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Thread: 30*, not 50*

  1. #1
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    30*, not 50*

    I am thinking the paradigm has now changed of late...see bolded sentence...

    http://www.ncbi.nlm.nih.gov/pubmed/21057122

    Radiographics. 2010 Nov;30(7):1823-42.
    Scoliosis imaging: what radiologists should know.

    Kim H, Kim HS, Moon ES, Yoon CS, Chung TS, Song HT, Suh JS, Lee YH, Kim S.

    Department of Radiology and Research Institute of Radiological Science, Gangnam Severance Hospital, Yonsei University, 146-92 Dogok-Dong, Gangnam-Gu, Seoul 135-720, Republic of Korea.
    Abstract

    Scoliosis is defined as a lateral spinal curvature with a Cobb angle of 10 or more. This abnormal curvature may be the result of an underlying congenital or developmental osseous or neurologic abnormality, but in most cases the cause is unknown. Imaging modalities such as radiography, computed tomography (CT), and magnetic resonance (MR) imaging play pivotal roles in the diagnosis, monitoring, and management of scoliosis, with radiography having the primary role and with MR imaging or CT indicated when the presence of an underlying osseous or neurologic cause is suspected. In interpreting the imaging features of scoliosis, it is essential to identify the significance of vertebrae in or near the curved segment (apex, end vertebra, neutral vertebra, stable vertebra), the curve type (primary or secondary, structural or nonstructural), the degree of angulation (measured with the Cobb method), the degree of vertebral rotation (measured with the Nash-Moe method), and the longitudinal extent of spinal involvement (according to the Lenke system). The treatment of idiopathic scoliosis is governed by the severity of the initial curvature and the probability of progression. When planning treatment or follow-up imaging, the biomechanics of curve progression must be considered: In idiopathic scoliosis, progression is most likely during periods of rapid growth, and the optimal follow-up interval in skeletally immature patients may be as short as 4 months. After skeletal maturity is attained, only curves of more than 30 must be monitored for progression.
    I'd like to know what evidence they based the claim about 50* on and what evidence they are basing the 30* on.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

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  2. #2
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    Here's another one stateing 30* is the paradigm, not 50*

    See bolded statements...

    http://www.ncbi.nlm.nih.gov/pubmed/19333102

    Spine (Phila Pa 1976). 2009 Apr 1;34(7):697-700.
    Curve progression in idiopathic scoliosis: follow-up study to skeletal maturity.

    Tan KJ, Moe MM, Vaithinathan R, Wong HK.

    Department of Orthopaedic Surgery, National University Hospital, National University of Singapore, 5 Lower Kent Ridge Road, Singapore. jinmi@pacific.net.sg
    Abstract

    STUDY DESIGN: This is a follow-up study to skeletal maturity on a cohort of students screened for a 1-year prospective epidemiological prevalence study for scoliosis.

    OBJECTIVES: This study aims to identify the prognostic factors for curve progression to a magnitude of 30 degrees at skeletal maturity in skeletally immature patients with adolescent idiopathic scoliosis.

    SUMMARY OF BACKGROUND DATA: The natural history of idiopathic scoliosis is not well understood. Previous reports have focused on the characteristics of curve progression where progression has been predefined at specific angles of 5 degrees to 6 degrees. However, the absolute curve magnitude at skeletal maturity is more predictive of long-term curve behavior rather than curve progression of a defined magnitude over shorter periods of skeletal growth. It is generally agreed that curves less than 30 degrees are highly unlikely to progress after skeletal maturity. Hence, defining the factors that influence curve progression to an absolute magnitude of more than 30 degrees at skeletal maturity would more significantly aid clinical practice.

    METHODS: One hundred eighty-six patients who fulfilled the study criteria were selected from an initial 279 patients with idiopathic scoliosis detected by school screening, and who were followed-up till skeletal maturity. The initial age, gender, pubertal status, and initial curve magnitude were used as risk factors to predict the probability of curve progression to more than 30 degrees at skeletal maturity.

    RESULTS: Curve magnitude at first presentation was the most important predictive factor for curve progression to a magnitude of more than 30 degrees at skeletal maturity. An initial Cobb angle of 25 degrees had the best receiver-operating characteristic of 0.80 with a positive predictive value of 68.4% and a negative predictive value of 91.9% for curve progression to 30 degrees or more at skeletal maturity.

    CONCLUSION: Initial Cobb angle magnitude is the most important predictor of long-term curve progression and behavior past skeletal maturity. We suggest an initial Cobb angle of 25 degrees as an important threshold magnitude for long-term curve progression. Initial age, gender, and pubertal status were less important prognostic factors in our study.
    If that holds, that is certainly far cheaper than doing Scoliscore and perhaps conservative approach researchers working on smaller budgets can use the 25* at diagnosis in lieu of Scoliscore. Unless a conservative approach beats the 70% -75% no surgery criteria by a mile, they are open to question about how many of the subjects had a Scoliscore <41. This 25* at diagnosis observation can help there I think.
    Last edited by Pooka1; 01-02-2011 at 05:55 PM. Reason: fixed link
    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."

  3. #3
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    I think 30 degrees has always been the paradigm. Less than 30 degrees at maturity has very little chance of progressing, and those people may well be able to get away without regular monitoring.

    More than 50 has a very high chance of progressing, and those people are mostly recommended for very close monitoring and/or surgery at maturity.

    That leaves the group between 30 and 50 as those who may or may not progress to surgical range and need to be monitored (but less frequently than the over 50 degree group).

    On the second topic: I just cannot wrap my mind around why the degree of the curve *at diagnosis* matters. If I'd noticed my son's curve six months or a year earlier, would his prognosis have changed? Why?

    I mean that as a genuine question. There are only two mechanisms I can think of that make sense of that statistic.

    The first is that there's *something* that people do or stop doing when their child is diagnosed that changes the course of the disease. I have no idea whether this is bracing, or getting their kids outside and exercising more, or what. It could even be several different things, or a combination of things.

    The second is that there is something more obvious about the curves that get diagnosed early. But, that would mean that whatever this thing was which made the curve more obvious, it would have to be tied to a *lessened* likelihood of progression.

    Does anyone ever say why the curve size at diagnosis matters?

  4. #4
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    Quote Originally Posted by hdugger View Post

    On the second topic: I just cannot wrap my mind around why the degree of the curve *at diagnosis* matters. If I'd noticed my son's curve six months or a year earlier, would his prognosis have changed? Why?
    I wonder about this too. My daughter was 8* when first diagnosed. She was 25* a year later. Can't quite figure out what that would mean in terms of this article.
    Mom to 11 year old DD who was:
    diagnosed 5/09: 8*L, 8*T
    braced 7/10: 17* L, 25*T, 20*C
    x-ray 11/10: 7*L, 17*T, 20*C (x-ray immediately OOB)
    most recent x-ray 06/11: 17*L, 24*T, 22* C (x-ray 24 hours OOB)

  5. #5
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    Quote Originally Posted by hdugger View Post
    I think 30 degrees has always been the paradigm.
    Not according to my information. Why do you think that?

    On the second topic: I just cannot wrap my mind around why the degree of the curve *at diagnosis* matters. If I'd noticed my son's curve six months or a year earlier, would his prognosis have changed? Why?
    This is far from the first article to say Cobb on diagnosis is predictive.

    I mean that as a genuine question. There are only two mechanisms I can think of that make sense of that statistic.

    The first is that there's *something* that people do or stop doing when their child is diagnosed that changes the course of the disease. I have no idea whether this is bracing, or getting their kids outside and exercising more, or what. It could even be several different things, or a combination of things.

    The second is that there is something more obvious about the curves that get diagnosed early. But, that would mean that whatever this thing was which made the curve more obvious, it would have to be tied to a *lessened* likelihood of progression.
    I have to think about it some more. It's a poser.

    Does anyone ever say why the curve size at diagnosis matters?
    Might just be empirical which in no way undermines it's observed predictive capacity if so.
    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."

  6. #6
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    Quote Originally Posted by JessicaNoVa View Post
    I wonder about this too. My daughter was 8* when first diagnosed. She was 25* a year later. Can't quite figure out what that would mean in terms of this article.
    Is you daughter JIS or AIS? I think it only applies to AIS.
    Last edited by Pooka1; 01-02-2011 at 05:08 PM.
    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."

  7. #7
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    Quote Originally Posted by Pooka1 View Post
    Is you daughter JIS or AIS? I think it only applies to AIS.
    She has AIS.
    Mom to 11 year old DD who was:
    diagnosed 5/09: 8*L, 8*T
    braced 7/10: 17* L, 25*T, 20*C
    x-ray 11/10: 7*L, 17*T, 20*C (x-ray immediately OOB)
    most recent x-ray 06/11: 17*L, 24*T, 22* C (x-ray 24 hours OOB)

  8. #8
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    Quote Originally Posted by Pooka1 View Post
    Not according to my information. Why do you think that?
    I thought the 30 to 50 was always a grey area, in research articles. Summary articles on the web often quoted below 50 as the "won't progress" point, but I didn't think research articles used that point. It would be hard to defend, given the number of people under 50 degrees who (slowly) progress to surgery in adulthood.

    Quote Originally Posted by Pooka1 View Post
    This is far from the first article to say Cobb on diagnosis is predictive.
    Yes, I've seen them before but I guess I hadn't actually paused to consider what it meant before this.

    It's very common for *treatable* diseases to emphasize where people are in the course of the disorder when they're diagnosed. Someone diagnosed with a stage 1 breast cancer, for example, has quite a different prognosis from someone diagnosed at stage 4. But that difference is due to the effects of early treatment.

    But, I've never seen a "watch and wait" disease where what stage someone was diagnosed at was significant.

  9. #9
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    Does the article say how many of the subjects received treatment? Were they braced? Or was it all just watch and wait?

  10. #10
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    Quote Originally Posted by hdugger View Post
    Does the article say how many of the subjects received treatment? Were they braced? Or was it all just watch and wait?
    I don't have the article but I'm guessing from the abstract that all the <25* upon diagnosis patients were watch/wait. It would be very sloppy if that wasn't the case because brace wear would be a potential confounder.
    Last edited by Pooka1; 01-02-2011 at 06:01 PM.
    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."

  11. #11
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    Quote Originally Posted by hdugger View Post
    I thought the 30 to 50 was always a grey area, in research articles. Summary articles on the web often quoted below 50 as the "won't progress" point, but I didn't think research articles used that point. It would be hard to defend, given the number of people under 50 degrees who (slowly) progress to surgery in adulthood.
    As I understood it, if a child was <50* at maturity, they would not be expected to progress to surgical territory in their lifetime. This may be technically true if a smallish percentage <50* ever needed surgery eventually. The average progression rate stated for curves >50* is one degree a year which would put most people well into surgery territory by the time they are young adults. But as we know, individual rates are all over the map and include 0*/year for decades in some cases.

    I would like to know the best estimate of kids 30*- 40* at maturity who progress to surgery.

    I would also like to know that figure broken out for brace wearers and watch/wait kids. Oh and also for PT kids in an obvious nod to McIntire. (smiley face)
    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."

  12. #12
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    Quote Originally Posted by hdugger View Post
    The first is that there's *something* that people do or stop doing when their child is diagnosed that changes the course of the disease.
    Maybe the kids who don't progress had their aquaria taken away per Alain Moreau's suggestion.

    I'm guessing that group probably also has a lower rate of choosing biology as a career which would be a huge negative effect. (smiley face).
    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."

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