Thoracolumbar Lordotic Intervention(TLI) in

spinal deformities. Effective mechanical growth modulation using muscular forces.

Piet JM van LoonRuud HGP van ErveA.J GrotenhuisEric BTM Thunnissen

Disclosure

PJM van Loon

• Partner Sit Active Group (ZAG BV) Zami stool

• Patent holder brace for Spinal Deformities EPO: 04 808 807.4-2310 / 2008

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TLI started by serendipity in 2000: extending in lordosis in Scheuermann and scoliosis works!

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Science by “reversed engineering”

11th Philip Zorab Symposium Oxford, England: 3–5 April 2006

UT TENSIO SIC VIS: NEW AND REVISITED ASPECTS IN (DE)FORMATION OF THE GROWING SPINE.

The connection between the basic Natural Laws of Hooke and the deepest biological knowledge on growth in Nature was made.

TLI is on stretch and strain in the total of the spine

IRSSD Liverpool 2008

Van Gesscher, 1792 : Remarks on spinal deformities

Dedicated to personal physician of King George III of England and King Christiaan VII of Denmark

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Nicholas Andry, 1741

David van Gesscher, 1792

Formula for spinal deformation !Anticipating Wolff’s Law and Volkmann Hueter principle

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Van Gesscher’s all lordotic corset was in use in Europe till the use of Plaster of Parisbecame popular but extension (lordosis) stayed the base for correcting the sagital contour in scoliosis . Unloading of the discs is the main function.

TLI Background Combining pre-PubMed science and own observations: Sound etiology around growth of the CNS by stretch and effects sitting on morphogenesis

Lack of extension( sitting) is crucial to get bad postures

Neuromuscular tightness is the deforming force (progression). Form follows Function is an undisputed axiomAll deformities share same features on MRI as in Roth’s pneumomyelographsExtended knowledge on kinesiology of TL joint TL joint first to deform

Their should be no “Idiopathy” (Karski, Serdyuk, Roth)

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Neuro-osseous growthrelations

Always early TL kyphosis

Understandable biomechanic solution

Stiff from aside

Scoliosis :intriguous play (Tensegrity)

TL joint gets kyphotic and stiff leading to shearforces (1792)

Coronal imbalance by torsional forces of diaphragm (1912) Rotation gives a longer action distance for the spine-

erecting muscles at one side ( and asymmetric tension on the cord)

Muscles in convexity perform a double job : hypertrophia

The heterolateral muscle loose much of their job. They slide out of their trolley ( but the distance between cord and the muscle-core will stay constant)

By that they ( cord and muscles) facilitate further torsion and will alter the complete shape of the spine by deforming the vertebral bone (Wolff’s Law)

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Constant equal sided triangle

Testing on tension

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Bending Sitting Supine

Tension disappears in proper extension exercises and in TLI bracing NSDS Amsterdam 2015

Jack in the box test

Consequent findings: Tension in youth with progressive deformation with tight neural structures on MRI

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“Gameboyback”≈Th.Lund et al.

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Why act at the TL Joint? Causal hypothesis

The behaviour of a fixed kyphosis at the Thoracolumbar junction resembles the dislocation of a central hinge, which excellerates the loss of the balancing forces in lordosis, resulting in a different distribution of rotational and other forces

So by reposition we mimic Ponseti’s technique

The outcome of the process that follows depends on genetic difference in stretch quality of nervous tissue . And in the resilience of cartilage , bone and their connecting ligaments ( girls!) against different moulding and deforming forces.

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Early deformation by sitting:Roth:Girls will escape in scoliosis

On this background of TLI we formulated and tested a congruent treatment concept:

Pure focus on TL joint Symmetrical application of forces Extension, extension, extension

(Klapp, Schroth, Heilgymnastik, yoga, Pilates etc.)

Freedom in movement, but avoids flexed posture

Promotes active sitting

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Spine 2008: Scientific proof of action in TLI

SPINE Volume 33, Number 7, pp 797–801

Forced lordosis on the thoracolumbarjunction can correct frontal plane

deformities

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TLI gives an immediate optimisation of the posture

40 children with double major scoliosisStrong relationships: P< 0,001 All had kyphosis between Th10-L2

standing supine on fulcrum

Confirming support

• SPINE Volume 35, Number 23, pp E1334–E1338• ©2010, Lippincott Williams & Wilkins

• An Increased Kyphosis of the Thoracolumbar

• Junction is Correlated to More Axial Vertebral

• Rotation in Thoracolumbar/Lumbar Adolescent

• Idiopathic Scoliosis

• Haijian Ni, MS, Xiaodong Zhu, MD, Shisheng He, MD, Changwei Yang, MD,

• Chuanfeng Wang, MS, Yingchuan Zhao, MS, Dajiang Wu, MS, Jin Xu, RN, and Ming Li, MD

• So , reason to publish the first results in 91 children

Precourse SOSORT 2015 13

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Curve localisation

Pair Group B Kyphosis +/-

Scoliosis <25°

n mean ± SD p value

Progression

rate

n (%)

Group A

Scoliosis ≥25°

n mean ± SD p value

Progression rate

n (%)

Thoracic right T0OB-IB 7 1.6 ± 6.6 0.55

29 6.7 ± 1.2 <0.001

T0 OB -T1 5 -1.8 ± 3.8 0.35 0 (0%) 28 8.9 ± 1.7 0.38 6 (21%)

Lumbar left T0OB-IB 4 7.3 ± 6.8 0.12 6 8.0 ± 3.2 0.045

T0 OB -T1 3 5.0 ± 2.0 0.049 0 (0%) 6 7.2 ± 2.9 0.53 1 (20%)

Thoracolumbar left T0OB-IB 9 7.8 ± 6.1 0.005

26 9.0 ± 6.3 <0.001

T0 OB -T1 8 1.8 ± 6.7 0.49 1 (12%) 24 0.92 ± 4.8 .36 1 (4.2%)

Pelvic obliquity T0OB-IB 4 6.5 ± 2.1 0.008 25 3.1 ± 4.1 0.001

T0 OB -T1 7 2.8 ± 4.2 0.12 0 (0%) 23 1.1 ± 4.9 0.24 1 (4.3%)

Thoracic sagittal T0OB-IB 40 13.3 ± 8.9 <0.001 21 8.2 ± 7.8 <0.001

T0 OB -T1 6 15.7 ± 6.2 0.002 0 (0%) 14 9.6 ± 10.0 0.008 0 (0%)

Thoracolumbar

sagittal

T0OB-IB 43 7.0 ± 7.1 <0.001 26 6.0 ± 6.7 <0.001

T0 OB -T1 10 7.4 ± 6.9 0.008 0 (0%) 20 7.6 ± 6.6 <0.001 0 (0%)

Lumbar

sagittal

T0OB-IB 38 8.7 ± 2.7 <0.001 21 6.7 ± 7.7 <0.001

T0 OB -T1 6 10.3± 13.6 0.13 0 (0%) 14 2.3 ± 7.1 0.29 3 (21%)

Pelvic incidence T0OB-IB 36 6.8 ± 6.3 <0.001 21 5.8 ± 6.2 0.001

T0 OB -T1 6 9.3 ± 9.8 0.07 0 (0%) 14 5.0 ± 6.3 0.011 0 (0%)

Sacral inclination T0OB-IB 36 2.6 ± 5.9 0.01 2 1.7 ± 4.6 0.001

T0 OB -T1 6 2.2 ± 6.8 0.47 0 (0%) 14 -1.1 ± 4.9 0.41 2 (14%)

van Loon et al. Scoliosis 2012, 7:19http://www.scoliosisjournal.com/content/7/1/19

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Curve localisation

Pair Group B Kyphosis +/-

Scoliosis <25°

n mean ± SD p value

Progression

rate

n (%)

Group A

Scoliosis ≥25°

n mean ± SD p value

Progression rate

n (%)

Thoracic right T0OB-IB 7 1.6 ± 6.6 0.55

29 6.7 ± 1.2 <0.001

T0 OB -T1 5 -1.8 ± 3.8 0.35 0 (0%) 28 8.9 ± 1.7 0.38 6 (21%)

Lumbar left T0OB-IB 4 7.3 ± 6.8 0.12 6 8.0 ± 3.2 0.045

T0 OB -T1 3 5.0 ± 2.0 0.049 0 (0%) 6 7.2 ± 2.9 0.53 1 (20%)

Thoracolumbar left T0OB-IB 9 7.8 ± 6.1 0.005

26 9.0 ± 6.3 <0.001

T0 OB -T1 8 1.8 ± 6.7 0.49 1 (12%) 24 0.92 ± 4.8 .36 1 (4.2%)

Pelvic obliquity T0OB-IB 4 6.5 ± 2.1 0.008 25 3.1 ± 4.1 0.001

T0 OB -T1 7 2.8 ± 4.2 0.12 0 (0%) 23 1.1 ± 4.9 0.24 1 (4.3%)

Thoracic sagittal T0OB-IB 40 13.3 ± 8.9 <0.001 21 8.2 ± 7.8 <0.001

T0 OB -T1 6 15.7 ± 6.2 0.002 0 (0%) 14 9.6 ± 10.0 0.008 0 (0%)

Thoracolumbar

sagittal

T0OB-IB 43 7.0 ± 7.1 <0.001 26 6.0 ± 6.7 <0.001

T0 OB -T1 10 7.4 ± 6.9 0.008 0 (0%) 20 7.6 ± 6.6 <0.001 0 (0%)

Lumbar

sagittal

T0OB-IB 38 8.7 ± 2.7 <0.001 21 6.7 ± 7.7 <0.001

T0 OB -T1 6 10.3± 13.6 0.13 0 (0%) 14 2.3 ± 7.1 0.29 3 (21%)

Pelvic incidence T0OB-IB 36 6.8 ± 6.3 <0.001 21 5.8 ± 6.2 0.001

T0 OB -T1 6 9.3 ± 9.8 0.07 0 (0%) 14 5.0 ± 6.3 0.011 0 (0%)

Sacral inclination T0OB-IB 36 2.6 ± 5.9 0.01 2 1.7 ± 4.6 0.001

T0 OB -T1 6 2.2 ± 6.8 0.47 0 (0%) 14 -1.1 ± 4.9 0.41 2 (14%)

van Loon et al. Scoliosis 2012, 7:19http://www.scoliosisjournal.com/content/7/1/19

Progressive passive correction possible because of progressive active extension

Adjustments at every control:

- adding more padding at TL, - shortening rims, - adjusting the sternal support more backward,

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What’s different in TLI bracing in relation to other TLSO?

No direct pressure on bony structures only on muscle bellies to get autocorrection by forcing the “cables”(muscle, fascie and tendons) in a compound pulley system

Always symmetric forces in any indication

Gently forces in time the total body to autocorrect the deformity ( reversing Volkmann-Hueter principle)

Focus on events in sagital plane

Simple and efficient technique for orthotists

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Characteristics Technique

Based on Coronal 3 pointforces

Directed at sagittal contour

Symmetricforces

Dynamic action required

Based on moulds or scans

Static /rigid in all Parts of TL spine

Meantime adaptations to enhance correction

Other IndicationsKyphosis

CTLSO (Milwaukee)

+ - - - +/- ++ - +

TLSO (Boston type)

++ +/- - - - + - -

TLSO (Cheneau type)

++ +/- - - + + - -

TLI - ++ + + + - ++ ++Dynamic (Spine-cor)

- - - ++ - - + -

TriaC +/- - - + - - - -Physio-Logic + + + - - - - -Night time overcorrection brace

++ - - - - + - -

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Results published in Scoliosis Journal 2012Customer satisfaction= compliance

In series (91 children with scoliosis >25⁰ or kyphosis) with TLI: no noncompliars first year.

26

35

25

25

41

45

53

49

22

12

15

16

9

7

7

10

2

1

1

1

Generally satisfied

Choose same again ?

Easy to wear ?

Satisfied with result?

% completely agree % agree % indifferent %do not agree % totally not agree

TLI bracing concept

Claimed effects on the growing spine in terms of growth modulation

Lengthening the canal (Porter) restoring mobility of facets ( by backward opening)restore sagittal balanceActivate muscle action

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Recent changes in “production” TLI

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Surface topography scanning

Lordometer to measure the maximum correction before moulding

Cadcam customised moulding

Indications TLI brace:

Scoliosis Kyphosis TL kyphosis ( Gameboyback with

wedged vertebrae) Spondylolisthesis Severe tension problems (e.g.

stiffness) with lesser curves

… if excersises++ etc. fail or need a passive “help”.

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Conclusion Based on indisputable knowledge on growth and tension lordotic intervention on the thoracolumbar joint restores

physiologic features TL joint (≈Ponseti reposition clubfoot) TLI is a dynamic treatment , augmented by exercises Good compliance: the child loves to get a natural posture TLI models your body , not an X-ray. The muscles do the work, so

surgery can be prevented. Simple technique for all deformities in growth Own results: improvement on X is lasting and statistically

significant;

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THANKS!THANKS !