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Thread: New Potential Indicator for Progression

  1. #1
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    New Potential Indicator for Progression

    J Spinal Disord Tech. 2009 Jul;22(5):367-71.Click here to read Links
    Drooping of apical convex rib-vertebral angle in adolescent idiopathic scoliosis of more than 40 degrees: a prognostic factor for progression.
    Modi HN, Suh SW, Song HR, Yang JH, Ting C, Hazra S.

    Department of Orthopedics, Scoliosis Research Institute, Korea University Guro Hospital, Seoul, South Korea.

    STUDY DESIGN: It is a retrospective analysis on radiograms of 113 adolescent idiopathic scoliosis (AIS) patients with a curve of 40 degrees or more at the time of presentation. OBJECTIVES: Our aim was to find out the prognostic factor for the curve progression for this group. SUMMARY AND BACKGROUND: There is general consensus in favor of operation when the curve is more than 40 degrees for AIS. There are number of reports on the prognostic and etiologic factors for the progression of scoliosis. Rib-vertebral angle (RVA) became a topic of interest regarding the progression of scoliosis for many researchers since Mehta introduced it in 1972. METHODS: There were 113 AIS patients (95 females and 18 males) who had a curve of more than 40 degrees at the time of presentation, with an average age of 12 years and 10 months. We measured RVA on the convex and concave sides at the apex and 12th vertebrae and measured rib-vertebral angle difference (RVAD) using Mehta's method at each follow-up. We also measured the drooping value of the convex rib after bracing and at final follow-up. RESULTS: Of the 113 patients, 84 responded to bracing and in 29 the curve progressed despite bracing at final follow-up. The average drooping of rib at the apex on the convex side was 11 degrees, which progressed compared with 0.12 degrees in those who responded to treatment. On analyzing the results we could not find any relationship in 12th vertebrae but there was a significant relationship between the drooping value of convex apical rib (RVA Cx) after bracing and curve progression, which is similar to RVAD. There was no relationship between curve progression and initial angle, age, Risser sign, or menarchal status at presentation. CONCLUSIONS: From our study, we conclude that a large number of curves can be treated with bracing; however, when we notice drooping of the convex apical rib along with RVAD, the curve will likely progress.

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    Wow, that's an interesting study Linda, thanks for posting. It's amazing that 84 of the 113 patients responded to bracing when they presented with an angle greater than forty degrees! I wonder what kind of bracing they use in South Korea.

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    where are the peer reviewers?

    It remains a mystery to me at least why journals continue to publish uncontrolled studies which would be summarily rejected for publication in other fields. The existence of the Braist Study would seem to be a giant clue about the problem of uncontrolled studies.

    We also don't know the long-term on these patients, specifically if the brace just delays surgery rather than avoids it for most, if not all, of these patients.

    What does, "responded to bracing" mean? Maybe it says in the paper. Maybe it means the curve is the same five minutes after removing the brace. Are the authors orthopedic surgeons?

    I think the issue of delaying versus avoiding surgery rises to an ethical concern that should be addressed given how kids fare better than adults on average. That has to be balanced by advances in surgical technique of course. I just would like to know the rates of delayed surgery versus avoided surgery in the long term. I think the numbers would be very interesting, if not eye-opening.

    The issue of collateral damage associated with simply having a curve over the years should also be addressed directly. I realize some large percentage of non-scoliotics have back problems but maybe most/all of scoliotics have back problems. Also, whereas a large fraction of non-scoliotics are not surgical candidates for these problems, maybe a large percentage of scoliotics are surgical candidates.

    So many open questions.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
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    "We are all African."

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    Quote Originally Posted by Pooka1 View Post
    It remains a mystery to me at least why journals continue to publish uncontrolled studies which would be summarily rejected for publication in other fields. The existence of the Braist Study would seem to be a giant clue about the problem of uncontrolled studies.

    We also don't know the long-term on these patients, specifically if the brace just delays surgery rather than avoids it for most, if not all, of these patients.

    What does, "responded to bracing" mean? Maybe it says in the paper. Maybe it means the curve is the same five minutes after removing the brace. Are the authors orthopedic surgeons?

    I think the issue of delaying versus avoiding surgery rises to an ethical concern that should be addressed given how kids fare better than adults on average. That has to be balanced by advances in surgical technique of course. I just would like to know the rates of delayed surgery versus avoided surgery in the long term. I think the numbers would be very interesting, if not eye-opening.

    The issue of collateral damage associated with simply having a curve over the years should also be addressed directly. I realize some large percentage of non-scoliotics have back problems but maybe most/all of scoliotics have back problems. Also, whereas a large fraction of non-scoliotics are not surgical candidates for these problems, maybe a large percentage of scoliotics are surgical candidates.

    So many open questions.
    Sharon...

    While I agree with what you've stated, when we're talking about such a vulnerable population (infants), the medical community needs something on which they can act, until better information is available.

    --Linda

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    Quote Originally Posted by LindaRacine View Post
    Sharon...

    While I agree with what you've stated, when we're talking about such a vulnerable population (infants), the medical community needs something on which they can act, until better information is available.

    --Linda
    Linda, this article deals with AIS, no?

    I saw the IIS article you posted but that is a different thread, yes?
    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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    Are the authors orthopedic surgeons?
    I think it's pretty clear that a Department of Orthopedics at a Scoliosis Research Institute at a research hospital would have orthopedic surgeons in it. But, I went ahead and looked it up for you and here's one of the authors of the study.

    http://guro.kumc.or.kr/ENG/CTR/index...1324&partno=10

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    Quote Originally Posted by Pooka1 View Post
    Linda, this article deals with AIS, no?

    I saw the IIS article you posted but that is a different thread, yes?
    You are correct Sharon. Sorry for the confusion.

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    You know, if medical folks don't have a control group or can't get one then that is simply a fact.

    But they shouldn't go on a blatantly misrepresent the data by ASSUMING that the braced folks responded to the brace as opposed to just not progressing in that particular time frame.

    We know separately that some curves move and then stabilize. This study is not a longitudinal study. This aspect is COMPLETELY uncontrolled in the study.

    But the main issue is what is happening in the out years. If most of the patients who are claimed to have responded to bracing later progress after the study ended then that just brings up the ethical question of delaying versus avoiding surgery.

    And I can't get Linda's comment out of my head about fusing earlier to save levels. If that is true then my kid at 36* - 40*, given her likely scoliosis cause and the outcome of her ID twin, probably can be fused now if it means staying out of the lumbar and returning her to the general population. I am getting heartburn over this issue. I need to email the surgeon on this point though I think he will respond again with only a small percentage of folks <50* at maturity ever progress to a point of needing surgery. I would like to see that set of studies showing that.
    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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