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Thread: Rib hump reduction surgery seemed to trigger curve progression

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  1. #1
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    Rib hump reduction surgery seemed to trigger curve progression

    I wonder if PT-based methods that seek to reduce rib humps have the same effect of triggering progression. If Schroth seeks to reduce the rib hump, maybe this explains the lack of evidence of efficacy to date though my bet is the lack of compliance has prevented any true test of Schroth on a meaningful scale.

    http://journals.lww.com/spinejournal...ure_for.8.aspx

    Isolated Percutaneous Thoracoplasty Procedure for Skeletally Mature Adolescent Idiopathic Scoliosis Patients, With Rib Deformity as Their Only Concern: Short-term Outcomes
    Yang, Jae Hyuk MD*; Bhandarkar, Amit Wasudeo MBBS, MS*; Kasat, Niraj Sharad MD*; Suh, Seung Woo MD, PhD*; Hong, Jae Young MD†; Modi, Hitesh N. MS, PhD*; Hwang, Jin Ho MD‡

    Abstract
    Study Design. Prospective case series study.

    Objective. To study the effect of percutaneous thoracoplasty–only procedure on curve pattern in mature adolescent idiopathic scoliosis (AIS).

    Summary of Background Data. The rib hump prominence on the convex side is the major cosmetic concern among patients with AIS. Thoracoplasty combined with spinal fusion is a commonly used procedure in scoliosis. However, there are no studies regarding the effect of isolated thoracoplasty procedure on curve pattern in skeletally matured patients with AIS.

    Methods. The study involved 7 skeletally matured female patients with AIS. The convex rib hump deformity was measured preoperatively using hump height and hump angle. We performed thoracoplasty without spinal fusion in patients with the Cobb angle less than 40° but with prominent hump deformity. Thoracoplasty was performed percutaneously using 1 or 2 transverse incisions along the rib hump, and apex portions of the deformed ribs were resected. The Cobb angle was measured before surgery, immediately after surgery, and at final follow-up visit. In all cases, clinical satisfaction was assessed using the Scoliosis Research Society Instrument (SRS-22 questionnaires) and trunk appearance perception scale before surgery and at final follow-up visit.

    Results. The mean patient age was 20.24 years and an average of 4 ribs were resected. The mean preoperative hump height and hump angle of 38.14 mm and 14.14° improved to 11.70 mm and 11.42° respectively, after surgery (P = 0.018 and 0.042). Preoperative and the final follow-up mean Cobb angles were 35.43° and 45.00°, respectively (P = 0.028). On average, the mean thoracic curve progressed by 9.57°. Preoperative Scoliosis Research Society Instrument SRS-22 questionnaires and trunk appearance perception scale scores of 4.09 and 2.57 respectively improved to and 4.26 and 3.66 after surgery (P = 0.126 and 0.014).

    Conclusion. Percutaneous thoracoplasty–only procedure gives significant rib humps correction and satisfactory clinical outcome. However, progression of the curve was observed after surgery. This suggests that the convex ribs function as a buttress for curve progression.
    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."

  2. #2
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    If Schroth seeks to reduce the rib hump, maybe this explains the lack of evidence of efficacy to date though my bet is the lack of compliance has prevented any true test of Schroth on a meaningful scale.
    Lack of proper instruction will be a huge factor in the lack of testing, Sharon. I agree that compliance will also be a huge factor. Weiss-like buck making a 3rd. And remember, KATERINA SCHROTH'S METHOD is NOT the method that is purveyed by the practitioners of Weiss's "Nu Power Schroth." We may NEVER get a test of K Schroth's method from any of these clinics.

    Quote Originally Posted by Pooka1 View Post
    I wonder if PT-based methods that seek to reduce rib humps have the same effect of triggering progression.
    The K Schroth method does seek to reduce the prominent convex ribs, what I call "the dorsal rib arch" (DRA). Tamzin no longer has one. Her thoracic curve is improved. What's the difference between this example of improved thoracic curve angle after K Schroth treatment and the surgical method that increased the curve angles?

    1) straightening the buckled ribs INCREASES corrective derotation of thoracic vertebrae. The DRA is caused by ribs that belong at the side rotating to the back and/or bucking the back ribs.

    2) surgically removing ribs leaves a gap AND rotation. Rotation is tied to lateral curvature. The curve increases.

    If I were to hazard a guess, I'd suspect that the surgical correction of the DRA may evaporate over time...the DRA will return.
    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...”

  3. #3
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    Yes but the rotation is due to the anterior overgrowth. If as in PT you use the ribs as a lever to try to untwist the spine, it might not simply resume a more normal, less curved, position because the anterior side is still longer than the other sides. I can't visualize where the vertebra go and in what position they go if you manually lever the ribs back towards the side from the back. Unless some space is made by hypokyphosing the back, it either can't work or will do something else with the vertebra.

    This is a general question for all PT... how can it overcome the anterior overgrowth? The spine curves because of that in a space-filling way. If you have seen video of de-rotation procedures prior to fusion, those guys are employing a significant amount of leverage directly on each vertebra to make it come straight. But the front of the vertebra are still longer. That is why it can be hyokyphosing as far as I can tell.

    I think braces work in part or in whole by forcing the ribs back to a more normal position which probably explains why they are hypokyphosing. Actually I have heard that the way they work is to hyperkyphose the back which is another way of saying they are making more room for the elongated fronts of the vertebrae to nevertheless still line up more correctly and not assume a space-filling arrangement.
    Last edited by Pooka1; 01-05-2013 at 03:51 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."

  4. #4
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    Quote Originally Posted by Pooka1 View Post
    Yes but the rotation is due to the anterior overgrowth.
    I'm being pedantic here, but it's important: rotation MAY BE due to anterior overgrowth. For example, in a kid with thoracic hyper-kyphosis, there may not be ANY anterior overgrowth, but still rotation. However, to conform to your hypothetical, let's use Tamzin who is more hypo- than hyper and, theoretically, may have or have had AO.

    If as in PT you use the ribs as a lever to try to untwist the spine, it might not simply resume a more normal, less curved, position because the anterior side is still longer than the other sides.
    In the K Schroth method (as distinct from general "PT" which is often damaging), specifically "directional/rotational angular breathing", the ribs are indeed used as levers to derotate the spine. You then switch from the effect on the dorsal rib arch/prominent/buckled ribs to the effect on the spine? Again, to adhere to your hypothetical--and both effects are important--it is possible that the ribs could straighten out (as with Tamzin), but assumed AO presents a barrier to this rib straightening derotating the actual vertebrae. The ANTERIOR of each vertebrae is ALSO rotated, i.e., the anterior isn't at the geometric front, the front of the concerned vertebrae would be slightly rotated c/w. The force directed onto the vertebrae by the straightened DRA ribs has to go somewhere, affect something, as you rightly question. In Tamzin's case, given the flattening of her DRA, correction of a 40-42 degree thoracic curve to <25 and reduction of thoracic rotation from 15 to 4 degrees, the force derotates and corrects the lateral curve. So we needn't speculate. In the absence of Tamzin as an example, your theoretical questioning is excellent.

    Furthermore, in the case of a hypo-kyphotic kid, that there is 'space' to the posterior, even the hypothetical existence of AO could in theory facilitate some restoration of a normal thoracic kyphosis.

    I can't visualize where the vertebra go and in what position they go if you manually lever the ribs back towards the side from the back. Unless some space is made by hypokyphosing the back, it either can't work or will do something else with the vertebra.
    Ach, I should have read this bit first. You've already reasoned that bit through.

    This is a general question for all PT... how can it overcome the anterior overgrowth?
    That is ALSO cutting edge questioning, Sharon. As Stokes et al explain, reversing the asymmetrical loading in growing vertebrae stops growth on the overgrown area of the growth plate and increases it on the retarded area. Asymmetrical growth can be reversed in growing spines. EDIT: I don't know how "all PT" can overcome anything! I thought we were talking about how Katernia Schroth's method overcomes anterior overgrowth. Talking about how "general PT" can overcome AO is like asking Usain Bolt to start doing 15 mile recovery jogs!

    I think braces work in part or in whole by forcing the ribs back to a more normal position which probably explains why they are hypokyphosing. Actually I have heard that the way they work is to hyperkyphose ...
    I've heard similar, Sharon. They ignore damage to the sagittal profile because they still implement theory from the middle ages. They do not force the ribs into normal position: e.g., restricted breathing in-brace keeps them contracted on the thoracic concave side, etc. Also depends on the brace. E.g., Cheneau do purport concern with the sagittal profile yet STILL result in cases with INCREASED rotation and compromised rib symmetry.

    I like the way you're questioning all this...great to see.
    Last edited by TAMZTOM; 01-05-2013 at 04:41 PM.
    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...”

  5. #5
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    I have always been perplexed by the comment I read in a paper saying pedicle screw constructs tended to be hypokyphosing as compared to say hooks. I could not understand what about pedicle screws was different from hooks and how can they be hypokyphosing if they bends the rods any way they like for the final balance. I now think the answer is that pedicle screws allow hyper-correction and unless they do osteotomies, the front of the spine is longer than the back and that will tend to decrease kyphosis when the vertebra are forced into alignment. My one kid was extremely rotated and had a 58* curve. After fusion she has no residual thoracic scoliosis, i.e., hyper-corrected. She also seems to be hypohyphotic. The other kid did not seem as rotated and she was only corrected to ~25* because she had a different type of T curve but she also seems a bit hypokyphotic.

    If you look at some of these fusion videos, just the act of de-rotating the vertebrae seems to decrease the curve. That would make sense if the overgrowth causes the rotation which causes the lateral curve as a space-filling mechanism.
    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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    If you look at some of these fusion videos, just the act of de-rotating the vertebrae seems to decrease the curve. That would make sense if the overgrowth causes the rotation which causes the lateral curve as a space-filling mechanism.
    As a factor of progression, yes, I've always thought the same. I believe one of my first posts in Tamzin's thread mentioned Katernia Schroth's thinking that there can be no sustainable lateral correction without derotation. I might have mentioned too that the Cheneau brace tried to counter the problem of earlier braces applying lateral force but messing up because they didn't address rotation. SpineCor research and 'theory' is in accord--they purport to tackle rotation before lateral curvature, as the latter would be pointless.

    I say as a factor of progression rather than cause, though. The issue remains, 'What caused the overgrowth?' We're into speculation then (e.g., some genetic asymmetrical mistiming on different areas of the growth plates).

    Quote Originally Posted by Pooka1 View Post
    ...unless they do osteotomies, the front of the spine is longer than the back and that will tend to decrease kyphosis when the vertebra are forced into alignment.
    I've sat here for hours in the past mentally constructing a curve of tilted, rotated, wedged and/or ''anteriorly overgrown' vertebrae. Wish I had a model! (Stokes does good ones, I think.) I think you're spot on with that reasoning. Because of AO, even assuming a perfect surgical derotation and lateral correction, there just wouldn't be sufficient space posteriorly to create such a correction, or, if they could, it'd be at the expense of causing hyper-kyphosis to accommodate the AO. A compromise may be optimal, but hard to achieve surgically because of the myriad calculations required. Sawing off sections of posterior ribs to accommodate the AO sounds theoretically possible....but, as the study you cited shows, doesn't work!

    My one kid was extremely rotated and had a 58* curve. After fusion she has no residual thoracic scoliosis, i.e., hyper-corrected. She also seems to be hypohyphotic. The other kid did not seem as rotated and she was only corrected to ~25* because she had a different type of T curve but she also seems a bit hypokyphotic.
    Does that suggest surgeons accept the sagittal flattening as the price for lateral and rotation correction? I wonder if that is why surgery results in translated force to the un-fused parts of the spine. Were both your kids hypo-kyphotic before the surgery? (We actually had a dispute once with the orthotist crew in Sheffield: the head orthotist's assistant/trainee, looking at the computer with all it's measurements on the SpineCor software, suggested aloud that she wasn't really hypo-kyphotic. The head guy--you know who I mean--said "Of course she is!" Ignored his own software. The assistant was correct--she didn't have full, normal kyphosis, but it wasn't that flat.)
    Last edited by TAMZTOM; 01-06-2013 at 06:28 PM.
    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...”

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