REVIEW CONSERVATIVE TREATMENT ARTICLE FOR IDIOPATHIC SCOLIOSIS R. A. DICKSON Because idiopathic gress during subdivided thus infantile, ognised scoliosis commences juvenile (Goldstein year-old baby unquestionably and and with has a 60 infantile adolescent, idiopathic many that juvenile-onset 134 patients with tentatively classified think these worth (James 1954). (Mehta infancy idiopathic scoliosis, untreated and and early common for will be discussed IDIOPATHIC is the of course, disability, aim; of surgical scoliosis The I 76 1 Fig. 2 idiopathic scoliosis-a very serious condition producing compromise and horrendous deformity. Figure 1Figure 2-Close-up in the forward-bending position. SCOLIOSIS strategy this is the for treating upon the size of progression. If the then preservation place of conserva- management. needs treatment then keep it In order at all, to the of leaving it untreated must be known. It known that scoliosis can cause significant with economic implications (Dahlberg and R. A. Dickson, MA, ChM. FRCS, Professor and Head of Department ofOrthopaedic and Traumatic Surgery, The University Leeds St Jarness University Hospital, Leeds LS9 7TF, England. ( 1985 British Editorial Society of Bone and Joint Surgery 030l-620X Fig. Early-onset cardiopulmonary Erect. first. If the deformity is unacceptable, be to make it acceptable and so; this is the aim decide if idiopathic is, and he did not infantile group as the strategy for treatvery considerably between Treatment for the more late-onset case is more therefore treatment. tive management. the objective must consequences adolescent-onset certainly started there is no clear early-onset and late1950; Figs I to 4). The and the consequences of idiopathic scoliosis depends principally the deformity and its potential for deformity is acceptable at presentation, of acceptability child; is an Such cases may well be a hangover from 1977). There is much merit therefore in and need one- thoracic curve classification as ofjuvenile onset separating from the LATE-ONSET The rec- a idiopathic scoliosis exists. Of thoracic scoliosis, only I 6 were scoliosis, as well its efficacy, differ late-onset types. and more benign “standard” pro- are While difficult the older the girl with a 90 curve considering only two categories, onset (Ponseti and Friedman prevalence rate, natural history ment types 1973). she does not have scoliosis, as the deformity earlier. Furthermore, years may it has been (James 1954); adolescent Waugh becomes progressively more and although a 12-year-old evidence James’ and the period of spinal growth, according to when it begins 85/2013 S2.00 the of Fig. 3 Fig. Late-onset idiopathic Figure 3-Erect. Figure THE scoliosis-a 4-Close-up JOURNAL 4 problem of deformity in the forward-bending OF BONE AND JOINT only. position. SURGERY CONSERVATIVE Nachemson 1977), plications can (Nachemson and Ponseti cases; and thoracic and be that (Davies deformity Nachemson’s only. differently from The original by the age parenchyma there are this subject surgeon. 52 late-onset study of their organic deformity, deformity the psychological 1968; Bengtsson obvious selected idiopathic patients counterparts more than of As there treatment groups has never been a controlled trial its efficacy can only be deter- it against of the sources the little we know late-onset curve. of information. of children who of the There are Early studies presented to two of scoliosis programmes which (Brooks et al. 1975; et al. non-structural have included a longitudinal survey Rogala, Drummond and Gurr 1978; 1980; Dickson 1983). are excluded, curves When children with 10% show only evidence of progression, whereas twice as many improve and more than two-thirds remain static. The greatest progression potential is associated with the young girl who has a right thoracic curve, but she represents less than one in a thousand of those screened. The difference between the data from these two sources, although difficult to interpret (Leaver, Alvik and Warren 1982), a change to a more benign natural history, and this is supported by the observation that where a lot of screening has been performed the need for both conservative and operative management has been much less suggests (Lonstein el a!. 1982). Conservative then be set against this background. methods need to be discussed: electrospinal Brace While various 67-B. No. 2. MARCH 1985 contraptions used since for conservative brace (Blount for the the time of treatment and Schmidt technology 1980). for Although the the conservative scoliosis, 1972; Moe that the distraction Galante between the head and the 1969; Galante et al. 1970) action dentition refers Alexander or- 1974); placed al. 1976). a clear purpose studies exerting effects on A change on reduction problems and led to three-point emphasis ci Riolo priof pelvis (Schultz and and this modeof by the harmful (Alexander 1966). and approach (Andriacchi Without this brace was not management to the throat mould type ofbrace led to a great in the distraction force with no obvious dental biomechanical to it was soon used for that 1973). Early mechanical brace might function by was corroborated thereby produced a change fixation the in with localiser understanding of pad the three- dimensional nature of the deformity it would be tempting to think that the brace might work in the manner described, but this is not so. The primary deformity of idiopathic scoliosis is a lordosis at the curve apex 1882; Somerville 1983, 1984) and which produces ideal ofconservative 1952; Roaf it is rotation the secondary treatment 1966; Dickson al. ci of this lordosis to the side scoliotic deformity. An would then be to recreate the normal spinal shape in the sagittal plane; this, however, would imply flexion, which enhances rotation and produces an increase in the secondary scoliotic deformity. In contradistinction, the opposite deformity, the kyphosis of Scheuermann’s disease, is ideally suited to conservative management, because the deformity is rotationally stable and braces which cause spinal extension produce a true physiological correction of the deformity (Bradford ci al. 1974). The brace is capable, however, effect of producing in idiopathic obliteration a small scoliosis. of the lumbar temporary Blount stressed lordosis in the corrective the need brace for (Blount and Moe 1973) and this produces thoracic extension above. There is now more room for the thoracic lordosis to be accommodated with a derotation effect, but at the possible expense of increasing the primary lordosis (Winter, Lovell and Moe 1975; Figs 5 and 6). The other important effect of the brace pelvis in the erect position harmful effect of flexion. With this mode of action that the optimal measures exactly result the is to splint the spine which thus prevents it is not of brace wearing same at the end surprising to the the to find is when the curve of treatment as it did at the beginning (Keiser and Shuffiebarger 1976; Edmondson and Morris 1977; Mellencamp, Blount and Anderson 1977; Tolo and Gillespie 1978: Blount 1981). These stimulation. treatment. scoliotic spine have been Hippocrates. real enthusiasm started with the Milwaukee VoL. treatment should Three conservative bracing, casting and Newer (cervical-thoracic-lumbar-sacral idiopathic (Blount suggested particular the 1958). (Nash intended as clinics suggested a considerable progression potential if the onset was under 10 years of age or before the menarche (Risser and Ferguson 1936; Ponseti and Friedman 1950; James 1954; Heine and Reher 1975). More recent data come from those school screening Dickson Blount as a CTLSO (Northway, social and Lundgren opinion on that 1957; thosis) manly 177 SCOLIOSIS brace in no 1968). With regard that the bigger the greater the likelihood of implications (Nilsonne and ci’ al. 1974). The patient’s matters cases fared IDIOPATHIC (Adams history different quite 130 organic scoliosis, even if Israel and Hall and Leatherman is a problem of straight-backed by evaluating natural mortality of seven or eight is developing no health (Nachemson it is of course true clearly Natural history. of conservative mined com- and consequences of late-onset idiopathic the deformity exceeds 100 (Kostuik, 1973; Ponder ci al. 1975; Dickson 1976). Late-onset idiopathic scoliosis regards to the FOR 1968; Nilsonne and Lundgren 1968; Collis 1969). But this applies only to early-onset then only to severe ones, for example, a and Reid 1971). contradistinction In cardiopulmonary of morbidity curve of over 60 when the pulmonary years. the a source TREATMENT progressed treatment, attenuated, deformities studies also suggest that beyond 30 before the less satisfactorily as gravity and the more successfully the more the curve has the commencement of can curve progression be rigidity of the secondary defeat the intentions of 178 R. A. DICKSON Milwaukee Stanish brace 1977; (Park Winter a!. ci and Watts, 1977; Carlson 1977); Hall this flexion of these low curves can be prevented underarm brace, TLSO (thoracic-lumbar-sacral sis). But the other mode of action, and is because even by an ortho- obliteration of the lumbar lordosis, is more obvious and produces a bigger temporary corrective effect. There are no controlled trials with an underarm brace and the follow-up is much Fig. shorter than with a Milwaukee efficacy also is questionable, lighter weight and smaller size able to the patient. 5 Another problem growth. The when growth Fig. 6 The effect of obliteration of the lumbar lordosis. Figure 5-A thoracic deformity associated with a lumbar lordosis viewed from above. Figure 6-The same deformity viewed from above with the lumbar lordosis obliterated. Marked derotation has occurred. treatment. The best results of brace therefore achieved with smaller curves; history, however, demonstrates that very progressed if left untreated. treatment are their natural few would have and Copel I 95 1 ; Inkster Larsen and Nordentoft Recent studies when and Ponseti that the performed. on idiopathic programme of spinal Although exercises curves (Stone is prescribed for out of the programme brace lest the should not, flexion are not usually have no corrective effect ci a!. 1979), an exercise the one hour a day spent spine become unduly stiff; this however, include flexion exer- will undo what the brace has been trying to for the previous 23 hours. Set against the background of natural history there is no evidence that Milwaukee brace treatment alters the course of the scoliosis. This is a very serious matter, as cises as these achieve countless treatment brace numbers for no on diluted or no girls of children detectable with progressive may benefit. have endured If the effect thoracic curves by the inclusion ofcurves at other sites progression potential, then the lumbar obliterating ought to Cognisant and flexion-preventing prevent of this progression problem effect the (Dickson British Association and the British Scoliosis right to stress the need for carefully Society controlled of brace of the was not with little lordosisthe brace a!. 1984). Orthopaedic ci (1983) studies idiopathic scoliosis, preferably throughout life. It recently became apparent that low thoracic lumbar curves did not require the full superstructure are of and of a the duration of spinal the intra-uterine phase is during the adolescent further 10 years until the vertebral epiphyses are fused and that the vertebral apophyses have nothing whatever to do with spinal growth nor does their fusion indicate cessation ofgrowth (Bick, Copel and Spector 1950; Bick etal cycles concerns only period after velocity increases growth spurt, which is maximal at about the age of 12 years in girls and 14 in boys (Scammon 1927). While idiopathic curves are particularly liable to deteriorate during this phase, general skeletal maturity is reached two years later (Tanner 1962). The conventional time when the patient is weaned from the brace has been when the iliac crest and vertebral ring apophyses fuse (Risser and Ferguson 1936; James 1954; Risser 1964). It is well known, however, that spinal growth continues for a The brace is supposed to be worn for 23 hours out of 24, although it would appear to be unnecessary at night repeated brace; consequently their though of course their make them more accept- of idiopathic maturity majority do, in fact. ofcases curves and While of not general 1983; studies on it ought I 962; 1982). skel- progression Bjerkreim these pregnancy factor, beyond demonstrate (Hassan 1983). effect responsible I 95 1 ; Calvo 1957; Tupman 1962; Bernick and Caillet Weinstein have ligaments in the suggested might to be forgotten be a that, in young women, the spine is still growing. Even if there was evidence that the brace did prevent progression, treatment would need to be continued for much longer than the patient would tolerate. Cast management. The pioneers of the treatment of obtained correction by using plaster casts (Risser ci al. 1953; Risser 1955) and it was remarkable to what good use they put them (Moe and Valuska 1966). With the advent of the Milwaukee brace, enthusiasm for scoliosis plaster in the many not parts lose conservative of the their developed the as an alternative faith EDF treatment world. French in plaster rapidly surgeons, waned in however, did and have techniques (elongation-derotation-flexion) to brace treatment (Cotrel and cast Morel 1964). The function of this cast is precisely that brace, with obliteration of the lumbar lordosis elimination of spinal flexion as the two priorities. cast is worn for three or four months until its wear of the and Each or the patient’s patients growth indicates that a new one is required. The cannot bathe, but it is extraordinary how easy it is to change the inner vest and the underwear while the THE JOURNAL OF BONE AND JOINT SURGERY CONSERVATIVE is in place. cast the concave anteriorly; pressure Furthermore, the cast TREATMENT has a window side posteriorly and one on the these facilitate derotation exercises pads or balloons to be inserted rotational treatment prominences. is to finish Since up with the object the least FOR on convex side and allow over the of conservative deformed torso, well to compare their end-results although, as with the majority of questions, the answer has never been by a controlled study. Between casts a proof non-skeletal traction and exercises is carried interesting out (Cotrel and D’Amore 1968). This however, in terms of curve correction Nordwell 1977; Dickson and Leatherman traction of its kind ofany provides any magnitude, natural range Glasgow of no real is of no (Nachemson 1978). benefit, and Indeed, correction of curves only moving each flexibility (Edgar, curve through Chapman and Recently, has 1982). Electrospinal directed scoliosis stimulation. been of the muscula- attention towards obtaining temporary correction by electrical stimulation of the spinal 1980). 179 SCOLIOSIS Here progression potential It was first thought that into two types-progressive upon the size of the (RVAD; “bracers” would do with French “casters” elucidated gramme IDIOPATHIC however, progressive, RVAD and three static and ofless and 1972). Mehta confidently diagnoses excess of 20 or one angle The is picture then reduces small curves (Mehta a definite progression The serious most hypotonic, has been (Mehta so clear, an in magnitude resolving curve, an RVAD in is increasing does not necess- a progressive curve. Other Thoracic and thoracolumbar initial difference not are now recognised(Mehta 1977). While which the that be divided resolving-depending arily imply important. 1980) tend to resolve, relevant. could rib-vertebra types resolving 20 than is particularly the condition 1977; while Thompson double potential factors and structural progression have a!. ci appears Bentley curves (Ceballos low birth weight baby referred to as “malignant” also are curves and 1980). to occur in the in whom the condition idiopathic scoliosis 1977). A very interesting trend has emerged over last the 35 ture on the convexity of the curve (Bobechko 1974). Like the development oforthotic and cast treatment, electrical stimulation focuses on the secondary coronal-plane years. Early reports indicated a great preponderance of the progressive type of curve (James 195 1 ; Scott and Morgan 1955; James ci a!. 1959), but this situation then changed dramatically and the last 20 years has seen a deformity marked range of stemmed and only elasticity. from moves the Furthermore, the belief basis to the substantiated deformity, (Dickson The that fact bends to mild been demonstrated (Bobechko, Herbert enjoys, follows 1 983). primary tive trical to be curvatures in then resumes the in curve magnitude muscle 1979); surface to with the deformity, kyphotic stimulation permanent can, like erect has stimulation this demon- the uniplanar however, brace (Axelgaard, correction and elec- or cast, give Brown and 1982). Natural history. IDIOPATHIC This fascinating Holland (Harrenstein birth to three years commonly than frequently Roberts girls condition, 1929), of age. and SCOLIOSIS Wynne-Davies No. 2. MARCH 1975; 1985 first reported tends to affect children Boys are affected more thoracic curves convex to the left (James 1951; and Pilcher 1959; Lloyd-Roberts 67-B, incidence declined Thompson are more James, and LloydPilcher and Bentley of the (Lloyd-Roberts and Bentley proportions with and Pilcher 1980; Ceballos of these infantile and the condition 90% 1965; ci a!. or more Mau 1968; 1980). The curves also has is now rare; whether rapidly or not this decline is due to prone lying in the cot is unclear (McMaster 1983). These changes in the natural history of early-onset progressive idiopathic scoliosis are very welcome, as these are the curves associated with serious cardiopulmonary develop horrifying Conservative curves were disease at an deformities. early age, and they also treatment. When malignant progressive more common, treatment presented great problems. Progression potential was far too great to be attenuated by a Milwaukee brace (James ci a!. 1959), but posterior fusion was withheld for as long as possible in order to avoid increasing the primary lordosis; meanwhile the deformity progressed inexorably in the brace. By the time posterior fusion was performed, the deformity was often too far advanced for treatment; moreover, there is no clear evidence that fusion reduced the rate of subsequent McMaster Unlike EARLY-ONSET VOL. and treatment; stable Swank 1965: coronal-plane during convex and Friedman conservative rotationally from from a neuromuscular is unlikely reversal resolving Thompson the innate flexibility that the mild idiopathic curve but there is no evidence that any real correction electrospinal stimulation (Axelgaard and Brown Again it is the rotationally unstable nature of the lordotic deformity which militates against effec- strates rise was its natural stimulation by stimulating muscles on one Monticelli ci a!. 1975; Bobechko, 1976) is not surprising. This is when someone with a straight one side improvement Some position. there a belief which ci a!. 1984). animals can be produced side (Olsen ci a!. 1975; Herbert and Friedman precisely what happens spine that spine within electrical progression and Macnicol late-onset (Letts 1979). deformities and there Bobechko is some 1974; evidence that early-onset idiopathic scoliosis can be treated conservatively. Mehta, who has contributed much to our knowledge of infantile idiopathic scoliosis, recognised early the bad prognosis associated with the hypotonic infant, and the moment she saw such a child she applied an elongation-rotation-flexion (EDF) cast (Mehta and Morel 1979). Surprisingly. the occasional case that had all the ingredients for rapid progression appeared to become static, or even to resolve, and the RVAD became 180 R. smaller or did not increase. This perhaps A. DICKSON Browne demonstrates of obliteration of the lumbar lordosis and the of flexion in these very supple spines; but the cast must also have allowed the thoracic spine to become naturally kyphotic in those that subsequently resolved. There are, clearly, two important aspects of the conservative prevention management and casting. to whether the deformity (Browne 1936) prone lying must be infant does an delay is due upon, particularly 1983). idiopathic serial (Mehta For all should the that Collis Cotrel of without and treatment oflateral London: J & A Churchill Alexander RG. The effects on tooth position growth during treatment of scoliosis Ani J Orthod 1966:52: 161-89. RA. Dickson RA, Lawton Dickson vertical brace. Axelgaard surface electrical idiopathic surface scoliosis. stimulation Spine S. human Bick Caillet R. vertebrae. EM, Copel Swank Orthop SM. Kyphosis Trans 1982:6:1. EM, Vertebral end-plate Spine 1982;7(2):97-102. JW. Contribution to 1951 :33-A:783-7. Bick Copel The treatment WP. 1958:19: WP. Blount for the 1983;8(3): WP. scoliosis. Blount WP, Wilkins, Blount human E. Surg [Am] In: Zorab PA, ed. scoliosis: causation. 1968:37-43. dans Ia correction spinal KD. Joint Surg des cohort alveoli Dis J 1983:286:615-8. asymmetry. Spinal [Am] J Bone deformity l976:58-A:729. traction, a pilot trial. scoliosis: clinical P, Sharp A-M, study clinical of Harker and Child The pathogenesis IA, et a!. Combined the essential lesion [Br] 1983:65-B:368. KD. Cotrel idiopathic controlled RA, Stamper of Arch Archer Leatherman J Bone Br Med IA, Butt WP. Biplanar JO, JW, Use of Edgar MA, Chapman by electrical adolescent 64-B: 530-5. of female of Joint of Surg median and idiopathic in adults: changing exercises, casting in the study and prospective Aeta Orthop Scand P. School course. Br screening for J 1980:281: Med with aging of the Galante of the J Bone human Joint Spector growth of osteogeny. J Bone to human and the Milwaukee brace. Bull Joint brace. Orthop Clin North WP, The virtue of early treatment Joint Surg [Am] 198 I:63-A:335-6. Moe JH. 1973. Schmidt The AC. J Bom’ Milwaukee The Joint Surg brace. of Harrenstein Dis Milwaukee brace [Am] I957;39-A:693. ischen 87-96. idiopathic Orthopaedic screening for HL, Azen prospective 1975 :57-A in the SP, Gerberg E, Brooks study. treatment Society. of Bone James James I. Progression Reher Acta H. Die bis Skoliose JIP, RP, Keiser Surg Kostuik Brash JC, London: ed. GC, Shufflebarger HL. evaluation 19-24. of structural Pilcher MF. The Milwaukee completed brace cases. surgery J Bone and operative at onset. J Bone Infantile 1959:41-B:719-35. JP, Israel J, Hall JE. Scoliosis idiopath1975:113: scoliosis. diagnosis the age [Br] 123 conser- Cunningham’s text-hook of Oxford University Press. the prognosis. patterns and Surg after unbehandelten 7 Orthop patterns in idiopathic [Br] 1951 :33-B:399-406. Joint Behandlung. structural in idiopathic Cliii Orthop in adults. Clin Orthop 1973 :93: 225-34. 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