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Adolescent idiopathic scoliosis, bracing and the Hueter-Volkmann principle
Proceedings of the NASS 16th Annual Meeting / The Spine Journal 2 (2002) 3S–44S cation use. This information was gathered from both clinic and hospital charts and by direct contact with the patients. The radiographic analysis compared preoperative sagittal and coronal balance with postoperative sagittal and coronal balance. In addition, the amount of correction obtained at the osteotomy site and the overall lumbar sagittal contour change from preand postoperative radiographs were evaluated. The coronal balance was measured from C7 to the middle of the sacrum on an AP film with a plum line. The overall sagittal balance was measured from the anterior/inferior edge of C7 to the posterior aspect of S1 again, with a plum line. The osteotomy correction was measured using the Cobb angle technique from the end plate immediately above and below the operative level. The degree of lumbar lordosis was measured from the inferior end plate of T12 to the superior end plate of S1. Results: Sixteen female and 11 male patients underwent pedicle subtraction osteotomy between 1996 and 2000. The average age was 49 years, with the mean number of previous spinal operations of three. Even in the multiply operated spine, pedicle fixation was obtained 100% of the time in the lumbar spine to aid in maintaining the appropriated sagittal contour. The average blood loss was 1,116 cc and the average operative time was 6 hours and 45 minutes, with a mean hospital stay of 6 days. The average preoperative coronal and sagittal imbalance were 4.38 cm and 12.22 cm, respectively. The postoperative correction on the immediate follow-up showed coronal and sagittal balance of 1.84 cm and 3.42 cm, respectively. This represents a 58% correction in the coronal plane and a 72% correction in the sagittal plane. This correction was maintained at the latest follow-up with only a .09 cm average loss of correction in the coronal plane and .04 cm average loss of correction in the sagittal plane. This loss of correction is well within measurement error and is considered to be negligible. The average follow-up examination was 15 months from the index procedure. The correction obtained through the osteotomy site was 31 degrees on average with an increase in lumbar lordosis from 28 degrees preoperatively to 49 degrees postoperatively. The overall satisfaction with surgery was quite high, even with nine patients having complications. There were no incidences of spinal cord injury or nerve root loss. There were four infections (one deep, three superficial), which resolved with the appropriate antibiotic course. There were four cases of pseudarthrosis requiring a second operation, all of which went on to a solid union. In evaluating the amount of pain medicines used pre- and postoperatively, 60% of patients went from narcotic use to only an anti-inflammatory agent or nothing for pain management. Seventeen percent of the patients still used an occasional narcotic pain pill to manage their back pain, but all patients had an overall decrease in the use of pain medicines. Conclusion: Pedicle subtraction osteotomy is a safe and effect treatment for patients who have flat back syndrome. It is the authors’ belief that pedicle subtraction osteotomy is a safer approach than the previously described methods of treating this problem. Pedicle subtraction osteotomy can be performed on patients who have had multiple spinal operations. This simple posterior procedure offers excellent radiographic and clinical improvements with limited complications. The role of measured resistance exercises in adolescent scoliosis Vert Mooney, MD, Allison Brigham, BS, San Diego, CA, USA Purpose: To document the effect of progressive strength training in torso rotation in individuals with adolescent scoliosis. Preliminary work at our center has demonstrated that all scoliotic adolescents had an asymmetry of rotation strength measured on specialized equipment, which isolates the torso rotation strength. In addition, surface electrode electromyograms had demonstrated inhibition of lumbar paraspinal muscles. The inhibition and strength corrected after several sessions of isolated progressive exercise training. Methods: Twenty-five adolescents (23 females, 2 males) with scoliosis ranging from 15 to 41 in their major curve were treated with a progressive resistive training program for torso rotation. They were treated twice a week until skeletal maturity or documented reduction of curve. None were braced during the period of treatment. Starting resistance was one third of body weight. Equal resistance was used for both left and right rotation, al-
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though initially rotation was weaker in one direction compared with the other. Once able to carry out 20 repetitions, the resistance was increased about 5%. Rotation range was increased as tolerated. Patients with surgical level of curves did not respond and were not followed. Results: Eighteen of 25 demonstrated curve reduction. Although there was some fluctuation, none of the rest had a persistent increase in curve. Pretraining average range was 28.2 13.2. Posttraining range was 23.0 14.1. The percentage improvement was 20% 23.3%. There was a 132.5% (61.4%) increase in dynamic strength. None went on to surgery or bracing. Discussion: Based on the demonstration of strength and asymmetry in rotation and inhibited lumbar extensor muscle activity, it is rational to place adolescents with scoliosis into a progressive resistance training program. In this small series, it offered notable benefit with documented control of curve progression. Parents were pleased that an active intervention was provided rather than “watch and wait” typical of presurgical adolescent scoliotic care. Lack of efficacy of exercise in previous studies may be because there was a lack of specific muscle training and measurement. No exercise program using equipment has previously been reported. Adolescent idiopathic scoliosis, bracing and the Hueter-Volkmann principle Frank P. Castro, MD, Amy Young, Richard T. Holt, MD, Mohammed E. Majd, MD, Louisville, KY, USA Purpose: Asymmetric chondrogenesis, in accordance with the HueterVolkmann principle, is frequently cited as a potential cause for adolescent idiopathic scoliosis (AIS). Brace treatment may reverse the abnormal forces across the apical vertebrae. The purpose of this investigation was to determine whether long-term brace treatment stimulated asymmetric chondrogenesis in the apical three vertebrae in patients with AIS. Three male and 38 female patients met the following inclusion criteria for the study: skeletal immaturity (Risser 0 or 1) at initial presentation, a major curve between 20 and 40 degrees, treatment consisting of a thoracolumbosacral orthosis, a minimum of 2 years of follow-up and documented skeletal maturity at final follow-up (Risser 5). Methods: Cobb angles and concave-to-convex height ratios of the apical three vertebral bodies were measured when bracing was indicated, in the brace, and after skeletal maturity. Measurements were compared by a repeated-measures analysis of variance statistic. Results: Cobb measurements improved 50% (p.0001) with the application of a brace. Immediate radiographic improvements were also measured in the cephalad (p.0027) and caudal (p.0004) apical height ratios when the brace was initially applied. On average, Cobb measurements increased six degrees after an average of 41 months of follow-up (p.001). Vertebral body remodeling by asymmetric chondrogenesis, as evidenced by changes in the concave-to-convex height ratios, were not appreciated. Conclusion: Application of a brace to patients with AIS resulted in immediate radiographic improvements in the Cobb measurements and concaveto-convex height ratios. Structural changes in vertebral body shape resulting from asymmetric chondrogenesis were not appreciated. Thus, the HueterVolkmann principle appears not to be applicable in patients with AIS with curves between 20 and 40 Cobb angle degrees treated with a brace. The Million Visual Analogue Scale: its utility for predicting outcomes after tertiary rehabilitation Tom Mayer, MD, Timothy Proctor, PhD, Robert J. Gatchel, PhD, Dallas, TX, USA Introduction: The Million Visual Analogue Scale (MVAS) [1] is a 15item visual analog measure of spinal pain disability. This instrument produces a total functional disability score ranging from 0 to 150. Like other “disability inventories,” such as the Oswestry and the Roland-Morris, the MVAS differs from a “pain inventory” in that the focus is on disability and function, as opposed to self-reported pain. The MVAS may be the strongest functional rating scale, because all questions relate to the patient’s ability to perform activities of daily living. In addition, this instrument has the advantage of a visual analog format, which is typically considered
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though initially rotation was weaker in one direction compared with the other. Once able to carry out 20 repetitions, the resistance was increased about 5%. Rotation range was increased as tolerated. Patients with surgical level of curves did not respond and were not followed. Results: Eighteen of 25 demonstrated curve reduction. Although there was some fluctuation, none of the rest had a persistent increase in curve. Pretraining average range was 28.2 13.2. Posttraining range was 23.0 14.1. The percentage improvement was 20% 23.3%. There was a 132.5% (61.4%) increase in dynamic strength. None went on to surgery or bracing. Discussion: Based on the demonstration of strength and asymmetry in rotation and inhibited lumbar extensor muscle activity, it is rational to place adolescents with scoliosis into a progressive resistance training program. In this small series, it offered notable benefit with documented control of curve progression. Parents were pleased that an active intervention was provided rather than “watch and wait” typical of presurgical adolescent scoliotic care. Lack of efficacy of exercise in previous studies may be because there was a lack of specific muscle training and measurement. No exercise program using equipment has previously been reported. Adolescent idiopathic scoliosis, bracing and the Hueter-Volkmann principle Frank P. Castro, MD, Amy Young, Richard T. Holt, MD, Mohammed E. Majd, MD, Louisville, KY, USA Purpose: Asymmetric chondrogenesis, in accordance with the HueterVolkmann principle, is frequently cited as a potential cause for adolescent idiopathic scoliosis (AIS). Brace treatment may reverse the abnormal forces across the apical vertebrae. The purpose of this investigation was to determine whether long-term brace treatment stimulated asymmetric chondrogenesis in the apical three vertebrae in patients with AIS. Three male and 38 female patients met the following inclusion criteria for the study: skeletal immaturity (Risser 0 or 1) at initial presentation, a major curve between 20 and 40 degrees, treatment consisting of a thoracolumbosacral orthosis, a minimum of 2 years of follow-up and documented skeletal maturity at final follow-up (Risser 5). Methods: Cobb angles and concave-to-convex height ratios of the apical three vertebral bodies were measured when bracing was indicated, in the brace, and after skeletal maturity. Measurements were compared by a repeated-measures analysis of variance statistic. Results: Cobb measurements improved 50% (p.0001) with the application of a brace. Immediate radiographic improvements were also measured in the cephalad (p.0027) and caudal (p.0004) apical height ratios when the brace was initially applied. On average, Cobb measurements increased six degrees after an average of 41 months of follow-up (p.001). Vertebral body remodeling by asymmetric chondrogenesis, as evidenced by changes in the concave-to-convex height ratios, were not appreciated. Conclusion: Application of a brace to patients with AIS resulted in immediate radiographic improvements in the Cobb measurements and concaveto-convex height ratios. Structural changes in vertebral body shape resulting from asymmetric chondrogenesis were not appreciated. Thus, the HueterVolkmann principle appears not to be applicable in patients with AIS with curves between 20 and 40 Cobb angle degrees treated with a brace. The Million Visual Analogue Scale: its utility for predicting outcomes after tertiary rehabilitation Tom Mayer, MD, Timothy Proctor, PhD, Robert J. Gatchel, PhD, Dallas, TX, USA Introduction: The Million Visual Analogue Scale (MVAS) [1] is a 15item visual analog measure of spinal pain disability. This instrument produces a total functional disability score ranging from 0 to 150. Like other “disability inventories,” such as the Oswestry and the Roland-Morris, the MVAS differs from a “pain inventory” in that the focus is on disability and function, as opposed to self-reported pain. The MVAS may be the strongest functional rating scale, because all questions relate to the patient’s ability to perform activities of daily living. In addition, this instrument has the advantage of a visual analog format, which is typically considered