Effect of rib cage deformity in primary thoracic idiopathic scoliosis on pulmonary function, airway morphology and lung volumes

Although scoliosis is defined as a Cobb angle of 10° or more as measured in the coronal plane, the combined three-dimensional distortions to both the spine and rib cage in scoliosis are best conceptualised as a thoracic deformity. There is much interest in the relationship between scoliosis and pulmonary function due to the increased morbidity of respiratory failure and mortality of those with untreated progressive scoliosis. Establishing the mechanisms of pulmonary function impairment in scoliosis is important in identifying patients with compromised lung function or those who will benefit from surgical intervention. In this work, the relationship between thoracic deformity in patients with right-sided, Lenke type 1 or 2, adolescent idiopathic scoliosis (AIS) and pulmonary function impairment is investigated. From radiographic and computer tomographic imaging, measurements of the thoracic deformity were found to be superior predictors of pulmonary function in AIS than conventional Cobb angles. A statistical shape model was constructed from biplanar radiographs to identify modes of variation in the thoracic configuration. Thoracic features such as the extent of the rib hump, narrowed convex hemithoracic width and spinal intrusion were found to be factors contributing to lung function impairment. Morphological analysis of the tracheobronchial tree demonstrated the presence of right-sided airway narrowing. In particular, patients with hypokyphosis demonstrated significant narrowing of the bronchus intermedius and its bifurcation as a result of extrinsic compression by the vertebral column. Right-sided airway obstruction was found to correspond to the presence of atelectasis and air-trapping in the right middle and lower lobe. Post-operative analysis demonstrated that restoration of natural kyphosis in patients with hypokyphosis and scoliosis resulted in improved lung function post-operatively. Although reduction in lung function in patients with scoliosis is multifactorial, variance in the sagittal thoracic profile plays a more important role in impairing lung function than is generally appreciated

Automated shape analysis and visualization of the human back.

Spinal and back deformities can lead to pain and discomfort, disrupting productivity, and may require prolonged treatment. The conventional method of assessing and monitoring tile de-formity using radiographs has known radiation hazards. An alternative approach for monitoring the deformity is to base the assessment on the shape of back surface. Though three-dimensional data acquisition methods exist, techniques to extract relevant information for clinical use have not been widely developed. Thi's thesis presentsthe content and progression of research into automated analysis and visu-alization of three-dimensional laser scans of the human back. Using mathematical shape analysis, methods have been developed to compute stable curvature of the back surface and to detect the anatomic landmarks from the curvature maps. Compared with manual palpation, the landmarks have been detected to within accuracy of 1.15mm and precision of 0.8111m.Based on the detected spinous process landmarks, the back midline which is the closest surface approximation of the spine, has been derived using constrained polynomial fitting and statistical techniques. Three-dimensional geometric measurementsbasedon the midline were then corn-puted to quantify the deformity. Visualization plays a crucial role in back shape analysis since it enables the exploration of back deformities without the need for physical manipulation of the subject. In the third phase,various visualization techniques have been developed, namely, continuous and discrete colour maps, contour maps and three-dimensional views. In the last phase of the research,a software system has been developed for automating the tasks involved in analysing, visualizing and quantifying of the back shape. The novel aspectsof this research lie in the development of effective noise smoothing methods for stable curvature computation; improved shape analysis and landmark detection algorithm; effective techniques for visualizing the shape of the back; derivation of the back midline using constrained polynomials and computation of three dimensional surface measurements.

Design, Optimization, and Evaluation of a Fusionless Device to Induce Growth Modulation and Correct Spinal Curvatures in Adolescent Idiopathic Scoliosis

RÉSUMÉ La scoliose est une déformation musculo-squelettique complexe et tridimensionnelle de la colonne vertébrale. Les mécanismes de progression de la scoliose sont liés au principe de Hueter-Volkmann. Selon cette théorie, les chargements asymétriques des plaques de croissance altèrent la croissance du rachis (cunéiformisation des vertèbres). Une courbure scoliotique présentant un angle de Cobb supérieur à 50° nécessite généralement une intervention chirurgicale avec fusion rachidienne. Cette chirurgie implique des procédures particulièrement invasives et coûteuses, ce qui a incité plusieurs chercheurs à tenter de développer d‘autres alternatives. Des techniques minimalement invasives et sans fusion ont ainsi été élaborées pour contrôler et corriger un mauvais alignement de la colonne vertébrale avant qu'une progression trop importante des déformations scoliotiques ne se produise. Ces techniques tentent d'exploiter la croissance vertébrale résiduelle afin de corriger la cunéiformisation locale et d‘aboutir à un réalignement progressif du rachis. Les traitements sans fusion semblent également mettre en péril la santé du disque intervertébral à long terme et se limitent à une correction 2D (plan frontal) de déformations intrinsèquement 3D. Mieux comprendre biomécaniquement la progression des déformations scoliotiques permettrait de développer des dispositifs sans fusion plus efficaces. Cela serait une contribution importante et innovatrice à l'amélioration du traitement de la scoliose idiopathique adolescente (SIA). L'objectif global de cette thèse était le développement, l‘optimisation, et l‘évaluation expérimentale d'implants sans fusion afin de moduler la croissance et de corriger les déformations scoliotiques. Les objectifs spécifiques étaient de 1) développer un modèle par éléments finis (MEF) de la colonne vertébrale intégrant une modélisation de la croissance; 2) exploiter ce MEF pour étudier les facteurs biomécaniques impliqués dans les mécanismes de progression de la SIA; 3) exploiter le MEF pour analyser la biomécanique des dispositifs sans fusion existant actuellement et repérer les améliorations pouvant être apportées à ces dispositifs; et 4) exploiter la plate-forme de conception conçue (analyses in silico, in situ, et in vivo) pour développer, optimiser, et valider de nouveaux dispositifs sans fusion modulateurs de croissance pour la correction des déformations de la SIA.----------ABSTRACT Scoliosis is a spinal musculoskeletal deformity defined by a 3D deformity of the spine. The pathomechanism of scoliotic progression may be in part explained by the Hueter-Volkmann principle. This theory describes how increased loading of growth plates will reduce regular growth rates while the converse is also accurate. Further, when extended to the pathogenesis of scoliosis, it defines how asymmetric loading of the vertebral bodies leads to the progression of the deformity via vertebral wedging. Currently, a scoliotic curve reaching a magnitude of 50° Cobb deformation requires surgical intervention involving instrumentation and spinal fusion. The process of fusion is among the most invasive and expensive procedures, which has motivated several researchers to develop other alternatives. The development of a less invasive technique, to control and correct a spinal misalignment before undesirable progression occurs, has subsequently been explored. Several fusionless devices have been developed that attempt to manipulate vertebral growth to correct vertebral wedging and, consequently, realign the spine. However, to date, these approaches have yet to be adopted in a clinical context. Moreover, devices actively pursued seemed to imperil the long term health of the intervertebral disc while corrective attempts are restricted to the unilateral manipulation of a 3D deformity. Therefore, enhanced biomechanical understanding of AIS pathomechanism in conjunction with the development of early and less invasive interventions would offer an important contribution to the improved treatment of AIS. The global objective of this thesis was to design, optimize, and evaluated experimentally fusionless device concepts to induce growth modulation and correct spinal curvatures in adolescent idiopathic scoliosis (AIS). The specific objectives were to: 1) develop a FEM of the spine with integrated growth dynamics; 2) exploit the FEM to explore biomechanical factors involved in the pathomechanism of AIS; 3) exploit the FEM to analyze biomechanically current fusionless growth sparring devices to identify available avenues of improvement; and 4) exploit the devised developmental platform (in silico, in situ, and in vivo analyses) to develop, optimize, and validate novel and improved fusionless growth modulating devices for AIS

Automated visual measurement of body shape in scoliosis.

This thesis describes the content and progression of research into automated non-contact methods for measuring the three-dimensional shape of the human back in scoliosis. Scoliosis is a condition in which the spine becomes distorted and a rib-hump appears on the surface of the back. The research was driven by the needs of the scoliosis clinician and was supported by the Royal Liverpool Children's Hospital, Merseyside. A number of optical methods for measuring back surface shape are considered. Moire contouring and Fourier transform profilometry are investigated through practical research in the laboratory. Stereophotogrammetry, phase stepping profilometry, optical scanning and raster pattern contouring are investigated through consideration of theory and literature review. However, none of these approaches is found to be free from limitations. The main novel content of the work presented in this thesis lies in the research into a new method for reconstructing back shape. A new optical method is proposed in which a modified multi-stripe structured light pattern is projected onto the surface of the back. Image processing operations, specialised for this application, process the image of the pattern to reconstruct three-dimensional shape. Further research demonstrates that the computer reconstruction can be interrogated to measure parameters of clinical significance such as Angle of Trunk Inclination and Standardised Trunk Asymmetry Score. A working clinical system was implemented and tested on scoliosis patients at the hospital. The method is evaluated in terms of technical qualities and as a usable clinical tool and was found to satisfy the criteria for a successful automated system

Wearable Torso Exoskeletons for Human Load Carriage and Correction of Spinal Deformities

The human spine is an integral part of the human body. Its functions include mobilizing the torso, controlling postural stability, and transferring loads from upper body to lower body, all of which are essential for the activities of daily living. However, the many complex tasks of the spine leave it vulnerable to damage from a variety of sources. Prolonged walking with a heavy backpack can cause spinal injuries. Spinal diseases, such as scoliosis, can make the spine abnormally deform. Neurological disorders, such as cerebral palsy, can lead to a loss of torso control. External torso support has been used in these cases to mitigate the risk of spinal injuries, to halt the progression of spinal deformities, and to support the torso. However, current torso support designs are limited by rigid, passive, and non-sensorized structures. These limitations were the motivations for this work in developing the science for design of torso exoskeletons that can improve the effectiveness of current external torso support solutions. Central features to the design of these exoskeletons were the abilities to sense and actively control the motion of or the forces applied to the torso. Two applications of external torso support are the main focus in this study, backpack load carriage and correction of spine deformities. The goal was to develop torso exoskeletons for these two applications, evaluate their effectiveness, and exploit novel assistive and/or treatment paradigms. With regard to backpack load carriage, current torso support solutions are limited and do not provide any means to measure and/or adjust the load distribution between the shoulders and the pelvis, or to reduce dynamic loads induced by walking. Because of these limitations, determining the effects of modulating these loads between the shoulders and the pelvis has not been possible. Hence, the first scientific question that this work aims to address is What are the biomechanical and physiological effects of distributing the load and reducing the dynamic load of a backpack on human body during backpack load carriage? Concerning the correction of spinal deformities, the most common treatment is the use of a spine brace. This method has been shown to effectively slow down the progression of spinal deformity. However , a limitation in the effectiveness of this treatment is the lack of knowledge of the stiffness characteristics of the human torso. Previously, there has been no means to measure the stiffness of human torso. An improved understanding of this subject would directly affect treatment outcomes by better informing the appropriate external forces (or displacements) to apply in order to achieve the desired correction of the spine. Hence, the second scientific question that this work aims to address is How can we characterize three dimensional stiffness of the human torso for quantifiable assessment and targeted treatment of spinal deformities? In this work, a torso exoskeleton called the Wearable upper Body Suit (WEBS) was developed to address the first question. The WEBS distributes the backpack load between the shoulders and the pelvis, senses the vertical motion of the pelvis, and provides gait synchronized compensatory forces to reduce dynamic loads of a backpack during walking. It was hypothesized that during typical backpack load carriage, load distribution and dynamic load compensation reduce gait and postural adaptations, the user’s overall effort and metabolic cost. This hypothesis was supported by biomechanical and physiological measurements taken from twelve healthy male subjects while they walked on a treadmill with a 25 percent body weight backpack. In terms of load distribution and dynamic load compensation, the results showed reductions in gait and postural adaptations, muscle activity, vertical and braking ground reaction forces, and metabolic cost. Based on these results, it was concluded that the wearable upper body suit can potentially reduce the risk of musculoskeletal injuries and muscle fatigue associated with carrying heavy backpack loads, as well as reducing the metabolic cost of loaded walking. To address the second question, the Robotic Spine Exoskeleton (ROSE) was developed. The ROSE consists of two parallel robot platforms connected in series that can adjust to fit snugly at different levels of the human torso and dynamically modulate either the posture of the torso or the forces exerted on the torso. An experimental evaluation of the ROSE was performed with ten healthy male subjects that validated its efficacy in controlling three dimensional corrective forces exerted on the torso while providing flexibility for a wide range of torso motions. The feasibility of characterizing the three dimensional stiffness of the human torso was also validated using the ROSE. Based on these results, it was concluded that the ROSE may alleviate some of the limitations in current brace technology and treatment methods for spine deformities, and offer a means to explore new treatment approaches to potentially improve the therapeutic outcomes of the brace treatment

A review of the effectiveness of lower limb orthoses used in cerebral palsy

To produce this review, a systematic literature search was conducted for relevant articles published in the period between the date of the previous ISPO consensus conference report on cerebral palsy (1994) and April 2008. The search terms were 'cerebral and pals* (palsy, palsies), 'hemiplegia', 'diplegia', 'orthos*' (orthoses, orthosis) orthot* (orthotic, orthotics), brace or AFO