Indications for Treatment and Outcomes Evaluation for the

Orthotic Management of Idiopathic ScoliosisThomas M. Gavin, C.O.

BioConcepts, inc. Burr Ridge, Illinois, USA

Musculoskeletal Biomechanics Laboratory.Veterans Administration Hospital, Hines, Illinois,

USAAOPA Seattle 2009

Timothy J. Newton, C.O.January 4th 1949-September 13th 2009

SRS Definition of Terms

ACCEPTEDNOMENCLATURE FOR SPINAL RELATED CONDITIONS AND PROCEDURES RELATED TO SPINAL DEFORMITIES.

IDIOPATHIC SCOLIOSIS

ORTHOTIC TREATMENT FOR IDIOPATHIC SCOLIOSIS

Why use an orthosis? When do we use an orthosis? How does an orthosis work? How long should it be worn? Which orthosis should I use? Is part-time treatment effective? What is the chance of still needing

surgery after orthotic management?

CURVE PATTERNS AND

MEASUREMENTS

Left Lumbar Curve

King Type I

Right Thoracic PrimaryLeft Lumbar CompensatoryCurves.

King Type II

King Right Thoracic Curve

King Type III

Thoracolumbar CurveKing Type IV

Cob

b A

n gl e

51°

A B C D E

A. 0 Rotation. Neutral. No Rotation.

B. +1 Rotation. Pedicle Towards Midline. Concave Direction.

C. +2 Rotation. Pedicle 2/3 to Midline.

D. +3 Rotation. Pedicle at Midline.

E. +4 Rotation. Pedicle Beyond Midline.

Vertebral Rotation.

Maturation and Development

Vertebral Ring Apophyses. Line of Risser. Development of Secondary

Sex Characteristics. Menarche. Growth Velocity.

VERTEBRALRING APOPHYSES

A B C

A. Ring Apophysis Begins To Form.

B. Ossification Complete, Not United With Body.

C. Ossified and United With Body. Mature.

RISSER SIGN

Risser 1 = 25% Capping. Risser 2 = 50% Capping.Risser 3 = 75% Capping.Risser 4 = 100% Capping.Risser 5 = 100% Capping + Fusion.

Line Of Risser

TANNER SIGNS

5 Stages of Breast and Pubic Hair Development

5 Stages of Genitalia and Pubic Hair Development

MATURITY AT ORTHOSIS INITIATION AFFECTS

OUTCOMES

From Bunch and Patwardhan: Scoliosis; Making Clinical Decisions. CV Mosby Company, 1989

Bracing initiated at 6- 18 months Premenarchal

From Bunch and Patwardhan: Scoliosis; Making Clinical Decisions. CV Mosby Company, 1989

Bracing Initiated 6 Months Premenarchal to 6 Months Post Menarche

From Bunch and Patwardhan: Scoliosis; Making Clinical Decisions. CV Mosby Company, 1989

Bracing Initiated 6-18 Months Post-Menarche

Determining Clinical Curve Stiffness.

Side Bending Correction of Each Curve.

Expressed As % Correction From Normal.

% Correction Thoracic: % Correction Lumbar = “Flexibility Index” As Reported by King Et Al.

A. B. C.

A. Normal Coronal Alignment .

B. Right Side Bending. Primary Thoracic Curve Resists Corrective Forces.

C. Left Side Bending. Compensatory Lumbar Curve Corrects To Nearly 0°.

Biological Changes in Bone Morphology

Epiphyseal Growth Is Slowed When Epiphyses Are

Compressed.(Hueter-volkman Principle)

HUETER-VOLKMAN WEDGING.

Concave Side Epiphysis Develops at a Slower Rate Than Convex Side Due to Compression.

Clinical Evaluation and Mechanism of Action

Orthoses must be designed and fitted to: Reduce Curve Maximally. Reduce Any Decompensation. Be Easily Adjusted. Keep Constant Force On Curves. Be As Comfortable As Possible.

NATURAL HISTORY:

RISK OF CURVE PROGRESSION.

CURVE PROGRESSION Age.

Older Children Are Less Likely to Progress at Curve Magnitudes That Are Progressive in Younger Children.

Magnitude. Larger Curves Are More “Unstable” Than

Smaller. Curve Pattern.

Thoracic and Double Primary Curves Progress Less Than Single Lumbar or Thoracolumbar Curves.

Risk of Progression by Risser Sign. Lonstein and Carlson 1984 JBJS

22%

1.6%

68 %

23 %

0%

10%

20%

30%

40%

50%

60%

70%

80%

5-19 deg. 20-29 deg.

% Progressed

Risser 0-1

Risser 2-4

Risk of Progression by Chronological Age.Lonstein and Carlson 1984 JBJS

45%

23%8%4%

100%

61%

37%

16%

0%

20%

40%

60%

80%

100%

5-19 deg 20-29 deg

% Progressed up to 10 yrs

11-12 yrs

13-14 yrs

15 and older

LONG-TERM CURVE PROGRESSION. (Avg. F/U 40 Years Post Diagnosis) From Weinstein et. al. 1984 JBJS

0%

10%

29%

0%

10%

20%

30%

40%

50%

< 30 Deg 30-50 Deg 50-75 Deg

% Progressed

Weinstein Zavala and Ponsetti 1984 JBJS

68% progressed > 5 degrees. 37% progressed in last 10

years. (avg. F/U 40 years post diagnosis.)

TREATMENT OUTCOME

EXPECTATIONS.

Moe and Kettleson. 1970 JBJS

169 Patients Treated With Milwaukee Brace.

23% Average Correction of Thoracic Curves Post-treatment.

18% Average Correction of Lumbar and Thoracolumbar Curves Post-treatment.

Short Term Results.

Carr et. al. JBJS 1980

Re-Reviewed Moe’s Patients From 1970. Reported on Late Losses of Correction. Showed Late Losses of Correction. Results Showed Residual Curves Still

Less Than Pre-orthosis Magnitude.

Residual Curve 5-Years Post-Treatment By Menarche Value at Initiation Of Orthosis.

Bunch and Patwardhan, Chapter 13, Scoliosis; Making Clinical Decisions. 1989.

63%

80%100%

0%10%20%30%40%50%60%70%80%90%

100%

18 - 6 Mo. Pre 6 Pre - 6 Post 6-18 Post

Residual Curve as % of Initial Curve

Surgical Rates Following Orthotic Treatment

Based on Initial Risser Sign. From: Milwaukee Brace Treatment Of Ais. Lonstein and Winter. JBJS 1994

32%

12%

45%

18%

0%

10%

20%

30%

40%

50%

60%

20-29 DEG 30-39 DEG

% of Patients Requiring Surgery After Orthotic Treatment

Risser 0 -1

Risser 2+

Bunch Reported Best Curve Reduction for Youngest Group

and Lonstein Reported Highest Surgical Rates for Youngest

Group?

Orthotic Outomes; Failure Boundary

PART-TIME VERSUS

FULL-TIME

49%60% 62%

91%99%

0%10%20%30%40%50%60%70%80%90%

100%

Control Charleston Brace 16-Hour TLSO 23-Hour TLSO 23 HourMilwaukee Brace

Weighted Mean Proportion Of Success

A META-ANALYSIS OF THE EFFICACY OF NONOPERATIVE TREATMENT FOR IDIOPATHIC SCOLIOSIS. Rowe et al. - J Bone and Joint Surgery [Am]. 79-A (5) 664-674, 1997.)

A Comparison Between The Boston Brace And The Charleston Bending Brace In Adolescent Idiopathic Scoliosis.

Katz DE, Richards S, Browne RH, Herring JA. Spine, 22(12); 1302-1312 ,1997.

61%

41%

19%

31%

0%

20%

40%

60%

80%

Success (p=0.001) Surgery (p= 0.021)

Risser 0-1 Patients Only

BostonBrace

CharlestonBrace

Primary Goals. Correct Curves >50%. Maintain Correction Throughout Duration

of Wear. Address Psycho-social Issues. Fulltime Until Proven Otherwise. Maximal Comfort. Minimal Structure.

Summary Orthoses Must Improve Stability To Yield

Optimal Outcome!Optimizing Orthotic Treatment Requires; 1. Proper Patient Selection (Age, Magnitude,

Documented Progression). 2.Utilization of All Mechanisms of Action to

Improve Stability. 3. Frequent Follow-Up Adjustments To Restore

Orthosis to Optimal Fit and Function.

4. Sound Clinical Procedures!

In-Orthosis Correction of the Curve Should Always Exceed 50%

Orthosis Should NOT Increase Decompensation.

When Curve Appears to Progress From “Best In Brace” Magnitude, Orthosis Should Be Adjusted To Restore Curve Reduction.

Weaning Should Be Gradual!

Summary

Thank You For Your Attention!

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