How tight should a night time brace be?

[mariaf]

I really think it's more of not wanting to put a child on the operating table, under anethesia, etc. in a case where they know it probably won't work (and I think doctors have a very good idea which cases will likely be successful).

I get what you are saying about weighing the risk/benefit, but I don't think it's about having clearance to use the staples only in certain cases. Initially, they were using them on a broader range of patients. Then several years into it, as they kept analyzing the data, they saw that the success rate was much higher in the curves under 35 degrees.

[hdugger]

[slip from Maria's post - yes, exactly]

I think they only have clearance to use the staples in a narrow range of cases - basically, where the long-term unknown risk is balanced by the chance that it would prove very beneficial for the child. Outside of that range, it would be considered to be too much risk for the perceived benefit.

[mariaf]

But what if is at more degrees no so much good amount of growth left and not so flexible spine, leading chances decreasing much but anyway very far form 0% and the parents knowing that anyway want to try it? What Drs. says to them? Sorry, although chances are not so bad, we prefer to treat only kids with greater chances.. otherwise our succesful statistics may decrease and Vbs would not be seen as something so good.. good luck with the other options!
I hope not. .

Hi flerc,

I think you are missing the point (at least if I understand you correctly). It's not about VBS being seen as something good. It's about putting a child on the operating table and performing surgery when the doctor knows that there is almost no chance that the surgery will be successful and achieve the desired result. Who in their right mind would even want to do that to their own child? That would be close to criminal in my view - and thankfully, no good doctor is going to do that.

[flerc]

But what if is at more degrees no so much good amount of growth left and not so flexible spine, leading chances decreasing much but anyway very far form 0% and the parents knowing that anyway want to try it? What Drs. says to them? Sorry, although chances are not so bad, we prefer to treat only kids with greater chances.. otherwise our succesful statistics may decrease and Vbs would not be seen as something so good.. good luck with the other options!
I hope not. .

[mariaf]

Mariaf, except when chances are very close to 0 as I said, I think the decision should to be taken by the patient, not the Dr.
You said is good to not accept patients without excelent chances. I think is good for the professionals, not the patients.
What we need in any treatment is the curve showing odds against type of curve (independent variable). Probably in Vbs case is something exponential, for instance (I know degrees is not the only one variable) 95% for 35º and only 15% for 36º . If it would be the case ok, but if they not accept cases of 39º because chances are around 60%, I do not see it as something good.. except they would be absolutely sure that with other option are 100% or very close.

Right, it's not like they draw a line and say "35 degrees OK", but "36 degrees no good".

They take a lot of factors into consideration. It's just that they have found that 35 degrees is where the success rate falls by a larger margin than at other points.

It's the same logic used when they recommend that women over 35 have amniocentesis when they are pregnant. Now 35 is not set in stone, but they have to draw that line someplace - and the risk of having a baby with Downs Syndrome increases significantly around 35 and then keeps increasing as maternal age increases. A pregnant woman who is 25 or 30 would have a very small chance of carrying a baby with this sort of condition so the risks of the test (although small) would not outweigh the benefit. But most doctors will talk to their patients about this - and particularly if a woman is borderline (say, 35 or 36 years old), they may for example, decide to forego the test if the woman feels strongly that she didn't want it.

Same with VBS. If a patient is at 35 degrees but has a good amount of growth left and a somewhat flexible spine, and the parents want to try it, the doctors may say OK.

[flerc]

Mariaf, except when chances are very close to 0 as I said, I think the decision should to be taken by the patient, not the Dr.
You said is good to not accept patients without excelent chances. I think is good for the professionals, not the patients.
What we need in any treatment is the curve showing odds against type of curve (independent variable). Probably in Vbs case is something exponential, for instance (I know degrees is not the only one variable) 95% for 35º and only 15% for 36º . If it would be the case ok, but if they not accept cases of 39º because chances are around 60%, I do not see it as something good.. except they would be absolutely sure that with other option are 100% or very close.

[mariaf]

Hi flerc,

I was referring to a situation where a patient presented with a curve that was too large or too rigid for the doctors to think VBS could work. Let's say the curve was 35-40 degrees.

Or we could be talking about a child who is almost done growing. In order for VBS to be successful, there has to be a good amount of growth remaining in the child.

Those are examples of cases where VBS would have only a minimal chance of success.

For patients with curves 35 degrees or less - and who have a significant amount of growth remaining - the chances of success are excellent.

I hope this is helpful.

[flerc]

Why do you are talking about only minimal chance of success at best?

The criteria for VBS has gotten much stricter than it was, say, in 2002. This is a good thing because knowing what they know today (after compiling and analyzing the data that has been gathered over the past decade), if a patient is accepted as a candidate for VBS, there is an excellent chance it will be successful.

Chances with Vbs are excelent or only minimal?

[mariaf]

It would only be right if it would not be any doubt about which option is always better than the others for any patient (according the curve, age..) and wich definitely cannot work in each case.
Doctors should to say the odds in each case. If someone with xº over the Vbs threshold wants to take it anyway, even after the Dr said him that odds with that degrees are only about y%, I don't think is something good to not accept him, except of course y would be very close to 0.

You say "I don't think is something good to not accept him".

Maybe we are not fully understanding each other, but I don't think it would be right for a doctor to accept him, and perform a surgery on someone knowing there was a very slim chance of success.

Having said that, let me assure you that in the case of Shriners in Philadelphia where my personal experience lies, they are very open to listening to parents and often taking a parent's wishes into consideration.

I still don't think that any good doctor would (or should) perform a surgery that they believe has only minimal chance of success at best.

Again, I may have misunderstood what you posted (if so, my apologies).

[flerc]

It would only be right if it would not be any doubt about which option is always better than the others for any patient (according the curve, age..) and wich definitely cannot work in each case.
Doctors should to say the odds in each case. If someone with xº over the Vbs threshold wants to take it anyway, even after the Dr said him that odds with that degrees are only about y%, I don't think is something good to not accept him, except of course y would be very close to 0.

[mariaf]

But they are not accepting patients without being sure it cannot not work in those cases!

Sorry, but I'm not sure what you mean, flerc.

Let me clarify. If a patient doesn't fit the current criteria for VBS, they won't be accepted for THAT procedure, but could be accepted as patients. The doctors might just recommend another option. For example, if the curve is too large for VBS, they might suggest tethering. If a child comes in with, say, a 30-35 degree curve but does not have enough growth left for VBS to work, they might suggest going with bracing until the remaining growth is completed - and hope the curve remains where it is, etc.

[flerc]

But they are not accepting patients without being sure it cannot not work in those cases!

[mariaf]

Sure, I'll be glad to see what I can find when I have a little more time.

Off the top of my head, it does makes some sense to me that only a portion of those patients would fit the new criteria, and therefore be deemed as useful to be included in the study. I know that one of the most significant findings over the years has been that curves over 35 degrees do not respond as well to VBS as those below that threshold.

The criteria for VBS has gotten much stricter than it was, say, in 2002. This is a good thing because knowing what they know today (after compiling and analyzing the data that has been gathered over the past decade), if a patient is accepted as a candidate for VBS, there is an excellent chance it will be successful.

[hdugger]

so I need to read through the most recent posts in this thread

Thanks, Maria. If it's possible (either through full text of articles you might have or access to Betz's team) could you confirm my 28/29 number for the kids that Betz is now considering in his research? I don't want to be quoting an incorrect number, but it's difficult to pull that info out of the abstracts.

What the Blue Cross paper said was that there were 96 VBS children total (at the time of the last review) but that Betz was only considering 29 of them because the rest did not fit the (revised) protocol (which I think was using the 2002 version of the staple, plus probably his tightening of the cobb angle requirements and after-procedure corrections).

[mariaf]

Yes, tethering. Seriously considered and casually recommended to parents new to the forum.

I am just catching up so I need to read through the most recent posts in this thread (I believe there is a more recent study on VBS, but I have to check).

I just wanted to point out one important fact. Tethering is not exactly an alternative to VBS. A lot of kids who are tethering candidates are not VBS candidates, and vice versa. Not always, but many times.

For instance, a young child with a 30 degree curve might not be a good candidate for tethering due to fear of over correction, but could very well be an excellent candidate for VBS.

Whereas, an older child with a larger curve might fit the criteria for tethering, but not VBS.