, such as a Cheneau type brace, a corset-like appliance that fits from armpits to hips and is custom-made from fiberglass or

Immediate effects of scoliosis-specific corrective exercises on the Cobb angle after one week and after one year of practice.

We are unaware of any studies describing the immediate effects of scoliosis-specific exercises on the Cobb angle measured by radiograph. This study aimed to describe the differences between radiographs obtained with and without corrective exercises after initial training and after one year. A female with adolescent idiopathic scoliosis was first seen at age 13 years, 0 months with a Risser 0. She had a 43<supo</sup left lumbar, 15<supo</sup right thoracic curve. She was seen again after 6, 18 and 30 months and performed exercises from 18 to 30 months. She performed Barcelona Scoliosis Physical Therapy School (BSPTS) exercises for a four-curve type (lumbar dominant with pelvis deviation to the lumbar concave side). At 18 and 30 months, x-rays were obtained with and without performing corrective exercises. At 6 months, her lumbar and thoracic curves measured 41<supo</sup and 28<supo</sup, respectively. At 18 months, her lumbar and thoracic curves measured 47 <supo</sup and 30<supo</sup, respectively. Also at 18 months, immediately after her x-ray in the relaxed standing position, she performed her corrective exercises in standing with arms lowered for a second x-ray. Her lumbar and thoracic curves remained similar and measured 43<supo</sup and 32<supo</sup, respectively. At 30 months, she performed unsolicited corrective exercises during the x-ray. Her lumbar and thoracic curves measured 26<supo</sup and 41<supo</sup, respectively. Another x-ray in the relaxed position revealed lumbar and thoracic curves measuring 39<supo</sup and 35<supo</sup, respectively. The immediate effect of corrective exercises after a year of training was a 33 % improvement at the lumbar spine compared to only a 9 % improvement the previous year. After initial training, corrective exercises during a standing x-ray did not significantly improve the Cobb angle for the major lumbar curve compared to the relaxed standing x-ray. However, a year after performing exercises, unsolicited corrective exercises resulted in a significantly improved Cobb angle compared to relaxed standing for the curve primarily targeted by the exercise program. Improved exercise ability and spinal flexibility may have contributed to the improved Cobb angle.

[Systematic Long-term Screening of Scolioses.].

The authors implemented in a defined region for a period of 14 years screening of scolioses in children, primary screening using Adams' test and secondary screening using a scoliometer. They selected as criterion for detection 5 degrees of asymmetry of the back, corresponding to 17 degrees according to Cobb on X-ray pictures. In three growth stages a total of 603 children with scoliosis were detected, incl. 382 girls and 221 boys. The detection rate was highest in the adolescent period (71 %), the majority of detected scolioses (77 %) were idiopathic. On examination with a scoliometer comparable results were achieved with the technique moiré (false positivity 5.2 %). Deformities of the spine were detected at a level (mainly grade Ib), where follow up and further treatment can be effective. Screening which was implemented involved small costs per child. A positive outcome of the screening was a reduced incidence of severe scolioses and this reduced among others the expenditure on treatment by orthesis of the trunk or surgery. Key words: scoliosis, screening, mechanical scoliometer.

Scoliosis

The standard method for assessing the curvature quantitatively is measuring the Cobb angle, which is the angle between two lines, drawn perpendicular to the upper endplate of the uppermost vertebra involved and the lower endplate of the lowest vertebra involved. For people with two curves, Cobb angles are followed for both curves. In some people, lateral-bending X-rays are obtained to assess the flexibility of the curves or the primary and compensatory curves. Congenital and idiopathic scoliosis that develops before the age of 10 is referred to as early-onset scoliosis. Progressive idiopathic early-onset scoliosis can be a life-threatening condition with negative effects on pulmonary function. Scoliosis that develops after 10 is referred to as adolescent idiopathic scoliosis. Screening adolescents without symptoms for scoliosis is of unclear benefit.

Scoliosis

As an alternative, a scoliometer may be used to diagnose the condition. When scoliosis is suspected, weight-bearing, full-spine AP/coronal (front-back view) and lateral/sagittal (side view) X-rays are usually taken to assess the scoliosis curves and the kyphosis and lordosis, as these can also be affected in individuals with scoliosis. Full-length standing spine X-rays are the standard method for evaluating the severity and progression of scoliosis, and whether it is congenital or idiopathic in nature. In growing individuals, serial radiographs are obtained at 3- to 12-month intervals to follow curve progression, and, in some instances, MRI investigation is warranted to look at the spinal cord.

Natural history and school screening for scoliosis.

In light of the questions and controversy regarding school screening for spinal deformities, should the programs be dropped? The natural history is not completely known and the results of nonoperative treatment questioned. The costs are high due to over-referral and numerous physician visits and radiographs. Would it not be best to wait until the epidemiologic questions are answered? The best approach is one in the middle ground. The program needs to be organized and strengthened. With the education of screeners, over-referral can be reduced. The treating physician must confirm the physical finding, take appropriate radiographs, and plan appropriate follow-up. In this way, the costs will be reduced. In addition, with knowledge regarding natural history, only larger curves or progressive curves will be treated. Nonoperative treatment of idiopathic scoliosis is effective. It can control progression and even result in correction of some curves. The overall effectiveness of braces and electrical stimulation needs to be constantly reviewed. How do these forms of nonoperative treatment affect the progressive curve, and do they reduce the need for surgery in idiopathic scoliosis? Only after we have more studies on natural history and on the results of nonoperative treatment can screening for scoliosis be reassessed to determine its role in the overall treatment program of spinal deformities.

[A clinical follow-up study on treatment of adolescent idiopathic scoliosis with brace].

To evaluate clinical outcomes of bracing and analyze related factors that influence curative effects in adolescents with idiopathic scoliosis, and to investigate indications of bracing. Seventy-nine patients with AIS who had no history of prior therapy were treated with a brace. Several parameters were consecutive measured and documented during the period of follow-up including Cobb's angles, curve patterns, menarche status, sitting heights, standing heights, Risser sign, apical vertebral rotation, and so on. The average period of followed-up was 30 months (12 months to 60 months). Twenty-one patients (26.6%) presented curve deterioration, 40 patients have no obvious curve change, 18 patients (22.8%) got a curve improvement. There was significantly lower percentage of curve progression and higher percentage of curve improvement in cases with Cobb's angle less than 35 degrees at the first visit (P < 0.05). The percentage of curve progression was significantly greater in the cases with apical vertebral rotation beyond grade III while the percentage of curve improvement was lower (P < 0.05). Curve patterns, Risser sign and other parameters were found to make their effects on the percentage of curve progression and improvement, which, however, was not statistically significant (P > 0.05). Bracing can limit or improve mild and moderate curve of idiopathic scoliosis effectively, especially in cases with initial curve magnitude ranging from 20 degrees to 35 degrees . Risser sign is not a reliable parameter for measuring the outcome of bracing treatment for idiopathic scoliosis. Surgery is advised as soon as possible for the cases with initial Cobb's angles greater than 45 degrees and initial apical vertebral rotation beyond grade III early while bracing did not work.

Surgical correction of a previously operated juvenile idiopathic scoliosis with crankshaft phenomenon: an illustrative case report.

Crankshaft phenomenon secondary to posterior fusion for scoliotic deformity at a young age has become rare and its management can be very challenging. We report the case of an 11-year-old girl who has been complaining of a progressively increasing hump in her back with waist and shoulders asymmetry during the past 6 months. Three years prior to presentation, she underwent in another institution posterior correction fusion from T3 to L3 for a juvenile idiopathic scoliosis with a Cobb angle of 60°. After the initial correction, follow-up X-rays revealed a progressive increase of the scoliosis angulation with the onset of a coronal malalignment mainly at the cervicothoracic junction. Full spine anteroposterior and lateral X-rays revealed a long right thoracolumbar scoliosis of 70° with a rib-vertebra angle difference of 27° and the proximal right screw pulled out from the rod. CT scan confirmed the posterior fusion between the apical vertebras. MRI did not show any congenital anomaly. The patient underwent a revision surgery with instrumentation from T1 to L4, and posterior column osteotomies at 6 levels between T4 and T10. Coronal Cobb angle corrected to 11° with satisfactory sagittal alignment and a maintained correction at 3 years of follow-up. This is the first case to thoroughly illustrate surgical management in the onset of a crankshaft phenomenon. Through a posterior-only approach, the use of posterior column osteotomies at the apex of the deformity in order to release the previous fusion is a safe and satisfactory option to reestablish proper coronal and sagittal alignment, with satisfactory clinical and radiological long-term results.