Importância da experiência clínica para a mensuração da curva escoliótica de crianças pela técnica de Cobb

La escoliosis se define como una alteración con curvatura lateral de la columna vertebral en el plano coronal, torsión de la columna vertebral y del tronco y trastorno en el perfil sagital. Esta alteración postural se evalúa mediante radiografía anteroposterior, utilizando el método de Cobb. El presente estudio tiene como objetivo verificar la influencia de la experiencia del evaluador para la fiabilidad intraexaminador e interexaminador del ángulo de Cobb en las curvaturas escolióticas de los niños. El estudio incluyó a 39 niños con escoliosis idiopática entre 7 y 18 años de edad. Los exámenes fueron evaluados por dos fisioterapeutas, un quiropráctico y un estudiante de fisioterapia, siendo que cada uno evaluó cada examen dos veces. Tras siete días, ocurrió una segunda evaluación para la fiabilidad intraexaminador. Además, las primeras evaluaciones proporcionaron datos para la fiabilidad interexaminador. El análisis estadístico se realizó con el coeficiente de correlación intraclase (ICC), con el análisis de Bland y Altman y con el análisis descriptivo de la desviación media absoluta, del error estándar de medición y del cambio mínimo detectable. Se observó una alta fiabilidad (ICC>0,5) en los análisis intraexaminadores entre los profesionales, y una baja fiabilidad (ICC=0,4) en los de evaluadores inexpertos. La fiabilidad interexaminador de los profesionales fue buena (ICC=0,6), y la presencia del evaluador inexperto fue baja (ICC=0,3). Las evaluaciones entre los profesionales mostraron una menor variabilidad de las medidas y valores de desviación estándar en comparación con los del evaluador inexperto. La medición de los ángulos de escoliosis utilizando el método de Cobb que había sido realizada por profesionales con experiencia mostró mejores índices de concordancia y fiabilidad intra e interexaminadores y una menor desviación estándar y variabilidad entre las mediciones.A escoliose é definida como uma deformidade com desvio lateral da coluna no plano coronal, torsão da coluna e do tronco e distúrbio no perfil sagital. Essa alteração postural é avaliada por meio de radiografia de incidência anteroposterior, utilizando-se o método de Cobb. O objetivo do estudo é verificar a influência da experiência do avaliador sobre a confiabilidade intraexaminador e interexaminador do ângulo Cobb em curvaturas escolióticas de crianças. Foram incluídas na pesquisa 39 crianças portadoras de escoliose idiopática, com idade entre 7 e 18 anos. Os exames foram avaliados por dois fisioterapeutas, um quiropraxista e um estudante de fisioterapia – cada um avaliando duas vezes cada exame. A segunda avaliação ocorreu após sete dias, para confiabilidade intraexaminador. Ademais, as primeiras avaliações forneceram dados para confiabilidade interexaminador. A análise estatística foi realizada com coeficiente de correlação intraclasse (CCI), análise de Bland e Altman e análise descritiva do desvio absoluto médio, erro-padrão de medição e mínima mudança detectável. Observou-se boa confiabilidade (CCI>0,5) para as análises intraexaminadores entre os profissionais, e confiabilidade fraca (CCI=0,4) para o avaliador inexperiente. A confiabilidade interexaminador dos profissionais foi boa (CCI=0,6), e com a presença do avaliador inexperiente foi fraca (CCI=0,3). As avaliações entre os profissionais apresentaram menor variabilidade das medidas e valores de desvio-padrão quando comparadas com as do avaliador inexperiente. A mensuração dos ângulos da escoliose por meio do método de Cobb realizada por profissionais experientes apresentou melhores índices de concordância e de confiabilidade intra e interexaminadores e menor desvio-padrão e variabilidade entre as medidas.| Scoliosis is defined as a deformity with lateral deviation of the spine in the coronal plane, torsion of the spine and trunk, and disturbances in the sagittal profile. This postural alteration is evaluated by anteroposterior incidence radiography using the Cobb method. The objective of this study was to verify the influence of evaluator experience on inter- and intra-rater reliability of the Cobb angle of scoliosis curvatures in children. In total, 39 patients aged 7 to 18 years with idiopathic scoliosis were included in this study. The exams were evaluated by two physical therapists, a chiropractor and a physical therapy student. Each evaluator rated each exam twice and the second evaluation occurred after seven days, characterizing the intra-rater reliability. Furthermore, the first evaluations provided the inter-rater reliability. Statistical analysis was performed with intraclass correlation coefficient (ICC), Bland-Altman analysis, descriptive analysis of mean absolute deviation, standard error of measurement, and minimum detectable chance. Correlations ranged from good (ICC>0.5) for intra-rater reliability among professionals to weak (ICC=0.4) for the inexperienced evaluator. The inter-rater reliability of the professional’s evaluations was good (ICC=0.6) and the same analysis with the presence of an inexperienced evaluator was weak (ICC=0.3). Evaluations among professionals showed less variability of measurements and standard deviation values compared to the inexperienced evaluator. The measurement of the angles of the scoliosis through the Cobb method carried out by experienced professionals showed better agreement as well as intra- and inter-rater reliability, lower standard deviation, and variability among the measurements

Idiopathic scoliosis : aspects on surgical and non-surgical treatment

The term scoliosis has been used to describe conditions that lead to deformation of the spine. It derives from the ancient Greek ‘σκολίωσις’ and the root word ‘σκολιός’ which means ‘bent or crooked’. In its most common form, scoliosis is of unknown - idiopathic - cause and origin. It affects roughly 3% of children and adolescents during growth and in mild cases no treatment is required. In moderate cases, bracing has been proposed, with the aim to halt progression of idiopathic scoliosis. It is most common with full-time bracing using rigid, custom made thoracolumbosacral orthoses. It is worn for 16-20 hours per day until skeletal maturity and has been shown to prevent scoliosis progression to a surgical threshold in about 70% of the cases. However, compliance to the treatment has been one of the major drawbacks seen with the full-time brace. Therefore, night-time braces, worn only during the night, have started to gain popularity over the years. Nevertheless, evidence on the effectiveness of night-time bracing has only been based on retrospective studies. More recently, specific scoliosis exercise regimes consisting of self-mediated correction maneuvers in 3 dimensions have also emerged. So far, there has been only one high quality study showing effectiveness of this modality, in patients with mild idiopathic scoliosis. A trial was performed consisting of 135 patients randomized to self-mediated physical activity in combination with either night-time brace, or scoliosis-specific exercise, or self-mediated physical activity alone. Night-time brace was shown to be more effective than self-mediated physical activity in preventing scoliosis progression. On the other hand, scoliosis-specific exercise did not show any clinical benefit when compared to the self-mediated physical activity. Additionally, comparison between the nigh-time brace group and a group of patients who declined participation in the trial and received a full-time brace showed similar effectiveness on the prevention of curve progression. In case the deformity progresses to more severe curves, surgery may be suggested. Over the last decades, a posterior exposure to the spine with a high number of implants and predominantly pedicle screw based fixation techniques has been favored over traditional techniques with low number of implants for the correction of scoliosis. These techniques have been suggested to increase correction and fusion rates and eliminate the risks associated with exposure of the chest wall and/or abdomen in anterior approaches to the spine. Disadvantages of the posterior approach to the spine include extended muscle dissection, need for a higher number of vertebrae to be fused and risk for neurological injuries to the spinal cord. To date, whether posterior based fusion may result in better clinical and radiographic outcomes compared to anterior fusion is still unclear. Moreover, whether higher number of implants per vertebra (implant density) results in better clinical and radiographic outcomes is still debatable. In a nationwide registry-based cohort, we identified patients who underwent anterior (n=27) and posterior (n=32) fusion surgery for a thoracolumbar/lumbar type of scoliosis. We found that despite a longer operative time in the anterior group and higher blood loss and longer fusion constructs in the posterior group, both procedures resulted in significant correction of the scoliosis with similar patient-reported outcome and satisfaction; suggesting that the type of approach is not related to health-reported quality of life. By using the same nationwide database, we also identified 328 surgically treated idiopathic scoliosis patients who were then divided into tertiles based on the number of implants used per operated vertebra. We found no differences in the correction rate of the curve and health-reported quality of life in the different tertiles, suggesting that a high number of implants is not necessarily beneficial in the surgical treatment of idiopathic scoliosis. Studies have shown that, what is perceived as successful radiographic outcome, may not necessarily correlate with patient´s own perception of successful outcome after surgery for idiopathic scoliosis. Patients may still experience persistent back pain and worse quality of life, despite an excellent radiographic outcome. By using the same nationwide database, we identified 280 patients treated with posterior fusion surgery for idiopathic scoliosis and divided them into a high (n=67) and a low (=213) postoperative pain group, based on their self-reported postoperative back pain scores. We found that patients in the high pain group also reported higher back pain and worse quality of life before surgery, compared to the low postoperative pain group. High preoperative back pain and low preoperative mental health were identified as predictors of persistent pain after surgery

Advances on Scoliogeny, Diagnosis and Management of Scoliosis and Spinal Disorders

This book contains research articles on the advances in the aetiology of idiopathic scoliosis (IS), the spinal growth related to the implementation of growth modulation for the surgical treatment of early-onset IS, the non-surgical treatment of IS using Physiotheraputic Scoliosis Specific Exercises, and braces. Additionally, it focuses on issues related to surgical treatment, issues related to body posture and the quality of life of this sensitive group of people. The high quality of published papers in this Special Issue of the JCM serve these objectives

The recognition and modelling of a backbone and its deformity

In this article the authors present a method for the backbone recognition and modelling. The process of recognition combines some classical techniques (Hough transformation, GVF snakes) with some new (authors present a method for initial curvature detection, which they call the Falling Ball method). The result enables us to identify high-quality features of the spine and to detect the major deformities of backbone: the intercrestal line, centre sacral vertical line, C7 plumbline; as well as angles: proximal thoracic curve, main thoracic curve, thoracolumbar/lumbar. These features are used for measure in adolescent idiopathic scoliosis, especially in the case of treatment. Input data are just radiographic images, meet in everyday practice

2011 SOSORT guidelines: Orthopaedic and Rehabilitation treatment of idiopathic scoliosis during growth

<p>Abstract</p> <p>Background</p> <p>The International Scientific Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT), that produced its first Guidelines in 2005, felt the need to revise them and increase their scientific quality. The aim is to offer to all professionals and their patients an evidence-based updated review of the actual evidence on conservative treatment of idiopathic scoliosis (CTIS).</p> <p>Methods</p> <p>All types of professionals (specialty physicians, and allied health professionals) engaged in CTIS have been involved together with a methodologist and a patient representative. A review of all the relevant literature and of the existing Guidelines have been performed. Documents, recommendations, and practical approach flow charts have been developed according to a Delphi procedure. A methodological and practical review has been made, and a final Consensus Session was held during the 2011 Barcelona SOSORT Meeting.</p> <p>Results</p> <p>The contents of the document are: methodology; generalities on idiopathic scoliosis; approach to CTIS in different patients, with practical flow-charts; literature review and recommendations on assessment, bracing, physiotherapy, Physiotherapeutic Specific Exercises (PSE) and other CTIS. Sixty-five recommendations have been given, divided in the following topics: Bracing (20 recommendations), PSE to prevent scoliosis progression during growth (8), PSE during brace treatment and surgical therapy (5), Other conservative treatments (3), Respiratory function and exercises (3), Sports activities (6), Assessment (20). No recommendations reached a Strength of Evidence level I; 2 were level II; 7 level III; and 20 level IV; through the Consensus procedure 26 reached level V and 10 level VI. The Strength of Recommendations was Grade A for 13, B for 49 and C for 3; none had grade D.</p> <p>Conclusion</p> <p>These Guidelines have been a big effort of SOSORT to paint the actual situation of CTIS, starting from the evidence, and filling all the gray areas using a scientific method. According to results, it is possible to understand the lack of research in general on CTIS. SOSORT invites researchers to join, and clinicians to develop good research strategies to allow in the future to support or refute these recommendations according to new and stronger evidence.</p

Investigating the ability to use the CT scan projection radiograph to monitor adolescent idiopathic scoliosis

Introduction: Adolescent idiopathic scoliosis (AIS) is a spinal deformity that causes the spine to bend laterally. Patients with AIS undergo frequent X-ray examinations to monitor the progression of the deformity through the measurement of the Cobb angle, increasing the risk of developing radiation-induced cancer. The aim of this study was to investigate the use of scan projection radiograph (SPR) in computed tomography (CT) to assess AIS by quantifying radiation dose from the SPR acquisitions and comparing it to those of digital radiography (DR) and a dedicated scoliosis imaging system (EOS) and by evaluating the accuracy of Cobb angle measurements on SPR images using a bespoke validated phantom. Methods: A dosimetry phantom representing a 10-year-old child and thermoluminescent dosimeters were used for measuring organ dose to calculate effective dose (ED) and effective risk (ER). Twenty-seven CT SPR protocols were used. A comparison was made to doses from imaging protocols using DR and the EOS system. The effectiveness of a scoliosis shawl for selected projections was also tested. To test the accuracy of Cobb angle measurements on SPR images, a scoliotic phantom was constructed and validated. Poly-methyl methacrylate (PMMA) and plaster of Paris (PoP) were used to represent human soft tissue and bone tissue, respectively, to construct a phantom exhibiting a 15° lateral curve of the spine. The phantom was validated by comparing the Hounsfield unit (HU) of its vertebrae with those of a human and an animal. Additionally, comparisons of signal-to-noise ratio (SNR) to those from a commercially available phantom were made. The angle of the curve in the phantom was measured directly to confirm that it was 15°. The constructed phantom was scanned in CT SPR mode, and the resulting images were visually evaluated against set criteria to determine their suitability for Cobb angle measurements. Those deemed of insufficient quality were excluded. Cobb angle measurements were then performed on the remaining images (n = 10) by 13 observers.Results: EOS had the lowest ED and ER when it was used to irradiate the phantom in AP positions. Five SPR AP imaging protocols and seven PA imaging protocols delivered significantly lower radiation dose and risk than their corresponding imaging positions in DR (p < 0.05). The scoliosis shawl significantly lowered the ED and ER of SPR and DR AP imaging protocols (p < 0.05). The validation of the PoP phantom revealed that the HU of the PoP vertebrae was 628 (SD= 56), human vertebrae was 598 (SD= 79) and sheep vertebra was 605 (SD= 83). The SNR values of the two phantoms correlated strongly (r = 0.93 [(p < 0.05]). The measured scoliosis angle was 14 degrees. When the phantom was imaged using SPR, the difference between the measured Cobb angle and the known angle was, on average, –2.75° (SD = 1.46°). The agreement among the observers was good (p = 0.861, 95% CI [0.70–0.95]) and comparable to similar studies on other imaging modalities which are used for Cobb angle estimation.Conclusion: EOS had the lowest dose. Where this technology is not available, there is a potential for organ dose (OD) reduction in AIS imaging using CT SPR compared with DR. The PoP phantom has physical characteristics (in terms of spinal deformity) and radiological characteristics (in terms of HU and SNR values) of the spine of a 10-year-old child with AIS. CT SPR images can be used for AIS assessment with the 5° margin of error that is clinically acceptable. A few SPR imaging protocols (CT4, 8 and 11) had the lower radiation risk compared with the DR and provided the most accurate Cobb angle measurements.Implications for practice: The bespoke phantom can be used to investigate new X-ray imaging techniques and technology in the assessment of scoliosis and has utility for the optimisation of X-ray imaging techniques in 10-year-old children. Overall, the outcome is promising for patients and health providers because it provides an opportunity to reduce patient dose and achieve clinically acceptable Cobb angle measurements whilst using existing CT technology