Announcement

Collapse
No announcement yet.

Brace Treatment Controls Progression in Adolescent Idiopathic Scoliosis - (The Proof)

Collapse
X
 
  • Filter
  • Time
  • Show
Clear All
new posts

  • #16
    Originally posted by hdugger View Post
    Actually, I was thinking it would be easier to show, since the group that's likely to progress from 25 to 35 degrees is larger than the group that's likely to progress from 25 to 50 or 60.
    Yes agreed. Good point.

    So, if you tool a bunch of people with 25 degree curves and through a conservative treatment kept them all at 25, that would be of greater significance then just keeping them from advancing to surgery.
    Well we have to know the natural history of a bunch of 25* curves. It could be that 90% of them stay there or even reduce with sitting on the couch and eating ice cream. Who knows. Then the researcher is faced with trying to beat 90% in the face of measurement error and such with most curves probably all hovering in the same general range.

    The Scoliscore results, if they stand, have raised the bar on conservative treatments really high, perhaps too high to show any clean results. They have to beat an ~75% "success" rate unless they can show those kids have a score >41.

    But that's only part 2 of the question. Part 1 is, whether or not science can prove it, is it *desireable* to keep a 25 degree curve from getting to 35 for reasons of cosmetics/pain/further progression in adulthood.
    That's another good question that I doubt any surgeon can even answer. Maybe though.

    The issue of measurement error that I mentioned really bothers me. That was perhaps the most significant criticism of Katz et al. as I understand the comments. There is something I'm missing here if measurement error is the potentially largest Achilles heel of that work. While that would naturally increase the variability, I still have a sense that the precision must be better than they think though it would be hard to show and I would never be able to prove it.

    In my own field, let's say an analysis has a precision of 15%. If I subtract two numbers the precision on the difference is the square root of the sum of the squares as I am told which is about 21%. And the error keeps blowing up from there for other reasons. But to look at the data, it must be that some errors cancel because the data do not look like the total error blew up.

    I understand the various sources of error in a Cobb measurement but I think the biggest ones are easy to control for... selecting the same end vertebrae and taking all radiographs in the early morning I think. And I don't actually understand how experts can even select differ end vertebra if they follow the simple rule.

    The range of measurements in the paper on Hawes demands an explanation and none was forthcoming from the authors. That was beyond frustrating in trying to understand these issues. Some of it was different end vertebra but then why the heck aren't these experts using the simple rule? Her curve is not that complicated either as far as I can tell... single T. It is all very perplexing.
    Last edited by Pooka1; 01-01-2011, 11:51 AM.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

    Comment


    • #17
      But, the scolioscore's 75% is still measuring into surgical territory, isn't it?

      On the variability, yes, I'd like to figure out why two people can't more closely agree on xrays.

      Comment


      • #18
        Originally posted by hdugger View Post
        But, the scolioscore's 75% is still measuring into surgical territory, isn't it?
        Yes. Therefore we know ~75% of caucasian girls with small AIS curves will not reach 40*. So that's the majority of cases out there who are potential test subjects for seeing if a conservative approach keeps them further under 40* than the natural history would dictate. Am I missing your point?

        On the variability, yes, I'd like to figure out why two people can't more closely agree on xrays.
        I am very perplexed by the measurement situation claimed to be so problematic. I mean I accept it because folks who know what the hell they are talking about claim it but I am not fully grasping why they can't control for the largest sources of error. It just seems to me that can.

        And I am extremely doubtful that you can every get a +/- 10* inter-reader precision if the same end vertebra are selected. There is only one way to select vertebra as far as I know. How two experts can pick different end vertebra is definitely beyond my understanding. I can imagine two vertebrae being tilted "almost" the same but then the measurement will be "almost" the same.
        Sharon, mother of identical twin girls with scoliosis

        No island of sanity.

        Question: What do you call alternative medicine that works?
        Answer: Medicine


        "We are all African."

        Comment


        • #19
          POSNA awards 2010 Best Clinical Scientific Paper

          POSNA awarded the study discussed in this thread as the best clinical scientific paper in 2010. Kudos to Texas Scottish Rite Hospital!

          2010 Best Clinical Scientific Paper

          Brace Treatment Controls Progression in Adolescent
          Idiopathic Scoliosis
          Donald E. Katz, CO, John A. Herring, MD,
          Richard H. Browne, PhD, Derek M. Kelly, MD,
          John G. Birch, MD

          http://posna.org/meetings/anmeet/201...rePgmFINAL.pdf

          Comment


          • #20
            For the bracing newcomers, here's a study you may find interesting if you follow the link to the POSNA presentation in the initial post.

            Comment


            • #21
              Syd turned 11 this week and we are officially into the adolescent stage (maybe we have been in it already). The juvenile years have been good to us with bracing and some PT to reduce her 36T to about 15-16T and 20+L to about 11L.

              So there is no doubt that bracing can stop progression and even reduce the size of the curve for juveniles (for some like Syd). And Syd's rotation has reduced from 15 to 11. I assume there is not much debate on this subject for juveniles.

              So, is this discussion whether these kind of results, whether stopping progression or reducing the size of the curve can happen with adolescents and especially during the growth spurt?

              I am not challenging anyone's thinking or ideas, but seeking clarity (juvenile vs adolescent). We (Syd) are in the adolescent years now and I realize I may need to relearn what works and what does not work.

              I wrestle with this all the time. Should we keep bracing and maybe hold it where it is today, maybe get some more reduction or maybe there will be some progression, but continue bracing for the next 5 years. Or just give up on the bracing and move forward with VBS.

              That is probably my biggest challenge/dilemna today. I just want to make sure that if we cannot hold the curve through the adolescent years or there is a risk if we do and when she is out of brace at 15-16 yr. old the curve progresses, maybe to the level of needing surgery, then maybe we are better off to just proceed with VBS, especially while the curve is small, she is flexible, and she has not hit her growth spurt (all criteria that help VBS).

              To me the question is bracing or VBS. It would be good to know more whether bracing works during adolescent years and maybe more important, if it does, will the curve not progress after the brace is removed. If there is a risk of either of these then VBS seems like the better option and we should just do it now and get out of the brace.

              To me if there is any risk of the curve progressing during the adolescent years or later to the point that surgery is required, then I feel that I owe it to Syd to move forward now with VBS and give her a chance with a minimal invasive surgery.

              I welcome all comments and recommendations. We have accomplished what we have to date based a lot on advice/experience from others on this forum. Thanks

              Mike

              Comment


              • #22
                she's will always be considered JIS

                Hi Michael,

                It is great to hear your positive update, as I have often wondered how you and Syd were doing! I will comment further later when I have more time, but I just wanted to share a quick thought from reading your post.

                Syd will always be a JIS case, even once she enters her adolescent years. I really don't think you can accurately compare her case to strict AIS cases, as far as trying to understand her case based on the literature. There are a (very) few papers about what happens when our JIS kids grow through adolescence, but not many.

                Out of curiosity, what does her orthopedist recommend or predict at this point?

                I will write more later today. Glad to hear she's doing so well.
                Gayle, age 50
                Oct 2010 fusion T8-sacrum w/ pelvic fixation
                Feb 2012 lumbar revision for broken rods @ L2-3-4
                Sept 2015 major lumbar A/P revision for broken rods @ L5-S1


                mom of Leah, 15 y/o, Diagnosed '08 with 26* T JIS (age 6)
                2010 VBS Dr Luhmann Shriners St Louis
                2017 curves stable/skeletely mature

                also mom of Torrey, 12 y/o son, 16* T, stable

                Comment


                • #23
                  Hi Michael,

                  Great update.

                  Although I never heard anyone say a surgeon addressed it with them, I agree with Gayle that JIS cases remain JIS cases and don't morph into AIS as the child ages out. That is good because you don't see bracing correcting curves in AIS whereas there are any number of such testimonials for JIS. So that's a good thing. That is a key difference between JIS and AIS... there is no evidence of long-term correction of curves in AIS through bracing. There might be through never-ending PT, I don't know.

                  I see your dilemma with bracing versus VBS. But you are dealing with the top guy to answer that question - Betz. If he said that she will be okay if she entered the growth spurt at 15* then he must have some reason for saying that. And if the curve starts progressing, you can have the VBS before the end of the growth spurt. You are already a Betz patient so there is no chance you will miss the VBS window as far as I can tell.

                  At 15*-16*T, I am assuming Betz does not consider Syd as a VBS candidate. So you really don't have a choice at the moment between bracing and VBS as I understand this and I may not. If it was AIS then I think she would be a candidate because the absolute expectation is the curve WILL go back to at least 36* and that is NOT protective against future progression to surgery range. So again, JIS is so different than AIS.

                  Good work and good luck.
                  Sharon, mother of identical twin girls with scoliosis

                  No island of sanity.

                  Question: What do you call alternative medicine that works?
                  Answer: Medicine


                  "We are all African."

                  Comment


                  • #24
                    My understanding is that once you get a scoliosis diagnosis, it stays with you. That's how the coding is done for the big multi-center studies. It's not a perfect system, but it's as good as anyone can do until there's something that allows mankind to know exactly when the spine starts curving.
                    Never argue with an idiot. They always drag you down to their level, and then they beat you with experience. --Twain
                    ---------------------------------------------------------------------------------------------------------------------------------------------------
                    Surgery 2/10/93 A/P fusion T4-L3
                    Surgery 1/20/11 A/P fusion L2-sacrum w/pelvic fixation

                    Comment


                    • #25
                      Hi Michael

                      I received your PM. Cannot respond to it as you've switched off private message responses.

                      You can contact me at:

                      ..................

                      Regards
                      Tom

                      Originally posted by michael1960 View Post
                      Syd turned 11 this week and we are officially into the adolescent stage (maybe we have been in it already). The juvenile years have been good to us with bracing and some PT to reduce her 36T to about 15-16T and 20+L to about 11L.

                      So there is no doubt that bracing can stop progression and even reduce the size of the curve for juveniles (for some like Syd). And Syd's rotation has reduced from 15 to 11. I assume there is not much debate on this subject for juveniles.

                      So, is this discussion whether these kind of results, whether stopping progression or reducing the size of the curve can happen with adolescents and especially during the growth spurt?

                      I am not challenging anyone's thinking or ideas, but seeking clarity (juvenile vs adolescent). We (Syd) are in the adolescent years now and I realize I may need to relearn what works and what does not work.

                      I wrestle with this all the time. Should we keep bracing and maybe hold it where it is today, maybe get some more reduction or maybe there will be some progression, but continue bracing for the next 5 years. Or just give up on the bracing and move forward with VBS.

                      That is probably my biggest challenge/dilemna today. I just want to make sure that if we cannot hold the curve through the adolescent years or there is a risk if we do and when she is out of brace at 15-16 yr. old the curve progresses, maybe to the level of needing surgery, then maybe we are better off to just proceed with VBS, especially while the curve is small, she is flexible, and she has not hit her growth spurt (all criteria that help VBS).

                      To me the question is bracing or VBS. It would be good to know more whether bracing works during adolescent years and maybe more important, if it does, will the curve not progress after the brace is removed. If there is a risk of either of these then VBS seems like the better option and we should just do it now and get out of the brace.

                      To me if there is any risk of the curve progressing during the adolescent years or later to the point that surgery is required, then I feel that I owe it to Syd to move forward now with VBS and give her a chance with a minimal invasive surgery.

                      I welcome all comments and recommendations. We have accomplished what we have to date based a lot on advice/experience from others on this forum. Thanks

                      Mike
                      Last edited by TAMZTOM; 10-09-2012, 07:36 AM.
                      07/11: (10yrs) T40, L39, pelvic tilt, rotation T15 & L11
                      11/11: Chiari 1 & syrinx, T35, L27, pelvis 0
                      05/12: (11yrs) stopped brace, assessed T&L 25 - 30...>14lbs , >8 cm
                      12/12: < 25 LC & TC, >14 cms, >20 lbs, neuro symptoms abated, but are there
                      05/13: (12yrs) <25, >22cms height, puberty a year ago

                      Avoid 'faith' in 'experts'. “In consequence of this error many persons pass for normal, and indeed for highly valuable members of society, who are incurably mad...”

                      Comment

                      Working...
                      X