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FixScoliosis
06-10-2009, 08:29 AM
“It is very difficult to know precisely what the natural history of untreated surgical idiopathic scoliosis is, because most patients have surgical treatment of their curves when the Cobb measurement exceeds 50°. The only way of definitively proving that the natural history of surgical treatment of idiopathic scoliosis is better than untreated scoliosis would be to undertake a study involving a prospective, randomized group of patients with curves more than 50°, treated surgically with modern-day instrumentation and then compare the results with those of a similar group of untreated patients matched for age, deformity, and other parameters. Those two groups of patients would then have to be followed up in 10-year intervals to determine their relative function, pain and cosmetic appearance. No such study exists. If it were possible, it would take between 20 and 40 years to obtain a definitive answer.”

Too bad this was not written on a lunch napkin by a neighborhood quack, so that it could have been easily dismissed by many, but it was written by Keith H. Bridwell, MD a former President of SRS and was published in SPINE.

Dr. Bridwell is also the Asa C. and Dorothy W. Jones Professor of Orthopaedic Surgery at Washington University School of Medicine, and he is Chief of Pediatric and Adult Spinal Surgery in the Orthopaedic Department at Washington University in St. Louis.

What Dr Bridwell is saying that there is no solid proof that surgery gives a better outcome in Idiopathic Scoliosis than leaving it alone.

He also stated:
"Many surgeons feel that 50° is the surgical tidemark for treating idiopathic scoliosis … This “magic number” comes in part as an extrapolation from … studies of natural history and in part that most 50° curves are very visible cosmetically.”



Almost forgot the reference:
1: Bridwell KH. Surgical treatment of idiopathic adolescent scoliosis. Spine.
1999 Dec 15;24(24):2607-16. Review.


Links on Dr Bridwell
http://www.srs.org/professionals/meetings/am03/photos.php
http://www.bridwell-spinal-deformity.com/about-keith-bridwell

Ballet Mom
06-10-2009, 08:54 AM
Very interesting from a former president of SRS! Thanks for posting.

LindaRacine
06-10-2009, 12:56 PM
Yes, but it would never be ethical to put someone with a 100 degree curve into a control group.

Dr. Bridwell is not saying that surgery isn't a cure. He's saying that they can't prove surgery is a cure.

--Linda

Pooka1
06-10-2009, 02:35 PM
Doesn't the fact that there is an agreed upon angle for surgery suggest that failure to operate at that point is likely to lead to a worse outcome?

They selected 50* for a reason.

I wish they would revisit that number with some more data evaluation because I suspect more than 5% of folks with curves > 40* but < 50* at maturity go on to need surgery in their lifetime. And they tend to get it when they are less able to cope.

Maybe it isn't half but maybe it's 30%.

FixScoliosis
06-10-2009, 05:31 PM
If we are all comfortable with those terms for accepting surgery as a treatment option for surgery, without having no solid proof we should then give alternative ways the same leeway.

and also, like Linda writes
"He's saying that they can't prove surgery is a cure."

It is true they can't prove it, so we should not blame others for lacking proof and continuing with their practice.
But, what he is really saying, is that they can't prove that surgery lead to a better outcome than no surgery. He doesn't even talk about cure.

I thought solid PROOF was the only thing that counted here on the NSF and not mere suggestions. Well, that's what it seems like when I have read many posts.

I am glad now that, suggestions and lack of proof is acceptable and I wish it will remain that way.

It would keep this forum a lot more pleasant for everybody.

LindaRacine
06-10-2009, 05:45 PM
If we are all comfortable with those terms for accepting surgery as a treatment option for surgery, without having no solid proof we should then give alternative ways the same leeway.

and also, like Linda writes
"He's saying that they can't prove surgery is a cure."

It is true they can't prove it, so we should not blame others for lacking proof and continuing with their practice.
But, what he is really saying, is that they can't prove that surgery lead to a better outcome than no surgery. He doesn't even talk about cure.

I thought solid PROOF was the only thing that counted here on the NSF and not mere suggestions. Well, that's what it seems like when I have read many posts.

I am glad now that, suggestions and lack of proof is acceptable and I wish it will remain that way.

It would keep this forum a lot more pleasant for everybody.

Fix...

At least there are long-term followup studies for surgery. When the alternatives start publishing those, I'll be delighted to jump on board.

--Linda

Pooka1
06-10-2009, 06:12 PM
He also stated:
"Many surgeons feel that 50° is the surgical tidemark for treating idiopathic scoliosis … This “magic number” comes in part as an extrapolation from … studies of natural history and in part that most 50° curves are very visible cosmetically.”

Maybe this 1999 article is stale because our surgeon seems to think there is evidence why 50* is "magic." It has to do with the percentages that progress at particular rates above that point. Given the average life span, 50* is the magic number.

In re the longer Bridwell quote at the top of the OP, I'm going to ask for a comment on this comment from our surgeon. I think we might be missing some context.

mamamax
06-10-2009, 06:23 PM
Fix...

At least there are long-term followup studies for surgery. When the alternatives start publishing those, I'll be delighted to jump on board.

--Linda

Hi Linda - I've been looking for some long term follow up studies for surgery but am not very good at it - can you cite some please? Thanks.

Pooka1
06-10-2009, 06:24 PM
pain is the issue (http://journals.lww.com/spinejournal/Abstract/2006/02010/Nonoperative_Treatment_for_Adolescent_Idiopathic.1 7.aspx)

"Conclusions. Although pain, disability, HRQOL, and psychological general well-being are quite satisfactory on an absolute level, curve size was found to be a significant predictor for pain in a long-term follow-up."

Hence, they operate above a certain target angle.

Pooka1
06-10-2009, 06:26 PM
Hi Linda - I've been looking for some long term follow up studies for surgery but am not very good at it - can you cite some please? Thanks.



The only long-term studies would be for old instrumentation no longer in use.

I think they extrapolate from that and the known the improvements in the current instrumentation over the historical-use instrumentation to predict the long-term outcomes of the current instrumentation.

mamamax
06-10-2009, 06:34 PM
The only long-term studies would be for old instrumentation no longer in use.

I think they extrapolate from that and the known the improvements in the current instrumentation over the historical-use instrumentation to predict the long-term outcomes of the current instrumentation.

I've found the one's on older instrumentation but surely there must be some by now for pedicle (sp?) screws by now?

Pooka1
06-10-2009, 06:37 PM
I've found the one's on older instrumentation but surely there must be some by now for pedicle (sp?) screws by now?

Not sure it is just for the screws and not other newer techniques used.

I don't even know how long the screws have been in use.

Linda would know.

LindaRacine
06-10-2009, 06:42 PM
The only long-term studies would be for old instrumentation no longer in use.

I think they extrapolate from that and the known the improvements in the current instrumentation over the historical-use instrumentation to predict the long-term outcomes of the current instrumentation.

Sharon is correct. This is as close as one can get to current implant outcomes:

http://www.ncbi.nlm.nih.gov/pubmed/17907428?ordinalpos=31&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Long-term clinical and radiographic results of Cotrel-Dubousset instrumentation of right thoracic adolescent idiopathic scoliosis.
Boos N, Dolan LA, Weinstein SL.

Dept. of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA. nboos@balgrist.unizh.ch

Little substantive data is available in the literature on the long-term clinical and radiological results of Cotrel-Dubousset instrumentation (CDI) for the treatment of adolescent idiopathic scoliosis. We therefore retrospectively investigated the long-term clinical and radiographic outcome of patients who underwent (CDI) for right thoracic adolescent idiopathic scoliosis. 54 consecutive patients (45 females, 9 males) who underwent CDI for right thoracic adolescent idiopathic scoliosis with an average age of 14 years (range 10-21 years) at surgery were included in this series. There were 18 King Type II, 19 Type III, 5 Type IV, 3 Type V and 9 double major curves. The average coronal Cobb angle of the primary thoracic curve preoperatively, postoperatively and at latest follow-up was 55 degrees, 17 degrees and 22 degrees, respectively. The lumbar curve (secondary and double major) averaged 40 degrees, 21 degrees and 23 degrees, respectively. Coronal balance (deviation from the central sacral line) was slightly improved from 13 mm to 11 mm. The average shoulder elevation increased from 3 degrees to 5 degrees, presumably as a result of the rod derotation maneuver. Thoracic kyphosis (20 degrees to 22 degrees) and lumbar lordosis (49 degrees to 54 degrees) was preserved or even improved by the instrumentation. All patients were doing well and had no complaints with regard to a substantial limitation of professional or sports activity. There were no apparent non-unions, infections or neurological complications. CDI of adolescent right thoracic idiopathic scoliosis provides encouraging clinical and radiographic results at an average follow-up of 9 years (2 to 16 years). Overall patient satisfaction, functional status and subjective cosmetic improvement is high.

And, from a separate spine center:

http://www.ncbi.nlm.nih.gov/pubmed/17762812?ordinalpos=34&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Idiopathic scoliosis treated with Cotrel-Dubousset instrumentation: evaluation 10 years after surgery.
Bjerkreim I, Steen H, Brox JI.

Rikshospitalet-Radiumhospitalet Medical Center, Orthopaedic Department, University of Oslo, Oslo, Norway.

STUDY DESIGN: Prospective cohort study with 10-year follow-up. OBJECTIVE: To evaluate long-term results after operative treatment with Cotrel-Dubousset (CD) instrumentation for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Limited knowledge exists in the evaluation of long-term function with quality of life measures after CD instrumentation in patients with AIS. METHODS: A total of 100 (76 females and 24 males) consecutive AIS patients all with single primary curves were included. Radiologic measures and pain were registered at baseline and at 1- to 5-year follow-up. Quality of life and back specific measures, including EuroQol (EQ) and Oswestry Disability Index (ODI), were obtained by a questionnaire mailed to the patients at 10 years after surgery. RESULTS: Mean age at operation was 16.8 (SD, 5.3) years, mean Risser sign was Grade 3.2 (SD, 1.5). All patients were observed for 2 years. The average primary curve was reduced from 56 degrees to 19 degrees, and this correction was maintained during follow-up. Fourteen patients had minor complications, and 5 patients had implants removed because of late clinically suspected infections. A total of 86 patients answered the 10-year questionnaire; 97% of the patients considered back function as excellent, good, or fair, and 96% would have done the operation again. Scores for EQ-5D and ODI were slightly worse than in the normal population. Despite this observation, 45% of the patients reported to have consulted a physician or received physiotherapy for back pain during the last year before the 10-year follow-up. CONCLUSION: Radiologic results, patient satisfaction, and mean scores for quality of life and back function were excellent after CD instrumentation for AIS, but a considerable number of patients had treatment for back problems.

And, for TSRH implants (not sure if they're still being used):

http://www.ncbi.nlm.nih.gov/pubmed/16924553?ordinalpos=49&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Minimum 10 years follow-up surgical results of adolescent idiopathic scoliosis patients treated with TSRH instrumentation.
Benli IT, Ates B, Akalin S, Citak M, Kaya A, Alanay A.

Department of Orthopedics and Traumatology, Faculty of Medicine, UFUK University, Mithatpasa Cad. 59/2, Kyzylay, Ankara 06420, Turkey. cutku@ada.net.tr

Last two decades witnessed great advances in the surgical treatment of idiopathic scoliosis. However, the number of studies evaluating the long-term results of these treatment methods is relatively low. During recent years, besides radiological and clinical studies, questionnaires like SRS-22 assessing subjective functional and mental status and life-quality of patients have gained importance for the evaluation of these results. In this study, surgical outcome and Turkish SRS-22 questionnaire results of 109 late-onset adolescent idiopathic scoliosis patients surgically treated with third-generation instrumentation [Texas Scottish Rite Hospital (TSRH) System] and followed for a minimum of 10 years were evaluated. The balance was analyzed clinically and radiologically by the measurement of the lateral trunk shift (LT), shift of head (SH), and shift of stable vertebra (SS). Mean age of the patients was 14.4+/-1.9 and mean follow-up period was 136.9+/-12.7 months. When all the patients were included, the preoperative mean Cobb angle of major curves in the frontal plane was 60.8 degrees +/-17.5 degrees . Major curves that were corrected by 38.7+/-22.1% in the bending radiograms, postoperatively achieved a correction of 64.0+/-15.8%. At the last follow-up visit, 10.3 degrees +/-10.8 degrees of correction loss was recorded in major curves in the frontal plane with 50.5+/-23.1% final correction rate. Also, the mean postoperative and final kyphosis angles and lumbar lordosis angles were 37.7 degrees +/-7.4 degrees , 37.0 degrees +/-8.4 degrees , 37.5 degrees +/-8.7 degrees , and 36.3 degrees +/-8.5 degrees , respectively. A statistically significant correction was obtained at the sagittal plane; mean postoperative changes compared to preoperative values were 7.9 degrees and 12.9 degrees for thoracic and lumbar regions, respectively. On the other hand, normal physiological thoracic and lumbar sagittal contours were achieved in 83.5% and 67.9% of the patients, respectively. Postoperatively, a statistically significant correction was obtained in LT, SH, and SS values (P<0.05). Although, none of the patients had completely balanced curves preoperatively, in 95.4% of the patients the curves were found to be completely balanced or clinically well balanced postoperatively. This rate was maintained at the last follow-up visit. Overall, four patients (3.7%) had implant failure. Early superficial infection was observed in three (2.8%) patients. Radiologically presence of significant consolidation, absence of implant failure, and correction loss, and clinical relief of pain were considered as the proof of a posterior solid fusion mass. About ten (9.2%) patients were considered to have pseudoarthrosis: four patients with implant failure and six patients with correction loss over 15 degrees at the frontal plane. About four (3.7%) patients among the first 20 patients had neurological deficit only wake-up test was used for neurological monitoring of these patients. No neurological deficit was observed in the 89 patients for whom intraoperative neurological monitoring with SSEP and TkMMEP was performed. Overall, average scores of SRS-22 questionnaire for general self-image, function, mental status, pain, and satisfaction from treatment were 3.8+/-0.7, 3.6+/-0.7, 4.0+/-0.8, 3.6+/-0.8, and 4.6+/-0.3, respectively at the last follow-up visit. Results of about 10 years of follow-up these patients treated with TSRH instrumentation suggest that the method is efficient for the correction of frontal and sagittal plane deformities and trunk balance. In addition, it results in a better life-quality.

LindaRacine
06-10-2009, 06:47 PM
I've found the one's on older instrumentation but surely there must be some by now for pedicle (sp?) screws by now?

They wouldn't be considered long-term.

A Pubmed search of scoliosis and pedicle screws brings up 224 references.

LindaRacine
06-10-2009, 06:55 PM
I've found the one's on older instrumentation but surely there must be some by now for pedicle (sp?) screws by now?
Here's a 3 year followup:

http://www.ncbi.nlm.nih.gov/pubmed/18552676?ordinalpos=45&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Operative treatment of adolescent idiopathic scoliosis with posterior pedicle screw-only constructs: minimum three-year follow-up of one hundred fourteen cases.
Lehman RA Jr, Lenke LG, Keeler KA, Kim YJ, Buchowski JM, Cheh G, Kuhns CA, Bridwell KH.

Walter Reed Army Medical Center, USA.

STUDY DESIGN: Preoperative review of a prospective study, single institution, consecutive series. OBJECTIVE.: To analyze the intermediate-term follow-up of consecutive adolescent idiopathic scoliosis (AIS) patients treated with pedicle screw constructs. SUMMARY OF BACKGROUND DATA: There have been no reports of the intermediate-term findings in North America following posterior spinal fusion with the use of pedicle screw-only constructs. METHODS: One hundred and fourteen consecutive patients having a minimum 3-year follow-up (mean 4.8 +/- 1.1; range, 3.0-7.3 years) with AIS were evaluated. The average age at surgery was 14.9 +/- 2.2 years. Radiographic measurements included preoperative (Preop), postoperative (PO), 2-year (2 years), and final follow-up (FFU). A chart review evaluated PFTs, Scoliosis Research Society scores, presence of thoracoplasty, Risser sign, Lenke classification, and complications. RESULTS: The most frequent curve pattern was Lenke type 1 (45.6%), followed by type 3 (21.9%). The average main thoracic curve measured 59.2 degrees +/- 12.2 SD Preop, and corrected to 16.8 degrees +/- 9.9 PO (P < 0.0001). Sagittal thoracic alignment (T5-T12) decreased from 25.8 degrees to 15.5 degrees at FFU (P = 0.05). Nash-Moe grading for apical vertebral rotation (AVR) in the proximal thoracic curve decreased from 2.0 Preop to 1.1 at FFU (P < 0.0001), and AVR in the thoracolumbar/lumbar spine decreased from 1.6 Preop to 1.1 at FFU (P < 0.0001). Importantly, the horizontalization of the subjacent disc measured -8.3 degrees Preop which decreased to -0.9 degrees PO (P < 0.001). PFT follow-up averaged 2.4 years with a 7.1% improvement in FVC (P = 0.004) and 8.8% in FEV1 (P < 0.0001). SRS scores averaged 83.0% at latest follow-up. Age, gender, Risser sign, or complications did not have a significant effect on outcomes. There were 2 cases of adding-on, 3 late onset infections, 1 with a single pseudarthrosis, but no neurologic complications. CONCLUSION: This is the largest (N = 114), consecutive series of North American patients with AIS treated with pedicle screws having a minimum of 3-year follow-up. The average curve correction was 68% for the main thoracic, 50% for the proximal thoracic, and 66% for the thoracolumbar/lumbar curve at final follow-up.

mamamax
06-10-2009, 07:35 PM
Thank you Linda. Such is the nature of true scientific study i suppose. With surgical techniques, by the time we have a 10 year study, new techniques have been developed? A bit bothersome, to me - and making a decision towards surgery based on long term studies not really possible. Personally, i would have to rely more on a leap of faith than i would long term evidence of any technique i would choose today. Would have to say the pedicle screws look promising but certainly more time is required before deeming them a success (i.e., how will these same patients fare when they are 70 or 80. We do need techniques that will give near perfect correction (vs 50-70 %) while allowing excellent range of motion - and is what we look for in the future.

In 1969, i broke my neck in a car accident. A wonderful neurosurgeon named Richard King Neal III (now retired) - literally saved my life. When he saw my xrays he broke out in a cold sweat - one of the vertebra was cutting through my spinal chord, near 50% he told me later (i realize some may not believe this, but it is true). Anyway he fused 5-6 using bone from my hip, entering from the front (anterior?). At 3 month follow up, he was amazed that i had full range of motion to move my head from left to right & up and down. Forty years later .. have never had a problem.

Maybe one day - we will have surgical techniques allowing for similar spinal range of motion without future complication. Certainly, this is what we need to truly improve quality of life.

My question is - is this what selective fusion attempts to do (offer greater range of motion)?

Pooka1
06-10-2009, 08:02 PM
(snip good points)

With surgical techniques, by the time we have a 10 year study, new techniques have been developed? A bit bothersome, to me - and making a decision towards surgery based on long term studies not really possible.

Yes but the newer techniques aren't usually created in a vacuum, going off on a complete tangent though some are. They are designed to improve the previous ones in specific ways I imagine.

For example, we had the Harrington rods. Though many patients had no problems, a certain number had a similar problem (flatback syndrome). So the next generation of instrumentation was designed to hopefully avoid that problem as far as I know.

The techniques build on what was learned from the previous generation. At some point, it gets pretty good hopefully.

My one kid, we didn't have a choice due to documented rapid progression. And she was also in big need of a cosmetically better outcome than she had at 58* and torqued around like crazy. I assume these surgeries are never covered by insurance for cosmesis alone but I wonder if she would have wanted it just for that reason. I don't know... depends on how much worse it would get and how bad it made her feel.

My sub-surgical kid is just damn lucky to have almost no rotation and so her curve is not noticeable to the uneducated eye. But she does wish her back looked like her sister's looks now at 5* and virtually no rotation.

FixScoliosis
06-10-2009, 08:06 PM
So is then safe to say that when HR Weiss wrote:

"CONCLUSIONS: No evidence has been found in terms of prospective controlled studies to support surgical intervention from the medical point of view. In the light of the unknown long-term effects of surgery and in concluding on the lack of evidence already found that surgery might change the signs and symptoms of scoliosis, a randomized controlled trial (RCT) is long overdue. Until such a time that such evidence exists, there can be no medical indication for surgery. The indications for surgery are limited for cosmetic reasons in severe cases and only if the patient and the family agree with this." pubmed (http://www.ncbi.nlm.nih.gov/pubmed/18432438)

which is quite similar to what Bridwell says and therefore does not deserve to be called or considered a quack?

Pooka1
06-10-2009, 08:12 PM
So is then safe to say that when HR Weiss wrote:

"CONCLUSIONS: No evidence has been found in terms of prospective controlled studies to support surgical intervention from the medical point of view. In the light of the unknown long-term effects of surgery and in concluding on the lack of evidence already found that surgery might change the signs and symptoms of scoliosis, a randomized controlled trial (RCT) is long overdue. Until such a time that such evidence exists, there can be no medical indication for surgery. The indications for surgery are limited for cosmetic reasons in severe cases and only if the patient and the family agree with this." pubmed (http://www.ncbi.nlm.nih.gov/pubmed/18432438)

which is quite similar to what Bridwell says and therefore does not deserve to be called or considered a quack?

No that Weiss quote is most definitely quacky and can be shown to be false in several instances. It differs from the Bridwell quote.

Also, can you cite the controlled study on surgical treatment of setting broken arms bones? Weiss needs to do that unless he admits a randomized controlled trial doesn't need to be done there. Then he has to say why not.

I would like to know how other orthopedic surgeons view Weiss. Anybody know?

LindaRacine
06-10-2009, 08:20 PM
No that Weiss quote is most definitely quacky and can be shown to be false in several instances. It differs from the Bridwell quote.

Also, can you cite the controlled study on surgical treatment of setting broken arms bones? Weiss needs to do that unless he admits a randomized controlled trial doesn't need to be done there. Then he has to say why not.

I would like to know how other orthopedic surgeons view Weiss. Anybody know?

Apparently increasing pain, loss of function, and severely limited pulmonary function take a back seat to cosmesis. Quack Quack

The surgical cost of treating scoliosis is nothing when compared to putting us all on long-term disability for the rest of our lives.

Sharon, I think most scoliosis specialists don't spend any amount of time thinking about attacks from alternative practitioners. They have pretty full plates already.

mamamax
06-10-2009, 09:20 PM
So is then safe to say that when HR Weiss wrote:

"CONCLUSIONS: No evidence has been found in terms of prospective controlled studies to support surgical intervention from the medical point of view. In the light of the unknown long-term effects of surgery and in concluding on the lack of evidence already found that surgery might change the signs and symptoms of scoliosis, a randomized controlled trial (RCT) is long overdue. Until such a time that such evidence exists, there can be no medical indication for surgery. The indications for surgery are limited for cosmetic reasons in severe cases and only if the patient and the family agree with this." pubmed (http://www.ncbi.nlm.nih.gov/pubmed/18432438)

which is quite similar to what Bridwell says and therefore does not deserve to be called or considered a quack?

Speaking of the referenced paper, which is: an observation of all available Pub Med literature ~

His opinion is based upon a review of Pub Med literature evidence which (he states through observation) does not reveal evidence that surgery is superior to natural history (in terms of outcome parameter and rate of progression using only prospective controlled studies that have considered treatment vs natural history).

This paper was written in 2008 - if his observation of the published material was not accurate (or grossly inaccurate), i'm pretty sure someone would have written a rebuttal by now? Why do we not see this rebuttal?

I don't see Weiss (MD Orthopaedic Surgeon) as a Quack. Actually several decades ago, before the advent of Harrington rods, surgeons often recommended non surgical methods for their scoliosis patients (many had great success - a pity it was not well documented). I see Weiss (and others like Rivard/Collard) as carrying on with such work and making up for the lack of earlier documentation. I don't know what other orthopaedic surgeons may think of HR Weiss but certainly many cite his work - and often.

I see this paper (as stated), as an observation of published material in the Pub Med library - if rebuttal is justified ... where is it?

pubmed (http://www.ncbi.nlm.nih.gov/pubmed/18432438)

LindaRacine
06-10-2009, 09:40 PM
Speaking of the referenced paper, which is: an observation of all available Pub Med literature ~

His opinion is based upon a review of Pub Med literature evidence which (he states through observation) does not reveal evidence that surgery is superior to natural history (in terms of outcome parameter and rate of progression using only prospective controlled studies that have considered treatment vs natural history).

This paper was written in 2008 - if his observation of the published material was not accurate (or grossly inaccurate), i'm pretty sure someone would have written a rebuttal by now? Why do we not see this rebuttal?

I don't see Weiss (MD Orthopaedic Surgeon) as a Quack. Actually several decades ago, before the advent of Harrington rods, surgeons often recommended non surgical methods for their scoliosis patients (many had great success - a pity it was not well documented). I see Weiss (and others like Rivard/Collard) as carrying on with such work and making up for the lack of earlier documentation. I don't know what other orthopaedic surgeons may think of HR Weiss but certainly many cite his work - and often.

I see this paper (as stated), as an observation of published material in the Pub Med library - if rebuttal is justified ... where is it?

pubmed (http://www.ncbi.nlm.nih.gov/pubmed/18432438)



Maxene...

You can't have it both ways. If there's no evidence that surgery is better than natural history, than there certainly is no evidence that any alternative works. So, I assume you'll be discontinuing your treatment. Right? After all, since the one thing that the Spinecor is known to help, pain, is of no substance.

mamamax
06-10-2009, 10:03 PM
Linda ~The point i'm trying to make is .. this paper is a review of Pub Med literature and based only on that (the documented literature) - the study is then taken a step further and confined to observation of: outcome parameter and rate of progression using only prospective controlled studies that have considered treatment vs natural history.

Essentially Weiss is stating that if surgery is superior to natural history (meeting the above criteria within the literature in the Pub Med library) then ... documentation (in the Pub Med library) is woefully lacking.

To read some of these papers is rather like trying to interpret state or federal statutes. And you are correct, truly superior documentation is lacking in both areas. I believe SOSORT was created to help make up for this - am i correct?

I will continue on with my Spinecor treatment, it is serving me well, which is substance enough for me. Nothing like personal observation.

LindaRacine
06-10-2009, 10:32 PM
Essentially Weiss is stating that if surgery is superior to natural history (meeting the above criteria within the literature in the Pub Med library) then ... documentation (in the Pub Med library) is woefully lacking.

Yes, because thankfully, there's a shortage of parents who are wacky enough to withhold surgery from their kids with curves > 50 degrees.

hope404
06-10-2009, 11:14 PM
"no evidence that surgery is better then natural history"

Is it possible that Laura Ingalls was walking(happily) around the prairie with a 50 degree curve and did not know it???

Are we all too obsessed about the numbers??? What if we didn't have xray?


The human body has an incredible ability to adapt...one arm...one leg...one eye...one tooth

Our doctor told us he can't count the times a 60-70 year old person will walk in the office with a 50 degree curve and have ZERO signs or symptoms and will not have known.

No doubt highly..progressive, rapidly, moving curves have to be STOPPED.
But is some of our anxiety, PERFECTION based....braces for teeth were unheard of 60 some odd years ago. Now your lucky to meet someone with UNPERFECT teeth.

Personally, I want my daughter perfect and I don't want that little hump on her back. I want her to have a straight, beautiful back.

But maybe the surgeon is just making the point that in many cases (that aren't highly progressive) a full happy healthy life can be lived ...

txmarinemom
06-11-2009, 01:26 AM
This paper was written in 2008 - if his observation of the published material was not accurate (or grossly inaccurate), i'm pretty sure someone would have written a rebuttal by now? Why do we not see this rebuttal?

Has is occurred to you that maybe real orthopedic surgeons think he's a quack, and a rebuttal isn't worth their time? This is the man who claimed scoliosis surgery is cosmetic ONLY, and I KNOW *that's* incorrect.


I don't see Weiss (MD Orthopaedic Surgeon) as a Quack. Actually several decades ago, before the advent of Harrington rods, surgeons often recommended non surgical methods for their scoliosis patients (many had great success - a pity it was not well documented). I see Weiss (and others like Rivard/Collard) as carrying on with such work and making up for the lack of earlier documentation. I don't know what other orthopaedic surgeons may think of HR Weiss but certainly many cite his work - and often.

Just curious where you saw Weiss listed as an orthopedic surgeon ... I've never even seen him referred to as an M.D. - only Dr.

"Many" had great success with non-surgical approaches? Really. Let's hear more detail about that, please? If it wasn't well-documented, how are you able to claim "many" had success?

"Many" cite his work, and often? I'd like to see those details, as well, if you're willing to make the claim.


I see this paper (as stated), as an observation of published material in the Pub Med library - if rebuttal is justified ... where is it?

pubmed (http://www.ncbi.nlm.nih.gov/pubmed/18432438)


Mamamax, I think you underestimate the veracity of everything that's "published material in the PubMed library". Just because it's there doesn't mean it's accurate ... and again, why would REAL doctors argue with a person clueless enough to claim surgery is cosmetic?

Pooka1
06-11-2009, 05:53 AM
This paper was written in 2008 - if his observation of the published material was not accurate (or grossly inaccurate), i'm pretty sure someone would have written a rebuttal by now? Why do we not see this rebuttal?"

Maybe for the same reason many scientists won't debate creationists. Actually I'm betting that is the reason.

I question whether that article was peer-reviewed.


I see this paper (as stated), as an observation of published material in the Pub Med library - if rebuttal is justified ... where is it?

Occasionally, I will come across a really bad paper in my field. Sometimes I just toss it. Sometimes I point out the problems in the margins for my own amazement and marvel at it. If I keep the paper to amaze others, I label it with "UGH" across the top. I only have a few such papers.

That Weiss paper is sloppy in its thinking, pretends that out of date references are relevant today, and has typos.

Most lay people will not realize that his conclusions are based on decades old information and so are irrelevant today. If that is a peer-reviewed pub then it could be exhibit A in why most published research results are false. The entire bracing literature except a few papers (controlled studies) is Exhibit B.

That paper is Exhibit A why he is likely marginalized within the orthopedic community.

Pooka1
06-11-2009, 05:56 AM
I will continue on with my Spinecor treatment, it is serving me well, which is substance enough for me. Nothing like personal observation.

No actually personal observation is very faulty for known reasons.

That's why we have science.

Pooka1
06-11-2009, 06:00 AM
Our doctor told us he can't count the times a 60-70 year old person will walk in the office with a 50 degree curve and have ZERO signs or symptoms and will not have known.

Yes 50*. But how many people have walked in there with a much higher curve and didn't know it?


No doubt highly..progressive, rapidly, moving curves have to be STOPPED.
But is some of our anxiety, PERFECTION based....braces for teeth were unheard of 60 some odd years ago. Now your lucky to meet someone with UNPERFECT teeth.

Then why do insurance companies kick out all that money for "cosmetic" back surgery when they refuse to pay for other cosmetic surgery?


But maybe the surgeon is just making the point that in many cases (that aren't highly progressive) a full happy healthy life can be lived ...

Apparently, if you are above 50* at maturity, you likely won't have that full happy healthy life to live.

mamamax
06-11-2009, 06:04 AM
Has is occurred to you that maybe real orthopedic surgeons think he's a quack, and a rebuttal isn't worth their time? This is the man who claimed scoliosis surgery is cosmetic ONLY, and I KNOW *that's* incorrect.



Just curious where you saw Weiss listed as an orthopedic surgeon ... I've never even seen him referred to as an M.D. - only Dr.

"Many" had great success with non-surgical approaches? Really. Let's hear more detail about that, please? If it wasn't well-documented, how are you able to claim "many" had success?

"Many" cite his work, and often? I'd like to see those details, as well, if you're willing to make the claim.



Mamamax, I think you underestimate the veracity of everything that's "published material in the PubMed library". Just because it's there doesn't mean it's accurate ... and again, why would REAL doctors argue with a person clueless enough to claim surgery is cosmetic?

Pam ~

To answer your questions/statements: It has occurred to me that if Weiss's statements were grossly inaccurate, that they would not have gone unchallenged or without rebuttal. Furthermore the referenced paper is about documentation .. if one reads it with a keen eye.

One of the many places that Dr. Weiss is listed as both medical doctor and surgeon is at the SOSORT Foundators page: http://sosort.tleonardi.eu/cms.php?table=page_history

As for success with non surgical approaches - Joe O'Brien just referred to that i see (in Setting The Record Straight) ... think you are capable of doing the research on that Pam, if you are really interested. You can also search Pub Med and Scoliosis Journal to see where Dr. Weiss is quoted.

Don't think i am underestimating anything ... i am reading the referenced paper with a keen eye - rather than through an emotional perspective.

Tell us Pam .. are you still threatening legal action against Dr. Joseph O'Brien? http://www.scoliosis.org/forum/member.php?u=114

Pooka1
06-11-2009, 06:19 AM
To answer your questions/statements: It has occurred to me that if Weiss's statements were grossly inaccurate, that they would not have gone unchallenged or without rebuttal. Furthermore the referenced paper is about documentation .. if one reads it with a keen eye.

No. Quacks are marginalized and ignored. Within biology, there are a few "geniuses" with legit doctorates from accredited schools but are nonetheless creationists. Few legit researchers deal with them in a serious way. Dawkins and Gould specifically and publicly refused to debate them because debates require two sides and it's dopey to debate science versus religion.

Pooka1
06-11-2009, 06:40 AM
Here is the page Lehigh University has to have up to avoid anyone thinking they are as nutty as Behe, an Intelligent Design Creationist who is also tenured...

How to handle Behe (http://www.lehigh.edu/~inbios/news/evolution.htm)

They used to have this splash page come up if you tried to get to the Biology page so that it was the FIRST thing you could read before going to the Biology Department. That's how important they thought it was. People who don't think scientifically shouldn't be calling themselves scientists.

And by the way, Behe at least accepts common descent and a few billion year old earth. So there is a limit to his nuttiness.

concerned dad
06-11-2009, 08:30 AM
Sharon, Comparing Dr. Weiss to creation scientists is wrong.
Linda, Calling this physician a "quack" is wrong.
Pam, Quoting statements from his technical literature out of context (surgery and cosmesis) is wrong.

M.D. 1986;
Residency in traumatology 1986;
Residency in orthopedic surgery 1987 – 1992.
Orthopaedic surgeon since 1992,

What does he have to say about surgery? In his 2003 paper available in full PDF from the link below he says:
Conclusions: If conservative management does reduce the proportion of children with adolescent idiopathic scoliosis that require surgery, (CD- As he believes he shows in his paper) it can be said to provide a real and meaningful advantage to both the patients and the community. It is contended that conservative methods of treatment should never be ruled out from scoliosis management, because they can and do offer a viable alternative to those patients who cannot or will not opt for surgical treatment. Does anyone have a problem with THAT statement?

Link (http://www.scoliosisxpert.com/uk/pageuk.php?va=1)

Did I piss everyone off yet?:D

To blow a kiss to mamamax, I believe she is 100% correct. The paper is about documentation (evidence and proof). Part of the issue relates to the fact that English is not his first language.

concerned dad
06-11-2009, 09:40 AM
Sharon,
I wonder if this hobby (http://www.scoliosisxpert.com/uk/5.php?va=2) of his changes your opinion.

Pooka1
06-11-2009, 11:30 AM
Sharon,
I wonder if this hobby (http://www.scoliosisxpert.com/uk/5.php?va=2) of his changes your opinion.

I hand it to you in finding his credentials and this web page.

I see he is one of a growing number of Europeans who are gloming onto western riding disciplines. It is becoming the rage. Reining and balance seat at least are directly analogous to dressage.

I guess the Germans were getting bored with DOMINATING dressage for decades until recently when The Netherlands dominates. :D

In re Scroth, I have heard Germans claim it is a very fringe treatment even in that country.

CHRIS WBS
06-11-2009, 12:18 PM
Tell us Pam .. are you still threatening legal action against Dr. Joseph O'Brien? http://www.scoliosis.org/forum/member.php?u=114

How dare she threaten legal action against someone who has provided such a valuable service to so many of us. When I was at my wit’s end four years ago, I stumbled on to this site and have always believed that God steered me here to find answers. It provided the answer to my prayer when I asked to be led to the doctor who was right for me and I am forever grateful for having found this site. Thank you Joe and Linda.

Pooka1
06-12-2009, 07:17 AM
Pam, Quoting statements from his technical literature out of context (surgery and cosmesis) is wrong.

We have that ENTIRE article. The context doesn't save that quote. It is not supported by facts.


What does he have to say about surgery? In his 2003 paper available in full PDF from the link below he says:
Conclusions: If conservative management does reduce the proportion of children with adolescent idiopathic scoliosis that require surgery, (CD- As he believes he shows in his paper) it can be said to provide a real and meaningful advantage to both the patients and the community. It is contended that conservative methods of treatment should never be ruled out from scoliosis management, because they can and do offer a viable alternative to those patients who cannot or will not opt for surgical treatment. Does anyone have a problem with THAT statement?

Well I would say that excerpt is about alternative methods, NOT surgery.

I also wonder why he hasn't gathered more data for alternative methods since becoming a surgeon and why his grandmother (K. Schroth) didn't either and why Schroth is still a fringe treatment even in Germany. Why aren't other surgeons convinced by now?

Last, if those are fully trained horses on his web site, he paid a pretty penny, whether he imported them from the States or they are homebreds.

And I find it amusing to think Germans import horses when for decades 99.99999% of the import traffic has been German horses going abroad, often to the US. Germans know how to breed sport horses and have been perfecting it for a long, long time.

concerned dad
06-12-2009, 12:09 PM
The term “Medical Indication” is central to the issue surrounding the Weiss quote. When I said "context", I meant in the context of the scientific debate.

Sometimes (most times, I hope) scientific debate is carried out in the technical literature.

But imagine this: An SRS doctor says “You bozo’s over at SOSORT have no good evidence that your conservative treatments work."

The SOSORT doctor says, “oh yeah bud? You can’t prove that surgery works. Put that in your pipe and smoke it”

But, that’s not how it plays out. Thankfully it is a bit more civil.

Dr. Dolan says “the use of bracing relative to observation is supported by “troublingly inconsistent or inconclusive studies of any level.”

And Dr. Weiss responds : In the light of the unknown long-term effects of surgery …… Until such a time that such evidence exists, there can be no medical indication for surgery.

Then, seemingly JUST to piss of Pam, he adds:

The indications for surgery are limited for cosmetic reasons in severe cases.

Acknowledging that there is evidence that rises to the level of proof that cosmesis is improved after scoliosis surgery.

I dunno, that's my take on it anyway. Could be wrong, wouldnt be the first time.

Pooka1
06-12-2009, 12:22 PM
The term “Medical Indication” is central to the issue surrounding the Weiss quote. When I said "context", I meant in the context of the scientific debate.

As far as I know, the context is where most of the rest of the surgeons and virtually all insurance companies think the following:

from one of the "anointed" :D links on the NSF sites...

indications for surgery (http://www.spine-surgery.com/index.cfm/fuseaction/site.content/mode/dtl/type/44446/post/40688.cfm)

Surgical Treatment

Surgery is generally only considered in patients who have continual pain, difficulty breathing, significant disfigurement, or a steadily worsening curve angle.

So cosmesis is one of FOUR indications for surgery.

I suggest in the debate that Weiss is sitting out there at around 6 sigma on the spectrum of surgeon opinion on this issue.

LindaRacine
06-12-2009, 08:27 PM
Sharon, Comparing Dr. Weiss to creation scientists is wrong.
Linda, Calling this physician a "quack" is wrong.
Pam, Quoting statements from his technical literature out of context (surgery and cosmesis) is wrong.

M.D. 1986;
Residency in traumatology 1986;
Residency in orthopedic surgery 1987 – 1992.
Orthopaedic surgeon since 1992,

What does he have to say about surgery? In his 2003 paper available in full PDF from the link below he says:
Conclusions: If conservative management does reduce the proportion of children with adolescent idiopathic scoliosis that require surgery, (CD- As he believes he shows in his paper) it can be said to provide a real and meaningful advantage to both the patients and the community. It is contended that conservative methods of treatment should never be ruled out from scoliosis management, because they can and do offer a viable alternative to those patients who cannot or will not opt for surgical treatment. Does anyone have a problem with THAT statement?

Link (http://www.scoliosisxpert.com/uk/pageuk.php?va=1)

Did I piss everyone off yet?:D

To blow a kiss to mamamax, I believe she is 100% correct. The paper is about documentation (evidence and proof). Part of the issue relates to the fact that English is not his first language.
I totally agree that that statement is true.

And, for the record, I never (at least publicly) called Weiss a quack. I called a statement of his quacky, which I still believe.

--Linda

LindaRacine
06-12-2009, 08:29 PM
Tell us Pam .. are you still threatening legal action against Dr. Joseph O'Brien? http://www.scoliosis.org/forum/member.php?u=114

[/COLOR]
Joe has said many times, that he is not a medical professional (nor is he a PhD).

LindaRacine
06-12-2009, 08:34 PM
CD...

I know you love the underdog, but occasionally you go around the bend. :)

If RCTs are the only valid studies, then technically there is no proof that scoliosis surgery is effective. However, there are long-term studies galore, which is a lot more than one can say about any of the alternative studies.

And, so when your kid's curve reaches say 70-80 degrees, I assume you'll allow them to be put in a control group and not have surgery. Right? ;-)

--Linda

Pooka1
06-12-2009, 08:35 PM
I totally agree that that statement is true.

And, for the record, I never (at least publicly) called Weiss a quack. I called a statement of his quacky, which I still believe.

--Linda

The entire paragraph, almost stem to stern, is bone fide Q-U-A-C-K-Y. Quakiness itself. Quacky incarnate. Not even a little bit NOT quacky. The opposite of mainstream. EX-mainstream.

Apologies to Monty Python.

:D:D:D

Pooka1
06-12-2009, 08:39 PM
Joe has said many times, that he is not a medical professional (nor is he a PhD).

Mamamax, have you seen O'Brien use the "Dr." title? Why did you refer to him as a Doctor?

Pooka1
06-12-2009, 08:42 PM
And, so when your kid's curve reaches say 70-80 degrees, I assume you'll allow them to be put in a control group and not have surgery. Right? ;-)

In these situations, I ask, WWWD? (What Would Weiss Do?)

I think he wouldn't put the kid in a control group but might suggest some exercises. :)

Karen Ocker
06-12-2009, 09:06 PM
Progression of 1-3 degrees a year: Do the math.

A significantly curved spine brings all the internal organs along with it.

I never even think of cosmesis being an indication for surgery; if it looks that bad it will only get worse.

60deg curves can result in lung impairment:eek:-I cited several studies in an earlier post. This happened to me and I actually lost lung tissue. Lost lung tissue does not come back.
:mad:
Regarding pedicle screws in older persons-like me(67). I am 6 years post revision with Isola rods, pedicle screws, laminar wires, and cages. Guess what! I am pain free, still able to work and have a normal life. Without the surgery I would be disabled and a burden on my dear husband and family. I give significant help to my 92 year old mom--who is bent and twisted. Her curve was barely noticeable when I was a child--and it still progressed!!!

Alternative methods helped me reduce pain but did not stop the progression and loss of lung capacity. At age 52 my major curve was 62 degrees by age 59 it was 80 deg.

If a curve is significant at skeletal maturity wishing, hoping and arguing will not stop it. Surgery has definitely shown to reduce curves permanently most of the time. Before the advent of surgery traction was tried along with exercises and braces. That was all they had. I had a patient a few months ago whose scoliosis was so bad she needed a ventilator. She was 74. She has no other medical problems and her scoliosis was going to kill her.

Pooka1
06-12-2009, 09:19 PM
Progression of 1-3 degrees a year: Do the math.

A significantly curved spine brings all the internal organs along with it.

I never even think of cosmesis being an indication for surgery; if it looks that bad it will only get worse.

60deg curves can result in lung impairment:eek:-I cited several studies in an earlier post. This happened to me and I actually lost lung tissue. Lost lung tissue does not come back.
:mad:
Regarding pedicle screws in older persons-like me(67). I am 6 years post revision with Isola rods, pedicle screws, laminar wires, and cages. Guess what! I am pain free, still able to work and have a normal life. Without the surgery I would be disabled and a burden on my dear husband and family. I give significant help to my 92 year old mom--who is bent and twisted. Her curve was barely noticeable when I was a child--and it still progressed!!!

Alternative methods helped me reduce pain but did not stop the progression and loss of lung capacity. At age 52 my major curve was 62 degrees by age 59 it was 80 deg.

If a curve is significant at skeletal maturity wishing, hoping and arguing will not stop it. Surgery has definitely shown to reduce curves permanently most of the time. Before the advent of surgery traction was tried along with exercises and braces. That was all they had. I had a patient a few months ago whose scoliosis was so bad she needed a ventilator. She was 74. She has no other medical problems and her scoliosis was going to kill her.

What I wouldn't give to hear a comment from Weiss on your post.

Karen Ocker
06-13-2009, 08:10 AM
I travel to Germany almost every year on vacation. I always see, on every visit, native, adult Germans with severe scoliosis. If Schroth has been used there for 40 years I wonder why these persons haven't been helped since they have universal health insurance.

I have read many abstracts written by Weiss. Some of his patients still need surgery. Then the issue arises if his "successes" had the gene for non-progressive scoliosis. Is there a long term follow-up? His protocol uses a brace(nothing new there) and intensive PT.

I am 6 years in a follow-up study by Dr. Boachie. Some long term studies might be difficult to pull off. Successes don't always bother to go back; they go on with their lives, don't go back because of the cost of travel, lack of insurance or move away.

mariaf
06-13-2009, 01:06 PM
Regarding pedicle screws in older persons-like me(67). I am 6 years post revision with Isola rods, pedicle screws, laminar wires, and cages. Guess what! I am pain free, still able to work and have a normal life.

Hi Karen,

Folks often bring up the potential problems down the line from the nitanol (sp?) staples used in VBS. While the staples themselves are relatively new, I have oftened thought about all of the other different types of hardware used in spinal surgery and about all the people walking around with rods, screws, hooks, wires, etc. On the whole, it seems to me that (while I'm sure there are some folks who experience problems) most folks don't have major problems from the hardware.

Hearing that you have all this hardware in you and are doing so well at age 67 is great to hear - and I wish you continued health and happiness!!

Regards,

LindaRacine
06-13-2009, 01:13 PM
Maria...

Of all the research papers I've read on scoliosis, and that's pretty numerous, the one linked below has been my absolute favorite. The moral of the story is that implants in the hands of a hack can be disastrous, but perfectly safe in the hands of a master.

Interestingly, it also addresses the issue of "control" groups in terms of scoliosis surgery.

http://www.scoliosislinks.com/RobertWinterArticle.htm

Regards,
Linda

Pooka1
06-13-2009, 01:18 PM
Hi Karen,

Folks often bring up the potential problems down the line from the nitanol (sp?) staples used in VBS. While the staples themselves are relatively new, I have often thought about all of the other different types of hardware used in spinal surgery and about all the people walking around with rods, screws, hooks, wires, etc. On the whole, it seems to me that (while I'm sure there are some folks who experience problems) most folks don't have major problems from the hardware.

Hearing that you have all this hardware in you and are doing so well at age 67 is great to hear - and I wish you continued health and happiness!!

Regards,

Not that I have researched to death but I haven't heard about problems with the new staples. Old ones, yes. The new ones have a very good track record, no? Like almost perfect I thought.

In re fusion and new generation of surgery, I think the main issue with the previous fusion instrumentation was flatback syndrome. Not everyone got flatback but I think everyone who did had the old instrumentation. I suspect the new instrumentation was specifically designed to address that problem; based on the one study Linda posted recently, the new instrumentation brings sagittal balance to correct. If that pans out, based on that, I think some new problem is going to have to crop up in the out years that hasn't been seen for the new fusion instrumentation to fail. Not impossible but maybe unlikely. I suspect that is why our surgeon can claim my fused daughter is back in the population for the rest of her life but I don't know that.

mariaf
06-13-2009, 09:45 PM
Not that I have researched to death but I haven't heard about problems with the new staples. Old ones, yes. The new ones have a very good track record, no? Like almost perfect I thought.


Sharon,

I haven't heard about any problems with any of the staples used in the past 7- 8 years (that's not to say there aren't any - but I probably have talked to more parents of VBS patients than just about anyone - LOL!)

I think anyone who brings up the subject is referring to "potential" problems down the road, NOT because there is any reason to think that there will necessarily BE any problems, but because nobody is 10, 20 or 30 years post-op.

So, just as there COULD be problems - it could also turn out that there are none. I hope that makes sense - here's an excerpt from the article Linda posted which I hope explains it better:

"Dr. Harrington did not just begin inserting metal rods into patients. He studied the anatomy carefully; he worked for 10 years with engineers from Baylor University, and did not release the rods for general use until he had spent all those years perfecting them. His patients who were treated early were well informed that this was a new idea. They were proud to be part of history."

Linda,

That was a great - and VERY interesting article - thanks!!! It's funny, but when I read the quote above, I realized I was once told the same thing about VBS by someone - he said that the doctors didn't just one day decide to start inserting staples into patients, but that they had worked for years on it, etc. Also, as stated above, those who have inquired about VBS were told going in that it was relatively new and there were no long-term (i.e., 10-20 years or more) results.

Bottom line - just because something is new doesn't mean it won't work. Weren't ALL procedures used today "new" at one time?

concerned dad
06-15-2009, 12:11 PM
CD...

I know you love the underdog, but occasionally you go around the bend. :)

If RCTs are the only valid studies, then technically there is no proof that scoliosis surgery is effective. However, there are long-term studies galore, which is a lot more than one can say about any of the alternative studies.

And, so when your kid's curve reaches say 70-80 degrees, I assume you'll allow them to be put in a control group and not have surgery. Right? ;-)

--Linda



Sometime’s the underdog deserves a good look. Why I didn’t place that $100 bet on Mine That Bird to win the Derby I’ll never know.

This is the thing about the RCT, you’re absolutely right. I wouldn’t put her in a control group, we would opt for surgery (long before 70-80 degrees if possible). But, Neither would I put her in a control group for the SRS bracing study.

The SRS doctors challenged the method of treatment SOSORT believes in. They did this (in part) by way of a metanalysis showing that a REVIEW of the literature did not rise to the level of strong evidence that bracing reduces the need for surgery. There was some shenanagins involved (designing the study such that published research involving BOTH bracing and exercise was NOT included).

Then SOSORT says, “two can play by this game”. They do a metanalysis that shows there is a lack of evidence surgery improves things in the long term. Their shenanagins involved designing their study (in the same way SRS did “tit for tat”) such that certain papers where excluded (using only those old studies that provided LONG term evidence).

You cant be outraged by the Weiss quote in this context without being outraged by the Dolan quote as well. Personally, I’m not outraged by either (OK, maybe I HAD been outraged in the past about Dolan and confused about Weiss). When viewed in the context of the scientific debate we are able to understand what is transpiring.

You also have to remember that, at the time this paper was written, the bracing RCT criteria included curves 25-40 degrees. The likelihood of progression of these curves in premenarchal girls is very high. SOSORT believes in earlier intervention (before 25-40 degrees), they likely viewed this RCT as being “loaded” to show a high incidence of bracing failure (they have since modified it to include curves above 20 degrees, rather than 25).

So, all the comments above and elsewhere in this forum about how ridiculous it is to suggest there is no reason to have surgery are valid. But the SOSORT views about bracing and excericse may also be valid.

Again, just my 2 cents and I could be wrong.

Pooka1
06-15-2009, 12:25 PM
The SRS doctors challenged the method of treatment SOSORT believes in. They did this (in part) by way of a metanalysis showing that a REVIEW of the literature did not rise to the level of strong evidence that bracing reduces the need for surgery. There was some shenanagins involved (designing the study such that published research involving BOTH bracing and exercise was NOT included).

I would not call those shenanigans at all. I think it would have been okay in effect to include brace+exercise studies but then you would have pouting and bellyaching from the PT crowd that the SRS are effectively "assuming" PT doesn't work in including those studies. Now I think we have decades of information to think PT has yet to show permanent reduction of curves so they could have included those studies in my opinion. But since we can't prove PT doesn't work at this time, they had to exclude them.


Then SOSORT says, “two can play by this game”. They do a metanalysis that shows there is a lack of evidence surgery improves things in the long term. Their shenanagins involved designing their study (in the same way SRS did “tit for tat”) such that certain papers where excluded (using only those old studies that provided LONG term evidence).

That's not shenanigans... that intellectually dishonest. Nobody gives a hoot about outcome of instrumentation that hasn't been in use for years. Lay folks reading these papers are sometimes/often not clear that they are irrelevant. We have seen examples of this confusion.


You cant be outraged by the Weiss quote in this context without being outraged by the Dolan quote as well. Personally, I’m not outraged by either (OK, maybe I HAD been outraged in the past about Dolan and confused about Weiss). When viewed in the context of the scientific debate we are able to understand what is transpiring.

The context is mainstream thought identifies at least four indicators for spinal fusion for scoliosis and Weiss only recognizes one of these. Yes/no?


So, all the comments above and elsewhere in this forum about how ridiculous it is to suggest there is no reason to have surgery are valid. But the SOSORT views about bracing and excericse may also be valid.

Again, just my 2 cents and I could be wrong.

Folks who demand evidence for the validity of spinal fusion need to first pony up evidence of the validity of setting broken arm bones. Otherwise, they are not being consistent.

concerned dad
06-15-2009, 01:34 PM
What, no comment on Mine That Bird?
:D


Lay folks reading these papers are sometimes/often not clear that they are irrelevant. We have seen examples of this confusion

Dont forget, these papers are not meant for lay folks like you and I.

I guess we have a difference of opinion on the whole topic. That's OK.
Gimme a few weeks and I'll probably change my mind anyway.
But for now, I like my "take" on the issue.

Pooka1
06-15-2009, 01:38 PM
What, no comment on Mine That Bird?
:D

I don't believe 3-year olds should be raced and I certainly don't believe 2-year olds should be in under saddle training.


Don't forget, these papers are not meant for lay folks like you and I.

I guess we have a difference of opinion on the whole topic. That's OK.
Gimme a few weeks and I'll probably change my mind anyway.
But for now, I like my "take" on the issue.

Alrighty then!

BTW, I haven't yet had time to wade through you email. I will.

Pooka1
06-16-2009, 01:03 PM
Bridwell KH. Surgical treatment of idiopathic adolescent scoliosis. Spine.
1999 Dec 15;24(24):2607-16. Review.

---

Does anyone know if this article is available on-line? I want to make sure that blurb wasn't inadvertently quote-mined. Not claiming Fix did that.

LindaRacine
06-16-2009, 01:56 PM
Bridwell KH. Surgical treatment of idiopathic adolescent scoliosis. Spine.
1999 Dec 15;24(24):2607-16. Review.

---

Does anyone know if this article is available on-line? I want to make sure that blurb wasn't inadvertently quote-mined. Not claiming Fix did that.

I looked on the day Fix posted it, but couldn't fine the full text online.

Pooka1
06-16-2009, 01:58 PM
I looked on the day Fix posted it, but couldn't fine the full text online.

Darn. I couldn't find it online either. That's why I asked.

PNUTTRO
06-16-2009, 03:56 PM
“It is very difficult to know precisely what the natural history of untreated surgical idiopathic scoliosis is, because most patients have surgical treatment of their curves when the Cobb measurement exceeds 50°. The only way of definitively proving that the natural history of surgical treatment of idiopathic scoliosis is better than untreated scoliosis would be to undertake a study involving a prospective, randomized group of patients with curves more than 50°, treated surgically with modern-day instrumentation and then compare the results with those of a similar group of untreated patients matched for age, deformity, and other parameters. Those two groups of patients would then have to be followed up in 10-year intervals to determine their relative function, pain and cosmetic appearance. No such study exists. If it were possible, it would take between 20 and 40 years to obtain a definitive answer.”

This is a verbatim quotation from the article. I don't see how anyone can ague about Bridwell's statements so far. He is saying what ya'll have been saying for weeks. There is NO study out there that says that any intervention (surgery/bracing/exercise) is better than doing nothing because it would take 20-40 years to complete such a study.



He also stated:
"Many surgeons feel that 50° is the surgical tidemark for treating idiopathic scoliosis … This “magic number” comes in part as an extrapolation from … studies of natural history and in part that most 50° curves are very visible cosmetically.”

Yes. Here is the part left out of the quotation.

"This “magic number” comes in part as an extrapolation from the Edgar and Mehta and Weinstein studies of natural history and in part that most 50° curves are very visible cosmetically. However, there are other factors to consider."

Table 3. Goals of Surgery for Thoracic Curves
Deformity correction; preserve sagittal balance
Preservation or improvement of pulmonary function
Positive influence on the lumbar spine
Minimal morbidity/pain for the patient
Maximize patient return to full function



Another quote:

"Idiopathic adolescent scoliosis has an extremely varied spectrum of clinical features of severity, curve pattern, and progression. Prospective randomized studies are most appropriate with homogeneous disorders, which idiopathic adolescent scoliosis is not. This makes comparison of surgically treated versus untreated idiopathic scoliosis very complex. There are studies in which investigators have prospectively analyzed the natural history of idiopathic scoliosis in a longitudinal manner. In this author’s opinion, such studies would be more helpful if they analyzed only curves considered surgical or at risk for progression (i.e., only curves more than 50° by Cobb measurement). Granted, using that tidemark is debatable, because a Cobb measurement is a one-dimensional analysis of a three-dimensional deformity."

Bridwell KH. Surgical treatment of idiopathic adolescent scoliosis. Spine.
1999 Dec 15;24(24):2607-16. Review.

Edgar M, Mehta M. Long-term follow-up of fused and unfused idiopathic
scoliosis. J Bone Joint Surg 1988;70B:712–6.

Weinstein SL. Idiopathic scoliosis. Natural history. Spine 1986;11:780–3.

Does that help?

I want to note that this paper is ten years old. None of these patients had pedicle screws.

Pooka1
06-16-2009, 04:15 PM
Does that help?

Yes! Your analysis hits the nail on the head. :)