Effectiveness of complete conservative treatment for adolescent idiopathic scoliosis (bracing and exercises) based on SOSORT management criteria: results according to the SRS criteria for bracing studies - SOSORT Award 2009 Winner

Abstract

Background: The SRS criteria give the methodological reference framework for the presentation of bracing results, while the SOSORT criteria give the clinical reference framework for an appropriate bracing treatment. The two have not been combined in a study until now. Our aim was to verify the efficacy of a complete, conservative treatment of Adolescent Idiopathic Scoliosis (AIS)according to the best methodological and management criteria defined in the literature.

Methods: Study Design. Retrospective study. Population. We included all AIS patients respecting the SRS inclusion criteria (age 10 years or older; Risser test 0-2; Cobb degrees 25-40 degrees ; no prior treatment; less than one year post-menarchal) who had reached the end of treatment since our institute database start in 2003. Thus we had 44 females and four males, with an age of 12.8 +/- 1.6 at the commencement of the study. Methods. According to individual needs, two patients have been treated with Risser casts followed by Lyon brace, 40 with Lyon or SPoRT braces (14 for 23 hours per day, 23 for 21 h/d, and seven for 18 h/d at start), and two with exercises only (1 male, 1 female): these were excluded from further analysis. Outcome criteria. SRS (unchanged; worsened 6 degrees or more; over 45 degrees at the end of treatment; surgically treated; two years' follow-up); clinical (ATR, Aesthetic Index, plumbline distances); radiographic (Cobb degrees); and ISICO (optimal; minimal). Statistics. Paired ANOVA and t-test, Tukey-Kramer and chi-square test.

Results: Median reported compliance during the 4.2 +/- 1.4 treatment years was 90% (range 5-106%). No patient progressed beyond 45 degrees , nor was any patient fused, and this remained true at the two-year follow-up for the 85% that reached it. Only two patients (4%) worsened, both with single thoracic curve, 25-30 degrees Cobb and Risser 0 at the start. We found statistically significant reductions of the scoliosis curvatures (-7.1 degrees ): thoracic (-7.3 degrees ), thoracolumbar (-8.4 degrees ) and lumbar (-7.8 degrees ), but not double major. Statistically significant improvements have also been found for aesthetics and ATR.

Conclusion: Respecting also SOSORT management criteria and thus increasing compliance, the results of conservative treatment were much better than what had previously been reported in the literature using SRS criteria only.

Figure 1

Step-by-step theory. The step-by-step Sibilla theory [13].

Figure 2

Individual patients radiographic results. A. Starting data (Cobb degrees) of the patients included in this study. B. Final radiographic results (Cobb degrees) of each single patient included in the study. C. Results of brace treatment in all patients included in the study: 2 patients worsened, 18 improved. The blue lines represent the SRS inclusion criteria (from 25 to 40 Cobb degrees), while the red ones report the final SRS end-point not to be reached at the end of treatment (45 Cobb degrees). The maroon lines indicate the ± 5 Cobb degrees that represents the significant limit to achieve a clinical change in single patients.

Figure 3

One of the best results obtained in this study. A. Starting x rays. B. Final x-rays. P decreased from 33° at 13 years of age, Risser 1, pre-menarchal to 4° at 16 years, Risser 5.

Figure 4

Typical result in this study. A. Starting x rays. B. Final x-rays. C. Aesthetic final result. F decreased from 30-40° at 14 years of age, Risser 1, pre-menarchal to 23-31° at 18 years, Risser 5.

Figure 5

Results of a male patient. A. Starting x rays. B. Final x-rays. C. Aesthetic final result. C decreased from 30° at 14 years of age, Risser 2 to 21° at 18 years, Risser 5.

Figure 6

ISICO outcomes. The ISICO outcomes [7] are a representation of the evidence-based clinical practice approach used in this paper. According to individual needs, based on the starting x-rays, a radiographic desired optimal result is defined (Table 2); according to this starting criterion and to what is gradually obtained, based on compliance and curvature resistance to treatment, a minimal criterion can be considered. In these graphs the sub-group analysis are reported. It is easier to obtain optimal results in thoraco-lumbar and lumbar curvatures, in scoliosis up to 35 degrees, and in the youngest patients.