Clinical improvement and radiological progression in a girl with early onset scoliosis (EOS) treated conservatively--a case report

Abstract

Background: Chêneau-Brace treatment of a certain standard reduces the rate of surgery, prevents progression and in a certain patient population leads to marked improvement of Cobb angle and cosmetic appearance. During the last two years a patient refusing surgery with a double major curvature of initially 60 degrees showed a clear cosmetic improvement and a clear radiological progression at the same time. The findings of this patient have been reviewed in order to find out how cosmetic appearance and Cobb angle can develop differently.

Methods: The patient entered conservative treatment at the age of 13 years, premenarchial with Tanner II and a Cobb angle of 60 degrees thoracic and 59 degrees lumbar. The angle of trunk rotation (ATR; Scoliometer) was 13 degrees thoracic and 13 degrees lumbar. We have documented the findings of this patient (Surface topography, ATR, Cobb angles and angles of vertebral rotation (according to Raimondi) during the treatment period (27 Month) until 2 years after the onset of menarche.

Results: After a treatment time of 27 Month the Cobb angle increased to 74 degrees thoracic and 65 degrees lumbar. The angles of vertebral rotation according to Raimondi increased slightly from 26 degrees thoracic and 28 degrees lumbar to 30 degrees thoracic and 28 degrees lumbar. The ATR improved to 12 degrees thoracic and 5 degrees lumbar while Lateral deviation improved from 22.4 mm to 4.6 mm and average surface rotation improved from 10.6 degrees to 6 degrees. In the X-rays a reduction of decompensation was visible. The patient felt comfortable with the cosmetic result.

Conclusion: Conservative treatment may improve cosmetic appearance while the curve progresses radiologically. This could be explained by assuming that (1) the Rigo Chêneau brace is able to improve cosmetic appearance by changing the shape of the thorax when the curve itself is too stiff to be corrected by a brace, that (2) reduction of decompensation leads to significant cosmetical improvements or (3) that the patient gained weight and therefore the deformation is masked. However, the weight the patient gained cannot explain the cosmetical improvement in this case. Conservative treatment with a certain standard of quality seems a viable alternative for patients with Cobb angles of > 60 degrees when surgical treatment is refused. Specialists in scoliosis management should be aware of the fact that curve progression can occur even if the clinical measurements show an improvement.

Figure 1

Clinical history of the patient. On the left the patient can be seen at the start of treatment, on the middle left in the first brace, on the middle right clinically after one year of treatment and on the right after 27 months of treatment before the weaning brace was adjusted. A considerable cosmetic improvement can be seen comparing the picture at the start of treatment (left) to the picture two years after the onset of menarche (right).

Figure 2

Clinical history of the patient as documented by surface topography. On the upper left the patients reconstructed back can be seen at the start of treatment, on the upper middle picture 6 months and on the upper right picture 12 months while treated with the brace. A little improvement is visible after 12 month of treatment. On the lower left the patients reconstructed back can be seen 15 month after the start of treatment, on the lower middle picture 20 months and on the lower right picture 27 months while treated. A clear cosmetic improvement is visible when the initial surface reconstruction (upper left) is compared to the last one on the lower right.

Figure 3

Radiological history of the patient. From left (x-ray taken outside our centre before start of treatment) to right the radiological course of the patient can be seen (last picture after 27 months on the right). A progression of the curve is visible.

Figure 4

Clinical history of the patient as documented by angle of trunk rotation (Scoliometer) and surface topography (lateral deviation and surface rotation). On the top course of the thoracic ATR and lumbar ATR; on the bottom the course of lateral deviation and surface rotation during the time of treatment (27 Months).

Figure 5

Clinical history of a patient with 45° at the age of 13 and 27° at the age of 16 after brace weaning. On the left the patient can be seen at the start of treatment, on the middle left clinically after one year of treatment, on the middle right in her second brace, and on the right after 36 months of treatment after weaning. A considerable cosmetic improvement can be seen comparing the picture at the start of treatment (left) to the picture two years after the onset of menarche (right) while the curve has improved 18° Cobb at the same time.

Figure 6

Clinical history of the patient as documented by surface topography (second year of treatment). On the left the patients reconstructed back can be seen at the start of treatment, on the middle picture 12 months and on the right picture 36 months after weaning. A clear cosmetic improvement is visible when the initial surface reconstruction is compared to the last one on the right.