Research into Spinal Deformities 6

RESEARCH INTO SPINAL DEFORMITIES 6 Studies in Health Technology and Informatics This book series was started in 1990 t...

Author: P. Dangerfield

122 downloads 1080 Views 12MB Size Report

This content was uploaded by our users and we assume good faith they have the permission to share this book. If you own the copyright to this book and it is wrongfully on our website, we offer a simple DMCA procedure to remove your content from our site. Start by pressing the button below!

Report copyright / DMCA form

DOWNLOAD PDF

RESEARCH INTO SPINAL DEFORMITIES 6

Studies in Health Technology and Informatics This book series was started in 1990 to promote research conducted under the auspices of the EC programmes’ Advanced Informatics in Medicine (AIM) and Biomedical and Health Research (BHR) bioengineering branch. A driving aspect of international health informatics is that telecommunication technology, rehabilitative technology, intelligent home technology and many other components are moving together and form one integrated world of information and communication media. The complete series has been accepted in Medline. Volumes from 2005 onwards are available online. Series Editors: Dr. J.P. Christensen, Prof. G. de Moor, Prof. A. Famili, Prof. A. Hasman, Prof. L. Hunter, Dr. I. Iakovidis, Dr. Z. Kolitsi, Mr. O. Le Dour, Dr. A. Lymberis, Prof. P.F. Niederer, Prof. A. Pedotti, Prof. O. Rienhoff, Prof. F.H. Roger France, Dr. N. Rossing, Prof. N. Saranummi, Dr. E.R. Siegel, Dr. P. Wilson, Prof. E.J.S. Hovenga, Prof. M.A. Musen and Prof. J. Mantas

Volume 140 Recently published in this series Vol. 139. A. ten Teije, S. Miksch and P. Lucas (Eds.), Computer-based Medical Guidelines and Protocols: A Primer and Current Trends Vol. 138. T. Solomonides et al. (Eds.), Global Healthgrid: e-Science Meets Biomedical Informatics – Proceedings of HealthGrid 2008 Vol. 137. L. Bos, B. Blobel, A. Marsh and D. Carroll (Eds.), Medical and Care Compunetics 5 Vol. 136. S.K. Andersen, G.O. Klein, S. Schulz, J. Aarts and M.C. Mazzoleni (Eds.), eHealth Beyond the Horizon – Get IT There – Proceedings of MIE2008 – The XXIst International Congress of the European Federation for Medical Informatics Vol. 135. T.B. Grivas (Ed.), The Conservative Scoliosis Treatment – 1st SOSORT Instructional Course Lectures Book Vol. 134. B. Blobel, P. Pharow and M. Nerlich (Eds.), eHealth: Combining Health Telematics, Telemedicine, Biomedical Engineering and Bioinformatics to the Edge – Global Experts Summit Textbook Vol. 133. J. Hammer, M. Nerlich and S. Dendorfer (Eds.), Medicine Meets Engineering – Proceedings of the 2nd Conference on Applied Biomechanics Regensburg Vol. 132. J.D. Westwood, R.S. Haluck, H.M. Hoffman, G.T. Mogel, R. Phillips, R.A. Robb and K.G. Vosburgh (Eds.), Medicine Meets Virtual Reality 16 – parallel, combinatorial, convergent: NextMed by Design Vol. 131. R. Latifi (Ed.), Current Principles and Practices of Telemedicine and e-Health

ISSN 0926-9630

Research into Spinal Deformities 6

Edited by

Peter H. Dangerfield The University of Liverpool, Royal Liverpool Children’s Hospital, Liverpool and Staffordshire University, Stoke on Trent, UK

Amsterdam • Berlin • Oxford • Tokyo • Washington, DC

© 2008 The authors and IOS Press. All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without prior written permission from the publisher. ISBN 978-1-58603-888-5 Library of Congress Control Number: 2008929935 Publisher IOS Press Nieuwe Hemweg 6B 1013 BG Amsterdam Netherlands fax: +31 20 687 0019 e-mail: [email protected] Distributor in the UK and Ireland Gazelle Books Services Ltd. White Cross Mills Hightown Lancaster LA1 4XS United Kingdom fax: +44 1524 63232 e-mail: [email protected]

Distributor in the USA and Canada IOS Press, Inc. 4502 Rachael Manor Drive Fairfax, VA 22032 USA fax: +1 703 323 3668 e-mail: [email protected]

LEGAL NOTICE The publisher is not responsible for the use which might be made of the following information. PRINTED IN THE NETHERLANDS

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved.

v

Preface The International Research Society for Spinal Deformities (IRSSD) was founded in 1994. The first concepts of forming the Society were raised by a group of researchers who had first gathered in Vermont in 1980 to hold what subsequently became a series of biennial meetings devoted to surface topography and deformity. At a meeting held in 1992 in Montreal, focussed on 3 dimensional interpretations of spinal deformities, discussions were held into whether a formal Society should be formed, and while debate rejected this concept at the time, it was two years later at a meeting in Pescara, Italy 1994 that the IRSSD finally came into being. The Society has its roots in mathematical modelling, biomechanics and medical research and has always encouraged researchers to report their on-going projects in all aspects of the spinal deformities associated with scoliosis and other spinal deformity conditions. The biomechanical approach led to a better understanding of how the vertebral column behaves under stresses and how the surface shape related to the underlying columnar deformity. Developments in imaging and electronics allowed researchers to develop systems such as ISIS as a non-invasive method of recording back shape in out patient clinics as well as a tool for researchers. Biologically based studies were also reported. It was appreciated early on by the membership that children with scoliosis have a range of growth disturbances associated with a marked skeletal asymmetry. While the biological approach has enabled a considerable amount of data to be amassed which relates to etiology and pathogenesis, no actual breakthrough into fully understanding why the spinal column rotates and curves to cause scoliosis has yet occurred. The biennial meetings of the Society chart this research progress in each of the volumes of proceedings, with some reports being final papers while others are progress reports. This is a unique resource for the researcher, holding the key to many different aspects of the problems of the spine. However, some authors choose not to submit to the volumes as they are publishing elsewhere in peer-reviewed Journals, a trend which is inevitably going to challenge the way conference proceedings are reported in the future. There is therefore a challenge to the IRSSD to find an answer to this issue. 2008 could be viewed as a time of potentially exciting breakthroughs in our understanding of the deformity of scoliosis. The rapid advances in imaging technology will allow better and more detailed images of the spine, both on its surface and deeper internally, using techniques such as Laser scanning, Magnetic Resonance Imaging and ultrasound. There is little doubt these technologies are going to advance massively, new ones will come into the hands of clinicians and researchers and a better understanding of the complex functional anatomy of the spine will be developed. This will undoubtedly aid biomechanicians to model the spine and its function, under gravity and movement, allowing new insight into progressions of curves and ways to surgically control deformities. However, it is probably the potential of biology and medical research which offer the greatest opportunities to further our understanding. The incredible advances at the molecular level, the expanding knowledge of genetics and the recent discoveries in the field of neurophysiology offer for the first time real potential for unravelling the puz-

vi

zles of etiology. The discovery of molecular biochemical pathways, signalling agents, hormones such as leptin, genetic markers and a greater appreciation of the role of the nervous systems, both central, peripheral and autonomic, all indicate that the research field could expand dramatically with new ideas and inputs from research workers in fields outside the traditional ones devoted to the spine. It is thus clear that to find a solution, we must build on these new developments and look beyond the spine to the whole body to discover if its biological functions are disturbed. A growing child is a dynamic environment internally, with rapid growth changes reflected in adolescence and these are known to result in tall, thin and asymmetrical children. These changes point to a whole body biological involvement. Researchers must reflect on this totality since it must ultimately allow us to explain the etiology and pathology of what are probably going to prove to be secondary events manifest as spinal curvatures. These are exciting times and I hope the participants in the Liverpool meeting in 2008 will look back on it as a watershed in our understanding of the spinal deformities. Let’s hope this is true, since a therapeutic intervention must surely be better than surgery or external bracing from the purely psychological, if not cosmetic, view of a growing child. I would like to thanks all participants and authors for submitting their work to the meeting and to my colleagues Professor Nachi Chockalingam, Mr. Ashley Cole and Mr. El-Nasri Ahmed, for their help and support and to our sponsors who supported the meeting in Liverpool, European Capital of Culture 2008. Peter Dangerfield Liverpool, UK April 2008

vii

Contents Preface Peter Dangerfield

v

Chapter 1. Genetics Cytogenic Abnormalities in Buccal Cells During Spinal Deformities in Children M.Y. Karganov, M.I. Kozhevnikva, A.V. Aleschenko, N.N. Khlebnikova, I.B. Alchinova, I.I. Pelevina, A.M. Serebranyi, K.S. Ternovoy and L.A. Noskin

3

Chapter 2. Growth Body Mass Index of Girls in Health Influences Menarche and Skeletal Maturation: A Leptin-Sympathetic Nervous System Focus on the Trunk with Hypothalamic Asymmetric Dysfunction in the Pathogenesis of Adolescent Idiopathic Scoliosis? R.G. Burwell, R.K. Aujla, A.S. Kirby, P.H. Dangerfield, A. Moulton, A.A. Cole, F.J. Polak, R.K. Pratt and J.K. Webb Volumetric Thoracic Growth in Children with Moderate and Severe Scoliosis Compared to Subjects Without Spinal Deformity Y.P. Charles, A. Dimeglio, M. Marcoul, J.-F. Bourgin, A. Marcoul and M.-C. Bozonnat Back Trunk Morphology in 3301 Children Aged 3–9 Years Old T.B. Grivas, E.S. Vasiliadis, C. Mihas, C. Maziotou and G. Triandafyllopoulos The Role of the Intervertebral Disc in Correction of Scoliotic Curves. A Theoretical Model of Idiopathic Scoliosis Pathogenesis T.B. Grivas, E.S. Vasiliadis, G. Rodopoulos and N. Bardakos Ultrasound Femoral Anteversion (FAV) Relative to Tibial Torsion (TT) is Abnormal After School Screening for Adolescent Idiopathic Scoliosis (AIS): Evaluation by Two Methods R.G. Burwell, R.K. Aujla, A.S. Kirby, A. Moulton, P.H. Dangerfield, B.J.C. Freeman, A.A. Cole, F.J. Polak, R.K. Pratt and J.K. Webb Risser Sign: The Value of the Lateral Spinal Radiograph to Assess the Excursion of the Iliac Apophysis T. Kotwicki Stature and Growth Compensation for Spinal Curvature I.A.F. Stokes Clinical Detectable Tension in the Growing Body: New and Revisited Signs in Clinical Examination in Children with Postural Problems and Spinal Deformities P.J.M. van Loon

9

22

29

33

37

44 48

52

Chapter 3. Biomechanics, Surface Topography and Imaging Quantification of Intervertebral Efforts During Walking: Comparison Between a Healthy and a Scoliotic Subject M. Raison, C.-É. Aubin, C. Detrembleur, P. Fisette and J.-C. Samin

61

viii

Measuring the Rib Hump in Scoliosis with ISIS2 F. Berryman, P. Pynsent and J. Fairbank Thoracic Kyphosis Angle Measurements with ISIS2 F. Berryman, P. Pynsent and J. Fairbank Sagittal Alignment Correction of the Thoracolumbar Junction in Idiopathic Scoliosis by in Situ Bending Technique Y.P. Charles, N. Meyer and J.-P. Steib A 3-D Skeleton Model & SEMG Approach for Integrated Neck and Low Back Pain Analysis Test Batteries M. D’Amico, G. D’Amico, M. Frascarello, M. Paniccia, P. Roncoletta and M. Vallasciani Analysis of the Mechanisms of Idiopathic Scoliosis Progression Using Finite Element Simulation X. Drevelle, J. Dubousset, Y. Lafon, E. Ebermeyer and W. Skalli The Relationship Between Hip Flexion/Extension and the Sagittal Curves of the Spine C. Driscoll, C.-E. Aubin, H. Labelle and J. Dansereau Constrained Intensity-Based Image Registration: Application to Aligning Human Back Images A.S. Elsafi, N.G. Durdle and J.V. Raso Ergonomically Designed Kneeling Chairs Are They Worth It?: Comparison of Sagittal Lumbar Curvature in Two Different Seating Postures J. Bettany-Saltikov, J. Warren and M. Jobson Faulty Posture and Style of Life in Young Adults A. Czakwari, K. Czernicki and J. Durmala Finite Element Modeling of Vertebral Body Stapling Applied for the Correction of Idiopathic Scoliosis: Preliminary Results N.M. Lalonde, C.-É. Aubin, R. Pannetier and I. Villemure Influence of Correction Objectives on the Optimal Scoliosis Instrumentation Strategy: A Preliminary Study Y. Majdouline, C.-É. Aubin and H. Labelle Development of an Apparatus to Evaluate Adolescent Idiopathic Scoliosis by Dynamic Surface Topography T.M.L. Shannon Biomechanical Modelling of a Direct Vertebral Translation Instrumentation System: Preliminary Results X. Wang, C.-É. Aubin, H. Labelle and D. Crandall SpineCor vs. Natural History – Explanation of the Results Obtained Using a Simple Biomechanical Model H.-R. Weiss Comparison of the Kyphosis Angle Evaluated by Video Rasterstereography (VRS) with X-Ray Measurements H.-R. Weiss and N. Elobeidi Postural Changes in Patients with Scoliosis in Different Postural Positions Revealed by Surface Topography K. Schumann, I. Püschel, A. Maier-Hennes and H.-R. Weiss Quantification of Localized Vertebral Deformities Using a Sparse Wavelet-Based Shape Model R. Zewail, A. Elsafi and N. Durdle

65 68

72

79

85

90

96

103 107

111

116

121

128

133

137

140

144

ix

Computer-Assisted Cobb Angle Measurement on Posteroanterior Radiographs J. Zhang, E. Lou, L.H. Le, D. Hill, J. Raso and Y. Wang New Method of Scoliosis Deformity Assessment: ISIS2 System A. Zubović, N. Davies, F. Berryman, P. Pynsent, N. Quraishi, C. Lavy, G. Bowden, J. Wilson-MacDonald and J. Fairbank A Novel Solution for Registration of Stereo Digital Torso Images of Scoliosis Patients A. Kumar, N. Durdle and J. Raso Marker Placement for Movement Analysis in Scoliotic Patients: A Critical Analysis of Existing Systems N. Chockalingam, T.L. Chevalier, M.K. Young and P.H. Dangerfield The Central Cord-Nervous Roots Complex and the Formation and Deformation of the Spine; The Scientific Work on Systematic Body Growth by Milan Roth of Brno (1926–2006) P.J.M. van Loon and L.W. van Rhijn

151 157

161

166

170

Chapter 4. Etiology Leg-Arm Length Ratios Correlate with Severity of Apical Vertebral Rotation in Girls After School Screening for Adolescent Idiopathic Scoliosis (AIS): A Dynamic Pathomechanism in the Initiation of the Deformity? R.G. Burwell, R.K. Aujla, A.S. Kirby, P.H. Dangerfield, A. Moulton, B.J.C. Freeman, A.A. Cole, F.J. Polak, R.K. Pratt and J.K. Webb New Clinical Observations Connected with “Biomechanical Aetiology of so Called Idiopathic Scoliosis” (2006–2007) T. Karski Etiologic Theories of Idiopathic Scoliosis: Autonomic Nervous System and the Leptin-Sympathetic Nervous System Concept for the Pathogenesis of Adolescent Idiopathic Scoliosis R.G. Burwell, P.H. Dangerfield, A. Moulton and S.I. Anderson Etiologic Theories of Idiopathic Scoliosis. Somatic Nervous System and the NOTOM Escalator Concept as One Component in the Pathogenesis of Adolescent Idiopathic Scoliosis R.G. Burwell, P.H. Dangerfield and B.J.C. Freeman

189

194

197

208

Chapter 5. Screening and Prevention of Scoliosis Carrying a Rucksack on Either Shoulder or the Back, Does It Matter? Load Induced Functional Scoliosis in “Normal” Young Subjects J. Bettany-Saltikov, J. Warren and M. Stamp Ultrasound Femoral Anteversion (FAV) and Tibial Torsion (TT) After School Screening for Adolescent Idiopathic Scoliosis (AIS) R.G. Burwell, R.K. Aujla, A.S. Kirby, A. Moulton, P.H. Dangerfield, B.J.C. Freeman, A.A. Cole, F.J. Polak, R.K. Pratt and J.K. Webb Positional Relationship Between Leg Rotation and Lumbar Spine During Quiet Standing N. Parker, A. Greenhalgh, N. Chockalingam and P.H. Dangerfield

221

225

231

x

Aetiology of Idiopathic Scoliosis. What Have We Learned from School Screening? T.B. Grivas, E.S. Vasiliadis and G. Rodopoulos Suggestions for Improvement of School Screening for Idiopathic Scoliosis T.B. Grivas, E.S. Vasiliadis and J.P. O’Brien Can Future Back Pain in AIS Subjects Be Predicted During Adolescence from the Severity of the Deformity? D. Hill, E. Parent, E. Lou and J. Mahood A Machine Learning Approach to Assess Changes in Scoliosis L. Ramirez, N.G. Durdle and V.J. Raso

240 245

249 254

Chapter 6. Mathematical Modelling The Posterior Skeletal Thorax: Rib-Vertebral Angle and Axial Vertebral Rotation Asymmetries in Adolescent Idiopathic Scoliosis 263 R.G. Burwell, R.K. Aujla, B.J.C. Freeman, P.H. Dangerfield, A.A. Cole, A.S. Kirby, F.J. Polak, R.K. Pratt and A. Moulton Prediction of the T2-T12 Kyphosis in Adolescent Idiopathic Scoliosis Using a Multivariate Regression Model 269 S. Kadoury, F. Cheriet and H. Labelle Intervertebral Disc Changes in an Animal Model Representing Altered Mechanics in Scoliosis 273 I.A.F. Stokes, C.A. McBride and D.D. Aronsson Chapter 7. Education Knowledge About Idiopathic Scoliosis Among Students of Physiotherapy D. Ciazynski, K. Czernicki and J. Durmala

281

Chapter 8. Treatment of Scoliosis Thoracoplasty in the Surgical Treatment of Adolescent Idiopathic Scoliosis T. Greggi, G. Bakaloudis, F. Lolli, M. Di Silvestre, A. Cioni, S. Giacomini, G. Barbanti Brodano, F. Vommaro, K. Martikos and P. Parisini Preliminary Validation of Curve Progression Model for Brace Treatment E. Lou, D. Hill, E. Parent, J. Raso, J. Mahood, M. Moreau and D. Hedden BRACE MAP, a Proposal for a New Classification of Braces S. Negrini, F. Zaina and S. Atanasio Clinical and Postural Behaviour of Scoliosis During Daily Brace Weaning Hours S. Negrini, C. Fusco, M. Romano, F. Zaina and S. Atanasio Do Imbalance Situations Stimulate a Spinal Straightening Reflex in Patient with Adolescent Idiopathic Scoliosis? M. Romano, V. Ziliani, S. Atanasio, F. Zaina and S. Negrini Congenital Scoliosis – Presentation of Three Severe Cases Treated Conservatively H.-R. Weiss Conservative Scoliosis Treatment in Patients with Prader-Willi Syndrome H.-R. Weiss and S. Bohr

289

294 299 303

307

310 314

xi

Chapter 9. Abstracts FBN3 Gene Polymorphisms in Adolescent Idiopathic Scoliosis Patients Xing-bing Cao, Yong Qiu, Xu-sheng Qiu, Zhi-jun Chen, Hai-ou Chen and Wen-jun Chen Investigation on the Association Between Estrogen β Receptor Gene Polymorphisms and the Susceptibility of Adolescent Idiopathic Scoliosis Hai-ou Chen, Zhi-jun Chen, Yong Qiu, Xu-sheng Qiu, Xing-bing Cao, Zhen Liu and Wei-guo Li Vitamin D Receptor Gene Polymorphisms: No Association with Low Bone Mineral Density in Adolescent Idiopathic Scoliosis Girls Wen-Jun Chen, Yong Qiu, Xing-Bing Cao, Xu-Sheng Qiu, Zhi-Jun Chen and Hai-Ou Chen Expression and Significance of Sox9 in Chondrocyte Cells from Adolescent Idiopathic Scoliosis Patients A. Huang, Y. Qiu and G. Sun Promoter Polymorphism of Matrilin-1 Gene (MATN1) Is Associated with Susceptibility to Adolescent Idiopathic Scoliosis: A Case-Control Study Y. Qiu, Z. Chen, N.L.-S. Tang and J.C.-Y. Cheng Left-Right Asymmetry Gene Expression Domains Are Reversed in Adolescent Idiopathic Scoliosis A. Moreau, B. Azeddine, D.S. Wang, H. Labelle, B. Poitras, C.-H. Rivard, G. Grimard, J. Ouellet and S. Parent SNPs Analysis of CHD7 Gene and Idiopathic Scoliosis (IS) in Chinese N.L. Tang, H.Y. Yeung, H. Fan, R. Kwok, V.W. Hung, K.M. Lee, T.P. Lam, B.W. Ng, Y. Qiu and J.C. Cheng Collagen I Alpha 2 Gene Polymorphism Association Study in Adolescent Idiopathic Scoliosis H.Y. Yeung, N.L. Tang, V.W.Y. Hung, R. Kwok, K.M. Lee, L. Qin, B.K.W. Ng and J.C.Y. Cheng A Genetic Model for Studying the Etiopathogenesis of Late-Onset Idiopathic Scoliosis N.L.S. Tang, H.Y. Yeung, K.M. Lee, X. Qiu, Y. Qiu and J.C.Y. Cheng Physical Exercises and Adolescent Idiopathic Scoliosis: Results of a Comprehensive Systematic Review of the Literature M. Romano, C. Fusco, S. Minozzi, S. Atanasio, F. Zaina and S. Negrini Identification of SRS 22r Domains Using Factor Analysis Methodology D.C. Burton, S.M. Lai and M.A. Asher Variations of Semicircular Canals Orientation and Left-Right Asymmetry in Adolescent Idiopathic Scoliosis (AIS) Comparing with Normal Controls: MR Morphometry Study Using Advanced Image Computation Techniques W.C.W. Chu, L. Shi, D. Wang, T. Paus, R.G. Burwell, G.C.W. Man, A. Cheng, H.Y. Yeung, K.M. Lee, P.A. Heng and J.C.Y. Cheng The SRS Outcome Questionnaire Can Discriminate Between Patients with Spondylolisthesis and Normal Healthy Adolescents S. Parent, J. Joncas, M. Roy-Beaudry, M. Beausejour, G. Grimard, M. Forcier and H. Labelle

321

322

323

324

325

326

327

328

330

331 332

333

334

xii

The Use of a Decision Tree Increases Accuracy when Classifying Adolescent Idiopathic Scoliosis Using Lenke Classification P. Phan, N. Mezghani, S. Parent, J.A. de Guise and H. Labelle Are There Sub-Types in Lenke-1 Curves? A.P. Sangole, C.-E. Aubin, I.A.S. Stokes and H. Labelle Posterior Instrumented Scoliosis Correction in Thoracic Late Onset Idiopathic Scoliosis: Two Year Results A.A. Cole, S.A. Qaimkhani, S. Sharma, B. Naylor, C. Hughes, L.M. Breakwell and D.L. Douglas Can Surgical Reduction Correct Spino-Pelvic Alignment in L5-S1 Developmental Spondylolisthesis? H. Labelle, P. Roussouly, D. Chopin, E. Berthonnaud, T. Hresko and M. O’Brien The Relationship Between Pelvic Balance and a Dome-Shaped Sacrum in Developmental Spondylolisthesis H. Labelle, P. Roussouly, É. Berthonnaud, S. Hu and C. Brown A Historical and Observational Study to Expose Some Etiopathogenetic Factors that May Be Relevant to Adolescent Idiopathic Scoliosis (AIS) in Some Patients M.E. McMaster French-Canadian Validation of the Spinal Appearance Questionnaire (SAQ) in the Adolescent Patients at a Scoliosis Clinic and Its Clinical Application S. Parent, M. Roy-Beaudry, J. Joncas, M. Beauséjour, M. Forcier, S. Bekhiche, G. Grimard and H. Labelle An Energy-Based Mechanobiological Growth Model for Simulating Vertebral Progressive Deformities Under Multi-Direction Loads H. Lin, C.-É. Aubin, I. Villemure and S. Parent US and European Risser Grading Systems: Which One Best Predict the Curve Acceleration Phase in Adolescent Idiopathic Scoliosis? M.L. Nault, S. Parent, H. Labelle, M. Roy-Beaudry and M. Rivard Decreased Lean Mass in Adolescent Idiopathic Scoliosis Weiguo Li and Yong Qiu The Relationship Between RANKL/OPG and the Decreased Bone Mass in Adolescent Idiopathic Scoliosis Patients Z. Liu, Y. Qiu, B. Wang, W. Ma, F. Zhu, Z. Zhu, Y. Yu and B. Qian Association Between Growth Hormone Gene and Adolescent Idiopathic Scoliosis Xu-Sheng Qiu, Nelson Leung-Sang Tang, Hiu-Yen Yeung, Jack Chun-Yiu Cheng and Yong Qiu Expression of Melatonin Receptor in Chondrocyte of Adolescent Idiopathic Scoliosis Guangquan Sun, Weijun Wang, Aibing Huang, Jack Chun-Yiu Cheng and Yong Qiu mRNA Expressions of Type I Collagen, Osteocalcin and Osteoprotegerin in Iliac Cancellous Bone from Girls with Adolescent Idiopathic Scoliosis Xu Sun, Yong Qiu, Weiguo Li, Bin Wang, Weiwei Ma, Feng Zhu, Zezhang Zhu, Yang Yu and Bangping Qian Expression of Runx2 and Type X Collagen in Human Vertebral Growth Plate of Adolescent Idiopathic Scoliosis Shoufeng Wang, Yong Qiu, Weiguo Li, Bin Wang, Weiwei Ma, Feng Zhu, Zezhang Zhu, Yang Yu and Bangping Qian

335 336

337

338

339

340

341

342

343 344

345 346

347

348

349

xiii

Is Corticospinal Tract Organization Different in Idiopathic Scoliosis? D. Mihaila and B. Calancie Effects of in vivo Mechanical Loading on Extracellular Matrix Components of the Growth Plate M. Cancel, I. Villemure, F. Moldovan and G. Grimard Transverse Plane Pelvic Rotation Following Rotationally Corrective Instrumentation of Adolescent Idiopathic Scoliosis Double Curves M.A. Asher, D.C. Burton, S.M. Lai, J.L. Gum and B. Carlson A Multivariate Regression Model for Predicting the T2-T12 Kyphosis in Adolescent Idiopathic Scoliosis S. Kadoury, F. Cheriet and H. Labelle Poor Bone Mechanical and Structural Properties in 528 AIS Patients – Using Non-Invasive Quantitative Ultrasound V.W.Y. Hung, L. Qin, H.Y. Yeung, W.T.K. Lee, K.M. Lee and J.C.Y. Cheng The Effect on the Intervertebral Pressure Distribution in a Goat Spine upon Implementation of a Spring-Like Device X.C. Liu, R. Rizza, J. Thometz, C. Tassone and R. Lyon Stress Shielding Within the Scoliotic Spine: A Progressive Risk Factor? M. Driscoll, C.-É. Aubin, S. Parent and A. Moreau Suspension Is Better than Side-Bending to Assess Spinal Flexibility in Adolescent Idiopathic Scoliosis M.-E. Lamarre, S. Parent, H. Labelle, C.-E. Aubin, J. Joncas and Y. Petit Classification of Scoliosis Deformity 3-D Spinal Shape by Cluster Analysis Ian A.F. Stokes, Archana P. Sangole and Carl-Eric Aubin Alteration of Mobility and Trunk Muscle Activation During Walking and Bending in AIS Patients with Posterior Fusion C. Tassone, X.C. Liu, T. Jones, J. Thometz and R. Lyon Three-Dimensional MRI Analysis of the Skull Morphometry in Adolescent Idiopathic Scoliosis Girls: A Pilot Study H.Y. Yeung, L. Shi, W.C.W. Chu, C.W. Man, T.H. Cheng, V.W.Y. Hung, K.M. Lee, P.A. Heng, B.K.W. Ng and J.C.Y. Cheng Enhancement of Low Intensity Pulsed Ultrasound on Spinal Fusion Augmented with Stem Cell-Bioceramic Composite Chun Wai Chan, Celine F.F. Hui, Wei Man Pan, Kwong Man Lee, Ling Qin, Yun Yu Hu, Kwok Sui Leung and Jack C.Y. Cheng A New System for Classifying Torso Deformities in Scoliosis Using Localized Shape Indices P.O. Ajemba, N.G. Durdle and V.J. Raso A Novel Visualization Scheme for Monitoring and Tracking of Torso Deformities in Scoliosis P.O. Ajemba, N.G. Durdle and V.J. Raso Analysis of Trunk External Asymmetry in Side-Bending Valérie Pazos, Fethia Miled, Philippe Debanné, Hubert Labelle and Farida Cheriet Sagittal Spino-Pelvic Alignment in Lumbosacral Spondylolisthesis Jean-Marc Mac-Thiong, Zhi Wang, Jacques A. de Guise and Hubert Labelle

350

351

352

353

354

355 356

357 358

359

360

361

362

363 364

365

xiv

Cerebrospinal Fluid (CSF) Flow Dynamics at the Craniocervical Junction in Adolescent Idiopathic Scoliosis: Morphological and Functional Study with Phase Contrast Magnetic Resonance Imaging W.C.W. Chu, G.C.W. Man, W.W.M. Lam, H.Y. Yeung, B.K.W. Ng, T.P. Lam, K.M. Lee and J.C.Y. Cheng Is There Any Regional Difference of Brain Tissue Densities Between Adolescent Idiopathic Scoliosis (AIS) Patients and Normal Controls: A Morphometric Study with High Resolution MR Brain Imaging W.C.W. Chu, L. Shi, D. Wang, T. Paus, A. Pitiot, R.G. Burwell, G.C.W. Man, A. Cheng, H.Y. Yeung, K.M. Lee, P.A. Heng, B. Freeman and J.C.Y. Cheng A Significant Number of Patients with AIS Exhibit Transverse Plane Pelvis Deformation J.E. Meunier, C.-E. Aubin, H. Labelle, A. Sangole, R. Jackson, L. Lenke and P. Newton Reducing Radiation Exposure for Scoliosis S. Parent, S. Deschênes, G. Charron, G. Beaudoin, M.-C. Miron, J. Dubois and H. Labelle Abnormal Proliferative Response of Chondrocytes to Melatonin in Girls with Adolescent Idiopathic Scoliosis Wei-Jun Wang, Hiu-Yan Yeung, Chi-Wai Man, Kwong-Man Lee, Kin-Wah Ng, Yong Qiu and Jack Chun Yiu Cheng Normal Expression of Melatonin Receptors (MT1, MT2) in BMSCs from Adolescent Idiopathic Scoliosis Patients and Its Significance Haibo Li, Weijun Wang, Guangquan Sun, Jack Chun-Yiu Cheng and Yong Qiu Elevated Plasma Factor P Is Involved in Idiopathic Scoliosis Onset and Curve Progression A. Moreau, A. Franco, B. Azeddine, P.H. Rompré, I. Turgeon, K.M. Bagnall, B. Poitras, H. Labelle, C.-H. Rivard, G. Grimard, J. Ouellet, S. Parent, G. Larouche and G. Lacroix The Effect of Melatonin on Proliferation and Differentiation of Osteoblasts in Adolescent Idiopathic Scoliosis vs Normal Control G.C.W. Man, Y.H. Yeung, W.J. Wang, K.M. Lee, B.K.W. Ng, W.Y. Hung, Y. Qiu and J.C.Y. Cheng A Randomized Controlled Trial on Treatment Outcome and Patient’s Acceptance of the SpineCor vs Rigid Bracing System for AIS Girls T.P. Lam, M.S. Wong, B.K.W. Ng, S.W. Sin, R.H.K. Kwok, W.T.K. Lee, S.L.F. Shum, D.H.K. Chow and J.C.Y. Cheng Is Full Torso Imaging for the Assessment of Torso Deformity in Scoliosis Worth Its Cost? P.O. Ajemba, N.G. Durdle and V.J. Raso Importance of the Immediate Correction for the Effectiveness of Brace Treatment in AIS J. Clin, C.-É. Aubin, S. Parent and H. Labelle

366

367

368

369

370

371

372

373

374

375

376

Subject Index

377

Author Index

381

Chapter 1 Genetics

This page intentionally left blank

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-3

3

&\WRJHQLFDEQRUPDOLWLHVLQEXFFDOFHOOVGXU LQJVSLQDOGHIRUPLWLHVLQFKLOGUHQ 0<.$5*$1290 ,.2=+(91,.9$$ 9$/(6&+(1.2 11.+/(%1,.29$, %$/&+,129$, ,3(/(9,1$ $06(5(%5$1<,. 67(51292</ $126.,1

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ɋRHIILFLHQWRINDU\RO\VLV GHFUHDVHVZLWKLQFUHDVLQJ DQWKURSRJHQLFORDG,QSXSLOVRIDVSHFLDOVFKRROLQ0RVFRZWKHVHFRHIILFLHQWVZHUHVLPLODU$QDO\VLV RIFRHIILFLHQWVVKRZHGWKDWNDU\RO\VLVFRHIILFLHQWZDVUHGXFHGLQPRWKHUVRIFKLOGUHQZLWKVSLQDOGH IRUPLWLHV HPDLOPNDUJDQRY#PDLOUX .H\ZRUGV %XFFDOHSLWKHOLDOFHOOVF\WRJHQHWLF DEQRUPDOLWLHVODVHUFRUUHODWLRQVSHF WURVFRS\PHWDEROLFVKLIWVPXVFXORVNHOHWDOGLVRUGHUV

,QWURGXFWLRQ (QKDQFHGF\WRWR[LFDQGJHQRWR[LFORDGPDQLIHVWVLQLQFUHDVHGQXPEHURIFHOOVZLWKDEQRU PDOQXFOHL7KHLQFLGHQFHRIQXFOHXVDEQRUPDOLWLHVDQGWKHFRUUHVSRQGLQJPHWDEROLFVKLIWV ZHUHIRXQGWRGHSHQGRQWKHSUHVHQFHRIVSLQHGHIRUPLWLHVDQGHFRORJLFDOIDFWRUV7KHPRVW G\QDPLF SDUDPHWHU ZDV QXPEHU RI FHOOV ZLWK NDU\RUUKH[LV7KH SUREOHP RI IRUPDWLRQ RI ULVNJURXSVIRUVSLQHGHIRUPLWLHVLQHFRORJLFDOO\XQIDYRUDEOHUHJLRQVLVGLVFXVVHG

2EMHFWLYH DQG0HWKRGV 7KH PHWKRG XVHG ZDV WKH FRXQWLQJ QXFOHXV DEQRUPDOLWLHV 1$ LQ EXFFDO HSLWKHOLDO FHOOV %(& >@ :HH[DPLQHG\HDUROGFKLOGUHQLQWKUHHVFKRROVJHQHUDOHGXFDWLRQVFKRRO SXSLOV DQG WKHLU SDUHQWV Q 0RVFRZ ERDUGLQJ VFKRRO IRU FKLOGUHQ ZLWK VFROLRVLV DQG N\SKRVLV SXSLOV FRXQWU\ VFKRRO LQ HFRORJLFDOO\ FOHDQ 1RYJRURG UHJLRQ SX SLOV $SHFXOLDULW\ RI1$ FRXQWLQJLQEXFFDOHSLWKHOLXPLVDYDLODELOLW\DQGVLPSOHSURFH GXUH RI FHOO LVRODWLRQ 2UDO PXFRVD LV OLQHG E\ VWUDWLILHG VTXDPRXV HSLWKHOLXP ZKLFK LV UHQHZHGGXHWRGLYLVLRQRIEDVDOFHOOV 0DWXULQJFHOOVDUHGLVSODFHGILUVWWRWKHLQWHUPHGLDWH

4

M.Y. Karganov et al. / Cytogenic Abnormalities in Buccal Cells

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³QRUPDO´VSHFWUDDQGVSHFWUDZLWKSUHGRPLQDQFHRIDQDEROLF DQG FDWDEROLF SURFHVVHV UHVSHFWLYHO\ 7KH VDPSOHV ZHUH REWDLQHG DQG WKH PHDVXUHPHQWV ZHUHSHUIRUPHGDVGHVFULEHGSUHYLRXVO\>@ 7KH GDWD ZHUH DQDO\]HG XVLQJ 6WDWLVWLFD VRIWZDUH RQHZD\ GLVSHUVLRQ DQDO\VLV QRQSDUDPHWULFWHVWV

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ɋRHIILFLHQW RI NDU\RO\VLV GHFUHDVHV ZLWK LQFUHDVLQJ DQWKURSRJHQLF ORDG WKH UDWLRV RI WKHVHFRHIILFLHQWVLQWKHJURXSRIFKLOGUHQLQPRVWHFRORJLFDOO\FOHDQWHUULWRU\Q DQGLQ 0RVFRZQ ZHUHDQGUHVSHFWLYHO\ )LJXUH

5

M.Y. Karganov et al. / Cytogenic Abnormalities in Buccal Cells

1$SHUFHOO UDWLRRIFHOOVZ LWKNDU\RO\VLVWR1$

1RYJRURG

0RVFRZ

ERDUGLQJVFKRRO 0RVFRZ

)LJXUH 7KHUDWLRVRIFRHIILFLHQWVLQYDULRXVJURXSRIFKLOGUHQ

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

'LVFXVVLRQ +LJK1$FRHIILFLHQWZKLFKFDQEHGHWHUPLQHGE\ERWKHFRORJLFDODQGSDWKRORJLFDOIDFWRUV DWWHVWVWRLQVXIILFLHQF\RIUHSDUDWLRQPHFKDQLVPVXQGHUWKHVHFRQGLWLRQVFDOOVZLWKNDU\R

6

M.Y. Karganov et al. / Cytogenic Abnormalities in Buccal Cells

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

&RQFOXVLRQV 7KHLQFLGHQFHRIPXVFXORVNHOHWDOGLVHDVHVGLUHFWO\FRUUHODWHVZLWKWKHGHJUHHRIHQYL URQPHQWDOSROOXWLRQ7KHFRPELQDWLRQRIF\WRJHQHWLFDQDO\VLVRI EXFFDOHSLWKHOLDOFHOOVDV SHULSKHUDOPDUNHURIGDPDJHWRWKHJHQHWLFDSSDUDWXVDQG/&6FDQKHOSWRGHWHUPLQHULVN JURXSVIRUWKHGHYHORSPHQWRIVSLQHGHIRUPLWLHVXQGHUFRQGLWLRQVRIHFRORJLFDOKD]DUG

5HIHUHQFHV >@ .DUJDQRY 0 <X .R]KHYQLNRYD 0, $OHVFKHQNR $9HW DO &RUUHODWLRQ EHWZHHQ F\WRJHQLF DEQRUPDOLWLHV LQ FHOOV DQG PHWDEROLF VKLIWV GXULQJ VSLQDO GHIRUPLWLHV LQ FKLOGUHQ ,QW 5HV 6RF RI6SLQDO'HIRUPLWLHV6\PSRVLXP%HOJLXP >@ 7ROEHUW 3( 6K\&9 $OOHQ -: 0LFURQXFOHL DQG RWKHU QXFOHDU DQRPDOLHV LQ EXFFDO VPHDUVPHWKRGVGHYHORSPHQW 0XWDWLRQ5HV >@ %D]KRUD <X , 1RVNLQ /$ /DVHU FRUUHODWLRQ VSHFWURVFRS\ LQ PHGLFLQH 2GHVVD

Chapter 2 Growth

This page intentionally left blank

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-9

9

Body mass index of girls in health influences menarche and skeletal maturation: a leptin-sympathetic nervous system focus on the trunk with hypothalamic asymmetric dysfunction in the pathogenesis of adolescent idiopathic scoliosis? RG BURWELL1, RK AUJLA1, AS KIRBY1, PH DANGERFIELD2, A MOULTON3 AA COLE1, FJ POLAK1, RK PRATT1 J K WEBB1 1

Centre for Spinal Studies and Surgery, Nottingham University Hospitals Trust, Queen’s Medical Centre Campus, Nottingham, UK, 2 The University of Liverpool and Staffordshire University, UK, 3 Department of Orthopaedic Surgery, King’s Mill Hospital, Mansfield, UK (Supported by AO), Abstract. Lower body mass index (BMI) and lower circulating leptin levels have been reported in girls with AIS. In this paper we evaluate skeletal sizes and asymmetries by higher and lower BMI subsets about the means for each of three groups of girls age 1118 years: 1) normals, 2) school screening referrals, and 3) preoperative girls. Higher and lower BMI subsets, likely to have separated subjects with higher from those with lower circulating leptin levels, identify: 1) girls with relatively earlier and later menarche; 2) trunk width size greater in the higher than in the lower BMI subset, of all three groups; 3) abnormal upper arm length (UAL) asymmetries (right minus left) in the lower BMI subset of the preoperative girls; and 4) in thoracic AIS of screened and preoperative girls, Cobb angle and apical vertebral rotation each significantly and positively correlate with UAL asymmetry in the lower BMI subset but not in the higher BMI subset. In preoperative girls, the lower BMI subset shows the combination of relatively reduced pelvic width and abnormal UAL asymmetry, suggesting that both are linked to lower circulating leptin levels. An earlier puberty with hormonal changes provides a plausible explanation for the larger trunk width at the shoulders and pelvis especially at the younger ages in the higher BMI subsets. At the shoulders, this widening is driven by the ribcage which, in human evolution was acquired with decoupling of head and trunk movements required for efficient bipedal gait. The UAL asymmetry patterns within the groups and BMI subsets are not explained by hormonal mechanisms. It is hypothesized that 1) normal trunk widening of the thoracic cage by hormones in human adolescence is supplemented via the sympathetic nervous system under leptin-hypothalamic control influenced by energy stores (metabolic fuel); and 2) hypothalamic dysfunction with altered hypothalamic sensitivity to leptin through a SNS-driven asymmetric effect may create skeletal length asymmetries in upper arms, ribs, ilia and vertebrae, and initiate AIS. Additional mechanisms acting in the spine and

10

R.G. Burwell et al. / BMI of Girls in Health Inﬂuences Menarche and Skeletal Maturation trunk may be required for AIS to progress including 1) somatic nervous system dysfunction, 2) biomechanical spinal growth modulation, and 3) osteopenia. Key words.. Idiopathic scoliosis, pathogenesis, spine, body mass index, leptin, shoulder girdle, pelvis, ribcage, human evolution

1. Introduction Lower body mass index (BMI) has been detected in girls with AIS by some [1-7] but not by all [8] and BMI is normal before developing scoliosis [9]. Qiu et al [7] reported that low body mass index in AIS girls is associated with a marked decrease in circulating leptin compared with controls and leptin was found to correlate positively with corrected height. They comment [7] on clinical and experimental evidence strongly suggesting that leptin acts on bone tissue through both central and peripheral pathways; a central pathway driven by hypothalamic nuclei and the sympathetic nervous system (SNS), and peripherally by stimulating osteoblastic differentiation and inhibiting osteoclastic activity, resulting in enhanced bone formation and reduced bone resorption, and that leptin may regulate body growth during childhood and adolescence. There are no other reports on how skeletal size in AIS girls may relate to BMI. In this paper we evaluate skeletal sizes and asymmetries by higher and lower BMI subsets. The findings give some support to our leptin-SNS concept for the pathogenesis of adolescent idiopathic scoliosis [10]. 2. Methods and subjects 2.1 Three groups of subjects Data from three groups of female subjects age 11-18 years were studied: 1) normals (n=274, mean age 13.4 years); 2) school screening referrals (n=137, mean age 14.8 years, mean Cobb angle 15.8 degrees, mean apical vertebral rotation (AVR) 12.6 degrees, thoracic 37, thoracolumbar 41, lumbar 41, double 15, straight 3); and 3) preoperative subjects (n=110, mean age 14.8 years, mean Cobb angle 55.6 degrees, mean apical vertebral rotation 27.1 degrees, thoracic 81, thoracolumbar 25, lumbar 4). The numbers include subjects with a complete set of upper arm lengths, standing height and weight but tibial lengths were not recorded in some of the screened and preoperative girls. The normal subjects were examined by one observer (RGB) in 1973-1981. The scoliosis screening girls were referred to hospital by a routine quantitative protocol [11] and examined by the same observer in 1988-1999. The preoperative subjects were examined by one of three observers (RGB, AAC or RKP) in 1993-1999. 2.2 Anthropometry (Figure 1) The anthropometric techniques utilized the Harpenden Anthropometric Instruments (Holtain Ltd, Crosswell, Crymych, Pembs. SA41 3UF UK)[12,13]. Standing and sitting heights were recorded and subischial height calculated as standing height minus sitting height. Corrected standing and sitting heights for the screened and preoperative girls were calculated with the Bjure-Nachemson Formula [14]. A Harpenden

R.G. Burwell et al. / BMI of Girls in Health Inﬂuences Menarche and Skeletal Maturation

11

anthropometer was used to measure biacromial width, biiliac width, upper arm lengths (UALs) forearm-with-hand lengths and tibial lengths. UAL asymmetry and tibial length asymmetry were calculated as right minus left. An association between AIS thoracic curve AVR and UAL asymmetries was detected in a previous study [15,16]. Tibial length [TL] provided a model for the lower limbs in a previous study [17,18]. Menarcheal age was recorded. 2.3 Anthropometric error studies Intra-observer errors for RGB are (n=126): [19-21]: Standing height: Technical error of measurement (TEM)=2.1mm, coefficient of reliability R=0.99, Sitting height: TEM=1.9 mm R=0.97 Biacromial width: TEM= 3.3 mm Biiliac width: TEM=1.99 mm Upper arm length (right): TEM=2.9 mm, R=0.95, Upper arm length asymmetry: TEM=3.6 mm, R=0.39 Tibial length (right) TEM=3.2 mm, R=0.96 Tibial length asymmetry TEM=3.7mm, R=0.38. 2.4. Body mass index Body mass index (BMI=weight in kg/stature in metres) above and below the BMI mean for each group was used to define two subsets of subjects with higher and lower BMIs. Skeletal parameters were plotted against decimal age for these two BMI subsets of each group, including stature, sitting height, subischial height, biacromial width, biiliac width and for paired structures right and left for each of upper arm length (UAL), forearm-with-hand length, and tibial length (TL). Differences between each skeletal parameter by BMI subset was evaluated by analysis of variance (ANOVA) with age correction. Skeletal length asymmetries of UALs and TLs for the two subsets above and below the mean for each group were evaluated by an independent t-test. (The findings for each skeletal parameter by standard deviation scores will be reported separately). 2.5 Spinal radiographs The spinal radiographs were read by one observer (RGB) for the screened and 42 of the preoperative girls for Cobb angle and apical vertebral rotation (AVR)[22], and for the other preoperative girls by another observer (RKP). The intra-observer error for RGB fpr measuring Cobb angle is TEM=1.3 degrees, R=0.82, n=10; and for AVR, TEM=3.3 degrees, R=0.63, n=10 [15]. 3. Results 3.1 Body mass index. BMI means and standard deviations for the three groups are respectively 19.2±2.7, 19.6±2.7 and 19.6±3.3 and not significantly different between any of the groups

12

R.G. Burwell et al. / BMI of Girls in Health Inﬂuences Menarche and Skeletal Maturation

(analysis of variance, correcting for age). BMI increases significantly with age in each of normals (ρ=0.408, p<0.001). screening referrals (ρ=0.181 p=0.026) and preoperative girls (ρ =0.271, p=0.002)(Spearman rank correlation coefficients). 3.2. General skeletal growth (Figures 1 and 2) and menarche In each of the three groups, normals, screened and preoperative girls, significantly larger size is attained in those subjects in the higher BMI subset than in those in the lower BMI subset with respect to biacromial width and biiliac width (ANOVA with correction for age). Figure 1 for the screened girls shows for the anatomical regions the statistical levels of significance between the higher and lower BMI subsets. In preoperative girls, the biacromial and biiliac widths are significantly larger in the higher BMI subset than in the lower BMI subset (p<0.001), but not in sitting height, upper arm length or tibial length. In the normals, the effect is present in biiliac width (p=0.014) and biacromial width (p=0.0.036) and not in sitting height or upper arm length. The mean age at menarche for the screened girls, is significantly earlier in the higher BMI subset, than in the lower BMI subset (12.5 and 13.1 years, p=0.003, n=51 and 60 respectively) (Figure 2) (overall, premenarcheal 23, postmenarcheal 111, not known in 3). 3.3 Extra-spinal skeletal length asymmetries by higher and lower BMI subsets In asymmetries of upper arm length and tibial length differences by higher and lower BMI subset were calculated by independent t-test and by analysis of variance (ANOVA) without and with correction for age respectively. 3.3.1 Upper arm length asymmetries (Figure 3) a)

Normal girls not significantly different (higher BMI 2.4 mm, lower BMI 2.1 mm, p=0.623, n=131 and 143 respectively), ANOVA p=0.960, p=0.910. b) Screened girls not significantly different (higher BMI 1.3 mm, lower BMI -0.5 mm, p=0.070, n=54 and 83 respectively), ANOVA p=0.062, p=0.146. c) Preoperative girls significantly different (higher BMI 3.4 mm, lower BMI 7.0 mm, p=0.017, n=54 and 56 respectively), ANOVA p=0.063, p=0.503 Figure 3 shows that UAL asymmetries of girls with higher BMI subsets are not significantly different between groups but for lower BMI subsets are significantly different between the preoperative and each of the screened and normal girls (each p<0.001). 3.3.2 Tibial length asymmetries a) Normal girls not significantly different (higher BMI -0.2 mm, lower BMI -0.3 mm, p=0.805, n=131 and 142 respectively), ANOVA p=0.486, p=0.570. b) Screened girls not significantly different (higher BMI 1.4 mm, lower BMI 2.4 mm p=0.214, n=55 and 78 respectively)., ANOVA p=0.227, p=0.770. c) Preoperative girls not significantly different (higher BMI 0.4 mm, lower BMI 1.1 mm, p=0.561, n=41 and 44 respectively), ANOVA p=0.973, p=0.905.

R.G. Burwell et al. / BMI of Girls in Health Inﬂuences Menarche and Skeletal Maturation

13

Figure 1. Photographs of six anthropometric techniques and a drawing for scoliosis screened girls showing statistical findings by analysis of variance with correction for age. Some skeletal regions show relatively larger sizes for the higher than for the lower BMI subset with p-values given; these are: biacromial width, biiliac width, upper arm length and sitting height. Findings are shown only for right limbs. A similar pattern of trunk features is present in normal and preoperative girls at different levels of statistical significance.

Figure 2. Scoliosis screened girls. Graph showing best-fit quadratic regression lines for biiliac widths by age in years for girls in the higher and lower BMI subsets. The girls in the higher BMI subset have relatively larger biiliac widths than the girls in the lower BMI subset especially at the younger ages. (p=0.001, analysis of variance with correction for age). Mean menarcheal ages are shown for the higher BMI (MH) and lower BMI (ML) subsets.

14

R.G. Burwell et al. / BMI of Girls in Health Inﬂuences Menarche and Skeletal Maturation

Figure 3. Plots of mean asymmetries for upper arm length (UAL mm. right minus left) for the three groups – normal, screened and preoperative girls by higher and lower BMI subsets; the numbers beneath the means show the number by group in each subset and below the mean Cobb angle (CA). BMI=body mass index, H=higher BMI subset, L=lower BMI subset. The statistical significances levels for the comparisons are indicated above the horizontal bars (ANOVA with correction for age). Note, that the mean UAL asymmetries associated with the higher BMI subset (upper block) are not significantly different for any of the comparisons, while the UAL asymmetry associated with the preoperative lower BMI subset (lower block) is significantly more than that of the screened and normal girls [see 10].

3.4. Thoracic curves: Cobb angles and AVRs 3.4.1 Mean values of AVR and Cobb angles In thoracic AIS of screened and preoperative girls (to provide a range of curve severities) absolute AVR (but not absolute Cobb angle) is significantly larger in the higher BMI subset than in the lower BMI subset (mean AVR 23.3 degrees and 19.8 degrees, p=0.026 independent t-test; mean Cobb angle 45.4 degrees and 43.9 degrees,

R.G. Burwell et al. / BMI of Girls in Health Inﬂuences Menarche and Skeletal Maturation

15

p=0.680 independent t--test, n=57, with 6 left curves, and n=61 with 6 left curves respectively). Comparing the higher with the lower BMI subsets by ANOVA with age correction for AVR p= 0.811 and for Cobb angle p=0.944. 3.4.2. AVR and Cobb angle are each associated with upper arm length asymmetry. In the same group of thoracic AIS screened and preoperative girls, in the lower BMI subset, but not in the higher BMI subsets, both AVR and Cobb angle correlate significantly with UAL length asymmetry – lower BMI subset AVR r=0.459 p<0.001; Cobb angle r=0.526, p<0.001 n=61; higher BMI subset AVR r=0.145, p=0.287; Cobb angle r=0.032, p=0.857, n=57.. Comparing the higher with the lower BMI subsets by ANOVA without age correction for AVR p=0.001 and for Cobb angle p=0.102, and with age correction for AVR p= 0.689 and for Cobb angle p=0.655. 4. Discussion 4.1. Body mass index. The mean BMIs for screened and preoperative girls (each 1990s) are not different from the mean BMI for normals (1973-1981). Using normal BMI findings obtained in the mid-1990s (Aujla RK and Kirby AS, unpublished observations) the screened, but not the preoperative, girls have significantly lower BMIs (p=0.014 and p=0.230 respectively). 4.2. General skeletal growth features, focus on the trunk and relatively earlier skeletal maturation especially of trunk width in subjects with higher BMIs 4.2.1. Broadening of the human shoulder girdle held on the ribcage (Figure 1). The higher and lower BMI subsets are likely to have separated subjects with higher from those with lower circulating leptin levels [7]. Supposed higher circulating leptin levels in all three groups are associated with relatively larger growth in the trunk biacromial and biiliac widths and statistically most evident in the preoperative girls. Contrariwise, supposedly lower circulating leptin levels are associated with relatively less growth in trunk widths. Biacromial width reflects the shoulder girdle which is held on the broad human thoracic cage [23]; the width of the shoulder girdle in human evolution was acquired with the decoupling of head and trunk movements [24,25] required for efficient bipedal gait [26]. Hence, biacromial widths are evidently associated with the lateral growth of the human thoracic cage and clavicles; and our findings suggest that the growth of both widths may be affected by circulating leptin levels in humans but may not in non-human primates and quadrupeds. 4.2.2. Relatively earlier menarche and relatively earlier skeletal maturation in the biacromial width and pelvic width with higher BMIs In the screened girls, the relatively earlier menarche by about 6 months of the higherto- lower BMI subset respectively is in keeping with knowledge of a link between

16

R.G. Burwell et al. / BMI of Girls in Health Inﬂuences Menarche and Skeletal Maturation

body fat and the timing of puberty with leptin playing a permissive role [27,28] and kisspeptin activation of the G-protein coupled receptor-54 [28-31] providing a critical metabolic signal initiating puberty through pulsatile GnRH secretion [29]. Hence, relatively earlier skeletal maturation in the higher BMI subset due to relatively earlier puberty with hormonal changes provides a plausible explanation for the trunk width differences by BMI subset at the shoulder (pectoral) girdle) and pelvis. The adult human pelvis is wider than it is high [32]. 4.2.3. How to explain the skeletal asymmetries – trunk width and human bipedal gait While this hormonal interpretation is a plausible explanation for the relative differences in trunk width growth by higher and lower BMI subsets, it does not explain: a) The upper arm length (UAL) asymmetry patterns which differ between preoperative and each screened and normal girls (Figure 3). This UAL asymmetry effect is evident in the preoperative lower BMI subset composed of taller and thinner girls, in whom trunk width growth is reduced relative to higher BMI girls suggesting both are linked to lower circulating leptin levels. b) In thoracic AIS, Cobb angle and apical vertebral rotation are each associated with upper arm length (UAL) symmetry in the lower, but not the higher, BMI sunset. These patterns with respect to UAL asymmetry can be explained by postulating asymmetry from asynchrony in the upper arm growth plates from intrinsic or extrinsic mechanisms. There is no evidence for an intrinsic mechanism, but there is clinical and experimental evidence to suggest that a SNS-driven asymmetry mechanism in right thoracic AIS in girls determines concave periapical rib relative overgrowth [33-35] and in AIS of the lower spine (thoracolumbar and lumbar curves) determines the concave ilium relative overgrowth [36]. If this putative SNS-driven effect may create skeletal asymmetries, it may also supplement the hormonal contribution to trunk width by an SNS-driven general effect on trunk width growth. This SNS effect may be particular to humans and, as already stated, at the shoulders be driven by the ribs in a process that evolved with decoupling of head and trunk movements [24,25] required for efficient bipedal human gait [26,37]. 4.3. A leptin-sympathetic nervous system (SNS) effect on biacromial widths?

and pelvic

We propose the hypothesis that the hormonally-driven skeletal width growth in the human trunk is supplemented by a normal leptin-hypothalamic-SNS-driven mechanism related to energy stores (metabolic fuel) with leptin as a signal to the hypothalamus. In general, the coupling of skeletal growth to energy balance [38,39] involves leptin and Y2-receptors on neuropeptide Y (NPY-ergic) hypothalamic neurons [40,41 ]. . 4.4. Hypothalamic dysfunction and altered sensitivity to circulating leptin? In the lower BMI subset of the screened with preoperative girls with thoracic AIS, larger Cobb angles and larger AVRs are each associated with a longer right-to-left

R.G. Burwell et al. / BMI of Girls in Health Inﬂuences Menarche and Skeletal Maturation

17

upper arms. This pattern suggests a mechanism linking each of 1) circulating leptin levels, 2) growth of humeri, ribs and vertebrae, and 3) development of the scoliosis deformity. In the preoperative girls, the presence of abnormal UAL asymmetry with the lower BMI subset (Figure 3) is consistent with a putative dysfunction of the hypothalamus [10] with stress in response to lower circulating leptin levels and expressed as ‘upper arm wide asymmetry’, defined as affecting upper arms, ribs and vertebrae. The absence in preoperative girls of abnormal UAL asymmetry with the higher BMI subset suggests a protective effect of circulating leptin levels on the dysfunctional hypothalamus, with the breadth of the induced skeletal asymmetry being limited to the ribs and/or spine as ‘trunk wide asymmetry’, defined as affecting spine and/or ribs but not humeri. For the spine these concepts may be evaluated, in part, by combined MRI and histological studies of periapical vertebral growth plates [42] in relation to BMI. 4.5. Tibial length asymmetries The absence of tibial length asymmetries being significantly associated with higher and lower BMI subsets suggests a focus on the trunk of girls for the putative SNSdriven effect that may determine the asymmetries of each of UAL, periapical ribs and spine. 4.6. SNS-driven asymmetries in 3D? The postulated SNS-driven effects on growing bones may exert their asymmetries in the spine in 3D. Sagittal plane severity of thoracic AIS needs to be evaluated by higher and lower BMI subsets. 5. Other mechanisms in curve progression In addition to the hormonal and putative leptin-hypothalamic-SNS-driven effects on certain growing bones (humeri, ribs and vertebrae) in the screened and preopertative girls, we suggest that somatic nervous system dysfunction (? Relative postural maturational delay) may also be needed for progression of AIS curves to the severity requiring surgery [37,43]. 6. Conclusions 1. In terms of general skeletal growth, significantly larger size in trunk widths (biacromial and biiliac) is attained in girls in the higher BMI subset than in those in the lower BMI subset.. 2. Higher and lower BMI subsets are likely to have separated girls with elevated from those with reduced circulating leptin levels. 3. In the screened girls, the relatively earlier menarche by about 6 months of the higher–to-lower BMI subset is in keeping with knowledge of a link between body fat and the timing of puberty with leptin as a signal playing a permissive role [27,28]. 4. Relatively earlier skeletal maturation in the higher BMI subset due to an earlier puberty with hormonal changes provide a plausible explanation for the relatively larger

18

R.G. Burwell et al. / BMI of Girls in Health Inﬂuences Menarche and Skeletal Maturation

trunk width at the shoulders and pelvis. 5. This interpretation does not explain the abnormal upper arm length (UAL) asymmetry differences in the lower BMI subset between preoperative and each of screened and normal girls (Figure 3). Nor does it explain in thoracic AIS in the lower BMI subset the statistically significant association between each of Cobb angle and AVR with UAL asymmetry and not in the higher BMI subset. 6. In the lower BMI subset composed of taller and thinner girls, UAL asymmetry is most evident in the preoperative group (Figure 3), and in whom trunk width growth for age is reduced relative to the higher BMI girls, suggesting that both UAL asymmetry and the relatively reduced trunk width growth are linked to lower circulating leptin levels. 7. These UAL asymmetries can be explained by postulating asymmetry from asynchrony in the upper arm growth plates from intrinsic or extrinsic mechanisms. There is no evidence of mechanisms intrinsic to humeral growth plates but clinical and experimental evidence [10] suggests that a SNS-driven asymmetric mechanism in AIS girls may determine concave periapical rib relative overgrowth in right thoracic AIS in girls [33-35] and concave ilium relative overgrowth in lower spine AIS (thoracolumbar and lumbar curves) [36]. 8. If this putative SNS-driven asymmetric effect can create such skeletal length asymmetries, it may also supplement the hormonal contribution to trunk width growth 9. We propose the hypothesis that the hormonal stimulus to normal human trunk width growth is supplemented by a normal leptin-hypothalamic-SNS-driven stimulus related to energy stores (metabolic fuel) with leptin as a signal to the hypothalamus [10]. 10. Biacromial width reflects the breadth of the human thoracic cage [23]. The width of the shoulder (pectoral) girdle was acquired in human evolution with decoupling of the head and trunk movements [24,25] required for efficient bipedal gait [26], as was pelvic widening [32]. 11. It is suggested that the thoracic AIS of screened and preoperative girls was initiated by dysfunction of a normal hypothalamic control of trunk width growth associated with altered hypothalamic sensitivity to leptin (Figure 3). 12. Our hypothesis for AIS in girls states that [10] given adequate nutrition and energy stores, circulating leptin talks to the hypothalamus where dysfunction leads to an altered sensitivity to leptin resulting in increased SNS activity contributing with neuroendocrine mechanisms to: 1) earlier age at, and increased peak height velocity, 2) general skeletal overgrowth, 3) earlier skeletal maturation, 4) extra-spinal skeletal length asymmetries, including periapical ribs, and the ilia, 5) generalized osteopenia, and 6) lower BMI. 13. In AIS girls, a dysfunctional hypothalamus under stress from lower circulating leptin levels, expresses skeletal length asymmetry through the SNS in the upper arms, ribs and spine (‘upper arm wide asymmetry’) but, with high circulating leptin levels, is not expressed in the upper arms (‘trunk wide asymmetry’) where the asymmetry is limited to vertebrae and/or ribs. 14. In addition to the hormonal and the putative leptin-hypothalamic-SNS-driven asymmetric effects [10] that may initiate AIS in girls, other mechanisms required for curve progression may include 1) somatic nervous system dysfunction (? Relative postural maturational delay) [37,43], 2) spinal growth modulation [44], and 3) osteopenia. [45].

R.G. Burwell et al. / BMI of Girls in Health Inﬂuences Menarche and Skeletal Maturation

19

15. Evidence suggests that right thoracic AIS in females is initiated by the sympathetic nervous system [33-35]. Left thoracic AIS in females in a pilot study showed MRI changes in the somatic nervous system (cerebral hemispheres and corpus callosum)[46]. Does this imply different relative contributions of the autonomic and somatic nervous systems to the pathogenesis of right and left thoracic AIS respectively in females? 16. Compared with the brains of non-scoliotic girls, may the brains of girls who develop AIS have other differences of asymmetric functions [47] some sexually dimorphic and possibly linked to raised testosterone levels [10], of which the scoliosis is a solitary expression? References [1] [2]

[3]

[4]

[5] [6]

[7] [8]

[9] [10]

[11]

[12] [13] [14] [15]

[16]

Shohat M, Shohat T, Nitzan M et al, Growth and ethnicity in scoliosis. Acta Orthop Scand 1988 59(3):310-313. Cole AA, Burwell RG, Dangerfield, PH et al, Anthropometry, In: Etiology of Adolescent Idiopathic Scoliosis: Current Trends and Relevance to New Treatment Approaches, Edited by: Burwell RG, Dangerfield PH, Lowe TG, Margulies JY. State of the Art Reviews: Spine 2000, 14(2):411-421, Philadelphia, Hanley & Belfus Inc. Cheung CSK, Lee WTK, Tse YK et al, Generalized osteopenia in adolescent idiopathic scoliosis association with abnormal pubertal growth, bone turnover, and calcium intake? Spine 2006, 31(2):330338. Suh KT, Lee S-S, Hwang SH et al, Elevated soluble receptor activity of nuclear factor-kB ligand and reduced bone mineral density in patients with adolescent idiopathic scoliosis. Eur Spine J 2007 16:1563-1569. Smith FM, Latchford G, Hall RM et al, Indications of disordered eating behaviour in adolescents with idiopathic scoliosis. J Bone Joint Surg (Br) 2002, 84(3):392-394. Davey RC, Cochrane T, Dangerfield PH et al, Anthropometry and body composition in females with adolescent idiopathic scoliosis. In International Research Society of Spinal Deformities Symposium 2004, Edited by Sawatzky BJ, University of British Columbia, 2004, 323-326. Qiu Y, Sun X, Qiu X et al, Decreased circulating leptin level and its association with body and bone mass in girls with adolescent idiopathic scoliosis. Spine 2007,32(24):2703-2710. Grivas TB, Arvaniti A, Maziotou C et al, Comparison of body weight and height between normal and scoliotic children. In Research into Spinal Deformities 4, Studies in Health Technology and Informatics Volume 91. Edited by Grivas TB. Amsterdam, IOS Press; 2002:47-53. Nissinen M, Heliovaara M, Seitsamo J et al, Trunk asymmetry, posture, growth, and risk of scoliosis. A three-year follow-up of Finnish prepubertal school children. Spine 1993, 19(1):8-13. Burwell RG, Dangerfield PH, Moulton A et al, Etiologic theories of idiopathic scoliosis: autonomic nervous system and the leptin-sympathetic nervous system concept for the pathogenesis of adolescent idiopathic scoliosis. This Meeting. Burwell RG, Patterson JF, Webb JK et al, School screening for scoliosis – The multiple ATI system of back shape appraisal using the Scoliometer with observations on the sagittal declive angle. In: Surface Topography and Body Deformity. Proceedings of the 5th International Symposium, September 29October 1, Wien 1988, Stuttgart: Gustav Fischer, 1990, 17-23. Cameron N, The measurement of human growth London: Croom Helm, 1984. Burwell RG, Chapter 10, Anthropometry., In Assement methodology in orthopaedics. Edited by Pynsent PB, Fairbank JCT, Carr AJ.1997, 131-166. Bjure J, Nachemson A. Non-treated scoliosis. Clin Orthop. 1973, 93:44-52. Burwell RG, BJC Freeman, Dangerfield PH et al, Left-right upper arm length asymmetry associated with apical vertebral rotation in subjects with thoracic scoliosis: anomaly of bilateral symmetry affecting vertebral, costal and upper arm physes? In Research into Spinal Deformities 5, Studies in Health Technology and Informatics Volume 123. Edited by Uyttendaele D, Dangerfield PH, Amsterdam, IOS Press; 2006: 66-71. Burwell RG, Aujla RK, Freeman BJC et al, Left-right upper arm length asymmetries associated with apical vertebral rotation in subjects with thoracic adolescent idiopathic scoliosis (AIS): Age-related anomalies of bilateral symmetry affecting vertebral, costal and upper arm physes? Clin Anat 2006, 19(8):769.

20

R.G. Burwell et al. / BMI of Girls in Health Inﬂuences Menarche and Skeletal Maturation

[17] Burwell RG, Aujla RK, Freeman BJC, Dangerfield PH, Cole AA, Kirby AS, Pratt RK, Webb JK, Moulton A: Patterns of extra-spinal left-right skeletal asymmetries and proximo-distal disproportion in adolescent girls with lower spine scoliosis: ilio-femoral length asymmetry and bilateral tibial-foot length disproportion. In: Research into Spinal Deformities 5, Studies in Health Technology and Informatics Volume 123. Edited by: Uyttendaele D, and Dangerfield PH, Amsterdam, IOS Press; 2006: 101-108. [18] Burwell RG, Aujla RK, Freeman BJC et al, Proximo-distal skeletal length disproportion in lower limbs of girls with adolescent idiopathic scoliosis (AIS) compared with normal girls: tibial length/foot length is larger bilaterally and associated with left-right tibial length asymmetry and scoliosis Clin Anat 2007, 20(4):467. [19] Burwell RG, Vernon CL, Dangerfield PH. Chapter 38, Skeletal measurement, In Scientific Foundations of Orthopaedics and Traumatology, Edited by Owen R, Goodfellow J, Bullough P, London: William Heinemann Medical Books Limited, 1980, 317-329. [20] Cole AA: Quantitation of scoliosis before and after surgery. DM thesis, University of Nottingham, UK, 2005. [21] Ulijasek SJ, Mascie-Taylor CGN, Chapter 3, Intra- and inter-observer error in anthropometric measurement. In Anthropometry: the individual and the population. Cambridge:University Press, 1994, 30-55. [22] Perdriolle R, La Scoliose, son etude tridimensionelle. Maloine SA Editeur, 27 Rue de l’Ecole-deMedicine, 75005, Paris 1979. [23] Aiello L, Dean C, Chapter 17, The hominoid arm. In, An Introduction to Human Evolutionary Anatomy, London: Academic Press 1990, pp 342-371. [24] Alemseged Z, Spoor F, Kimbel WH, Bobe R, Geraads D, Reed D, Wynn JG: A juvenile hominid skeleton from Dikika, Ethiopia. Nature 2006, 443:296-301. [25] Wong K. Lucy’s baby. An extraordinary new human fossil renews debate over the evolution of upright walking. Sci Amer 2006, 295(6):56-63. [26] Bramble DM, Lieberman DE. Endurance running and the evolution of Homo. Nature 2004, 432:345352. [27] Ebling FJP, The neuroendocrine timing of puberty. Reproduction 2005, 129:675-683. [28] Kaplowitz PB, Link between body fat and the timing of puberty. Pediatrics 2008, 121, Supplement S208-S217. [29] Crown A, Clifton DK, Steiner RA. Neuropeptide signaling in the integration of metabolism and reproduction. Neuroendocrinol 2007, 86(3):175-182. [30] Kauffman AS, Clifton DK, Steiner RA, Emerging ideas about kisspeptin-GPR54 signaling in the neuroendocrine regulation of reproduction. Trends Neurosci 2007, 30(10):504-51. [31] Plant TM, The role of KISS-1 in the regulation of puberty in higher primates. Eur J Endocrinol 2006, 155 Suppl 1:511-516. [32] Aiello L, Dean C, Chapter 20, The Hominoid pelvis, In, An Introduction to Human Evolutionary Anatomy, London: Academic Press 1990, pp429-456. [33] Sevastik JA: The thoracospinal concept of the pathogenesis of idiopathic scoliosis. In Etiology of Adolescent Idiopathic Scoliosis: Current Trends and Relevance to New Treatment Approaches, Edited by Burwell RG,.Dangerfield PH, Lowe TG, Margulies JY. State of the Art Reviews: Spine 2000, 14(2):391-400, Philadelphia, Hanley & Belfus Inc. [34] Sevastik J, Burwell RG, Dangerfield PH: A new concept for the etiopathogenesis of the thoracospinal deformity of idiopathic scoliosis: summary of an electronic focus group debate of the IBSE. Eur Spine J 2003. 12:440-450. [35] Sevastik J.A: Right convex thoracic female adolescent scoliosis in the light of the thoracospinal concept. In Research into Spinal Deformities 5, Studies in Health Technology and Informatics Volume 123. Edited by Uyttendaele D, Dangerfield PH, Amsterdam, IOS Press; 2006:552-558. [36] Burwell RG, Aujla RK, Freeman BJC et al, Patterns of extra-spinal left-right skeletal asymmetries in adolescent girls with lower spine scoliosis: relative lengthening of the ilium on the curve concavity and of right lower limb segments. In Research into Spinal Deformities 5, Studies in Health Technology and Informatics Volume 123. Edited by Uyttendaele D, Dangerfield PH, Amsterdam, IOS Press; 2006: 5765. [37] Burwell RG, Dangerfield PH, Freeman BJC: Concepts on the pathogenesis of adolescent idiopathic scoliosis. Bone growth and mass, vertebral column, spinal cord, brain, skull, extra-spinal left-right skeletal length asymmetries, disproportions and molecular pathogenesis. In 1st SOSORT Instructional Course Lecture Book. The conservative scoliosis treatment, Studies in Health Technology and Informatics Volume 135, Edited by Grivas TB, Amsterdam IOS Press, 2008, 3-52.

R.G. Burwell et al. / BMI of Girls in Health Inﬂuences Menarche and Skeletal Maturation

21

[38] Gat-Yablonski, G, Phillip M, Leptin and regulation of linear growth. Curr Opin Clin Nutr Metab Care 2008, 11(3):303-308. [39] Iwaniec UT, Boghossian S, Lapke PD et al, Central leptin gene therapy corrects skeletal abnormalities in leptin-deficient ob/ob mice Peptides 2007, 28:1012-1019. [40] Allison SJ, Baldock PA, Herzog H, The control of bone remodeling by neuropeptide Y receptors Peptides 2007, 28: 320-325. [41] Baldock PA, Allison SJ, Lundberg P et al, Novel role of Y1 receptors in the coordinated regulation of bone and energy. J Biol Chem 2007, 282(26):19092-19102. [42] Day G, Frawley K, Phillips B et al, The vertebral body growth plate in scoliosis: a primary disturbance in growth? Scoliosis 2008;3:3 doi 10.1186/1748-7161-3-3. [43] Burwell RG, Dangerfield, PH, Freeman BJC et al,, Etiologic theories of idiopathic scoliosis. Somatic nervous system and the NOTOM escalator concept as one component of the pathogenesis of adolescent idiopathic. This Meeting. [44] Stokes IAF: Analysis and simulation of progressive adolescent scoliosis by biomechanical growth modulation. Eur Spine J 2007, 16:1621-1628. [45] Lee WT, Cheung CS, Tse YK et al, Association of osteopenia with curve severity in adolescent idiopathic scoliosis: a study of 919 girls. Osteopor Intern 2005, 16(12):1924-1932 [46] Chu W, Shi L, Wang D, Paus T et al, Anatomical difference of brains in subjects with right thoracic and left thoracic adolescent idiopathic scoliosis (AIS): MR-based morphometric study [abstract]. In Proceedings of Britspine, Fifth Combined Meeting, 30th April-2nd May 2008, Belfast Waterfront Hall, Belfast, Northern Ireland. [47] Goldberg CJ, Dowling FE, Fogarty EE et al, Adolescent idiopathic scoliosis and cerebral asymmetry. Examination of a nonspinal perceptual system. Spine 1995, 20(15):1685-1691.

22

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-22

9ROXPHWULFWKRUDFLFJURZWKLQFKLOGUHQ ZLWKPRGHUDWHDQGVHYHUHVFROLRVLVFRPSDUHG WRVXEMHFWVZLWKRXWVSLQDOGHIRUPLW\ <3&+$5/(6$',0(*/,2 00$5&28/-)%285*,1 $0$5&28/ 0&%2=211$7 6HUYLFHG¶2UWKRSpGLH3pGLDWULTXH&+80RQWSHOOLHU)UDQFH 0DUFHQDF'XFURV6$0RQWSHOOLHU)UDQFH ,QVWLWXW8QLYHUVLWDLUHGH5HFKHUFKH&OLQLTXH0RQWSHOOLHU)UDQFH

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ñ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

,QWURGXFWLRQ

,GLRSDWKLF VFROLRVLV UHSUHVHQWV D WKUHHGLPHQVLRQDO ' VSLQDO GHIRUPLW\ ZKLFK

Y.P. Charles et al. / Volumetric Thoracic Growth in Children

23

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³WKRUDFLF LQVXIILFLHQF\ V\QGURPH´ 'XERXVVHW HW DO > @ GHILQHG WKH ³VSLQDO SHQHWUDWLRQ LQGH[´ IRU VHYHUH WKRUDFLF ORUGRVFROLRVLV ZKLFK TXDQWLILHV WKH YHUWHEUDO ERG\ SURWUXVLRQ LQWR WKH WKRUD[ FUHDWLQJ DLUZD\ FRPSUHVVLRQ 0RGHUQ FRQFHSWV VXFK DV H[SDQVLRQ WKRUDFRSODVW\ DQG YHUWLFDO H[SDQGDEOH SURVWKHWLF WLWDQLXP ULE GLVWUDFWLRQ > @ SULPDULO\WUHDWWKHWKRUDFLFGHIRUPLW\7KLVDOORZVDQLQGLUHFWWUHDWPHQWRIWKHVFROLRVLVLQ \RXQJHUFKLOGUHQ DQGDOVRFUHDWHVEHWWHUFRQGLWLRQVIRUYHUWHEUDODQGSXOPRQDU\JURZWK> @ 7KUHHGLPHQVLRQDOWKRUDFLFJURZWKKDVEHHQVWXGLHGE\'LPpJOLRDQG%RQQHO>@ZKR HVWLPDWHG YROXPHWULF SURSRUWLRQV FOLQLFDOO\ IURP WKH WKRUDFLF SHULPHWHU 1HYHUWKHOHVV DFFXUDWH WKRUDFLF YROXPH DVVHVVPHQW UHPDLQV GLIILFXOW 7KH SXUSRVH RI WKLV VWXG\ LV WR PHDVXUH WKRUDFLF GLPHQVLRQVDQG YROXPHUHODWHGWR JURZWK DQGWRYHULI\ WKH LQIOXHQFHRI VHYHUH DQGPRGHUDWH VFROLRVLVRQWKRUDFLFJURZWK

0DWHULDOVDQG0HWKRGV

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

24

Y.P. Charles et al. / Volumetric Thoracic Growth in Children

)XUWKHUPRUHWKRUDFLFYROXPHIURPDWUDQVYHUVHVHFWLRQRIWKHERG\DWWKHWKULEPDUNHU XSWRWKHMXJXODUQRWFKFRXOGDOVREHFDOFXODWHG7KHYROXPHFRUUHVSRQGLQJWRWKHEUHDVWLQ DGROHVFHQWJLUOVZDVVXEWUDFWHGPDQXDOO\DWWKLVVWDJHLQRUGHUWRDYRLGDELDVRIWKHYROXPH RIWKHULEFDJH

)LJXUH$QDWRPLFDO'UHFRQVWUXFWLRQRIWKHWUXQNZLWKWKHRUHWLFDOVSLQHPRGHO

7KRUDFLF SDUDPHWHUV ZHUH FRPSDUHG LQ PRGHUDWH VFROLRVLV DQG UHIHUHQFH JURXSV IRU JLUOV DQG ER\V VHSDUDWHO\ XVLQJ WKH .UXVNDO:DOOLV WHVW 7KH QXPEHU RI SDWLHQWV LQ WKH VHYHUHVFROLRVLVJURXSZDVWRRVPDOOWRREWDLQDQDGHTXDWHVWDWLVWLFDOFRPSDULVRQ0HGLDQ YDOXHV RI WKRUDFLF YROXPHV ZHUHWKHQUHODWHG WR FKLOGUHQ¶VFKURQRORJLFDO DJHV LQ VFROLRVLV DQGUHIHUHQFHJURXSVIRUER\VDQGJLUOVVHSDUDWHO\7KHUHODWLRQVKLSEHWZHHQGLUHFWWKRUDFLF PHDVXUHPHQWV FP DQG SHUFHQWDJHV RI VLWWLQJ KHLJKW PHDVXUHPHQWV FP ZDV VWXGLHG E\ FDOFXODWLQJLQWUDFODVVFRUUHODWLRQFRHIILFLHQWV7KHGHJUHHRIFRUUHODWLRQZDVFRQVLGHUHGDV YHU\JRRGLIUJRRGLIU ±PRGHUDWHLIU ±SRRULIU ±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

25

Y.P. Charles et al. / Volumetric Thoracic Growth in Children

5HIHUHQFH JURXS $YHUDJH 6'

0RGHUDWHVFROLRVLV $YHUDJH 6'

3YDOXH

7KRUDFLFYROXPHGPñ

7KRUDFLFSHULPHWHUFP

$3GLDPHWHUFP

7UDQVYHUVDOGLDPHWHUFP

77OHQJWKFP

6WHUQDOOHQJWKFP

3DUDPHWHU

7DEOH &RPSDULVRQRIWKRUDFLFSDUDPHWHUVEHWZHHQUHIHUHQFHDQGPRGHUDWHVFROLRVLVJURXSVLQER\V

5HIHUHQFH JURXS $YHUDJH 6'

0RGHUDWHVFROLRVLV $YHUDJH 6'

3YDOXH

7KRUDFLFYROXPHGPñ

7KRUDFLFSHULPHWHUFP

$3GLDPHWHUFP

7UDQVYHUVDOGLDPHWHUFP

77OHQJWKFP

6WHUQDOOHQJWKFP

3DUDPHWHU

7DEOH &RPSDULVRQRIWKRUDFLFSDUDPHWHUV EHWZHHQUHIHUHQFHDQGPRGHUDWHVFROLRVLVJURXSVLQ JLUOV

,Q PRGHUDWH VFROLRVLV DQG UHIHUHQFH JURXSV WKH WKRUDFLF YROXPH LQFUHDVHG ZLWK FKURQRORJLFDODJHDVGHPRQVWUDWHGLQ)LJXUH,QWKHUHIHUHQFHJURXSRIER\VWKHPHGLDQ WKRUDFLFYROXPHPHDVXUHGGPñDW\HDUVDQGLWUHDFKHGDPD[LPDOYDOXHRIGPñ XQWLO WKH DJH RI \HDUV ,Q WKH PRGHUDWH VFROLRVLV JURXS RI ER\V WKH WKRUDFLF YROXPH UDQJHGIURPGPñWRGPñ,QJLUOVWKHWKRUDFLFYROXPHZDVVPDOOHUWKDQLQER\V,Q WKHUHIHUHQFHJURXSRIJLUOVWKHPHGLDQWKRUDFLFYROXPHPHDVXUHGGPñDWWKHDJHRI \HDUV $W WKH DJH RI \HDUV WKH PD[LPDO PHGLDQ YROXPH PHDVXUHG GPñ ,Q WKH PRGHUDWHVFROLRVLVJURXSRIJLUOVWKHPHGLDQWKRUDFLFYROXPHUDQJHGEHWZHHQGPñDQG GPñ ,W DSSHDUV WKDW WKRUDFLF YROXPH UHSUHVHQWV DSSUR[LPDWHO\ DW WKH DJH RI \HDUVDW\HDUVLWUHSUHVHQWVRILWVYROXPH FRPSDUHGZLWKDJH

26

Y.P. Charles et al. / Volumetric Thoracic Growth in Children

7KRUDFLF YROXPHV RI SDWLHQWV ZKR KDG VHYHUH VFROLRVLV ZLWK D &REE DQJOH ! GHJUHHV ZHUH WKHQ SORWWHG RQ WKLV GLDJUDP $OWKRXJK D VWDWLVWLFDO FRPSDULVRQ ZDV QRW SHUIRUPHG EHFDXVH RI WKH VPDOO QXPEHU RI SDWLHQWV LQ WKLV JURXS RI VHYHUH VFROLRVLV D WHQGHQF\RIVPDOOHUWKRUDFLFYROXPHVLQUHVSHFWLYHDJHVHFWLRQVZDVREVHUYHG

)LJXUH0HGLDQWKRUDFLFYROXPHVUHODWHGWRFKURQRORJLFDODJH

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

'LVFXVVLRQ

7KHWKRUDFLFGHIRUPLW\FDXVHGE\VFROLRVLVLVPHDVXUDEOHZLWKWKHRSWLFDO257(1V\VWHP /\RQ )UDQFH ZKLFK LV QRUPDOO\ XVHG IRU EUDFH FRQIHFWLRQ >@ 7KLV WRRO DOORZV

Y.P. Charles et al. / Volumetric Thoracic Growth in Children

27

PHDVXULQJZLGWKGHSWKFLUFXPIHUHQFHDQGYROXPHRIWKHWKRUD['XERXVVHWHWDO>@DV ZHOO DV 'LPp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

)LJXUH 7UHDWPHQWRIWKHWKRUDFLFDQGVSLQDOGHIRUPLW\ZLWKJURZLQJVSLQHSURILOHU

5HIHUHQFHV >@ &DPSEHOO 506PLWK 0'0D\HV 7&HWDO 7KHFKDUDFWHULVWLFVRIWKRUDFLFLQVXIILFLHQF\V\QGURPHDVVRFLDWHG ZLWKIXVHGULEVDQGFRQJHQLWDOVFROLRVLV-%RQH-RLQW6XUJ$P >@ 'XERXVVHW - :LFDUW 3 3RPHUR 9 HW DO 6FROLRVHV WKRUDFLTXHV /HV JLEERVLWpV H[R HW HQGR WKRUDFLTXHV HW O¶LQGH[GHSpQpWUDWLRQ$ UDFKLGLHQQH5HY&KLU2UWKRS5HSDUDWULFH$SSDU0RW

28

Y.P. Charles et al. / Volumetric Thoracic Growth in Children

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pJOLR $)%RQQHO/HUDFKLVHQFURLVVDQFH6SULQJHU3DULV >@ &RWWDORUGD - .RKOHU 5 *DULQ & /HFDQWH 7UDLWHPHQW RUWKRSpGLTXH GH OD VFROLRVH 1RXYHOOH WHFKQLTXH GH SULVHG HPSUHLQWHRSWLTXHSDU3SURFpGpRSWLTXH $UFK3HGLDWU >@ .RKOHU5&RWWDORUGD-*DULQ &/HFDQWH3,QWpUrWG XQFDSWHXURSWLTXHWULGLPHQVLRQQHOVDQVFRQWDFWSRXUOD PHVXUHGXWURQFKXPDLQ%LRP+XP$QWKURSRO >@ &RWWDORUGD-.RKOHU5*DULQ &HWDO2UWKRVHVIRUPLOGVFROLRVLV$SURVSHFWLYHVWXG\FRPSDULQJWUDGLWLRQDO SODVWHUPROGPDQXIDFWXULQJZLWKIDVWQRQFRQWDFWGLPHQVLRQDODFTXLVLWLRQ 6SLQH

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-29

29

Back trunk morphology in 3301 children aged 3-9 years old T B. GRIVAS, E S. VASILIADIS, C MIHAS, C MAZIOTOU, G TRIANDAFYLLOPOULOS Scoliosis Clinic, Orthopaedic Department, “Thriasio” General Hospital, G. Genimata Avenue, Magula, 19600, Athens, Greece. Abstract. The present cross sectional study reveals trunk asymmetry (TA) in "normal" Mediterranean juveniles for the first time. The scoliometer readings in both standing and sitting forward bending position (FBP) of 3301 children, (1645 boys, and 1656 girls) aged from 3 to 9 years old were studied. TA was quantified by measuring angle of trunk rotation (ATR) and children were divided in two groups. In group I the ATR was 1° to 6° degrees and in group II ≥7°. 71.25% of boys and 73.27% of girls in standing while 81.13% of boys and 80.74% of girls in sitting FBP, were symmetric (ATR = 0o). The symmetry difference at standing minus sitting FBP for boys and girls was 9.88% and 7.43% respectively. Severe asymmetry (ATR≥7°) was found in 1.74% of boys and in 1.75% of girls at the standing and in 1.21% and 1.22% at the sitting FBP respectively. Analysing ATR by age it appears that significant TA changes occur between 8 - 9 years of age for boys and between 6-7 and 8 - 9 years for girls. The amount of trunk asymmetry in children is the indicator for referral and further orthopaedic assessment. This report provides, for the first time information about the variability of back morphology in “normal” juveniles which is worth knowing when a child is examined for juvenile scoliosis. Keywords. Juvenile idiopathic scoliosis, juveniles, back morphology, trunk asymmetry.

1.

Introduction

Trunk asymmetry (TA) is considered by many authors as the clinical presentation of scoliosis [1, 2, 3]. Although the incidence of scoliosis in juveniles is much smaller than adolescents, in younger girls referred from a school-screening program there was a discrepancy between the thoracic asymmetry and the morphology of the spine [4]. Twenty five per cent of children with Angle of Trunk Rotation (ATR) ≥ 7o had either a straight spine or a curve smaller than 10o [4], which means that in juveniles, trunk asymmetry is not a sensitive clinical sign for scoliosis. As a baseline for further research on this observation, we need to know what the incidence of trunk asymmetry in a normal juvenile population is. In a previous study we reported trunk asymmetry in normal adolescents [5]. The present cross sectional study quantifies for the first time trunk asymmetry in "normal" Mediterranean juveniles. 2.

Method and Material

The scoliometer readings in both standing and sitting forward bending position (FBP) of 3301 children, (1645 boys, and 1656 girls) aged from 3 to 9 years old were studied. TA was quantified

30

T.B. Grivas et al. / Back Trunk Morphology in 3301 Children Aged 3–9 Years Old

by measuring angle of trunk rotation (ATR) in the thoracic, thoracolumbar and lumbar regions of the back. Children were divided in three groups. In group 0 children were symmetric, in group 1 the ATR was 1°-6° (moderate asymmetry) and in group 2 the ATR was ≥7° (severe asymmetry). Frequency of symmetry, moderate and severe asymmetry for both boys and girls was quantified in standing and in sitting FBP for all the examined regions of the back. The difference of trunk asymmetry between standing and sitting FBP as well as differences between boys and girls in frequency of trunk asymmetry were also calculated. 3.

Results

74.2 % of boys and 77% of girls were symmetric (ATR=0o) in the thoracic region in standing FBP, while 82.7% of boys and 84.1% of girls were symmetric in the thoracic region in sitting FBP. Symmetry and asymmetry in all the three examined regions of the spine in the standing FBP is shown for boys in Table 1 and for girls in Table 2, while in the sitting FBP it is shown for boys in Table 3 and for girls in Table 4.

Thoracic

Thoraco lumbar

Lumbar

Symmetry

1

-1

2

-2

Missing

Total

N

1209

264

142

11

3

16

1645

%

74.22

16.21

8.72

0.68

0.18

N

1155

275

168

22

9

%

70.90

16.88

10.31

1.35

0.55

N

1118

302

169

28

12

%

68.63

18.54

10.37

1.72

0.74

100.00 16

1645 100.00

16

1645 100.00

Table 1: Frequency of symmetry and asymmetry in boys. Scoliometer readings are obtained at standing forward bending position. 1: mild right asymmetry (ATR 1-6o), 2: severe right asymmetry (ATR ≥7o), -1 mild left asymmetry (ATR 1-6o), -2: severe left asymmetry (ATR ≥7o).

Thoracic

Thoraco lumbar

Lumbar

Symmetry

1

-1

2

-2

Missing

Total

N

1262

221

139

8

9

17

1656

%

77.00

13.48

8.48

0.49

0.55

N

1185

254

168

19

13

%

72.30

15.50

10.25

1.16

0.79

N

1156

255

191

25

12

%

70.53

15.56

11.65

1.53

0.73

100.00 17

1656 100.00

17

1656 100.00

Table 2: Frequency of symmetry and asymmetry in girls. Scoliometer readings are obtained at standing forward bending position. 1: mild right asymmetry (ATR 1-6o), 2: severe right asymmetry (ATR ≥7o), -1 mild left asymmetry (ATR 1-6o), -2: severe left asymmetry (ATR ≥7o).

31

T.B. Grivas et al. / Back Trunk Morphology in 3301 Children Aged 3–9 Years Old

Thoracic

Thoraco lumbar

Lumbar

Symmetry

1

-1

2

-2

Missing

Total

N

1348

143

128

6

4

16

1645

%

82.75

8.78

7.86

0.37

0.25

N

1335

144

129

13

8

%

81.95

8.84

7.92

0.80

0.49

N

1282

182

137

19

9

%

78.70

11.17

8.41

1.17

0.55

100.00 16

1645 100.00

16

1645 100

Table 3: Frequency of symmetry and asymmetry in boys. Scoliometer readings are obtained at sitting forward bending position. 1: mild right asymmetry (ATR 1-6o), 2: severe right asymmetry (ATR ≥7o), -1 mild left asymmetry (ATR 1-6o), -2: severe left asymmetry (ATR ≥7o).

Thoracic

Thoraco lumbar

Lumbar

Symmetry

1

-1

2

-2

Missing

Total

N

1378

136

116

6

3

17

1656

%

84.08

8.30

7.08

0.37

0.18

N

1315

159

141

12

12

%

80.23

9.70

8.60

0.73

0.73

N

1277

179

156

17

10

%

77.91

10.92

9.52

1.04

0.61

100.00 17

1656 100.00

17

1656 100.00

Table 4: Frequency of symmetry and asymmetry in girls. Scoliometer readings are obtained at sitting forward bending position. 1: mild right asymmetry (ATR 1-6o), 2: severe right asymmetry (ATR ≥7o), -1 mild left asymmetry (ATR 1-6o), -2: severe left asymmetry (ATR ≥7o).

The difference in the frequency of asymmetry between standing and sitting FBP, in all the examined regions of the spine, for boys and girls are shown in table 5.

Boys Symmetry ATR=0o

ATR 1o- ATR ≥ 7o 6o

Symmetry ATR=0o

Girls ATR 1o6o

ATR ≥ 7o

Thoracic

Thoracolumbar Lumbar

8,5%

8,3%

0,4%

7,1%

6,6%

0,5%

11%

10,4%

0,6%

7,9%

7,5%

0,5%

10,1%

9,3%

0,7%

7,4%

6,8%

0,6%

Table 5. The difference (%) of the frequency of asymmetry between standing and sitting FBP, in the three examined regions of the spine, for both boys and girls.

32

4.

T.B. Grivas et al. / Back Trunk Morphology in 3301 Children Aged 3–9 Years Old

Discussion

It is axiomatic, that any screening procedure for abnormality is based on knowledge of normality. Normal juvenile girls appear to be more symmetric than juvenile boys, a finding which is opposite in adolescents [5, 6]. Juveniles appear to have a smaller frequency of trunk asymmetry than adolescents. Furthermore, in the present study the frequency of asymmetry was detected in greater percentage in the standing than in the sitting FBP, the same as in adolescents, which implies leg length or pelvic difference in pathogenesis of trunk asymmetry. The amount of trunk asymmetry in children is the indicator for referral and further orthopaedic assessment if a spinal curve is detected. This report provides, for the first time information about the variability of back morphology in “normal” juveniles which is worth knowing when a child is examined for juvenile scoliosis. References [1] [2] [3] [4]

[5] [6]

Nissinen MJ, Heliövaara MM, Seitsamo JT, Könönen MH, Hurmerinta KA, Poussa MS, Development of trunk asymmetry in a cohort of children ages 11 to 22 years. Spine 25(5) (2000), 570–74. Vercauteren M, van Beneden M, Verplaetse R, Croebe P, Uyttendale D, Verdonk R, Trunk asymmetries in a Belgian school population. Spine 7 (1982), 555–62. Burwell RG, James NJ, Johnson F, Webb JK, Wilson, Standardised trunk asymmetry scores. J Bone Joint Surg 65B (1983), 452–63. YG Grivas TB, Vasiliadis ES, Mihas C, Savvidou OD, The effect of growth on the correlation between the spinal and rib cage deformity. Implications on idiopathic scoliosis pathogenesis. Scoliosis 2(1) (2007), 11. Grivas TB, Vasiliadis E, Koufopoulos G, Segos D, Triantafyllopoulos G, Mouzakis, Study of trunk asymmetry in normal children and adolescents. Scoliosis 1(1) (2006), 19. V Grivas TB, Vasiliadis, Polyzois VD, Mouzakis V, Trunk asymmetry and handedness in 8245 school children. Pediatric ES Rehabilitation, 9(3) (2006), 259-266.

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-33

33

The role of the intervertebral disc in correction of scoliotic curves. A theoretical model of Idiopathic Scoliosis pathogenesis T B. GRIVAS, E S. VASILIADIS, G RODOPOULOS, N BARDAKOS Scoliosis Clinic, Orthopaedic Department, “Thriasio” General Hospital, G. Genimata Avenue, Magula, 19600, Athens, Greece. e-mail: [email protected] Abstract. Wedging of the scoliotic inter-vertebral disc (IVD) was previously reported as a contributory factor for progression of idiopathic scoliotic (IS) curves. The present study introduces a theoretical model of IVD’s role in IS pathogenesis and examines if, by reversing IVD wedging with conservative treatment (full- and night-time braces and exercises) or fusionless IS surgery with staples, we can correct the deformity of the immature spine. The proposed model implies the role of the diurnal variation and the asymmetric water distribution in the scoliotic IVD and the subsequent alteration of the mechanical environment of the adjacent vertebral growth plates. Modulation of the IVD by applying corrective forces on the scoliotic curve restores a close-to-normal force application on the vertebral growth plates through the Hueter-Volkmann principle and consequently prevents curve progression. The forces are now transmitted evenly to the growth plate and increase the rate of proliferation of chondrocytes at the corrected pressure side, the concave. Application of appropriately directed forces, ideally opposite to the apex of the deformity, likely leads to optimal correction. The wedging of the elastic IVD in the immature scoliotic spine could be reversed by application of corrective forces on it. Reversal of IVD wedging is thus amended into a “corrective”, rather than “progressive”, factor of the deformity. Through the proposed model, treatment of progressive IS with braces, exercises and fusionless surgery by anterior stapling could be effective. Keywords. Idiopathic scoliosis, intervertebral disc, asymmetrical growth, pathogenesis of idiopathic scoliosis, conservative treatment of Idiopathic scoliosis, fusionless surgery of Idiopathic scoliosis, stapling of the spine.

1.

Introduction

The rationale for management of idiopathic scoliosis (IS) during skeletal growth assumes a biomechanical mode of deformity progression, based on the HueterVolkmann principle [1], whereby extra axial compression decelerates growth and reduced axial compression accelerates it [2]. In treating IS conservatively, application of corrective forces does nothing more than exploiting this principle, by applying appropriately directed forces through the skin, soft tissues and ribs to the vertebral growth plates. The role of the IVD as a contributory factor to the development of the scoliotic curve has been emphasized in a previous study [3]. The response of IVD to abnormal stresses imposed on them in scoliosis is essential to the long-term prognosis of untreated lumbar and thoracolumbar curves [4] and it is very likely that the changes in cartilagenous endplate (vertebral body growth plate) and IVD are key factors in the progression of scoliosis and the manner in which the curve will respond to different therapeutic regimens [5].

34

T.B. Grivas et al. / The Role of the Intervertebral Disc in Correction of Scoliotic Curves

The present study illustrates the effect of IVD modulation and its subsequent benefits in IS treatment. The proposed model is examined on conservative treatment (full- and night-time braces and exercises) and fusionless IS surgery with staples. 2.

Material and Methods

A theoretical model of IVD’s role in progressive IS pathogenesis is introduced. The IVD contains the aggrecans of glycosaminoglycans (GAGs) which imbibe water through the so called Gibbs-Donnan mechanism. The highest concentration of GAGs is in the nucleus pulposus (NP) where they are entrapped in a type II collagen network [6] and are exposing a convex-wise asymmetrical distribution. There is an increased collagen content in the NP of the apical IVD but also in the adjacent discs in IS, which is maximal at the apex of the curvature. Furthermore, in the scoliotic spine the NP in the IVD is displaced towards the convex side of the wedged interspaces [4]. Differences also exist in the collagen distribution between the concave and convex sides of the scoliotic annulus fibrosus in IS, with fewer collagen fibres in the concave compared to the convex side [7]. A diurnal variation in the water content of lumbar IVD has also been documented [8, 9], resulting in diurnal variations in loading of the vertebral growth plates, because of IVD’s periodical “swelling” (during night time) and “shrinkage” (for the period of day time under the application of the body load during the upright posture) during the 24 hour period. This asymmetrical pattern of water distribution in the scoliotic IVD, combined with the diurnal variation in the water content of IVDs resulting to a sequence of “swellings” and “shrinkages”, imposes asymmetrical, convex-wise, concentrated cyclical loads to the IVD and the adjacent immature vertebrae growth plates of the child during the 24 hours period [3]. The convex side of the wedged IVD sustains greater amount of cyclic (swelling) expansion than the concave side, leading to the sequelae of asymmetrical growth of adjacent vertebrae (Hueter-Volkmann’s law). Consequently, the response of bone growth to asymmetrical loading follows an asymmetrical pattern and gradually can enhance the correction of the deformity if optimal corrective forces are applied, with full time and night time braces, exercises and fusionless surgery. 3. Results The IVD may be modulated by applying corrective forces on the curve thereby eliminating any asymmetrical accumulation of water in the apical and adjacent IVDs. This, in turn, restores a close-to-normal force application on the vertebral growth plates through the Hueter-Volkmann principle and consequently may prevent curve progression. The forces are now transmitted evenly to the growth plate increasing the rate of proliferation of chondrocytes at the corrected pressure side, the concave. All the stated treatment methods aim at alteration of the mechanical environment and modulation of the endochondral growth of the immature vertebrae. Application of appropriately directed forces, ideally opposite to the apex of the deformity, likely leads to optimal correction. Exercises for IS are using techniques to correct and maintain the correction which has been achieved, during every day activities. By activating the appropriate muscle groups, corrective forces are transmitted on the wedged IVD and are reversing to a degree the wedging, altering the mechanical environment of the adjacent vertebral growth plates.

T.B. Grivas et al. / The Role of the Intervertebral Disc in Correction of Scoliotic Curves

35

Full time braces, through the 3D correction and the combination of derotation together with the three point pressure principle, are exerting constant corrective forces on the wedged IVD and are restoring a close to normal force application on the vertebral growth plates. The mechanical stimulus to the concave side of the growth plate is weaker, allowing new cells to be produced in the proliferateve zone and extracellular matrix to be produced in the hypertrophic zone of the growth plate, according to Hueter – Volkmann principle. As a consequence, longitudinal growth is faster at the concave side of the curve, when a skeletally immature scoliotic child is treated with a full time brace and eventually this could stop its progression or even correct the curve, depending on child’s growth potential. The night time braces are rather overcorrecting the mild or moderate scoliotic curves, simulating gravity, acting also on the apical and adjacent wedged IVDs [10]. Their action is by reducing the previously described asymmetrically imbibed water (greater amount in the convex rather that in the concave side), but additionally they are taking advantage of the diurnal variation in the water content of IVD, which is increased during the night. Hypercorrection of the IVD with the nighttime brace results in vertebral growth under more normal conditions. Under the action of the nighttime brace, the convex side sustains no greater amount of expansion than the concave side, (ceasing the asymmetrical application of Hueter - Volkmann law), reversing the deleterious hypothesis of progression of IS curves; consequently, the growth of the apical and adjacent immature vertebrae turns more normal, within a close - to - normal biomechanical environment. Fusionless surgery with staples, theoretically allows preservation of growth, motion, and spinal function, and perhaps has a reduced risk of adjacent segment degeneration and other spinal de-compensation problems [11]. This method has been shown to retard growth on the convex side while allowing the concave side to continue growing, enabling the abnormal curve to “self-correct” [12]. Additionally, stapling between two adjacent vertebrae at the side of curve convexity inhibits IVD expansion due to its asymmetrical water distribution and therefore, one significant factor for curve progression is eliminated. Theoretically, by stapling the growth plates, the accelerated growth on the convexity of a curve is ceased, both by inhibiting the longitudinal growth (acting directly on the convexwise vertebral end-plate cells) and by eliminating the effect of IVD asymmetrical force application on the growth plates. Perhaps growth is stimulated on the concavity of a curve, and therefore correction of the deformity can occur (Hueter-Volkmann principle). The goal of stapling is to harness the scoliosis patient’s inherent abnormal spinal growth and alter it to achieve correction, rather than progression. 4. Discussion The proposed theoretical model requires three conditions in order to be successful. First, there must be enough growth potential left; otherwise the final correction will be suboptimal. Second, the elastic properties of the IVD should allow adequate modulation and through that adequate alteration of the mechanical environment of the growth plate and third, the corrective forces should be towards the correct level, ideally perpendicular to the level of maximum deformity. The wedging of the elastic IVD in the immature scoliotic spine could be reversed by application of corrective forces on it. Reversal of IVD wedging, by altering the mechanical environment of the adjacent growth plates, is thus amended into a

36

T.B. Grivas et al. / The Role of the Intervertebral Disc in Correction of Scoliotic Curves

“corrective”, rather than “progressive”, factor of the deformity. Through the proposed mechanism, treatment of progressive IS with full time and night time braces, exercises and fusionless surgery by anterior stapling could be effective. References [1]

Stokes IA, Analysis and simulation of progressive adolescent scoliosis by biomechanical growth modulation, Eur Spine J 16(10) (2007), 1621-8. [2] Mente PL, Stokes IA, Spence H, Aronsson DD, Progression of vertebral wedging in an asymmetrically loaded rat tail model, Spine 22(12) (1997), 1292-6. [3] Grivas TB, Vasiliadis E, Malakasis M, Mouzakis V, Segos D, Intervertebral disc biomechanics in the pathogenesis of idiopathic scoliosis. Stud Health Technol Inform 123 (2006), 80-3. [4] Taylor T.K.F, Melrose J., The role of the intervertebral disc in adolescent idiopathic scoliosis, Spine: State of the Art Reviews 14 (2000), 359-369. [5] Roberts S., Caterson B., Urban J.B.G, Structure and composition of the cartilage end plate and intervertebral disc in scoliosis, Spine: State of the Art Reviews 14 (2000), 371-381. [6] Melrose J., Gurr K.R., Cole T.C., A. Darvodelsky, Ghosh P., Taylor T.K., The influence of scoliosis and ageing on proteoglycan heterogeneity in the human intervertebral disc, J Orthop Res, 9(1) (1991), 68-77. [7] Bushell G.R., Ghosh P., Taylor T.K., Sutherland, The collagen of the intervertebral disc in adolescent idiopathic scoliosis, J Bone Joint Surg Br, 61(4 J.M.) (1979), 501-8. [8] Dangerfield P.H., Roberts N., Walker J. et al, Investigation of the diurnal variation in the water content of the intervertebral disc using MRI and its implication for scoliosis. In: M. D'Amico, A. Merolli, G. C. Santambrogio (editors). Three Dimensional Analysis of Spinal Deformities. IOS Press 1995, 447-451. [9] Beauchamp M, Labelle H, Grimard G, Stanciu C, Poitras B, Dansereau J, Diurnal variation of Cobb angle measurement in adolescent idiopathic scoliosis. Spine 18(12) (1993), 1581-3. [10] Grivas TB, Rodopoulos GI, Bardakos NV, Biomechanical and Clinical Perspectives on Nighttime Bracing for Adolescent Idiopathic Scoliosis. Stud Health Technol Inform 135 (2008), 274-290. [11] Betz RR, Kim J, D’Andrea LP, Mulcahey MJ, Balsara RK, Clements DH, An Innovative Technique of Vertebral Body Stapling for the Treatment of Patients With Adolescent Idiopathic Scoliosis: A Feasibility, Safety, and Utility Study. Spine 28(20S) (2003), S255–S265. [12] Braun JT, Ogilvie WJ, Akyuz E, Brodke DS, Bachus KN, Fusionless Scoliosis Correction Using a Shape Memory Alloy Staple in the Anterior Thoracic Spine of the Immature Goat. Spine 29(18) (2004), 1980–1989.

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-37

37

Ultrasound femoral anteversion (FAV) relative to tibial torsion (TT) is abnormal after school screening for adolescent idiopathic scoliosis (AIS): evaluation by two methods RG BURWELL1, RK AUJLA1, AS KIRBY1, A MOULTON2, PH DANGERFIELD3,BJC FREEMAN4, AA COLE1, FJ POLAK1, RK PRATT1, J K WEBB1 1 Centre for Spinal Studies and Surgery, Nottingham University Hospitals Trust, Queen’s Medical Centre Campus, Nottingham, UK, 2Department of Orthopaedic Surgery, King’s Mill Hospital, Mansfield, UK. 3Children’s Hospital, University of Liverpool, 4Department of Spinal Surgery, Royal Adelaide Hospital, Adelaide, Australia (Supported by AO and Arthritis and Rheumatism Council UK) Abstract. In the scoliotic spine, torsion is generally evaluated in relation to axial rotation of the apical vertebra. In the lower limbs, the changes in torsion by age of femoral anteversion (FAV) relative to tibial torsion (TT) have been studied in dried bones, normal growing subjects and adults and subjects with osteoarthritis of the hip or the knee. This paper reports the application of real-time ultrasound to FAV and TT in normal children age 11-18 years and in scoliosis screening referrals with particular reference to how FAV relates to TT as 1) ratios, and 2) tibiofemoral index (TFI) of torsion, calculated as TT minus femoral FAV. The FAV/TT ratio findings show an abnormal normal relationship of FAV to TT both proximo-distally and in leftright asymmetry. These may express torsional abnormalities in femoral and/or tibial growth plates with left-right asynchrony suggesting the possibility of similar torsional abnormalities in vertebral end-plates and/or rib growth plates initiating the deformity of AIS. TFI of the right limb in the scoliosis girls is greater than in the normals that is interpreted as resulting from earlier skeletal maturation of FAV. FAV/TT ratios and TFI are unrelated to the spinal deformity (Cobb angle and apical vertebral rotation) except for boys where TFI is associated with apical vertebral rotation. FAV/TT ratios may be a more accurate method estimating the relationship of FAV to TT. than TFIs. Key words. Idiopathic scoliosis, pathogenesis, spine, ultrasound, femoral anteversion, tibial torsion, growth plate

1. Introduction 1.1 Torsion of femur relative to tibia in bones, health and osteoarthritis at hip or knee In dry normal adult human femora and tibiae a weak statistically significant correlation was reported between FAV/TT [1]. In healthy children [2] and healthy adults [3-5] FAV/TT did not correlate significantly and no left-right asymmetry was found. In contrast, in adults with osteoarthritis of the hip [6] or knee [7] FAV and TT correlated significantly. Goutallier et al [8] using a tibio-femoral index (TT minus

38

R.G. Burwell et al. / Ultrasound FAV Relative to TT is Abnormal After School Screening for AIS

FAV) in lateral or medial knee arthrosis, concluded that femoral and tibial torsions play a part in lateralized knee arthrosis together with frontal plane mechanical factors. There may be ethnic and sex differences in the relationship between torsions of the lower limbs and knee osteoarthrosis [9,10]. The above findings, considered in the perspective of torsions in the normal spine and lower limb bones (Figure 1), suggested the need to evaluate the relation of FAV to TT in girls with AIS. Two methods are used here: 1) FAV/TT ratio, and 2) tibio-femoral index [8]. No data on TFIs for normal subjects are published. 1.2. Normal postnatal changes in femoral and tibial torsion 1.2.1. Femoral anteversion (FAV), or torsion, decreases postnatally into puberty [1114](Figure 1). This age-related change is generally attributed to muscular forces acting across the hip [15], and other mechanical forces [16], but there is a view that external torsion at the distal femoral growth plate (in the same direction as tibial external torsion) also contributes to femoral detorsion [17]. Estrogen may abet mechanical forces to drive femoral detorsion during postnatal growth [13].

Figure 1. Diagram to show the two types of postnatal growth in femora and tibiae – growth in length mainly from growth plates at the knees, and torsion in both bones, in the femur internal torsion (detorsion) through puberty and in the tibia external torsion mainly before puberty. GP=growth plate.

1.2.2. Tibial torsion (TT) increases mainly in the first 5 years of life [18, but see 19] and mostly before puberty [13] aligning the feet in gait before the adolescent growth spurt. TT is thought to be determined at the ankle with the medial malleoli rotating forwards in relation to the lateral malleoli [18,20]. Both FAV and TT express growthplate function influenced partly by mechanical factors and strongly by genetic control [21].

R.G. Burwell et al. / Ultrasound FAV Relative to TT is Abnormal After School Screening for AIS

39

2. Femoral anteversion/tibial torsion correlations are significant, abnormal and asymmetric in the scoliosis subjects 2.1. The scoliosis referrals and normals The scoliosis referrals, age 11-18 years, were referred to hospital by school nurses in routine prescriptive screening for the rotational back shape asymmetry of AIS using a quantitative protocol [22] during 1993-99 (girls 93, boys 35). Clinical evaluation (RGB) identified types of AIS: thoracic (30), thoracolumbar (38), lumbar (25), double (14), pelvic tilt scoliosis (16) and straight spine (5). Normal subjects, age 11-18 years were 301 (girls 157, boys 144) examined in the community by two radiographers (RKA, ASK). The spinal radiograph measurements made by one observer (RGB) included Cobb angle and apical vertebral rotation [23]. 2,2. Ultrasound methods Real-time ultrasound was used to measure femoral anteversion (FAV) and tibial torsion (TT) in the scoliosis referrals and normals by a radiographer (RKA or ASK): FAV was measured between upper end of femur and femoral condyles by the method of Zarate et al [24], and TT between upper tibial shaft and talus by the method of Kirby et al [25]. 2.3. Results A preliminary account of the findings has been published [26]. 2.3.1 Reproducibility The interobserver error (RKA and ASK, n=107, normal subjects) are for FAV: coefficient of reliability left leg 0.82, right leg 0.85 [27]: technical error of measurement left leg 3.1 degrees, right leg 3.0 degrees; intra-class correlation coefficient left leg 0.76, right leg 0.77. For TT: coefficient of reliability left leg 0.85, right leg 0.80: technical error of measurement left leg 4.3 degrees, right leg 4.8 degrees; intra-class correlation coefficient left leg 0.76, right leg 0.74. None of the FAV/TT correlation coefficients for data from normal subjects by the two radiographers are statistically significant. Normal

Scoliosis

Figure 2.Diagram showing the correlations of right and left FAV to TT (FAV/TT) to be weakly significant in normals and very significant in the scoliosis subjects. p-values are shown (***=p<0.001).

40

R.G. Burwell et al. / Ultrasound FAV Relative to TT is Abnormal After School Screening for AIS

2.3.2. Normal and scoliosis subjects In the normals, FAV and TT show a weakly significant positive correlation in each leg (right p=0.013, left p=0.014) without asymmetry (p=0.454)(ANOVA after correcting for age and sex). In scoliosis referrals, FAV and TT correlate positively and significantly in each leg (p=0.001) with asymmetry (p=0.009), and very significantly different from normals (right p<0.001, left p=0.008). The FAV/TT correlation in each leg is not significantly different by scoliosis curve side or severity (ANOVA). FAV, TT, left-right differences; and FAV/TT sums are not significantly associated with spinal curve severity (Cobb angle, apical vertebral rotation). 2.4. Conclusion In the scoliosis subjects, the abnormal FAV/TT correlations are evidently determined in femoral and/or tibial growth plates. These FAV/TT findings show an abnormality of the normal relationship of FAV to TT both proximo-distally and in left-right asymmetry. These may express torsional abnormalities in femoral and/or tibial growth plates suggesting the possibility of similar torsional abnormalities in vertebral endplates and/or rib growth plates initiating the deformity of AIS. 3. Tibio-femoral index (TFI) of torsion in normal subjects increase with age but not in girls screened for scoliosis suggesting earlier skeletal maturation 3.1. Definition Tibio-femoral index (TFI) of torsion, calculated as tibial torsion (TT) minus femoral anteversion (FAV)[8]. A preliminary account of the findings has been published [28]. 3,2. Methods and subjects The subjects, screened scoliosis and normals were the same as for the FAV evaluation. FAV and TT were measured as stated above. 3.3. Results 3.3.1 Reproducibility The interobserver error (RKA and ASK, n=88, normal subjects) for TFI is: coefficient of reliability left leg 0.84, right leg 0.78 [26]: technical error of measurement left leg 5 degrees, right leg 6.0 degrees; intra-class correlation coefficient left leg 0.76, right leg 0.70. 3.3.2. Normal children. Normal subjects show an increase in TFI with age (quadratic regression, <0.001, r values: girls right 0.360, left 0.471), boys right 0.515, left 0.504, while from 11-18 years, TFIs on the right increase with age (r & p values: girls right 0.174 p=0.029, left 0.098 NS; boys right r=0.249 p=0.003, left 0.108 NS). In girl scoliosis referrals, TFIs do not increase with age but do so in boys (girls right r=0.014 NS, left r=0.022 NS, boys right r=0.743, p<0.001; left r=0.341 p=0.045) with side differences in boys (p<0.002)

R.G. Burwell et al. / Ultrasound FAV Relative to TT is Abnormal After School Screening for AIS

41

Figure 3. Right leg of normal and scoliosis girls. TFIs plotted against age. The findings for the scoliosis girls are significantly different from the normals (p=0.001) but not for the left leg TFI (p=0.107, ANOVA correcting for age).

3.3.3. Scoliosis referrals, In girl scoliosis referrals, TFIs are 1) in the right leg are significantly different from normal (p right=0.001, left p=0.107, ANOVA corrected for age) and not significant in the boys, and 2) unrelated to curve severity but in boys are associated with apical vertebral rotation but not Cobb angle. 3,4. Conclusions 3.4.1 Normals girls and boys. TFIs increase during growth as TT increases and FAV decreases. 3.4.2 Scoliosis girls In the scoliosis girls, TFIs in the right leg are significantly greater than normal without detectable left-right asymmetry. The greater right TFIs is explained in the scoliosis girls by FAV being significantly less than in normals [14,29] whereas TT is not significantly different from normal [14,30]. This FAV decrease [14.29] may result from abnormally increased femoral detorsion, maturationally earlier than normals [14,29]. FAV asymmetry [14,29] detected by both FAV and FAV/TT ratios is not evident in the TFIs, perhaps because TFI has a greater measurement error than that of FAVs. FAV/TT ratios may be a more accurate method for estimating the relationship of FAV to TT than are TFIs. References [1] [2] [3] [4] [5]

Kobylianski E, WEissman SL, Nathan H, Femoral and tibial torsion: a correlation study in dry bones. Int Orthop 1979, 3(2):145-147 Pasciak M, Stoll TM, Hefti F, Relation of femoral to tibial torsion in children measured by ultrasound. J Pediatr Orthop B 1996, 5(4):268-272. Reikeras O, Is there a relationship between femoral anteversion and leg torsion? Skel Radiol 1991, 20:409-411. Strecker W, Keppier P, Gebhard F et al, Length and torsion of the lower limb. J Bone Joint Surg (Br) 1997, 79-B(6):1019-1023. Seber S, Hazer B, Kose N et al, Rotational profile of the lower extremity and foot progression angle: computerized tomographic examination of 50 male subjects. Arch Orthop Traum Surg 2000, 120(56):255-258.

42

R.G. Burwell et al. / Ultrasound FAV Relative to TT is Abnormal After School Screening for AIS

[6]

Rittmeister M, Hanusek S, Starker M, Does tibial rotation correlate with femoral anteversion: Implications for hip arthroplasty. J Arthroplasty 2006, 21(4):53-558. et al 2006 Takai S, Sakakida K, Yamashita F et al, Rotational alignment of the lower limb in osteoarthritis of the knee. Int Orthop 1985, 9(3):209-215. Goutallier D, Garabedian JM, Allain J et al, Effect of osseous torsions of the lower limb on the development of lateral femoro-tibial knee arthrosis. Rev Chir Orthop Reparatrice Appar Mot 1997, 83(7):613-621 (French). Tamari K, Tinley P, Briffa A et al, Ethnic- gender-, and age-related differences in femorotibial angle, femoral antetorsion, and tibiofibular torsion: cross-sectional study among healthy Japanese and Australian Caucasians. Clin Anat 2006, 19(1):59-67. Tamari K, Briffa NK, Tinley P et al, Variations in torsion of the lower limb in Japanese and Caucasians with and without knee osteoarthritis. J Rheumatol 2007, 34(1):134-150. Upadhyay SS, Burwell RG, Moulton A et al, Femoral anteversion in healthy children. Application of a new method using ultrasound. J Anat 1990, 169:49-61. Kirby AS, Aujla RK, Burwell RG et al, Torsion in the limb bones of healthy subjects. In Research into Spinal Deformities 1, Studies in Health Technology and Informatics Volume 37, Edited by Sevastik JA and Diab KM, Amsterdam, IOS Press; 1997, 53-56. Burwell RG, Aujla RK, Kirby AS et al, Tibial torsion increase occurs mainly before puberty and femoral anteversion decrease mainly from puberty in normal subjects: An ultrasound study suggests intrinsic (genetic) torsion-sensitivity to estrogen. Clin Anat 21(2):195. Burwell RG, Aujla RK, Kirby AS, Ultrasound femoral anteversion (FAV) and tibial torsion (TT) after school screening for adolescent idiopathic scoliosis (AIS). This Meeting Morscher E, Development and clinical significance of the anteversion of the femoral neck. Reconstr Surg Traumatol 1964, 64:469-472. Tayton E, Femoral anteversion: a necessary angle or an evolutionary vestige?. J Bone Joint Surg (Br) 2007, 89(10):1283-1288. Lau DPC, Femoral anteversion and the nature of the twist in the femur with views on the mechanism of postnatal femoral detorsion. The effects of different lower end datum lines and variations in condylar anatomy in then anteversion angle. A quantitative study. Volumes I & II, B Med Sci Thesis, School of Biomedical Sciences, University of Nottingham, UK, 1987 Kristiansen LP, Gunderson RB, Steen H et al, The normal development of tibial torsion. Skel Radiol 2001, 30(9):519.522. Campos FF, Maiques IAP, The development of tibio-fibular torsion. Surg Radiol Anat 1990, 12:109112. Krishna M, Evans R, Spring A et al, TT measured by ultrasound in children with talipes equinovarus. J Bone Joint Surg 1991, 63-B(2):207-210. Burwell RG, Aujla RK, Kirby AS et al, Percentage changes of tibial torsion and femoral anteversion from a juvenile baseline in normal subjects by age, bone and sex: An ultrasound study suggests mechanisms intrinsic (genetic) to growth plates. Clin Anat 2008, 21(2):195. Burwell RG, Patterson JF, Webb JK et al, School screening for scoliosis – The multiple ATI system of back shape appraisal using the Scoliometer with observations on the sagittal declive angle. In: Surface Topography and Body Deformity. Proceedings of the 5th International Symposium, September 29October 1, Wien 1988, 17-23. Perdriolle R, La Scoliose, son etude tridimensionelle, Maloine S A Editeur, 27 Rue de l’Ecole-deMedicine, 75006, Paris. Zarate R, Cuny C, Sazos P, Determination de l’anteversion du col du femur par echographie. J de Radiol 1983, 64:307-311. Kirby AS, Burwell RG, Aujla RK et al, A new method for measuring tibial torsion (TT) angles and findings for young adolescents. Clin Anat 1994, 7(1):55-56. Burwell RG, Aujla RK, Kirby AS et al, Ultrasound femoral anteversion/tibial torsion correlations are significant, abnormal and asymmetric after school screening for adolescent idiopathic scoliosis (AIS): lower limb torsional markers for initiation of the trunk torsional deformity of AIS?. Clin Anat 2007, 20(7):855. Ulijasek SJ, Mascie-Taylor CGN, Chapter 3, Intra- and inter-observer error in anthropometric measurement. In Anthropometry: the individual and the population. Cambridge:University Press, 1994, pp 30-55. Burwell RG, Aujla RK, Kirby AS et al, Tibio-femoral index (TFI) of torsion: an increase with age in normal subjects but not in girls screened for scoliosis suggests earlier skeletal maturation: an ultrasound study. Clin Anat 2008, 21(2):195.

[7] [8]

[9]

[10] [11] [12]

[13]

[14] [15] [16] [17]

[18] [19] [20] [21]

[22]

[23] [24] [25] [26]

[27]

[28]

R.G. Burwell et al. / Ultrasound FAV Relative to TT is Abnormal After School Screening for AIS

43

[29] Burwell RG, Aujla RK, Kirby AS et al, Ultrasound femoral anteversion (FAV) is decreased and asymmetric after school screening for adolescent idiopathic scoliosis (AIS): femora show torsional anomalies that if in the trunk may initiate the deformity [abstract]. Clin Anat 2007, 20(7):855. [30] Burwell RG, Aujla RK, Kirby AS et al, Ultrasound tibial torsion (TT) and TT asymmetry are not abnormal after school screening for adolescent idiopathic scoliosis (AIS): in scoliosis boys TT is decreased relative to scoliosis girls without asymmetry - the result of altered maturation at knee tibial growth plates? Clin Anat 2007, 20(7):855.

44

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-44

Risser sign: the value of the lateral spinal radiograph to assess the excursion of the iliac apophysis T KOTWICKI Department of Pediatric Orthopedics and Traumatology University of Medical Sciences, Poznan, Poland [email protected] Abstract. The course of the ossification of the iliac apophysis is considered in adolescent patients with idiopathic scoliosis, under the name of the Risser sign, to determine the remaining spinal growth. Although the iliac crest develops in the three-dimensional space as a complex structure, the iliac apophysis ossification has been assessed only on a one plane frontal spinal radiograph. This study points out the usefulness of the lateral radiograph for the visualization of the whole iliac crest, especially the posterior region which otherwise cannot be observed. Two young female pelvis specimen were examined with anatomical measurements and radiography. Lateral spinal radiographs of 201 girls were analyzed for the iliac apophysis excursion. The measures of the width of the iliac bone beneath the iliac crest revealed one anterior and one posterior thick regions, coupled with an intermediate thin region. The regions of the maximal thickness corresponded to the earliest appearance of the apophysis ossification (Risser 1), while the thin part of the iliac bone corresponded to late appearance of the apophysis ossification (Risser 3-4). The ossification of the posterior part of the crest was best visualized with the lateral radiograph, which was exclusive in showing the posterior superior iliac spine region. On the frontal spinal radiograph the end of the course of the apophysis (Risser 3-4) is usually searched at the level of the sacroiliac joint, while in reality this point was found to be situated more caudal, and accessible for observation on the lateral radiograph.

1.

Introduction

The cranio-caudal growth of the human spine is not linear; the main phases of the most intensive growth concern the first two years of age as well as the early puberty (usually 11-13 years in girls). Increase of the structural scoliotic curvature occurs during this rapid growth phase [1, 2]. The growth potential running out, the evolution of a spinal deviation loses in its dynamics. Thus, the knowledge of the developmental stage of an adolescent with scoliosis is crucial for making therapeutic decisions: planning of surgery, brace treatment or brace weaning. In adolescence the biological age does not always correspond to the chronological age. That is why a number of indices has been developed to assess the bone age with radiography. The Risser sign [3] is one of the most popular. The determination of the Risser sign value (from zero to five) reposes on the assessment of the excursion of the secondary ossification center of the iliac crest (iliac apophysis). In is believed that the ossification starts at the superior anterior iliac spine (SAIS), continues along the iliac crest from anterior to posterior and completes at the posterior superior iliac spine (PSIS). Minor asymmetries of the left-right apophysis

T. Kotwicki / Risser Sign

45

ossification have been described [4]. The assessment of the Risser sign value is performed after an antero-posterior (AP) or a postero-anterior (PA) spinal radiograph comprising the pelvis. The assessment after the lateral spinal radiograph has not been reported. The complex shape of the female pelvis reflects the function of the osseous pelvic girdle providing stability for transmitting the trunk load to the lower limbs throughout the pelvic ring. The most upper part of the left and right iliac bones, namely the iliac crests develop their shape in the three dimensional (3-D) space. Starting from the ASIS the iliac crest continues in the superior and posterior direction, then posterior, then progressively more medial to the L5 level and finally rapidly down and posterior up to the PSIS. As any 3-D structure cannot be seen on one plane radiograph, it is admitted in orthopedic surgery to systematically visualize bony structures using two perpendicular projections: a frontal one and a lateral (or axial) one. However, only the frontal one has been used so far to evaluate the iliac apophysis excursion for the Risser sign value. The aim of the study was to investigate the size, shape, width and the spatial orientation of the iliac crest using two anatomic specimen and to assess the development of the iliac apophysis using lateral radiography.

Fig. 1. The pelvic specimen (bottom) and its radiography (top), both seen in the frontal (left), transverse (middle) and lateral (right) plane. ASIS – anterior superior iliac spine. PSIS – posterior superior iliac spine. aPSIS – apparent PSIS – the point commonly considered to be the PSIS, which is actually situated at the junction of the 70% anterior and the 30% posterior of the total length of the iliac crest. This posterior part can be seen on the lateral radiograph exclusively.

2.

Material and Methods

Two young female pelvic specimen were examined with frontal and lateral radiography, attaching metal markers along the iliac crest (Fig. 1). The thickness of the iliac bone was measured just beneath the iliac crest, along the whole distance from the ASIS to the PSIS at 1cm intervals. Moreover lateral radiographs of 201 girls with

46

T. Kotwicki / Risser Sign

idiopathic scoliosis, aged 10.2 to 20.0 years, mean 14.6 ± 2.2 years, were examined to reveal the excursion of the apophysis. The X-rays were taken from the charts of the patients, and not ordered because of this study. The position of the PSIS was studied and related to the vertebral level (to the vertebral body level or the intervertebral disc level). 3.

Results

The length of the iliac crest of was 23.5cm for the first specimen, and 21.5cm for the second one. The iliac bone was the thickest in two regions, one adjacent to the ASIS and another one to the PSIS. In the ASIS region the width of the iliac bone varied from 10.7mm to 17.3mm, mean 13.7mm (the first specimen), and from 11.2mm to 14.9mm, mean 13.1mm (the second specimen). In the region of the PSIS the width of the iliac bone varied from 10.4mm to 15.7mm, mean 12.8mm (the first specimen), and from 11.4mm to 17.6mm, mean 15.5mm (the second one). The iliac bone was thin in between the two above mentioned regions. In the first specimen the width of the thin region varied from 5.8mm to 7.4mm, mean 6.5mm, while in the second specimen the width varied from 8.1mm to 10.1mm, mean 9.6mm. The radiography of the pelvic specimen revealed that the regions of the maximal width of the iliac bone corresponded to the regions of the first appearance of the ossification of the iliac crest. The analysis of the position of the PSIS revealed the level of L5 in 3 cases, the disc L5/S1 in 4 cases, the S1 in 96 cases, the disc S1/S2 in 52 cases and S2 in 35 cases. The ossification of the iliac apophysis was clearly seen on the lateral radiograph. Various stages of the ossification were observed: (1) no ossification, (2) short and thin shadows of the beginning ossification, (3) full length excursion or (4) fusion of the apophysis with the iliac crest (Fig. 2.). Thus, the lateral radiograph excursion of the iliac apophysis was proposed to be quantified in four grades [paper submitted for publication].

Fig. 2. Lateral radiograph showing the full excursion of the iliac apophysis up to the posterior superior iliac spine. The most posterior and inferior portion of the iliac crest is not visible on the frontal plane radiograph, however it can be observed on the lateral one.

T. Kotwicki / Risser Sign

4.

47

Discussion

This study confirmed what is already known from anatomical studies, that the value of the width of the iliac bone can present important variations, and that the regions of maximal or minimal width are distributed in the systematic way: the anterior maximum, the middle minimum, the posterior maximum. The knowledge of the size of the iliac bone is useful in clinical practice: both the anterior and the posterior thick regions are the preferable sources to harvest the bone graft in orthopedic surgery. It was interesting to notice that the regions of the iliac bone which revealed the maximal width corresponded to the regions of the first appearance of the apophysis ossification (Risser 1). The amount of the underlining bone would be the main reason for early appearance of the ossification in particular regions of the iliac crest. Also, the sequence typical for the Risser sign development may be explained by the sequence of ossification beginning at the large bony regions and followed by the progressive ossification of the thinner regions. It worth mentioning that the region of the posterior maximum thickness of the iliac bone cannot be seen on the frontal pelvic radiograph. On the other hand, it is well seen on the lateral radiograph. When studying the representations of the Risser sign which are reproduced in the manuals of orthopedics, one can easily notice that the excursion of the posterior apophysis is designed as stopping at the level of L5 vertebra, lateral and superior to the sacroiliac joint. In this study the PSIS was found to be situated much lower, at the level of S1 to S2 vertebra. These findings strongly support the thesis that there exists a posterior part of the iliac crest which cannot be observed on the frontal radiograph, however it can be seen on the lateral one. 5.

Conclusions

The complex 3-D shape of the iliac bone bordered with the iliac crest cannot be accurately studied from the one plane frontal radiograph. The additional use of the lateral radiograph allows detecting of the ossification of the posterior part of the iliac crest. The thickness of the iliac bone represents two maxima joined with a thin region in the middle. The thick regions correspond to the radiographic early appearance of the ossification of the iliac apophysis (Risser 1) while the thin regions correspond to the late ossification (Risser 3-4). References [1] Bunnell WP. The natural history of idiopathic scoliosis before skeletal maturity. Spine 1986; 11: 773-776. [2] Lonstein J Carlson JM. The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Joint Surg Am. 1984; 66: 1061-1071. [3] Risser JC. The iliac apophysis. An invaluable sign in the management of scoliosis. Clin Orthop 1958; 11: 111-119. [4] Little DG Sussman M. The Risser sign: a critical analysis. J Pediatr Orthop 1994; 14: 569-575.

48

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-48

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

,QWURGXFWLRQ

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

0HWKRGV

$GDWDVHWRIPHDVXUHPHQWRIFDOLEUDWHGVWHUHRUDGLRJUDSKVRUSDWLHQWVZLWKDGLDJQRVLV RILGLRSDWKLFDGROHVFHQWRUMXYHQLOHLGLRSDWKLFVFROLRVLVZDVXVHGWRDQDO\]HWKHUHODWLRQVKLS EHWZHHQ &REE DQJOH VSLQDOOHQJWK DQG VSLQDOKHLJKW 'DWD ZHUH LQFOXGHG LQWKH SUHVHQW VWXG\IRUSDWLHQWVEHWZHHQDQG\HDUVROGEHIRUHDQ\VXUJHU\EXWVRPHSDWLHQWVZHUH OLVWHGLQWKHGDWDEDVHDVXQGHUJRLQJEUDFHWUHDWPHQW7KHUDGLRJUDSKVZHUHPDGHEHWZHHQ

I.A.F. Stokes / Stature and Growth Compensation for Spinal Curvature

49

WKH \HDUV ±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¶VULJKWVLGHRUDERYH WKHKRUL]RQWDO )RU HDFK VWHUHRUHFRQVWUXFWLRQ RI WKH VSLQHYHUWHEUDOODQGPDUNV YHUWHEUDO HQGSODWHVDQGEDVHVRISHGLFOHV KDGEHHQSUHYLRXVO\LGHQWLILHGPDUNHGDQGGLJLWL]HGIURP HDFK UDGLRJUDSK DFFRUGLQJ WR WKH PHWKRGV GHVFULEHG >@ WR REWDLQ WKH ' FRRUGLQDWHV RI HDFKODQGPDUN 7KH UHODWLRQVKLS EHWZHHQ KHLJKW ORVV DQG &REE DQJOH ZDV GHWHUPLQHG E\ UHJUHVVLRQ DQDO\VLVVHSDUDWHO\IRUVLQJOHDQGGRXEOHFXUYHV,QWKHFDVHRIGRXEOHFXUYHVWKHVSLQDO GHIRUPLW\ZDVTXDQWLILHGE\WKHDYHUDJHRIWKHWZR&REEDQJOHV

5HVXOWV

7KHUHODWLRQVKLSEHWZHHQKHLJKWORVVDQG&REE DQJOHZDVREVHUYHGWREHQRQOLQHDU)LJXUH 4XDGUDWLFUHJUHVVLRQDQDO\VLVRIWKHVXSSRVHGUHODWLRQVKLSEHWZHHQKHLJKWORVVDQGWKH PHDQ&REEDQJOHLQWKHIRUP +HLJKW ORVV & % &REE $ &REE ZDV HPSOR\HG JHQHUDWLQJ SDUDPHWHU YDOXHV OLVWHG LQ 7DEOH $ VLPLODU DQDO\VLV ZDV HPSOR\HG E\ @ ZKLFK JHQHUDWHG D UHODWLRQVKLSVLPLODUWRWKDWIRXQGIRUGRXEOHFXUYHVLQWKHSUHVHQWVWXG\)LJXUH & % $ 3DWLHQWVZLWKVLQJOHFXUYHV 3DWLHQWVZLWKGRXEOHFXUYHV
50

I.A.F. Stokes / Stature and Growth Compensation for Spinal Curvature

6LQJOHFXUYHV

'RXEOHFXUYHV

2EVHUYHGGDWD 4XDGUDWLFILW

+HLJKW/RVVPP

+HLJKW/RVVPP

2EVHUYHGGDWD 4XDGUDWLF)LW

&REE$QJOH

0HDQ&REE$QJOH

)LJXUH/HIW 2EVHUYHGUHODWLRQVKLSEHWZHHQ+HLJKWORVVDQG&REEDQJOHIRUVLQJOHFXUYHV5LJKW 2EVHUYHG UHODWLRQVKLS EHWZHHQ+HLJKW ORVVDQGPHDQRIWZR &REEDQJOHV IRU GRXEOH FXUYHV7KHUHODWLRQVKLS JLYHQ E\ @LVDOVRSORWWHGLQWKHULJKWSDQHOJUDSK

'LVFXVVLRQDQG&RQFOXVLRQV

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
I.A.F. Stokes / Stature and Growth Compensation for Spinal Curvature

51

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

5HIHUHQFHV >@ @ %MXUH-1DFKHPVRQ$1RQWUHDWHGVFROLRVLV&OLQ2UWKRS5HODW5HV-XQ >@ %URRNHQWKDO.5/RVVRIKHLJKWLQVFROLRVLVGXHWRGHJUHHRIFXUYDWXUH 6FROLRVLV5HVHDUFK6RFLHW\([KLELW >@ 6WRNHV ,$) %LJDORZ /& 0RUHODQG 06 7KUHHGLPHQVLRQDO VSLQDO FXUYDWXUH LQ LGLRSDWKLF VFROLRVLV - 2UWKRS5HV ± >@ 6WRNHV,$:LQGLVFK/9HUWHEUDOKHLJKWJURZWKSUHGRPLQDWHVRYHULQWHUYHUWHEUDOGLVFKHLJKWJURZWKLQWKH DGROHVFHQWVSLQH 6SLQH >@ 1LFRORSRXORV .6 %XUZHOO 5* :HEE -. 6WDWXUH DQG LWV FRPSRQHQWV LQ KHDOWK\ FKLOGUHQ VH[XDO GLPRUSKLVPDQGDJHUHODWHGFKDQJHV -$QDW ±

52

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-52

Clinical detectable tension in the growing body: new and revisited signs in clinical examination in children with postural problems and spinal deformities Restoration of lordosis on the thoracolumbar junction can correct sagittal and coronal plane deformity; a new (revisited) linked approach on the treatment and etiology of adolescent spinal deformities

P J.M. van Loon, MD. Department of orthopaedic surgery 1 Slingeland Hospital, Doetinchem, The Netherlands Abstract: Unclear etiology in scoliotic and kyphotic deformities of the spine is responsible for uncertainty in treatment options. Normal all-day factors can be of importance. Newly developed or revisited clinical examination of sitting and supine children and consequent testing of neuro-muscular tightness shows to be useful in understanding the different spinal deformations and postural problems during growth and point to neuromuscular tension in growth. The goal is: -Better understanding of the role and individual characteristics of the central nervous system, especially the cord and roots in proper and improper growth of the human spine.- Clarifying that preservation of lordosis and good function at the thoracolumbar junction at the end of growth can be of value for normal configuration and function of the spine in adult life.Present obvious important and consistent clinical observations in children in sitting and supine position with early and advanced adolescent deformities, by photographic studies and video fragments. --Use of work on growth and deformation of the spine by Milan Roth on uncoupled neuro-osseous growth and other historical literature. -Relate these clinical findings and background literature with common knowledge about adolescent spinal deformities and mechanical laws on tensile and compressive forces in structures. Overview of relevant clinical tests in the growing child presented with deformities show possible correlation with the proposed internal balancing problem (uncoupled neuro- osseous growth) researched by Roth. Concomitant radiological and MRI signs are shown. Around 1900 most orthopaedic surgeons and anatomists saw relationship between the new habitude of children to sit for prolonged periods in schools and spinal deformities. A physiological explanation as adaptations needed by the total neuromuscular system (“the growing system”) was widely postulated ( Hueter-Volkmannprinciple) and subject in research but a concise theory was not achieved. By recognising positive effects of creating lordosis at the thoracolumbar junction of the spine and consistent clinical findings in early deformations scientific support was found by earlier experimental work of Roth. With a leading role of the central nervous system in growth of the spine of standing and sitting vertebrates by steering a tension based system, deformation can be understand as adaptations. Consequences for new preventive measures and therapeutic strategies in deformities seems possible Keywords: scoliosis, kyphosis, spinal tension, biomechanics, thoracolumbar spine, osteoneural growth, historic studies

P.J.M. van Loon / Clinical Detectable Tension in the Growing Body

53

1. Introduction If scoliosis and other deformities are assumed to be the visible results (using X-rays as the gold standard for diagnosis) of a mismatch in the speed and control of growth between the different systems of the body and tensile forces which contribute to these differences, it is important to know if these tensile forces (or tensions) are detectable is growing children. If so, new tools in assessment, screening and treatment can be developed. Tension is always present in the musculo-skeletal system. No posture or movement is possible without a certain amount of this tension developing. Roth’s spring models of deformities (Fig. 1 and 2) are ways of understanding the links between these physical forces relating to the complex spine/cord relationships. This paper reviews aspects of the work of Roth in this area, developed in conjunction with his practice devoted to examining children, and highlighting his contribution to scoliosis research, with the object of stimulating debate on his ideas and contributions [1-6]. In 1927, Lambrinudi’s work on scoliosis noted the importance of assessing muscular tightness in the legs in relationship to a progressing spinal deformity [7, 8]. In recent years, I have revisited and incorporated several tests on neuromuscular tightness and the assessing of functional properties of the spine into the clinical investigation of children. Photographs and video-fragments will be used in the lecture to demonstrate this. The tests for tensile forces give clues on factors leading to progression of deformities. These are: 1.) The use of the Adam’s bending test from the posterior (torsion) and the lateral positions; the type of kyphotic curvature present and the likelihood of achieving a horizontal lumbar spine; 2.) A “scoop” test on thoracolumbar extension pattern, using the head coming up first from the bending test with the neck grasped by both hands. A normal spine firstly creates a “scoop” or lordosis at the TL area before the hips extend. Early deformities present as a kyphosis while the hips are extended. 3) A straight leg sitting test on spinal mobility: with tense neuromuscular structures, children without visible deformation in the standing position will sit more on their sacrum than on the ischial tuberosities and will thus not be able to stretch or even lordose their spines. Sitting the subject on the edge of an examination couch gives space for the long lever-arms of the upper legs and restores opportunities for stretching and lordosing the spine. 4.) The Unilateral Straight Leg Raising test in supine children: assessment of the leg-couch angle and/or femorotibial angle: This is widely used in Scheuermann’s disease [9] and is often found different between the left and right sides in scoliosis. In the early progressing phase of scoliosis some real tightness will sometimes be detected. 5.) Bilateral Straight Leg Raising test: tightness will be found when raising the feet in a fixed stretched position of the hips and knees, followed by lifting of the buttocks off the couch, extending up into the whole spine as far as the shoulders. (This is referred to “Brettsteiff” in German ie as stiff as a board). 6.) A ‘Jack in the box’ reflex test: assessment of the protecting tightness while lowering the lifted legs back onto the couch after bilateral straight leg raising. In children with a tense trunk, they lift their head or involuntary assume a more than complete sitting position.

54

P.J.M. van Loon / Clinical Detectable Tension in the Growing Body

The variability found in all these tests is assumed to be dependant on multiple factors like age, gender, joint mobility, familiar predisposition, “stiffness” in gymnastics, phase of growth spurts, results of bodily exercises, good compliance in bracing etc. It makes scientific, reproducible measurements less reliable than the gold standard used for measurements on X-rays and has had to be interpreted on an individual basis. An important issue is the visualisation and recognition of the children and their parents of the sometimes unusual findings in these tests. Their subsequent disappearence as a result of good exercise or brace compliance offers a positive psychological effect in normally long-term treatment. Where do these tests fits in the neurovertebral and osteoneural growth relations? As discussed elsewhere in this volume in the context of the contributions of Milan Roth to understanding scoliosis, his views on the causation of scoliosis state that: “Idiopathic scoliosis may be interpreted as an adaptive morphogenetic reaction of the vertebral column upon the growth insufficiency of the intraspinal nervous structures: The growth process of the vertebral column, though continuing undisturbed at the cellular level, is adapted at the organ level by “waves” to the growth-insufficient cordnerve complex with the musculature as the force delivering organ. Morphological features of the scoliotic vertebra together with the typical position of the spinal cord within the spinal canal speak in favour of the suggested vertebro-neural concept which offers a plausible explanation of the congenital and experimental scoliosis as well”.

Figure1 Roth’s simple model using a spring and a thread to represent a scoliotic deformity demonstrate where tensile and compressive forces are located.

P.J.M. van Loon / Clinical Detectable Tension in the Growing Body

55

Figure 2 Roth’s simple model using a spring and a thread to represent a kyphotic deformity demonstrate where tensile and compressive forces are located. As in figure 1 changing terms as lordosis or scoliosis into unilateral compression and contra lateral distraction or shortening and lengthening helps in understanding the role of tension as a present force.

Roth is equally clear about what happens in adjusting growing forces, and the therapeutic implications this might have: “Adjustment or rectification of the deformed structure like a scoliotic spine is not accompanied by lengthening, notwithstanding the fact that the scoliotic trunk is elongated; the curved spine is adjusted, not lengthened. The adjustment involves a contraction or reduction of the convexe side of the discs. Consequently in adjusting– paradoxally but irrefutably- the spinal canal is rather shortened”. In our opinion he considered that the natural actions embodied within the HueterVolkmann principle could be reversed by an elastic (tensile) deforming force. The question is now posed relating to how we can achieve modifying the position and curvature of the spine so that these tensile forces and their producing muscles can be addressed. It should be noted that providing the answer to this question was not the principle object of Roth’s research. However, some clues, which might lead to an answer to the problem, can be found elsewhere in Roth’s work. Here, he stated that a lordotic form of the lumbar and thoracolumbar spine is of great importance for proper function of this complex and mobile region of the spine in childhood. This would then facilitate an improved function within the lower thoracic ribs cage, which are elevated by muscular forces and also retro-pulsed themselves. The bellows-like function of the diaphragm is also optimised by these actions. The practical outcomes of this hypothesis will be discussed later. 2. Disproportionate growth Roth paved the way to develop a new framework of neurovertebral and osteoneural growth relations, which would allow research into these concepts of etiology of scoliosis. By introducing the research community to the work of previous generations

56

P.J.M. van Loon / Clinical Detectable Tension in the Growing Body

of scientists, like Roth, there is hope to stimulate debate and new directions of research with modern-time possibilities[10-13]. For us, Roth’s findings on disproportionate growth mean that an elegant incorporation of his concepts into modern research becomes possible. By developing these concepts, a new coherent system of interdependent hypotheses for the explanation of growth, and the (mal) functioning of the spine and the cord may be advanced. If form always follows function and no (muscular) function is without purpose, osteoneural growth relations are controlled. In turn, this could give us clues for formulating further research on proper treatment or prevention. How did we get to this statement? The published work of Roth had to be reconciled with other studies of natural behaviour: 1 the very interesting work of Gracovetsky and Farfan on the optimum spine or where nature is heading for; 2 with developments in the last ten years in biomechanics or how does nature do things in order to copy this (robotology, prosthesiology), 3 with own clinical observations on tension related features or how nature shows itself For me, the most elegant feature of these three concepts is that of the connecting element or type of forces that connects all of these three concept lines This is tension in its different manifestations and this, natural, element that is able to withstand gravity should be incorporated into orthopaedic biomechanical knowledge 3. The elements of the new concepts The formulation of the main elements of this system of concepts fall into three parts. 3.1 Roth’s concept of disproportionate growth of the cord vs. the skeleton. Roth’s concept of neurovertebral and osteoneural growth relations of the cord vs. the skeleton(and joints and discs) implies that there should be a clear and challenging domain for what triggers the manifestation of several spinal deformities. It means that research in this field can then be directed from nowadays interest in bone growth and hormonal pathways towards the causes of differences in the quality of cord stretching and the intrinsic role of growth spurts in that type of growth. While this is not the normal domain for orthopaedic surgeons, it does set a clear agenda for co-operation with geneticists, neurologists, neurosurgeons and paediatricians to research these concepts further. The way disproportionate growth manifests itself in a (de) formation of the spine however is another separate subject and field of research. There clinical tests and practical possibilities to intervene (exercises, bracing) to stop progression or correct already present deformities come into the practice of orthopaedics. From this presumed cause of conflicting elements in two types of growth in one body that works out in the actual formation of the spine then divides in two different concepts. 3.2 How normal movements and posture create the shape of the spine. In this area, we feel very comfortable with the progress in biomechanics that has been made in the last ten years. New ideas and concepts have been developed particularly by Gracovetsky and Farfan [14, 15]. In their work on the optimum spine, but also by

P.J.M. van Loon / Clinical Detectable Tension in the Growing Body

57

several other authors [16, 17]. Movement is necessary for proper development of a child’s body. The issue what could be suggested or added in those research lines is getting improved knowledge of characteristics of the thoracolumbar area in a good functioning spine as in pre-adolescents and the role of always present tensile forces in a living body. 3.3 How moulding and shape of the bony elements of the spine occurs. Given the concepts embodied in ideas 1 and 2, how does moulding (in embryologic and postnatal growth) of the bony elements of the spine occur? We consider that, for proper understanding, a “multi-component mortar” concept is required. Bone tissue grows by normal cell divisions as a part of the normal cell cycle. Every bony element is a result of generation (osteoblasts) and degeneration (osteoclasts) of cells where the pace of cell division creates the shape as we see it. It is also known that the resultant pace of growth is different throughout all bony structures. In the concept of “multi component mortar”, tension as an underestimated natural force forms the activating component that then triggers the other biochemical components of the “mortar” to format certain dimensions. This is very well researched in trees with applications in engeneering18, 19 4. Conclusion: the application of the concepts. In practice and through recent research, I have concentrated on applying the concepts under 1 and 2 on how to restore spinal deformities following the principles as stated by Roth. My conclusion is that restoring lordosis through the thoracolumbar joint appears to be the key to achieving the appropriate adjustments to the total, inter-connected components of the spine. The thoracolumbar joint function in what should, or can, be seen as a three-dimensional hinge in a complex, connected inverted pendulum, the spine, strives to maintain an equilibrium state. Where form follows function, the coordinated neuro-muscular tension of the dynamic tension cables, the musculature, directs the positioning and form of the bony structures in order to create an intrinsically well-balanced system. In our recent article in Spine 2008 we presented what might be called a controlled test of the principle of the working of lordotic intervention [20]. We tested the hypothesis that correction of scoliosis may benefit from a lordotic fulcrum force in the sagittal plane on the thoracolumbar spine. The results were statistically significant. Additionally, during the last five years we have developed a spinal correction method based on this principle called thoracolumbar lordotic intervention (TLI). As a matter of fact not yet published on the neuromechanic but only biomechanic results I consequently experienced in the performance of pedicle subtraction osteotomies at the thoracolumbar spine in deformities a impressive tension releasing feature [21]. In TLI-bracing we do not put corrective force on the bone structures, but more logically, onto the tension cables, namely the muscles. Rearrangement of tensile forces is required because of a complete chance in the postural balance. Instead of a slight or clear flexed trunk position, we restore antero-posterior curvatures, and thus, this rearrangement of masses and muscle forces needed to control balance will end in a corrected three-dimensional posture. Then the presence or need of “tight hamstrings” disappears. We gently force the child’s growing body to auto correct the deformity

58

P.J.M. van Loon / Clinical Detectable Tension in the Growing Body

while we focus on intervening only in the sagittal plane. Shoulders and buttocks regain their relative posterior position, while the thoracolumbar area is passively and actively placed at a more anterior position. The first results in this type of “conservative” treatment were presented at the SOSORT-Athens 2008 meeting giving strong support to the incorporation of Roth’s work in further therapeutic directions. To revisit older or almost forgotten work of earlier scientists, not only in orthopaedics but other fields, allows the possibilities of linking such concepts and ideas together leading to an innovative path for a range of medical and scientific disciplines. References [1] [2] [3] [4] [5] [6] [7] [8] [9] [10]

[11]

[12]

[13]

[14] [15] [16] [17] [18] [19] [20]

[21]

Roth M. [Some normal and pathologic aspects of growth relations between the spinal cord and the spine in the pneumomyelographic picture]. Cesk Radiol 1967 Jan;21(1):1-12. Roth M. Idiopathic scoliosis caused by a short spinal cord. Acta Radiol Diagn (Stockh) 1968 May;7(3):257-71. Roth M. [Relative osteo-neural growth--some phylogenetic, ontogenetic and clinical aspects]. Radiol Diagn (Berl) 1971;12(1):81-97. Roth M. [Morphogenesis of physiological and developmentally conditioned pathological curvatures of the spine]. Cesk Radiol 1972 Jul;26(4):179-88. Roth M. [Neuromorphology of joint movement]. Cesk Neurol Neurochir 1981 Nov;44(6):341-9. Roth M. [Idiopathic scoliosis and Scheuermann's disease: essentially identical manifestations of neurovertebral growth disproportion]. Radiol Diagn (Berl) 1981;22(3):380-91. Lambrinudi C. A method of treating lumbar scoliosis. Proceedings of the Royal Society of Medicine 1927. Lambrinudi C. Adolescent and senile kyphosis. British Medical Journal 1934;2:800-4. Hosman AJ, de KM, Anderson PG, van LJ, Langeloo DD, Veth RP, et al. Scheuermann kyphosis: the importance of tight hamstrings in the surgical correction. Spine 2003 Oct 1;28(19):2252-9. Chu WC, Lam WW, Chan YL, Ng BK, Lam TP, Lee KM, et al. Relative shortening and functional tethering of spinal cord in adolescent idiopathic scoliosis?: study with multiplanar reformat magnetic resonance imaging and somatosensory evoked potential. Spine 2006 Jan 1;31(1):E19-E25. Chu WC, Ng BK, Li AM, Lam TP, Lam WW, Cheng JC. Dynamic magnetic resonance imaging in assessing lung function in adolescent idiopathic scoliosis: a pilot study of comparison before and after posterior spinal fusion. J Orthop Surg 2007;2:20. Chu WC, Man GC, Lam WW, Yeung BH, Chau WW, Ng BK, et al. A detailed morphologic and functional magnetic resonance imaging study of the craniocervical junction in adolescent idiopathic scoliosis. Spine 2007 Jul 1;32(15):1667-74. Chu WC, Man GC, Lam WW, Yeung BH, Chau WW, Ng BK, et al. Morphological and functional electrophysiological evidence of relative spinal cord tethering in adolescent idiopathic scoliosis. Spine 2008 Mar 15;33(6):673-80. Gracovetsky S, Farfan H. The optimum spine. Spine 1986 Jul;11(6):543-73. Gracovetsky S. An hypothesis for the role of the spine in human locomotion: a challenge to current thinking. J Biomed Eng 1985 Jul;7(3):205-16. Cholewicki J, Panjabi MM, Khachatryan A. Stabilizing function of trunk flexor-extensor muscles around a neutral spine posture. Spine 1997 Oct 1;22(19):2207-12. MacKinnon CD, Winter DA. Control of whole body balance in the frontal plane during human walking. J Biomech 1993 Jun;26(6):633-44. Mattheck Claus. Biomechanical Optimum in Wooden Stems. In: Barbara L.Gartner, editor. Plant Stems: Physiology and Functional Morphology. Academic Press; 1995. Mattheck C, Bethge K, Erb D, Blomer W. Successful shape optimisation of a pedicular screw. Med Biol Eng Comput 1992 Jul;30(4):446-8. van Loon PJ, Kuhbauch BA, Thunnissen FB. Forced lordosis on the thoracolumbar junction can correct coronal plane deformity in adolescents with double major curve pattern idiopathic scoliosis. Spine 2008 Apr 1;33(7):797-801. van Loon PJ, van SG, van Loon CJ, van Susante JL. A pedicle subtraction osteotomy as an adjunctive tool in the surgical treatment of a rigid thoracolumbar hyperkyphosis; a preliminary report. Spine J 2006 Mar;6(2):195-200.

Chapter 3 Biomechanics, Surface Topography and Imaging

This page intentionally left blank

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-61

61

4XDQWLILFDWLRQRILQWHUYHUWHEUDOHIIRUWVGXULQJ ZDONLQJFRPSDULVRQEHWZHHQDKHDOWK\DQGD VFROLRWLFVXEMHFW 0 5$,621&e $8%,1& '(75(0%/(853 ),6(77( DQG- & 6$0,1

8QLYHUVLWpFDWKROLTXHGH/RXYDLQ8&/ &HQWUHIRU5HVHDUFKLQ0HFKDWURQLFV &(5(0 /RXYDLQOD1HXYH%HOJLXP (FROH3RO\WHFKQLTXHGH0RQWUpDO 6DLQWH-XVWLQH8QLYHUVLW\+RVSLWDO&HQWHU 0RQWUpDO4XpEHF 8QLYHUVLWpFDWKROLTXHGH/RXYDLQ8&/ 5HKDELOLWDWLRQDQG3K\VLFDO0HGLFLQH8QLW 5($' &OLQLTXH6DLQW/XF%UX[HOOHV%HOJLXP $EVWUDFW 7KH DFFXUDWH TXDQWLILFDWLRQ RI LQWHUQDO HIIRUWV LQ WKH KXPDQ ERG\ LV VWLOO D FKDOOHQJH LQ ELRPHFKDQLFV 7KH DLP RI WKLV VWXG\ LV WR TXDQWLI\ WKH LQWHUYHUWHEUDO HIIRUWV DORQJ WKH VSLQH GXULQJ ZDONLQJ LQ RUGHU WR FRPSDUH WKH G\QDPLFDO EHKDYLRXUV EHWZHHQ D KHDOWK\ DQG D VFROLRWLF VXEMHFW 3UDFWLFDOO\ RQH KHDOWK\ VXEMHFW RQH VFROLRWLFSDWLHQW EHIRUHDQLQVWUXPHQWDWLRQ VXUJHU\&REE DQGDIWHUWKLVLQVWUXPHQWDWLRQ&REE ZDONHG RQDWUHDGPLOODWNPK7KHDFTXLVLWLRQ V\VWHP LQFOXGHG RSWRNLQHWLF VHQVRUV UHFRUGLQJ WKH 'MRLQW FRRUGLQDWHV D WUHDGPLOO HTXLSSHG ZLWK VWUDLQ JDXJHVPHDVXULQJWKHH[WHUQDOIRUFHVLQGHSHQGHQWO\DSSOLHGWRERWKIHHWDQGELSODQDUUDGLRJUDSKV HQDEOLQJWKH'UHFRQVWUXFWLRQRIWKHVSLQHIURP&WR/XVLQJDIUHHIRUPLQWHUSRODWLRQWHFKQLTXH 7KHLQWHUYHUWHEUDOHIIRUWVZHUHFRPSXWHGXVLQJDQLQYHUVHG\QDPLFDOPRGHORIWKHKXPDQERG\LQ' $V UHVXOWV VLJQLILFDQW GLIIHUHQFHV RI WKH VSLQH NLQHPDWLFV ZHUH UHFRUGHG ZKLFK OHDG WR GLIIHUHQW LQWHUQDOHIIRUWEHKDYLRXULQPDJQLWXGHVKLIWFRRUGLQDWLRQDQGSDWWHUQZKHQQRUPDOL]HGWRWKHVXEMHFW PDVV 3DUWLFXODUO\ WKH QRUPDOL]HG DQWHURSRVWHULRU LQWHUYHUWHEUDO WRUTXHV DUH OHVV XQLIRUP IRU WKH VFROLRWLFSDWLHQWIURPPLQWRPD[1PNJ WKDQWKHKHDOWK\VXEMHFWIURPWR1PNJ 7KLV GLVHTXLOLEULXP LQ WKH OHIWULJKW EDODQFH RI WKH VFROLRWLF SDWLHQW LV D ELW UHFWLILHG DIWHU VXUJHU\ IURP WR1PNJ .H\ZRUGV,GLRSDWKLF VFROLRVLVJDLWLQWHUYHUWHEUDOHIIRUWV PXOWLERG\G\QDPLFV VSLQH PRGHOLQJGXDONULJLQJ

,QWURGXFWLRQ

7KHLQYLYRDFFXUDWHTXDQWLILFDWLRQRILQWHUQDOHIIRUWVLQWKHKXPDQERG\LVVWLOODFKDOOHQJH LQ ELRPHFKDQLFV 7KLV TXDQWLILFDWLRQ FRXOG HQKDQFH UHKDELOLWDWLRQ WRROV IRU SDWLHQWV ZLWK PRWLRQOLQNHGSDWKRORJLHV7KHSXUSRVHRIWKLVVWXG\LVWKHTXDQWLILFDWLRQRILQWHUYHUWHEUDO HIIRUWV DORQJ WKH VSLQH GXULQJ ZDONLQJ LQ RUGHU WR FRPSDUH WKH G\QDPLFDO EHKDYLRXU EHWZHHQD KHDOWK\DQG DVFROLRWLFVXEMHFW

62

M. Raison et al. / Quantiﬁcation of Intervertebral Efforts During Walking

0HWKRGV

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

)LJXUH *HQHUDOSULQFLSOHRIWKLV PHWKRGWRTXDQWLI\WKHLQWHUYHUWHEUDOHIIRUWVGXULQJJDLW

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

& T &&)H[W0H[WJ 4= ITT

M. Raison et al. / Quantiﬁcation of Intervertebral Efforts During Walking

63

& DQG T && DQG UHSUHVHQWV WKH LQYHUVH G\QDPLFDO ZKHUH I LV D IXQFWLRQ RI TT PRGHO RI WKH KXPDQ ERG\ RQ WKH EDVLV RI WKH H[WHUQDO IRUFHV )H[W DQG WRUTXHV 0H[W DSSOLHGWRWKHV\VWHPDQGDOVRJUDYLW\ /HW XV QRWH WKDW WKHVH HTXDWLRQV ZHUH V\PEROLFDOO\ JHQHUDWHG E\ WKH 5RERWUDQ VRIWZDUH >@ GHYHORSHG DW WKH &(5(0 ± 8&/ ZKLFK DOORZV XV WR VWUDLJKWIRUZDUGO\ LQWHUIDFH WKHVH HTXDWLRQV ZLWK DQ\ QXPHULFDO SURFHVV VXFK DV WKHRSWLPL]DWLRQSURFHVVSUHVHQWHGDERYHDQGWKHWLPHVLPXODWLRQRIWKHWULDOV

5HVXOWV

6LJQLILFDQW GLIIHUHQFHV RI WKH VSLQH NLQHPDWLFV ZHUH UHFRUGHG ZKLFK OHDG WR GLIIHUHQW LQWHUQDOHIIRUWEHKDYLRXULQPDJQLWXGHVKLIWFRRUGLQDWLRQDQGSDWWHUQZKHQQRUPDOL]HGWR WKHVXEMHFWPDVV

E

D

F )LJXUH)RUD WKHKHDOWK\VXEMHFWE WKHVFROLRWLFSDWLHQWEHIRUHLQVWUXPHQWDWLRQVXUJHU\DQGE WKLVVFROLRWLF SDWLHQW DIWHU VXUJHU\ DOO ZDONLQJ DW NPK RQ D WUHDGPLOO FRPSDULVRQ EHWZHHQ DQWHURSRVWHULRU LQWHUYHUWHEUDO WRUTXHV FRUUHVSRQGLQJ WR WKH VSLQH H[WUHPLWLHV 0VDFUXP/ DQG 0'& WKH DSLFHV 0'' DQG 0'' DQG WKH PD[LPDOODWHUDOLQIOH[LRQ0'' RIWKHVFROLRWLFSDWLHQW

)LJXUH VKRZVVLJQLILFDQWGLIIHUHQFHVEHWZHHQWKHWKUHHFDVHV • 7KH PD[LPDO DEVROXWH PDJQLWXGH RI WKH QRUPDOL]HG DQWHURSRVWHULRU WRUTXHV 1$37 LV KLJKHU IRU WKH VFROLRWLF SDWLHQW EHIRUH VXUJHU\ 1PNJ WKDQ WKLV SDWLHQWDIWHUVXUJHU\ 1PNJ DQG WKHKHDOWK\VXEMHFW1PNJ • 7KH1$37PD[LPDDQGPLQLPDDUHUDWKHUV\PPHWULFDOIRUWKHKHDOWK\VXEMHFW DQG 1PNJ UHVS ZKLOH WKH VFROLRWLF SDWLHQW EHIRUH VXUJHU\ SUHVHQWV D

64

M. Raison et al. / Quantiﬁcation of Intervertebral Efforts During Walking

•

•

VLJQLILFDQW1$37VKLIWRI1$37PD[LPDDQGPLQLPDDQG1PNJUHVS WKDWUHSUHVHQWVDGLVHTXLOLEULXPLQWKHOHIWULJKWEDODQFHRIYHUWLFDOIRUFHVEHWZHHQ YHUWHEUDHWKLVVKLIWLVDELWUHFWLILHGIRUWKHVFROLRWLFVXEMHFWDIWHUVXUJHU\ DQG 1PNJUHVS 7KH 1$37 JHQHUDO SDWWHUQV SUHVHQW FOHDU ©FUHQHOW\SHª OHIWULJKW VZLQJV IRU WKH KHDOWK\ VXEMHFW D PRUH SHUWXUEHG DQG PRUH ©UDPSW\SHª EHKDYLRXU IRU WKH VFROLRWLF SDWLHQW EHIRUH VXUJHU\ DQG ILQDOO\ D UDWKHU ©FUHQHOW\SHª VZLQJ DQG VPRRWKHUJDLWIRUWKH VFROLRWLFSDWLHQW DIWHUVXUJHU\ )RU WKH VFROLRWLF SDWLHQW EHIRUH VXUJHU\ WKH 1$37 DUH VLJQLILFDQWO\ GLIIHUHQW EHWZHHQ HDFK YHUWHEUD ZKLOH WKHVH HIIRUWV DUH UDWKHU VLPLODU IRU HDFK YHUWHEUD FRQFHUQLQJWKHVFROLRWLFSDWLHQWDIWHUVXUJHU\DQGWKHKHDOWK\VXEMHFW

'LVFXVVLRQDQGFRQFOXVLRQV

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

$FNQRZOHGJHPHQWV )XQGHGE\ WKH )45174XHEHF

5HIHUHQFHV >@ >@ >@ >@

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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-65

65

0HDVXULQJWKH5LE+XPSLQ6FROLRVLVZLWK ,6,6 )%HUU\PDQ 33\QVHQW-)DLUEDQN

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±PPVGPP DQGWKHWROHUDQFHOLPLWVZHUH±PPWR PP&KDQJHVRIJUHDWHUWKDQPPDUHWKHUHIRUH QHFHVVDU\DVLQGLFDWLYHRIFOLQLFDOFKDQJH .H\ZRUGV,6,6VFROLRVLVULEKXPSYLVXDOLVDWLRQ

,QWURGXFWLRQ 7KH JROG VWDQGDUG PHWKRG RI DVVHVVLQJ EDFN GHIRUPLW\ LQ VFROLRVLV LV WKH &REE DQJOH +RZHYHU SDWLHQWV DUH JHQHUDOO\ PRUH FRQFHUQHG DERXW WKHLU ULE KXPSV DQG WKHUH LV QRW QHFHVVDULO\ D GLUHFW UHODWLRQVKLS EHWZHHQ &REE DQJOH DQG WKH PDJQLWXGH RI WKH KXPS $ PHWKRG RI DVVHVVLQJ WKH KXPS ZRXOG WKHUHIRUH EH XVHIXO WR VSLQDO VXUJHRQV DQG SDWLHQWV DOLNHHVSHFLDOO\LILWZDVQRQLQYDVLYH

0HWKRGV 7KHWKUHHGLPHQVLRQDOVKDSHRIDSDWLHQW¶VEDFNLVPHDVXUHGXVLQJGLJLWDOSKRWRJUDSK\DQG VWUXFWXUHGOLJKWXVLQJ,6,6>@DQRQFRPPHUFLDOVXUIDFHWRSRJUDSK\V\VWHP7KHKHLJKW RI WKH VXUIDFH LV FDOFXODWHG XVLQJ )RXULHU WUDQVIRUP SURILORPHWU\ ZLWK DQ DFFXUDF\ RI ±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

66

F. Berryman et al. / Measuring the Rib Hump in Scoliosis with ISIS2

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±PP VG DQG WKH WROHUDQFHOLPLWVFRYHULQJRIWKHSRSXODWLRQ>@ZHUH ±WRPP

)LJXUH([DPSOHRIZLUHIUDPHDQGFRQWRXUSORWV

F. Berryman et al. / Measuring the Rib Hump in Scoliosis with ISIS2

67

)LJXUH%ODQG$OWPDQ SORWIRUULEKXPSPHDVXUHGZLWK,6,6

'LVFXVVLRQDQGFRQFOXVLRQ 7UDGLWLRQDOO\SDWLHQWVZLWKVFROLRVLVDUHDVVHVVHGE\PHDVXULQJWKHLUVSLQDOFXUYDWXUHLQWKH FRURQDOSODQHXVLQJUDGLRJUDSK\>@+RZHYHUUDGLRJUDSK\SURYLGHVQRLQIRUPDWLRQDERXW WKH VL]HRI DQ\ ULE KXPSWKDW LV SUHVHQW 3DWLHQWV WHQGWR EH PRUH LQWHUHVWHG LQWKHLU EDFN VKDSH ±ZKDWWKHLUEDFNORRNVOLNHDQGKRZWKHLUFORWKHVKDQJ&RVPHWLFIDFWRUVVXFKDVVL]H RIULEKXPSSOD\DODUJHSDUWLQWKHUHTXLUHPHQWIRUWUHDWPHQW>@6XUIDFHWRSRJUDSK\FDQ SURYLGHWKLVH[WUDLQIRUPDWLRQ7KHZLUHIUDPHDQGFRQWRXUSORWVSURGXFHGE\,6,6SUHVHQW TXDQWLWDWLYHLQIRUPDWLRQRQEDFNVKDSHDQGSURYLGHDXVHIXOSLFWRULDOUHSUHVHQWDWLRQRIWKH ZKROH EDFN SURYLGLQJ WKH VXUJHRQ DQG SDWLHQW ZLWK DQ DGGLWLRQDO REMHFWLYH WRRO IRU DVVHVVLQJEDFNVKDSH 7KHSDLUHGWHVWLQJVKRZHGWKDWWKHYDULDWLRQLQKXPSKHLJKWEHWZHHQPHDVXUHPHQWVLV UHODWLYHO\KLJKFRQILGHQFHOLPLWVEHLQJMXVWXQGHUPP&KDQJHVLQKXPSKHLJKW RIOHVVWKDQPPLQ,6,6FDQWKHUHIRUHQRWEHUHJDUGHGDVLQGLFDWLYHRIFOLQLFDOFKDQJH 7KLVYDULDWLRQUHIOHFWVWKHQDWXUDOFKDQJHVLQWKHVXUIDFHVKDSHFDXVHGE\VWDQFHEUHDWKLQJ DQG PXVFOH WHQVLRQ 1R SUHYLRXV PHDVXUHPHQWV RI YDULDELOLW\ LQ VXFK D SDUDPHWHU FDQ EH IRXQGLQWKHOLWHUDWXUHIRUFRPSDULVRQ 5HSUHVHQWLQJWKHVKDSHRIWKHEDFNLQDVLQJOHQXPHULFDOSDUDPHWHUUHPDLQVDGLIILFXOW SUREOHPDQGRXUUHVHDUFKFRQWLQXHVWRWU\WRLPSURYHWKHFRUUHODWLRQRISDUDPHWHUVREWDLQHG IURPQRQLQYDVLYHVXUIDFHWRSRJUDSK\ZLWKWKHRSLQLRQVRI WKHSDWLHQWDQGVXUJHRQ 5HIHUHQFHV >@ ) %HUU\PDQ 3 3\QVHQW - )DLUEDQN DQG 6 'LVQH\ $ QHZ V\VWHP IRU PHDVXULQJ WKUHHGLPHQVLRQDO EDFN VKDSHLQVFROLRVLV (XURSHDQ6SLQH-RXUQDO LQSUHVV >@ 0 %ODQG DQG ' $OWPDQ 6WDWLVWLFDO PHWKRGV IRU DVVHVVLQJ DJUHHPHQW EHWZHHQ WZR PHWKRGV RI FOLQLFDO PHDVXUHPHQW/DQFHW ± >@ 06FKRUNDQG55HPLQJWRQ6WDWLVWLFVZLWKDSSOLFDWLRQVWRWKHELRORJLFDODQGKHDOWKVFLHQFHV3UHQWLFH+DOO 8SSHU6DGGOH5LYHU1- >@ -&REE2XWOLQHIRUWKHVWXG\RIVFROLRVLV$PHULFDQ$FDGHP\RI2UWKRSHGLF6XUJHRQV,QVWUXFWLRQDO&RXUVH /HFWXUHV ± >@ 77KHRORJLV5-HIIHUVRQ$6LPSVRQ$7XUQHU6PLWKDQG-)DLUEDQN4XDQWLI\LQJWKHFRVPHWLFGHIHFWRI DGROHVFHQWLGLRSDWKLFVFROLRVLV 6SLQH ±

68

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-68

7KRUDFLF.\SKRVLV$QJOH0HDVXUHPHQWV ZLWK,6,6 )%HUU\PDQ 33\QVHQW-)DLUEDQN

8QLYHUVLW\RI:ROYHUKDPSWRQ6FKRRORI(QJLQHHULQJDQGWKH%XLOW(QYLURQPHQW7HOIRUG 8. 5HVHDUFKDQG7HDFKLQJ&HQWUH5R\DO2UWKRSDHGLF+RVSLWDO%LUPLQJKDP8. 1XIILHOG2UWKRSDHGLF&HQWUH2[IRUG8. $EVWUDFW7KRUDFLFN\SKRVLVDQJOHPHDVXUHPHQWVXVLQJVXUIDFHWRSRJUDSK\ZLWK,6,6ZHUHFDUULHG RXW WR HVWLPDWH WKH LQKHUHQW YDULDELOLW\ LQ WKH SDUDPHWHU FDXVHG E\ QDWXUDO FKDQJH LQ WKH SDWLHQW¶V VWDQFH EUHDWKLQJDQG PXVFOH WHQVLRQ $ PHDQN\SKRVLVDQJOHRIVGUDQJH ZDV PHDVXUHG IURPUHSHDWWHVWVRQSDWLHQWV7KH PHDQGLIIHUHQFHEHWZHHQWKH SDLUV RI PHDVXUHPHQWV ZDV ±VG DQGWKHWROHUDQFHOLPLWVZHUH ±WR7KLV YDULDELOLW\LVORZHUWKDQ WKHFOLQLFDOO\VLJQLILFDQW FKDQJH LQN\SKRVLVDQJOHUHSRUWHGLQWKHOLWHUDWXUH7KXVN\SKRVLVDQJOHLQ ,6,6LVVXLWDEOHIRUPRQLWRULQJSURJUHVVLQN\SKRWLFGHIRUPLWLHV .H\ZRUGV ,6,6N\SKRVLV

,QWURGXFWLRQ

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¶VVXLWDELOLW\IRUGHWHFWLQJFOLQLFDOO\VLJQLILFDQWFKDQJH LQSDWLHQWVZLWKN\SKRWLFGHIRUPLWLHV

F. Berryman et al. / Thoracic Kyphosis Angle Measurements with ISIS2

)LJXUH([DPSOHRISDWLHQWLPDJH

69

)LJXUH.\SKRVLVDQJOHPHDVXUHPHQW

0HWKRGV

6PDOOWXUTXRLVHVWLFNHUVZHUHSODFHGRQWKHSDWLHQW¶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

5HVXOWV

6HTXHQWLDO SDWLHQWV DWWHQGLQJ WKH VFROLRVLV FOLQLF ZKHUH WKH VXUJHRQ UHTXHVWHG VXUIDFH WRSRJUDSK\ZHUHDVNHGLIWKH\ZRXOGWDNHSDUWLQWKHSURMHFWDQGWKRVHZKRDJUHHGKDGWKH

70

F. Berryman et al. / Thoracic Kyphosis Angle Measurements with ISIS2

DGGLWLRQDOSKRWRJUDSKWDNHQ7KHSDLUVRISKRWRJUDSKVZHUHDFTXLUHGRYHUDSHULRGRIILYH PRQWKVIRUDWRWDORISDWLHQWV7KHPHDQDJHZDVVGUDQJH± \HDUV 7KH PHDQ N\SKRVLV DQJOH PHDVXUHG RYHU DOO SKRWRJUDSKV ZDV VG UDQJH ± %ODQG$OWPDQ DQDO\VLV >@ ZDV FDUULHG RXW RQ WKH SDLUHG GDWD 7KH GLIIHUHQFHV EHWZHHQWKH SDLUVRI PHDVXUHPHQWV ZHUH FDOFXODWHGDQGWKHPHDQ VWDQGDUG GHYLDWLRQDQG OLPLWVRIDJUHHPHQWFRPSXWHG7KHGLIIHUHQFHVZHUHSORWWHGDJDLQVWWKHPHDQVRIWKHSDLUV DQG DUH VKRZQ LQ )LJXUH ZKHUH QR HYLGHQFH RI ELDV FDQEH VHHQ 7KH PHDQ GLIIHUHQFH EHWZHHQ SDLUV RI PHDVXUHPHQWV RQ WKH SDWLHQWV ZDV ± VG DQG WKH WROHUDQFHOLPLWVFRYHULQJRIWKHSRSXODWLRQ>@ZHUH ±WR

)LJXUH%ODQG$OWPDQSORWIRUN\SKRVLVDQJOHPHDVXUHGZLWK,6,6

'LVFXVVLRQDQGFRQFOXVLRQ

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±&OLQLFDOO\VLJQLILFDQWFKDQJHLQWKRUDFLFN\SKRVLVDQJOHLVDOVRUHSRUWHGHOVHZKHUHLQ WKHOLWHUDWXUHDVJUHDWHUWKDQ>@ $VWKHYDULDELOLW\LQ,6,6WKRUDFLFN\SKRVLVDQJOHLV OHVV WKDQ LW FDQ EH XVHG DV D SDUDPHWHU WR PRQLWRU SURJUHVV RI N\SKRWLF GHIRUPLWLHV

F. Berryman et al. / Thoracic Kyphosis Angle Measurements with ISIS2

71

0RQLWRULQJ E\ VXUIDFH WRSRJUDSK\ SDUDPHWHUV ZLOO UHGXFH WKH H[SRVXUH RI SDWLHQWV WR UDGLDWLRQ 5HIHUHQFHV >@ )%HUU\PDQ3 3\QVHQW-)DLUEDQNDQG6'LVQH\ $QHZ V\VWHP IRU PHDVXULQJWKUHHGLPHQVLRQDO EDFN VKDSHLQVFROLRVLV (XURSHDQ6SLQH-RXUQDO LQSUHVV >@ 0 %ODQG DQG ' $OWPDQ 6WDWLVWLFDO PHWKRGV IRU DVVHVVLQJ DJUHHPHQW EHWZHHQ WZR PHWKRGV RI FOLQLFDO PHDVXUHPHQW/DQFHW ± >@ 0 6FKRUN DQG 5 5HPLQJWRQ 6WDWLVWLFV ZLWK DSSOLFDWLRQV WR WKH ELRORJLFDO DQG KHDOWK VFLHQFHV 3UHQWLFH +DOO8SSHU6DGGOH5LYHU1- >@ '+DUULVRQ5 &DLOOLHW'+DUULVRQ7-DQLNDQG% +ROODQG 5HOLDELOLW\RI FHQWURLG&REEDQG+DUULVRQ SRVWHULRUWDQJHQWPHWKRGVZKLFKWRFKRRVHIRUDQDO\VLVRIWKRUDFLFN\SKRVLV 6SLQH (±( >@ 5 -DFNVRQ DQG $ 0F0DQXV 5DGLRJUDSKLF DQDO\VLV RI VDJLWWDO SODQH DOLJQPHQW DQG EDODQFH LQ VWDQGLQJ YROXQWHHUVDQGSDWLHQWVZLWKORZEDFNSDLQPDWFKHGIRUDJHVH[DQGVL]H6SLQH ± >@ 5 9LDOOH 1 /HYDVVRU / 5LOODUGRQ $ 7HPSOLHU : 6NDOOL DQG 3 *XLJXL 5DGLRJUDSKLF DQDO\VLV RI WKH VDJLWWDODOLJQPHQWDQGEDODQFHRI WKHVSLQHLQDV\PSWRPDWLFVXEMHFWV-RXUQDORI%RQHDQG-RLQW6XUJHU\ $ ± >@ 63URSVW3URFWRUDQG(%OHFN5DGLRJUDSKLFGHWHUPLQDWLRQRIORUGRVLVDQGN\SKRVLVLQQRUPDODQGVFROLRWLF FKLOGUHQ -RXUQDORI3HGLDWULF2UWKRSDHGLFV ± >@ '.ROHVVDU*6WROOVWHLPHUDQG5%HW]7KHYDOXHRIWKHPHDVXUHPHQWIURP77DVDVFUHHQLQJWRROLQ GHWHFWLQJDEQRUPDON\SKRVLV -RXUQDORI6SLQDO'LVRUGHUV ± >@ 6 *RK 5 3ULFH 3 /HHGPDQ DQG . 6LQJHU $ FRPSDULVRQ RI WKUHH PHWKRGV IRU PHDVXULQJ WKRUDFLF N\SKRVLVLPSOLFDWLRQVIRUFOLQLFDOVWXGLHV 5KHXPDWRORJ\ ± >@ '&DUPDQ 5%URZQHDQG- %LUFK 0HDVXUHPHQW RI VFROLRVLVDQGN\SKRVLVUDGLRJUDSKV-RXUQDORI%RQH DQG-RLQW6XUJHU\ $ ± >@ $$ODQD\03HNPH]FL2.DUDHPLQRJXOODUL($FDURJOX0@ 3-XWWH6:XLWH%7KH5YDQ$OWHQDDQG$9HOGKXL]HQ3UHGLFWLRQRIGHIRUPLW\LQVSLQDOWXEHUFXORVLV &OLQLFDO2UWKRSDHGLFVDQG5HODWHG5HVHDUFK ±

72

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-72

6DJLWWDODOLJQPHQWFRUUHFWLRQRIWKH WKRUDFROXPEDUMXQFWLRQLQLGLRSDWKLFVFROLRVLV E\LQVLWXEHQGLQJWHFKQLTXH <3&+$5/(610(<(5 -367(,% 6HUYLFHGH&KLUXUJLHGX5DFKLV+{SLWDX[8QLYHUVLWDLUHVGH6WUDVERXUJ)UDQFH 'pSDUWHPHQWGH6DQWp3XEOLTXH+{SLWDX[8QLYHUVLWDLUHVGH6WUDVERXUJ)UDQFH

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¶V 1DVK DQG 0RH¶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

,QWURGXFWLRQ

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

Y.P. Charles et al. / Sagittal Alignment Correction of the Thoracolumbar Junction

73

PHDQVRIDOWHUQDWHPHGLDOL]DWLRQLQWKHIURQWDOSODQHDQGLQFUHDVHRIN\SKRVLVDQGORUGRVLV LQWKHVDJLWWDOSODQHZKLOHGHURWDWLRQLVPDLQWDLQHGPDQXDOO\ 7KHSXUSRVHRIWKLVVWXG\ZDVWRLGHQWLI\W\SLFDOSDWWHUQVE\FRPSDULQJIURQWDOSODQH GHIRUPLWLHV DQG YHUWHEUDO URWDWLRQ OHDGLQJ WR D VDJLWWDO UHFWLWXGH DW WKH WKRUDFROXPEDU MXQFWLRQ 7KH UHOHYDQFH RI WKLV SDUWLFXODU GHIRUPLW\ IRU VXUJLFDO FRUUHFWLRQ E\ LQ VLWX EHQGLQJDQGSRVWRSHUDWLYHWKRUDFROXPEDUDOLJQPHQWZHUHWKHQDQDO\]HG

0DWHULDOVDQG0HWKRGV

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ȤðWHVW$GHWDLOHG SUHDQGSRVWRSHUDWLYHDQDO\VLVRIWKHWKRUDFROXPEDUMXQFWLRQZDVSHUIRUPHGE\FRPSDULQJ WKH QXPEHU RI OHYHOV WKDW GLVDSSHDUHG IURP WKH ]RQH RI UHFWLWXGH DIWHU LQ VLWX EHQGLQJ PDQHXYHUVDQG WKHQXPEHU RI OHYHOV WKDWUHPDLQHGLQ WKLV]RQH7KH VLJQLILFDQFH OHYHO LQ WKLVVWXG\ZDVVHWDWS

5HVXOWV

3UH DQG SRVWRSHUDWLYH DYHUDJH YDOXHV DQG VWDQGDUG GHYLDWLRQV RI &REE DQJOHV WKRUDFLF N\SKRVLVOXPEDUORUGRVLV7DQG7WLOWSHOYLFWLOWSHOYLFLQFLGHQFHDQGVDFUDOVORSHDUH

74

Y.P. Charles et al. / Sagittal Alignment Correction of the Thoracolumbar Junction

FRPSDUHGLQ7DEOH&REEDQJOHVRISULPDU\FXUYHVUDQJHGEHWZHHQDQGGHJUHHV SUHRSHUDWLYHO\EHWZHHQDQGGHJUHHVSRVWRSHUDWLYHO\&REEDQJOHRIVHFRQGDU\FXUYHV UDQJHG EHWZHHQ DQG GHJUHHV SUHRSHUDWLYHO\ EHWZHHQ DQG GHJUHHV SRVWRSHUDWLYHO\7KHVXUJLFDOFRUUHFWLRQRIWKHVHSDUDPHWHUVLQWKHIURQWDOSODQHZDVKLJKO\ VLJQLILFDQW $OWKRXJK WKH UHGXFWLRQ RI WKH VSLQDO GHIRUPLW\ ZDV ' JOREDO VDJLWWDO SDUDPHWHUVDVZHOODVSRVLWLRQDODQGDQDWRPLFDOVSLQRSHOYLFPHDVXUHPHQWVZHUHQRWFOHDUO\ LQIOXHQFHGE\VXUJHU\

3UHRSHUDWLYH $YHUDJH6'

3RVWRSHUDWLYH $YHUDJH6'

3YDOXH

&REESULPDU\FXUYH

&REEVHFRQGDU\FXUYH

77N\SKRVLV

//ORUGRVLV

7WLOW

7WLOW

3HOYLFWLOW

3HOYLFLQFLGHQFH

6DFUDOVORSH

3DUDPHWHU

7DEOH3UH DQGSRVWRSHUDWLYHUDGLRJUDSKLFPHDVXUHPHQWVGHJUHHV RI&REEDQJOHVDQGVDJLWWDOSDUDPHWHUV

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

Y.P. Charles et al. / Sagittal Alignment Correction of the Thoracolumbar Junction

75

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

76

Y.P. Charles et al. / Sagittal Alignment Correction of the Thoracolumbar Junction

)LJXUH &UDQLDOSURORQJDWLRQRIUHFWLWXGHLQPDLQWKRUDFLFFXUYHDQGSRVWRSHUDWLYHFRUUHFWLRQ

)LJXUH &UDQLDODQGFDXGDOSURORQJDWLRQRIUHFWLWXGHLQGRXEOHPDMRUFXUYHDQGSRVWRSHUDWLYHFRUUHFWLRQ

Y.P. Charles et al. / Sagittal Alignment Correction of the Thoracolumbar Junction

77

)LJXUH &DXGDOSURORQJDWLRQRIUHFWLWXGHLQOXPEDUFXUYHDQG SRVWRSHUDWLYHFRUUHFWLRQ

'LVFXVVLRQ

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

78

Y.P. Charles et al. / Sagittal Alignment Correction of the Thoracolumbar Junction

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

5HIHUHQFHV >@

.RWZLFNL76DJLWWDODQGWUDQVYHUVDOSODQHGHIRUPLW\LQWKRUDFLFVFROLRVLV6WXG+HDOWK7HFKQRO,QIRUP >@ 6WHLE -38QHDXWUHIDoRQGHUpGXLUHOHVGp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¶H[WHQVLRQ HW GH OD URWDWLRQ YHUWp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
Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-79

79

$'6NHOHWRQ0RGHO 6(0*$SSURDFK )RU,QWHJUDWHG1HFN$QG/RZ%DFN3DLQ $QDO\VLV7HVW%DWWHULHV 0'¶$0,&2*'¶$0,&20)5$6&$5(//203$1,&&,$3521&2/(77$ 09$//$6&,$1, /$032/DERUDWRULR$QDOLVLGHO0RYLPHQWRH3RVWXUD ,VWLWXWRGL 5LDELOLWD]LRQH 66WHIDQR9LD$SUXWLQD3RUWR3RWHQ]D3LFHQD0& ,WDO\ %LRHQJLQHHULQJ %LRPHGLFLQH&RPSDQ\/WG9LD$WHUQR6DQ*LRYDQQL 7HDWLQR&KLHWL ,WDO\

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

,QWURGXFWLRQ

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

80

M. D’Amico et al. / A 3-D Skeleton Model & SEMG Approach

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¶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

0DWHULDOVDQG0HWKRGV

$ QRQLRQLVLQJ DSSURDFK EDVHG RQ ' RSWRHOHFWURQLF PHDVXUHPHQWV RI ERG\ ODQGPDUNV ODEHOOHG E\ SDVVLYH PDUNHUV KDV EHHQ FKRVHQ WR EXLOG WKH ' SDUDPHWULF ELRPHFKDQLFDO VNHOHWRQ PRGHO >@7KH GHYHORSHG PRGHO FDQ ZRUNDWGLIIHUHQW VWDJHV RI FRPSOH[LW\ 7KDW LV GHSHQGLQJ RQ GLIIHUHQW DQDO\VLV SXUSRVHV DQG QHFHVVLWLHV WKH SDUDPHWULF VFDOLQJ FDQEHGHWDLOHGZLWKVHYHUDODFFXUDWHDQWKURSRPHWULFPHDVXUHPHQWVDQGWKHGLPHQVLRQVRI HDFK VNHOHWRQ¶V FRPSRQHQW DUH HVWLPDWHG DQG ILWWHG WR PDWFK WKH VXEMHFW¶V VNHOHWRQ 7KH DFFXUDF\DQGSUHFLVLRQRIWKHPRGHOUHOLHVERWKRQDQDWRPLFDOILQGLQJV>@UHSRUWHGLQ OLWHUDWXUH DQG RQ WKH DSSURDFK DQG VLJQDO SURFHVVLQJ SURFHGXUHV ZH ODUJHO\ GHVFULEHG

M. D’Amico et al. / A 3-D Skeleton Model & SEMG Approach

81

>@7RDQDO\VHKXPDQSRVWXUHDQGVSLQDOUHODWHGSDWKRORJLHVVFROLRVLVEDFNSDLQHWF DPDUNHUVSURWRFROKDVEHHQVHWDQGWHVWHGH[WHQVLYHO\LQFOLQLFDOHQYLURQPHQW>@ *LYHQ WKH IRFXV RI WKH FXUUHQW VWXG\ RQ QHFN DQG EDFN SDLQ VSHFLILF WHVW EDWWHULHV KDYH EHHQ HVWDEOLVKHG WR HYDOXDWH WKH UHODWHG SRVWXUDO DQG VSLQH G\VIXQFWLRQ ,Q WKLV FDVH D IXUWKHUPDUNHUVVHWSODFHGRQDKHDGEDQGDUHDGGHGWRWKHPDUNHUSURWRFROLQRUGHUWR EH DEOH WR UHFRQVWUXFW KHDG DQG QHFN HYHQ GXULQJ D IRUZDUG EHQGLQJ WHVW ,Q IDFW GXULQJ SDWLHQW¶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

5HVXOWV

6HYHUDO VWXGLHV DUH FXUUHQWO\ EHLQJ FDUULHG RXW E\ RXU JURXS DERXW VSLQH DQG SRVWXUH GLVRUGHUV ZLWK WKH GHVFULEHG PHWKRGRORJ\ *LYHQ WKH OHQJWK OLPLW RI WKLV SDSHU RQO\ SDUDGLJPDWLFH[DPSOHVIURPWKHDSSOLFDWLRQRIWKHSURSRVHGDSSURDFKDUHSUHVHQWHG

82

M. D’Amico et al. / A 3-D Skeleton Model & SEMG Approach

)LJXUHVDQG)RUZDUGEHQGLQJUHVXOWVIRUKHDOWK\ILJ DQGORZEDFNSDLQVXEMHFWILJVDQG 6HHWH[W IRUH[SODQDWLRQ

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

M. D’Amico et al. / A 3-D Skeleton Model & SEMG Approach

83

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

)LJXUH +HDGDQGWUXQND[LDOURWDWLRQV

)LJXUH VKRZV WKH FDSDELOLW\ RI WKH' VNHOHWRQ UHFRQVWUXFWLRQ WR GHVFULEH LQ D YHU\ GHWDLOHG ZD\ SRVWXUDO DQG VSLQHPRUSKRORJ\ FKDQJHV WRJHWKHU ZLWK IXOOUDQJHV RI PRWLRQ GXULQJWKHSHUIRUPDQFHRIKHDGDQGWUXQND[LDOURWDWLRQ7KLVLVDQH[DPSOHRIWHVWUHVXOWV LQWKHIXQFWLRQDOHYDOXDWLRQRIQHFNSDLQSDWLHQWV

'LVFXVVLRQ

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¶VDWWHPSWWRVWDELOL]HLQMXUHGRUGLVHDVHGVSLQDOVWUXFWXUHVWKHUHE\ SURWHFWLQJWKHPIURPIXUWKHULQMXU\DQGDYRLGLQJSDLQ 2XU H[SHULHQFH FRQILUPHG UHVXOWV IURP SUHYLRXV VWXGLHV RQ )53 7KH PDMRULW\ RI WKHP KRZHYHUFRQFHUQHGRQO\6(0*DQDO\VLVZKLOHIHZRIWKHPWRRNLQWRDFFRXQWJURVVVSLQH

84

M. D’Amico et al. / A 3-D Skeleton Model & SEMG Approach

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¶V GDWD - %LRPHF >@ 6HLGHO * HW DO +LS -RLQW &HQWHU /RFDWLRQ IURP 3DOSDEOH %RQ\ /DQGPDUNV $ &DGDYHU 6WXG\ - %LRP >@ '¶$PLFR 0 HW DO $OJRULWKP IRU (VWLPDWLRQ &ODVVLILFDWLRQ DQG *UDSKLFDO 5HSUHVHQWDWLRQ RI &OLQLFDO 3DUDPHWHUVLQWKH 0HDVXUHPHQW RI6FROLRVLVDQG 6SLQDO'HIRUPLWLHV E\ 0HDQVRI1RQ,RQLVLQJ 'HYLFHLQ 7KUHH'LPHQVLRQDO$QDO\VLVRI6SLQDO'HIRUPLW\(GV0'¶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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-85

85

Analysis of the mechanisms of idiopathic scoliosis progression using finite element simulation X.DREVELLE*1, J.DUBOUSSET1, Y.LAFON1, E.EBERMEYER2, W.SKALLI1 1

Laboratoire de Biomécanique, Arts & Métiers ParisTech – CNRS UMR 8005, Paris, France 2 University School of Medicine, Saint-Etienne, France

Abstract. The mechanisms of idiopathic scoliosis progression are still not fully understood. The aim of this study is to explore, using finite element simulation, effect of the combination of gravity and anterior spinal overgrowth on scoliosis progression. 14 adolescents (10 girls, 4 boys) with an average age of 10.8 years [range 9; 13] were divided in three groups: thoracolumbar scoliosis (TL), lumbar scoliosis (L), asymptomatic patients (A). Accurate 3D reconstructions of the spine have been built using bi-planar X-rays. A patient specific validated finite element model has been used. Simulations have been launched with simulation of the combined effect of gravity and growth. The progression during the simulation was defined by a maximal axial rotation movement greater or equal than 4° and a maximal lateral displacement greater or equal than 5 mm (“first order progression” for one criterion, “second order” for the both criteria). In the group TL, we notice an aggravation for 4 patients (Cobb angle increase at least by 4°, mean at 5.9°). Only three patients of the group L show a progression with a smaller Cobb angle increase (mean 3.9°). For the group A, no progression is found for 3 and a progression is found for 1. An anterior spinal overgrowth combined with gravity and a preexistent curve in the spine could lead to a progression of scoliosis. It seems necessary to consider differently lumbar curves from other curves. Numerical simulation with a patient specific model appears as a useful tool to investigate mechanisms of scoliosis aggravation. Keywords: scoliosis; progression; growth; finite element simulation

1.

Introduction

Because of the number of factors involved, the mechanisms of idiopathic scoliosis progression are still not fully understood. These mechanisms are bound both to the nature of the deformation and to the growth process. Particularly the factors that induce the well known torsion phenomenon with vertebral axial rotation, lateral deviation and sagittal extension still remain obscure. The aim of this study is to explore, using finite element simulation, biomechanical mechanisms involved in the progression of scoliosis. We will focus on the combination of gravity and anterior spinal overgrowth. *

Corresponding author. Email: [email protected]

86

2.

X. Drevelle et al. / Analysis of the Mechanisms of Idiopathic Scoliosis Progression

Materials and methods

Fourteen adolescents (10 girls, 4 boys) with an average age of 10.8 years [9; 13] were divided in three groups: thoraco-lumbar group (TL), lumbar group (L) and asymptomatic group (A) (Table 1). The group TL is composed of 4 patients (3 girls, 1 boy) who have a thoracolumbar scoliosis, with an average age of 10.3 years [range 9.5; 11] and a mean Cobb angle of 13.3° [range 8.8°; 17°]. The group L includes 6 patients (5 girls, 1 boy) who have a lumbar scoliosis. The patients present an average age of 11.3 years [range 9; 13] and a mean Cobb angle of 11.1°[range 3.1°; 18.8°]. The group A is composed of 4 asymptomatic patients (2 girls, 2 boys). The patients present an average age of 10.3 years [range 9; 12].

The X-Rays data used for the groups TL and L were performed within routine exams after their first visit for scoliosis. All the patients of groups TL and L present a Risser index of 0. Patients of the group A are involved in a parallel project which was led at the Laboratoire de Biomécanique (with ethics committee approval). Using bi-planar X-rays and an accurate reconstruction method [1], accurate 3D reconstructions are obtained (Figure 1.a). A patient specific finite element model, which was described and validated in a previous study [2; 3], is built from the reconstructions (Figure 1.b). For each functional unit, a global model is considered. Vertebrae are represented using stiff elastic beams connecting attachment points for discs and ligaments. Surfaces are attached to these beams to represent joint facets, their orientation being defined according to the vertebral level. Ligaments are modelled using tension-only cable elements. The pelvis is taken into account as a quasi-rigid body represented by a set of stiff beams connecting attachment points of iliolumbar ligaments. Discs are modelled using modified beam elements: to take into account the torsional effects of the disc fibers, mechanical properties are set to differentiate behaviour in bending and torsion.

X. Drevelle et al. / Analysis of the Mechanisms of Idiopathic Scoliosis Progression

87

All degrees of freedom of each node modelling the pelvis are blocked. The z-axis translation is free and all others degrees of freedom are blocked for T1. The gravity effect is modelled by a 400N z-axis compression force on T1 vertebral body. The anterior spinal overgrowth is modelled by a 15% z-axis lengthening of each vertebral body (i.e. on each beam modelling each vertebral body) with no specific constraints on the posterior part. For each patient a simulation has been launched with the combined effect of gravity and growth. The progression during the simulation is defined by a maximal axial rotation movement greater or equal than 4° and a maximal lateral displacement greater or equal than 5 mm. When one criteria is observed, the progression is classified “P1” and “P2” when both criteria are observed. The observations are completed with the modification of the Cobb angle and the T5-T12 kyphosis. 3.

Results

Simulations show various results for the subjects (Table 2). In the TL group, we notice a progression for 4 patients on 4.The Cobb angle increases at least by 4° (mean 5.9°). The mean maximal movement for axial rotation and lateral displacement are respectively 4.6° [range 3.0°; 7.3°] and 8.0mm [range 5.7mm; 10.0mm]. Considering the L group, 3 patients on 6 show a progression with a smaller Cobb angle increase (mean 3.9°). For these three patients, the mean maximal movement is 4.8° [range 4.7°; 5.0°] for axial rotation and 4.3mm [range 2.7mm; 5.1mm] for lateral displacement. For the other three patients, these values are 2.5° [range 2.0°; 2.5°] for axial rotation and 2.2mm [range 1.8mm; 2.6mm] for lateral displacement. For the group A, maximal movement is under 3° for the axial rotation and under 5mm for the lateral displacement (for all except one). For all the 14 patients, we notice a decrease of the thoracic kyphosis (mean -7.4°, [range -2.8°; -11.9°]). In some cases the thoracic curve became lordotic.

88

4.

X. Drevelle et al. / Analysis of the Mechanisms of Idiopathic Scoliosis Progression

Discussion and conclusion

Several authors have investigated the anterior spinal overgrowth leading to scoliosis progression according to the “rotational lordosis” [4; 5].Some have developed this theory by defining the “vicious cycle” [6] based on the asymmetrical growth due to the stress distribution. On this study we focus only on the spinal anterior overgrowth without growth modulation and use finite element simulation to investigate this. Several others studies use numerical simulation to investigate scoliosis progression. Most of them support the “Hueter-Volkmann law” with integration of growth modulation [7; 8]. However some authors have already investigated the “anterior spinal overgrowth by using the finite element simulation. Azegami et al investigate the reaction of the spine under different buckling mode inducing by thoracic anterior spinal overgrowth [9]. Goto et al investigate the influence of bone modelling on the same buckling mode [10]. Both found that the second bending mode on the sagittal plane due to thoracic anterior spinal overgrowth combined with bone resorption lead to scoliosis and progression. The results of this preliminary study support this theory. It seems that with some pre-existing deformations anterior growth can explain lateral deviation, axial rotation and Cobb angle progression. This Cobb angle increase could itself yield an asymmetric growth as a secondary effect. However this combination seems not to be an initiating factor on a normal spine, while it could aggravate a pre-existing deformation. Even if the number of subjects is too small to perform statistical tests, initial pattern plays a particular role: TL group seem more likely to progress under our hypothesis than L group. Then, the mechanisms of progression seem to be different in lumbar curves and in thoraco-lumbar ones. An investigation on a larger group of subjects will provide us a better understanding of scoliosis pattern role. Numerical simulation with a patient specific model appears as a useful tool to investigate mechanisms of scoliosis aggravation. • An anterior spinal overgrowth combined with gravity and a pre-existent curve in the spine could lead to scoliosis progression. • It seems necessary to consider differently lumbar curves progression mechanisms from other curves. • Numerical simulation with a patient specific model appears as a useful tool to investigate mechanisms of scoliosis aggravation.

X. Drevelle et al. / Analysis of the Mechanisms of Idiopathic Scoliosis Progression

89

Acknowledgments The authors gratefully acknowledge S.CAMPANA, I.COURTOIS, C.FEDELICH and B.SANDOZ for their collaboration. Data for asymptomatic subjects were obtained thanks to ANR support (ANR_06_0385 SECUR ENFANT project).

References [1]

Pomero V, Mitton D, Laporte S, de Guise JA, Skalli W. Fast accurate stereoradiographic 3Dreconstruction of the spine using a combined geometric and statistic model. Clin Biomech (Bristol, Avon). 2004 Mar; 19(3):240-7. [2] Humbert, L., De Guise, J.A., Godbout, B., Parent, S., Dubousset, J., and Skalli, W. 3D Reconstruction of the Spine from Biplanar X-Rays using longitudinal and transversal inferences. in Computer Assisted Radiology and Surgery. Berlin, Germany 2006. [3] Lafage V, Dubousset J, Lavaste F, & Skalli W, 3D finite element simulation of Cotrel–Dubousset correction. Computer Aided Surgery, 2004; 9(1/2): 17–25 [4] Roaf R. The basic anatomy of scoliosis. J Bone Joint Surg Br. 1966 Nov; 48(4):786-92. [5] Somerville EW. Rotational lordosis; the development of single curve. J Bone Joint Surg Br. 1952 Aug;34-B(3):421-7. [6] Stokes IA, Spence H, Aronsson DD, Kilmer N. Mechanical modulation of vertebral body growth. Implications for scoliosis progression. Spine. 1996 May 15;21(10):1162-7. [7] Stokes IA. Analysis and simulation of progressive adolescent scoliosis by biomechanical growth modulation. Eur Spine J. 2007 Oct;16(10):1621-8. Epub 2007 Jul 26. [8] Lafortune P, Aubin CE, Boulanger H, Villemure I, Bagnall KM, Moreau A. Biomechanical simulations of the scoliotic deformation process in the pinealectomized chicken: a preliminary study. Scoliosis. 2007 Nov 9;2:16. [9] Azegami, H., Murachi, S., Kitoh, J., Ishida, Y., Kawakami, N. & Makino, M. Etiology of idiopathic scoliosis. computational study. Clin Orthop Relat Res. 1998 Dec;(357):229-36.. [10] Goto, M., Kawakami, N., Azegami, H., Matsuyama, Y., Takeuchi, K. & Sasaoka, R. Buckling and bone modeling as factors in the development of idiopathic scoliosis, Spine. 2003 Feb 15;28(4):364-70; discussion 371.

90

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-90

The Relationship Between Hip Flexion/Extension and the Sagittal Curves of the Spine C DRISCOLL1,2, C-E AUBIN1,2, H LABELLE2, J DANSEREAU1 1 – Dept. of Mechanical Engineering, École Polytechnique de Montréal P.O. Box 6079, Station Centre-Ville Montréal, Québec, H3C 3A7, Canada 2 – Saint-Justine University Hospital Center 3175 Cote-Ste-Catherine Rd. Montreal, Quebec, H3T 1C5, Canada Abstract. The objective of this study was to develop a finite element model (FEM) in order to study the relationship between hip flexion/extension and the sagittal curves of the spine. A previously developed FEM of the spine, rib cage and pelvis personalized to the 3D reconstructed geometry of a patient using biplanar radiographs was adapted to include the lower limbs including muscles. Simulations were performed to determine: the relationship between hip flexion / extension and lumbar lordosis / thoracic kyphosis, the mechanism of transfer between hip flexion / extension and pelvic rotation, and the influence that knee bending, muscle stiffness, and muscle mass have on the degree to which sagittal spinal curves are modified due to lower limb positioning. Preliminary results showed that the model was able to accurately reproduce published results for the modulation of lumbar lordosis due to hip flexion; which proved to linearly decrease 68% at 90o of flexion. Additional simulations showed that the hamstrings and gluteal muscles were responsible for the transmission of hip flexion to pelvic rotation with the legs straight and flexed respectively, and the important influence of knee bending on lordosis modulation during lower limb positioning. The knowledge gained through this study is intended to be used to improve operative patient positioning. Keywords: surgical positioning, lower limbs, spine, scoliosis, biomechanics, finite element modeling.

1. Introduction Patient positioning is increasingly being recognized as an important step in spinal surgeries [1,2,3]. One of the most important desired outcomes of spinal instrumentation surgeries is preservation / restoration of sagittal balance [4], which can improve long term fusion results [5,6]. The relationship between hip flexion and lumbar lordosis has been studied by Stephen et al. [7] on the Andrews frame and Befanti et al. [8] on the Wilson frame who concluded that that hip flexion results in a loss of lumbar lordosis and that the correlation between the two is subject to inter-patient variability. As a general rule hips should not be flexed greater than 30o in order to maintain sufficient lumbar lordosis to avoid flat back symptoms. The influence of lower limb positioning on thoracic kyphosis has received little attention. The mechanism of transfer between

C. Driscoll et al. / Relationship Between Hip Flexion/Extension & the Spine’s Sagittal Curves

91

lower limb positioning and resulting geometrical changes to the spine has not been properly defined. Stokes et al. [9] have reported on the influence of the hamstring muscles on lumbar lordosis in sitting while others have reported on the possible contribution of the gluteal muscles with knees flexed [10]. Finite element modeling (FEM) has been previously used to study the impact of patient positioning on the geometry of the vertebral column. Duke et al.2 looked at the impact of dynamic positioning parameters on the geometry of the vertebral column using a FEM, the impact of lower limb positioning was approximated through the modulation of pelvic inclination +/- 15o. Our overall objective is to develop a patient-specific FEM which is able to simulate the impact of lower limb positioning on the geometry of the spine. It is hypothesized that manipulation of lower limb position, hip and knee flexion/extension, can significantly impact lumbar lordosis and thoracic kyphosis. It is also hypothesized that the mechanism of transfer between lower limb positioning and pelvic angle modulation includes both the hamstring and gluteal muscles groups and is dependent on the degree of knee flexion. The specific objectives of this pilot study were to use the developed FEM to analyze the relationship between hip flexion/extension and the sagittal curves of the spine. 2. Materials and Methods A previously developed simplified global beam FEM of the spine, rib cage and pelvis [11] which uses a biplanar reconstruction technique [12] to obtain patient specific geometry was adapted to include the lower limbs. Complementary detailed geometry of the femur, tibia, and fibula was taken from Visible Human Project (VHP) data with scaling based on anthropological equations factoring height and sex13. A total of 31 muscles per leg were modeled with origins and insertions obtained by mapping of the coordinates defined by White et al. [14]. Lower limb muscle cross-sectional data and material properties were taken from literature [15,16]. Hip and knee joints were represented as well as ligaments. In all, the model contains 1790 nodes and 1247 elements (Figure 1).

Figure 1 - Frontal and Lateral Views of the FEM developed

92

C. Driscoll et al. / Relationship Between Hip Flexion/Extension & the Spine’s Sagittal Curves

Simulations were performed in order to evaluate the model’s ability to reproduce published results for loss of lumbar lordosis due to hip flexion [5,6]. The geometric reconstruction of a healthy young male subject taken from the databases at SainteJustine University Hospital measuring 150 cm with an initial L1-S1 lordosis of 44 o and a T4-T12 kyphosis of 31o was used for this and subsequent simulations. Hamstring muscle initial strains were uniformly adjusted such that the percent loss of lumbar lordosis obtained through FEM simulations matched the average results obtained by Befanti et al [6] for 30o of hip flexion. These conditions were maintained and additional simulations performed for 60o and 90o hip flexion with the results compared to the averages obtained by Stephen et al.5 in similar conditions. A sensitivity study was performed in order to determine the relative impact that hamstring muscle initial strain (representing flexibility), cross-sectional area, and elastic modulus have on the degree to which hip flexion impacts the sagittal profile of the spine. 30o hip flexion simulations were performed while varying hamstring muscle initial strain 0-10%, doubling and halving cross-sectional area baseline values, and elastic modulus +/- 50% their baseline value. In order to evaluate the muscles responsible for transmission of lower limb positioning to pelvic rotation and the impact of knee flexion on this relationship, hip flexion / extension simulations were performed, over their respective ranges of motion [17], at intervals of 20o while maintaining the knees different degrees of flexion 0o, 30o, 60o, and 90o. In each case, the resultant impacts on lordosis, kyphosis, and lower limb muscle strains were recorded. Muscles with strains exceeding their initial strain were considered stretched and to contribute passively to the transfer of lower limb positioning to pelvic rotation. 3. Results The results of the model validation based on published references are outlined in Table 1. They were obtained for a uniform hamstring initial strain of 4%.

Hip Flexion 30° 60° 90°

L1-S1 Lumbar Lordosis Simulated Results Published values5,6 33° 33° 24° 23° 14° 15°

Table 1 - Validation of the relationship between hip flexion and loss of lumbar lordosis

The sensitivity study demonstrated that the most influential factor impacting the degree to which hip flexion impacts the sagittal profile of the spine is muscle flexibility; a 5% increase in hamstring initial strain caused an additional 9% reduction of lordosis at 30o of hip flexion. The impacts of muscle cross-sectional area and elastic modulus were less important; doubling cross-sectional area and elastic modulus respectively caused an additional 4% and 6% loss of lumbar lordosis. The muscles found to be responsible for the transmission of straight leg hip flexion to pelvic rotation were the hamstrings (semimembranosus, biceps femoris long

C. Driscoll et al. / Relationship Between Hip Flexion/Extension & the Spine’s Sagittal Curves

93

head). Once knee flexion reached approximately 60o, the gluteals (gluteus medius) started increasingly contributing. The primary muscles responsible for the transmission of hip extension to pelvic rotation are the anterior thigh muscles (rectus femoris, satorius, vastus medialis, tensor fasciae latae) up until the maximum hip range of motion. The degree of knee flexion (0o to 90o) for 30o hip flexion simulations contributed to additional modification of lordosis of 14%. The impact of lower limb positioning (90o of flexion to 30o of extension, while maintaining the knees at 30o of flexion) on lordosis (L) and kyphosis (K) is outlined in Figure 2. 4. Discussion One aspect of the model, which remains to be validated, is its ability to accurately reproduce the impact of hip extension on spinal geometry. Since no literary data was available, anterior thigh muscles were given the same initial strain determined for thehamstring muscles. Due to the nature of beam FEMs not all origin and insertion coordinates coincided with an anatomical representation, specifically with regards to the un-represented ilium, and had to be translated to the nearest available element. However, this factor was assumed to negligibly impact the results as the translation distances did not exceed 4 cm. Also it is important to note that only passive contribution of the lower limb muscles was considered as once a patient is place on a surgical frame, the current position can be maintained and variations to the lower limb position can be made without inducing voluntary or involuntary muscular contractions. In addition with any spinal surgical procedures, the patient is under general anaesthesia.

L = 48 K = 29 L = 45 K = 30

L = 42 K = 31

L = 33 K = 32 L = 23 22 K = 33 L = 13 12 K = 35

Figure 2 - Impact of Lower Limb Positioning

The results obtained for the mechanism of transfer between hip flexion and pelvic rotation is in agreement with those proposed in literature. This study was able to show which muscles of the hamstring and gluteal groups are responsible for this transmission and at what degree of knee flexion does the transmission from the hamstrings to gluteals take place. The inter-patient variability found in literature with regards to lumbar lordosis modulation with hip flexion can be attributed to individual lower limb flexibilities. It is proposed that any attempt made to predict patient specific modulation of spinal

94

C. Driscoll et al. / Relationship Between Hip Flexion/Extension & the Spine’s Sagittal Curves

geometry due to lower limb positioning incorporate clinical flexibility testing data into personalized FEMs. 5. Conclusion The FEM developed has shown good agreement with published results in its ability to reproduce the impact of lower limb positioning on spinal geometry in a patient-specific manner. Its preliminary exploitation has allowed for a more detailed study of the mechanisms of transfer and influential factors between lower limb positioning and spinal geometry than has been previously reported in literature. It is believed that the use of surgical frames which allow lower limb positioning in conjunction with knowledge of how lower limb positioning impacts patient specific spinal geometry can be used in order to facilitate an improve upon current operating procedures. Acknowledgements Project funded by the Natural Sciences and Engineering Research Council of Canada (Industrial Research Chair Program, with Medtronic). References [1] [2] [3]

[4] [5]

[6] [7] [8]

[9] [10] [11] [12]

[13] [14] [15]

Schonauer C, Bocchetti A, Barbagallo G, Albanese V, Moraci A. Positioning on surgical table. Eur Spine J. 2004 Oct;13 Suppl 1:S50-5. Epub 2004 Jun 22. Review. Duke K, Aubin CE, Dansereau J, Labelle H. Computer simulation for the optimization of patient positioning in spinal deformity instrumentation surgery. Med Biol Eng Comput. 2008 Jan;46(1):33-41. Delorme S, Labelle H, Poitras B, Rivard CH, Coillard C, Dansereau J. Pre-, intra-, and postoperative three-dimensional evaluation of adolescent idiopathic scoliosis. J Spinal Disord. 2000 Apr;13(2):93101. Majdouline Y, Aubin CE, Robitaille M, Sarwark JF, Labelle H. Scoliosis correction objectives in adolescent idiopathic scoliosis. J Pediatr Orthop. 2007 Oct-Nov;27(7):775-81. Edwards CC, Levine AM. Complications associated with posterior instrumentation in the treatment of thoracic and lumbar injuries. In: Garfin SR, ed. Complications of Spine Surgery. Baltimore: Williams and Wilkins, 1989:164-99. Herkowitz HN. Lumbar spinal stenosis: Indications for arthrodesis and spinal instrumentation. Instructional Course Lectures 1994:43:425-33. Stephens GC, Yoo JU, Wilbur G. Comparison of lumbar sagittal alignment produced by different operative positions. Spine. 1996 Aug 1;21(15):1802-6; discussion 1807. Benfanti PL, Geissele AE. The effect of intraoperative hip position on maintenance of lumbar lordosis: a radiographic study of anesthetized patients and unanesthetized volunteers on the Wilson frame. Spine. 1997 Oct 1;22(19):2299-303. Stokes IA, Abery JM. Influence of the hamstring muscles on lumbar spine curvature in sitting. Spine. 1980 Nov-Dec;5(6):525-8. Tafazzoli F, Lamontagne M. Mechanical behaviour of hamstring muscles in low-back pain patients and control subjects. Clin Biomech (Bristol, Avon). 1996 Jan;11(1):16-24. Clin J, Aubin CE, Labelle H., Virtual prototyping of a brace design for the correction of scoliotic deformities. Med Biol Eng Comput. 2007 May;45(5):467-73. Delorme S, Petit Y, de Guise JA, Labelle H, Aubin CE, Dansereau J. Assessment of the 3-D reconstruction and high-resolution geometrical modeling of the human skeletal trunk from 2-D radiographic images. IEEE Trans Biomed Eng. 2003 Aug;50(8):989-98. Bhasin MK, Malik SL, editors. Anthropology: Trends and Applications. New Delhi: Kamala-Raj Enterprises, 2002. p.141-147. White SC, Yack HJ, Winter DA. A three-dimensional musculoskeletal model for gait analysis. Anatomical variability estimates. J Biomech. 1989;22(8-9):885-93. Klein Horsman MD, Koopman HF, van der Helm FC, Prosé LP, Veeger HE. Morphological muscle and joint parameters for musculoskeletal modelling of the lower extremity. Clin Biomech (Bristol, Avon). 2007 Feb;22(2):239-47. Epub 2006 Nov 28.

C. Driscoll et al. / Relationship Between Hip Flexion/Extension & the Spine’s Sagittal Curves

95

[16] Kovanen V, Suominen H, Heikkinen E. Collagen of slow twitch and fast twitch muscle fibres in different types of rat skeletal muscle. Eur J Appl Physiol Occup Physiol. 1984;52(2):235-42. [17] Luttgens, Kathryn and Hamilton, Nancy. Kinesiology : Scientific Basis of Human Motion. Madison, WI : Brown & Benchmark, 1997

96

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-96

&RQVWUDLQHG,QWHQVLW\EDVHG,PDJH 5HJLVWUDWLRQ$SSOLFDWLRQWR$OLJQLQJ +XPDQ%DFN,PDJHV $6 (/6$),1* '85'/(-9 5$62

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

97

A.S. Elsaﬁ et al. / Constrained Intensity-Based Image Registration

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

(X =∑

[∈Y

(I

W

[ −

I X [ ) 7

V

(1)

:KHUHIV DQGIW DUH WKH SDLU RI LPDJHV WR EH UHJLVWHUHGǌ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

98

A.S. Elsaﬁ et al. / Constrained Intensity-Based Image Registration

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

' =%∑ +7

:KHUH% LV DQ V ; Q PDWUL[ V LV WKH VL]H RI WKH GHIRUPDWLRQ LPDJH DQG Q LV WKH QXPEHURIGHIRUPDWLRQPDSVXVHGLQWKHWUDLQLQJ ZKRVHFROXPQVDUHWKHRUWKRQRUPDO GHIRUPDWLRQ EDVHVDQGȈ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

; = $6

,QRUGHUWRGHILQHDQLQGHSHQGHQWFRPSRQHQWUHSUHVHQWDWLRQRIWKHWUDQVIRUPDWLRQ ZDUSV D VWDWLVWLFDO PRGHO ZLOO EH IRUPXODWHG ZKHUH WKH ILHOGV DUH FRQVLGHUHG DV REVHUYDWLRQVDQG WKH YDOXH RI WKH GHIRUPDWLRQ DW HDFK SL[HO DVUDQGRP YDULDEOHV 7KH WDUJHW LV WR JHQHUDWH D IDFWRULDO FRGH UHSUHVHQWDWLRQ FRQVLVWHG RI WKH LQGHSHQGHQW FRHIILFLHQWV8IRUWKHOLQHDUFRPELQDWLRQRIEDVLVZDUSV7KHREMHFWLYHRI,&$WUDLQLQJ LVWRILQGWKHGHPL[LQJPDWUL[: $ WKDWPDNHVWKHFRHIILFLHQWV8ZKHUH8 :;DV LQGHSHQGHQWDVSRVVLEOH >@

A.S. Elsaﬁ et al. / Constrained Intensity-Based Image Registration

99

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

([SHULPHQWVDQGUHVXOWV )RU RXU H[SHULPHQWV LPDJHV IURP YROXQWHHUV IURP XQLYHUVLW\ RI $OEHUWD LQ DGGLWLRQ WR LPDJHV FDSWXUHG IRU FDVW PRGHO IRU WKH KXPDQ WRUVR ZHUH WDNHQ 7KH WUDLQLQJ VHW FRQWDLQV LPDJH SDLUV 7KH WHVWLQJ ZDV GRQH XVLQJ D VHW FRQWDLQLQJ LPDJH SDLUV 'LIIHUHQW SDLUV ZHUH XVHG IRU WHVWLQJ )LJXUH VKRZV VDPSOHV RI WKH LPDJHVXVHGLQWKH H[SHULPHQWV

)LJXUH6DPSOHRIWKHPXOWLYLHZSDLUVXVHGLQWKHH[SHULPHQWV

100

A.S. Elsaﬁ et al. / Constrained Intensity-Based Image Registration

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

)LJXUH %ORFNGLDJUDPIRUWKHSURSRVHGLPDJHUHJLVWUDWLRQIUDPHZRUN

7KHSHUIRUPDQFHRIWKHSURSRVHGIUDPHZRUNVLQWHUPVRIURRWPHDQVTXDUHHUURU 506( IRUWKH XVHGGDWDEDVHLVVKRZQLQILJXUH7KHUHVXOWVVKRZUHGXFWLRQLQWKH URRWPHDQVTXDUHHUURUZKHQFRPSDUHGWRWKHHODVWLFUHJLVWUDWLRQDOJRULWKPSUHVHQWHGLQ >@ 0RUHRYHU WKH UHGXFWLRQ RI WKH FRPSXWDWLRQDO FRPSOH[LW\ LV PHDVXUHG XVLQJ WKH

A.S. Elsaﬁ et al. / Constrained Intensity-Based Image Registration

101

LPSURYHPHQWLQWKH&38WLPHLHWKHDPRXQWRIWLPHXVHGE\DFRPSXWHUSURJUDPLQ SURFHVVLQJ FHQWUDO SURFHVVLQJ XQLW &38 LQVWUXFWLRQV )LJXUH VKRZV DQ DYHUDJH RI UHGXFWLRQ RI WKH FRPSXWDWLRQDO WLPH ZKHQ XVLQJ WKH SULRU NQRZOHGJH WR UHSODFH WKH LQWHULPDJHVPRRWKQHVVFRQVWUDLQWVXVHGLQPRVWLQWHQVLW\EDVHGLPDJHUHJLVWUDWLRQ

)LJXUH 506(IRUWKHSURSRVHGIUDPHZRUNDQGWKH JOREDOFRQVWUDLQWVV\VWHP

)LJXUH &38WLPHIRUWKHSURSRVHGDQGWKHJOREDOFRQVWUDLQWVV\VWHP

102

A.S. Elsaﬁ et al. / Constrained Intensity-Based Image Registration

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

5HIHUHQFHV >@ -+DMQDO'+LOODQG'+DZNHV0HGLFDO,PDJH5HJLVWUDWLRQ&5&3UHVV%RFD5DWRQ >@ %=LWRYD-)OXVVHU³,PDJHUHJLVWUDWLRQ PHWKRGVD VXUYH\´,PDJHDQG 9LVLRQ &RPSXWLQJ 9RO 1R >@ % 'DZDQW ³1RQULJLG UHJLVWUDWLRQ RI PHGLFDO LPDJHV SXUSRVH DQG PHWKRGV D VKRUW VXUYH\´ 3URFHHGLQJVRI,(((,QWHUQDWLRQDO6\PSRVLXPRQ%LRPHGLFDO,PDJLQJ >@ 63HULDVZDP\DQG+)DULG³0HGLFDO,PDJH5HJLVWUDWLRQZLWK3DUWLDO'DWD´0HGLFDO,PDJH$QDO\VLV 9ROSS >@ :&UXP7+DUWNHQVDQG'+LOO³1RQULJLGLPDJHUHJLVWUDWLRQWKHRU\DQGSUDFWLFH´ %ULWLVK-RXUQDO RI5DGLRORJ\ 66 >@ , -ROOLIIH3ULQFLSDO&RPSRQHQW$QDO\VLV6SULQJHU9HUODJ %HUOLQ+HLGHOEHUJ1HZ@ - :RXWHUVD ( '¶$JRVWLQR ) 0DHV ' 9DQGHUPHXOHQ DQG 3 6XHWHQV ³1RQULJLG EUDLQ LPDJH UHJLVWUDWLRQ XVLQJ D VWDWLVWLFDO GHIRUPDWLRQ PRGHO´ 0HGLFDO LPDJLQJ 3URF RI 63,( 9RO >@ $+\YDULQHQ -.DUKXQHQ(2MD,QGHSHQGHQWFRPSRQHQWDQDO\VLV 1HZ@ 0%DUWOHWW - 0RYHOODQ7 6HMQRZVNL³)DFHUHFRJQLWLRQ E\LQGHSHQGHQW FRPSRQHQWDQDO\VLV´,((( 7UDQVDFWLRQVRQ1HXUDO1HWZRUNV9RO,VVXH >@ $ +\YDULQHQ ³)DVW DQG UREXVW IL[HGSRLQW DOJRULWKPV IRU LQGHSHQGHQW FRPSRQHQW DQDO\VLV´ ,((( 7UDQVDFWLRQVRQ1HXUDO1HWZRUNV9RO,VVXH²

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-103

103

(UJRQRPLFDOO\GHVLJQHGNQHHOLQJFKDLUVDUH WKH\ZRUWKLW"&RPSDULVRQRIVDJLWWDO OXPEDUFXUYDWXUHLQWZRGLIIHUHQWVHDWLQJ SRVWXUHV

-%(77$1<6$/7,.29-:$55(10-2%6213 6HQLRU/HFWXUHULQ5HVHDUFK0HWKRGV6FKRRORI+HDOWKDQG6RFLDO&DUH 6HQLRU OHFWXUHULQ9LVXDOL]DWLRQ6FKRRORI&RPSXWLQJ 3K\VLRWKHUDS\6WXGHQW 6FKRRORI+HDOWKDQG6RFLDO&DUH e-mail:[email protected] $EVWUDFW *HQHUDO DJUHHPHQW DPRQJ UHVHDUFKHUV VXJJHVWV WKDW SRRU VHDWLQJ SRVWXUH PD\ SUHGLVSRVH LQGLYLGXDOV WR GHYHORSLQJ ORZ EDFN SDLQ $ YDULHW\ RI PHWKRGV VXFK DV HUJRQRPLFDOO\ GHVLJQHG FKDLUV KDYH EHHQ GHYHORSHG WR DVVLVW SHRSOH WR PDLQWDLQ JRRG SRVWXUH DQG SUHVHUYH WKH µQDWXUDO¶ OXPEDU FXUYH 7KH DLP RI WKLV VWXG\ ZDV WR FRPSDUH OXPEDU FXUYDWXUH RQ DQ HUJRQRPLFDOO\ GHVLJQHG NQHHOLQJ FKDLU (.& ZLWK WKDW RQ D VWDQGDUGFRPSXWHUFKDLU6&& ZLWKUHIHUHQFHWRWKHVWDQGLQJOXPEDUFXUYDWXUH7KHVWXG\ XVHG D UHSHDWHG PHDVXUHV ZLWKLQVXEMHFWV GHVLJQ $ FRQYHQLHQFH VDPSOH RI WZHQW\ SDUWLFLSDQWV ZDV UHFUXLWHG DJHG PDOH DQG IHPDOH /XPEDU FXUYDWXUH ZDV PHDVXUHG XVLQJ WKH µ0LGGOHVEURXJK ,QWHJUDWHG $VVHVVPHQW 6\VWHP¶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

.H\ZRUGV3RVWXUH/XPEDU/RUGRVLV(UJRQRPLFV3K\VLRWKHUDS\

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

104

J. Bettany-Saltikov et al. / Ergonomically Designed Kneeling Chairs Are They Worth It?

6LWWLQJ LV D SRVWXUH LQ ZKLFK WKH ERG\¶V ZHLJKW LV WUDQVIHUUHG WKURXJK WKH LVFKLDO WXEHURVLWLHVDQGVXUURXQGLQJVRIWWLVVXHVRIWKHEXWWRFNVDQGWKHWKLJKVWRWKHVHDWRIDFKDLU $IOH[HGVHDWHGSRVWXUHLVRQHWKDWUHYHUVHVDQLQGLYLGXDOVQRUPDOO\ORUGRWLF OXPEDUFXUYH LQWR D N\SKRWLF SRVLWLRQ >@ $Q H[WHQGHG VLWWLQJ SRVWXUH HQFRXUDJHV RU PDLQWDLQV WKH OXPEDUFXUYHFORVHWRWKDWRIDQLQGLYLGXDO¶VORUGRWLFVWDQGLQJSRVWXUH>@ 6&&V W\SLFDOO\ SURGXFH D WUXQNWKLJK DQJOH RI ° RU OHVV >@ :KHQ PRYLQJ IURP VWDQGLQJWRXQVXSSRUWHGVLWWLQJWKHOXPEDUORUGRVLVGHFUHDVHVE\RQDYHUDJH°>@RUXS WR >@ 'HVLJQ RI WKH(.& HQFRXUDJHV JRRG SRVWXUH E\ VOLGLQJWKHKLSV IRUZDUGDQG DOLJQLQJWKHEDFNVKRXOGHUVDQGQHFN7KHFKDLUKDVDIRUZDUGVODQWLQJVHDWWKDWOHDGVWRD PRUH µQDWXUDO¶ SRVLWLRQ IRU WKH VSLQH >@>@ $ SUHYLRXV VWXG\ E\ )UH\ DQG 7HFNOLQV >@ FRQFOXGHGWKDWWKH%0&:HVWQRID%DODQV®0XOWL&KDLU VHWDW°PDLQWDLQHGOXPEDU FXUYDWXUH WR D JUHDWHU H[WHQW WKDQ WKH 6&& ,I WKH (.& FDQ EH VKRZQ WR FRUUHFW SRRU SRVWXUHLQFUHDVHOXPEDUORUGRVLV WKHQSK\VLFDOWKHUDSLVWVFRXOGUHFRPPHQGLWWRLPSURYH SRVWXUHDQG GHFUHDVHWKHLQFLGHQFH RIORZEDFNSDLQ

0HWKRGRORJ\ 3DUWLFLSDQWV 7KHVDPSOHSRSXODWLRQFRQVLVWHGRI DFRQYHQLHQFHVDPSOHRIWZHQW\ 8QLYHUVLW\RI7HHVVLGH SK\VLRWKHUDS\6WXGHQWVPDOHVDQGIHPDOHV 7KHDJHRIWKHSDUWLFLSDQWVUDQJHGIURP ± \HDUV RI DJH 3DUWLFLSDQWV ZHUH H[FOXGHG IURP WKH VWXG\ LI WKH\ KDG D KLVWRU\ RI UHFXUULQJ EDFN SDLQ RU LI WKH\ KDG D NQRZQ DOOHUJ\ WR WKH VHOIDGKHVLYH VWLFNHUV XVHG IRU VXUIDFHPDUNLQJ (TXLSPHQW 7KH ORZFRVW SRUWDEOH ' PHFKDQLFDO GLJLWL]HU 0LFURVFULEH '; ,PPHUVLRQ &RUS /WG DOVR UHIHUUHG WR DV WKH µ0,'$6 6\VWHP¶ ± LH µ0LGGOHVEURXJK ,QWHJUDWHG $VVHVVPHQW 6\VWHP¶>@>@ ZDVXVHGWRDVVHVVOXPEDUFXUYDWXUH

)LJXUH6WDQGDUGFRPSXWHUFKDLU6&& EDFNUHVWUHPRYHG

)LJXUH (UJRQRPLFNQHHOLQJFKDLU(.&

J. Bettany-Saltikov et al. / Ergonomically Designed Kneeling Chairs Are They Worth It?

105

3URFHGXUH $QDWRPLFDO ODQGPDUNV RQ WKH SDUWLFLSDQW¶V EDFNV ZHUH SDOSDWHG DQG LGHQWLILHG ZLWK VHOI DGKHVLYHVWLFNHUV7KH3RVWHULRU6XSHULRU,OLDF&UHVW36,6 ZDVSDOSDWHGIROORZHGE\DOO WKH OXPEDU VSLQRXV SURFHVVHV 7KH FXUYDWXUH RI WKH OXPEDU VSLQH ZDV PHDVXUHG RQ HDFK SDUWLFLSDQWLQ WKUHH GLIIHUHQW SRVLWLRQV ZKHQ VWDQGLQJ ZKHQ VLWWLQJ RQ D 6&& ZLWK WKH EDFNUHVWUHPRYHG DQG ZKHQ VDWRQ DQ(.& 7KH EDFNUHVW ZDV UHPRYHG IURP WKH 6&&WRDOORZWKHUHVHDUFKHUWRHDVLO\WRXFKWKHVXUIDFHPDUNLQJVZLWKWKHVW\OXVWLSRIWKH 0,'$6V\VWHP7KH(.&ZDVDGMXVWHGVRWKDWWKHVHDWZDVLQFOLQHGDW°WKH6&&VHDW ZDVDGMXVWHGWREHRI DQHTXLYDOHQWKHLJKWIURPWKHJURXQG 'DWDZDVFROOHFWHGE\WRXFKLQJ WKH0,'$6VW\OXVWLSRQHDFKRIWKHPDUNHGSRLQWVLQWKHIROORZLQJRUGHU//// DQG / OHIW 36,6 DQG ILQDOO\ ULJKW 36,6 IRU HDFK RI WKH WKUHH SRVWXUHV $OO PHDVXUHPHQWV ZHUH WDNHQ GXULQJ RQH VHVVLRQ WR UHGXFH WKH SUREDELOLW\ RI YDULDWLRQV LQ SRVWXUH

5HVXOWV 7KH GDWD ZDV DQDO\VHG XVLQJ 6366 6WDWLVWLFDO 3DFNDJH IRU 6RFLDO 6FLHQFHV YHUVLRQ IRU :LQGRZV7KHPLQLPXPPD[LPXPDQGPHDQOXPEDUFXUYDWXUHIRUWKHWKUHHSRVWXUHV DUH VKRZQ LQ WDEOH $ UHSHDWHG PHDVXUHV RQH ZD\ $129$ IDFWRU ZLWK OHYHOV IROORZHG E\ D SRVWKRF %RQIHUURQL WHVW ZDV XVHG WR GHWHUPLQH ZKHWKHU WKH UHVXOWV ZHUH VWDWLVWLFDOO\ VLJQLILFDQW $ ODUJH PHDQ GLIIHUHQFH LQ WKH OXPEDU FXUYDWXUH ZDV IRXQG EHWZHHQ VWDQGLQJ DQG VLWWLQJ RQ WKH 6&& ° DQG VWDQGLQJ DQG VLWWLQJ RQ WKH (.& ° 6HH WDEOH &RPSDULVRQ RI WKH VXEMHFW¶V OXPEDU FXUYDWXUH LQ HDFK FKDLU UHYHDOHGDPHDQGLIIHUHQFHRI° 6HHWDEOH

3RVWXUH

1

0LQ

0D[

0HDQ

'HJUHH

'HJUHH

'HJUHH

6WG'HY

6722'

6&&

(.&

7DEOH 0LQLPXP0D[LPXPDQG0HDQOXPEDUFXUYDWXUHIRUWKHWKUHHSRVWXUHV

3RVWXUHV 6722' 6&& (.&

YV6&& YV YV

0HDQ'LII'HJUHH

6WG(UURU

SYDOXH

(.&

6722'

7DEOH 0HDQGLIIHUHQFHDQGSYDOXHVIRUWKHWKUHHSRVWXUHV

106

J. Bettany-Saltikov et al. / Ergonomically Designed Kneeling Chairs Are They Worth It?

&RQFOXVLRQ

7KHDLPRIWKLVVWXG\ZDVWRGHWHUPLQHLIWKHUHZDVDVWDWLVWLFDOO\VLJQLILFDQWGLIIHUHQFHLQ WKHOXPEDUFXUYHSURGXFHGE\VLWWLQJRQWZRGLIIHUHQWFKDLUVHUJRQRPLFNQHHOLQJFKDLUVHW DW ° LQFOLQDWLRQ DQG VWDQGDUG FRPSXWHU FKDLU ZLWK WKH EDFN UHVW UHPRYHG ZKHQ FRPSDUHG WR VWDQGLQJ $QDO\VLV RI WKH GDWD VKRZHG D VWDWLVWLFDOO\ VLJQLILFDQW GLIIHUHQFH EHWZHHQVWDQGLQJDQGWKHWZRVHDWHGSRVLWLRQV6722'6&&S DQG6722'(.& S DQG WKHUH ZDV D VWDWLVWLFDOO\ VLJQLILFDQW GLIIHUHQFH EHWZHHQ WKH WZR VHDWHG SRVLWLRQVWKHPVHOYHV6&&(.&S 7KH PHDQ OXPEDU FXUYDWXUH IRU WKH VWDQGDUG FRPSXWHU FKDLU ZDV ° ZKLOVW WKH PHDQFXUYDWXUHIRUWKH(.&ZDV°$OWKRXJKWKH(.&OXPEDUFXUYDWXUHGLGPRUH FORVHO\ DSSUR[LPDWH WR WKDW REVHUYHG LQ VWDQGLQJ ° WKH DQJXODU GLIIHUHQFH EHWZHHQ WKH WZR VHDWHG SRVWXUHV ZKLOVW VWDWLVWLFDOO\ VLJQLILFDQW GLIIHUHQW ZDV IDLUO\ VPDOO DQGLWLVXQFOHDUZKHWKHUWKLVLVVXIILFLHQWO\ODUJHHQRXJKWR SURGXFH DQ\ WDQJLEOH EHQHILWV )XWXUHUHVHDUFKLVUHTXLUHGWRH[SDQGDQGDWWHPSWWRXQGHUVWDQGWKHWRSLFIXOO\7KH FXUUHQW UHVHDUFK IRXQG D VOLJKWO\ FORVHU DSSUR[LPDWLRQ WR WKH VWDQGLQJ OXPEDU FXUYDWXUH ZKHQVLWWLQJRQDQ(.&ZLWKWKHVHDWLQFOLQHGWR°WKDQZKHQVLWWLQJRQD6&& ,WLVVXJJHVWHGWKDWLQYHVWLJDWLQJWKHHIIHFWRILQFUHDVLQJWKHLQFOLQDWLRQRIWKHVHDWRQ WKH(.&WR° FRXOGH[SDQGWKLVUHVHDUFK

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± $5HOLDELOLW\6WXG\,Q $7DQJX\DQG%3HXFKRW HGV 5HVHDUFKLQWR6SLQDO'HIRUPLWLHV $PVWHUGDP ,263UHVV >@ %HWWDQ\6DOWLNRY -6/3DSDVWHIDQRX39DQ6FKDLNDQG -*:DUUHQ(YLGHQFHEDVHGSRVWXUDODVVHVVPHQW IRU XVH LQ WKHUDS\ DQG UHKDELOLWDWLRQ ,QWHUQDWLRQDO -RXUQDO RI 7KHUDS\ DQG 5HKDELOLWDWLRQ

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-107

107

)DXOW\3RVWXUHDQG6W\OHRI/LIHLQ

,QWURGXFWLRQ

*RRGSRVWXUHUHIOHFWVKHDOWKDQGKDUPRQ\LQWKHERG\EXLOG 3RVWXURJHQHVLV±WKHFRXUVHRI GHYHORSPHQW RI WKH SRVWXUH ±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

108

A. Czakwari et al. / Faulty Posture and Style of Life in Young Adults

PRWRU DFWLYLW\ UHVXOWV LQ VWUDLJKW VOLP VKDSH EHWWHU PXVFXODWXUH UHVLOLHQW JDLW EHWWHU SK\VLFDOHIILFLHQF\DQGJHQHUDOZHOOQHVV>@

$LPRIWKHVWXG\

6WXG\ ZDV DLPHG DW WKH LQFLGHQFH RI SRVWXUDO IDXOWV OHYHO RI SK\VLFDO DFWLYLW\ DQG WKHLU SRVVLEOHUHODWLRQVKLSLQ\RXQJDGXOWV

0DWHULDODQGPHWKRGV

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

)LJXUH 7KHLQFLGHQFHRISRVWXUDOIDXOWVDQGVFROLRVLVLQDVVHVVHGJURXS

A. Czakwari et al. / Faulty Posture and Style of Life in Young Adults

109

5HVXOWV

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

'LVFXVVLRQ

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

&RQFOXVLRQV

5HIHUHQFHV >@ .UDZDQVNL $ 2QWRJHQHW\F]Q\ SURFHV IRUPRZDQLD VLĊ SRVWDZ\ FLDáD F]áRZLHND >2QWRJHQHWLF SURFHVV RI GHYHORSPHQWRIKXPDQSRVWXUH@:66(3R]QDĔ

110

A. Czakwari et al. / Faulty Posture and Style of Life in Young Adults

>@ 0DURP.OLEDQVN\5'URU\<3K\VLFDODFWLYLW\IRUWKHHOGHUO\+DUHIXDK >@ .DVSHUF]\N7:DG\SRVWDZ\FLDáDGLDJQRVW\NDLOHF]HQLH>3RVWXUDOIDXOWVGLDJQRVWLFVDQGWKHUDS\@.DVSHU .UDNRZ >@ =H\ODQG0DODZND(2NU\WHULDFKRFHQ\SRVWDZ\>$ERXWFULWHULRQVRISRVWXUHHYDOXDWLRQ@$:).DWRZLFH >@ %HUQDDUGV &0 $UHQV *$ +LOGHEUDQGW 9+ 7KH FRVW HIIHFWLYHQHVV RI D OLIHVW\OH SK\VLFDO DFWLYLW\ LQWHUYHQWLRQLQDGGLWLRQWRDZRUNVW\OHLQWHUYHQWLRQRQWKHUHFRYHU\IURPQHFNDQGXSSHUOLPEV\PSWRPVLQ FRPSXWHUZRUNHUV%0&0XVFXORVNHOHW'LVRUG >@ $WNLQVRQ * 'DYHQQH ' 5HODWLRQVKLSV EHWZHHQ VOHHS SK\VLFDO DFWLYLW\ DQG KXPDQ KHDOWK 3K\VLRO %HKDY >@ $DJDDUG+DQVHQ-6DEDO36WHLQR36WRUU3DXOVHQ$%DFNKHDOWKRIVWXGHQWV1RUG0HG >@ )DMGDV]$=DWRQ.7KHVSLQDOFROXPQIRUPDWLRQLQ\RXQJVZLPPHUV0HG6SRUW >@ 8HWDNH 7 2KWVXNL ) 6DJLWWDO FRQILJXUDWLRQ RI VSLQDO FXUYDWXUH OLQH LQ VSRUWVPHQ XVLQJ 0RLUH WHFKQLTXH 2NDMLPDV)ROLD$QDW-SQ >@ :RGHFNL 3 *XLJXL 3 +DQRWHO 0& &DUGLQQH / 'HEXUJH $ 6DJLWWDO DOLJQPHQW RI WKH VSLQH FRPSDULVRQ EHWZHHQ VRFFHU SOD\HUV DQG VXEMHFWV ZLWKRXW VSRUWV DFWLYLWLHV 5HY &KLU 2UWKRS 5HSDUDWULFH $SSDU 0RW >@ :RMW\V(0$VKWRQ0LOOHU-$+XVWRQ/-0RJD3-7KHDVVRFLDWLRQEHWZHHQDWKOHWLFWUDLQLQJWLPHDQGWKH VDJLWWDOFXUYDWXUHRIWKHLPPDWXUHVSLQH$P-6SRUWV0HG

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-111

111

)LQLWHHOHPHQWPRGHOLQJRIYHUWHEUDOERG\ VWDSOLQJDSSOLHGIRUWKHFRUUHFWLRQRI LGLRSDWKLFVFROLRVLVSUHOLPLQDU\UHVXOWV 10/$/21'( &e$8%,153$11(7,(5 , 9,//(085( (FROH3RO\WHFKQLTXHGH0RQWUpDO &DQDGD 6DLQWH-XVWLQH 8QLYHUVLW\+RVSLWDO&HQWHU 0RQWUpDO &DQDGD eFROH1DWLRQDOH6XSpULHXUHGHV0LQHVGH6We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

.H\ZRUGV6FROLRVLVVWDSOHVXUJHU\ILQLWHHOHPHQWPRGHOLPSODQWFRQILJXUDWLRQ

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

112

N.M. Lalonde et al. / Finite Element Modeling of Vertebral Body Stapling

LQYHVWLJDWLRQVRQYHUWHEUDOERG\VWDSOLQJVKRZSURPLVLQJUHVXOWV5HFRPPHQGDWLRQV>@>@ KDYHEHHQPDGHVXFKDVXVLQJDSSURSULDWHVWDSOHDFFRUGLQJO\WRWKHVL]HRIHDFKYHUWHEUD LPSODQWLQJ VWDSOHV SHU OHYHO LQVWUXPHQWLQJ WKH GLIIHUHQW &REE OHYHOV DQG VHOHFWLQJ SDWLHQWV ZLWK LPPDWXUH VNHOHWRQ DQG FXUYHV EHWZHHQ R +RZHYHU WKH RSWLPDO LQVWUXPHQWDWLRQ GHVLJQ VWLOO QHHGV WR EH HVWDEOLVKHG 7KH REMHFWLYH RI WKLV SURMHFW ZDV WR PRGHO E\ ILQLWH HOHPHQWV WKH LPPHGLDWH FRUUHFWLRQ REWDLQHG IURP WZR VWDSOLQJ FRQILJXUDWLRQV

0HWKRGV $VLPSOLILHGQRQOLQHDU SDUDPHWULFILQLWHHOHPHQWPRGHORIDULJKWWKRUDFLFVFROLRWLFVSLQH &REEDQJOH/HQNHW\SH ZDVJHQHUDWHGEDVHGRQD'UHFRQVWUXFWLRQ >@REWDLQHG IURPWKHSRVWHURDQWHULRUDQGODWHUDO[UD\VRIDVFROLRWLFSDWLHQW7KHSRVWHULRUHOHPHQWVRI WKHYHUWHEUDHZHUHQHJOHFWHGDQGRQO\WKHYHUWHEUDOERGLHVDQGGLVFVZHUHPRGHOOHG 7KH IRXUUHFRQVWUXFWHGFRUQHUVSRVWHULRUDQWHULRUOHIWULJKW RIHDFKHQGSODWHUHIHUUHGKHUHDV WKHJURZWKSODWHLQDGROHVFHQWV ZHUHXVHGWRJHQHUDWHWKHWRSDQGERWWRPFRQWRXUVRIWKH YHUWHEUDOERGLHV ZLWKVSOLQHV)LJXUH $SDUDPHWULFDSSURDFKZDVXVHGWRJHQHUDWHDQG PRGHO WKH GLIIHUHQW JURZWK SODWH ]RQHV LQVLGH WKH YHUWHEUDO ERG\ 7KH UHVHUYH ]RQH ZDV PRGHOOHGE\VKHOOVWKUHHQRGHWULDQJXODUHOHPHQWV DQGWKHSUROLIHUDWLYHDQGK\SHUWURSKLF ]RQHVDVVROLGYROXPHVVL[QRGHZHGJHHOHPHQWV 7KHJURZWKSODWHZDVDVVXPHGWREH PPWKLFNZLWKWKHSUROLIHUDWLYHDQGK\SHUWURSKLF]RQHVUHSUHVHQWLQJUHVSHFWLYHO\DQG RI LWV WKLFNQHVV >@ $ YROXPH UHSUHVHQWLQJ WKH MXQFWLRQ PHWDSK\VLV EHWZHHQ WKH FDQFHOORXV ERQH DQG WKH JURZWK SODWH ZDV DOVR LQFOXGHG 7KH FRQWRXUV RI DGMDFHQW PHWDSK\VLV ZHUH WKHQ FRQQHFWHG WR FUHDWH D F\OLQGULFDO YROXPH IRXUQRGH VROLG WHWUDKHGURQV UHSUHVHQWLQJ WKH FDQFHOORXV ERQH ZKLFK ZDV VXUURXQGHG E\ D FRUWLFDO VKHOO WKUHHQRGH WULDQJXODU HOHPHQWV 7KH UHPDLQLQJ VSDFH EHWZHHQ WZR DGMDFHQW YHUWHEUDO ERGLHV PRGHOHG WKH GLVF DQQXOXV DQG QXFOHXV EDVHG RQ WKH SUHYLRXVO\ GHILQHG JURZWK SODWH FRQWRXUV 7KH DQQXOXV DQG QXFOHXV ZHUH PHVKHG ZLWK HLJKWQRGH VROLG KH[DKHGUDO HOHPHQWVDQGVL[QRGHVROLGZHGJHHOHPHQWVUHVSHFWLYHO\7KHUHZHUHDSSUR[LPDWHO\ HOHPHQWVSHUYHUWHEUDDQGSHUGLVF0HFKDQLFDOSURSHUWLHVRIERQHDQGRWKHUWLVVXHV ZKLFKZHUHDVVXPHGKRPRJHQRXVDQGLVRWURSLFZHUHWDNHQIURP*RHOHWDO >@ 6WXGLHVKDYHVKRZQWKDWVSLQDOGHIRUPLW\FDQGHFUHDVHE\R EHWZHHQVWDQGLQJDQG VXSLQHSRVLWLRQV>@>@%HIRUHLPSOHPHQWLQJWKHVWDSOHVDVLPSOLILHGODWHUDOGHFXELWXV SRVLWLRQ DV VHHQ LQ VXUJHU\ ZDV VLPXODWHG E\ D WUDFWLRQ ORDG LQ WKH FUDQLDO GLUHFWLRQ DFFRUGLQJO\ WR 6FKXOW]¶V ODZ H[SUHVVHG LQ 9LOOHPXUH HW DO >@ DQG E\ DSSO\LQJ ODWHUDO IRUFHVFRUUHVSRQGLQJWRWKHZHLJKWRIWKHWKRUD[¶VFURVVVHFWLRQV1 )RXU VWDSOHVL]HV SURQJVSDFLQJRIPP0HGWURQLF6RIDPRU'DQHN XVHGLQVXUJHU\ZHUHWKHQ PRGHOOHGZLWKIRXUQRGHWHWUDKHGURQV6WDSOHVZHUHLQVHUWHGLQWRWKHYHUWHEUDOERGLHVDQG WKH SURQJV¶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¶V ODZ WRVLPXODWHWKH SRVWRSHUDWLYH VWDQGLQJSRVLWLRQ 7RDYRLGIUHHERG\PRWLRQERXQGDU\ FRQGLWLRQVZHUHDSSOLHGDW/DVZHOODV7LQWKHWUDQVYHUVHSODQH RQO\

N.M. Lalonde et al. / Finite Element Modeling of Vertebral Body Stapling

113

)LJXUH $ DQDWRPLFDO ODQGPDUNV % VLPSOLILHG YHUWHEUDO ERG\ JHRPHWU\ DQG VWDSOH PRGHOOLQJ DQG & WRWDO VSLQHPRGHOOLQJDQGVWDSOHLQVHUWLRQ

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

114

N.M. Lalonde et al. / Finite Element Modeling of Vertebral Body Stapling

)LJXUH$SUH DQGSRVWRSHUDWLYHJHRPHWULHV% 6WUHVVHVLQWKH ORZHUSUROLIHUDWLYH]RQH RIWKH 7 JURZWKSODWH DQGVWDSOHVIRUERWKFRQILJXUDWLRQV LQVHUWHGEHWZHHQ77

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

N.M. Lalonde et al. / Finite Element Modeling of Vertebral Body Stapling

115

SULQFLSOH>@ ZKLFK FRXOGUHVXOW LQDORQJWHUPUHGXFWLRQRI WKH &REE DQJOH>@ 0RUH VWDSOHFRQILJXUDWLRQVVKRXOGEHWHVWHGWRRSWLPL]HWKHJURZWKPRGXODWLRQHIIHFW 7KHPRGHOLVFXUUHQWO\XQGHUYDOLGDWLRQZLWKGDWDIURPVXUJLFDOFDVHVWKXVWKHUHVXOWV VKRXOG EH FRQVLGHUHG DV SUHOLPLQDU\ )LQDO VWHS ZLOO EH RULHQWHG WRZDUGV WKH DQDO\VLV RI YHUWHEUDO VWDSOLQJ VWUDWHJLHV IRU GLIIHUHQW VFROLRWLF FXUYHV DQG SHUVRQDOL]LQJ PDWHULDO SURSHUWLHV

$FNQRZOHGJHPHQWV3URMHFWIXQGHGE\16(5&&DQDGDDQGE\)5644XHEHF

5HIHUHQFHV >@ %HW] 55 .LP - '¶$QGUHD /3 0XOFDKH\ 0- %DOVDUD 5. &OHPHQWV '+ $Q LQQRYDWLYH WHFKQLTXH RI YHUWHEUDO ERG\ VWDSOLQJ IRU WKH WUHDWPHQW RI SDWLHQWV ZLWK DGROHVFHQW LGLRSDWKLF VFROLRVLV D IHDVLELOLW\VDIHW\DQGXWLOLW\VWXG\ 6SLQH6 66 >@ %HW]55'¶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¶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

116

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-116

,QIOXHQFHRIFRUUHFWLRQREMHFWLYHVRQWKH RSWLPDOVFROLRVLVLQVWUXPHQWDWLRQVWUDWHJ\$ SUHOLPLQDU\VWXG\ <0$-'28/,1(&e$8%,1+/$%(//(

%LRPHGLFDO(QJLQHHULQJ,QVWLWXWHeFROH3RO\WHFKQLTXHGH0RQWUpDO 32%R[ 6WDWLRQ&HQWUHYLOOH0RQWUpDO+&$&DQDGD 6DLQWH-XVWLQH 8QLYHUVLW\+RVSLWDO&HQWHU&{WH6WH&DWKHULQH5G0RQWUpDO +7$ &DQDGD $EVWUDFW,QWKUHHUHFHQWVWXGLHVZHKDYHVKRZQKRZGLIIHUHQWFRUUHFWLRQREMHFWLYHVIURPD JURXSRIH[SHULHQFHGVSLQHVXUJHRQV DGGWRWKHYDULDELOLW\LQ$,6LQVWUXPHQWDWLRQVWUDWHJLHV 7KLV VWXG\ H[DPLQHG WKH HIIHFW RI FRUUHFWLRQ REMHFWLYHV RI WKUHH VXUJHRQV RQ WKH RSWLPDO LQVWUXPHQWDWLRQ VWUDWHJ\ $Q RSWLPL]DWLRQ PHWKRG XVLQJ VL[ LQVWUXPHQWDWLRQ GHVLJQ SDUDPHWHUVHJ OLPLWV RIWKHLQVWUXPHQWHGVHJPHQWQXPEHUW\SHDQGORFDWLRQRI LPSODQWV DQG URG VKDSH WKDW ZHUH PDQLSXODWHG LQ D XQLIRUP H[SHULPHQWDO GHVLJQ IUDPHZRUN ZDV OLQNHG WR D SDWLHQWVSHFLILF ELRPHFKDQLFDO PRGHO WR DQDO\]H WKH HIIHFWV RI D VSHFLILF LQVWUXPHQWDWLRQFRQILJXUDWLRQ7KHRSWLPL]DWLRQ FRVW IXQFWLRQZDV IRUPXODWHGWR PD[LPL]H FRUUHFWLRQ LQ WKH WKUHH DQDWRPLF SODQHV DQG ZLWK PLQLPDO QXPEHU RI LQVWUXPHQWHG OHYHOV 7KUHHVXUJHRQVIURPWKH6SLQDO'HIRUPLW\6WXG\*URXSSURYLGHGWKHLUUHVSHFWLYHFRUUHFWLRQ REMHFWLYHVIRUDVLQJOHSDWLHQWWKRUDFLFDQGOXPEDU&REEDQJOH )RUHDFKVXUJHRQ VXUJLFDO FRQILJXUDWLRQV ZHUH LWHUDWLYHO\ VLPXODWHG XVLQJ D ELRPHFKDQLFDO PRGHO 7KH LQIOXHQFH RI WKH WKUHH GLIIHUHQW FRUUHFWLRQ REMHFWLYHV RQ WKH RSWLPDO VXUJLFDO VWUDWHJ\ ZDV HYDOXDWHG7KHUHVXOWLQJRSWLPDOIXVLRQOHYHOVZHUH7/7/DQG7/$:LOFR[RQ QRQ SDUDPHWULF WHVW DQDO\VLV VKRZHG WKDW IXVLRQ OHYHOV DQG WKH ORFDWLRQ RI LPSODQWV VLJQLILFDQWO\ZHUHLQIOXHQFHGE\WKHFRUUHFWLRQREMHFWLYHVVWUDWHJLHVS 7KHRSWLPDO QXPEHU RI LPSODQWV DOWKRXJK GLIIHUHQW YV YV ZDV QRW VWDWLVWLFDOO\ VLJQLILFDQW S! 7KXV GLIIHUHQW VXUJHRQVSHFLILHG FRUUHFWLRQ REMHFWLYHV SURGXFHG GLIIHUHQW RSWLPDO LQVWUXPHQWDWLRQVWUDWHJLHVIRUWKHVDPHSDWLHQW .H\ZRUGV$GROHVFHQWLGLRSDWKLFVFROLRVLVVFROLRVLVVXUJHU\VXUJHU\VLPXODWRU ELRPHFKDQLFVH[SHULPHQWDOGHVLJQRSWLPL]DWLRQ'FRUUHFWLRQ

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

Y. Majdouline et al. / Correction Objectives on the Optimal Scoliosis Instrumentation Strategy

117

VSHFLILFFRUUHFWLRQREMHFWLYHVRIDJLYHQVXUJHRQ7KHDLPRIWKLVVWXG\ZDVWRHYDOXDWHWKH LQIOXHQFHRIFRUUHFWLRQREMHFWLYHVRQWKHRSWLPDOLQVWUXPHQWDWLRQVWUDWHJ\ 0DWHULDOVDQG0HWKRGV 2QH IHPDOH \HDU FDQGLGDWH IRU VXUJLFDO WUHDWPHQW RI $,6 ZLWK /HQNH FXUYH W\SH $ WKRUDFLF&REEDQJOH OXPEDU&REEDQJOH ZDVVHOHFWHG)LJXUH

)LJXUH 3UHRSHUDWLYHUDGLRJUDSKVRIWKHSDWLHQW

7KH JOREDO VSLQDO FRUUHFWLRQ ZDV TXDQWLILHG E\ DQ REMHFWLYH IXQFWLRQ ĳ WKDW LQFOXGHG GLIIHUHQW JHRPHWULF SDUDPHWHUV GHVFULELQJ WKH ' VSLQDO GHIRUPLWLHV DQG ZDV RULHQWHG WR PLQLPL]H WKH QXPEHU RI LQVWUXPHQWHG OHYHOV PRELOLW\ 7KH SDUDPHWHUV ZHUH WDNHQ IURP WKH6'6* 5DGLRJUDSKLF 0HDVXUHPHQW 0DQXDO 7KHREMHFWLYH IXQFWLRQ ĳ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

θ ; θ θ + D ⋅ 07 + D ⋅ 7/ / + D⋅ $97 @ φ =: ⋅>D ⋅ 37 θ37 θ07 θ7// ;$97 Q θ7. −θ7.Q θ// −θ// + ⋅ @ E Q θ7. −θ7.Q θ// −θ// θ −$95 θ −$95 θ −230' θ −230' θ + G ⋅ 07 + G⋅ 7/ /−230' + G ⋅ 37 + G⋅ 07 +: ⋅>G ⋅ 37 θ θ07 θ37 θ θ −230' 37 − $95 − $95 07 −230' 7//−230' θ + G⋅ 7/ /−$95 @ θ7//−$95

+: ⋅>E ⋅

+:⋅>

) @ )

118

Y. Majdouline et al. / Correction Objectives on the Optimal Scoliosis Instrumentation Strategy

$QJOHșZDVGHILQHGDVWKHSUHRSHUDWLYHDQJOH7KHµQRUPDO¶WKRUDFLFN\SKRVLVθQ7N DQG OXPEDU ORUGRVLV θQ// ZHUH DUELWUDULO\ GHILQHG DV DQG UHVSHFWLYHO\ )ZDV GHIHQGHGDV WKH PD[LPXPQXPEHURIXQIXVHGYHUWHEUDHLQDOOWKHVWUDWHJLHV 7DEOH :HLJKWVDVVLJQHGWRWKHWHUPVRIWKHREMHFWLYHIXQFWLRQIRUREMHFWLYHRIJHRPHWULFFRUUHFWLRQ

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ĳ[ 2QFHWKHDSSUR[LPDWLRQPRGHOGHVFULELQJWKHUHODWLRQVKLSEHWZHHQ GHVLJQ YDULDEOHV DQG WKH REMHFWLYH IXQFWLRQ ZDV REWDLQHG WKH PLQLPXP ZDV IRXQG XVLQJ

Y. Majdouline et al. / Correction Objectives on the Optimal Scoliosis Instrumentation Strategy

119

WKH 0DWODE 2SWLPL]DWLRQ 7RROER[ 0DWK:RUNV 86$ 7R VROYH WKH QRQOLQHDU RSWLPL]DWLRQSUREOHPVWKHIXQFWLRQ³IPLQFRQ´ ZDVXVHG 8VLQJ WKLV RSWLPL]DWLRQ DSSURDFK WKH RSWLPDO VWUDWHJLHV IRU HDFK VXUJHRQ ZHUH REWDLQHG WKXVWKHLQIOXHQFHRIWKHGLIIHUHQWFRUUHFWLRQREMHFWLYHVRQWKHRSWLPDOVXUJLFDOVWUDWHJ\ZDV HYDOXDWHG $QDO\VHV ZHUH FRQGXFWHG XVLQJ 6WDWLVWLFD VRIWZDUH 6WDW6RIW 86$ 7KH LQIOXHQFH RI WKH WKUHH GLIIHUHQW FRUUHFWLRQ REMHFWLYHV RQ WKH RSWLPDO VXUJLFDO VWUDWHJ\ ZDV HYDOXDWHGXVLQJD:LOFR[RQQRQSDUDPHWULFWHVWDQGDOHYHORIVLJQLILFDQFHVHWDW

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

'LVFXVVLRQDQGFRQFOXVLRQ 2XUVWXG\HYDOXDWHGWKHHIIHFWRIWKHREMHFWLYHVFRUUHFWLRQRQWKHRSWLPDOLQVWUXPHQWDWLRQ VWUDWHJ\IRUDVSHFLILFSDWLHQW%DVHGRQRXUUHVXOWVGLIIHUHQWVXUJHRQVSHFLILHGFRUUHFWLRQ REMHFWLYHV SURGXFHG GLIIHUHQW RSWLPDO LQVWUXPHQWDWLRQ VWUDWHJLHV IRU WKH VDPH SDWLHQW ,Q IDFWWKHRSWLPDOLQVWUXPHQWDWLRQGHVLJQSDUDPHWHUV/,98,9QXPEHUW\SHDQGORFDWLRQ RI LPSODQWV DQG URG VKDSH ZHUH GLIIHUHQW DFFRUGLQJ WR WKH GLIIHUHQW VXUJHRQ¶V REMHFWLYHV FRUUHFWLRQ 6HYHUDOSXEOLFDWLRQVKDYHUHYHDOHGYDULDELOLW\ LQWKHFKRLFHRILQVWUXPHQWDWLRQVWUDWHJ\ RQD VLJQLILFDQW JURXS RI H[SHULHQFHG VSLQH VXUJHRQV7KH SUHOLPLQDU\ UHVXOWV REWDLQHG ZLWK WKLV VWXG\ GHPRQVWUDWH WKDW WKLV YDULDELOLW\ FDQ EH DWWULEXWHG WR WKH REMHFWLYHV RI VXUJLFDO FRUUHFWLRQ )XUWKHU LQYHVWLJDWLRQ ZLWK PRUH VXUJHRQV ZRXOG EH QHHGHG WR YDOLGDWH WKLV LQIOXHQFHEHWZHHQWKHFRUUHFWLRQREMHFWLYHVRQRSWLPDOLQVWUXPHQWDWLRQVWUDWHJLHV

120

Y. Majdouline et al. / Correction Objectives on the Optimal Scoliosis Instrumentation Strategy

)LJXUH 7KHVLPXODWLRQRIWKHWKUHHRSWLPDOVXUJHU\XVLQJ6

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¶V *XLGH´ 9HUVLRQ 7KH 0DWK:RUNV ,QF 1DWLFN 0$ KWWSZZZPDWKZRUNVFRP

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-121

121

Development of an Apparatus to Evaluate Adolescent Idiopathic Scoliosis by Dynamic Surface Topography T.M.L. Shannon Department of Computer Science, School of Technology, Oxford Brookes University. Oxford, U.K. Abstract. For cases of Adolescent Idiopathic Scoliosis (AIS), commonly the first indicator is a change in the surface shape of the back over time. A proportion of patients so diagnosed require surgical intervention to prevent further progression and to improve cosmesis. The results of a preliminary literature survey have revealed that significant work has already been published on the static acquisition and analysis of back surface shape. There is new interest in establishing correlations between breathing, posture, the underlying spinal deformity and changes in the surface topography of the back during clinical sessions together with an increased focus on the impact of the cosmetic defect on the patient and in the measurement of pre and postoperative dynamic capability. The continuing development of an apparatus based on established optical motion capture technologies, that generates a sequence of tri-dimensional images and provides measurements derived from changes in the position of anatomical reference landmarks and of the surface topography of the back will be presented. If, using the same landmarks, the trunk range of motion could be captured concurrently, it is hoped that the resulting data would form the basis of a useful clinical study.

1.

Introduction

Between 1984 and 1988, the author was involved with the development and introduction of the commercial version of the Integrated Shape Imaging System (I.S.I.S.) [1] based on the previous work of Turner-Smith and Houghton [2, 3]. For the past twenty years he has concentrated on the development and application of optical motion capture technologies to the fields of clinical gait analysis, rehabilitation, sports biomechanics and ergonomics. Within the last decade, the same technology has been widely applied to the creation of animated background characters used in the crowd scenes of many major film productions including Titanic, Troy, Gladiator, Star Wars II and III. In recent years the technology has advanced to a degree where it is now being used to capture the subtleties of characteristic whole body motion and facial expressions of well known actors as the main characters in feature films such as The Polar Express and Beowulf. The aim of the study was to investigate how it might be possible to apply similar technologies and experience to synchronously capture video images to quantify, in three dimensions, the changes in the position of surface anatomical landmarks and back surface shape during clinical presentations.

122

T.M.L. Shannon / Development of an Apparatus to Evaluate Adolescent Idiopathic Scoliosis

Earlier work by many researchers concentrated on attempting to reduce the radiographic exposure to AIS patients by investigating if there was a reliable correlation between the progression of an underlying spinal deformity and changes in back surface topology over time [4,5,6]. The techniques applied and the relational algorithms developed were found to be prone to error by postural and non-spinal artifacts and were in-sufficiently robust to accommodate all cases so limiting their measurement sensitivity, specificity and usefulness as general clinical tools. A recent paper [7] focussed on the need to quantify the cosmetic defect of spinal deformity and work has been published on the evaluation of tri-planar spine range of motion following spinal fusion [8], implying a need still exists for apparatus [9] that can dynamically acquire the location of pre-defined anatomical surface landmarks and back topology to within clinically acceptable accuracies.

2. Materials and Methods Previous work using optical motion capture technology has been published. Rotelli and Santambrogio [10] placed an array of passive detectable markers across the surface of the back and captured the resulting tri-dimensional positions. Aliverti et al. [11] used a laser scanning mechanism to apply a moving point of light to the surface synchronized to each acquisition of the apparatus optical sensors. Rotelli and Santambrogio’s method had the advantage of presenting an absolute measure of the location of all markers during each acquisition but would not be a feasible option for routine clinical sessions due to the time needed to apply sufficient markers before each measurement. The approach by Aliverti et al. would have been prone to errors introduced by postural and breathing artifacts, so was not considered further. 2.1. Data Acquisition The study used an obsolete and modified 6 Camera, VICON motion capture system (Vicon Motion Systems Ltd., Oxford, U.K.) to acquire anatomical landmark positions and surface data simultaneously at a rate of 60 frames/second. Fig. 1 depicts the arrangement of two groups of three, optically isolated, cameras and a projector used to generate an array of points. VICON systems use spherical markers coated (Fig. 2) with a material that reflects light directly back to a strobed source surrounding a camera lens. The cameras are shuttered to open only during a strobe flash and contain filters optically matched to the spectra of the light source. Only circular bright markers will be sampled by each camera sensor, independent of the rate of subject movement and ignoring skin, fabric and other objects within the field of view. The centre of markers are calculated as positions within the two dimensional image illuminating the sensor during a given frame by analyzing the relative intensities of light impinging onto groups of adjacent pixels. Before each capture session, calibration objects with markers attached at known positions are used to establish the global coordinate system of the measurement volume; the physical position and orientation of each camera and the scaled

T.M.L. Shannon / Development of an Apparatus to Evaluate Adolescent Idiopathic Scoliosis

123

relationship between the acquired coordinates and the actual positions. The optical distortion of the cameras (particularly from the lenses at the corners) is also calculated and a linearization correction applied to each subsequent frame captured. Within the measurement volume defined by the lenses chosen and the distance to the object, accuracy of marker centre reconstruction was determined by experiment to be within a mean of ± 0.1mm, S.D. 0.3mm, n = 4,500.

Fig. 1. Acquisition Apparatus

Fig. 2. Anatomical Markers

Fig. 3. Projected Point Cloud

To detect the markers, three shuttered, strobing cameras were configured to emit and detect light in the visible red spectral region (660 nm). Three further passive cameras were fitted with optical, short-pass filters to exclude light in the red spectra but to allow passage of the image of the projected surface point cloud (Fig. 3) to the camera sensors. The centres of the points were determined in the same way as for the markers. Providing a minimum of two calibrated cameras see a marker or a point anywhere within the measurement volume, the third dimension can be calculated in exactly the same way as humans estimate distance with two offset eyes viewing a common object [12]. The presence of a third or more cameras further improves the reliability of point and marker re-construction. 2.2. Surface Data Processing Figures 4 and 5 depict the presentation of anatomical marker (Fig. 4) and surface point cloud (Fig. 5) locations in two dimensions, acquired from a single frame from cameras in each group. Supporting software has been developed to automatically separate marker and point data into two files for further processing into frames of three– dimensional coordinates. The resulting three dimensional data were normalised to a reference plane defined by the positions in each frame of the markers placed by palpation over the vertebra prominens (C7/T1) and the left and right posterior superior iliac spines (PSIS) [1]. Two additional markers were applied to the acromion to provide a measure of shoulder droop. For pre-operative cases, 10-13 additional markers were applied to the spinous

124

T.M.L. Shannon / Development of an Apparatus to Evaluate Adolescent Idiopathic Scoliosis

processes and a tri-planar cubic spline interpolation calculated to define the delineation between the left and right sagittal surface sections. Placement of markers in postoperative cases should follow the convention established by Jefferson et al. [13]. Boundary cubic splines were also calculated based on a proportion of the height of the spine between C7/T1 and the bisection point between the PSIS to remove data not required for further analysis such as the arms. Algorithms have been developed that automatically identify the reference markers and order spinous process markers in most expected cases within defined degrees of freedom. Table 1 lists the clinical data that are calculated and Fig. 6 depicts an example graph of changes in imbalance over 440 frames (7.3 s) captured from a normal subject.

Fig. 4. Anatomical Markers

Fig. 5. Surface Cloud Points

Prior to export for display and surface data interpolation, the resulting point cloud data were automatically allocated into one of twenty transverse sections above the normalised reference plane to further amplify volumetric differences between the sagittal sections. A number of third party surface topography interpolation and display packages (Surfer 8 © and Voxler ©, Golden Software Inc.) are currently being investigated for suitability. Fig. 7 depicts the resulting Voxler © output for frame 45 of a 150 frame capture of the subject’s back. Further work is being undertaken to use the results obtained to develop numerical measures to describe volumetric asymmetries. 2.3 Range of Motion Data Processing Range of motion data were captured from the same subject using common marker placements by switching off the point array projector and switching on the strobes (in the blue spectra) of the three surface capture cameras to improve the reconstruction accuracy of more rapidly moving markers within the measurement volume. Fig. 8 depicts the display of markers in three dimensional space and Fig. 9 a graphical sample of the angle subtended between C7/T1, the central spinous process marker and the marker adjacent to the PSIS over 2000 frames (33 s). The impact of skin movement of the markers on results will be considered as part of the final study.

T.M.L. Shannon / Development of an Apparatus to Evaluate Adolescent Idiopathic Scoliosis

Parameter Height Tilt Imbalance Pelvic Tilt Pelvic Obliquity Shoulder Droop

Units mm degrees (+/-) mm (L/R) degrees (L/R) degrees (to L/R) mm (L/R)

Table 1. Calculated Parameters

Fig. 6. Variations in Imbalance from a Normal Subject over 7.3 s.

Fig. 6. Variations in Imbalance from a Normal Subject over 7.3 s

Fig 7. Voxler© Data and Contour Image - Frame 45

125

126

T.M.L. Shannon / Development of an Apparatus to Evaluate Adolescent Idiopathic Scoliosis

Fig. 8. Markers Single Fame

Fig. 9. Range of Motion Angles

3. Conclusion Development of the apparatus and supporting algorithms continues with the goal of producing a tool to quantify and express changes in back surface shape and the range of motion during a clinical session. The resulting data are hoped to form the basis of a useful clinical study.

References [1]

Turner-Smith A.R., Shannon T., Houghton G.R., Knopp D. Assessing idiopathic scoliosis using a surface measurement technique. Surgical Rounds for Othopaedics, 1988, June:5263. [2] Turner-Smith A. A television/computer three-dimensional surface shape measurement system. Journal of Biomechanics,1988,21(6):515-529 [3] Tuner-Smith A.R., Harris J., Houghton G.R., Jefferson R.J. A method for analysis of back shape in scoliosis. Journal of Biomechanics,1988,21(6):497-509 [4] Weisz I., Jefferson R.J., Turner-Smith A.R., Houghton G.R., Harris J. ISIS scanning: a useful assessment technique in the management of scoliosis. Spine, 1988:13(4):405-408. [5] Turner-Smith A.R. Surface topography should not replace radiography in the evaluation of scoliotic deformities. Proceedings of the International Symposium on 3-D Scoliotic Deformities, Dansereau J. 1992,Gustav Fischer Verlag: 178-180. [6] Stokes A.I.F. Point of View: Early Detection of Progression in Adolescent Idiopathic Scoliosis by Measurement of Changes in Back Shape with the Integrated Shape Imaging System. Spine, 1997:22(11):P1228. [7] Theologis T.N., Jefferson R.J., Simpson A.,Turner-Smith A.R. ,Fairbank J.C.T., Cosmesis in Adolescent Idiopathic Scoliosis. Proceedings of the 10th Philp Zorab Symposium, 2002 [8] Engsberg J., Kenke L., Reitenbach A., Hollander K. et al., Prospective evaluation of trunk range of motion in adolescents with idiopathic scoliosis undergoing surgery. Spine 27(12):1346-1354. [9] De Wilde T.,Huysmans T.,Denis K. Forausberger C. et al. A contact-free optical measuring system for the dynamic acquisition of anatomical structures in 3D.Proceedings of the 14th Conference of the European Society of Biomechanics, 4-7 July 2004. [10] Rotelli F., Santambrogio G.C., Three-Dimensional Dynamic Reconstruction of Back Shape. Three Dimensional Analysis of Spinal Deformities, M.D. D’Amico et als.(Eds), IOS Press, 1995:45-50.

T.M.L. Shannon / Development of an Apparatus to Evaluate Adolescent Idiopathic Scoliosis

127

[11] Aliverti A., Ferrigno G., Rotelli F., Santambrogio G.C., Back Surface Analysis by Laser Beam Scanning and Stereo-Photogrammetry. Three Dimensional Analysis of Spinal Deformities, M.D. D’Amico et als.(Eds), IOS Press, 1995:51-56. [12] HartleyR.I.,Zisserman,A.,Multiple View Geometry in Computer Vision, 2nd Edition, 2004, Cambridge University Press, ISBN: 0521540518. [13] Jefferson R.J., Weisz I., Turner-Smith A.R., Harris J.D., Houghton G.R. Scoliosis Surgery and it’s Effect on Back Shape. J Bone Joint Surg [Br],1988;70-B:261-6.

128

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-128

%LRPHFKDQLFDO0RGHOOLQJ RID'LUHFW 9HUWHEUDO7UDQVODWLRQ,QVWUXPHQWDWLRQ 6\VWHP3UHOLPLQDU\5HVXOWV ;:$1* &e$8%,1 +/$%(//( '&5$1'$// 'HSWRI0HFKDQLFDO(QJLQHHULQJeFROH3RO\WHFKQLTXHGH0RQWUpDO 32%R[6WDWLRQ&HQWUHYLOOH0RQWUpDO+&$&DQDGD 6DLQWH-XVWLQH8QLYHUVLW\+RVSLWDO&HQWHU&{WH6WH&DWKHULQH5G0RQWUpDO+7 $&DQDGD 6RQRUDQ6SLQH&HQWHU3KRHQL[$UL]RQD86$

$EVWUDFW 0DQ\ QHZ VSLQH LQVWUXPHQWDWLRQ FRQFHSWV ZHUH LQWURGXFHG LQ UHFHQW \HDUV OLNH WKH LQFUHPHQWDO GLUHFW YHUWHEUDO WUDQVODWLRQ 7KH REMHFWLYH ZDV WR GHYHORS D ELRPHFKDQLFDO PRGHO LQ RUGHU WR DQDO\]H WKH ELRPHFKDQLFV RI WKLV LQVWUXPHQWDWLRQ V\VWHP 7KH SDWLHQW VSHFLILFVSLQHPRGHOZDVEXLOWXVLQJWKH'UHFRQVWUXFWLRQEDVHGRQELSODQDUUDGLRJUDSKVRI D VFROLRWLF SDWLHQW WKRUDFROXPEDU &REE 7KH PHFKDQLFDO SURSHUWLHV ZHUH GHULYHG IURPOLWHUDWXUHH[SHULPHQWVRQFDGDYHUVSLQHVDQGSDWLHQW¶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

X. Wang et al. / Biomechanical Modelling of a Direct Vertebral Translation

129

URG FRQQHFWRU LV HTXLYDOHQWWR WKH FRPELQDWLRQ RI WZR WHOHVFRSLF MRLQWV DQG RQH XQLYHUVDO MRLQWZKLFKEHFRPHDULJLGFRQQHFWLRQRQFHWKHVHWVFUHZLVWLJKWHQHG 7KHREMHFWLYH RIWKLVZRUNZDVWRGHYHORSD ELRPHFKDQLFDOPRGHOLQRUGHUWRDQDO\]HWKH ELRPHFKDQLFVRIWKLVLQVWUXPHQWDWLRQV\VWHP %LRPHFKDQLFDOPRGHOLQJ 7KHVSLQH'JHRPHWU\ RID \HDUROGLGLRSDWKLFVFROLRVLVSDWLHQW&REE7KRUDFLF /XPEDU ZDVGHULYHGIURPWKH'UHFRQVWUXFWLRQFRPSXWHGIURPELSODQDUUDGLRJUDSKV )LJXUH

)LJXUH3DWLHQWVSLQHPRGHO

)LJXUH &RQVWUXFWVLPSOLILFDWLRQ

6LQFH WKH YHUWHEUD GHIRUPDWLRQ LV QHJOLJLEOH FRPSDUHG WR LWV JOREDO GLVSODFHPHQW GXULQJ FRUUHFWLRQ PDQRHXYUHV HDFK YHUWHEUD ERG\ ZDV FRQVLGHUHG DV D ULJLG ERG\ >@ 7KH ELRPHFKDQLFDO LQWHUYHUWHEUD EHKDYLRXU ZDV PRGHOOHG DV D GLPHQVLRQ JHQHUDO IRUFH KDYLQJDOLQHDUFRUUHODWLRQZLWKWKHGLPHQVLRQJHQHUDOLQWHUYHUWHEUDGLVSODFHPHQW7KLV OLQHDUFRUUHODWLRQLVUHSUHVHQWHGE\DE\VWLIIQHVVPDWUL[ZKRVHLQLWLDOYDOXHVFRPHIURP WKHLQYLWURH[SHULPHQWDOGDWDUHSRUWHGLQWKHOLWHUDWXUH>@DQGWKHQDGMXVWHGE\DSSO\LQJ ZHLJKWLQJIDFWRUVFRPSXWHGIURPWKHSDWLHQW¶VVLGHEHQGLQJ&REDQJOHV>@ 7KHLQVWUXPHQWDWLRQFRQVWUXFWLVFRPSRVHGRIDSHGLFOHVFUHZDSRVWKLQJHGWRWKHSHGLFOH VFUHZ DQG D FRQQHFWRU 7KH FRQQHFWRU KDV WZR SDUWV LH WKH SRVW FRQQHFWRU DQG WKH URG FRQQHFWRUKDYLQJDRQHGHJUHHRIIUHHGRP'2) URWDWLRQDOUHODWLYHPRELOLW\DURXQGWKHLU

130

X. Wang et al. / Biomechanical Modelling of a Direct Vertebral Translation

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

)LJXUH &RQVWUXFWDVVHPEO\

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

X. Wang et al. / Biomechanical Modelling of a Direct Vertebral Translation

131

)LJXUH&RUUHFWLRQVIRUHDFKVLPXODWLRQVWHS

)LJXUH)RUFHHYROXWLRQGXULQJWKHZKROHVLPXODWLRQ

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

132

X. Wang et al. / Biomechanical Modelling of a Direct Vertebral Translation

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¶SRVW RSHUDWLYH VSLQH UHFRQVWUXFWLRQ PRGHO :KHQ WKH PRGHO YDOLGDWLRQ ZLOO EH FRPSOHWHG WKH V\VWHPFDQVHUYHDVDSUHRSHUDWLYHSODQQLQJWRROWRRSWLPL]HLQVWUXPHQWDWLRQVWUDWHJLHV

)LJXUH3RVWHULRUYLHZVIRUVWHSVWR

$FNQRZOHGJHPHQWV 3URMHFW IXQGHG E\ WKH 1DWXUDO 6FLHQFHV DQG (QJLQHHULQJ 5HVHDUFK &RXQFLO RI &DQDGD ,QGXVWULDO5HVHDUFK&KDLUZLWK0HGWURQLF 5HIHUHQFHV >@ &UDQGDOO ' 0RUULVRQ 0 %DNHU ' 6ODXJKWHU ' 5HYHOOD - 0RRUH & $GXOW VFROLRVLV FRUUHFWLRQ E\ GLUHFW YHUWHEUDOWUDQVODWLRQWHFKQLTXH\HDUFOLQLFDODQGUDGLRJUDSKLFUHVXOWV3URFHHGLQJVRIWKH1$66WK$QQXDO 0HHWLQJ7KH6SLQH-RXUQDO 6±6 >@$XELQ&(3HWLW<6WRNHV,$)3RXOLQ)*DUGQHU0RUVH0/DEHOOH+%LRPHFKDQLFDOPRGHOLQJRISRVWHULRU LQVWUXPHQWDWLRQRIWKHVFROLRWLFVSLQH&RPS0HWKRGV%LRPHFK%LRPHG(QJ ± >@3DQMDEL002[ODQG75@ *DUGQHU0RUVH 0 6WRNHV ,$) 6WUXFWXUDO EHKDYLRXU RI KXPDQ OXPEDU VSLQDO PRWLRQ VHJPHQWV - %LRPHFK >@ 3HWLW < $XELQ &( /DEHOOH + 3DWLHQWVSHFLILF PHFKDQLFDO SURSHUWLHV RI D IOH[LEOH PXOWLERG\ PRGHO RI WKH VFROLRWLFVSLQH0HG%LRO(QJ&RPS >@$XELQ&(/DEHOOH+&KHYUHILOV&'HVURFKHV*&OLQ-%RLYLQ$3UHRSHUDWLYHSODQQLQJVLPXODWRUIRUVSLQDO GHIRUPLW\ VXUJHULHV6SLQHLQSUHVV

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-133

133

SpineCor vs. Natural History – Explanation of the results obtained using a simple biomechanical model H-R WEISS Asklepios Katharina Schroth Spinal Deformities Rehabilitation Centre, Korczakstr. 2, 55566 Bad Sobernheim, Germany, [email protected] Abstract. In the recent peer reviewed literature the SpineCor is described as an effective method of treatment for patients with scoliosis. However until recently no prospective controlled end-result study is presented comparing the results obtained with this soft brace to natural history. The objective was to determine whether the results obtained by the use of the SpineCor are better than natural history during pubertal growth spurt. The method employed prospective comparison of the survival rates of SpineCor treatment vs. natural history with respect to curve progression during pubertal growth spurt. 12 Patients with Cobb angles between 16 and 32 degrees (at average 21 degrees) during pubertal growth spurt are presented as a case series treated with the SpineCor. Survival rate of this sample is described and compared to natural history (SRS brace study 1995). All girls treated in both studies were at risk for being progressive with the first clinical signs of maturation (Tanner 2-3). During the pubertal growth spurt most of the patients (11/12) with SpineCor progressed clinically and radiologically as well (at least 5 degrees). Progression could be stopped changing SpineCor to the Chêneau brace in most of the sample described (7/10). The avarage Cobb angle at the start of treatment with the SpineCor was 21.3 degrees, after an average observation time of 21.5 months 31 degrees. At 24 months of treatment time 33% of the patients with the SpineCor where still under treatment with their original bracing concept, at 72 months follow-up time 8 % of the patients with the SpineCor survived with respect to curvature progression. Survival proportion in the SpineCor sample, though was 0.08, while in the natural history cohort it was 0.34. The SpineCor treatment during pubertal growth spurt seems to lead to a worse outcome than observation only. The use of a simple biomechanical model explains that in the brace the compression forces exceed the lateral forces used for the corrective movement. Therefore SpineCor does not seem to be indicated as a treatment during pubertal growth spurt. Keywords. Adolescent idiopathic scoliosis, SpineCor, natural history, growth spurt

1.

Introduction

In the recent peer reviewed literature the SpineCor is described as an effective method of treatment for patients with scoliosis [1,2]. However until recently no prospective controlled end-result study is presented comparing the results obtained with this soft brace to natural history. Two studies reveal data that support the hypothesis, that the use of the SpineCor brace is less successful than the use of other braces during pubertal growth spurt [3,4].

134

H.-R. Weiss / SpineCor vs. Natural History

Figure 1. SpineCor as adjusted by the original authors [1,2] at our centre. No changes have been made to the original adjustments unless a clear progression has been detected.

Objectives: If the use of the SpineCor during pubertal growth spurt is less successful than the use of other braces, the question remains to be answered as to whether one can expect at least results superior to natural history using this soft brace. To determine whether the results obtained by the use of the SpineCor are better than natural history during pubertal growth spurt, this study has been undertaken.

2.

Material and Methods

This is a prospective comparison of the survival rates of SpineCor treatment vs. natural history with respect to curve progression during pubertal growth spurt. 12 Patients with Cobb angles between 16 and 32 degrees during pubertal growth spurt are presented as a case series treated with the SpineCor. Survival rate of this sample is described and compared to natural history as presented in the control group of the SRS brace study [5]. All girls treated in both studies were at risk for being progressive with the first clinical signs of maturation (Tanner 2-3), the girls from the SpineCor sample all were premenarchial at the start of treatment.

3.

Results

During the pubertal growth spurt most of the patients (11/12) with SpineCor progressed clinically and radiologically as well (at least 5 degrees). Progression could be stopped changing SpineCor to the Chêneau brace in most of the sample described (7/10). The avarage Cobb angle at the start of treatment with the SpineCor was 21.3 degrees, after an average observation time of 21.5 months 31 degrees. At 24 months of treatment time 33% of the patients with the SpineCor where still under treatment with their original bracing concept, at 72 months follow-up time 8 % of the patients with the SpineCor survived with respect to curvature progression. Survival proportion in the SpineCor-sample, though was 0.08, while in the Natural History cohort it was 0.34.

H.-R. Weiss / SpineCor vs. Natural History

135

SRS study finished

Observation (estimated)

SpineCor final result

6,0 Years

Figure 2. Survival analysis comparing natural history [modified from 5] to SpineCor treatment (fat grey line) during pubertal growth spurt clearly shows worse results for the SpineCor sample at 4 years.

4.

Discussion

In this study no patients have been lost for follow-up. Therefore the results of our study can be compared to other studies with similar study design [4]. The material in the study performed by Nachemson et al. [5] however, is slightly different including also postmenarchial girls (65 premenarchial, 46 postmenarchial) with clear signs of maturation (82 with Risser 0-1, 28 with Risser 2-5). Follow-up time is not shorter in our study compared to Nachemsons (72 vs. 48 Month) and the last remaining patient (18 years of age) in our study was no more of risk for progression at the end of the observation period. The proportion of patients without progression (rate of success) under Boston brace treatment was 74 % (worst case 50%) whereas the Chêneau sample from our previous study did quite better with a success rate of 80% [3] (no patient lost, one patient Risser 1, the others Risser 0 in the Chêneau sample of patients). Success rate for the SpineCor sample was 8% compared to the success rate of the natural history sample in the Nachemson study [5] of 34%. So we cannot expect the SpineCor treatment to change natural history, although we must admit the SpineCor sample to have a slightly worse prognosis (being more immature) than the controls [5]. The poor results of SpineCor treatment during pubertal growth spurt may be explained by the fact, that this soft brace leads to axial loading (Fig. 3.) with kyphosing effects to the thoracolumbar junction as shown in lateral x-rays [2], while sagittal realignment with lumbar re-lordosation has been shown to be beneficial in the treatment of patients with scoliosis [6-8] and therefore this should be implemented in actual bracing concepts.

5.

Conclusions

The SpineCor treatment during pubertal growth spurt seems to lead to a worse outcome than observation only. The use of a simple biomechanical model explains that in the

136

H.-R. Weiss / SpineCor vs. Natural History

Figure 3: In a sphere wrapped into elastic material the compression forces can be estimated to be the same at every point (left). In a lengthwise oval model (right) – independently of any lateral forces applied – axial compression forces will always overweight the lateral forces leading to a junctional thoracolumbar kyphosis with the consequence of an instable segmental alignment in this area.

brace the compression forces exceed the lateral forces used for the corrective movement. Therefore SpineCor does not seem to be indicated as a treatment during pubertal growth spurt.

References [1] [2] [3] [4]

[5]

[6] [7] [8]

Coillard Ch, Leroux MA, Zabjek KF, Rivard Ch: SpineCor – a non-rigid brace for the treatment of idiopathic scoliosis: post-treatment results. Eur Spine J 12:141-148, 2003. Coillard Ch, Circo AB, Rivard Ch: SpineCor treatment for early scoliosis: 15 to 25°. 5th. Internationel Conference on the Conservative Management of Spinal Deformities, Athens, April 2-5, 2008 Weiss HR, Weiss GM: Brace treatment during pubertal growth spurt in girls with idiopathic scoliosis (IS): a prospective trial comparing two different concepts. Pediatr Rehabil. 2005 Jul-Sep;8(3): 199-206. Wong MS, Cheng CY, Ng BWK, Lam TP, Sin SW, Lee-Shum LF, Chow HK, Tam YP: A prospective study on clinical efficacy and patients´ acceptance of SpineCor and rigid spinal orthoses in treatment of AIS. 5th. Internationel Conference on the Conservative Management of Spinal Deformities, Athens, April 2-5, 2008 Nachemson AL, Peterson LE: Brace study group of SCR. Effectiveness of treatment with a brace in girls who have AIS. A prospective, controlled study based on data from the brace study of the SRC. J Bone Jt Surg, 77-A:815-822, 1995. Weiss HR, Dallmayer R, Gallo D: Sagittal counter forces (SCF) in the treatment of idiopathic scoliosis: a preliminary report.Pediatr Rehabil. 2006 Jan-Mar;9(1):24-30. Weiss HR, Rigo M: The chêneau concept of bracing - actual standards.Stud Health Technol Inform. 2008;135:291-302. van Loon PJ, Kühbauch BA, Thunnissen FB: Forced lordosis on the thoracolumbar junction can correct coronal plane deformity in adolescents with double major curve pattern idiopathic scoliosis. Spine, 2008 Apr 1;33(7):797-801.

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-137

137

Comparison of the kyphosis angle evaluated by video rasterstereography (VRS) with x-ray measurements H-R WEISS, N ELOBEIDI Asklepios Katharina Schroth Spinal Deformities Rehabilitation Centre, Korczakstr. 2, 55566 Bad Sobernheim, Germany, [email protected] Abstract. Surface topography evaluations are prone to technical errors due to postural sway of the patients measured. The technical error of lateral deviation (rms) and surface rotation (rms) may vary between 15 and 20%, while the kyphosis angle (IP-ITL) has a technical error of only 5% (2,5 degrees), which is comparable to the x-ray measurement. Purpose of this study was to investigate the hypothesis that video rasterstereography can be used for prognostication of a kyphosis patient. Materials and Methods. 53 Patients (23 females, 30 males, average age 17 years with a range from 11 to 56 years) undergoing in-patient rehabilitation have been measured with the help of video rasterstereography (VRS) before starting the treatment program and the values for kyphosis angle have been correlated to the kyphosis angle measured on a lateral x-ray (XR) not older than 6 weeks before VRS measurement. 26 had a thoracic Scheuermann, 3 a thoracolumbar, 15 an Idiopathic Kyphosis and 9 a kyphosis of other origin. Results. Average Kyphosis angle XR was 49 degrees (SD 17) and VRS 63 degrees (SD 13). There was a high significant Pearson correlation of 0.78 and a high significant difference of 14 degrees in the t-test (t –9,6, p<0,001). Conclusions. The kyphosis angle VRS (Vertebra prominens – lower neutral zone of inclination) seems to allow a follow-up of individual kyphosis patients. The XR kyphosis angle according to Stagnara is measured from T4 to the lower end vertebra and therefore is lower than the VRS kyphosis angle measured from T1. The difference found between XR and VRS kyphosis angles may be explained by the angle between T1 (VRS) and T4 (XR) differently used as the upper end vertebra. Therefore the prognostication of an individual patient seems possible within certain limits. Keywords. Kyphosis angle, videorasterstereography, VRS, radiography

1.

Background

Surface topography evaluations are prone to technical errors due to postural sway of the patients measured. The technical error of lateral deviation (rms) and surface rotation (rms) may vary between 15 and 20% [1,2], while the kyphosis angle (IP-ITL) has a technical error of only 5% (2,5 degrees), which is comparable to the x-ray measurement [3]. Purpose of this study was to investigate the hypothesis that video rasterstereography can be used for prognostication of a kyphosis patient. 2.

Material and Methods

53 Patients (23 females, 30 males, average age 17 years with a range from 11 to 56 years) undergoing in-patient rehabilitation have been measured with the help of video

138

H.-R. Weiss and N. Elobeidi / Comparison of the Kyphosis Angle Evaluated by VRS

rasterstereography (VRS) before starting the treatment program and the values for kyphosis angle have been correlated to the kyphosis angle measured on a lateral x-ray (XR) not older than 6 weeks before VRS measurement. 26 had a thoracic Scheuermann, 3 a thoracolumbar, 15 an Idiopathic Kyphosis and 9 a kyphosis of other origin.

Th 4

Th 1

Figure 1. The XR kyphosis angle according to Stagnara is measured from T4 to the lower end vertebra and therefore is lower than the VRS kyphosis angle measured from T1.

3.

Results

Average kyphosis angle XR was 49 degrees (SD 17) and VRS 63 degrees (SD 13). There was a high significant Pearson correlation of 0.78 and a high significant difference of 14 degrees in the t-test (t –9,6, p<0,001). 4.

Discussion

The kyphosis angle VRS (Vertebra prominens – lower neutral zone of inclination) seems to allow a follow-up of individual kyphosis patients. The XR kyphosis angle according to Stagnara is measured from T4 to the lower end vertebra and therefore is lower than the VRS kyphosis angle measured from T1. The difference of at average 14 degrees found between XR and VRS kyphosis angles may be explained by the angle between T1 (VRS) and T4 (XR) differently used as the upper end vertebra. Therefore the prognostication of an individual patient seems possible within certain limits using VRS. VRS kyphosis angles therefore seem to be precise and can be used for prognostication and follow-up of kyphosis patients as well.

H.-R. Weiss and N. Elobeidi / Comparison of the Kyphosis Angle Evaluated by VRS

139

15 degrees should be subtracted from the VRS (VP – ITL) kyphosis measurements to estimate the XR Stagnara angle of kyphosis. 5.

Conclusions

The kyphosis angle VRS (Vertebra prominens – lower neutral zone of inclination) seems to allow a follow-up of individual kyphosis patients. The XR kyphosis angle according to Stagnara is measured from T4 to the lower end vertebra and therefore is lower than the VRS kyphosis angle measured from T1. The difference found between XR and VRS kyphosis angles may be explained by the angle between T1 (VRS) and T4 (XR) differently used as the upper end vertebra. Therefore the prognostication of an individual patient seems possible within certain limits. References [1]

[2]

[3]

Weiss, HR, K. Lohschmidt, N. El Obeidi: The Automated Surface Measurement of the Trunk. Technical Error. In: J.A. Sevastik and K.M. Diab (Eds.): Research into Spinal Deformities I, IOS Press, 1997, pp: 305-308 Weiss, HR, K. Lohschmidt, N. El Obeidi: Trunk Deformity in Relation to Breathing. A Comparative Analysis with the Formetric System. In: J.A. Sevastik and K.M. Diab (Eds.): Research into Spinal Deformities I, IOS Press, 1997, pp: 323 – 326 Weiss, H.R., Dieckmann J, Gerner, J.: The practical use of surface topography: following up patients with Scheuermann’s disease. Pediatr Rehabil. 2003 Jan-Mar;6(1):39-45

140

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-140

Postural changes in patients with scoliosis in different postural positions revealed by surface topography K SCHUMANN, I PÜSCHEL, A MAIER-HENNES, H-R WEISS Asklepios Katharina Schroth Spinal Deformities Rehabilitation Centre, Korczakstr. 2, 55566 Bad Sobernheim, Germany, [email protected] Abstract. Claims have been made that surface topography is an objective tool, however there are significant postural influences (relatively large technical error due to postural sway) those measurements are prone to. Purpose of this study was to help estimate these influences by measuring patients with scoliosis in three standardized postural positions. Material and Methods. We studied the surface-topography measurement in 100 inpatients with idiopathic scoliosis divided into different age-groups. First group: 7 to 12 years (n=12), second group: 13 to 16 years (n=51), the third 17 to 20 years (n=15) and the fourth > 21 years (n=22) (7 males and 93 females). The thoracic Cobb angle was 26.4 degrees, lumbar Cobb angle 25.7 degrees. We investigated the average lateral deviation (rms) and average surface rotation (rms). Measurements were taken one day before the patients left the clinic, after a 3 or 4 week in-patient intensive rehabilitation program (SIR), in three different postures: Normal posture: no specific instructions: standing with feet in an standardized way. Conscious posture: The patients acquired this posture during intensive daily exercising. Corrected posture: The most corrected posture the patients are able to achieve by using specific muscle tension and specific breathing techniques. We compared the results between the different postures. Then we calculated the results for the different age groups. Results. There are significant differences in both parameters tested, some of them more than 40% to 67% greater than the measurement error calculated. The best results were achieved in the second and the third group with the conscious posture, the adult group had the best valued in most corrected posture. For the youngest patients there were no significant changes with the different postures. Conclusions. Surface measurements can be influenced by artificial postures and therefore cannot be attributed as objective. This is why the surface measurements should be made by someone independent from the treatment process in order to exclude any bias as far as possible. Surface topography may be used for postural monitoring in the rehabilitation process of patients with scoliosis. Keywords. Videorasterstereography, VRS, rehabilitation, postural control, objectivity

1.

Background

Claims have been made that surface topography is an objective measurement, however there are significant postural influences (relatively large technical error) that influence such measurements [1-3]. The purpose of this study was to help estimate these influences by measuring patients with scoliosis in three standardized postural positions.

K. Schumann et al. / Postural Changes in Patients with Scoliosis in Different Postural Positions

2.

141

Material and Methods

We studied the surface topography measurement in 100 in-patients with idiopathic scoliosis divided into different age-groups. First group: 7 to 12 years (n=12), second group: 13 to 16 years (n=51), the third 17 to 20 years (n=15) and the fourth > 21 years (n=22) (7 males and 93 females). The thoracic Cobb angle was 26.4 degrees, lumbar Cobb angle 25.7 degrees. We investigated the average lateral deviation (rms) and average surface rotation (rms). Measurements were taken one day before the patients left the clinic, after a 3 or 4 week in-patient intensive rehabilitation program (SIR), in three different postures: Normal posture: No specific instructions: standing with feet in an standardized way. Conscious posture: The patients acquired this posture during intensive daily exercising. Corrected posture: The most corrected posture the patients are able to achieve by using specific muscle tension and specific breathing techniques. We compared the results between the different postures. Then we calculated the results for the different age groups.

3.

Results

There are significant differences in both parameters tested, some of them more than 40% to 67% greater than the measurement error calculated. The best corrective effects were achieved in the second and the third group with the conscious posture. The adult group had the best values in most corrected posture. For the youngest patients there were no significant changes with the different postures. The results are listed in table 1 and 2. Group

age

NP

ADLP

CP

I II III IV

10,8 (SD 1,7) 14,6 (SD 1,0) 17,7 (SD 1,0) 39,8 (SD 12,9)

11,1 (SD 6,7) 11,4 (SD 6,0) 13,8 (SD 5,3) 17,2 (SD 6,8)

10,1 (SD 6,6) 8,9 (SD 4,8) 11,1 (SD 4,8) 14,9 (SD 7,5)

10,6 (SD 5,6) 8,3 (SD 4,4) 11,2 (SD 4,7) 12,8 (SD 6,3)

Table 1. Average lateral deviation (rms) in the four different age groups in “normal” (scoliotic) posture (NP), ADL posture (ADLP) and in corrected posture (CP).

Group

age

NP

ADLP

CP

I II III IV

10,8 (SD 1,7) 14,6 (SD 1,0) 17,7 (SD 1,0) 39,8 (SD 12,9)

5,6 (SD 2,1) 6,8 (SD 3,0) 7,4 (SD 2,8) 8,7 (SD 2,9)

6,3 (SD 4,1) 6,2 (SD 2,8) 6,5 (SD 2,3) 7,7 (SD 2,8)

6,2 (SD 1,9) 7,3 (SD 4,5) 7,9 (SD 3,6) 9,0 (SD 3,2)

Table 2. Surface rotation (rms) in the four different age groups in “normal” posture (NP), ADL posture (ADLP) and in corrected posture (CP). The changes achieved here are not as clear as the changes in lateral deviation.

142

4.

K. Schumann et al. / Postural Changes in Patients with Scoliosis in Different Postural Positions

Discussion

With the outcomes for the different age groups, we are able to create a more evidence based model for conservative treatment in order to improve postures that enable patients to stop the vicious cycle of scoliosis progression by a more balanced loading (unloading) of spine.

5.

Conclusions

Surface measurements can be influenced by artificial postures and therefore cannot be attributed as objective. This is why the surface measurements should be made by someone independent from the treatment process in order to exclude any bias as far as possible. Surface topography may be used for postural monitoring in the rehabilitation process of patients with scoliosis [4-7]. The limitations of the use of surface topography to document the outcome of patients during conservative management have well been described [8].

Figure 1. Surface reconstruction of a patient in her scoliotic posture (NP) on the left and corrected during an exercise to achieve best corrected posture (CP) in daily activities.

References [1] [2]

[3]

[4]

Weiss, H.R., Dieckmann J, Gerner, J.: The practical use of surface topography: following up patients with Scheuermann’s disease. Pediatr Rehabil. 2003 Jan-Mar;6(1):39-45 Weiss, HR, K. Lohschmidt, N. El Obeidi: The Automated Surface Measurement of the Trunk. Technical Error. In: J.A. Sevastik and K.M. Diab (Eds.): Research into Spinal Deformities I, IOS Press, 1997, pp: 305-308 Weiss, HR, K. Lohschmidt, N. El Obeidi: Trunk Deformity in Relation to Breathing. A Comparative Analysis with the Formetric System. In: J.A. Sevastik and K.M. Diab (Eds.): Research into Spinal Deformities I, IOS Press, 1997, pp: 323 - 326 Weiss, HR, Ch. Verres, N. El Obeidi: Ermittlung der Ergebnisqualität der Rehabilitation von Patienten mit Wirbelsäulendeformitäten durch objektive Analyse der Rückenform. Phys Rehab Kur Med 9 (1999) 41-47

K. Schumann et al. / Postural Changes in Patients with Scoliosis in Different Postural Positions [5] [6]

[7]

[8]

143

Weiss HR, Steiner A, Reichel D, Petermann F, Warschburger P, Freidel K. Medizinischer Outcome nach stationärer Intensivrehabilitation bei Skoliose. Phys Med Rehab Kuror 2001;11:100-103 Weiss, HR, Ch. Verres, K. Steffan, I. Heckel: Outcome Measurement of Scoliosis Rehabilitation by Use of Surface Topography. In: I.A.F. Stokes (Hrsg) Research into Spinal Deformities 2, IOS Press 1999, pp 246-249 Rigo M, Quera-Salvá G, Villagrasa M, Ferrer M, and Casas A: Effect of specific exercises on the sagittal profile of scoliotic spines. 4th International Conference on Conservative Management of Spinal Deformities, Boston, MA, USA. 13–16 May 2007. Scoliosis 2007, 2(Suppl 1):S7 Weiss HR: Conservative treatment effects in spinal deformities revealed by surface topography – a critical review of literature. 5th. Internationel Conference on the Conservative Management of Spinal Deformities, Athens, April 2-5, 2008

144

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-144

4XDQWLILFDWLRQRI/RFDOL]HG 9HUWHEUDO 'HIRUPLWLHV8VLQJD6SDUVH :DYHOHWEDVHG 6KDSH0RGHO 5=(:$,/$(/6$),1'85'/( 'HSDUWPHQWRI(OHFWULFDODQG&RPSXWHU(QJLQHHULQJ8QLYHUVLW\RI$OEHUWD (GPRQWRQ&DQDGD

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

R. Zewail et al. / Quantiﬁcation of Localized Vertebral Deformities

145

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

146

R. Zewail et al. / Quantiﬁcation of Localized Vertebral Deformities

[ \ 7 6Q => VQ[VQP VQ\VQP @ ZKHUHPN

1H[W ZH XVH WKH ,QGHSHQGHQW &RPSRQHQW $QDO\VLV ,&$ WR PRGHO YDULDWLRQV LQ WKHGRPDLQRIWKHGLPHQVLRQDOO\UHGXFHGVSDUVHVKDSHUHSUHVHQWDWLRQV:HFRQVLGHUWKH SURMHFWLRQVRIWKHVKDSHVLQWKHWUDLQLQJVHWDVPL[WXUHVRILQGHSHQGHQWVRXUFHVLJQDOV ZLWKDQXQNQRZQ PL[LQJPDWUL[7KH )DVW,&$DOJRULWKP>@LV XVHG WR HVWLPDWH WKH GHPL[LQJPDWUL[ )LQDOO\WKHOLQHDUJHQHUDWLYHPRGHOLVIRUPXODWHGDVIROORZV

6 = μ + ϕ,&$E

ZKHUH μ LV WKH PHDQ VKDSH LQ WKH VSDUVH GRPDLQ DQG ϕ,&$ LV WKH ,&$ EDVLV PDWUL[FDOFXODWHGXVLQJWKHHVWLPDWHGGHPL[LQJPDWUL[ ,QWKHVKDSHVSDFHWKHEDVLVPDWUL[FRQVWLWXWHVVHWVRIORFDOL]HGSDWKRORJ\UHODWHG GHIRUPDWLRQV$Q\VKDSHFDQWKHQEHDSSUR[LPDWHGDVDOLQHDUFRPELQDWLRQRIWKHPHDQ VKDSHSOXVZHLJKWHG VXPRIWKHVHORFDOL]HGPRGHVRIGHIRUPDWLRQV 9HUWHEUDOTXDQWLILFDWLRQ XVLQJVXSSRUWYHFWRUPDFKLQHV %\SURMHFWLQJWKHVKDSHVRQWRDQ\VSHFLILFVXEVHWRIWKHORFDOL]HGGHIRUPDWLRQPRGHV ZHREWDLQDORZGLPIHDWXUHYHFWRUWKDWLVUHODWHGWRVSHFLILFYHUWHEUDRILQWHUHVW7KHVH IHDWXUH YHFWRUV DUH WKHQ XVHG DV DQ LQSXW WR D VXSSRUW YHFWRU PDFKLQH FODVVLILHU WR DFKLHYHYHUWHEUDOTXDQWLILFDWLRQ :LWKHDFKYHUWHEUDEHLQJODEHOHGE\H[SHUWUDGLRORJLVWVDVQRUPDORUDEQRUPDOWKH VXSSRUW YHFWRU PDFKLQH FODVVLILHU 690 >@ LV WKHQ WUDLQHG WR GLVWLQJXLVK EHWZHHQ QRUPDODQGSDWKRORJ\SRSXODWLRQV

([SHULPHQWDO 5HVXOWV ([SHULPHQWDO6HWXS ([SHULPHQWV LQ WKLV SDSHU ZHUH SHUIRUPHG RQ D GDWDVHW RI ODWHUDO OXPEDU VSLQH [UD\ LPDJHV5HVXOWVUHSRUWHGIRFXVRQWKHDQWHULRURVWHRSK\WHVDVWKHSDWKRORJ\RILQWHUHVW 7KH VSLQH [UD\ GDWDVHW ZHUH SURYLGHG E\ WKH 1DWLRQDO /LEUDU\ RI 0HGLFLQH>@ )RU HDFK[UD\LPDJHWKHOXPEDUYHUWHEUDH//DUHDQQRWDWHGDQGODEHOHGDVQRUPDORU DEQRUPDOLHZLWKRVWHRSK\WHSDWKRORJ\ E\H[SHULHQFHGUDGLRORJLVWV)LJXUHVKRZV KRZDGDWDVHWRIOXPEDUVSLQHVKDSHVLVEXLOW

R. Zewail et al. / Quantiﬁcation of Localized Vertebral Deformities

147

)LJXUH %XLOGLQJDGDWDVHWRIVKDSHVRIWKHOXPEDUVSLQHD 6DPSOH;UD\LPDJHRIOXPEDUVSLQH E %RXQGDU\SRLQWVVHOHFWHGE\DQH[SHUWF ,QWHUSRODWHGVKDSHRIWKHOXPEDUVSLQH

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

148

R. Zewail et al. / Quantiﬁcation of Localized Vertebral Deformities

)LJXUH 6KDSH SUHGLFWLRQ IRU QRUPDO DQG DEQRUPDO YHUWHEUDH XVLQJ 3&$EDVHG PRGHO WRS URZ DQG SURSRVHGPRGHOERWWRP URZ DG DUHQRUPDOYHUWHEUDHEFHI DUHYHUWHEUDHZLWKRVWHRSK\WHVSDWKRORJ\

)LJXUH3UHGLFDWLRQDELOLW\RIWKHSURSRVHGVKDSHPRGHO63,&$ DQG3&$EDVHGPRGHO

7KHSHUIRUPDQFHRIWKHYHUWHEUDOTXDQWLILFDWLRQVFKHPHLVDOVRHYDOXDWHGXVLQJWKH 5HFHLYHU 2SHUDWLQJ FKDUDFWHULVWLFV FXUYHV 52& IRU YHUWHEUDO SDWKRORJ\ GHWHFWLRQ )LJXUH VKRZV WKH UHFHLYHU RSHUDWLQJ FKDUDFWHULVWLF FXUYHV IRU DQ / YHUWHEUD $W VHQVLWLYLW\ WUXHSRVLWLYH RIRXUPHWKRGDFKLHYHVDQDYHUDJHVSHFLILW\RI YHUVXV DQ DYHUDJH VSHFLILW\ IDOVH SRVLWLYH RI IRU WKH 3&$EDVHG FODVVLILFDWLRQ

R. Zewail et al. / Quantiﬁcation of Localized Vertebral Deformities

149

)LJXUH 52&FXUYHVIRURVWHRSK\WHVGHWHFWLRQ/YHUWHEUD

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

$FNQRZOHGJPHQWV 7KHDXWKRUVZLVKWRDFNQRZOHGJHWKH861DWLRQDO/LEUDU\RI0HGLFLQHIRUPDNLQJWKH GLJLWDO [UD\ LPDJHV DYDLODEOH $OVR DFNQRZOHGJPHQWV JR WR L&25( ,QIRUPDWLFV &LUFOHRI 5HVHDUFK([FHOOHQFH DQGWKH.LOODP7UXVWVIRUWKHILQDQFLDOVXSSRUWRIWKLV ZRUN

150

R. Zewail et al. / Quantiﬁcation of Localized Vertebral Deformities

5HIHUHQFHV >@

$QWDQL6/5/RQJ*57KRPD56WDQOH\³9HUWHEUDVKDSHFODVVLILFDWLRQXVLQJ0/3IRUFRQWHQW EDVHGLPDJHUHWULHYDO´3URFHHGLQJVRIWKH,QWHUQDWLRQDO-RLQW&RQIHUHQFHRQ1HXUDO1HWZRUNV YRO -XO\ >@ $QWDQL6;LDRTLDQ;X/5/RQJ*57KRPD³3DUWLDO6KDSH0DWFKLQJIRU&%,5RI6SLQH;UD\ ,PDJHV´ 3URFHHGLQJV RI 63,( (OHFWURQLF ,PDJLQJ 6WRUDJH DQG 5HWULHYDO 0HWKRGV DQG $SSOLFDWLRQV IRU0XOWLPHGLD9RO-DQ >@ $QWDQL 6 / 5 /RQJ * 7KRPD ³$SSO\LQJ 9HUWHEUDO %RXQGDU\ 6HPDQWLFV WR &%,5 RI 'LJLWL]HG 6SLQH ;UD\ ,PDJHV´ 3URFHHGLQJV RI ,6 763,( (OHFWURQLF ,PDJLQJ 6FLHQFH DQG 7HFKQRORJ\ 6WRUDJHDQG5HWULHYDO0HWKRGVDQG$SSOLFDWLRQVIRU0XOWLPHGLD9RO >@ 6P\WK 3 3 & 7D\ORU - ( $GDPV ³9HUWHEUDO VKDSH DXWRPDWLF PHDVXUHPHQW ZLWK DFWLYH VKDSH PRGHOV´5DGLRORJ\9ROQR >@ 5REHUWV0*7)&RRWHV-( $GDPV³9HUWHEUDO0RUSKRPHWU\6HPLDXWRPDWLF'HWHUPLQDWLRQRI 'HWDLOHG 9HUWHEUDO 6KDSH IURP ';$ ,PDJHV XVLQJ $FWLYH $SSHDUDQFH 0RGHOV´ ,QYHVWLJDWLYH 5DGLRORJ\ 9RO1RSS >@ GH %UXLMQH 0 3& 3HWWHUVHQ /% 7DQNy DQG 0 1LHOVHQ ³9HUWHEUDO )UDFWXUH &ODVVLILFDWLRQ´ LQ 0HGLFDO,PDJLQJ,PDJH3URFHVVLQJ3URFHHGLQJVRI63,( 63,(3UHVV >@ 0 GH %UXLMQH 07 /XQG /% 7DQNy 3& 3HWWHUVHQ DQG 0 1LHOVHQ ³4XDQWLWDWLYH YHUWHEUDO PRUSKRPHWU\XVLQJ QHLJKERUFRQGLWLRQDO VKDSH PRGHOV´LQ0HGLFDO,PDJH&RPSXWLQJ &RPSXWHU $VVLVWHG,QWHUYHQWLRQ /HFWXUH1RWHVLQ&RPSXWHU6FLHQFH SS±6SULQJHU >@ 0DOODW6³$:DYHOHW7RXURI6LJQDO3URFHVVLQJ´$FDGHPLF3UHVV >@ &RLIPDQ 5 5 0 :LFNHUKDXVHU ³(QWURS\EDVHG DOJRULWKPV IRU EHVW EDVLV VHOHFWLRQ´ ,((( 7UDQVDFWLRQRQ,QIRUPDWLRQ7KHRU\YRO SS >@ +\YlULQHQ$³)DVWDQG5REXVW)L[HG3RLQW$OJRULWKPVIRU,QGHSHQGHQW&RPSRQHQW$QDO\VLV´,((( 7UDQVDFWLRQVRQ1HXUDO1HWZRUNV >@ :HEE $5³6WDWLVWLFDO3DWWHUQ5HFRJQLWLRQ´6HFRQG(GLWLRQ >@ /RQJ /5 6 $QWDQL *5 7KRPD ³,PDJH LQIRUPDWLFV DW D 1DWLRQDO 5HVHDUFK &HQWHU´ &RPSXWHUL]HG 0HGLFDO,PDJLQJDQG*UDSKLFVSS

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-151

151

&RPSXWHU$VVLVWHG&REE$QJOH 0HDVXUHPHQWRQ3RVWHURDQWHULRU5DGLRJUDSKV -=+$1*D(/28E/ + /(D'+,//E-5$62E<:$1*F D

'HSDUWPHQWRI5DGLRORJ\DQG'LDJQRVWLF,PDJLQJ 8QLYHUVLW\RI$OEHUWD (GPRQWRQ$% &DQDGD7*( E &DSLWDO+HDOWK±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¶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

,QWURGXFWLRQ

&XUUHQWO\ [UD\ LV WKH PRVW FRPPRQO\ XVHG LPDJH PRGDOLW\ WR GLDJQRVH DQG DVVHVV VFROLRVLV DQG WKH &REE DQJOH PHWKRG >@ LV WKH JROG VWDQGDUG WR DVVHVV WKH VHYHULW\ RI VFROLRVLV $ VSLQDO GHIRUPLW\ ZLWK D &REE DQJOH PRUH WKDQ GHJUHHV LV FRQVLGHUHG VFROLRVLV 7UHDWPHQWPRGDOLWLHV DUHSHUVRQDOL]HG GHSHQGLQJRQ SDWLHQW¶VUHVSRQVLYHQHVV WR WUHDWPHQWH[SHFWDWLRQVVNHOHWDOPDWXULW\FXUYHVHYHULW\ DQGW\SHVXUIDFHGHIRUPLWLHVDQG WKHULVNRISURJUHVVLRQ5HJXODUREVHUYDWLRQRUWKRWLFEUDFH WUHDWPHQWDQGVXUJHU\ >@DUH WKH PRVW FRPPRQO\ XVHG WUHDWPHQWV LQ 1RUWK $PHULFD ,Q JHQHUDO D VSLQDO FXUYH ZLWK D &REE DQJOH RI WR GHJUHHV ZLOO EH H[DPLQHGUHJXODUO\ %UDFH WUHDWPHQW LV JHQHUDOO\ FRQVLGHUHG IRU FXUYDWXUH EHWZHHQ WR GHJUHHV LQ DJURZLQJ FKLOG6XUJHU\ LV XVXDOO\ FRQVLGHUHGZKHQWKHVSLQDOFXUYHSURJUHVVHV EH\RQGGHJUHHV,QJHQHUDOFKDQJHPRUH

152

J. Zhang et al. / Computer-Assisted Cobb Angle Measurement on Posteroanterior Radiographs

WKDQ GHJUHHV LQ WZR VXFFHVVLYH UDGLRJUDSKV LV DQ LQGLFDWLRQ RI FXUYH SURJUHVVLRQ RU FOLQLFDOO\PHDQLQJIXOFKDQJHEH\RQGPHDVXUHPHQWHUURU>@ 7RPHDVXUHWKH&REEDQJOHWZRHQGYHUWHEUDHZLWKLQWKHFXUYHZHUHLGHQWLILHG7KH HQGYHUWHEUDHFKRVHQWLOWPRVWVHYHUHO\WRZDUGWKHFRQFDYLW\RIWKHVSLQDOFXUYH$IWHUWKH HQGYHUWHEUDHDUHVHOHFWHGWKH&REEDQJOHșLVFDOFXODWHGDVWKHVXPRIWKHDQJOHVRIWKH HQGYHUWHEUDH ș ș șDVVKRZQLQ)LJXUH 7KH DFFXUDF\ DQG UHSHDWDELOLW\ RI PDQXDO PHDVXUHPHQW RI &REE DQJOH GHSHQGV SDUWLDOO\ RQWKHRSHUDWRU¶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

)LJXUH&REEDQJOH PHDVXUHPHQW

0DWHULDOVDQG0HWKRGV

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

J. Zhang et al. / Computer-Assisted Cobb Angle Measurement on Posteroanterior Radiographs

153

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î SL[HOV FRQWDLQLQJ WKH VHOHFWHG HQGYHUWHEUDH ZHUH FUHDWHG E\ WKH DOJRULWKP 7KH DQLVRWURSLF GLIIXVLRQDOJRULWKP>@ZDVXVHGWRGHQRLVHWKH52,LPDJHV7KH&DQQ\HGJHGHWHFWRU>@ ZDV WKHQ DSSOLHG WR WKH GHQRLVHG 52, LPDJHV WR REWDLQ WKH HGJH LPDJHV ZKLFK ZHUH SUHUHTXLVLWHWRLPSOHPHQW WKH +RXJK7UDQVIRUP>@ 2.)X]]\+RXJK7UDQVIRUP)+7 +RXJK WUDQVIRUP +7 >@ZDV RULJLQDOO\ SURSRVHG DV DWHFKQLTXH WR GHWHFW VWUDLJKW OLQHV $SSO\LQJ +7 WR D VHW RI HGJH SRLQWV UHVXOWV LQ WKH DFFXPXODWRU DUUD\ &ȡN șN ZKLFK UHSUHVHQWVWKHQXPEHURIHGJHSRLQWVRQWKHOLQHVSHFLILHGE\ȡNșN %\ILQGLQJWKHORFDO SHDNVRI&ȡNș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ȡș & ȡș «DQG&O ȡO șO GHQRWHWKH OSHDNVVHOHFWHG 6HFRQGO\WKHSHDNVVDWLVI\LQJ_șL șM_ZHUHSDLUHG/HW θ GHQRWHWKHDYHUDJHDQJOHRI DSDLURISHDNVLH θ _șL șM_7KLUGO\WKHSDLUVZKLFKVDWLVILHG − < θ < DQG _ȡL ȡM _ZHUHVHOHFWHGDVWKHKRUL]RQWDOFDQGLGDWHSDLUV WKH SDLUVZKLFKVDWLVILHG θ !RU θ DQG_ȡL ȡM _ZHUHVHOHFWHGDVWKHYHUWLFDOFDQGLGDWHSDLUV/HW θ+Q DQG θ9Q UHVSHFWLYHO\UHSUHVHQWWKH DYHUDJH DQJOHV RI WKHQWKKRUL]RQWDODQG YHUWLFDO

154

J. Zhang et al. / Computer-Assisted Cobb Angle Measurement on Posteroanterior Radiographs

FDQGLGDWH SDLUV )RXUWKO\ WKH FDQGLGDWH FRXSOHV RI SDLUV VDWLVI\LQJ__ θ+Q −θ 9P _−_< ZHUH VHOHFWHG )LQDOO\ WKH WZR SDLUV ZLWK WKH PD[LPXP DYHUDJH&YDOXHVRI ZKLFKWKHKRUL]RQWDOSDLUDYHUDJHDQJOH θ+ ZDV FRQVLGHUHGDVWKH SHDNVWKDWFRUUHVSRQGHGWRWKHHQGSODWHVZHUHLGHQWLILHG7KHDQJOH θ+ ZDVFRQVLGHUHGDV WKHDQJOHRIWKHYHUWHEUD$VDQH[DPSOH)LJXUHVKRZHGWKUHHFDVHVRIYHUWHEUDHDQGWKH OLQHVHJPHQWVGHWHFWHGE\WKH)+7XQGHUWKHYHUWHEUDOVKDSHFRQVWUDLQWV,QHDFKFDVHWZR OLQHVZHUH ILWWHGWRWKHHQGSODWHVDQGWKHPLGGOHOLQHLQGLFDWHGWKHYHUWHEUDOGLUHFWLRQθ+ %DVHGRQWKHGHWHFWHGDQJOHVθ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

)LJXUH (GJH LPDJHV RI YHUWHEUDH DQG GHWHFWHG OLQH VHJPHQWV D HGJH LPDJHV RI YHUWHEUDH E GHWHFWHG YHUWHEUDOGLUHFWLRQVDQGOLQHVHJPHQWVWKDWILWWRWKHYHUWHEUDOHQGSODWHV

5HVXOWV

)RU HDFK FXUYH W\SH WKH &REE DQJOHV IURPWKH VXUJHRQ DQG WZR H[DPLQHUV ZHUH OLVWHG LQ 7DEOH,WFDQEHVHHQWKDWWKHDYHUDJHGLIIHUHQFHVRIWKHLQWHUPHWKRGLQWHUREVHUYHUDQG LQWUDREVHUYHUZHUHOHVVWKDQGHJUHHVUHJDUGOHVVRIWKHFXUYHW\SHV )RU HDFK FXUYH W\SH WKH ,&& YDOXHV VKRZQ LQ 7DEOH LQGLFDWHG WKHKLJK DJUHHPHQW EHWZHHQ WKH DXWRPDWLF DQG PDQXDO PHDVXUHPHQWV ,&&V ! 7KH LQWHUREVHUYHU DQG

J. Zhang et al. / Computer-Assisted Cobb Angle Measurement on Posteroanterior Radiographs

155

LQWUDREVHUYHU DQDO\VLV UHVXOWV ZHUH JLYHQ LQ 7DEOH DQG 7DEOH UHVSHFWLYHO\ 7KH ,&& YDOXHVRIKLJKHUWKDQLQGLFDWHGWKHKLJKLQWHUREVHUYHUDQGLQWUDREVHUYHUUHOLDELOLW\RI WKHSURSRVHGPHWKRG

7DEOH &REEDQJOHPHDVXUHGE\WKHVXUJHRQDQGWZRH[DPLQHUV 7\SHFDVHV

7\SHFDVHV

7\SHFDVHV

7\SHFDVHV

6

( VW PHDV

(QGPHDV

(VW PHDV

(QG PHDV

7DEOH ,QWHUPHWKRGDQDO\VLV

VW

7\SHFDVHV

7\SHFDVHV

7\SHFDVHV

7\SHFDVHV

6YV( PHDV

6YV(QGPHDV

6YV(VW PHDV

6YV(QG PHDV

7DEOH ,QWHUREVHUYHUDQDO\VHV 7\SHFDVHV

7\SHFDVHV

7\SHFDVHV

7\SHFDVHV

(YV( VW PHDV

(YV(QGPHDV

7DEOH ,QWUDREVHUYHUDQDO\VHV 7\SHFDVHV

7\SHFDVHV

7\SHFDVHV

7\SHFDVHV

(VW YVQG PHDV

(VW YVQG PHDV

&RQFOXVLRQ

%DVHGRQWKHVWXG\RI3$UDGLRJUDSKVWKH SURSRVHGFRPSXWHUDLGHGPHWKRGZDVDEOHWR SURYLGH DQ DFFXUDWH DQG PRUH UHOLDEOH PHDVXUHPHQW RI WKH &REE DQJOHV WKDQ KDV EHHQ UHSRUWHGIRUPDQXDOPHDVXUHPHQWV 7KHUHVXOWVZHUHQRWVHQVLWLYHWR FXUYH W\SHV +RZHYHU WKH GHYHORSHG PHWKRG VWLOO UHTXLUHG XVHU MXGJPHQW LQ WKH SUHSURFHVVLQJ VWDJH$OWKRXJKWKHVKDSHFRQVWUDLQWVZHUHUHDVRQDEOHIRUPRVWUDGLRJUDSKVIDOVHGHWHFWLRQ PLJKW RFFXU LI D YHUWHEUD WLOWHG PRUH WKDQ GHJUHHV RU WKH YHUWHEUD KDG D VHYHUHO\

156

J. Zhang et al. / Computer-Assisted Cobb Angle Measurement on Posteroanterior Radiographs

GHIRUPHGVKDSHWKDWGLGQRWVDWLVI\ WKHVKDSHFRQVWUDLQWV,QDGGLWLRQWKHSURSRVHGPHWKRG FDQQRWEHXVHGWRPHDVXUHWKHSRVWVXUJLFDOFDVHV

$FNQRZOHGJHPHQWV 7KLVZRUNZDVVXSSRUWHGE\ (GPRQWRQ2UWKRSHGLF 5HVHDUFK6RFLHW\ DQG&DSLWDO+HDOWK

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± >@ &DQQ\ - $ FRPSXWDWLRQDO DSSURDFK WR HGJH GHWHFWLRQ ,((( 7UDQV 3DWWHUQ $QDO 0DFK ,QWHOO >@ +RXJK39&0HWKRGDQGPHDQVIRUUHFRJQL]LQJFRPSOH[SDWWHUQV863DWHQW >@ +DQ-+.RF]\/73RVWRQ7)X]]\ +RXJKWUDQVIRUP3DWWHUQUHFRJQLWLRQOHWWHUV

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-157

157

1HZ0HWKRGRI6FROLRVLV'HIRUPLW\ $VVHVVPHQW,6,66\VWHP $=8%29,û1'$9,(6)%(55<0$133<16(171485$,6+, &/$9<*%2:'(1-:,/6210$&'21$/'-)$,5%$1.

1XIILHOG2UWKRSDHGLF&HQWUH+HDGLQJWRQ2[IRUG8. 8QLYHUVLW\RI :ROYHUKDPSWRQ6FKRRORI(QJLQHHULQJDQGWKH%XLOW(QYLURQPHQW 7HOIRUG8. 5HVHDUFKDQG7HDFKLQJ&HQWUH5R\DO2UWKRSDHGLF+RVSLWDO%LUPLQJKDP8.

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a PP ZLWK IULQJH IUHTXHQF\ RI a IULQJHVPP a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

158

A. Zubovi´c et al. / New Method of Scoliosis Deformity Assessment: ISIS2 System

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

0HWKRG ,6,6FRQVLVWVRIDFDPHUDDQGSURMHFWRUKRXVLQJDWHOHVFRSLFFROXPQDSDWLHQWVWDQG ZLWKUHIHUHQFH SODQH DQGD FRPSXWHU FRQWUROOLQJWKHSURMHFWRUDQG FDPHUD 3L[HO VL]H ZDVaPPZLWKIULQJHIUHTXHQF\RIaIULQJHVPPaPPIULQJH 7KLVJLYHV DQDFFXUDF\RI ±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¶VWWHVW

7DEOH ,6,6PHDVXUHPHQWV

9DULDEOH

0HGLDQYDOXH

%DFNOHQJWK

PP

3HOYLFURWDWLRQ

Û

&,

0LQYDOXH

0D[YDOXH

WR

PP

PP

WR

±Û

Û

A. Zubovi´c et al. / New Method of Scoliosis Deformity Assessment: ISIS2 System

0D[VNLQDQJOH

Û

WR

Û

Û

0LQVNLQDQJOH

±Û

±WR ±

±Û

Û

,PEDODQFH

PP

WR

±PP

PP

8SSHUODWHUDODV\PPHWU\

±Û

WR

±Û

Û

/RZHUODWHUDODV\PPHWU\

Û

WR

±Û

Û

)OH[LRQH[WHQVLRQ

Û

WR

±Û

Û

/RUGRVLVDQJOH

Û

WR

±Û

Û

.\SKRVLVDQJOH

Û

WR

Û

Û

/HIWYROXPHWULFDV\PPHWU\

WR

5LJKWYROXPHWULFDV\PPHWU\

WR

159

5HVXOWV $ WRWDO RI ,6,6 VFDQV ZHUH SHUIRUPHG RQ SDWLHQWV IURP )HEUXDU\ WR 'HFHPEHU 7KH SDWLHQWV LQFOXGH PDOHV PHGLDQ DJH \HDUV 6' PLQLPXP \HDUV PD[LPXP \HDUV DQG IHPDOHV PHGLDQ DJH \HDUV 6' PLQ \HDUV PD[ \HDUV 2QDYHUDJH WKHUH ZHUH VFDQV SHU SDWLHQW ZLWK WKHUDQJHRIVFDQV5LJKWVLGHGWKRUDFLFFXUYHVSUHGRPLQDWHG 7KHPHDVXUHG,6,6YDOXHVDUHSUHVHQWHGLQ7DEOH

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¶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

160

A. Zubovi´c et al. / New Method of Scoliosis Deformity Assessment: ISIS2 System

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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-161

161

A Novel Solution for Registration of Stereo Digital Torso Images of Scoliosis Patients 1

A KUMAR1, N DURDLE1 J RASO2 Dept of Electrical & Computer Eng, University of Alberta, Edmonton, AB, Canada 2 Glenrose Rehabilitation Hospital, Edmonton, AB, Canada Abstract. This paper presents a procedure for registration of a pair of stereo digital images giving an improvement in accuracy and speed over existing methods. It does so by a novel approach combining color based image segmentation and differential geometry. It involves three stages: image segmentation, adaptive local pixel matching, and deferential geometry in a tree weighted belief propagation procedure. The registration was compared to 2 existing registration procedures, segment-based adaptive belief propagation (adaptive BP) and color-weighted hierarchical belief propagation (hierarchical BP). A 3D scan of a mannequin was obtained and errors in reconstruction were measured for each of the 360 cross sections of the mannequin. The proposed procedure outperforms existing methods, particularly for high curvature regions and significantly large cross sections. Its accuracy of reconstruction ranged from 85-100% compared to 75-100% for other existing methods. It was 35% to 40% faster. This work provides a solution to the registration problem and is an important step in developing a cost effective technique for measuring torso shape and symmetry of scoliosis patients using stereo digital cameras. Keywords. Scoliosis, Registration, Image Segmentation, Pixel Matching, Belief Propagation

1.

Introduction

Scoliosis is a condition characterized by lateral deviation of the spine coupled with rotation of individual vertebra resulting in visible torso asymmetries [10]. Assessment of the severity of scoliosis is traditionally done using radiographs of the spine [11]. However, radiographs do not describe the visible torso deformity associated with scoliosis. Torso imaging can describe torso deformities and reduce the need for radiographs, effectively reducing the risk of cancer [11]. Optical/Imaging methods have been used for assessment of scoliosis and monitoring of its progression. Some of these are Moiré topography, ISIS scanning, Quantec system scanning, rasterstereography, laser scanning and stereo vision imaging [11]. Much advancement has been made in improving each of these methods over the past years. However, ISIS scanning is a slow process and produces poor resolution images. The Quantec system scanning, laser scanning and rasterstereography are expensive due to the hardware components involved and also immobile. Images produced via Moiré topography are highly dependent on posture of the patient and provide a relative measure based on contours rather than a quantitative measure. In light of the problems associated with 3D imaging of the torso, stereo vision has become a cost effective alternative. Progress in computer vision and availability of faster computer processors has lead to development of stereo vision algorithms for simultaneous stereo camera capture, calibration and reconstruction. Stereo capture systems consist of digital or TV cameras

162

A. Kumar et al. / A Novel Solution for Registration of Stereo Digital Torso Images

positioned with known geometry. Significant advances have been recently made in the area of computer vision, as a result of publically available performance testing such as the Middlebury data set [1], which has allowed researchers to compare their algorithms against all state-of-the-art algorithms [7]. Stereo correspondence or registration of stereo images is one of the most active research areas in computer vision [1]. In the area of stereo vision research, stereo images refer to images captured at different viewpoints using cameras with known geometry [5]. In order to register the stereo images, we need to determine the closest (least error) or best point-to-point correspondence between the two images. Stereo registration algorithms can be used on stereo images captured using calibrated digital or TV cameras to obtain three dimensional (3D) point set data. A triangulation algorithm is primarily applied on point set data to obtain a 3D surface. 3D surface reconstructions of scenes or localized objects in a scene using stereo vision has modern applications in 3D modelling, computer graphics, facial expression recognition, surgical planning, architectural structural design etc. [2,8]. The 3D scene geometry established from this process can be used to reconstruct 3D torso images to study scoliosis. However a problem associated with the existing stereo registration algorithms such as that developed by Klauss, Sormann and Karner [4] is that it assumes frontal parallel plane geometry. This means that it assumes depth is constant (with respect to the rectified stereo pair) over a region under consideration [3]. Reconstruction of smooth and curved surfaces where depth is constantly changing violates this assumption. Li and Zucker [8] have tried to solve this problem using differential geometry but they have not applied their algorithm to the one developed by Klauss, Sormann and Karner [4]. Belief Propagation and Graph Cuts are the most commonly used methods for refinement of the registration process [1]. Tree Re-weighted Message Passing, which might become a serious rival to Belief Propagation and Graph Cuts [13], has not been used with differential geometry. Tree Reweighted Message Passing’s improvement over Belief Propagation and Graph Cuts becomes significant for more difficult functions [13]. This paper presents a procedure for registration of a pair of stereo digital images using image segmentation, adaptive local pixel matching, and differential geometry in a tree reweighted belief propagation procedure. The major contribution of this paper lies in incorporating differential geometry and Tree Reweighted Message Passing to Segment-Based Stereo Matching Using Belief Propagation and a Self-Adapting Dissimilarity Measure [4] to create a novel procedure with better accuracy and speed. 2.

Materials and Methods

Stereo registration methods are assessed using univalued disparity function of one image with respect to the other (referred to as reference image). When first introduced in human vision literature, disparity was used to describe the difference in location of corresponding features seen by the left and right eye [1]. The x, y spatial coordinates of the disparity space are taken to be coincident with the pixel coordinates of a reference image. The correspondence between a pixel in a reference image and pixel in the matching image is linearly related to each other by the disparity function. The disparity function obtained over the 2D images is known as the disparity space image (DSI). DSI gives a 3D point set data using the calibration

A. Kumar et al. / A Novel Solution for Registration of Stereo Digital Torso Images

163

parameters of the stereo cameras. It represents the confidence or log likelihood of a match implied by the disparity function. The procedure for obtaining disparity is divided into three stages: mean shift color segmentation, adaptive local pixel matching, and differential geometry in a tree reweighted belief propagation procedure as illustrated in Figure 1.

STEREO REGISTRATION PROCEDURE

Mean Shift Color Segmentation

Adaptive Local Pixel Matching

Differential Tree Reweighted Belief Propagation

Figure 1. Flow-chart of stereo registration procedure.

The process of color segmentation is to decompose the reference image into regions of color or grayscale [4]. The mean-shift analysis approach is essentially defined as a gradient ascent search for maxima in a density function defined over a high dimensional feature space [4]. Comaniciu and Meer’s [13] mean shift segmentation is insensitive to differences in camera gain and is therefore used. The next step involving local pixel matching is an essential step for defining a disparity plane. The aim of this step is to provide an initial estimate of the disparity space image (DSI). This basic idea is to obtain a measure of disparity that can be optimized and refined. The disparity plane is based on 3D x-y-d space supporting slanted and curved surfaces where x, y are spatial coordinates and d is the inverse depth or disparity. The disparity planes are calculated using local pixel matching. Local pixel matching requires calculation of a matching score and an aggregation window [4]. Matching score is obtained using a self-adapting dissimilarity measure that combines the sum of absolute pixel intensity differences (SAD) and a gradient-based measure as implemented by Klauss, Sormann and Karner [4]. The last stage involves calculation of the final disparities. The algorithms that perform well in this stage are based on an energy minimization framework. This means that we need to choose at each pixel the disparity associated with the minimum cost value [1]. It involves minimizing two separate energy functions that are summed together to calculate the final energy minimization term as given by the equation, E(d) = Edata(d) + λEsmooth(d) (1) where d represents disparity. The symbol Edata(d) measures how well the disparity function agrees with the input image pair and is given by the summation of matching score over the spatial coordinates. The formulation of Edata(d) is Edata(d) = Σ C(x, y, d(x, y)) (2) where C is the matching score. The symbol Esmooth(d) encodes smoothness in the image by measuring the differences between the neighboring pixels’ disparities [1]. It is given by the following equation,

164

A. Kumar et al. / A Novel Solution for Registration of Stereo Digital Torso Images

Esmooth(d) = Σ ρ(d(x, y) − d(x+1, y)) + ρ(d(x, y) − d(x, y+1)) (3) where ρ is some monotonically increasing function of disparity difference. The Esmooth(d) operates on the frontal parallel assumption that is altered in this procedure as suggested by Li and Zucker using “floating” disparities [2]. Li and Zucker apply “Floating disparities” on the Max-Product Belief Propagation framework. TreeReweighted Message Passing as defined by Kolmogorov [13] is used in this procedure as the energy minimization framework. The key subroutine of the Tree-Reweighted Message Passing algorithm is Max-Product Belief Propagation [13]. The “floating” disparities [2] are therefore added to the Max-Product Belief Propagation component of Tree-Reweighted Belief Propagation. The Tree-Reweighted Belief Propagation is advantageous because messages are passed in a sequential order rather than a parallel order requiring half the space. Convergence is reached in two passes rather than having a convergence condition as in the case of Max-Product Belief Propagation. Therefore applying differential geometry to Tree-Reweighted Belief Propagation produces better results. Stereo digital images of 400x300 resolution from the Middlebury dataset [1] and the resultant DSI obtained using the above procedure are shown in Figure 2 below.

a

b

c

Figure 2. A. Digital Image from left camera. B. Digital Image from right camera. C. Disparity Space Image taking image from left camera as reference image and image from right camera as matching camera.

3.

Results

The registration was compared to 2 existing registration procedures, segment-based adaptive belief propagation (adaptive BP) and color-weighted hierarchical belief propagation (hierarchical BP). A 3D scan of a mannequin was obtained and errors in reconstruction were measured for each of the 360 cross sections of the mannequin. The proposed procedure outperforms existing methods, particularly for high curvature regions and significantly large cross sections. Its accuracy of reconstruction ranged from 85-100% compared to 75-100% for other existing methods. It was 35% to 40% faster. 4.

Discussion

This work provides an improvement over existing stereo correspondence methods. It is an important step in developing a cost effective technique for measuring torso shape

A. Kumar et al. / A Novel Solution for Registration of Stereo Digital Torso Images

165

and symmetry of scoliosis patients. Future work will focus on validating the procedure on larger and more complex datasets. References [1] [2] [3] [4] [5] [6] [7]

[8] [9]

[10] [11]

[12] [13]

Scharstein D Szeliski R A Taxonomy and Evaluation of Dense Two-Frame Stereo Algorithms Int J Computer Vision, 2002 47(1/2/3):7-42. Li G Zucker SW “Surface Geometric Constraints for Stereo in Belief Propagation. Computer Vision and Pattern Recognition, 2006 IEEE Computer Society Conference 2006 2 2355 - 2362 Li G Zucker SW. Differential Geometric Consistency Extends Stereo to Curved Surfaces, In: Proc. 9-th European Conference on Computer Vision ECCV 2006 (3) 44-57 Klaus A Sormann M Karner K Segment-Based Stereo Matching Using Belief Propagation and a SelfAdapting Dissimilarity Measure, Pattern Recognition, ICPR 2006, 3,: 15-18 Sun J Zheng N-N Shum H-Y Stereo Matching Using Belief Propagation. Pattern Analysis and Machine Intelligence, IEEE Transactions, 2003 25, (7) 787 - 800 Bleyer M Gelautz M Graph-based surface reconstruction from stereo pairs using image segmentation Proceedings of the SPIE, 2004 5665, 288-299 Yang Q Wang, L Yang R Stewenius H Nister D Stereo Matching with Color-Weighted Correlation, Hierarchial Belief Propogation and Occlusion Handling, Computer Vision and Pattern Recognition, IEEE Computer Society Conference 2006 2, 2347- 2354 Li G Zucker SW. Stereo for Slanted Surfaces: First Order Disparities and Normal Consistency Proc. EMMCVPR, LNCS, 2005 - Springer Zhang L Curless B Seitz SM. Rapid Shape Acquisition Using Structured Light and Multi-pass Dynamic Programming First International Symposium on 3D Data Processing Visualization and Transmission (3DPVT'02) 2002. 24 Ajemba PO Durdle NG; Hill DL Raso VJ. Re-positioning Effects of a Full Torso Imaging System for the Assessment of Scoliosis. Canadian Conf on Electrical and Computer Eng. 2004, 3, 1483-1486 Ajemba PO Durdle NG; Hill DL Raso VJ. A Torso Imaging System for Quantifying the Deformity Associated with Scoliosis Instrumentation and Measurement, IEEE Transactions. 2007 56, Issue 5, Oct. 1520 - 1526 Kolmogorov V. Convergent Tree-Reweighted Message Passing for Energy Minimization, IEEE Transactions on Pattern Analysis and Machine Intelligence, 2006 28, 10 Comaniciu D; Meer P. Mean Shift: A Robust Approach Toward Feature Space Analysis, IEEE Transactions on Pattern Analysis and Machine Intelligence, 2002 24 (5) 603-619

166

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-166

0DUNHUSODFHPHQWIRUPRYHPHQWDQDO\VLVLQ 6FROLRWLFSDWLHQWV$FULWLFDODQDO\VLVRI H[LVWLQJV\VWHPV 1&+2&.$/,1*$07/&+(9$/,(50.<281* 3+ '$1*(5),(/'

)DFXOW\RI+HDOWK6WDIIRUGVKLUH8QLYHUVLW\6WRNHRQ7UHQW67') 7KH8QLYHUVLW\ RI/LYHUSRRO/LYHUSRRO/*(8.

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

,QWURGXFWLRQ

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

N. Chockalingam et al. / Marker Placement for Movement Analysis in Scoliotic Patients

167

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

0DWHULDOVDQG0HWKRGV

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

168

N. Chockalingam et al. / Marker Placement for Movement Analysis in Scoliotic Patients

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¶V JXLGHOLQHV DW WKH EHJLQQLQJ DQG HQG RI HDFK GDWD FROOHFWLRQ VHVVLRQ

)LJXUH 0DUNHU6HWSURSRVHGE\ :KLWWOHDQG /HYLQH

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

N. Chockalingam et al. / Marker Placement for Movement Analysis in Scoliotic Patients

169

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± >@ 3HDUF\0- 0HDVXUHPHQWRIEDFNDQGVSLQDOPRELOLW\&OLQLFDO%LRPHFKDQLFV >@ 3HDUF\ 0-*LOO- 0+LQGOH5--RKQVRQ*5 0HDVXUHPHQWVRI KXPDQ EDFN PRYHPHQWV LQWKUHH GLPHQVLRQVE\RSWR HOHFWURQLFGHYLFHV&OLQLFDO%LRPHFKDQLFV ±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

170

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-170

The central cord-nervous roots complex and the formation and deformation of the spine; the scientific work on systematic body growth by Milan Roth of Brno (1926-2006) P. J.M. van Loon1 and L W. van Rhijn2 1

Slingeland Hospital, Doetinchem, The Netherlands Department of Orthopaedic Surgery, University Hospital Maastricht, The Netherlands

2

1. Introduction and biography. Professor Milan Roth died on April 4, 2006. He was a professor of neuro-radiology of the J.Ev.Purkynẽ-University (now: Masarek-University) in Brno, Czechoslovakia, now the Czech Republic. Milan Roth was born on October 6, 1923 in Lelekovice, a small village north of Brno, in local schoolmaster's family. After completing his grammar school studies in Brno in 1942, he spent a year improving his language skills because the Czech universities were closed at the wartime. Since 1943 till the end of World War II, he was a "Totaleinsatz" in an armament factory in Kurim near Brno. After the war, he studied at the Medical Faculty of (now)Masaryk University in Brno, completing his studies on September 29,1949. After completing his studies, he was assigned to the department of surgery at the local hospital in Brunntal in northern Moravia (till January 31, 1950). During 1950-1952 he served in the army, most of the time at the Department of Radiology of the Military Hospital in Plzen (Pilsen). After completing his military service, he spent a short time at the pulmonary department of the local hospital in Prerov, and then at the Central Department of Radiology of the Medical Faculty in Olomouc (now Palacky University- both Prerov and Olomouc are located in central Moravia, northeast of Brno). Since November 1, 1954, he has been with the Central Department of Radiology of the Medical Faculty in Brno (now Masaryk University) that became Department of Radiology and Nuclear Medicine in 1960, and this was his workplace till his retirement in August1989. He had an appointment in research too, in the field of anatomy. In this part of his working live he produced his impressive work, both quantitative and without doubt now also qualitative. After his retirement on the University he stayed a part-time radiologist of the Radiodiagnostic Clinic of the hospital in Brno-Bohunice. He suffered a brain stroke early in 1999, became seriously afatic. Just before the planned visit of the first author,

P.J.M. van Loon and L.W. van Rhijn / The Central Cord-Nervous Roots Complex

171

his medical condition detoriated quickly. Milan Roth passed away peacefully amidst his family on April 4 2006. His work remained largely unnoticed in the mainstream of the international world of orthopaedics, neurology or neurosurgery.

Fig .1 Milan Roth at the age of 80.

Roth had a major disadvantage in exporting his knowledge to a more global scientific forum, that a large part of his career, while developing and unfolding his ideas and concepts, he worked behind the Iron Curtain. Only in his early career he worked as a fellow, not accompanied by his young family as that was forbidden in the communistic regime, at the Karolinska Institute of the University in Stockholm. His analytical work was first mainly published in German and Czech language, and in publications not well noticed because inaccessible for the mainstream. Only in the beginning of the 1980`s he had a few articles in English more international orientated journals in the field of Radiology. . At the end of this contribution a bibliography of selected articles is added with the main purpose to disclose them to a wider audience. His main concept is the concept of skeletal morphogenesis he developed which is based on the existence of 2 different types of growth of the spinal column, viz., the cellular-divisional (mitotic) growth of bone and soft tissues and the extensive (stretch) growth of the nervous structures. The neural extensive growth proceeds at a slower rate than the bone growth. Which is manifested most conspicuously in the ascent of the spinal cord. In his concept a number of normal as well as pathological features of the skeletal morphogenesis- above all the gross deformities of the body-parts which grow rapidly in length such as the spine, the extremities or the facial skeleton – are explained by the disturbed relation of the two growth types caused by an insufficiency of the vulnerable neural extensive growth. 2. Overview of the work of Roth We are not able to specify, discuss or review all his work in this contribution. It can however be divided it in four main chapters:

172

P.J.M. van Loon and L.W. van Rhijn / The Central Cord-Nervous Roots Complex

1.

2.

3.

4.

Analytical work, undertaken mainly during the decade 1960-1970, in which he laid the fundamental of the research examining and integrating interpretation of older work in the fields of biology, embryology, anatomy and physiology. Developing mechanical models of the spine, spinal growth and deformations in order to explain and visualise the processes of interrelated types of growth in the growing body in regard of time and the processing of forces. Proposing the integrated concept of neuro-osseous growth and its role in explaining the normal development of tissues creating the organs and organic systems, viewing the spine as a crucial part of the skeleton Published articles in the 1970 and 1980`s in which he consequently built upon his integrated concepts. This included papers on topics such as the Arnold Chiari malformation and Syringomyelia, and also the role and development of the neural foramen and the deformations in the lumbosacral spine based on secondary changes, like stenosis. These subjects are not discussed in the present paper.

This paper will consider this contribution focussing mainly on the developing of Roth’s integrated concept of neuro-osseous growth which was published in several papers the early nineteen-seventies. 2.1. Analytical work Roth’s knowledge of the superb work of European scientists on the spine, which he often quoted, was prodigious, even with his insight into their disputing certain concepts. An increasing number of great scientists were investigating medical problems in Europe in the early twentieth century, which included spinal deformations, with names such as Lorenz, Nicolodani, Albert and Schulthess noted. They conducted anatomical studies, mainly on cadaver vertebrae and discs. Roth was the first to correlate their individual findings from their painstaking anatomical study with his own discoveries resulting from the early application of pneumencephalo- and myelography to the position, calibre, direction and suspected tension of the central cord and vertebral roots in normal and scoliotic spines. He stated: “The traction effect of the spinal nerves is of decisive influence upon the position of the spinal cord within the spinal canal as well as upon the shaping of the vertebral foraminae, a conclusion we reached in our own radiographic studies, published in 1965 and 1966. 2.2 Phylogenetic work. The hypothesis that the tensionless position of the central nervous system matures into the adult animal vertebrate body was demonstrated in worms and other, more higher developed animals as well as in radiological and cadaver human studies. By applying study to the normal state allowed an development of understanding of the requirements of the central nervous tissues d to grow and develop. 2.3 Experimental teratogenic work. In order to understand the role biochemistry plays (and still plays) in the development of a range of deformities of the spine, extremities and jaw, Roth conducted experimental studies on teratogenesis to clarify the role of the up to then neglected osteo-neural growth patterns, an area in which the interaction of growth in the nervous

P.J.M. van Loon and L.W. van Rhijn / The Central Cord-Nervous Roots Complex

173

system interacts with other tissues. . Roth was able to impair the stretching properties of the nervous system by exposing it ( intra-uterinal) to either teratogenic substances or by lowering the level of oxygen within it. In these experiments, he was able to create spinal deformities as scoliosis. His experiments demonstrated that the so-called passive role of neurogenic tissue, especially in the central cord, was transformed into a major, active role during the development and growth of the spine and the extremities. This ability of nervous tissue to grow by extension is phylogenetically determinate. Growth and errors of growth of the vertebrate spinal skeleton was thus removed, allowing the “intimate relation existing from the very beginning of development between the nervous and the bony tissue to continue working incessantly during the whole growth period of life”. 2.4 Mechanical models of the spine, spinal growth and deformations. With his interests in the growth and deformation of the spine and knowledgeable in related fields of biological or medical science, Roth developed his own mechanical models for different issues in a quest for an better understanding of the development of the normal, as well as the distorted or deformed spine. He was fully aware that forces in nature are often invisible, such as the growth and tensions within the body. He realised that only the consequences of these forces on a body can be seen and thus a conceptual clarification of the universally adopted relationship between form and function (ie acting forces) is essential in order to understand these important processes in nature. In an paper on the models of vertebro-neural relations, Roth described an elastic model which could dynamically reproduce the physiological relationships of the growth of osseous structures with that of nervous tissue. Using Plexiglas, rubber, textile and metal he was able to construct an accurate model representing all the components of his concept of proportioned and disproportional growth between different tissues. The dynamic role played by normal living, the tensions created by growth, all superimposed on the pressures present in all living structures maintaining an upright position or on the pretension existing before making any movements, were developed in a range of experiments. Roth created all his models himself. He fully realised that there were contrasts between the early embryological patterns and the later adult state. Radiographs were made of these models in different stages of applied forces of tension, using different planes in order to demonstrate the close similarities with the radiographic images of living individuals. The model also explained the ascent of the conus medullaris during growth, widely seen then as a passive displacement. In some pathological conditions, like myelomeningocele, the ascent is said to be hindered by a tight string of fibrous tissue, the filum terminale, causing a “tethered cord”. Roth claimed that the less elongated or more stretched and tense spinal cord and associated attached roots would explain the impossibility of it “ascending” properly into the position of the conus at the T12-L1 area whereas in other animals the conus is low in the lumbar spine. The ascent was thus seen as an adaptation to the prevailing upright position of the body in mankind. The so-called “tethering” is thus not a passive binding by strings, but an intrinsic quality of nervous tissue. The stressed lordotic component of the thoracolumbar spine required in order to create optimal biomechanical and neuromechanical conditions is also a very interesting aspect of his models.

174

P.J.M. van Loon and L.W. van Rhijn / The Central Cord-Nervous Roots Complex

Fig 2 A photograph of a single segment of the thoracic spine in the transversal plane with modelling of the ribs, roots and cord. From: Roth M. [Models of vertebro neural relations]. Cesk Radiol 1970 Sep; 24(5): 189-94. (Courtesy of Roth’s heirs).

Fig 2b The whole construct of spine, inhabitants and ribs in two different positions distinguished by a certain amount of tension in the combined system of different tissues. From: Roth M. [Models of vertebro neural relations]. Cesk Radiol 1970 Sep; 24(5): 189-94. (Courtesy of Roth’s heirs).

For his concept of the osteo-neural growth concept, Roth devised a very simple model, made from beads on a string. This “necklace” model, which can be easily copied today with materials such as slightly deformable beads, gives an insight in what can happen when nervous tissue is unable to keep up to the extending energy growing bone is delivering. The tension within the bones or the counteracting energy of

P.J.M. van Loon and L.W. van Rhijn / The Central Cord-Nervous Roots Complex

175

muscle actions occurring as a result of activity act as supercharged engine dictated by nervous tissue itself. Normal growth leads to the development of slender and long bones, but as the trend towards lengthening of bones takes place, the resulting retardation of extension of nervous tissue leads to the beads becoming compressed and thereby deformed. 2.5. The concept of osteo-neural growth. The underlying reason for the focus of Roth’s scientific work on the relationship between the central nervous system and the osseous components of, the spine, is not made clear. The quest must have been strong enough to allow him unrestrained research across all fields of biological and medical science. Certainly the existence of scoliotic curves in the human spine, not encountered in other animals, puzzled him as much as it still does today, concentrating his mind in his attempts to clarify the neglected role of the central spinal cord. Furthermore, the biomechanical adage that form always follows or reflects function was a mainstay in his thinking throughout his published work. What is certain is that attention was drawn to the relationship between nervous tissues and the spinal canal by his pioneering work as a neuroradiologist, employing the techniques of pneumencephalography, myelography and positive contrast examinations of the scoliotic spine. 2.6 Biological studies The comparison of the growth of animal nervous tissue by extension and the growth of central fibres in plants has already been fully explained and is undeniable. It has also been demonstrated that there is no cell proliferation of nervous tissue after birth in animals. Nervous tissue, in vertebrates as in all other animals, must possess an alternate pattern of growth, unlike all other tissues in the body. These grow or renew themselves at all stages of life, by rapid and intensive cell proliferation during growth. ``As in trees, the growth pattern is by extension of the cells (extensive growth; German: Streckungswachstum). Roth compared the governing phytohormon auxine, a trypthophane derivate driving this type of growth in plants which is said to be highly susceptible to a number of growth inhibitors (Gutenberg, Lehrbuch der Botanik) with the role of serotonine in the growth of nerves in animals. The energy necessary to stretch cells is generated by tensile power in the surrounding tissues during growth. In the spine, the vertebrae and discoligamentary complex, growing by cell proliferation, is responsible for the energy needed to stretch associated nervous tissues: “tag on tow”. With his interest in biology and, specifically the biological literature relating to plant and animal growth, Roth adapted the law of cephalocaudal differential growth in which growth in animals, just as in plants, is found to be directed from the first embryological components to develop such as the central tissue of an animal. In the vertebrate, the central cord, in the early embryological stages, is advanced when compared to the first segmentation of adjacent tissues. Although describing a leading role for the osseous structures to play by acting in the lengthening of the central nervous structures, by application of the law of cephalocaudal differential growth, Roth placed the phylogenetically oldest part of nervous system, the central cord and brainstem, as an initiating, architectural and controlling component and contributor to the lay-out of the surrounding tissues. These in turn form the basis of the biomechanical properties of the even more intriguing spine.

176

P.J.M. van Loon and L.W. van Rhijn / The Central Cord-Nervous Roots Complex

Fig 3. A schematic drawing of the necklace model in which prolonged or progressive tension on the string gives deformation of the vertebrate skeleton like beads. From: Roth M.: The relative osteo-Neural growth; a concept of Normal and pathological (Teratogenic) skeletal Morphogenesis.Gegenbauer’s morph. Jahrb. Leipzig 119 (1973)2, S.250-274 (courtesy of Roth’s heirs)

Fig. 4 A schematic drawing showing the difference in how tissues in vertebrate animals grow, namely by cell proliferation comparing the epiphyseal zones around a schematic joint at the left, and the elongation by stretching of a none proliferating nervous tissue cell. (From: Roth M. [Idiopathic scoliosis--a special type of osteo-neural growth disproportion]. Z Orthop Ihre Grenzgeb 1969 Nov;107(1): 37-46). Courtesy of Roth’s heirs.

P.J.M. van Loon and L.W. van Rhijn / The Central Cord-Nervous Roots Complex

177

3. The leading role of the nervous tissue in morphogenesis of the axial skeleton. Roth stresses that, prior to his work (and not really changed subsequently), the primary role and place of the nervous tissue in development and growth of the body in the context of other systems, such as the vascular, gastrointestinal or musculo-skeletal, was ignored. By demonstration of an exaggerated ventral-concave curvature (hyperkyphosis) of the early embryo, Roth referd to and used schematic drawings, with examples, of earlier work of Blechschmidt.

Fig. 5. Schematic drawing of embryological stages in which the enormous relative volume of the nervous system and the comma like shape is depicted, gradually changing to a stretched and more slender configuration, before the biomechanical needed cervical and lumbar lordosis is created. From: Roth M.: The relative osteo-Neural growth; a concept of Normal and pathological (Teratogenic) skeletal Morphogenesis.Gegenbauer’s morph.Jahrb., Leipzig 119 (1973)2, S.250-274 (courtesy of Roth’s heirs)

178

P.J.M. van Loon and L.W. van Rhijn / The Central Cord-Nervous Roots Complex

When the ascent of the conus-cauda occurs, until now seen as a passive event, the associated lengthening of the spinal nerve roots are widely considered as being dragged along by the rapid growth of the spinal column. Roth, however, hypothesized an opposite view, suggesting that there is also a controlling role for the central nervous system in achieving the final form of the spine in adulthood. He compares it to the leading role the unrolling and growing brain substances play in the formation of the skull (calva) at the end of growth. Roth also explained why the conus in man is present at the thoracolumbar joint other than in the lower lumbar spine as it is in almost all other quadrupeds. 4. Summary It is clear from his writings that Roth applied his on-going practical experience of the clinical picture of children with deformations of the spine to his postulations. He observed that a normal lordotic shape of the lumbar and thoracolumbar spine is of great importance in allowing the correct functioning of the complexities of this area, the most mobile part of the spine in childhood. He described the requirement that the lower thoracic ribs should elevate, but also to retro-pulse, aided by the bellows-like function of the diaphragm. The tension placed on the neuromuscular structures can be measured by applying the mechanical law’s of Robert Hooke on properties of tensile bodies. However, while springs may be of value in understanding the complexities involved in biomechanics and nervous system control, this was not foreseen by Roth . The deformation of intervertebral discs and the osseous elements of the spine the result of the same forces which allow standing, sitting, balancing and movement. delivered by the muscular system. No muscle acts without nervous instruction. 5. The consequences of Roth’s work on scoliosis and practice. Roth applied his concepts and explanations of the mechanism of the deformities of: scoliosis. Roth stated that: “There exists a most intimate interrelationship between the rapid cranio-caudal growth-in-length of the axial skeleton and the slower, proceeding, extensive growth of the spinal cord and the nerve roots. The latter type of growth requires a greater energy supply and, consequently, is more vulnerable than the former one. The vertebro-neural growth relationship is similar to that existing between the developing brain and the skull. The growth in length of individual vertebrae, and of the spine as a whole, is adapted to the growth-potentiality of the intraspinal nervous structures, viz.; the former is determined by the availability of space among the latter. Idiopathic scoliosis may be interpreted as an adaptive morphogenetic reaction of the vertebral column to the growth insufficiency of the intraspinal nervous structures: The growth processes of the vertebral column, though continuing undisturbed at the cellular level, is adapted at the organ level by “waves” of the growth-insufficient cord-nerve complex. Morphological features of the scoliotic vertebra, coupled to the typical position of the spinal cord within the spinal canal, support the hypothesis of a vertebro-neural concept which offers a plausible explanation of both congenital and experimental scoliosis.” It might be argued that restoring the form e.g. by bracing; is not that harmful because it lengthens the spine, and thereby increases tension on the cord. Roth again provided an answer:

P.J.M. van Loon and L.W. van Rhijn / The Central Cord-Nervous Roots Complex

179

“Adjustment or rectification of a deformed structure like a scoliotic spine is not accompanied by lengthening, notwithstanding the fact that the scoliotic trunk is elongated; the curved spine is adjusted, not lengthened. This adjustment involves a contraction or reduction of the convexe side of the intervertebral discs. Consequently in adjusting– paradoxally but irrefutably- the spinal canal is rather shortened.” [15]. 6. The work of Milan Roth: new challenges for future research Science is an ongoing process possessing its own dynamics. Several recent publications indicate that Roth’s hypotheses and concepts are now receiving attention. We are convinced that full disclosure and understanding of the work of Roth will inspire many of our colleagues to start new research and that these challenges will be taken up in many different fields of (medical) science. This will include: 1.) Reproducing and clarifying several of his analytical studies (pneumencapholgraphy) by using modern technologies such as MRI, Spiral CTscan. Also neuro-physiological studies, using SSEP and surface EMG, can be undertaken in situations with higher tensions in the neuromuscular structures. For instance, the recent publication of Cheng et al (2008) on the short spinal cord with scoliosis is evidence that this kind of work is already in progress. 2.) Research on what can cause differences in the quality of stretch growth of the cord in order to elicit if this is the background of the misunderstood variation of spinal forms such as curvature, disc-height, vertebral height and shape. Should genetic backgrounds also be investigated? 3.) A new coordinated effort between biomechanics and biochemistry to clarify the mechanism behind and between the growth (proportionate or disproportionate) of bone and tissues in relation with the stretch growth of the neural tissues. For biomechanics, following Roth, this includes the role of tension, tension patterns and tension regulation. For biochemistry, this requires research on the role of transmitters, such as serotonine, already implicated in a range of processes and diseases. What is their role, how do they work in the period of growth and is their function altered in body with deformations, even mild ones? How is the process of distribution of the lava-like material surrounding the notochord, as Roth calls it, organised? Roth concepts could give clues as to the final form of the body and organs. 4.) New concepts for treating patients by conservative or operative treatments with emphasis on the requirements for the nervous system as part of the complex “game” of compressive and tensile forces References Milan Roth: a selected list of his publications This bibliography with relevant publications by Roth consists of publications collected by the first author in recent years. Some of the articles were acquired from Roth’s family. The publications are presented in chronological order. To allow maximum disclosure all articles are presented in the following way: • An English version of the title • Statement of the language in which the original was published • An English summary or abstract (mostly original, sometimes extended) is added [1]

Roth, M (1965), Caudal end of the spinal cord, Acta Radiologica Diagnosis Vol. 3 (1965) Original Language: English

180

P.J.M. van Loon and L.W. van Rhijn / The Central Cord-Nervous Roots Complex Abstract: The normal position of the spinal cord with special emphasis on the “dorsolumbar junction” as the part of the spine lacking a detailed knowledge of gross anatomic features as demonstrated at negative contrast myelography is discussed. Material consisted of 34 adults and 8 children without symptoms in this part or known remote disorders. The variation in position, the calibre and the intrinsic curvature of the cord at the different levels is explained by developmental factors, among which the morphology of the vertebrae is stressed. A cadaver study with fresh spinal cords specimen hanging freely showed a constant intrinsic curvature in the distal cord as a “reminder “of the embryological existent complete rounded configuration. Also the eccentric “lodgement” of the roots in the neuroforaminae is depicted as a consequence of the ascent of the cord, as seen in humans.

[2]

Roth, M. (1966), Vertebro-medullary interrelations as observed in gas myelography, Acta Radiologica Diagnosis Vol. 4 (1966), p. 569-580 Original language: English Abstract: The typical position of the spinal cord within the membranous sac, possibly derived from the close developmental relations between the neural tissue and the vertebral column, is described. The significance of the characteristic shape of the intervertebral foramina in predicting the depth of the ventral subarachnoid space is discussed. It is shown that small thoracic disk protrusions, with a narrow ventral subarachnoid space especially at the level of the lumbar intumescences, may give rise to myelopathy.

[3]

Roth, M. (1968), Idiopathic scoliosis caused by a short spinal cord, Acta Radiologica Diagnosis Vol. 7 (1968), p. 257-271. Original language: English Abstract: An explanation of the pathogenesis of idiopathic scoliosis based on the disturbance of the relative vertebro-neural growth is presented. This concept is supported by neuroradiologic, experimental and clinical observations.

[4]

Roth, M. (1969), Models of vertebro-neural relations, Acta Radiologica Diagnosis. Vol. 9 (1969) Original Language: English Abstract: The basic principles of vertebro-neural growth relations with special reference to the pathogenesis of idiopathic scoliosis are discussed. Plexiglas models, constructed to assist in the demonstration, are described. All models have in common that they do not only reflect a static threedimensional condition but represent the incorporated forces in life and growth by visible movements and represent also a condensation of what happens in the fourth dimension: time.

[5]

Roth, M. (1971), The relative osteo-neural growth-some phylogenetic, ontogenetic and clinical aspects, ad. Diagn. 1971, 1, p 81-97 Original language: German Abstract: The growth in length of the nervous structures necessitates a higher energetic level than that of the bones. A harmonic side-by-side growth course of the growth rates, cellular-divisional and neural-extensive, is indispensable for the normal body growth in length. Comparisons are made with features of growth in different animals and embryological knowledge. The relative osteo-neural growth represents therefore an important factor in the phylogenetic and ontogenetic development of the skeleton as well as in the pathogenesis of bone dysplasias.

[6]

Roth, M., The relative osteo-neural growth Part 1: Gegenbaur Morph. Jahrb. , Leipzig 117 (1971) 2, S. 232-255 Part II: Gegenbaur Morph. Jahrb. , Leipzig 117 (1972) 3, S. 312-334 Part III: Gegenbaur Morph. Jahrb. , Leipzig 117 (1972) 4, S. 421-440 Original language: German Abstract: These three articles compose a total concept and explanation of the osteo-neural growth by extracting supporting evidence out of first class previous research in biological, anatomical, embryological, histological and orthopaedic and neurological textbooks and literature. With own modelling, all sort of research, and stepping over of “scientific” boundaries, he tries to fit all visible formation and deformation of at least the skeletal development in his holistic explanation of how Nature “works”. In Part I the function of the Ascensus Medullae in Homo erectus is discussed.. The inhibititive (“braking”) power of the more energy asking stretch type of growth of the neural system on the growth by mitosis of the osseous and arthrogenic skeleton gives an insight in the complex system of tension regulation and strive for optimalisation growth in nature is. The earlier discovered and described craniocaudad and posteroanterior directed growth in ante- and postnatal growth in animals is completely incorporated in Roth’s conceptual thinking. The change in relative size of the primitive

P.J.M. van Loon and L.W. van Rhijn / The Central Cord-Nervous Roots Complex

181

neural structures from huge to small is depicted and discussed as is the very clear present brachy-or Platyspondylie in siblings. The position, direction and calibre of the nerve roots in the neuroforaminae found at earlier pneumencephalographic studies at all different levels are made understandable. Different types of vertebral forms, especially the incisura vertebrae caudalis (roof of the foramen) are clarified. Different affections like Scheuermann, Platy- (or better: brachyspondylie, Dysplasia spondylo-epiphysealis tarda are according to Roth examples of clear “braking” of growth by hindered stretching capacity of the neural tissue. The formatted bone is like the narrow disc spaces diverged in horizontal directions. Roth destilles out of his daily practice, that the thoracolumbar junction is the most inflicted in flattening of the discs and vertebrae in adolescent kyphotic deformities. There fore he ends with the statement that the length of the total spine is fixed by the intraspinal nerve structures.

Fig.6 The formation of the pulmonary groove depends on the extension of the completely kyphotic and rolled up configuration of the embryonic body. Roth created a beautiful mechanical model on the change of all dimensions and relationships initiated by the gradual extension of the body.

Fig.7 The impressive relative change in proportions between cord and roots and vertebral bodies in animals, normal human spine, a scoliotic spine and a platyspondylic spine.

182

P.J.M. van Loon and L.W. van Rhijn / The Central Cord-Nervous Roots Complex Part II. Roth tries to come to a complete system of growth and formation of the body especially the complete skeleton based on earlier work of scientists and own studies. What seems true for the vertebra seems true for every piece of bone.

Fig 8. Schematic drawing of different skeletal deformities with the suspected relation with the concomitant, but primary events in the stretching type of growth of the central cord. Part III. On the form of the body and the physiological curvatures of the spine out of animal experiments in rats and frogs: “The nervous structures exert an influence on the morphogenesis of the skeleton even for the very reason of their existence in space, by their mass of a certain size and shape. The surrounding and /or accompanying skeletal masses adapt their general shape to that of the nervous structures. obviously under mediation of a “trophic” neural effect. Through this primary neural influence the gross shape of the skeleton most appropriate for the given species in a given environment is elaborated. The stimuli and information reaching the organism by neural pathways are thus reflected in the morphogenesis of the skeleton .The role of the blood and the vessels (hormones-authors), of the physical stresses and of the hereditary (genetics- authors) appear only of secondary importance only in the light of osteo-neural growth relations”. [7]

Roth, M. (1973), The relative Osteo-Neural growth: a concept of normal and pathological (Teratogenic) Skeletal Morphogenesis, Gegenbauers morph. Jahrb. Leipzig 119 (1973) 2, S. 250-274 Original Language: German Abstract: A concept of skeletal morphogenesis is proposed which is based on the existence of 2 different types of growth in the vertebrate body, viz., the cellular-divisional bone growth and the extensive (stretch-) growth of the nervous structures. The latter type requires a higher energy and oxygen supply than the former. Consequently, the neural extensive growth proceeds at a slower rate than the bone growth. Which is manifested most conspicuously in the ascent of the spinal cord. The slower growth rate, however, is a general feature of the nervous structures throughout the vertebrate body. A number of normal as well as pathological features of the skeletal morphogenesis- above all the gross deformities of the body-parts which grow rapidly in length such as the spine, the extremities or the facial skeleton – can be readily explained by the disturbed relation of the two growth types caused by an insufficiency of the vulnerable neural extensive growth.

[8]

Roth, M. (1975), Spinal cord and Scoliosis. The cause and the Effect, Acta Chir. Orthop. Traumas. Czech. 42, 1975, no. 6, p. 507-517. Original language: Czech Abstract: There exist the most intimate interrelation between the rapid craniocaudad growth-in-length of the axial skeleton and the slower proceeding extensive growth of the spinal cord and the nerve roots. The latter type of growth requires a higher supply with energy and, consequently, is more vulnerable than the former one. The vertebro-neural growth relation is similar to that existing between the developing brain and its bony case. The growth in length of the individual vertebrae and of the spine as a whole is adapted to the growth-potentiality of the intraspinal nervous structures, viz.; the former is determined by the availability of space among the latter. Idiopathic scoliosis may be

P.J.M. van Loon and L.W. van Rhijn / The Central Cord-Nervous Roots Complex

183

interpreted as an adaptive morphogenetic reaction of the vertebral column upon the growth insufficiency of the intraspinal nervous structures: The growth process of the vertebral column, though continuing undisturbed at the cellular level, is adapted at the organ level by “waves” to the growthinsufficient cord-nerve complex. Morphological features of the scoliotic vertebra together with the typical position of the spinal cord within the spinal canal speak in favour of the suggested vertebroneural concept, which offers a plausible explanation of the congenital and experimental scoliosis as well. [9]

Roth, M. , The vertebral groove, Acta Radiol.9; 1965 p. 740-745. Original language: English Abstract: Roth shows the presence, and gives name to the peculiar anatomical bilateral groove at the posterior surface of the bony spine. The development of the vertebral groove at the posterior side of the lamina as a unique feature in the human skeleton is explained and its influence via the spinal nerves on the shape of the intervertebral foramina is described. It fits in Roth’s view about the supposed working of the musculature to provide forces on bony structures that will add in their final shape as form is dictated by functional request. In the axiom that form follows function it is the far more posterior presence of the facet joints and processi mammilaris in human that is specific for the species and originates from the tremendous greater pulling forces of the musculus Erector Trunci in the osseous insertions in the upright man.

[10] Roth, M. (1969), Idiopathic scoliosis- A special form of osteo-neural growth disproportion Z Orthop Ihre Grenzgeb 1969 Nov;107(1):37-46) Original language: German Abstract: Idiopathic scoliosis is explained as a pathological increase of the vertebro-neural growth disproportion, the physiological degree of which is reflected in the ascent of the spinal cord. This disproportion roots in the two different types of growth occurring in vertebrates, viz., the cellulardivisional and the neural-extensive. The latter is generally encountered in plant-kingdom. The morphological findings on scoliotic vertebrae as well as model experiments point to the primary growth insufficiency of the intraspinal nervous structures as the actual cause of the idiopathic scoliosis. Roth, M., The experimental Teratogenesis of the skeleton. An experimental disturbance of the relative osteo-neural growth.Gegenbaur Morph. Jahrb. , Leipzig 122 (1976) 5, S. 686-730 Original language: German Abstract: The previously suggested concept of the closest growth relations existing between the bony and the nervous tissue at the organ level of the spinal cord and the peripheral (including the facial) nervous trunks is experimentally buttressed. It is shown that the normal gross-morphological features of the vertebrae as well as of the tubular bones (viz., their length, physiological curvatures and terminal expansions) result from the adaptation of the bone growth to the slower proceeding and vulnerable neural extensive growth, viz., from a physiological osteo-neural growth disproportion. The more or less conspicuous growth in the length of the facial skeleton depends upon the phylogenetically established, more or less evolved extensive-growth potentially of the facial nervous trunks as well. The growth relation existing between the developing brain and its bony case applies essentially even for the axial organ, the extremities as well as for the facial skeleton. The experimental findings speak in favour of the theoretical expectation that the typical teratogenic deformities of the extremities (micromelia), of the spine (scoliosis, defects of the vertebrae and of the ribs) as well as of the beak (jaws) which may be produced by a great number of most diverse teratogens, result from the adaptation of the bone growth to the growth-insufficient nervous trunks, viz., from the pathologically enhanced osteo-neural growth disproportion. The cleft palate and the digital defects (syndactylia, oligodactylia) may be readily explained by the growth-inhibition of the palate and digital nervous structures as well. The vertebrate body may be thus conceived as composed of 2 growth types, viz., the neural-extensive and the cellular-divisional (mitotic). The former is represented by an extremely dense felt work of nerve fibers and trunks (the Donaldson’s “ nervous skeleton”), which is “ stuffed “ with the other, mostly mitotic growing tissues. The 2 growth types are closely related partly at the macro- (organ-) level concerning the normal and teratogenic morphogenesis of the skeleton, partly at the micro-level of the utmost periphery, viz., of the terminal extensive meshwork and the individual cells or groups of cells. The cells which escape from the extensive felt work (i.e. from the “ nervous skeleton”) such as the superficial cells of the epidermis or mucous membranes and, in all probability, the elements of the haemopoetic organs, perish under normal conditions, suffer a planned, highly purposeful death. With regard to the lack of normal nerves within malignant tumors, the malignant cell may be conceived as

184

P.J.M. van Loon and L.W. van Rhijn / The Central Cord-Nervous Roots Complex the one escaped from the limiting confines of the extensive felt work and, in spite of that, continues to live instead of “ committing suicide”.

[11] Roth, M., J. Krkoška and I. Toman Morphogenesis of the spinal canal, normal and stenotic, Neuroradiology 10, 277-286 (1976) Original language: English Abstract: The shape of the canal in transverse view, the shape and the position of the facet joints and the foraminate are discussed in normal and pathological conditions, like the developmental stenosis (Verbiest) and degenerative stenotic and degenerative changes are explained by the conductive role the neural tissues play in growth. Histological specimens are used. New models of the relationship between roots and vertebrae are introduced (fig). But nevertheless the base of the early base of any deformation seems still orchestrated by the necessary normal or disturbs the developmental balance between the two tissues (neural and osseous- discoligamentary). Roth states firmly in this paper that the role of the Notochord, a prominent structure in fishes, amphibians and reptiles is vestigial in higher mammals and its morphogenetic role in the developmental events of the axial skeleton is grossly overestimated (The Dispensability of the Notochord).

Fig 9 Modelling of the relationship of the roots, their directions and the presumed thight contact between the roots and the bony surroundings in the lumbar spine. [12] Roth, M. (1981), Idiopathic scoliosis from the point of view of the neuroradiologist, Neuroradiology (1981) 21: 133-138 Original language: English Abstract: There is a simple morphological interrelation between the growing spinal cord-nerve root complex and the vertebral column, not unlike that between the growing brain and the skull. The shape of the enveloping vertebral skeleton mirrors the anatomical features of the enclosed neural contents. During the cranio-caudally directed growth, spurts of elongation of the vertebral column may be too rapid for the slower growth rate of the spinal cord and nerve roots. The resulting disproportion of growth between spine and nervous system is compensated for by adaptive scoliotic curvature of the otherwise normally growing spine. The proposed pathogenetic concept readily explains the main clinical features of the deformity and is supported by a spring model experiment. [13] Roth, M. (1981), Idiopathic scoliosis and Scheuermann “disease”: Essentially identical manifestation of neuron-vertebral growth disproportion. Radiol. Diagn. 22 (1981), H.3, 380-391 Original language: German Abstract: With the knowledge postulated on the disproportionate growth between the nervous tissue and the spine, Roth gives with his spring models a true to nature morphological presentation of the proportioned relations of the cord and the deformed vertebrae (compression of the spring windings at the concavity, rope in the concavity). As the eccentric position of the cord and cauda was already known in literature (Lindgren 1941, Jirout 1964) Roth reverses this with arguments as it was seen as a secondary effect of the deformity towards a primary position with the deformity of the spine as a nervous tissue conducted developmental feature of the surrounding bony tissue. To Roth` s finding the lower thoracic and thoracolumbar spine function as the most predilected area for the first dicongruencies between the two types of growth in otherwise healthy children in their growth. In his

P.J.M. van Loon and L.W. van Rhijn / The Central Cord-Nervous Roots Complex

185

view the modificated muscular activity to keep the new posture with its relocated axial loading and unloading. He also gives a understandable discussion in his concept of the existence of congenital scoliosis and kyphosis. [14] Roth, M. (1985), Once more spinal cord and scoliosis, Acta Chir. Orthop. Traum. Czech. 52, 1985, no. 6, p. 532-543 Original Language: Czech Abstract: Morphogenesis of the spine as well as of the neurocranium cannot be understood from the growing bone tissue alone, regardless of the morphology and growth peculiarities of the neural content, the brain and the spinal cord-nerve roots complex. Idiopathic scoliosis may be explained as a consequence of excessive discrepancy between the neural and the vertebral growth rates. Growth rate differential is a well-established factor of morphogenesis resulting, among others, in curvature of two adjacent structures growing in length at different rates. The periods of growth spurt are particularly prone to neurovertebral growth disproportionateness since the spinal cord-nerve roots complex may be unable to keep pace with the too rapidly growing spine. The latter is then laid in adaptive kyphoscoliotic curvatures alone the growth insufficient neural content. The relative growth deficit of the “Wirbelbogenreihe”as compared with the “Wirbelkorperreihe”, a feature characteristic for idiopathic scoliosis seems to result from the primary retarding effect of the spinal nerves, which run reins like along the pedicles. This neural retarding effect may be elicited either by excessive stimulation of the vertebral growth or by inhibition of the spinal neural growth, or by combination of both. The basic gross features of idiopathic scoliosis including the deformity of the thoracic cage and the concave sided eccentric position of the spinal cord may be reproduced by means of a neuro-costovertebral model. [15] Roth, M. (1986), Cranio-cervical growth collision: another explanation of the Arnold Chiari malformation and of basilar impression, Neuroradiology (1986) 28: 187-194 Original language: English Abstract: Analysis of neuro-cranio-spinal development suggests a cranio-cervical growth conflict as the cause of the Arnold Chiari malformation and of basilar impression .In gross (Meningomyelocele) and slight (adolescent deformities) impairment of distal spinal growth, a reversal of cervical growth occurs, the initial descent (uncoiling) of the primordial brain curvatures is compromised owing to the growth collision with the ascending cervical spine. The availability of space is subject of the struggle. [16] Roth, M (1989’, The `Enveloping` versus the Biomechanical function of the spine, Cs. Radiologie 43, 1989, No. 1, c. 1-13. Original language: Czech Abstract: As a continuation of argumentation presented in a number of previous communications, the author advocates the view according to which the developing spine and its neural content (“ spinal cord-nerve roots complex”) are linked by an equally intimate morphogenetic relation like that existing between the brain and its skeletogenic envelope. A specific feature of the neurovertebral developmental relation consists in the fact that the elongated spinal cord-nerve roots complex is enveloped by its skeletogenic case both in the transversal and in the longitudinal direction. The matter is further complicated by lagging of the spinal neural growth behind that of the vertebral column. The development of the basic anatomical features of the individual vertebrae such as their length and width, the girth of the vertebral body as well as the shape of the intervertebral foramina cannot be understood without taking into account the gross developmental dynamics of the two main components of the axial organ, viz., of the spinal cord-nerve roots complex and of the vertebral column. [17] Roth, M. (1994), Traumatic Spondodylolysis in the hedgehog. A contribution to the Problem of Dysplasia of the Isthmus, Z. Orthop. 132 (1994), p. 33-37 Original language: German Traumatic Spondylolysis in a hedgehog is reported. On the basis of that rare thinning of the vertebral isthmus frequently associated with Spondylolysis in man is claimed to be related to the “neuroenveloping “function of the spine shared with that of the neurocranium. Dysplasia of the isthmus results from abnormal ganglio-foraminal interrelation in the embryo rather than from any primary derangement of the vertebral bone growth proper.

186

P.J.M. van Loon and L.W. van Rhijn / The Central Cord-Nervous Roots Complex

Acknowledgments We thank Milan Roth’s widow Mrs. Milada Rothova and sons Tomas and Michal for their help in providing his biographical material and photographs and their approval to use all his published work to be brought under attention of the present medical world interested in unanswered questions on growth. Also thanks to Dr.Kayo Styblo PhD, now orthopedic surgeon in Zaandam the Netherlands. who originates from Czechoslovakia, translated the Czech articles of Milan Roth into Dutch.

Chapter 4 Etiology

This page intentionally left blank

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-189

189

/HJDUPOHQJWKUDWLRVFRUUHODWHZLWKVHYHULW\ RIDSLFDOYHUWHEUDOURWDWLRQLQJLUOVDIWHU VFKRROVFUHHQLQJIRUDGROHVFHQWLGLRSDWKLF VFROLRVLV$,6 DG\QDPLFSDWKRPHFKDQLVP LQWKHLQLWLDWLRQ RIWKHGHIRUPLW\" 5*%85:(//5.$8-/$$6.,5%<3+'$1*(5),(/'$028/721 %-&)5((0$1 $$&2/( )-32/$.5.35$77-.:(%% &HQWUHIRU6SLQDO6WXGLHVDQG6XUJHU\1RWWLQJKDP8QLYHUVLW\+RVSLWDOV7UXVW4XHHQ¶V 0HGLFDO&HQWUH&DPSXV1RWWLQJKDP8.7KH8QLYHUVLW\RI/LYHUSRRODQG6WDIIRUGVKLUH 8QLYHUVLW\8. 'HSDUWPHQWRI2UWKRSDHGLF6XUJHU\.LQJ¶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

190

R.G. Burwell et al. / Leg-Arm Length Ratios Correlate with Severity of Apical Vertebral Rotation

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

)LJXUH:DONF\FOHRIDQRUPDO\HDUROGQRUPDOJLUOIURP6XWKHUODQGHWDO>@

)LJXUH /HIW 5RWDWLRQ FRQWURO RI WKH VSLQH LQ JDLW VKRZLQJ SHOYLVSLQDO URWDWLRQV DQG FRXQWHUURWDWLRQV LQ WKH XSSHU VSLQHEDVHGRQWKH ILQGLQJVRI*UHJHUVHQDQG/XFDV>VHH@0RGLILHG IURP%XUZHOO>@ 5LJKW 6FKHPDWLFGUDZLQJWRVKRZWKHJDLWGULYHQVSLQDOURWDWLRQ1RWWLQJKDP FRQFHSWIRU$,60RGLILHGIURP%XUZHOO HW DO>VHH@

0HWKRGVDQGVXEMHFWV ,QVFUHHQLQJE\DURXWLQHTXDQWLWDWLYHSURWRFRO>@VXEMHFWVZHUHUHIHUUHGWRKRVSLWDO GXULQJZKHUHFOLQLFDOHYDOXDWLRQ5*% LGHQWLILHGW\SHV RIVFROLRVLVJLUOVDJH SRVWPHQDUFKHDO KDG OHJ DQG DUP PHDVXUHPHQWV ZLWK &REE DQJOH DQG DSLFDO YHUWHEUDOURWDWLRQ $95>@ UHFRUGHG ULJKW FXUYHV OHIW VSLQDO VFROLRVLV WKRUDFLF WKRUDFROXPEDU OXPEDU GRXEOH SHOYLF WLOW VFROLRVLV VWUDLJKW VSLQH

R.G. Burwell et al. / Leg-Arm Length Ratios Correlate with Severity of Apical Vertebral Rotation

191

&RQWUROVZHUHQRUPDOJLUOVDJH7RWDOOHQJWKVRIOHJVDQGDUPVZHUHPHDVXUHG ZLWK D WDSH E\ RQH REVHUYHU 5*% XVLQJ VWDQGDUG DQWKURSRPHWULF XSSHU OLPE DQG RUWKRSDHGLF ORZHU OLPE PHWKRGV >@ 7KH UDGLRJUDSKV ZHUH PHDVXUHG E\ WKH VDPH REVHUYHULQFOXGLQJ&REEDQJOHDQGDSLFDOYHUWHEUDOURWDWLRQ>@7KHLQWUDREVHUYHUHUURUV RIWKHDQWKURSRPHWULF>@DQGUDGLRORJLFDO>@PHWKRGVDUHHVWDEOLVKHG

)LJXUH 5LJKW OHJDUP UDWLRV SORWWHG DJDLQVW DSLFDO YHUWHEUDO URWDWLRQ $95 DQG &REE DQJOH 4XDGUDWLF UHJUHVVLRQ DQDO\VHV 1RWH WKH KLJKO\ VLJQLILFDQW DVVRFLDWLRQ EHWZHHQ WKH OHJDUP UDWLR DQG $95 EXW QRW &REE DQJOH/RQJHUDUPVUHODWLYHWROHJVDUHDVVRFLDWHGZLWKPRUHDSLFDOYHUWHEUDOURWDWLRQ

5HVXOWV)LJXUH /HJDUP OHQJWK UDWLRV RI UHIHUUDOV DUHQRW VLJQLILFDQWO\ GLIIHUHQW IURP QRUPDOV 4XDGUDWLF UHJUHVVLRQ DQDO\VLV RI UHIHUUDOV E\ DJH VKRZV OHJDUP UDWLRV GHFUHDVH ULJKW S OHIW S DQG $95V LQFUHDVH S EXW QRW &REE DQJOHV /HJDUP UDWLRV FRUUHODWH QHJDWLYHO\ ZLWK DEVROXWH $95V ULJKW ȡ S OHIW ȡ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

192

R.G. Burwell et al. / Leg-Arm Length Ratios Correlate with Severity of Apical Vertebral Rotation

5HIHUHQFHV >@ >@ >@ >@ >@ >@ >@ >@ >@ >@

>@ >@ >@

>@ >@ >@ >@ >@ >@ >@ >@ >@

>@

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³GLQQHU SODWH´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

R.G. Burwell et al. / Leg-Arm Length Ratios Correlate with Severity of Apical Vertebral Rotation

193

>@ %XUZHOO5*'DQJHUILHOG3+0RXOWRQ$HWDO(WLRORJLFWKHRULHVRILGLRSDWKLFVFROLRVLVDXWRQRPLFQHUYRXV V\VWHPDQGWKHOHSWLQV\PSDWKHWLFQHUYRXVV\VWHPFRQFHSWIRUWKHLQLWLDWLRQDQGSDWKRJHQHVLVRI$,67KLV 0HHWLQJ >@ %XUZHOO5*$XMOD5..LUE\$6HWDO%RG\PDVVLQGH[RIJLUOVLQKHDOWKLQIOXHQFHVPHQDUFKHDQGVNHOHWDO PDWXUDWLRQ D OHSWLQV\PSDWKHWLF QHUYRXV V\VWHP IRFXV RQ WKH WUXQN ZLWK K\SRWKDODPLF DV\PPHWULF G\VIXQFWLRQLQDGROHVFHQWLGLRSDWKLFVFROLRVLV" 7KLV0HHWLQJ

194

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-194

1HZ FOLQLFDOREVHUYDWLRQVFRQQHFWHGZLWK ³ELRPHFKDQLFDODHWLRORJ\RIVRFDOOHG LGLRSDWKLFVFROLRVLV´ 7.DUVNL 'HSDUWPHQWRI3HGLDWULF2UWKRSHGLFVDQG5HKDELOLWDWLRQ0HGLFDO8QLYHUVLW\RI/XEOLQ &KRGĨNL6WUHHW 3RODQG

$EVWUDFW 2YHU WKH ODVW IHZ \HDUV DQ HWLRORJLFDO FDXVH RI VFROLRVLV KDV EHHQ GHYHORSHG DW /XELQ 3RODQG 7KLV LV EDVHG RQ WKH ILQGLQJV RI ZDV OLPLWHG DGGXFWLRQ RU DEGXFWLRQ FRQWUDFWXUH RI ULJKW KLS FRXSOHG WR DV\PPHWU\ RI PRYHPHQWV EHWZHHQ ULJKW DQG OHIW KLS ZKLFKLQIOXHQFHVJURZWKRIVSLQHWKURXJK³DV\PPHWULFDOJDLW´DQGDV\PPHWULFDOVWDQGLQJ

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³DV\PPHWULFDOJDLW´DQGDQDV\PPHWULFDOVWDQGLQJ SRVLWLRQ³DWHDVH´ 7KHSULPDU\FDXVHRIWKHVHDV\PPHWULHVLVDWWULEXWHGWRWKH³V\QGURPH RIFRQWUDFWXUHVDQGGHIRUPLWLHV´ >@

T. Karski / New Clinical Observations

195

%LRPHFKDQLFDOPRGHOV µ6¶GRXEOHVFROLRVLV,HSJ ,QDQ6VKDSHGGRXEOHFXUYHGHYHORSPHQWRI ERWKFXUYHV RFFXUVDWWKHVDPHWLPHDQGLV DVVRFLDWHG ZLWK FRQWUDFWXUH LQ WKH ULJKW KLS DQG ODUJH PRYHPHQWV RI OHIW KLS ,Q WKLV ELRPHFKDQLFDOPRGHOWKHFRQVHTXHQFHVRIFKDQJHVWRJDLWDQGWKHHIIHFWVRQ WKHVWDQGLQJ SRVLWLRQ RQ WKH ULJKW OHJ OHDGV WR WKH HVWDEOLVKPHQW RI DQ ³6´ GRXEOH VFROLRVLV ZLWK DVVRFLDWHG VWLIIQHVV RI WKH VSLQH DQG D ULE KXPS RQ WKH ULJKW VLGH ,Q VRPH FDVHV ³ORUGRVFROLRVLV´DOVRLVSUHVHQW,QWKHVHFXUYHVSURJUHVVLRQLVFRPPRQO\REVHUYHG µ&¶ RQHFXUYHVFROLRVLV,,$HSJ ,QWKHULJKWKLSVPDOOOLPLWDWLRQRIPRYHPHQWLVIRXQGEXWDVVRFLDWHGZLWKDIXOOUDQJHRI PRYHPHQWLQWKH OHIWKLS ,QWKLVELRPHFKDQLFDOPRGHOZLWKWKHSUHVHQFHVRIDSHUPDQHQW VWDQGLQJSRVLWLRQ³DWHDVH´RQWKHULJKWOHJ D SK\VLRORJLFDOGHYLDWLRQRI WKH OXPEDUVSLQHWR WKHOHIWVLGHGHYHORSVILUVWWREHIROORZHGE\WKHDSSHDUDQFHRID ³&´VKDSHGVFROLRVLV ,Q ROGHU SDWLHQWV WKLV SURGXFHV WKH FOLQLFDO SLFWXUH RI ³GHJHQHUDWLYH VFROLRVLV´ 7KLV W\SH RI FXUYHUDUHO\KDV SURJUHVVLRQ ,QFKLOGUHQZLWKMRLQWOD[LW\RUWKRVHLQZKRPWKH ZURQJW\SHVRIH[HUFLVHVKDYHEHHQ SURYLGHGD³6´GRXEOHVFROLRVLV,,%HSJ GHYHORSV ZLWKD VHFRQGDU\ WKRUDFLFFXUYH ,Q WKH VDPH ELRPHFKDQLFDO PRGHO DV LQ ,,$ HSJ EXW DVVRFLDWHG ZLWK D SHUPDQHQW VWDQGLQJSRVLWLRQRQWKHULJKWOHJQR VSLQDOVWLIIQHVVLVSUHVHQW7KHVHDVPDOOFXUYHVODFN VLJQLILFDQWULEKXPSDQGLQVRPHLQVWDQFHVWKHUHPD\ EHDN\SKRVFROLRVLV 7KLVW\SHRI VFROLRVLVVKRZVQR SURJUHVVLRQ µ,¶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

196

T. Karski / New Clinical Observations

,QIOXHQFHVRIWKH &16LQVPDOOFKLOGUHQDQG³VFROLRVLVLQIXWXUH´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³6´ ± , HSJ ³&´,,$ HSJ ³6´,,% HSJ ³,´ ± ,,, HSJ LGHQWLILHG LQ WKH GHYHORSPHQW RI VFROLRVLV GHSHQGLQJ RQ WKH UDQJH RI DV\PPHWU\ RI PRYHPHQWV RI KLSV ELRPHFKDQLFDO PRGHOV RI GHYHORSPHQW RI VFROLRVLV DOO DVVRFLDWHG ZLWKJDLWDQG DVWDQGLQJ SRVLWLRQ³DWHDVH´RQWKHULJKWOHJ (YHQLQFDVHVRI DEGXFWLRQFRQWUDFWXUHDQGH[WHUQDOURWDWLRQFRQWUDFWXUHRIWKH ULJKWKLS EXW ZLWKRXW ELRPHFKDQLFDO LQIOXHQFHV RFFXUULQJ GXULQJ ZDONLQJJDLW DQG VWDQGLQJ LQ WKH SRVLWLRQ³DWHDVH´ WKHVFROLRVLVGRHVQRWGHYHORSDV IRUH[DPSOH LQEOLQGFKLOGUHQ 7KH FRH[LVWHQFH RI PLQLPDO EUDLQ GDPDJH 0%' DQG FRQWUDFWXUHV RI WKH WUXQN H[WHQVRUVPXVFOHVDQGWKHV\QGURPHRIFRQWUDFWXUHVDQGGHIRUPLWLHVH[SRVHVFKLOGUHQWRD YXOQHUDELOLW\ WRGHYHORSVRFDOOHGLGLRSDWKLFVFROLRVLVHVSHFLDOO\LQ, HSJ )XWXUH LQYHVWLJDWLRQV ZLOO LQFOXGHFOLQLFDO REVHUYDWLRQV DVVRFLDWHG ZLWK WKHELRPHFKDQLFDO DHWLRORJ\RILGLRSDWKLFVFROLRVLV 5HIHUHQFHV >@ >@ >@

>@

>@ >@

0DX+'LH$WLRSDWRJHQHVHGHU6NROLRVH%FKHUHLGHV2UWKRSl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yMFLNRZVN .DUVND-2NR¦VNL 02OHZL¦VND2NR¦VND0 .DNXFNL-%XF]HN.DDNXFND6 1H[W UHVHDUFK LQ H[SODQDWLRQ RI ELRPHFKDQLFDO HWLRORJ\ RI WKH VRFDOOHG LGLRSDWKLF VFROLRVLV 1HZ FODVVLILFDWLRQ,PSRUWDQFHRIJDLWDQGVWDQGLQJLQGHYHORSPHQWRIGHIRUPLW\:K\WKHEOLQG GRQRWKDYHVFROLRVLV"&(2&B)LQ3URJ$6WUiQND

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-197

197

Etiologic theories of idiopathic scoliosis: autonomic nervous system and the leptinsympathetic nervous system concept for the pathogenesis of adolescent idiopathic scoliosis RG BURWELL1, PH DANGERFIELD2, A MOULTON3, SI ANDERSON4 1

Centre for Spinal Studies and Surgery, Nottingham University Hospitals Trust, Queen’s Medical Centre Campus, Nottingham, UK, 2 The University of Liverpool, The Royal Liverpool Children’s Hospital and Staffordshire University, 3Department of Orthopaedic Surgery, King’s Mill Hospital, Mansfield, UK, and 4School of Biomedical Sciences, University of Nottingham, UK Abstract. The autonomic nervous system through its hypothalamic neuroendocrine control of puberty, skeletal growth and menarche contributes importantly to the pathogenesis of adolescent idiopathic scoliosis (AIS). Melatonin dysfunction detected in AIS subjects also involves the autonomic nervous system. The thoracospinal concept for the pathogenesis of right thoracic AIS in girls thought by some to result from dysfunction of the sympathetic nervous system (SNS), is supported by recent vascular and peripheral nerve studies. Lower body mass index (BMI).in girls with AIS is associated with decreased circulating leptin levels. Leptin, secreted by adipocytes, is a master hormone with many regulatory functions for growth and reproduction, including: 1) appetite repression, anorexigenic; 2) initiation of puberty in girls in a permissive action, and 3) in mice, longitudinal bone growth, chondrogenic and angiogenic, and in bone formation, antiosteogenic acting centrally through the SNS and possibly directly. In AIS girls, autonomic nervous system activity was reported to be higher than in controls. We suggest that in AIS susceptible girls, given adequate nutrition and energy stores, circulating leptin talks to the hypothalamus where dysfunction leads to an altered sensitivity to leptin resulting in increased SNS activity contributing with neuroendocrine mechanisms to: 1) earlier age at, and increased peak height velocity, 2) general skeletal overgrowth, 3) earlier skeletal maturation, 4) extraspinal skeletal length asymmetries, including periapical ribs and ilia, 5) generalized osteopenia, and 6) lower BMI. The SNS-driven effects may also add adventitious changes to the spine including asymmetries complicating the neuroendocrine effects on adolescent spinal growth. In AIS pathogenesis, the leptin-SNS concept is complementary to our NOTOM escalator concept involving the somatic nervous system. Together these two concepts view AIS in girls as being initiated by a hypothalamic dysfunction of energy metabolism (bioenergetics) affecting skeletal growth in the trunk. Where, in susceptible girls, the postural mechanisms of the somatic nervous system fail to control the asymmetric spinal and/or rib growth changes in a rapidly enlarging adolescent spine; this failure becomes evident as mild backshape shape asymmetry, or scoliosis. The environmentally-enhanced stature of normal subjects in the last 300 years, in girls susceptible to AIS, may have exaggerated any

198

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis developmental dysharmony between the autonomic and somatic nervous systems being fought out in the spine and trunk of the girl – possibly making mild back-shape asymmetry, or scoliosis more prevalent today than hitherto. Key words. Idiopathic scoliosis, pathogenesis, spine, leptin, hypothalamus, sympathetic nervous system

1. Introduction 1.1. Autonomic nervous system and the new neuroskeletal biology In reviewing the new field of neuroskeletal biology Patel and Elefteriou [1] summarize long-standing clinical observations relating to bone and the nervous system including reflex sympathetic dystrophy, hyperplastic callus associated with head injury and myelomeningocoele, and osteopenia associated with stroke, spinal cord injury and peripheral neuropathy. They comment that the hypothalamus with its ‘sensing’ functions and capacity to send efferent hormonal and neuronal signals has the capacity to integrate skeletal physiology with the daily physiological changes triggered by the environment and by endogenous rhythms. Conflicting reports on the effect of βadrenergic blockers for risk of fractures are published [2-4]. The new field of neuroskeletal biology involves leptin, the hypothalamus, sympathetic nervous system and skeletal tissues [1]. Here, we consider a theoretical appraisal of how this new field of neuroskeletal biology may relate to growing skeletal tissues and AIS pathogenesis (Figure 1). 1.2 The leptin-hypothalamic-SNS concept (leptin-SNS concept, Figure) We suggest that in AIS susceptible girls, given adequate nutrition and energy stores, circulating leptin talks to the hypothalamus where dysfunction leads to an altered sensitivity to leptin resulting in increased sympathetic nervous system (SNS) activity contributing to skeletal changes (mainly in the trunk and upper arms) including putative asymmetric changes to the spine complicating the traditional neuroendocrine effects on spinal growth. In AIS pathogenesis. the leptin-SNS concept is complementary to our NOTOM escalator concept involving the somatic nervous system [14,15]. Together these two concepts view AIS in girls as being initiated by a hypothalamic dysfunction of energy metabolism (bioenergetics) favouring growth and where, in susceptible subjects, the postural mechanisms of the somatic nervous system fail to control the asymmetric spinal changes in a rapidly enlarging adolescent spine; this failure becomes evident as mild back-shape shape asymmetry, or scoliosis deformity. In this paper 1) we review evidence on which the leptin-SNS concept for AIS pathogenesis is based, and 2) outline the hypothesis. 1.3. Autonomic nervous system and AIS 1.3.1. Menarche In AIS, the age at menarche has been reported as early, normal and delayed [5].

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis

199

Figure 1. Concepts for the pathogenesis of AIS involving the autonomic and somatic nervous systems. The sensory input, motor output and PPC relate to the somatic nervous system and the rest to the autonomic nervous system. Shown are some neuroendocrine controls (‘infantry’) and sympathetic nervous system (‘cavalry’) of skeletal and adipose tissues. Ganglia=ganglionated sympathetic trunk. Sympathetic nerves are shown as thin continuous lines and hormones as interrupted lines. Pre- and post-ganglionic sympathetic nerves are shown on one side with arrows indicating enhancement of function and blunted lines as inhibition. F=frontal lobe, P=parietal lobe, PPC=posterior parietal cortex (Area 7 with body schema), VC=visual cortex, GnRH=gonadotropin-releasing hormone, FSH=follicle stimulating hormone, LH=luteinizing hormone, ICA=intercostal artery,., T/L=thoracolumbar. For further details of the somatic nervous system concept see [13-15].

200

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis

1.3.2. Skeletal growth velocity An undisputed factor in AIS curve progression is pubertal skeletal growth and its velocity as it affects the spine [5]. In AIS girls, greater peak height velocity of growth in early puberty may be related to the increased secretion of growth hormone [7-9] dehydroepiandrosterone (DHA) and plasma testosterone [7,10,11] with normal estrogens [10,11]. The pathogenesis of AIS in girls evidently involves the autonomic nervous system and neurendocrine mechanisms. The mechanism(s) by which velocity of skeletal growth contributes to the pathogenesis of AIS in girls is unclear [12]. Castelein [12] states that the role of growth in the pathogenesis of AIS may be causative, conditional, amplifying, or coincidental. We suggest [13-15] that the dependence of AIS progression on growth is explained by rapid skeletal enlargement beyond the capacity of the postural mechanisms of the somatic nervous system to control the initiating deformity rather than by the velocity of growth, i.e. the role of skeletal growth is conditional [12]. 1.3.3. Circulating melatonin and melatonin-signaling pathway dysfunction In AIS subjects, a deficiency of circulating melatonin [16] and a systemic melatoninsignaling pathway dysfunction affecting osteoblasts and other cells [17] have been reported. The latter may represent a dysfunction of circadian rhythms in peripheral tissues similar to that detected in skin fibroblasts [18]. Any deficiency of circulating melatonin in AIS subjects could reflect altered sympathetic activity since the pineal gland is controlled by sympathetic fibers from the superior cervical ganglion – though normally one would expect any increased sympathetic activity to be reflected in greater nocturnal secretion of melatonin from the hypothalamus [Ebling FJP personal communication]. 1.3.4. Generalized osteopenia In girls with AIS, Cheung et al [19] found that the lower bone mass compared with controls could be explained by faster anthropometric growth, higher bone turnover, and lower calcium intake. The calcium intake in AIS patients was found to be very low with low consumption of dairy products, and likely to be insufficient for normal bone mineralization. Suh et al [20] reported evidence implicating imbalance and disturbed interaction of RANK ligand (RANKL) and the osteoprotegerin (OPG) decoy receptor in the osteopenia of AIS girls. 1.3.5. Disordered eating behavior There are several reports of lower body mass index in girls with AIS [5,19,21-23] but not all [24,25] and there is some evidence of disordered eating behavior [21,26,27]. The low body-mass index of girls with AIS is said not to be the result of the eating disorder [26]. 1.3.6. Right thoracic AIS in girls, sympathetic nervous system and rib-length asymmetry Sevastik’s thoracospinal concept [28-30] based on experimental, anatomical and clinical evidence, applies only to right thoracic adolescent idiopathic scoliosis in girls. There are six sequential processes as follows (linear causality): 1) Dysfunction of the autonomic nervous system[30]. 2) Increased vascularity of left anterior hemithorax. 3) Overgrowth of left periapical ribs which -

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis

201

4) disturbs the equilibrium of the forces that determine the normal alignment of the thoracic spine, that – 5) triggers the thoracospinal deformity simultaneously in the three cardinal planes. 6) Biomechanical spinal growth modulation [31]. This concept is supported by recent vascular [32] and peripheral nerve [33] studies 1.3.7. Leptin and AIS in girls In AIS girls, Qiu et al [23] reported a marked decrease in circulating leptin compared with controls. Positive correlations were found between leptin and each of age, menstrual status, weight, corrected height, body-mass index (BMI), Risser sign, bone mineral content and bone mineral density (lumbar spine and femoral neck) but not Cobb angle. Qiu et al comment on evidence strongly suggesting that leptin may 1) act on bone tissue through both central and peripheral pathways; a central pathway mediated by hypothalamic nuclei and the sympathetic nervous system (SNS), and peripherally “…by stimulating osteoblastic differentiation and inhibiting osteoclastic activity…” resulting in enhanced bone formation and reduced bone resorption; 2) regulate body growth during childhood and adolescence; and 3) mediate energy expenditure in females. 1.3.8. Body-mass index (BMI) and skeletal growth in the trunk of AIS and normal girls Elsewhere [25] we present a preliminary report showing in three groups of adolescent girls – normals, screened and preoperative - that body-mass index above and below mean levels separates subjects in all three groups with larger and smaller skeletal growth mainly in trunk width. It is hypothesized that: 1) normal trunk widening of the thoracic cage by hormones in human adolescence is supplemented via the sympathetic nervous system under leptinhypothalamic control influenced by energy stores (metabolic fuel); and 2) hypothalamic dysfunction with altered hypothalamic sensitivity to leptin through a SNS-driven asymmetric effect may create skeletal length asymmetries in vertebrae, ribs, upper arms and ilia, and initiate AIS. 1.3.9. Autonomic nervous system activity in AIS girls In a study of 56 AIS patients compared with 25 controls, a higher level of autonomic nervous system activity was found [34]. The authors suggested that this finding may be another manifestation of a systemic neurologic imbalance in AIS subjects. Cutaneous patterns of sympathetic activity are found in association with other clinical abnormalities of the musculoskeletal system [35]. 1.4. Hypothalamus (Figure) Buijs et al [36] write: The hypothalamus integrates information from the brain and body; this activity is essential for the survival of the individual (adaptation to the environment) and the species (reproduction). As a result, countless functions are regulated by the neuroendocrine and autonomic hypothalamic processes in concert with the appropriate behavior that is mediated by neuronal influences on other brain areas.

202

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis

1.5. Energy balance and signals in relation to growth and reproduction Energy balance requires precise coordination between peripheral nutrient-sensing molecules (related to food intake and stores) and central regulatory networks [37-42]. Fertility is gated by nutrition and the availability of energy reserves (metabolic fuel) stored as fat and glycogen to allow for growth and reproduction [41,42]. So that the normal female is ready for pregnancy and lactation, there is a link between body fat and the timing of puberty with leptin playing a permissive role [43] and kisspeptin activation of the G-protein coupled receptor-54 [41,44] providing a critical metabolic signal initiating puberty through pulsatile GnRH secretion [45] (Figure1). Other hypothalamic gates, or stiles, may have to be opened before menarche is reached [39]. 1.6. Leptin and the sympathetic nervous system – the new field of neuroskeletal biology Leptin, best known as a signal of energy sufficiency, is one of several hormones secreted by adipocytes. In girls there are gradual age- and body-weight related increases in circulating leptin levels [46]. Lower leptin levels, found in boys than girls [46], also rise until the early stages of puberty after which they decline [47]; leptin levels in men are lower than in women at all decades of life [40]. The sex difference may result from stimulatory effects of estrogen on leptin production and inhibitory actions of testosterone [47]. Leptin is a master pleiotropic hormone involved in the regulation of a variety of physiological processes, including [41,48]: 1) appetite repression, anorexigenic; 2) thermogenesis, 3) metabolism of glucose and lipid, 4) initiation of puberty in girls with kisspeptin stimulating GnRH secretion; and 5) complex effects on growing bones with fat having a protective effect on bone tissue [49]. Leptin is reported to stimulate linear growth by regulating the energy balance of the body and by stimulating the production and secretion of growth hormone; at the same time it has a direct effect on chondrocytes of the growth plate and is involved in bone remodelling [48]. Iwaniec et al [50] propose the hypothesis that hypothalamic leptin plays a role in coupling energy homeostasis and bone growth. Leptin appeared in evolution with the bony skeleton [51]. The coupling of skeletal growth to energy balance [48,50] involves leptin and Y2receptors on neuropeptide Y (NPY-ergic) hypothalamic neurons [52,53]. Other metabolic hormones, insulin and thyroid hormone as well as sex steroids also target hypothalamic neurons (arcuate nuclei) to ensure metabolic efficiency [41](Figure1). In mice, adipocytes talk to bone through leptin acting centrally through a hypothalamic pathway via the SNS [54,55] which releases the neurotransmitter noradrenaline to increase longitudinal bone growth and inhibit osteoblast function and proliferation [1,47,50,52]. In mice, leptin stimulates longitudinal bone growth, being chondro-osteogenic and angiogenic, and in bone formation, antiosteogenic acting centrally through the SNS and possibly with an opposite direct effect on bone [47,50,52]. The skeleton exerts an endocrine regulation of energy metabolism. [51,56] (Figure 1). 1.7. Sympathetic nervous system (SNS) and innervation of white adipose tissue White adipose tissue in rats and Siberian hamsters is innervated by the SNS [39,57,58] which may play a significant role in lipid mobilization [39,57], and inhibition of proliferation [57](Figure).

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis

203

2. Hypotheses 2.1. Leptin-SNS concept - effects on skeletal and white adipose tissues in girls with AIS In AIS susceptible girls, given adequate nutrition and energy stores, in the leptin-SNS concept circulating leptin talks to the hypothalamus with dysfunction and altered sensitivity to leptin which leads to increased SNS activity contributing with neuroendocrine mechanisms to (Figure 1): a) earlier age at, and increased peak height velocity [5,9,59] b) general skeletal overgrowth [5,60] c) earlier skeletal maturation [5,25] d) extra-spinal skeletal length asymmetries, including periapical ribs [5,13,14] and ilia [61] e) generalized osteopenia [19,21], and f) lower body fat and BMI [5,19,21-23]. The extra-spinal skeletal length asymmetries are a manifestation of developmental stress in hypothalamic neurons as they adjust to lower leptin levels which they helped to create. The SNS-driven effects also add adventitious changes to the spine including asymmetries complicating the neuroendocrine effects on spinal growth. The SNS contributes to the osteopenia of AIS by activating β2-adrenergic receptors on osteoblasts [62] causing them to produce RANKL which acts on the osteoclast receptor RANK to stimulate osteoclast formation [63]. In young ballet dancers, the high prevalence of scoliosis, fractures and delayed menarche attributed to hypoestrogenism [64] may also involve low circulating leptin levels and increased hypothalamic-SNS-driven activity on growing bones. 2.2. Putative changes in the spine and the somatic nervous system in AIS When the SNS-driven putative adventitious changes in the enlarging adolescent spine are associated with relative postural maturational delay in the somatic nervous system the spine deforms [13-15]. The postural mechanism may be linked to higher testosterone levels in AIS girls affecting brain white matter maturation in girls [7,10,11,15]. There is direct and indirect evidence suggesting that asymmetries affect vertebral body growth plates [13,14,65]. 2.3. Putative hypothalamic dysfunction and the NOTOM escalator concept In AIS girls, we hypothesize that the hypothalamic gates controlling skeletal growth via neuroendocrine and autonomic outputs open earlier to advance skeletal maturation [Ebling FJP, personal communication]. The leptin effect via the SNS may add to the neuroendocrine effect of both growth hormone and estrogen driving adolescent skeletal growth in girls [5-8]. Alternatively, the dysfunction in hypothalamic neurons as putative altered sensitivity to leptin may result from an abnormality of a Gprotein-coupled receptor to leptin, or Gprotein - possibly as the critical part of a systemic abnormality similar to the melatonin-signalling pathway dysfunction detected in osteoblasts, muscle cells and lymphocytes [66]. In AIS pathogenesis, the leptin-SNS concept is complementary to our NOTOM escalator concept involving the somatic nervous system [14,15]. Together these two

204

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis

concepts enable AIS to be viewed as being initiated in girls by a hypothalamic dysfunction of energy metabolism (bioenergetics) favoring growth in a secular trend; and where, in susceptible subjects, the postural mechanisms of the somatic nervous system fail to control the adventitious spinal changes in a rapidly enlarging adolescent spine; this failure becomes evident as mild back-shape shape asymmetry, or scoliosis deformity. 2.4. A secular trend in normal stature with significance for AIS pathogenesis? Stature has increased since the mid 18th century due to environmentally-induced changes [67,68]. This secular height increase, attributed to better nutrition and reduced infections by advances in technology resulting in vital organs having improving robustness and capacity, is interpreted by the hypothesis of technophysio evolution [69]. The biological mechanism underlying this secular trend in stature like the declining age at puberty [42] is likely to be driven by the hypothalamus [Ebling FJP, personal communication]. We suggest that in those girls who develop AIS the increased size for age from these secular changes in spine and trunk may be a factor weakening control by postural mechanisms for holding a spine straight. This environmentally-enhanced stature of normal subjects in the last 300 years in girls susceptible to AIS may have exaggerated any developmental dysharmony between the autonomic and somatic nervous systems being fought out in the spine and trunk of the girl – possibly making mild back-shape asymmetry, or scoliosis more prevalent today than hitherto. Acknowledgement We thank Professor FJP Ebling for a discussion of the autonomic nervous system and AIS and subsequently for reading the text and making helpful comments. References [1] [2]

Patel MS, Elefteriou F, The new field of neuroskeletal biology. Calc Tissue Int 2007, 80:337-347. Schwartzman RJ, New treatments for reflex sympathetic dystrophy. New Eng J Med 2000, 343:654656. [3] Pasco JA, Henry MJ, Sanders KM et al, Beta-adrenergic blockers reduce the risk of fracture partly by increasing bone mineral density: Geelong osteoporosis study. J Bone Miner Res 2004, 19:19-24 [4] Rejnmark L, Vestergaard P, Kassem M et al, Fracture risk in perimenopausal women treated with beta-blockers Calc Tissue Int 2004, 75:365-372. [5] Cole AA, Burwell RG, Dangerfield, PH et al, Anthropometry, In: Etiology of Adolescent Idiopathic Scoliosis: Current Trends and Relevance to New Treatment Approaches, Edited by: Burwell RG, Dangerfield PH, Lowe TG, Margulies JY. State of the Art Reviews: Spine 2000, 14(2):411-421, Philadelphia, Hanley & Belfus Inc. [6] Sanders JO, Khoury JG, Kishan S et al, Predicting scoliosis progression from skeletal maturity; a simplified classification during adolescence. J Bone Joint Surg 2008, 90;540-553. [7] Skogland LB, Miller JA, Growth related hormones in idiopathic scoliosis. An endocrine basis of accelerated growth. Acta Orthop Scand 1980, 51(5):779-780. [8] Ahl T, Albertsson-Wikland K, Kalen R, Twenty-four hour growth hormone profiles in pubertal girls with idiopathic scoliosis. Spine 1988, 13(2):139-142. [9] Hagglund G, Karlberg J, Willner S, Growth in girls with adolescent idiopathic scoliosis. Spine 1992, 17:108-111. [10] Edelmann P, Gupta D, Hormonal investigations in adolescent idiopathic scoliosis. Acta Endocrinol (Kbh) 1971, 184 (Suppl):71. [11] Raczkowski JW, The concentrations of testosterone and estradiol in girls with adolescent idiopathic scoliosis. Neuroendocrinol Letters 2007, 28(3):302-304.

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis

205

[12] Castelein RM, Dieën JH van, Smit TH: The role of dorsal shear forces in the pathogenesis of adolescent idiopathic scoliosis – a hypothesis. Med Hypoth 2005, 65:501-508. [13] Burwell RG, Freeman BJC, Dangerfield PH et al, Etiologic theories of idiopathic scoliosis: neurodevelopmental concept of maturational delay of the CNS body schema (“body-in-the-brain”). In: Research into Spinal Deformities 5, Studies in Health Technology and Informatics Volume 123. Edited by Uyttendaele D and Dangerfield PH, Amsterdam, IOS Press; 2006, 72-79. [14] Burwell RG, Dangerfield PH, Freeman BJC: Concepts on the pathogenesis of adolescent idiopathic scoliosis. Bone growth and mass, vertebral column, spinal cord, brain, skull, extra-spinal left-right skeletal length asymmetries, disproportions and molecular pathogenesis. In 1st SOSORT Instructional Course Lecture Book. The conservative scoliosis treatment, Studies in Health Technology and Informatics Volume 135, Edited by Grivas TB, Amsterdam IOS Press, 2008, 3-52. [15] Burwell RG, Dangerfield, PH, Freeman BJC. Etiologic theories of idiopathic scoliosis. Somatic nervous system and the NOTOM escalator concept as one component of the pathogenesis of adolescent idiopathic scoliosis. In: Research into Spinal Deformities 6, Studies in Health Technology and Informatics (This volume). Edited by Dangerfield PH, Amsterdam, IOS Press; 2008. [16] Machida M: Cause of idiopathic scoliosis. Spine 1999, 24:2576-2583. [17] Azeddine B, Letellier K, Wang DS et al, Molecular determinants of melatonin signaling dysfunction in adolescent idiopathic scoliosis . Clin Orthop Rel Res 2007, 462:45-52. [18] Brown SA, Kunz D, Dumas A et al, Molecular insights into human daily behavior. PNAS 2008, 105(5):1602-1607. [19] Cheung CSK, Lee WTK, Tse YK, Lee KM, Guo X, Qin L, Cheng JCY: Generalized osteopenia in adolescent idiopathic scoliosis.- association with abnormal pubertal growth, bone turnover, and calcium intake? Spine 2006, 31(2):330-338. [20] Suh KT, Lee S-S, Hwang SH et al, Elevated soluble receptor activity of nuclear factor-kB ligand and reduced bone mineral density in patients with adolescent idiopathic scoliosis. Eur Spine J 2007 16:1563-1569. [21] Smith FM, Latchford G, Hall RM et al, Indications of disordered eating behaviour in adolescents with idiopathic scoliosis. J Bone Joint Surg (Br) 2002, 84(3):392-394. [22] Davey RC, Cochrane T, Dangerfield PH et al, Anthropometry and body composition in females with adolescent idiopathic scoliosis. In International Research Society of Spinal Deformities Symposium 2004, Edited by Sawatzky BJ, University of British Columbia, 2004, 323-326. [23] Qiu Y, Sun X, Qiu X et al, Decreased circulating leptin level and its association with body and bone mass in girls with adolescent idiopathic scoliosis. Spine 2007,32(24):2703-2710. [24] Grivas TB, Arvaniti A, Maziotou C et al, Comparison of body weight and height between normal and scoliotic children. In Research into Spinal Deformities 4, Studies in Health Technology and Informatics Volume 91. Edited by Grivas TB. Amsterdam, IOS Press; 2002:47-53. [25] Burwell RG, Aujla RK, Kirby AS et al, Body mass index of girls in health influences menarche and skeletal maturation: a leptin-sympathetic nervous system focus on the trunk with hypothalamic asymmetric dysfunction in the pathogenesis of adolescent idiopathic scoliosis? In: Research into Spinal Deformities 6, Studies in Health Technology and Informatics (This volume). Edited by Dangerfield PH, Amsterdam, IOS Press; 2008. [26] Smith FM, Latchford GJ, Hall RM et al, Do chronic medical conditions increase the risk of eating disorder? A cross-sectional investigation of eating pathology in adolescent females with scoliosis and diabetes. Adol Health 2008, 42(1):58-63 [27] Alborghetti A, Scimeca G, Costanzo G et al, The prevalence of eating disorders in adolescents with idiopathic scoliosis. Eat Disord 2008, 16(1):85-93. [28] Sevastik JA, The thoracospinal concept of the etiopathogenesis of idiopathic scoliosis. In: Etiology of Adolescent Idiopathic Scoliosis: Current Trends and Relevance to New Treatment Approaches, Edited by: Burwell RG, Dangerfield PH, Lowe TG, Margulies JY. State of the Art Reviews: Spine 2000, 14(2):391-400. [29] Sevastik J, Burwell RG, Dangerfield PH, A new concept for the etiopathogenesis of the thoracospinal deformity of idiopathic scoliosis: summary of an electronic focus group debate of the IBSE. Eur Spine J 2003. 12:440-450. [30] Sevastik J, Dysfunction of the autonomic nerve system (ANS) in the aetiopathogenesis of adolescent idiopathic scoliosis. In: Research into Spinal Deformities 3, Studies in Health Technology and Informatics Volume 88. Edited by Tanguy A, Peuchot B. Amsterdam, IOS Press; 2002:20-23. [31] Stokes IAF, Burwell RG, Dangerfield PH: Biomechanical spinal growth modulation and progressive adolescent scoliosis – a test of the ‘vicious cycle’ pathogenetic hypothesis: Summary of an electronic focus group debate of the IBSE. Scoliosis 2006,1:16 doi:10.1186/1748-7161-1-1 [32] Iliopoulos P, Korovessis P, Koureas G et al, Asymmetric evolution of anterior chest wall blood supply in female adolescents with progressive right-convex thoracic idiopathic scoliosis. Eur Spine J 2007, 16:1343-1346.

206

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis

[33] Repko M, Horky D, Krbec M, Chaloupka R, Brichtova E, Lauschová I: The role of the autonomic nervous system in the etiology of idiopathic scoliosis: prospective electron microscopic and morphometric study. Childs Nerv Syst 2008, Jan 11 [EPub ahead of print]. [34] Enslein K, Chan DPK, Multiparameter pilot study of adolescent idiopathic scoliosis. Spine 1987, 12(10):978-982. [35] Korr IM, Wright HM, Chace JA, Cutaneous patterns of sympathetic activity in clinical abnormalities of the musculoskeletal system. Acta Neurovegit 1964, 25:589-606. [36] Buijs RM, Scheer FA, Kreier F et al, Organization of circadian functions: integrartion with the body. Prog Brain Res 2006, 153:341-360. [37] Gil-Campos M, Aguilera CM, Canete R et al, Ghrelin: a hormone regulating food intake and energy homeostasis. Brit J Nutri 2006, 96(2):201-226. [38] Fekete C, Marks DL, Sarkar S et al, Effect of Agouti-related protein in regulation of the hypothalamicpituitary-thyroid axis in the melanocortin 4 receptor knockout mouse. Endocrinol 2004, 145(11):48164821. [39] Song CK, Jackson PM, Harris RB et al, Melanocortin-4 receptor mRNA is expressed in sympathetic nervous system outflow neurons to white adipose tissue. Am J Physiol, Regul Integr Comp. Physiol 2005, 289:R146-R1476. [40] Gomez JM, Serum leptin, insulin-like growth factor-1 components and sex hormone binding globulin. Relationship with sex, age and body composition in healthy population. Protein and Peptide Letters 2007,14(7):701-711. [41] Crown A, Clifton DK, Steiner RA. Neuropeptide signaling in the integration of metabolism and reproduction. Neuroendocrinol 2007, 86(3):175-182. [42] Ebling FJP, The neuroendocrine timing of puberty. Reproduction 2005, 129:675-683. [43] Kaplowitz PB, Link between body fat and the timing of puberty. Pediatrics 2008, 121, Supplement S208-S217. [44] Kauffman AS, Clifton DK, Steiner RA, Emerging ideas about kisspeptin-GPR54 signaling in the neuroendocrine regulation of reproduction. Trends Neurosci 2007, 30(10):504-51. [45] Plant TM, The role of KISS-1 in the regulation of puberty in higher primates. Eur J Endocrinol 2006, 155 Suppl 1:511-516. [46] Clayton PE, Gill MS, Hall CM et al, Serum leptin throughout childhood and adolescence. Clin Endocrinol 1997, 46:727-733. [47] Demerath EW, Towne B, Wisemandle W et al, Serun leptin concentration, body composition, and gonadal hormones during puberty. Intern J Obesity 1999, 23:678-685. [48] Gat-Yablonski, G, Phillip M, Leptin and regulation of linear growth. Curr Opin Clin Nutr Metab Care 2008, 11(3):303-308 [49] Thomas T, The complex effects of leptin on bone metabolism through multiple pathways. Curr Opin Pharmacol 2004, 4:295-300. [50] Iwaniec UT, Boghossian S, Lapke PD et al, Central leptin gene therapy corrects skeletal abnormalities in leptin-deficient ob/ob mice Peptides 2007, 28:1012-1019. [51] Lee NK, Sowa H, Hinoi, E et al, Endocrine regulation of energy metabolism by the skeleton. Cell 2007, 130:456-469. [52] Allison SJ, Baldock PA, Herzog H, The control of bone remodeling by neuropeptide Y receptors Peptides 2007, 28: 320-325. [53] Baldock PA, Allison SJ, Lundberg P et al, Novel role of Y1 receptors in the coordinated regulation of bone and energy. J Biol Chem 2007, 282(26):19092-19102. [54] Ducy P, Amling M, Takeda S et al, Leptin regulates bone formation through a hypothalamic relay: a central control of bone mass. Cell 2000, 100:197-200. [55] Takeda S, Elefteriou F, Levasseur R et al, Leptin regulates bone formation by the sympathetic nervous system. Cell 2002, 111:303-317. [56] Semenkovich CF, Teitelbaum SL, Bone weighs in on obesity. Cell 2007, 130:409-411. [57] Bamshad M, Aoki VT, Adkison MG et al, Central nervous system origins of the sympathetic nervous system outflow to white adipose tissue. Am J Physiol, Regul Integr Comp. Physiol 1998, 275:R291R299. [58] Foster MT, Bartness TJ, Sympathetic but not sensory denervation stimulates white adipose proliferation. Am J Physiol Regul Integr Comp Physiol 2006, 291(6):R1630-1637. [59] Nissinen M, Heliovaara M, Seitsamo J et al, Trunk asymmetry, posture, growth, and risk of scoliosis. A three-year follow-up of Finnish prepubertal school children. Spine 1993, 19(1):8-13. [60] Guo X, Chau W-W, Chan Y-L, Cheng J-Y-C: Relative anterior spinal overgrowth in adolescent idiopathic scoliosis. Results of disproportionate endochondral-membranous bone growth. J Bone Joint Surg (Br) 2003, 85-B:1026-1031. [61] Burwell RG, Aujla RK, Freeman BJC et al, Patterns of extra-spinal left-right skeletal asymmetries in adolescent girls with lower spine scoliosis: relative lengthening of the ilium on the curve concavity and of right lower limb segments. In Research into Spinal Deformities 5, Studies in Health

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis

[62] [63] [64] [65] [66] [67] [68] [69]

207

Technology and Informatics Volume 123. Edited by Uyttendaele D, Dangerfield PH, Amsterdam, IOS Press; 2006: 57-65. Togari A, Adrenergic regulation of bone metabolism; possible involvement of sympathetic innervation of osteoblastic and osteoclastic cells. Micros Res Techn 2002, 58(2):77-84. Elmquist JK, Strewler GJ, Do neural signals remodel bone? Nature 2005,434:447-448. Warren MP, Brooks-Gunn J, Hamilton LH et al, Scoliosis and fractures in young ballet dancers. Relation to delayed menarche and secondary amenorrhea. New Eng J Med 1986, 314(21):1348-1353. Day G, Frawley K, Phillips B, McPhee TB, Labrom R, Askin G, Mueller P: The vertebral body growth plate in scoliosis: a primary disturbance in growth? Scoliosis 2008;3:3 doi 10.1186/1748-71613-3. Azeddine B, Letellier K, Wang DS et al, Molecular determinants of melatonin signaling dysfunction in adolescent idiopathic scoliosis . Clin Orthop Rel Res 2007, 462:45-52. Tanner JM, The interaction of hereditary and environment in the control of growth, Chapter 9 In Foetus into man. Physical growth from conception to maturity. Wells: Open Books Publ Co, 1978, pp150-153. Finch CE, Nutrition and infection in developmental influences on aging. Chapter 4, In The biology of human longevity, inflammation, nutrition, and aging in the evolution of lifespan. Amsterdam: Elsevier, 2007, pp246-249. Fogel RW, Costa DL, A theory of technophysio evolution, with some implications for forecasting population, health care costs, and pension costs. Demography 1997, 34(1):49-66.

208

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-208

(WLRORJLFWKHRULHVRILGLRSDWKLFVFROLRVLV 6RPDWLFQHUYRXVV\VWHPDQGWKH12720 HVFDODWRUFRQFHSWDVRQHFRPSRQHQWLQ WKH SDWKRJHQHVLVRIDGROHVFHQWLGLRSDWKLF VFROLRVLV 5*%85:(//3+ '$1*(5),(/'%-&)5((0$1 &HQWUHIRU6SLQDO6WXGLHVDQG6XUJHU\1RWWLQJKDP8QLYHUVLW\+RVSLWDOV7UXVW4XHHQ¶V 0HGLFDO&HQWUH&DPSXV1RWWLQJKDP8. 7KH8QLYHUVLW\RI/LYHUSRRO6WDIIRUGVKLUH8QLYHUVLW\DQGWKH5R\DO/LYHUSRRO &KLOGUHQ¶V+RVSLWDO8. 'HSDUWPHQWRI6SLQDO6XUJHU\5R\DO$GHODLGH+RVSLWDO$GHODLGH$XVWUDOLD

$EVWUDFW 7KHUH LV QR JHQHUDOO\ DFFHSWHG VFLHQWLILF WKHRU\ IRU WKH FDXVHV RI DGROHVFHQW LGLRSDWKLF VFROLRVLV $,6 ,Q UHFHQW \HDUV HQFRXUDJLQJ DGYDQFHV WKRXJKW WR EH UHODWHG WR WKH SDWKRJHQHVLV RI $,6 KDYH EHHQ PDGH LQ VHYHUDO ILHOGV $IWHU UHYLHZLQJ FRQFHSWV RI $,6 SDWKRJHQHVLV ZH IRUPXODWHG D FROOHFWLYH PRGHO RI SDWKRJHQHVLV 7KH FHQWUDO FRQFHSW RI WKLV FROOHFWLYHPRGHOLVDQRUPDOQHXURRVVHRXVWLPLQJRIPDWXUDWLRQ 12720 V\VWHPRSHUDWLQJLQ D FKLOG¶V LQWHUQDO ZRUOG GXULQJJURZWKDQGPDWXUDWLRQWKLVSURYLGHVDG\QDPLFSK\VLRORJLFDO EDODQFH RI SRVWXUDO HTXLOLEULXP FRQWLQXRXVO\ UHQHZHG EHWZHHQ WZR V\QFKURQRXV SRODUL]HG SURFHVVHV 12720 HVFDODWRUV OLQNHG WKURXJK VHQVRU\ LQSXW DQG PRWRU RXWSXW QDPHO\ RVVHRXV HVFDODWRU LQFUHDVLQJ VNHOHWDO VL]H DQG UHODWLYH VHJPHQWDO PDVV DQG QHXUDO HVFDODWRU ± LQFOXGLQJ WKH &16 ERG\ VFKHPD 7KH ODWWHU LV UHFDOLEUDWHG FRQWLQXRXVO\ DV WKH ERG\ DGMXVWV WR ELRPHFKDQLFDO DQG NLQHPDWLF FKDQJHV UHVXOWLQJ IURP VNHOHWDO HQODUJHPHQW HQDEOLQJ LW WR FRRUGLQDWH PRWRU DFWLRQV :H VXJJHVW WKDW $,6 SURJUHVVLRQ UHVXOWV IURP DEQRUPDOLW\RIWKHQHXUDODQGRURVVHRXVFRPSRQHQWVRIWKHVHQRUPDOHVFDODWRUVLQWLPHDQGRU VSDFH±DVDV\QFKURQ\DQGRUDV\PPHWULHV±ZKLFKFDXVHDIDLOXUHRIQHXUDOV\VWHPVWRFRQWURO DV\PPHWULFJURZWKRIDUDSLGO\HQODUJLQJDQGPRYLQJDGROHVFHQWVSLQH7KLV SXWDWLYHLQLWLDWLQJ DV\PPHWULFJURZWKLQWKHVSLQHLVH[SODLQHG LQ VHSDUDWHSDSHUV DVUHVXOWLQJIURP G\VIXQFWLRQRI WKH K\SRWKDODPXV H[SUHVVHG WKURXJK WKH V\PSDWKHWLF QHUYRXV V\VWHP OHSWLQV\PSDWKHWLF QHUYRXVV\VWHPFRQFHSWIRU$,6SDWKRJHQHVLV ,QJLUOVWKHH[SUHVVLRQRI$,6PD\UHVXOWIURP G\VKDUPRQ\ EHWZHHQ WKH VRPDWLF DQG DXWRQRPLF QHUYRXV V\VWHPV ± UHODWLYH SRVWXUDO PDWXUDWLRQDO GHOD\ LQ WKH VRPDWLF QHUYRXV V\VWHP DQG K\SRWKDODPLF G\VIXQFWLRQ LQ WKH DXWRQRPLFQHUYRXVV\VWHPZLWKWKHFRQIOLFWEHLQJIRXJKWRXWLQWKHVSLQHDQGWUXQNRIWKHJLUO DQG FRPSRXQGHGE\ELRPHFKDQLFDOVSLQDOJURZWKPRGXODWLRQ .H\ ZRUGV ,GLRSDWKLF VFROLRVLV SDWKRJHQHVLV VSLQH VNHOHWDO JURZWK ERG\ VFKHPD QHXUR RVVHRXVWLPLQJRIPDWXUDWLRQ

,QWURGXFWLRQ (QFRXUDJLQJ DGYDQFHV WKRXJKW WR EH UHODWHG WR WKH SDWKRJHQHVLV RI DGROHVFHQW LGLRSDWKLF VFROLRVLV$,6 KDYHUHFHQWO\EHHQPDGHLQVHYHUDOILHOGVERQHPDVVERQHJURZWKVSLQDO JURZWK PRGXODWLRQ H[WUDVSLQDO OHIWULJKW VNHOHWDO OHQJWK DV\PPHWULHV ORZHU OLPE

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis

209

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¶VLQWHUQDOZRUOGGXULQJJURZWKDQGPDWXUDWLRQWKLV SURYLGHV D G\QDPLF SK\VLRORJLFDO EDODQFH RI SRVWXUDO HTXLOLEULXP FRQWLQXRXVO\ UHQHZHG EHWZHHQ WZR V\QFKURQRXV SRODUL]HG SURFHVVHV 12720 HVFDODWRUV OLQNHG WKURXJK VHQVRU\LQSXWDQGPRWRURXWSXWQDPHO\ DQRVVHRXVHVFDODWRULQFUHDVLQJVNHOHWDOVL]H DQGUHODWLYHVHJPHQWDOPDVVDQG DQHXUDOHVFDODWRU±LQFOXGLQJWKH &16ERG\VFKHPD 7KHODWWHULVUHFDOLEUDWHGFRQWLQXRXVO\DVWKHERG\DGMXVWVWRELRPHFKDQLFDODQGNLQHPDWLF FKDQJHV UHVXOWLQJIURPVNHOHWDOHQODUJHPHQWHQDEOLQJLWWRFRRUGLQDWHPRWRUDFWLRQV:H VXJJHVWWKDW$,6SURJUHVVLRQUHVXOWVLQSDUWIURPDEQRUPDOLW\RIWKHQHXUDODQGRURVVHRXV FRPSRQHQWV RI WKHVH QRUPDO HVFDODWRUV LQ WLPH DQGRU VSDFH ± DV DV\QFKURQ\ DQGRU DV\PPHWULHV±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³7KHUH LVRYHUZKHOPLQJHYLGHQFHWKDWWKHHPHUJHQFHRI FRRUGLQDWHG PRYHPHQWV LV LQWLPDWHO\ WLHG WR ERWK WKH JURZWK RI PXVFXORVNHOHWDO V\VWHP DQG WR WKH GHYHORSPHQW RI EUDLQ 7KH QHXUDO GHYHORSPHQW DQG OHDUQLQJ FDQQRW EH FRQVLGHUHG RXWVLGH RI WKHLU ELRPHFKDQLFDO FRQWH[W $ NH\ WKHRUHWLFDO LVVXH LV KRZ WKH FKDQJHV LQ EUDLQ FLUFXLWU\ FRQWUROOLQJ PXVFOHV DQG MRLQWV EHFRPH PDWFKHG WR VLPXOWDQHRXVO\RFFXUULQJGHYHORSPHQWDOFKDQJHVDWWKHSHULSKHU\´ 1HXURRVVHRXVWLPLQJRIPDWXUDWLRQ12720 LQQRUPDOGHYHORSPHQW ,Q QRUPDO KHDOWK WKH VNHOHWDO V\VWHP DQG QHUYRXV V\VWHP HYLGHQWO\ JURZ DQG PDWXUH WRJHWKHU LQ KDUPRQLRXV GHYHORSPHQW RI D QRUPDO QHXURRVVHRXV WLPLQJ RI JURZWK DQG PDWXUDWLRQ 12720 >@ 6XFK QRUPDO QHXURRVVHRXV GHYHORSPHQW RFFXUV EHWZHHQ WKH VSLQH DQG VSLQDO FRUG >@ DQG EHWZHHQ WKH EUDLQ DQG ERG\

210

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis

>@ DV D ZKROH LQ HVWDEOLVKLQJ WKH VHQVRU\PRWRU FRQWURO RI SRVWXUH DQG FRRUGLQDWHGPRYHPHQWV

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

&16 ERG\ VFKHPD µERG\LQWKHEUDLQ¶ DQG WKH 12720 HVFDODWRUV LQ QRUPDO JURZWKDQG$,6 &16ERG\VFKHPD)LJXUHV 7KH&16ERG\VFKHPDLQWKHDGXOWLVGHILQHGDVD³«V\VWHPRIVHQVRU\PRWRUSURFHVVHV WKDW FRQWLQXDOO\ UHJXODWH SRVWXUH DQG PRYHPHQW ± SURFHVVHV WKDW IXQFWLRQ ZLWKRXW UHIOHFWLYHDZDUHQHVVRUWKHQHFHVVLW\RISHUSHWXDOPRQLWRULQJ´>@7KLVFRQWUROLQYROYHV IUDPHV RI UHIHUHQFH LQ WKH SRVWHULRU SDULHWDO FRUWH[ ZKLFK SDUWLFLSDWH LQ WKH G\QDPLF UHSUHVHQWDWLRQRIWKH ERG\VFKHPDLQWHJUDWHGZLWKRWKHUFRUWLFDODUHDV>@

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis

211

2VVHRXVDQGQHXUDO12720HVFDODWRUVLQQRUPDOLW\)LJXUH )LJXUHSURYLGHVDQRXWOLQHRIWKH 12720HVFDODWRUFRQFHSWIRUQRUPDOLW\

•

WZRSRODUL]HGSURFHVVHVRIWKH 12720HVFDODWRUV

)LJXUH1RUPDOLW\1HXURRVVHRXVWLPLQJRIPDWXUDWLRQ12720 HVFDODWRUV>@7KH &16ERG\VFKHPDµERG\LQWKHEUDLQ¶µXQFRQVFLRXVERG\DZDUHQHVV¶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± ZLWK DV\QFKURQ\ DQG DV\PPHWU\LHV SURYLGH WKH FHQWUDO FRQFHSWRI RXU QHXURRVVHRXVGHYHORSPHQWDOFRQFHSWIRU$,6SDWKRJHQHVLV LQWKH VSLQHJURZLQJUDSLGO\ZLWKDV\PPHWU\LHV >@DQG

212

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis

LQ WKH &16 ERG\ VFKHPD PDLQO\ PDWXUDWLRQDO GHOD\ DEVROXWH RU UHODWLYH WR WKH VNHOHWDOV\VWHPSRVVLEO\ZLWKEUDLQDV\PPHWULHV>@WKHPDWXUDWLRQDOGHOD\ LQWKH&16PD\DULVHIURPDQDEQRUPDOLW\LQDIIHUHQWFHQWUDORUPRWRUPHFKDQLVPV >@RUEH UHODWLYHWRHDUOLHUVNHOHWDOPDWXUDWLRQVHHEHORZ

WZRSRODUL]HGSURFHVVHVRIWKH 12720 HVFDODWRUV )LJXUH$,6SDWKRJHQHVV$EQRUPDOQHXURRVVHRXVWLPLQJRIPDWXUDWLRQ12720 HVFDODWRUVDVDSSOLHGWRWKHVSLQH>@

7KH IDWH RI HDUO\ $,6 ±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

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis

213

6NHOHWDOILQGLQJVIRU$,6LQWHUSUHWHGE\12720HVFDODWRUFRQFHSW 9HORFLW\RIJURZWKVNHOHWDOPDWXULW\DQG$,6FXUYHSURJUHVVLRQ 7KHUHODWLRQRIVNHOHWDOJURZWKYHORFLW\DQGVNHOHWDOPDWXULW\WRFXUYHSURJUHVVLRQLQ$,6 LV HVWDEOLVKHG >@ EXW LWV PHFKDQLVP RI DFWLRQ LV XQFOHDU ±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

214

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis

3UHOLPLQDU\05EUDLQVWXGLHVRQQRUPDOVDQG$,6VXEMHFWV /HDUQLQJ SURFHVVHV KDYH ORQJ EHHQ DVVRFLDWHG ZLWK WKH V\QDSWLF SODVWLFLW\ RI JUD\ PDWWHU >@ 5HFHQW 05 EUDLQ VWXGLHV KDYH VKRZQ WKDW ZKLWH PDWWHU LV SRVVLEO\ DIIHFWHG E\ OHDUQLQJ>@ 1RUPDO\RXQJEUDLQ±ZKLWHPDWWHUYROXPHDW\HDUV )HPDOHVDQGPDOHVDW\HDUVRIDJHKDYHDERXWWKHVDPHUHODWLYHYROXPHRIZKLWHPDWWHU LQWKHLUEUDLQV $W\HDUVQRUPDOJLUOVKDYH DVLJQLILFDQWO\ ORZHUYROXPHRI ZKLWHPDWWHU WKDQGRWKHPDOHVDWWKLVDJH>@0D\JLUOVZLWKDVXVFHSWLELOLW\WRSURJUHVVLYH$,6KDYH D PDWXUDWLRQ RI WKHLU ZKLWH PDWWHU PRUH OLNH WKDW RI ER\V ± LQ DVVRFLDWLRQ ZLWK RWKHU IDFWRUV" *LUOVZLWK$,6DUHUHSRUWHGWRKDYHHOHYDWHGFLUFXODWLQJWHVWRVWHURQHOHYHOV>@ *LUOVZLWKOHIWDQGULJKWWKRUDFLF$,6±ZKLWHPDWWHUGHQVLW\ ,QDSLORWVWXG\>@JLUOVZLWKOHIWWKRUDFLF$,6Q KDYHVWDWLVWLFDOO\OHVVZKLWHPDWWHU GHQVLW\LQWKHOHIWVXSUDWHQWRULDOEUDLQLQWKUHHVLWHVFRPSDUHGZLWKDJHPDWFKHGFRQWUROV Q ±JHQXRIFRUSXVFDOORVXPDQWHULRUOLPERILQWHUQDOFDSVXOHDQGWKHZKLWHPDWWHU XQGHUO\LQJWKHRUELWRIURQWDOFRUWH[,QJLUOVZLWKULJKWWKRUDFLF$,6Q QRVLJQLILFDQW GLIIHUHQFHVZHUHGHWHFWHGLQZKLWHPDWWHUGHQVLW\ FRPSDUHGZLWKQRUPDOJLUOVQ 7KLV FRQWUDVW EHWZHHQ WKH EUDLQ ZKLWH PDWWHU DVVRFLDWHG ZLWK OHIW DQG ULJKW WKRUDFLF $,6 VXJJHVWV WKDW ORZHU ZKLWH PDWWHU GHQVLW\ RI OHIW WKRUDFLF $,6 LV QRW VHFRQGDU\ WR WKH VFROLRVLV *LUOVZLWKULJKWWKRUDFLF$,6±YROXPHVWXGLHV ,Q 05, EUDLQ VWXGLHV $,6 JLUOV FRPSDUHG ZLWK QRUPDO JLUOV VKRZHG VLJQLILFDQW XQLODWHUDOUHJLRQDOGLIIHUHQFHVDWVHYHUDOVLWHV>@

)XWXUHUHVHDUFK 05,EUDLQVWXGLHV /DUJHUVDPSOHVDUHQHHGHGIRUVXEMHFWVZLWKWKRUDFLF$,6RWKHUFXUYH W\SHVER\VZLWK$,6 DVZHOODVRI VXEMHFWVZLWKVHFRQGDU\VFROLRVLV 'HYHORSPHQWDO GLVKDUPRQ\ EHWZHHQ WKH DXWRQRPLF DQG VRPDWLF QHUYRXV V\VWHPV LQ WKHSDWKRJHQHVLVRI$,6" ,Q JLUOV WKH H[SUHVVLRQ RI $,6 PD\ UHVXOW IURP GLVKDUPRQ\ EHWZHHQ WKH VRPDWLF DQG DXWRQRPLF QHUYRXV V\VWHPV ± UHODWLYHSRVWXUDO PDWXUDWLRQDO GHOD\LQWKHVRPDWLFQHUYRXV V\VWHP DQG K\SRWKDODPLF G\VIXQFWLRQ LQ WKH DXWRQRPLF QHUYRXV V\VWHP ZLWK WKH FRQIOLFW EHLQJ IRXJKW RXW LQ WKH VSLQH DQG WUXQN RI WKH JLUO DQG FRPSRXQGHG E\ ELRPHFKDQLFDO VSLQDO JURZWK PRGXODWLRQ >@ )XWXUH UHVHDUFK RQ WKH12720 HVFDODWRU FRQFHSW RI WKH VRPDWLFQHUYRXVV\VWHPQHHGVWREHLQWHJUDWHGZLWKDQHYDOXDWLRQRI WKHOHSWLQV\PSDWKHWLF QHUYRXVV\VWHPFRQFHSWIRUWKHSDWKRJHQHVLVRI $,6>@

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis

215

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

>@ >@ >@ >@

>@ >@ >@ >@ >@ >@ >@ >@ >@

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±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

216

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis

>@ %XUZHOO 5* 'DQJHUILHOG 3+ +\SRWKHVHV RQ WKH SDWKRJHQHVLV RI DGROHVFHQW LGLRSDWKLF VFROLRVLV $,6 $ QHXURGHYHORSPHQWDO FRQFHSW LQYROYLQJ QHXURQDO OLSLG SHUR[LGDWLRQ DQG SRVVLEOH SUHYHQWLRQ E\ GLHW ,Q ,QWHUQDWLRQDO5HVHDUFK6RFLHW\RI6SLQDO'HIRUPLWLHV6\PSRVLXP(GLWHGE\6DZDW]N\%-8QLYHUVLW\RI %ULWLVK&ROXPELD >@ %XUZHOO5*)UHHPDQ%-&'DQJHUILHOG3+HWDO(WLRORJLFWKHRULHVRILGLRSDWKLFVFROLRVLVQHXURGHYHORSPHQWDO FRQFHSW RI PDWXUDWLRQDO GHOD\ RI WKH &16 ERG\ VFKHPD ³ERG\LQWKHEUDLQ´ ,Q 5HVHDUFK LQWR 6SLQDO 'HIRUPLWLHV 6WXGLHV LQ +HDOWK 7HFKQRORJ\ DQG ,QIRUPDWLFV 9ROXPH (GLWHG E\ 8\WWHQGDHOH ' DQG 'DQJHUILHOG3+$PVWHUGDP,263UHVV >@ 6SRUQV 2 (GHOPDQ *0 6ROYLQJ %HUQVWHLQ¶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p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sQ -+ YDQ 6PLW 7+ 7KH UROH RI GRUVDO VKHDU IRUFHV LQ WKH SDWKRJHQHVLV RI DGROHVFHQW LGLRSDWKLFVFROLRVLV ±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

R.G. Burwell et al. / Etiologic Theories of Idiopathic Scoliosis

217

>@ *XR ; &KDX :: &KDQ @ 'D\ * )UDZOH\ . 3KLOOLSV % HW DO 7KH YHUWHEUDO ERG\ JURZWK SODWH LQ VFROLRVLV D SULPDU\ GLVWXUEDQFH LQ JURZWK"6FROLRVLVGRL >@ 6WRNHV,$)%XUZHOO5*'DQJHUILHOG3+ %LRPHFKDQLFDOVSLQDOJURZWKPRGXODWLRQDQGSURJUHVVLYHDGROHVFHQW VFROLRVLV ±DWHVWRIWKHµYLFLRXVF\FOH¶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

This page intentionally left blank

Chapter 5 Screening and Prevention of Scoliosis

This page intentionally left blank

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-221

221

&DUU\LQJD5XFNVDFNRQHLWKHU6KRXOGHURU WKH%DFN'RHVLWPDWWHU"/RDG,QGXFHG )XQFWLRQDO6FROLRVLVLQ³QRUPDO´\RXQJ VXEMHFWV %(77$1<6$/7,.29-:$55(1- 67$030

6HQLRU/HFWXUHULQ5HVHDUFK0HWKRGV6FKRRORI+HDOWKDQG6RFLDO&DUH 6HQLRUOHFWXUHULQ9LVXDOL]DWLRQ6FKRRORI&RPSXWLQJ 3K\VLRWKHUDS\6WXGHQW6FKRRORI+HDOWKDQG6RFLDO&DUH

8QLYHUVLW\RI7HHVVLGH9LFWRULD5RDG0LGGOHVEURXJK8.76%$ (PDLOMEVDOWLNRY#WHHVDFXNDQGMJZDUUHQ#WHHVDFXN

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

%DFNJURXQG

5XFNVDFNV DUH FDUULHG E\ DSSUR[LPDWHO\ SHUFHQW RI VWXGHQWV DQG UHVXOW LQ PRUH WKDQ HPHUJHQF\ YLVLWV LQ WKH 86 DORQH HDFK \HDU>@ 7\SLFDOO\ WKH5XFNVDFNV DUH ORDGHG ZLWK EHWZHHQ WR RI WKH VWXGHQWV ERG\ ZHLJKW >@ 2YHUORDGLQJ WKH EDFN FDQ UHVXOWLQQXPHURXVGHWULPHQWDOHIIHFWVWRWKHERG\LQFOXGLQJEDFNQHFNDQGVKRXOGHUSDLQ QHUYHLQMXULHVGHFUHDVHGEORRGIORZWRWKHVKRXOGHUDQGDUPDVZHOODVORVVRIILQHPRWRU

222

J. Bettany-Saltikov et al. / Carrying a Rucksack on Either Shoulder or the Back, Does It Matter?

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

0HWKRGRORJ\

2.3DUWLFLSDQWV $FRQYHQLHQFHVDPSOHRIVWXGHQWVZDVUHFUXLWHGIRUWKLVVWXG\Q IHPDOHVDQG PDOHV$JHVUDQJHG±\HDUVPHDQ KHLJKWUDQJHG±FPPHDQ FP ZHLJKWUDQJHG±NJPHDQ NJ ZLWKRISDUWLFLSDQWVEHLQJ ULJKW KDQGHG DQG OHIW KDQGHG $Q\ VXEMHFWV SUHYLRXVO\ GLDJQRVHG ZLWK XSSHU RU ORZHU OLPEFRQGLWLRQVVSLQDOSDWKRORJLHVSURSULRFHSWLYHYHVWLEXODURUQHXURORJLFDOFRQGLWLRQVRU DQ\ NQRZQ DOOHUJLHV WR VHOIDGKHVLYH VWLFNHUV ZHUH H[FOXGHG IURP WKH VWXG\ (WKLFDO DSSURYDO ZDV JUDQWHG E\ WKH 8QLYHUVLW\ RI 7HHVVLGH 6FKRRO RI +HDOWK DQG 6RFLDO &DUH (WKLFV&RPPLWWHH 2.,QVWUXPHQWDWLRQ 7KH µ0,'$6¶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¶ERG\ZHLJKW7KLUWHHQNH\DQDWRPLFDOVSLQDOODQGPDUNVZHUHPDUNHG ZLWKPPGLDPHWHUVHOIDGKHVLYHVWLFNHUVLQVWDQGLQJ>@(DFKDQDWRPLFDOODQGPDUNZDV WKHQUHFRUGHGXVLQJWKHVW\OXVWLSILUVWO\ZLWKRXWWKH5XFNVDFNWKHQRQERWKVKRXOGHUVDQG ILQDOO\RQWKHULJKWDQGOHIWVKRXOGHUUHVSHFWLYHO\7KH5XFNVDFNZDVFDUULHGLQWKLVVWDWLF

J. Bettany-Saltikov et al. / Carrying a Rucksack on Either Shoulder or the Back, Does It Matter?

223

SRVWXUHIRUWZRPLQXWHVIRUHDFKWHVWFRQGLWLRQDOORZLQJDQ\SRVWXUDODGDSWDWLRQVWRRFFXU $UHVWSHULRGEHWZHHQHDFKWHVWFRQGLWLRQZDVXQGHUWDNHQWRXQORDGWKHVSLQH7KLVEULHI ORDGLQJWLPHZDVVHOHFWHGDVZKLOHPRVWSDUWLFLSDQWVKDGQRSUREOHPVFDUU\LQJWKHZHLJKW RQ ERWK VKRXOGHUV IRU D SHULRG RI IRXU PLQXWHV VRPH SDUWLFLSDQWV EHFDPH H[WUHPHO\ XQFRPIRUWDEOHGXULQJWKHWKLUGPLQXWH ZKLOVW FDUU\LQJWKH 5XFNVDFNRQRQHVKRXOGHU

)LJXUHV 6\PPHWULFDO DQG $V\PPHWULFDO ORDG FDUULDJH RQ ERWK VKRXOGHUV DQG WKH OHIW DQG ULJKW VKRXOGHU UHVSHFWLYHO\

2.6WDWLVWLFDODQDO\VLV 5HVXOWV ZHUH DQDO\]HG XVLQJ 6366 YHUVLRQ $ ZLWKLQ VDPSOH UHSHDWHGPHDVXUHV $QDO\VLV RI 9DULDQFH $129$ ZDV FRQGXFWHG WR FRPSDUH ORDG FDUULDJH PHWKRGV WR GLVWLQJXLVKDQ\VLJQLILFDQWUHVXOWVZLWKLQWKHGDWDFROOHFWHGWRS$6LGDNSRVWKRFWHVW ZDVXVHGWRGHWHUPLQHZKHUHVLJQLILFDQWGLIIHUHQFHVOD\

5HVXOWV

7DEOH0HDQYDOXHVDQGVWDQGDUGGHYLDWLRQIRUGLIIHUHQWPRGHVRIUXFNVDFNFDUULDJH LQ PP )URQWDO3ODQH9DOXHVLQ GHJUHHV

6DJLWWDO3ODQH9DOXHV LQGHJUHHV

/RDGORFDWLRQ

7KRUDFLFFXUYDWXUH

/XPEDU&XUYDWXUH

7KRUDFLF.\SKRVLV

/XPEDU/RUGRVLV

1RORDG

6'

6'

6'

6'

%RWKVKRXOGHUV

6'

6'

6'

6'

5LJKWVKRXOGHU

6'

6'

6'

6'

/HIW6KRXOGHU

6'

6'

6'

6'

9DOXHZDVVLJQLILFDQWO\GLIIHUHQWIURPEDVHOLQHDWS

224

J. Bettany-Saltikov et al. / Carrying a Rucksack on Either Shoulder or the Back, Does It Matter?

'LVFXVVLRQ

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¶V SRSXODWLRQ LQFUHDVHV LQ SRSXODULW\ LW LV LQFUHDVLQJO\ DSSDUHQW WKDW HGXFDWLRQ DQG FRUUHFW LQIRUPDWLRQ DUH HVVHQWLDO IRU 5XFNVDFN VDIHW\ 3XEOLF DZDUHQHVV QHHGV WR EH LQWHQVLILHG WR PDNH DOO VWXGHQWV DZDUH RI WKH LPSRUWDQFH RI FDUU\LQJ D 5XFNVDFN RQ ERWK VKRXOGHUV 7KH DXWKRUV VXJJHVW WKDW WKH DSSURSULDWH5XFNVDFN ZHLJKWDV ZHOO DV WKHPHWKRG RI FDUULDJHDUHNH\ FRQVLGHUDWLRQV LQ GHFUHDVLQJ WKH QHJDWLYH HIIHFWV RI VSLQDO ORDGLQJ )URP D SXEOLF KHDOWK DQG VDIHW\ SHUVSHFWLYH WKH UHVXOWV RI WKLV VWXG\ VWURQJO\ VXJJHVW WKDW FRQFHUWHG HIIRUWV VKRXOG EH GLUHFWHGDWGHFUHDVLQJ5XFNVDFNORDGVHQVXULQJFRUUHFWXVDJHZLWKWZRV\PPHWULFDOVWUDSV LQFUHDVLQJDZDUHQHVVRISRRUVSLQDOSRVWXUHDQGLQLWLDWLQJHGXFDWLRQDOVHPLQDUVDVZD\VIRU VWXGHQWVWRDYRLGORQJWHUP PHGLFDOSUREOHPVLQWKHEDFNVKRXOGHUQHFN DUPVDQGKDQGV

5HIHUHQFHV >@ ''3DVFRH '(3DVFRH%RRNEDJVKHOSWRVKRXOGHUWKHEXUGHQVRIVFKRROZRUN7HDFKLQJ(OHPHQWDU\ 3K\VLFDO+HDOWK0DUFK ± >@ 7KH 86 &RQVXPHU 3URGXFW 6DIHW\ &RPPLVVLRQ 1DWLRQDO (OHFWURQLF ,QMXU\ 6XUYHLOODQFH 6\VWHP 1(,66 GDWDEDVH 1XPEHUVTXRWHGDUHWKHQDWLRQDOHVWLPDWHGILJXUHV > @ 61HJULQL 5&DUDEDORQD5XFNVDFNVRQ6FKRROFKLOGUHQ¶VSHUFHSWLRQVRIORDGDQGDVVRFLDWLRQVZLWKEDFN SDLQDQGIDFWRUVGHWHUPLQLQJWKHORDG6SLQH ± >@ 71HXVFKZDQGHU% 0DFLDVDQG $ +DUJHQV $5XFNVDFN 6WUDSV FDQ GHFUHDVH EORRG IORZLQWKH VKRXOGHU DQGDUPDQGPD\UHVXOW LQ ORVV RI ILQH PRWRU FRQWUROVW $QQXDO 0HHWLQJ RIWKH $PHULFDQ 3K\VLRORJLFDO 6RFLHW\([SHULPHQWDO%LRORJ\VHFWLRQ >@ +0%UDFNOH\-06WHYHQVRQ$UH&KLOGUHQ¶V5XFNVDFN:HLJKW/LPLWV(QRXJK"$&ULWLFDO5HYLHZRIWKH 5HOHYDQW/LWHUDWXUH6SLQH 1R ± >@ -.QDSLN(+DUPDQDQG.5H\QROGV/RDGFDUULDJHXVLQJSDFNV$UHYLHZRI SK\VLRORJLFDOELRPHFKDQLFDO DQGPHGLFDODVSHFWV$SSOLHG(UJRQRPLFV >@ &-2C6KHD -$%HWWDQ\6DOWLNRY DQG -*:DUUHQ(IIHFWRI6DPHVLGHGDQG&URVVERG\ORDGFDUULDJHRQ' %DFN6KDSHLQ@ -*:DUUHQ -$ %HWWDQ\6DOWLNRY 3 9DQ 6FKLDN 6 3DSDVWHSKDQRX 6 (YLGHQFHG%DVHG 3RVWXUDO $VVHVVPHQW IRU 8VHLQ7KHUDS\DQG5HKDELOLWDWLRQ ,QWHUQDWLRQDO-RXUQDORI7KHUDS\DQG 5HKDELOLWDWLRQ QR

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-225

225

8OWUDVRXQGIHPRUDODQWHYHUVLRQ)$9 DQG WLELDOWRUVLRQ77 DIWHUVFKRROVFUHHQLQJIRU DGROHVFHQWLGLRSDWKLFVFROLRVLV$,6 5*%85:(//5.$8-/$$6.,5%<$ 028/7213+ '$1*(5),(/' %-&)5((0$1$$ &2/()-32/$.5.35$77-.:(%% &HQWUHIRU6SLQDO6WXGLHVDQG6XUJHU\1RWWLQJKDP8QLYHUVLW\+RVSLWDOV7UXVW4XHHQ¶V 0HGLFDO&HQWUH&DPSXV1RWWLQJKDP8.'HSDUWPHQWRI2UWKRSDHGLF6XUJHU\.LQJ¶V 0LOO+RVSLWDO0DQVILHOG8.&KLOGUHQ¶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

226

R.G. Burwell et al. / Ultrasound FAV and TT After School Screening for AIS

)LJXUH6FKHPDWLF GUDZLQJWRVKRZD[LDOYHUWHEUDOURWDWLRQVLQWKHWKRUDFLFVSLQHRIQRUPDODGXOWV>@DQG QRUPDO WRUVLRQDO FKDQJHV LQ WKH IHPRUD LQWHUQDO WRUVLRQ DQG WLELDH H[WHUQDO WRUVLRQ RI JLUOV DQG ER\V ZKLOH JURZLQJ>@

3URFKLDQW] >@ XVHG &7 WR VWXG\ IHPRUDO DQWHYHUVLRQ )$9 LQ HLJKW SDWLHQWV ZLWK LGLRSDWKLF VFROLRVLV DQG ZURWH ³,W DSSHDUV WKDW D QXPEHU RI FDVHV RI LGLRSDWKLF VFROLRVLV RULJLQDWH LQ DV\PPHWULF IHPRUDO DQWHYHUVLRQ´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

R.G. Burwell et al. / Ultrasound FAV and TT After School Screening for AIS

227

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±S )$9 DQG)$9DV\PPHWULHVDUHQRWVLJQLILFDQWO\DVVRFLDWHGZLWKVFROLRVLVVLGHRUVHYHULW\

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

228

R.G. Burwell et al. / Ultrasound FAV and TT After School Screening for AIS

0HWKRGVDQGVXEMHFWV 7KH VXEMHFWV QRUPDO DQG $,6 DQG WKH PHWKRGV XVHG ZHUH DV IRU WKH XOWUDVRXQG PHWKRG XVHGIRU77ZKLFKZDV PHDVXUHGEHWZHHQWLELDOFRQG\OHVDQGWDOXVE\DUDGLRJUDSKHU5.$ RU$6. XVLQJWKHPHWKRGRI.LUE\HWDO>@ 5HVXOWV)LJXUH 0HDQ77V GHJUHHV DUH JLUOUHIHUUDOVULJKW OHIW QRUPDOVULJKW OHIW ER\ UHIHUUDOV ULJKW OHIW QRUPDOV ULJKW OHIW 1RUPDOV 77V DQG 77 DV\PPHWU\ULJKWPLQXVOHIW VKRZVOLJKWLQFUHDVHVRUQRFKDQJHZLWKDJHER\VDUHPRUH DV\PPHWULF WKDQ JLUOV UHVSHFWLYHO\ S $129$ ZLWK DJH DQG VH[ FRUUHFWLRQV 5HIHUUDOVZLWKDJH77DQG77DV\PPHWU\LQJLUOVVKRZQRVLJQLILFDQWFKDQJH DQGLQER\VDQLQFUHDVHRIERWKULJKW77S DQG77DV\PPHWU\S 77DQG 77 DV\PPHWU\ LQ WKH VFROLRVLV VXEMHFWV DUH QRW VLJQLILFDQWO\ GLIIHUHQW IURP WKH QRUPDOV $129$FRUUHFWLQJIRUDJH 77LVGHFUHDVHGLQER\VUHODWLYHWRJLUOVULJKWS OHIW S 77 DV\PPHWU\ LQ ER\V FRPSDUHG ZLWK JLUOV LV QRW VLJQLILFDQW $129$FRUUHFWLQJIRUDJH 77VDQG77DV\PPHWU\DUHQRWDVVRFLDWHGZLWKVFROLRVLVVLGH RUVHYHULW\

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

&RQFOXVLRQ ,QVFROLRVLVER\VUHODWLYHWRVFROLRVLVJLUOV77GHFUHDVHZLWKRXWDV\PPHWU\PD\UHVXOWIURP VH[XDOO\GLPRUSKLFPDWXUDWLRQDWNQHHWLELDOJURZWKSODWHV"PDWXUDWLRQDOO\GHOD\HG77ZLWK OHIWULJKWV\QFKURQ\ 7KHUHODWLRQRI)$9WR77 7KH UDZ GDWD IRU )$9 DQG 77 LQ QRUPDOV DQG VFUHHQHG VXEMHFWV SURYLGH WKH EDVLV IRU HYDOXDWLQJ WKHUHODWLRQ RI )$9WR77 E\ DQ )$977 UDWLRDQGDQ LQGH[77PLQXV )$9 >@

R.G. Burwell et al. / Ultrasound FAV and TT After School Screening for AIS

229

5HIHUHQFHV >@ >@ >@ >@ >@ >@ >@ >@ >@ >@ >@ >@ >@ >@

>@ >@ >@ >@ >@ >@ >@ >@ >@ >@

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¶$FDG 1DW GH 0pG GLVFXVVLRQ )UHQFK 1DLTXH6%3RUWHU5&XQQLQJKDP$$HWDO6FROLRVLVLQDQ2UDQXWDQ6SLQH (( &DVWHOHLQ50'LHsQ-+YDQ6PLW7+7KHUROHRIGRUVDOVKHDUIRUFHVLQWKHSDWKRJHQHVLVRIDGROHVFHQW LGLRSDWKLFVFROLRVLV ±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

230 >@ >@ >@ >@

>@

>@ >@ >@ >@ >@

R.G. Burwell et al. / Ultrasound FAV and TT After School Screening for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±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¶(FROHGH 0HGLFLQH3DULV =DUDWH5&XQ\&6D]RV3'HWHUPLQDWLRQGHO¶DQWHYHUVLRQGXFROGXIHPXUSDUHFKRJUDSKLH-GH5DGLRO .LUE\ $6 %XUZHOO 5* $XMOD 5. HW DO $ QHZ PHWKRG IRU PHDVXULQJ WLELDO WRUVLRQ 77 DQJOHV DQG ILQGLQJVIRU\RXQJDGROHVFHQWV&OLQ$QDW

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-231

231

Positional relationship between leg rotation and lumbar spine during quiet standing N PARKER1, A GREENHALGH1,2, N CHOCKALINGAM1, P H DANGERFIELD1,3 1

Staffordshire University, Stoke on Trent ST4 2DF, 2University of Central Lancashire 3 The University of Liverpool Abstract. Healthcare professionals frequently evaluate spinal posture on visual assessment during the clinical examination. While this visual assessment of the spine has been shown to be unreliable, the use of a plumbline as to aid clinical visual assessment has also been reported. There is a "normal" sagittal contour that functions quite well in healthy people. It positions the head in space, it protects the neural axis, and it allows efficient, pain-free motion. Lumbar lordosis is routinely evaluated in most spine patients, but what constitutes a normal sagittal contour is less well defined. A key component of normal sagittal contour is lumbar lordosis. Changes in the lumbar lordosis frequently occur in pathological gait, usually in association with alterations in pelvic tilt, and commonly as a compensation for a limited range of flexion/extension at the hip joint. Recent investigations looked at the effect of hyperpronation on pelvic alignment in a standing position and supported the existence of a kinematic chain in healthy subjects, where hyperpronation can lead to an immediate shank and thigh internal rotation and change in pelvic position. While there is a wealth of research is available on the effectiveness of functional foot orthoses, the present investigation reports the effect of pronated foot position on the lumbar region of the back by employing an optoelectronic movement analysis system. Keywords: Lordosis, Lumbar, Spine, leg, foot, calcaneus

1.

Introduction

Lower back pain is a disabling condition that affects both the general and working population. While, Burton et al [1] indicated that shoe insoles are not recommended in the prevention of back problems, previous investigations have looked at the effectiveness of shoe inserts on back pain. The rationale for the use of foot orthoses to prevent or modify back pain is based on their impact attenuation ability during walking [2]. However, Dananberg [3, 4] has provided some evidence for an alternative rationale for treatment of back pain with functional foot orthoses. There is a "normal" sagittal contour of the spine that functions effectively in healthy people. It protects the neutral spine axis, and precipitates efficient, pain-free motion. Lumbar lordosis (LL) is a key component of the normal sagittal contour, it is routinely evaluated in most spine patients, but is not well defined. Changes in the LL frequently occur in pathological gait, usually in association with alterations in pelvic tilt, and commonly as a compensation for a limited range of flexion/extension at the hip joint [5, 6]. Although the invasiveness and risk of radiation preclude the use of the radiograph as

232

N. Parker et al. / Positional Relationship Between Leg Rotation and Lumbar Spine

a routine measurement in clinical practice, the gold standard measurement of LL is still a plain film x-ray [7,8,9,10]. Other spinal measurement techniques have been developed and reported [11], such as Goniometry [12], skin markers over the spinal processes [13] inclinometers [14] [15] and the use of flexible rulers [16]. These external measurements are easy to apply and non-invasive [17] [10]. Whittle & Levine [6] define the angle of LL as the difference in angle between the areas of skin over the T12-L1 junction and the L5-S1 junction, projected in the sagittal plane. Other researchers have reported different points of measurement relative to the technique being used [7, 8]. Whittle & Levine [6, 18-20] performed a range of studies to promote the use of gait analysis for measuring LL. They demonstrated a high level of significance and reliability when measuring LL based on extensive previous work using motion capture techniques. The relationship between the mechanics of the foot and lower extremity has been confirmed in various studies [21, 22] [23] [24, 25]. However the relationship between foot mechanics and the knee, hip and pelvis are less clear [26][27][28]. Studies investigating the lumbo-pelvic region demonstrated that increasing anterior pelvic tilt increased the LL and increasing posterior pelvic tilt did the opposite [18]. Later work showed the average pelvic tilt and average lumber lordosis relationship was out-of-phase. Pelvic tilt data was relatively consistent across subjects, but the LL showed a complete variety of patterns [6]. They concluded that LL has a highly individualist pattern of movement and that during gait appears to be variable from one subject to another which contrasted previous work which reported patterns of movement in the lumbar spine complemented those of the pelvis in the sagittal plane [29]. The maintenance of postural stability is a complex task that requires the coordination of visual, vestibular and somatosensory inputs [30]. Balance is defined as the process of maintaining the centre of gravity within the body’s base of support [31]. Centre of gravity (COG) is described by Winter [32]. Postural sway [33] compensates for small perturbations in stance; however the body cannot be considered as a complete segment. The trunk will always move independently to contribute to balancing the COM. Over time postural changes can occur due to muscular stretchweakness and weaknesses in proprioception. The current study investigates whether subtalar movement affects limb rotation and pelvic alignment, and if prevalent attempts to corrleate movement at the subtalar joints to movement and alterations in the lumbar lordosis.

2.

Materials and Methods

Ethical approval from appropriate ethics committee was received. Children and individuals receiving any type of treatment were excluded from the study. . Subjects were selected using convenience sampling according to their availability to data collection sessions. 17 subjects were recruited to the study (8 males and 9 females) between the ages of 18 and 40 (mean 26.23 years). Subjects were free of any musculoskeletal conditions and abnormalities which included back pain. All subjects gave an informed consent to take part in the study. Inclusion and exclusion criteria are detailed in Table 1.

N. Parker et al. / Positional Relationship Between Leg Rotation and Lumbar Spine

233

The upper age limit was set to 40 to exclude subjects with undetermined early degenerative changes in the lumbar spine. It has been suggested that the pathology peaks between the ages of 35 and 55 [34]. Subjects Inclusion criteria Exclusion criteria with obvious lower Ages between 18 and 40 Current or past back pain extremity deformity; No known lower extremity Obvious lower extremity particularly marked dysfunction dysfunction; particularly internal/external femoral marked internal/external or tibial torsion were femoral or tibial torsion. excluded on the basis that No LLD or LLD <5mm Leg Length Discrepancy these deformities may (>5mm) affect the translation of Palpable bony landmarks on the Subjects where bony landmarks rotation up the locomotor lumbar spine were not easily palpable. chain. Heavily pronated Foot Posture Index (Redmond Foot Posture score (Redmond et subjects were excluded et al 2006) score from -1 to +7 al 2006) of 7 or greater, <-1 from the study and only those with Foot Posture Table 1: Inclusion/Exclusion Index [35] score from -1 to +7 were admitted. Flexibility on the positive side of the score was permitted from subjects presenting easily palpable bony landmarks. Subjects with a leg length discrepancy >2cm were excluded in line with the European guidelines for the prevention of Low back pain [1]. Kinematic data was acquired using an optoelectronic motion analysis system (VICON, Oxford). The system utilised 8 infrared cameras to track 15mm reflective markers that were placed on specific landmarks on the lower limb, pelvic area and lumbar spine. The system was calibrated using the manufacturer’s guidelines at the beginning and end of each data collection session. Ground reaction forces (GRF) were collected using a force plate (AMTI). Pilot Study A single subject pilot study was completed and specific positions of the markers identified by the system were verified by using actual measurements. Two marker sets for evaluating lumbar spine curvature had previously been developed, 3Figure 1: 4 Marker Set (Whittle and Levine 1997) marker set and a 4-marker set [6]. The 4-marker set was chosen. Two standard VICON rigs were used each consisting of a flat baseplate, from the centre of which protruded a 100mm long wand with a retroflective marker mounted at its end. The marker on the upper baseplate was directly over L1 and the marker on the lower baseplate was directly over S2. The raw data was then exported to Microsoft Excel to calculate the magnitude of lumbar lordosis using a previously described method [6].

234

N. Parker et al. / Positional Relationship Between Leg Rotation and Lumbar Spine

Mean Age (years Weight (Kg) Height (m)

26.2 72.1 1.7

Standard Deviation ± 5.0 ± 11.4 ± 0.1

BMI (Kg/m2)

23.7

± 2.4

Range 21 - 36 53 - 97 1.6 1.87 19.2 28.4

Table 2: Participant characteristics n=17 (9 F: 8 M)

Standard anthropometric data (table 2) was collected and the Foot Posture Index (FPI) was determined by the same researcher (NP). Furthermore for every subject the skin markers for kinematic data acquisition were applied by the same researcher (NP). Prior to fixing the two rigs to the skin, the angle of the wand to the baseplate was validated on a supporting surface manually and by the system. The angle between the baseplate and the line joining the centres of the two markers was then calculated to be 42.84º. The subject was asked to stand in a relaxed position with their arms crossed and the palms of the hands resting on their shoulders to standardise the position and minimise any affect upper limb Test Conditions placement may have on the centre of pressure. Three Relaxed Standing dimensional kinematic data was collected for all conditions and 3.5° Rearfoot Wedges 3.5° Forefoot Wedges reported in table 3: 3.

3.5° Full foot Wedges 5° Rearfoot Wedges 5° Forefoot Wedges 5° Full foot Wedges 10° Rearfoot Wedges 10° Forefoot Wedges 10° Full foot Wedges

Results

Changes in magnitude of Lumbar Lordosis

Results for all subjects (Fig. 2) showed no substantial similarities between subjects. Table 3: Wedged conditions tested 105

100

Lumbar Lordosis (Degrees)

95

90

85

80

75

70 Standing

3º Rearfoot

3º Forefoot

3º Full

5º Rearfoot

Figure 2: Magnitude of Lumbar Lordosis

5º Forefoot

5º Full

10º Rearfoot 10º Forefoot

10º Full

N. Parker et al. / Positional Relationship Between Leg Rotation and Lumbar Spine

235

Analysing the change in LL from relaxed standing at rearfoot modes only shows a reduction that approaches a linear relationship (Figure 3).

Magnitude of Lumbar Lordosis (Degrees)

1.00

0.00

-1.00

-2.00

-3.00

-4.00

-5.00 3º Rearfoot

5º Rearfoot

10º Rearfoot

Figure 3: Change of Magnitude of Lordosis from relaxed standing for Rearfoot Conditions

Results were analysed according to Foot Posture Index (FPI) score. The objective of this exercise was to find if certain foot types affect the kinetic chain and therefore the magnitude of the LL in the standing position (Figure 4). The results suggest there may be a correlation between the slightly more pronated feet and an increased lumbar lordosis. There may also be correlations between the 3º and 5º rearfoot and forefoot wedge modes however the same cannot be said for the 10º results. Regarding the subjects with FPI scores of 2:2 there appears to be limited uniformity to the results, however all results except one are in the negative presenting a reduction in lordosis. 12.00 10.00

Magnitude of Lumbar Lordosis (Degrees)

8.00 6.00 4.00 2.00 0.00 -2.00 -4.00 -6.00 -8.00 -10.00 3º RF

3º FF

3º Full

5º RF

5º FF Total FPI 5:5

5º Full

10º RF

10º FF

10º Full

Total FPI 2:2

Figure 4: Subjects with Homogeneous FPI scores of 5:5 (n=4) and 2:2 (n=3)

Changes in the projection of the centre of gravity in the transverse plane (PCOG) Results from a sample of subjects were analysed to assess the translation of the centre of gravity. A negative change indicates that body posture had swayed anteriorly. The converse is true for a positive change in the COP.

236

N. Parker et al. / Positional Relationship Between Leg Rotation and Lumbar Spine

Mean values (Figure 6), show all points producing negative values, indicating an anterior translation of the centre of gravity. There is a wide variety of results with little pattern. Standard deviations show that this may not be the case for larger populations 12.00

Magnitude of Lumbar Lordosis (Degrees)

10.00

8.00

6.00

4.00

2.00

0.00 RF

FF 3º Results

5º Results

Figure 5: Subjects with Homogeneous FPI scores of 5:5 (Rearfoot and Forefoot only)

10.00

Translation of PCOG (mm)

5.00

0.00

-5.00

-10.00

-15.00 3º RF

3º FF

3º Full

5º RF

5º FF Mean

+2SD

5º Full

10º RF

10º FF

10º Full

-2SD

Figure 6: Mean Translation of Projection of COG (-ve = Ant Translation)

4.

Discussion

The main aims of the study were; to develop a measurement technique to show that LL can be measured successfully, via non-invasive motion capture analysis; to measure the relationship of the LL to foot function and to consider the effect of foot function on the centre of gravity of the body. The pilot study confirmed the work of previous studies [6, 18, 36]. In standing posture, increasing the amount of pelvic tilt increases the angle of lumbar lordosis, and vice versa. The intention of this research was to deliver normative data on the topic as a baseline before studying pathologic subjects. The direct foot to lordosis relationship was studied as previous investigations pertinent to

N. Parker et al. / Positional Relationship Between Leg Rotation and Lumbar Spine

237

other links had already been presented [23-27]. Post study evaluation was unable to elucidate trends from the findings. Changes in magnitude of Lumbar Lordosis Changes in LL showed no general patterns across the range of subjects. This agreed with previous research where an out-of-phase relationship between the average pelvic tilt and the average LL was found [20]. Different effects were found at the lumbar level depending where the wedge is placed, but with no noticeable patterns. Descriptive data from the present study supports the null hypothesis that, as wedges are applied to the rearfoot in increasing amounts the lordosis decreases (Fig. 3), but not with any direct relationship. Making comparisons across foot posture type there appeared to be a correlation between the slightly more pronated feet and an increased lumbar lordosis. The 3º and 5º rearfoot and forefoot wedge modes seemed to show a general increase, however the same cannot be said for the 10º results. This may be because the foot reached maximal pronation or calcaneal eversion and further eversion was not possible. By inference, and notwithstanding the small sample size, the question of whether such interventions can really alter anything at lumbopelvic level by altering foot posture remains. Changes in the projection of the centre of gravity in the transverse plane (PCOG) Hertel [37] postulated that the interface between differently shaped feet (as described by Root [38]) and a force plate could influence ground reaction forces and thus postural control measures during objective assessment of postural stability during single-leg stance. The purpose of this part of the study was to investigate if a foot more akin to pes planus posture affected postural stability by causing an anterior shift in the COP. There was a general movement of the PCOG in the anterior direction (Figure 6), suggesting that foot pronation induced a forward movement of the PCOG across the small sample size. The standard deviations show that this might not be the case for a larger population. If the body maintains balance in response to an anterior shift in the PCOG by altering the upper limb to lower limb relationship, then it did not show in the magnitude of the LL results and may take place elsewhere. Results of the present study suggest excessively pronated feet may cause an anterior translation of the PCOG although the findings are not supported in the literature. This reinforces the common anecdotal belief that pronated feet alter body posture in the anterior/posterior direction. Unfortunately no clear pattern evolved from the results and a larger sample size is recommended for future studies. Correction of excessive pronation may help to prevent the change in PCOG, although this study didn’t demonstrate a link to lumbar posture. The results do not support the research aim which was to find whether subtalar movement affects limb rotation and pelvic alignment, and if prevalent attempts to corrleate movement at the subtalar joints to movement and alterations in the lumbar lordosis. 5. Limitations The primary limitation of this study is the small sample size. A larger population of subjects would have contributed more validity to the results. Tighter Inclusion criteria would have made demonstrating trends in the results more achievable. Direct comparison of the results with previous studies was not possible due to the different methodology accompanied with the innovative parameters being measured.

238

N. Parker et al. / Positional Relationship Between Leg Rotation and Lumbar Spine

Reproducing previous studies [25] to validate their results could have been incorporated into the study methodology to allow direct comparisons with previously reported research (REFERENCES). Using smaller wedges may have limited the study to very small fluctuations in lumbar posture in the test group whereas larger wedges, although not representative of the clinical situation may have produced better results. The results of this study were dependent on visualizing changes within a static model, with the lack of conclusive results from this study, further investigation where dynamic stresses are in place and can be assessed, should be considered. 6. Conclusion The response of the Lumbar lordosis to changes in foot posture is varied and the paucity of relationships suggest further studies are required. There may be merit in investigating subjects with different back postures to establish a degenerative link. The results suggest that pronated feet cause an anterior movement of the centre of gravity and reinforce the common anecdotal belief that pronated feet alter body position and posture, although compensation for these changes may not be taking place exclusively in the lordotic region. References [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17]

[18] [19]

Burton, A.K., et al., European guidelines for prevention in low back pain, in European Spine Journal. 2006. S136-S168. Wosk, J. and A.S. Voloshin, Low back pain: conservative treatment with artificial shock absorbers, in Arch Phys Med Rehabil. 1985. p. 145--148. Dananberg, H.J., Gait style as an etiology to chronic postural pain. Part II. Postural compensatory process, in J Am Podiatr Med Assoc. 1993. p. 615--624. Dananberg, H.J., Gait style as an etiology to chronic postural pain. Part I. Functional hallux limitus, in J Am Podiatr Med Assoc. 1993. p. 433--441. 5Whittle, M., Gait Analysis:An Introduction. 1991. Whittle and D. Levine, Measurement of lumbar lordosis as a component of clinical gait analysis, in Gait and Posture. 1997. p. 101-107. Polly, D.W., et al., Measurement of lumbar lordosis. Evaluation of intraobserver, interobserver, and technique variability, in Spine. 1996. p. 1530--5; discussion 1535-6. Chernukha, K.V., R.H. Daffner, and D.H. Reigel, Lumbar lordosis measurement. A new method versus Cobb technique, in Spine. 1998. p. 74--9; discussion 79-80. Chen, Y.L., Vertebral centroid measurement of lumbar lordosis compared with the Cobb technique, in Spine. 1999. p. 1786--1790. Ng, J.K., et al., Range of motion and lordosis of the lumbar spine: reliability of measurement and normative values, in Spine. 2001. p. 53--60. Pearcy, M., Measurment of back and spinal mobility, in Clincal Biomechanics. 1986. p. 44-51. Burdett, R.G., K.E. Brown, and M.P. Fall, Reliability and validity of four instruments for measuring lumbar spine and pelvic positions, in Phys Ther. 1986. p. 677--684. Hart, D. and S. Rose, reliability of a non-invasive method for measuring lumbar curve, in Clinical Biomechanics. 1986. p. 44-51. Rondinelli, R., et al., Estimation of normal lumbar flexion with surface inclinometry. A comparison of three methods, in Am J Phys Med Rehabil. 1992. p. 219--224. Williams, R., et al., Reliability of the modified-modified Schöber and double inclinometer methods for measuring lumbar flexion and extension, in Phys Ther. 1993. p. 33--44. Lovell, F.W., J.M. Rothstein, and W.J. Personius, Reliability of clinical measurements of lumbar lordosis taken with a flexible rule, in Phys Ther. 1989. p. 96--105. Watson, A.W. and C. McDonncha, A reliable technique for the assessment of posture: assessment criteria for aspects of posture, in Journal of Sports Medicine and Physical Fitness [NLM - MEDLINE]. 2000. p. 260--. Levine, D. and M.W. Whittle, The effects of pelvic movement on lumbar lordosis in the standing position, in J Orthop Sports Phys Ther. 1996. p. 130--135. Whittle, Three-dimensional motion of the center of gravity of the body during walking, in Human Movement Science. 1997. p. 347--355.

N. Parker et al. / Positional Relationship Between Leg Rotation and Lumbar Spine

239

[20] Whittle, M. and D. Levine, Three-dimensional relationships between the movements of the pelvis and lumbar spine during normal gait, in Human Movement Science. 1999. p. 681-692. [21] Perry, J., Gait Analysis:Normal and Pathological Function. 1992. [22] Perry, J., Anatomy and biomechanics of the hindfoot, in Clin Orthop Relat Res. 1983. p. 9--15. [23] Nigg, B.M., G.K. Cole, and W. Nachbauer, Effects of arch height of the foot on angular motion of the lower extremities in running, in J Biomech. 1993. p. 909--916. [24] Nawoczenski, D.A., C.L. Saltzman, and T.M. Cook, The effect of foot structure on the threedimensional kinematic coupling behavior of the leg and rear foot, in Physical Therapy. 1998. p. 404--. [25] Khamis, S. and Z. Yizhar, Effect of feet hyperpronation on pelvic alignment in a standing position, in Gait Posture. 2006. [26] Reischl, S.F., et al., Relationship between foot pronation and rotation of the tibia and femur during walking, in Foot Ankle Int. 1999. p. 513--520. [27] Nester, C., The relationship between transverse plane leg rotation and transverse plane motion at the knee and hip during normal walking, in Gait Posture. 2000. p. 251--256. [28] Powers, C.M., et al., Comparison of foot pronation and lower extremity rotation in persons with and without patellofemoral pain, in Foot Ankle Int. 2002. p. 634--640. [29] Crosbie, J., R. Vachalathiti, and R. Smith, Patterns of spinal motion during walking, in Gait and Posture. 1997. p. 6-12. [30] Lord, S.R. and H.B. Menz, Visual contributions to postural stability in older adults, in Gerontology. 2000. p. 306--310. [31] Cote, K.P., et al., Effects of Pronated and Supinated Foot Postures on Static and Dynamic Postural Stability, in J Athl Train. 2005. p. 41--46. [32] 3Winter, D.A., A.B.C. (anatomy, biomechanics and control) of balance during standing and walking. 1995: Waterloo, Ontario : Waterloo Biomechanics. [33] .Kirby KA, Foot and Lower Extremity Biomechanics II: Precision Intricast Newsletters, 1997-2002. 2002: Precision Intricast, Inc., Payson, AZ, , pp. [34] Andersson, G.B.J., The Adult Spine: Principles and Practice, Fryomoyer, Editor. 1997, LippencottRaven, Philidelphia. p. 93-141. [35] Redmond, A., J.Crosbie, and R.Ouvrier, Development and validation of a novel rating system for scoring foot posture: the Foot Posture Index, in Clinical Biomechanics. 2006. p. 89-98. [36] Day, J.W., G.L. Smidt, and T. Lehmann, Effect of pelvic tilt on standing posture, in Phys Ther. 1984. p. 510--516. [37] Hertel, J., M. Gay, and C. Denegar, Differences in Postural Control During Single-Leg Stance Among Healthy Individuals With Different Foot Types, in J Athl Train. 2002. p. 129--132. [38] Root, M., W. Orien, and J. Weed, Normal and abnormalfunction of the foot: Clinical biomechanics. 1977: Clinical Biomechanics Corp. Los Angeles.

240

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-240

Aetiology of Idiopathic Scoliosis. What have we learned from School Screening? T B. GRIVAS, E S. VASILIADIS, G RODOPOULOS Scoliosis Clinic, Orthopaedic Department, “Thriasio” General Hospital, G. Genimata Avenue, Magula, 19600, Athens, Greece. [email protected] Abstract. The value of school screening as a research tool for Idiopathic Scoliosis (IS) aetiology has not been recognized adequately in the literature. The aim of the present study is to summarize the contribution of school screening in research of IS aetiology. All the relative publications about research of IS aetiology which originated from our scoliosis school screening program were analyzed. Information is provided about a) the influence of environmental factors in IS prevalence, b) the IS prevalence in girls with visual deficiency, c) the role of melatonin in IS pathogenesis, d) the age at menarche in IS girls and its relation to laterality of the curve, e) the role of the brain in trunk asymmetry and IS pathogenesis, f) the role of the thoracic cage in IS pathogenesis, g) the impact of the lateral spinal profile, h) the role of the intervertebral discs in IS pathogenesis, i) the association of cavus foot with IS and j) anthropometric data in IS patients. The present study provides evidence to support that school screening programs should be continued not only for early detection of IS or for health care purposes, but also as a basis for epidemiological surveys until we learn much more about the aetiology of IS. Keywords. Idiopathic scoliosis, school screening, aetiology of idiopathic scoliosis

1.

Introduction

Scoliosis school screening (SSS) continues to be controversial. There are studies which both support [1, 2] and discourage [3, 4] routine SSS. The initial goal of SSS is to detect scoliosis at an early stage when deformity is likely to go unnoticed [5] and a less invasive treatment is more effective [6], although it is not a diagnostic process. Negativists to SSS programs have focused on concerns about a low predictive value of screening and the cost effectiveness of referral. There have also been concerns about the possibility of unnecessary treatment including brace use and the effect of exposure to radiation when radiographs are obtained [5, 7, 8, 9]. On the contrary there is evidence that SSS provide valuable data for research on IS aetiology [10, 11, 12, 13, 14, 15]. Even the opponents of SSS agree that it has a role and should be carried out as a basis for epidemiological surveys until we know much more about the aetiology and factors likely to determine the natural history of late-onset IS [16]. The present study highlights the input of our SSS program in research of IS aetiology.

T.B. Grivas et al. / Aetiology of Idiopathic Scoliosis

2.

241

Material and Methods

We reviewed all the relative publications which originated from the “Thriasio” SSS program [17] and provided some input in research of IS aetiology. 3.

Results

IS prevalence at “Thriasio Pedio”, which is a heavily industrialized area was found similar to the prevalence reported in other non-industrialized areas of Greece. This implies that industrial environmental factors do not play any role for a possible difference in IS prevalence [18]. IS prevalence has been reported to be different in various geographic latitudes and demonstrates higher values in northern countries. This observation could be related to the influence of the geography of a specific region on human biology and could be determined by socioeconomic and environmental factors such as temperature, humidity and light. [19] Furthermore, in a different study the regression of prevalence of IS and age at menarche by geographical latitude was found statistically significant (p < 0.001) and both they were following a parallel course of their regression curves, especially in latitudes northern than 25 degrees, which means that late age at menarche was parallel with higher prevalence of IS. The positive association between prevalence of IS and geographic latitude is present only in girls and not in boys. We hypothesized that the increased levels of melatonin in northern countries with poor light environmental conditions are reducing the secretion of LH and causes delayed age at menarche. Delayed puberty results in a prolonged period of spine vulnerability when other aetiological factors are contributing to the development of IS [20]. Interestingly, in blind girls who were found to have a delayed age at menarche, IS prevalence was found to be 42.3%! [21, 22]. An aetiopathogenic role of cerebral cortex function in the determination of the thoracic surface morphology of the trunk was hypothesized after finding a possitive correlation between trunk asymmetry and lateralization of the brain as expressed by handedness in in children who are entitled at risk to develope IS. [23, 24] In a study of rib vertebra angles (RVAs) we showed that scoliotic children with small curves had under developed thoracic cage compared to non scoliotic counterparts. It was suggested that the differences of the RVAs between right and left side were the expression of asymmetric muscle forces acting on the thoracic cage, which deforms early and possibly transfers the deforming forces to the spine [13]. In a different study no correlation was found between the Cobb angle and the “rib index” [12] of thoracic, thoracolumbar and lumbar curves. A positive correlation of the “rib index” with each of T2, T3, T4, T5, T6 and T7 Lateral Spinal Profile (LSP) in girls with lumbar curves was found. The mean age of non-scoliotics was 1.5-2 years younger than scoliotics. Rib index was approximately 1.5, which implies pronounced thoracic asymmetry in terms of rib hump, in all SSS referrals who presented with an already developed deformity of the thorax. 70% of them were scoliotics, 10% had a curve < 9o and 20% had straight spines, as confirmed by an x-ray. This observation supports the hypothesis that in idiopathic scoliosis the deformity of the thorax precedes the deformity of the spine [12, 25]. Furthermore, the correlation between the rib cage

242

T.B. Grivas et al. / Aetiology of Idiopathic Scoliosis

deformity and the deformity of the spine is weak in younger children, [25] as 25% of children with ATI ≥7º had a spinal curve under 10º or had a straight spine. As a result of the effect of growth on the correlation between the thoracic surface deformity and the spinal deformity, the predictive value of the existing formulas which calculate the Cobb angle from surface measurements is poor. Therefore our recommendation is to take into consideration the effect of growth when developing such predictive models, otherwise they can be inaccurate. In a study of the LSP of mild (10o-20o) scoliotic curves, we demonstrated that hypokyphosis of the thoracic spine by alleviating axial rotation is not a predisposing factor but rather a compensatory mechanism for the initiation of mild scoliotic curves [14]. In a radiological study of SSS referrals, we showed that in mild scoliotic curves, the deformity appears first at the level of the intervertebral disc (IVD), which is found wedged. The deformity of the vertebral body or of the spinal column follows. The eccentric intervertebral disc in the scoliotic spine, through variation in its water concentration, produces asymmetrically cyclical load during the 24-hour period and an asymmetrical growth of the vertebral body (Hueter-Volkman’s law). The deformation of the apical IVD seems to be an important progressive factor in IS pathogenesis [26]. Flat foot, as well as cavus foot which was previously reported that is correlated positively with IS was not confirmed in our study [10]. A variety of findings regarding the stature and weight of IS children has been published. In a study in Mediterranean population, the somatometric parameters of height and weight in children with scoliosis, regardless of curve type and site, are not statistically different from their non scoliotic counterparts [15]. Finally, studying the age at menarche in IS girls it was found that there was not statistically significant difference of this variable between scoliotic and non scoliotic girls in the Mediterranean population studied [11]. 4.

Discussion

The important findings on the lack of statistically significant difference of the age at menarche between scoliotic and non scoliotic girls in the studied Mediterranean population and the similar findings on the somatometric parameters of height and weight in children with scoliosis, which are not statistically different from their non scoliotic counterparts motivated us to explore the possible role and impact of the geography - environmental factors (the light) on the pathogenesis of scoliosis. The findings are reported in our results. These observations could not be figured out without running a SSS program. The early detection of IS has been a major and growing commitment of Orthopaedists since the early 1960s. Early detection implies early treatment and by that less surgery. Although SSS’s aim is prevention and it should be regarded as a criterion of welfare of our civilization, it has been criticized for its negative cost-effectiveness. It is clear that a realistic evaluation of the cost is not feasible and could result in inaccurate overestimation of the total cost as it might take into consideration many qualitative and subjective factors [17]. On the other hand the financial profit from research of IS aetiology, which was analyzed in the present study cannot be estimated.

T.B. Grivas et al. / Aetiology of Idiopathic Scoliosis

243

The present study provides evidence to support that school screening programs should be continued not only for early detection of IS but also as a basis for epidemiological surveys until we learn much more about the aetiology of IS. References [1] [2] [3] [4] [5] [6]

[7] [8] [9] [10]

[11]

[12] [13]

[14]

[15] [16] [17] [18]

[19] [20]

[21] [22] [23]

Ashworth MA, JA Hancock, L Ashworth, KA Tessier. Scoliosis screening. An approach to cost/benefit analysis. Spine 13(10) (1988) 1187-8. Montgomery F, S Willner. Screening for Idiopathic Scoliosis. Comparison of 90 cases shows less surgery by early diagnosis. Acta Orthop Scand 64(4) (1993) 456-458. Yawn BP, RA Yawn, D Hodge, et al. A population-based study of school scoliosis screening. JAMA 282 (1999) 1427–1432. Morais T, M Bernier, F Turcotte. Age- and Sex-specific Prevalence of Scoliosis and the Value of School Screening Programs. AJPH 75(12) (1985) 1377-80. Bunnel WP, Selective screening for scoliosis. Clin Orthop Relat Res 434 (2005) 40-5. Grivas TB, MH Wade, S Negrini, JP O'Brien, T Maruyama, M Rigo, HR Weiss, T Kotwicki, ES Vasiliadis, LS Neuhaus, T Neuhous, School Screening for Scoliosis. Where are we today? Proposal for a consensus. Scoliosis 2(1) (2007) 17. Burwell RG, The British Decision and Subsequent Events. Spine 13(10) (1988) 1192-94. Morrissy RT, School screening for scoliosis: A statement of the problem. Spine 13 (1988) 1195–1197. US Preventive Service Task Force: Screening for Idiopathic Scoliosis in Adolescent. Recommendation statement. Agency for Healthcare Research and Quality, Rockville, MD, 2004. Grivas TB, P Stavlas, K Koukos, P Samelis, B Polyzois, Scoliosis and Cavus Foot. Is there a Relationship? Study in Referrals, with and without Scoliosis, from School Screening. Stud Health Technol Inform 88 (2002) 10-14. Grivas TB, Samelis P, AS Pappa, P Stavlas, D Polyzois, Menarche in Scoliotic and Nonscoliotic Mediterranean Girls. Is There Any Relation between Menarche and Laterality of Scoliotic Curves? Stud Health Technol Inform 88 (2002) 30-6. Grivas TB, S Daggas, B Polyzois, P Samelis, The double rib contour sign in lateral spinal radiographs. Aetiologic implications for scoliosis? Stud Health Technol Inform 88 (2002) 38-43. Grivas TB, P Samelis, T Chatziargiropoulos, D Polyzois, Study of the rib cage deformity in children with 10º-20º of Cobb angle late onset idiopathic scoliosis, using rib vertebra angles. Stud Health Technol Inform 91 (2002) 20-24. Grivas TB, S Daggas, P Samelis, C Maziotou, P Kandris, Lateral spinal profile in school-screening referrals with and without late onset idiopathic scoliosis 10˚-20˚. Stud Health Technol Inform 91 (2002) 25-31. Grivas TB, A Arvaniti, C Maziotou, M Manesioti, A Fergadi, Comparison of body weight and height between normal and scoliotic children. Stud Health Technol Inform 91 (2002) 47-53. Dickson RA, SL Weinstein, Bracing (and Screening) – Yes or No? J Bone Joint Surg 81B(2) (1999) 193-98. Grivas TB, ES Vasiliadis, C Maziotou, OD Savvidou, The direct cost of Thriasio school screening program. Scoliosis 2(1) (2007) 7. Grivas TB, P Samelis, B Polyzois, B Giourelis, D Polyzois, School screening in the heavily industrialized area. Is there any role of industrial environmental factors in IS prevalence? Stud Health Technol Inform 91 (2002) 76-80. Grivas TB, E Vasiliadis, O Savvidou, M Mouzakis, G Koufopoulos, Geographic latitude and prevalence of adolescent idiopathic scoliosis. Stud Health Technol Inform 123 (2006) 84-89. Grivas TB, E Vasiliadis, V Mouzakis, C Mihas, G Koufopoulos, Association between adolescent idiopathic scoliosis prevalence and age at menarche in different geographic latitudes. Scoliosis 1(1) (2006) 9. Grivas TB, OD Savvidou, E Vasiliadis, S Psarakis, G Koufopoulos, Prevalence of scoliosis in women with Visual Deficiency. Stud Health Technol Inform 123 (2006) 52-56. Grivas TB, OD Savvidou, Melatonin the "light of night" in human biology and adolescent idiopathic. Scoliosis 2(1) (2007) 6. Grivas TB, ES Vasiliadis, VD Polyzois, V Mouzakis, Trunk asymmetry and handedness in 8245 school children. Pediatr Rehabil 9(3) (2006) 259-66.

244

T.B. Grivas et al. / Aetiology of Idiopathic Scoliosis

[24] Grivas TB, K Mihas, E Vasiliadis, C Maziotou, S Karathanou, V Polyzois, Handedness and laterality of trunk rotation in children screened at school for Scoliosis. J Bone Joint Surg 86-B Supp II (2004) 172. [25] Grivas TB, ES Vasiliadis, K Mihas, OD Savvidou, The effect of growth on the correlation between the spinal and rib cage deformity. Implications on idiopathic scoliosis pathogenesis. Scoliosis 2(1) (2007) 11. [26] Grivas TB, ES Vasiliadis, M Malakasis, M Mouzakis, D Segos, Intervertebral disc biomechanics in the pathogenesis of idiopathic scoliosis. Stud Health Technol Inform 123 (2006) 80-83.

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-245

245

Suggestions for improvement of School Screening for Idiopathic Scoliosis T B. GRIVAS1, E S. VASILIADIS1, J P. O’BRIEN2 Scoliosis Clinic, Orthopaedic Department, “Thriasio” General Hospital, G. Genimata Avenue, Magula, 19600, Athens, Greece. 2 National Scoliosis Foundation (NSF), Boston, USA

1

Abstract. There is skepticism and the worth of school screening for the purposes of health care has been challenged. Numerous reasons are raised by the negativists to abandon these programs, even though the value of school screening is well documented in the literature. The aim of the present study is to update the evidence based recommendations for the improvement of school screening effectiveness, in order to support its continuation. All the relative research papers which originated from our scoliosis school screening program were analyzed. Specific suggestions for a) the organization, b) the optimal age of screening according to the geographical latitude, c) the best examined position, d) the standardization of referrals, e) the follow up of younger referrals with trunk asymmetry and f) the reduction of the financial cost are made. Today there is evidence that the incidence of surgery can significantly be reduced in areas where idiopathic scoliosis can be detected at an early stage through these programs. The introduction of these recommendations to all the existing school screening programs is strongly suggested, to reduce the negative impact they may have on families and on the health system and to improve their effectiveness. Keywords. Idiopathic scoliosis, school screening, improvement of school screening

1.

Introduction

There are numerous problems that prevent school screening for IS from being universally accepted. The low prevalence of IS, the high false positive referrals and the excessive cost, both direct and indirect, are raised by the negativists as reasons to abandon school screening programs. To our knowledge, there is no study in the literature to provide suggestions on how to improve the weak points of scoliosis school screening. The American Academy of Orthopaedic Surgeons, Scoliosis Research Society, Pediatric Orthopaedic Society of North America and American Academy of Pediatrics in their most recently published joint information statement on scoliosis screening do not support any recommendation against scoliosis screening, given the available literature [1]. Scoliosis screening has proven effective in many ways, and it is considered beneficial among the Orthopaedic community [2]. Furthermore, it provides the opportunity for early diagnosis and conservative treatment, which is often missed in the absence of screening [3]. The initial goal of scoliosis school screening was to detect IS at an early stage when deformity is likely to go unnoticed [3]. In an effort to enhance the effectiveness of school screening programs, the International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) recommended as a new goal to identify those

246

T.B. Grivas et al. / Suggestions for Improvement of School Screening for Idiopathic Scoliosis

children who will be at risk for developing scoliosis [2] and those children who have curves likely to require conservative treatment [4]. This would require better organization, selective screening of high-risk children, improved examination techniques, standardization of the referral process and cost reduction. 2.

Material-Method

We reviewed all the research papers which originated from the “Thriasio” school screening program [5] and provided evidence based recommendations for the improvement of school screening effectiveness. 3.

Results

School screening has to be set up on a district basis after obtaining permission from the state authorities to approach and examine the school children. A permanent team of examiners should be created, after adequate experience. The examiners should have a core of 2-3 health professionals who are experienced in screening techniques, data entry and occasionally can be staffed by other health professionals on a voluntary basis. The examiners and all the involved individuals (children and their families) must have easy access to the referral hospital. It is important to inform and train if necessary all the interested parties in advance, by distribution of informative material and lectures. Before visiting a school the parents or carerers must fill a consent form (Europe) or be notified by letter as a courtesy in countries where school screening is legislated (North America) and the pupils must fill a particular form regarding their personal and demographic data. The facilities for examination should be prepared by the school stuff in advance and the timetable of that day should be modified accordingly, so that the examination time is kept effectively to a minimum. In a previous study we reported that the regression curve of both the IS prevalence and age at menarche by geographical latitude is following a parallel ascending course, especially in latitudes northern than 25o, which means that late age at menarche was parallel with higher prevalence of IS [6]. In order to increase the predictive value of school screening, we should screen children for scoliosis at a range of age adjusted for the geographical latitude. In a study of trunk asymmetry of 2071 children and adolescents we found a significant reduction in the proportion of asymmetry between the standing and sitting forward bending position during examination [7, 8]. By screening children in sitting position with the use of a scoliometer, the number of referrals can be decreased dramatically because the effect of leg length inequality and pelvic obliquity on the spine is eliminated. [8] Children with leg length inequality could be referred independently for further consultation. Sitting position reveals the true trunk asymmetry which could be associated with IS and therefore it is recommended as a standard examination method in a school screening program as well as a second level test for all potential referrals. It is essential when we set up the screening process to collect information about the gender, the chronological age, the age at menarche, the pattern and the magnitude of asymmetry and the growth potential. All these are very important prognostic factors for progression of a detected asymmetry. [9,10]. Trunk asymmetry should be measured by the use of a scoliometer in three sites of the spine (thoracic,

T.B. Grivas et al. / Suggestions for Improvement of School Screening for Idiopathic Scoliosis

247

thoracolumbar and lumbar) [7] and a cut-off point of 7o together with the prognostic factors should be used for referral. The same factors can be used in scoliosis clinic to determine whether it is necessary to x-ray a child or not, by the more experienced Orthopaedic surgeons, as a second stage of screening. In the model we propose [5] we standardize the referral process, by documenting all these factors, Table 1. Table 1. Recommended criteria for referral in scoliosis school screening 1. Trunk asymmetry (scoliometer reading) 5. Pattern of asymmetry

2. Gender 6. Growth potential

3. Chronological age 7. Maturation

4. Age at menarche for girls

Although asymmetry in skeletally mature children is unlikely to be associated with a progressive scoliotic curve, we noticed in a previous study that in some younger referred girls from the school-screening program there is a discrepancy between the thoracic scoliometer readings and the morphology of their spine [11]. After statistical analysis no significant correlation was found between the surface and the spinal deformity in the younger referred girls aged 8-13 years old, while in older referred girls aged 14-18 years old, this correlation was statistically significant. Therefore, all the younger individuals who are identified with a surface deformity but without a severe scoliotic curve are at risk for IS development and need to be kept under observation and not be discharged from regular follow up. The financial cost of a school screening program can be either direct or indirect [12]. There is no general consensus among economists as to what constitutes the indirect cost in a cost effectiveness analysis because the indirect cost cannot be measured accurately as it is related to the effectiveness of the school screening program. A more effective screening program has lower indirect cost. Therefore the economic information on screening for scoliosis which is available to decision-makers should mainly be based on studies of the direct cost of such programs. In a six year performance of the “Thriasio” school screening program, the direct cost for the examination of each child was 2.04 €, which is considered low [5]. This study provides evidence that the direct cost of a screening program can be reduced to a minimum, if it is well organized and it is performed according to the model we propose [5]. 4.

Discussion

School screening programs are performed in different ways around the world. Unfortunately there is no consensus among the experts on specific criteria of screening. As a consequence of the luck of standards of scoliosis screening, there is no adequate evidence based on outcome results necessary to either enhance or eliminate the school screening process. Today there is evidence that the incidence of surgery can significantly be reduced where conservative treatment is available on a high standard [13, 14, 15]. In areas where scoliosis school screening has stopped, the referral mechanisms for IS are leading to a suboptimal case-mix in orthopaedics in terms of appropriateness of referral and resulted in increased late referrals with regards to brace treatment indications [16]. School screening through detection of IS at an early stage is the only tool we have to detect mild and moderate spinal curves which can be treated conservatively in an effective way. Physicians should be more interested in quality of care for their patients

248

T.B. Grivas et al. / Suggestions for Improvement of School Screening for Idiopathic Scoliosis

than in epidemiology, numbers, statistics, or money. Prevention instead of treatment, which was an axiom in Ancient Greece, must return as a standard health policy in civilized societies. And school screening is primarily a preventive process. Our screening vision should be strongly focused on how to improve its effectiveness so that we can change the paradigm from today’s “correction” and “fusion” goal to a stronger goal of maintaining the natural shape and mobility of the spine and “preventing” a spinal deformity from developing. References [1]

[2]

[3] [4] [5] [6]

[7] [8] [9] [10] [11]

[12] [13] [14] [15]

[16]

Information Statement: Screening for idiopathic scoliosis in adolescents. American Academy of Orthopaedic Surgeons (AAOS), Scoliosis Research Society (SRS), Pediatric Orthopaedic Society of North America (POSNA) and American Academy of Pediatrics (AAP), October 1, 2007. Grivas TB, MH Wade, S Negrini, JP O'Brien, T Maruyama, M Rigo, HR Weiss, T Kotwicki, ES Vasiliadis, LS Neuhaus, T Neuhous, School Screening for Scoliosis. Where are we today? Proposal for a consensus. Scoliosis 2(1) (2007) 17. Bunnel WP, Selective screening for scoliosis. Clin Orthop Relat Res 434 (2005) 40-5. Weiss HR, S Negrini, M Rigo, T Kotwicki, MC Hawes, TB Grivas, T Maruyama, F Landauer, Indications for conservative management of scoliosis (guidelines). Scoliosis 1(1) (2006) 5. Grivas TB, ES Vasiliadis, C Maziotou, OD Savvidou, The direct cost of “Thriasio” school screening program. Scoliosis 2(1) (2007) 7. Grivas TB, E Vasiliadis, V Mouzakis, C Mihas, G Koufopoulos, Association between adolescent idiopathic scoliosis prevalence and age at menarche in different geographic latitudes. Scoliosis 1(1) (2006) 9. Grivas TB, ES Vasiliadis, VD Polyzois, V Mouzakis, Trunk asymmetry and handedness in 8245 school children. Pediatr Rehabil 9(3) (2006) 259-66. Grivas TB, E Vasiliadis, G Koufopoulos, D. Segos, G Triantafilopoulos, V Mouzakis, Study of trunk asymmetry in normal children and adolescents. Scoliosis 1(1) (2006) 19. Bunnell WP, The natural history of idiopathic scoliosis before skeletal maturity. Spine 11 (1986) 773– 776. Soucacos PN, K Zacharis, K Soultanis, J Gelalis, Xenakis T, Beris AE, Risk factors for idiopathic scoliosis: Review of a 6-year prospective study. Orthopedics 23 (2000) 833–838. Grivas TB, ES Vasiliadis, K Mihas, OD Savvidou, The effect of growth on the correlation between the spinal and rib cage deformity. Implications on idiopathic scoliosis pathogenesis. Scoliosis 2(1) (2007) 11. Montgomery F, U Persson, G Benoni, S Willner, B Lindgern, Screening for scoliosis. A costeffectiveness analysis. Spine (1990) 15(2) 67-70. Weiss WR, G Weiss, HJ Schaar, Incidence of surgery in conservatively treated patients with scoliosis. Pediatr Rehabil 6(2) (2003) 111-8. Rigo M, C Reiter, HR, Effect of conservative management on the prevalence of surgery in patients with adolescent idiopathic scoliosis. Pediatr Rehabil 6(3-4) (2003) 209-14. Maruyama T, T Kitagawa, K Takeshita, K Mochizuki, K Nakamura, Conservative treatment for adolescent idiopathic scoliosis: can it reduce the incidence of surgical treatment? Pediatr Rehabil 6(34) (2003) 215-9. Beausejour M, M Roy-Beaudry, L Goulet, H Labelle, Patient characteristics at the initial visit to a scoliosis clinic: a cross-sectional study in a community without school screening. Spine 32 (2007) 1349-1354.

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-249

249

&DQ)XWXUH%DFN3DLQLQ$,66XEMHFWVEH 3UHGLFWHGGXULQJ$GROHVFHQFHIURPWKH 6HYHULW\RIWKH'HIRUPLW\" '+,//(3$5(17(/28-0$+22' &DSLWDO+HDOWK*OHQURVH6LWH$YH1:(GPRQWRQ$%7*%&DQDGD

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

.H\ZRUGV656TXHVWLRQQDLUHEDFNSDLQ$,6TXDOLW\RIOLIH

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

250

D. Hill et al. / Can Future Back Pain in AIS Subjects Be Predicted During Adolescence?

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¶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

D. Hill et al. / Can Future Back Pain in AIS Subjects Be Predicted During Adolescence?

251

7DEOH 6563DLQ'RPDLQ4XHVWLRQV :KLFKRQHRIWKHIROORZLQJEHVWGHVFULEHVWKHDPRXQWRISDLQ\RXKDYHH[SHULHQFHGGXULQJWKHSDVWPRQWKV" 6HYHUH 0RGHUDWH WRVHYHUH 0RGHUDWH 0LOG 1RQH :KLFKRQHRIWKHIROORZLQJEHVWGHVFULEHVWKHDPRXQWRISDLQ\RXKDYHH[SHULHQFHGRYHUWKHODVWPRQWK" 6HYHUH 0RGHUDWHWRVHYHUH 0RGHUDWH 0LOG 1RQH 'R\RXH[SHULHQFHEDFNSDLQZKHQDWUHVW" 9HU\RIWHQ 2IWHQ 6RPHWLPHV 5DUHO\ 1HYHU :KLFKRQHRIWKHIROORZLQJEHVWGHVFULEHV\RXUPHGLFDWLRQXVDJHIRU\RXUEDFN" 1DUFRWLFVGDLO\ 1RQQDUFRWLFVZHHNO\RUOHVVHJDVSLULQ7\OHQRO,EXSURIHQ 1RQQDUFRWLFVGDLO\ 1DUFRWLFVZHHNO\RUOHVVHJ7\OHQRO,,,/RURFHW3HUFRFHW 1RQH ,QWKHODVWPRQWKVKDYH\RXWDNHQDQ\VLFNGD\VIURPZRUNVFKRROGXHWREDFNSDLQDQGLIVRKRZPDQ\" RUPRUH

5HVXOWV $W EDVHOLQH 7DEOH WKHPHDQ &REE DQJOH RI WKHPDMRU FXUYHZDV GHJUHHV DQG UDQJHGIURPWRRGHFRPSHQVDWLRQZDVPPDQGWUXQNWZLVWZDVR $W IROORZXSWKH656VFRUHVZHUHJHQHUDOO\ ZHOOGLVWULEXWHGH[FHSWIRUTXHVWLRQVDQG ZKLFKWHQGHGWR EH FOXVWHUHGQHDUWKHWRSRIWKHVFDOH 7DEOH 2XWFRPHPHDVXUHVIURPVXEMHFWV %DVHOLQH /DUJHVWFXUYH&REE 'HFRPSHQVDWLRQ 7UXQN7ZLVW )ROORZXS 656WRWDOVFRUH 6563DLQ'RPDLQ 3DLQ'RPDLQ4XHVWLRQ 3DLQ'RPDLQ4XHVWLRQ 3DLQ'RPDLQ4XHVWLRQ 3DLQ'RPDLQ4XHVWLRQ 3DLQ'RPDLQ4XHVWLRQ

GHJUHHV PP GHJUHHV

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

252

D. Hill et al. / Can Future Back Pain in AIS Subjects Be Predicted During Adolescence?

7DEOH &HLOLQJDQGIORRUHIIHFWV IRU656TXHVWLRQQDLUH

&HLOLQJ )ORRU

656 WRWDOVFRUH

3DLQ'RPDLQ

4

4

4

4

4

7DEOH &RUUHODWLRQVEHWZHHQIHDWXUHVDQGTXHVWLRQQDLUHVFRUHV 'HIRUPLW\IHDWXUH

656 3DLQ'RPDLQ 7RWDO /DUJHVW&XUYH 'HFRPSHQVDWLRQ 7UXQN7ZLVW $OOFRUUHODWLRQVQRQVLJQLILFDQWS!

4

4

4

4

4

'LVFXVVLRQ 7KHK\SRWKHVLVZDVWKDWVXEMHFWVZLWKWKHPRVWVHYHUHVFROLRVLVZRXOGEHDWKLJKHVWULVNRI GHYHORSLQJIXWXUHEDFNSDLQ&RQWUDU\WRRXUK\SRWKHVLVVSLQDOGHIRUPLW\PHDVXUHVGXULQJ WHHQDJH \HDUV ZHUH QRW SUHGLFWLYH RI SDLQ FRPSODLQWV LQ \RXQJ DGXOWKRRG 7KH IROORZXS SHULRGPD\QHHGWREHH[WHQGHGDVSRVVLEOHIXWXUHEDFNSDLQPD\QRW\HWEHHYLGHQWLQWKH \RXQJDGXOW7KHUHZDVDOVRVHOHFWLRQELDV$GXOWVXEMHFWVFRQVXOWHGWKHLUVSLQHVXUJHRQDW WKHLUUHTXHVW7KHVHVXEMHFWVKDGVLJQLILFDQWVFROLRVLVDWEDVHOLQH7KHPDMRULW\RIVXEMHFWV ZKR DWWHQG WKH SHGLDWULF VSLQH VHUYLFH DV WHHQDJHUV GR QRW URXWLQHO\ VHH DQ RUWKRSHGLF VXUJHRQ DV \RXQJ DGXOWV 6XEMHFWV ZKR GLG QRW FRQVXOW WKHVSLQHVXUJHRQ DV DGXOWV HLWKHU PRYHG IURP WKH DUHD RU GLG QRW IHHO WKH\ UHTXLUHG IROORZXS 3DLQ PD\ EH WKH UHDVRQ MXVWLI\LQJ DQ DGXOW FRQVXOWDWLRQ DV \RXQJ DGXOWV $ ORQJLWXGLQDO VWXG\ LQFOXGLQJ VXEMHFWV ZLWK D ZLGHU UDQJH RI GHIRUPLW\ VHYHULW\ DW EDVHOLQH IROORZHG DV \RXQJ DGXOWV ZLWKRXW UHJDUGWRWKHLUVHHNLQJIXUWKHUFDUHZRXOGKHOSFODULI\ZKHWKHUDGXOWSDLQFDQEHSUHGLFWHG IURPGHIRUPLW\OHYHOVLQWKHWHHQDJH\HDUV5HFHQWZRUNDOVRVXJJHVWVWKDWWKHDVVRFLDWLRQ EHWZHHQGHIRUPLW\DQGSDLQPD\QRWEHOLQHDU>@ /DFNRIDVVRFLDWLRQEHWZHHQEDVHOLQHPHDVXUHVRIGHIRUPLW\DQGSDLQDWIROORZXSPD\ DOVREHGXHWKHLQWHUYHQLQJVXUJHU\LQPDQ\RIWKHVXEMHFWV&RUUHFWLYHVXUJHU\PD\DIIHFW WKHUHODWLRQ EHWZHHQGHIRUPLW\PHDVXUHVDQGSDLQ6XUJHU\ KRSHIXOO\ZRXOGKDYHUHGXFHG WKHVHYHULW\ RIEDFNSDLQ7KHVDPSOHVL]HGLGQRWDOORZH[DPLQLQJWKHDVVRFLDWLRQLQWKH VXEVHWRIVXEMHFWVZKRGLGRUGLG QRWKDYHVXUJHU\ &RQFOXVLRQ (YHQ WKRXJK WKH VDPSOH UHSUHVHQWHG D ZLGH UDQJH RI VFROLRVLV VHYHULW\ DW EDVHOLQH DQG D ZLGHUDQJHRISDLQVFRUHVWR DWIROORZXSEDVHOLQHVFROLRVLVGHIRUPLW\SDUDPHWHUVRI ODUJHVWFXUYHVL]HGHFRPSHQVDWLRQDQGWUXQNWZLVWGLGQRWSUHGLFWVFROLRVLVUHODWHGSDLQLQ \RXQJDGXOWKRRG $FNQRZOHGJPHQWV 7KLVSURMHFWZDVIXQGHGE\WKH6WROOHU\&KLOGUHQ V+RVSLWDO)RXQGDWLRQ5HVHDUFK*UDQW

D. Hill et al. / Can Future Back Pain in AIS Subjects Be Predicted During Adolescence?

253

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

254

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-254

A Machine Learning Approach to Assess Changes in Scoliosis L RAMIREZ 1, N G. DURDLE 1, V. J RASO 2 1

Department of Electrical and Computer Engineering, University of Alberta, Canada 2 Glenrose Rehabilitation Hospital, Capital Health Authority, Canada

Abstract. This paper presents a machine learning approach that can be used to evaluate the validity of the results obtained with an automated system to measure changes in scoliotic curves. The automated system was used to measure the inclinations of 141 vertebral endplates in spine radiographs of patients with scoliosis. The resulting dataset was divided into training and test set. The training set was used to configure three classifiers: a support vector classifier (SVC), a decision tree classifier (DT) and a logistic regression classifier (LR). Their performance was evaluated on the test set. The SVC had an accuracy of 86% discriminating Good Results (those in which the error was less than 3°) from Bad Results. This accuracy was better than that of the LR (76%) and DT (68%). The differentiation between Good and Bad Results using the proposed machine learning approach was achieved successfully. Keywords. Scoliosis, image registration, machine learning

1. Introduction Scoliosis is a condition that involves a lateral curvature and rotation of the spine that could cause noticeable trunk deformities. This condition affects between 2% and 4% of adolescents [1] and between 70% and 80% of the cases have an unknown cause [2]. The management of patients with scoliosis relies on subjective identification and measurement of a set of features on spine radiographs. These include: the Cobb angle [3], vertebral endplate tilt angles, and the apical and end vertebrae of the scoliotic curve. Because these features are assessed manually, they are prone to high inter- and intraobserver variability [4]. For instance, the typical inter- and intra-observer variability of the Cobb angle is accepted to be +/- 5 degrees, which is comparable to the threshold of change that is considered when making treatment decisions. In this paper, a machine learning approach that can be used to automatically assess the quality of the results obtained with an automated system to measure changes in scoliotic curves is presented. Since the clinical focus was on spinal deformities, the main interest was on measuring the inclinations of vertebrae in spine radiographs. Machine learning is concerned with the design and development of techniques that allow computers to learn from datasets. Among machine learning techniques, classification strategies can be used to discriminate between groups. In this work, a classification strategies is proposed to discriminate Good Results (those in which the inclination measurement had an error greater than 3 degrees) from Bad Results. The proposed classification strategy is based on Support Vector Classifiers (SVC) [5]. The

L. Ramirez et al. / A Machine Learning Approach to Assess Changes in Scoliosis

255

main goal was to determine whether SVC could predict results quality sufficiently well to be used in clinical practice. SVC were chosen because they usually outperform techniques such as Artificial Neural Networks when trained using small datasets as is usually the case in scoliosis research. Moreover, unpublished preliminary studies comparing the performance of radial basis function neural networks [6] and SVC indicated the superiority of the latter in our datasets of scoliosis patients. Finally, the results of applying a SVC to the dataset of scoliosis patients are compared to those obtained by applying logistic regression [7] and classification decision trees [8] to the dataset. 2. Methods Retrospectively, radiographs of patients with scoliosis from the database of the scoliosis clinic at the Glenrose Rehabilitation Hospital (Edmonton, Canada) were examined, after getting Ethics Approval, to select patients for the study. The following inclusion criteria were used: 1) having available a posterior-anterior standing radiograph with a maximum Cobb angle of less than 75°; 2) not having undergone surgery; and 3) having at least a visually identifiable vertebral endplate. Eighteen patients and a total of 141 vertebral endplates satisfied the inclusion criteria. Patients had a variety of spinal curvatures, with an average of maximum Cobb angle of 39° ± 18° (range 8°-74°). There were 7 (39%) patients with double curve and 11 (61%) patients with single curves. All images were carefully annotated to create the “ground truth”. A graphical user interface was used to allow the user to select two vertebral endplates to be analyzed (Figure 1). Based on the user selection, two regions of interest (ROIs) were created (Figures 2 and 3). A model (Figure 4) was then registered to the ROIs, using custom-made software, to find the location and orientation of the endplates under study (See Figure 5 for two unsuccessful registrations and Figure 6 for two successful registrations). The process was repeated for an average of 8 vertebrae per radiograph creating a database of 141 registration solutions. The data set for the experiments was divided into training and test set according to the time in which the data became available. The training set consisted of 14 radiographs from which 104 vertebral endplates were selected using the selection criteria previously discussed. The test set consisted of 4 radiographs that became available after the first group. From the second group of radiographs, 37 vertebral endplates were selected following the inclusion criteria previously discussed. Once the endplates were selected, model-to-image registrations were performed. After registration, each solution was evaluated with respect to the ground truth. If the difference in the rotation angle was greater than 3° the solution was labeled as a Bad Solution. Otherwise, the location of the registered model was assessed visually to assign one of two possible labels: Bad Results (BR) or Good Results (GR). For the training set there were 54 registration solutions labeled as BR and 50 registration solutions labeled as GR. For test set there were 25 registration solutions labeled as BR and 12 registration solutions labeled as GR. The training set was used to build three classifiers: a Support Vector Classifier (SVC), a Decision Tree Classifier (DT), and a Logistic Regression Classifier (LR). The performance of the classifiers was assessed using the test set.

256

L. Ramirez et al. / A Machine Learning Approach to Assess Changes in Scoliosis

Figure 1. Spine radiograph with user-entered landmarks (indicated with a *)

Figure 2. Region of interest around top landmark

Figure 3. Region of interest around bottom landmark

Figure 4. Model used for registration

L. Ramirez et al. / A Machine Learning Approach to Assess Changes in Scoliosis

Figure 5. Two un-successful registrations (indicated with straight lines)

Figure 6. Two successful registrations (indicated with straight lines)

257

258

L. Ramirez et al. / A Machine Learning Approach to Assess Changes in Scoliosis

3. Results This section compares the results, in testing, of the Support Vector Classifier (SVC) with those of the Decision Tree (DT) and Logistic Regression (LR) classifiers and evaluates their performance. The results of classifying the cases into Good Results (GR) and Bad Results (BR) (using the test data set) are summarized in Table 1. In terms of accuracy, the SVC outperformed the DT and LR classifiers with accuracy of 86% compared to 68% and 76%, respectively, for the DT and LR. Moreover, the SVC detected the largest percentage of cases with BR: 96%, compared to 64% of the LR and only 52% of the DT. Table 1. Classification problem: Bad Results versus Good Results. Test results with the SVC, DT, and LR classifiers on the test set. TO: True Output. CO: Classifier Output. BR: Bad Results. GR: Good Results.

TO\CO BR GR Accuracy

BR 24(96%) 4(33%)

SVC GR 1(4%) 8(67%) 86%

DT BR 13(52%) 0(0%)

GR 12(48%) 12(100%) 68%

LR BR 16(64%) 0(0%)

GR 9(36%) 12(100%) 76%

4. Discussion Results obtained from comparing classifiers with a test set showed that the support vector outperformed a decision tree and logistic regression classifiers. The classification accuracy for the SVC was 86% in testing. The classification accuracy for the DT was 68% in testing. The classification accuracy for the LR was 76% in testing. Even though, the SVC achieved a high discriminatory power to Bad Results, work on improving its discriminatory power continues because improvements in it will translate to early detection of Bad Results guaranteeing a high level of care for the patients. It was observed that 1 record in the test set was misclassified by all the classifiers. This may suggest that the misclassified record was an outlier present in the data set. Although the SVC-based method was designed for estimating the quality of model-to-image registrations of spine radiographs, the proposed approach may be useful in other contexts as well. 5. Conclusion In conclusion, it is possible to differentiate Good Results from Bad Results by using the proposed support vector classifier. This finding may be useful in identifying when an application for automatically measuring scoliosis severity requires domain expert intervention to provide new configuration settings that could improve the results 6. Acknowledgement This work benefited from economic support from the Alberta Provincial CIHR Training Program in Bone and Joint Health, NSERC, and Edmonton Orthopaedics Research Committee.

L. Ramirez et al. / A Machine Learning Approach to Assess Changes in Scoliosis

259

References [1] [2] [3] [4] [5] [6] [7]

[8]

Roach J.W., Adolescent idiopathic scoliosis, Orthop. Clin. N. Am., 1999; 30: 353-365. Khouri N., et al., Idiopathic scoliosis. Strategy, pathophysiology, and deformity analysis, EMC. Rhumatologie Orthopédie, 2004; 1: 17-44. Cobb J. R., Outline for the study of scoliosis, instructional course lectures, The American Academy of Orthopedic Surgeons, 1948; 5: 261-275. Morrissy R. T., et al. Measurement of the Cobb angle on radiographs of patients who have scoliosis. Evaluation of intrinsic error, J. Bone Joint Surg. Am, 1983; 65: 1302-1313. Vapnik V.N., “An overview of statistical learning theory,” IEEE Transactions on Neural Networks, vol. 10, no. 5, pp. 988-999, 1999. Bishop C.M., Neural Networks for Pattern Recognition. Oxford, U.K.: Claredon, 1995. Smith A.E., Nugent C. D., McClean S. I., “Evaluation of inherent performance of intelligent medical decision support systems: Utilizing neural networks as an example,” Artificial Intelligence in Medicine, vol. 27, no. 1, pp. 1–27, 2003. Cios K., Pedrycz W., Swiniarski R., Data Mining Methods for Knowledge Discovery. Boston: Kluwer Academic Publishers , 1998.

This page intentionally left blank

Chapter 6 Mathematical Modelling

This page intentionally left blank

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-263

263

7KHSRVWHULRUVNHOHWDOWKRUD[ULEYHUWHEUDO DQJOHDQGD[LDOYHUWHEUDOURWDWLRQ DV\PPHWULHV LQ DGROHVFHQWLGLRSDWKLFVFROLRVLV 5* %85:(//5. $8-/$%-& )5((0$13+ '$1*(5),(/' $$&2/( $6.,5%<)-32/$.5.35$77$028/721

&HQWUHIRU6SLQDO6WXGLHVDQG6XUJHU\1RWWLQJKDP8QLYHUVLW\+RVSLWDOV7UXVW4XHHQ¶V 0HGLFDO&HQWUH&DPSXV1RWWLQJKDP8.'HSDUWPHQWRI6SLQDO6XUJHU\5R\DO $GHODLGH+RVSLWDO$GHODLGH$XVWUDOLD 7KH8QLYHUVLW\RI/LYHUSRRO6WDIIRUGVKLUH 8QLYHUVLW\DQGWKH5R\DO/LYHUSRRO&KLOGUHQ¶V+RVSLWDO8. 'HSDUWPHQWRI 2UWKRSDHGLF6XUJHU\.LQJ¶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

264

R.G. Burwell et al. / The Posterior Skeletal Thorax

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

)LJXUH'UDZLQJRIDQRSHQHGWKRUDFLFFDJHODEHOHGWRVKRZD7DSLFDOYHUWHEUDDQGWKHORQJHVWWUXHULEVDW VLWXDWHGDERYH 7 RI ULJKWWKRUDFLF$,6

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

R.G. Burwell et al. / The Posterior Skeletal Thorax

265

)LJXUH/HIWFRQFDYHDQG FRQYH[ULEYHUWHEUDODQJOHVIURPZKLFKWRFDOFXODWHWKH 59$'>@5LJKW&RQFDYH DQGFRQ[H[ULEVSLQDODQJOHVWR76OLQH IURPZKLFK WRFDOFXODWHULEVSLQDODQJOH GLIIHUHQFH >@

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¶IRXUWKFROXPQRIVWUXFWXUDOWKRUDFLFVSLQHVXSSRUW¶>@ZLWKWKHORQJHVW ULEVDERXW 7KHFDXVHV RIWKH59$DV\PPHWULHVLVXQNQRZQ7KHDV\PPHWULHVPD\UHVXOWIURP D ULEVDGMXVWLQJSDVVLYHO\ZLWKLQWKHFRQVWUDLQWRIWKHIRXUWKFROXPQRIWKHVSLQH WR LQFUHDVLQJVSLQDOFXUYDWXUHIURPZKDWHYHUFDXVH>@DQGRU E WUXQN PXVFOH LPEDODQFH >@ DVVRFLDWHG ZLWK XSULJKW SRVWXUH DQG ELSHGDO JDLW FRQWULEXWLQJ WR WKH ULEYHUWHEUD DQJOH DV\PPHWULHV E\ ZHDNHQLQJ WKH VSLQDO URWDWLRQGHIHQGLQJV\VWHPLQELSHGDOJDLW>@LQLWLDWH ULJKWWKRUDFLF$,6>@LQ DVVRFLDWLRQZLWKWUXQNPRYHPHQWV>@

266

R.G. Burwell et al. / The Posterior Skeletal Thorax

)LJXUH/HIW7KHPHWKRGRIPHDVXULQJWKH59$WRWKH YHUWHEUDOHQGSODWH>@DQG59$'V WZR OHYHOV DERYH FXUYH DSH[SORWWHGDJDLQVW&REEDQJOHU S 5LJKW 7DEOH VKRZLQJ59$'V DERYH DQG 56$'V EHORZ FRUUHODWLRQV DQG VWDWLVWLFDO VLJQLILFDQFHVE\VSLQDOOHYHO DJDLQVWYHUWHEUDO WLOW&REEDQJOH$95DQG$97 S

S16 QRWVLJQLILFDQW

$V\PPHWULF ULE GURRSLQJ PD\ OHDG WR D ODWHUDO VSLQDO FXUYDWXUH E\WKRUDFLF YHUWHEUDH WLOWLQJWRZDUGVDGURRSLQJULEDVDUHIOH[QHXURPXVFXODUDGDSWDWLRQWRHOHYDWH WKHGURRSLQJ ULE DQG UHHVWDEOLVK V\PPHWU\ RI WKH FRVWDO EDVLV IRU ORQJLWXGLQDO PXVFOH IXQFWLRQ LQ WKH WUXQN>@ 'RHV YHUWHEUDO D[LDO URWDWLRQ DV\PPHWU\ LQ QRUPDO DQG $,6 VXEMHFWV GHWHUPLQH FXUYHODWHUDOLW\DQGPHGLDWHFXUYHSURJUHVVLRQ" 0HWKRGVDQGVXEMHFWV 5DGLRORJLFDODQGXOWUDVRXQGHYLGHQFHIURPVFROLRVLVVFKRROVFUHHQLQJVXEMHFWVVHOHFWHG E\DURXWLQHTXDQWLWDWLYHSURWRFROGXULQJZLWKWKRUDFLF7 RUWKRUDFROXPEDU 7/ $,6ZDVH[DPLQHGE\RQHREVHUYHU5*% JLUOVSRVWPHQDUFKHDOER\V PHDQ DJH \HDUV ULJKW FXUYHV OHIW FXUYHV PHDQ &REE DQJOH GHJUHHV GHJUHHV PHDQ $95 GHJUHHV GHJUHHV >@ DSLFDO YHUWHEUDO WUDQVODWLRQ WR PP 7KHXOWUDVRXQGPHWKRGXVHGZDVEULHIO\ GHVFULEHGSUHYLRXVO\ >@ 5HVXOWV $SUHOLPLQDU\DFFRXQWRIWKHILQGLQJVKDVEHHQSXEOLVKHG>@

R.G. Burwell et al. / The Posterior Skeletal Thorax

267

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

>@ >@ >@ >@ >@ >@ >@ >@

>@ >@

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

268 >@ >@

>@ >@ >@ >@ >@ >@ >@ >@ >@ >@ >@ >@ >@ >@ >@ >@ >@

>@ >@ >@

R.G. Burwell et al. / The Posterior Skeletal Thorax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sQ -+ YDQ 6PLW 7+ 7KH UROH RI GRUVDO VKHDU IRUFHV LQ WKH SDWKRJHQHVLV RI DGROHVFHQW LGLRSDWKLFVFROLRVLV ±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¶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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-269

269

3UHGLFWLRQRI WKH77.\SKRVLVLQ $GROHVFHQW,GLRSDWKLF6FROLRVLVXVLQJD 0XOWLYDULDWH5HJUHVVLRQ0RGHO 6.$'285<)&+(5,(7 + /$%(//(

(FROH3RO\WHFKQLTXHGH0RQWUpDO32%R[6XFF &HQWUH9LOOH 0RQWUHDO&DQDGD +&$ 6DLQWH-XVWLQH+RVSLWDO 5HVHDUFK&HQWHU &{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

,QWURGXFWLRQ $QDO\]LQJWKHFRURQDODQGVDJLWWDOSURILOHRIDVFROLRWLFVSLQHRQ;UD\LPDJHVLVQHFHVVDU\ IRU HYDOXDWLQJ DQG DVVHVVLQJ WKH SDWLHQW¶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

270

S. Kadoury et al. / Prediction of the T2-T12 Kyphosis in Adolescent Idiopathic Scoliosis

HYDOXDWH WKH IHDVLELOLW\ RI D PXOWLYDULDWH QRQOLQHDU SUHGLFWRU EDVHG RQ WKH YLVLEOH LQIRUPDWLRQ FROOHFWHG IURP WKH ;UD\ LPDJHV LQ RUGHU WR HVWLPDWH WKH WKRUDFLF N\SKRVLV PHDVXUHPHQWEHWZHHQWKH7DQG7YHUWHEUDHRQWKHVDJLWWDOLPDJHSODQH7KLVZRUNLV PDGH WRZDUGVDQDXWRPDWLFFODVVLILFDWLRQRIWKHVDJLWWDOVSLQDOFXUYH

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θ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Κ 7L −7 = α + I ^&07 /L7//θ 7`β + ε L

ZKHUHĮLVWKHLQWHUVHFWIWKHQRQOLQHDUUHJUHVVLRQIXQFWLRQDQGȕWKHYDULDEOHSDUDPHWHUV 7KH UHVLGXDO HUURUWHUP εL LV L εL = Κ L7−7 − I ^&07 /L7//θ 7`β

DQGWKH HPSLULFDOO\GHWHUPLQHG UHJUHVVLRQIXQFWLRQLVGHILQHGDV L I^&07 /L7//θ 7`β = β H[S− β /7//−β θ7 + β H[S− &07 L

L

L

$ GDWDEDVH FRQWDLQLQJ VFROLRWLF VSLQHV GHPRQVWUDWLQJ VHYHUDO W\SHV RI VFROLRWLF GHIRUPLWLHV ZDV XVHG WR WUDLQ WKH SURSRVHG V\VWHP 7KH GDWDEDVH ZDV VHSDUDWHG LQWR WZR SDUWV ZLWK WUDLQLQJ DQG WHVWLQJ VXEVHW RI VFROLRWLF VSLQHV 7UDLQLQJ RI WKH PRGHO ZDV SHUIRUPHG E\ FURVVYDOLGDWLRQ ZKLFK FRQVLVWV LQ GLYLGLQJ WKH WUDLQLQJ GDWD LQWR1 GLVMRLQW SDUWVRIHTXDOVL]H)RUHDFKSDUWDPRGHOLVEXLOWIURPWKH1RWKHUIROGVDQGHYDOXDWHG RQWKHUHPDLQLQJIROG7KLVSURFHGXUHZDVUHSHDWHGIRUDOO1IROGV,QRXUFDVH1 7KH ILQDOPRGHOZDVREWDLQHGXVLQJWKHHQWLUHGDWD

S. Kadoury et al. / Prediction of the T2-T12 Kyphosis in Adolescent Idiopathic Scoliosis

271

&RQVWUDLQHGN\SKRVLVPHDVXUHPHQW 2QFHWKHDQJXODUYDOXHRIWKHN\SKRVLVPHDVXUHPHQW.77LVREWDLQHGIURPWKHUHJUHVVLRQ PRGHO WKH PHDVXUHPHQW LV FRQVWUDLQHG EHWZHHQ WKH RULHQWDWLRQ θ7 DW 7 DQG WKH ' SRVLWLRQ RI WKH 7 YHUWHEUD RQ WKH VDJLWWDO LPDJH 7KH SRVLWLRQ RI 7 LV REWDLQHG E\ WKH HSLSRODU OLQH FRUUHVSRQGLQJ WR WKH ORFDWLRQ RI 7 LGHQWLILHG RQ WKH FRURQDO ;UD\ ,Q WKH FXUUHQW ZRUN WKH HSLSRODU JHRPHWU\ FDQ EH FRPSXWHG VLQFH WKH FDOLEUDWLRQ RI WKH UDGLRJUDSKLF DFTXLVLWLRQVFHQH LVNQRZQ>@)LJXUHLOOXVWUDWHVWKH SURSRVHGPHWKRGRORJ\

)LJXUH 3ULRULQIRUPDWLRQFROOHFWHGRQWKHFRURQDODQGVDJLWWDO;UD\LPDJHV

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± IRUQRUPDON\SKRWLFFXUYHVVSLQHVN\SKRVLVUDQJH± DVZHOODVIRUK\SHUN\SKRWLFFXUYHVVSLQHVN\SKRVLV!

272

S. Kadoury et al. / Prediction of the T2-T12 Kyphosis in Adolescent Idiopathic Scoliosis 7DEOH$FFXUDF\UHVXOWVIRUWKHQRQOLQHDUPXOWLYDULDWHUHJUHVVLRQPRGHO 7UDLQLQJ

+\SRN\SKRWLF

1RUPDO

+\SHUN\SKRWLF

6DPSOHVL]H 1

$FFXUDF\

'LVFXVVLRQ 7KH UHJUHVVHG EHVWILW PRGHO REWDLQHG IURP WKH H[SRQHQWLDOEDVHG HTXDWLRQ LV DEOH WR UHSOLFDWH YDULRXVW\SHVRIN\SKRWLFSURILOHVLQWKHVFROLRWLFSRSXODWLRQ:KHQFRPSDULQJWKH UHVXOWV REWDLQHG IURP WKH GLIIHUHQW JURXSV WKH SUHGLFWLYH PRGHO VHHPV WR HVWLPDWH PRUH DFFXUDWHO\ QRUPDO N\SKRWLF FXUYHV WR K\SR RU K\SHUN\SKRWLF SURILOHV 7KLV FDQ EH H[SODLQHGE\WKHVLJQLILFDQWO\ORZHUQXPEHURIWUDLQLQJGDWDDYDLODEOHIRUWKHVHWZR H[WUHPH W\SHVRISDWLHQWV 7KLVSDSHUSUHVHQWVSURPLVLQJUHVXOWVIRUDPXOWLYDULDWHUHJUHVVLRQPRGHOZKLFKLVDEOH WRSUHGLFWWKHVDJLWWDOWKRUDFLFN\SKRVLVEHWZHHQ7DQG7EXLOWRQWKHWKRUDFLF&REEDQG OXPEDUORUGRVLVPHDVXUHV$OWKRXJKWKHHVWLPDWHLVQRWSHUIHFWO\DFFXUDWHLWIDOOVZLWKLQD UHDVRQDEOH UDQJH WRDGHTXDWHO\DVVHVV WKH VDJLWWDO FXUYH RI WKH VSLQH )XWXUH GHYHORSPHQW LQFOXGHV EXLOGLQJ WKH SUHGLFWLYH PRGHO IURP DQ DXWRPDWLF GHWHFWLRQ RI WKH FRURQDO VSLQDO FXUYH DQG XVLQJVXSSRUWYHFWRUPDFKLQHV690 IRUWUDLQLQJWKHSUHGLFWLYHPRGHO>@

$FNQRZOHGJPHQWV 7KLV UHVHDUFK ZDV IXQGHG E\ WKH )RQGV 4XpEHFRLV GH OD 5HFKHUFKH VXU OD 1DWXUH HW OHV 7HFKQRORJLHV DQG 0(1725 D VWUDWHJLF WUDLQLQJ SURJUDP RI WKH &DQDGLDQ ,QVWLWXWHV RI +HDOWK5HVHDUFK

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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-273

273

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µ5HGXFHG PRELOLW\¶ ZDV SUHVHQW LQ DOO LQWHUYHQWLRQV DQG WKH FKDQJHV LQ WKH GLVFV ZLWK UHGXFHG PRELOLW\ DORQH ZHUH FRPSDUDEOH ZLWKWKRVHLQORDGHGDQGDQJXODWHGGLVFV7KLVVXJJHVWVWKDWLPSRVHGUHGXFHGPRELOLW\LVWKH PDMRUVRXUFHRIGLVFFKDQJHVDQGPD\EHDIDFWRULQGLVFGHJHQHUDWLRQLQVFROLRVLV)XUWKHU VWXGLHV DUH LQ SURJUHVV WR FKDUDFWHUL]H JHQH H[SUHVVLRQ PDWUL[ SURWHLQ V\QWKHVLV DQG FRPSRVLWLRQLQWKHVHGLVFV .H\ZRUGV,QWHUYHUWHEUDOGLVF,QYLYR*URZWK'HIRUPLW\5DWPRGHO%LRPHFKDQLFV

,QWURGXFWLRQ

$VFROLRVLVGHIRUPLW\DVPHDVXUHGE\WKH&REEDQJOHFRQVLVWVRI ZHGJLQJDV\PPHWU\RI WKH YHUWHEUDH DQG RI WKH LQWHUYHUWHEUDO GLVFV LQ DSSUR[LPDWHO\ HTXDO SURSRUWLRQV 7KH ZHGJLQJ DQG QDUURZLQJ RI WKH GLVFV LQ D VFROLRVLV FXUYH PD\ EH GXH LQ SDUW WR DOWHUHG ELRPHFKDQLFDOHQYLURQPHQW7KHSDWKRPHFKDQLVPRIWKHSURJUHVVLYHGHIRUPLW\RIERWKWKH YHUWHEUDHDQGWKHGLVFVLVSRRUO\XQGHUVWRRG7KHHYHQWXDODLPRIWKLVVWXG\LVWRGHWHUPLQH KRZLPPDWXUHLQWHUYHUWHEUDOGLVFVUHVSRQGPRUSKRORJLFDOO\PHFKDQLFDOO\DQGELRORJLFDOO\ WRFRPSRQHQWVRIWKHDOWHUHGPHFKDQLFDOHQYLURQPHQWWKDWRFFXUVLQVFROLRVLV7KHSXUSRVH RI WKH SUHVHQW VWXG\ LV WR GRFXPHQW PRUSKRORJLFDODQG ELRPHFKDQLFDO FKDQJHV LQ IRXU GLIIHUHQW PRGHOVRIDOWHUHGPHFKDQLFDOHQYLURQPHQWLQLQWHUYHUWHEUDOGLVFVRIJURZLQJUDWV

274

I.A.F. Stokes et al. / Intervertebral Disc Changes

0HWKRGV

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

)LJXUH 3KRWRJUDSK RIUDWWDLO ZLWKDSSDUDWXVLQVWDOOHGWRSURGXFH ERWK $QJXODWLRQ DQG &RPSUHVVLRQ *URXS % DW WKH LQVWUXPHQWHG LQWHUYHUWHEUDO GLVF 1RWH 7KH ULQJV ZHUH LQLWLDOO\ LQVWDOOHG RQ D VWUDLJKWWDLOZLWKDUHODWLYHDQJXODWLRQRIGHJUHHV

)LJXUH&RURQDO SODQH VHFWLRQWKURXJK PLFUR&7 LPDJH RI UDW WDLO LQ *URXS % WZR GD\V DIWHU LQVWDOODWLRQ RI WKH DSSDUDWXV 7KHVH LPDJHV ZHUH XVHG WR PHDVXUHWKHGLVFZHGJLQJDQGGLVFVSDFH /DEHOOHG GLVFV , ,QWHUYHQWDLRQ OHYHO 3 SUR[LPDO FRQWURO ' ' 'LVWDO FRQWUROV

$QLPDOVZHUHHXWKDQL]HGDIWHUZHHNV6HFWLRQVRIWKHWDLOLQFOXGLQJWKUHHYHUWHEUDH DQG GLVFV WKH LQWHUYHQWLRQ OHYHO DQG WKH DGMDFHQWGLVWDO FRQWURO ZHUH UHPRYHG IRU PHFKDQLFDOWHVWLQJ DQG D GLVF WZR OHYHOV SUR[LPDOWR WKH LQWHUYHQWLRQOHYHO DQG WKHWZR GLVFV GLVWDO WR WKH LQWHUYHQWLRQ OHYHO ZHUH UHPRYHG IRU KLVWRORJ\ DQG DOVR GDWD QRW

275

I.A.F. Stokes et al. / Intervertebral Disc Changes

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± LQQHU PLGGOHDQGRXWHU

5HVXOWV

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

)LQDOZHHN

'LIIHUHQFH

*URXS$1

*URXS%1

*URXS&1

*URXS'1

0HFKDQLFDO ,QFUHDVHG ODWHUDO EHQGLQJ VWLIIQHVV UHODWLYH WR ZLWKLQDQLPDO FRQWUROV ZDV REVHUYHG DW DOO JURXSV7UHQGVZHUHVLPLODUIRUERWKJURXSZLVHPHDQYDOXHVRIVWLIIQHVVDVPHDVXUHGDW PLQLPXPVWLIIQHVVDQGDVPHDVXUHGRYHUWKHILQLWHUDQJHRIGLVSODFHPHQWGHJUHHV 7DEOH 7KH PLQLPXP VWLIIQHVV ZDV UHFRUGHG DW DQ DQJOH FORVH WR WKH LQ YLYR YDOXH LQGLFDWLQJWKDWDQJXODWHGGLVFVKDGDGDSWHGWRWKHLPSRVHGGHIRUPLW\

276

I.A.F. Stokes et al. / Intervertebral Disc Changes

7DEOH$YHUDJHODWHUDOEHQGLQJVWLIIQHVVP1GHJUHH DWLQWHUYHQWLRQOHYHOVDQGDWGLVWDOFRQWUROOHYHOVRIIRXU JURXSV*URXS$$QJXODWLRQ *URXS%ERWK$QJXODWLRQDQG&RPSUHVVLRQ *URXS&03D&RPSUHVVLRQ DQG*URXS'5HGXFHGPRELOLW\

0LQLPXPVWLIIQHVV

*URXS$

*URXS%

*URXS&

*URXS'

Q

Q

Q

Q

Q

Q

Q

Q

Q

Q

Q

Q

Q

Q

Q

Q

LQWHUYHQWLRQOHYHO 0LQLPXPVWLIIQHVV GLVWDODGMDFHQWOHYHO )LQLWHUDQJHVWLIIQHVV LQWHUYHQWLRQOHYHO )LQLWHUDQJHVWLIIQHVV GLVWDODGMDFHQWOHYHO

+LVWRORJ\&ROODJHQFULPSLQJ $W WKH LQWHUYHQWLRQ OHYHOV RI WKH *URXS % DQJXODWHG DQG FRPSUHVVHG GLVFV WKHUH ZDV D VPDOO QRQVLJQLILFDQW GLIIHUHQFH LQ WKH DPRXQW RI FROODJHQ FULPSLQJ LQ WKH GLVF DQQXOL EHWZHHQ FRQFDYH DQG FRQYH[ VLGHV 7KLV ZDV FRQVLVWHQW ZLWK WKH FROODJHQ KDYLQJ UHPRGHOHG WR D VLPLODU VWUDLQ FRQGLWLRQ RQ HDFK VLGHRI WKHVH DQJXODWHG GLVFV 7KH FULPS SHULRGVDWWKHVHOHYHOVZDVVLJQLILFDQWO\OHVVWKDQDWWKHZLWKLQDQLPDOFRQWUROGLVFV7KLVLV FRQVLVWHQW ZLWK WKH IDFW WKDW WKH LQWHUYHQWLRQ OHYHO GLVFV ZHUH IL[HG ZLWK WKH DSSDUDWXV LQ SODFHDQJXODWLRQDQGFRPSUHVVLRQSUHVHQW 7DEOH 0HDQDQG6WDQGDUG'HYLDWLRQ RIFROODJHQFULPSOHQJWKDUELWUDU\XQLWV DQGFULPSDQJOHGHJUHHV LQ JURXSV RI DQLPDOV *URXS $ $QJXODWLRQ *URXS % ERWK $QJXODWLRQ DQG &RPSUHVVLRQ *URXS & 03D &RPSUHVVLRQ DQG*URXS'5HGXFHGPRELOLW\ DWWKHLQWHUYHQWLRQSUR[LPDODGMDFHQWDQGWZRGLVWDOGLVFV 1RWH PRUHFULPSHGFROODJHQKDVVKRUWHUFULPSSHULRGDQGJUHDWHUFULPSDQJOH ,QWHUYHQWLRQOHYHOGLVF

7ZR'LVWDO

&RQYH[

3UR[LPDO &RQFDYH

&RQYH[

&RQFDYH

&RQYH[

&RQFDYH

&ULPS/HQJWK DUELWDU\

&ULPS$QJOH GHJUHHV

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µEHQWWDLO¶FRQILJXUDWLRQLQDQJXODWHGGLVFV

I.A.F. Stokes et al. / Intervertebral Disc Changes

277

7KHGLVFVDWWKHOHYHOLPPHGLDWHO\GLVWDOWRWKHH[SHULPHQWDOLQWHUYHQWLRQOHYHODVZHOO DV GLVFV WZR GLVWDO DQG SUR[LPDO WR WKH H[SHULPHQWDO LQWHUYHQWLRQ OHYHOV ZHUH XVHG DV ZLWKLQDQLPDO FRQWUROV ,W VKRXOG EH QRWHG WKDWLQWKH DQJXODWHGWDLOHG *URXSV $DQG % WKHUHZHUHFRPSHQVDWLQJFXUYHV)LJXUH WKDWFRXOGUHVXOWLQVRPHZHGJLQJRIWKHVHGLVFV HVSHFLDOO\DWWKHDGMDFHQWGLVWDOOHYHO µ5HGXFHGPRELOLW\¶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

This page intentionally left blank

Chapter 7 Education

This page intentionally left blank

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-281

281

.QRZOHGJHDERXW,GLRSDWKLF6FROLRVLV $PRQJ6WXGHQWVRI3K\VLRWKHUDS\ '&,$=<16.,.&=(51,&.,-'850$/$ 'HSDUWPHQWRI0HGLFDO5HKDELOLWDWLRQ0HGLFDO8QLYHUVLW\RI6LOHVLD =LRORZD6W.DWRZLFH3RODQG UHK#JFPSO $EVWUDFW 7KH DLP RI WKH VWXG\ ZDV WR GHWHUPLQH WKH OHYHO RI EDVLF NQRZOHGJH DERXW LGLRSDWKLFVFROLRVLV ,6 DPRQJVWXGHQWVRISK\VLRWKHUDS\7KHVWXG\LQFOXGHGVWXGHQWVRI 0HGLFDO8QLYHUVLW\RI6LOHVLD)DQG0DJHGPHDQ DWWHQGLQJWKHUG \HDU RI D VW GHJUHH RI SK\VLRWKHUDS\ $OO VWXGHQWV KDG FUHGLWV LQ NLQHVLRWKHUDS\ LQFOXGLQJ PHWKRGV RI FRQVHUYDWLYH WUHDWPHQW RI ,6 6WXGHQWV ZHUH H[DPLQHG XVLQJ D TXHVWLRQQDLUH FRPSULVLQJJHQHUDONQRZOHGJHRI,6TXHVWLRQVUHODWHGWRVDJLWWDOSODQHFRUUHFWLRQLQIOXHQFH RI YDULRXVSK\VLFDODFWLYLWLHV RQ,6DQGNQRZQ PHWKRGV RI FRQVHUYDWLYHWUHDWPHQWRI VWXGHQWV FRQVLGHUHG ,6 DV ' GHIRUPLW\ RI WKRVH TXHVWLRQHG ZRXOG GLDJQRVH ,6 ZKHQ WKH &REE DQJOH UHDFKHV $OO VWXGHQWV DJUHHG WKDW WKH DHWLRORJ\ RI ,6 UHPDLQV XQNQRZQ FRQVLGHUHG IRUFLEOH H[WHQVRU\ H[HUFLVHV RI EDFN DV IDYRXUDEOH LQ ,6 4XHVWLRQHG VWXGHQWV PRVWO\ SUHIHUUHG VZLPPLQJ \RJD DQG PDUWLDO DUWV DVEHQHILFLDOWR,67KH PHWKRGVRIFRQVHUYDWLYHWUHDWPHQWZKLFKZHUHNQRZQEHVW ZHUH /HKQHUW6FKURWK:HLVV .ODSS 0DMRFK DQG 'RERVLHZLF] 7KH FRQFOXVLRQV LQGLFDWH WKDW WKH DYHUDJH OHYHO RI NQRZOHGJH RI LGLRSDWKLF VFROLRVLV DPRQJ VWXGHQWV RI SK\VLRWKHUDS\ LV XQVDWLVIDFWRU\ GHVSLWH WKH HGXFDWLRQ SURJUDPPHLQFOXGLQJWKH626257JXLGHOLQHV(GXFDWLRQLQWKHILHOGRIVFROLRVLVVKRXOGEH FRPSUHKHQVLYHDQGPHHWFRQWHPSRUDU\JXLGHOLQHVDQGVWDQGDUGV .H\ZRUGV LGLRSDWKLFVFROLRVLVHGXFDWLRQFRQVHUYDWLYHWUHDWPHQW

,QWURGXFWLRQ

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

$LPRIWKHVWXG\

7KH SXUSRVH RI WKH VWXG\ ZDV WR GHWHUPLQH WKHOHYHO RI EDVLF NQRZOHGJH DERXW LGLRSDWKLF VFROLRVLVDPRQJVWXGHQWVRISK\VLRWKHUDS\

282

D. Ciazynski et al. / Knowledge About Idiopathic Scoliosis Among Students of Physiotherapy

0DWHULDODQGPHWKRG

7KHVWXG\LQFOXGHGVWXGHQWVDWWKH 0HGLFDO8QLYHUVLW\RI6LOHVLD)DQG0DJHG PHDQ UDQGRPO\VHOHFWHG DQGLQ WKHUG \HDU RIWKHVW GHJUHH RISK\VLRWKHUDS\ VWXGLHV $OO VWXGHQWV ZHUH FUHGLWHG LQ NLQHVLRWKHUDS\ LQFOXGLQJ PHWKRGV RI FRQVHUYDWLYH WUHDWPHQW RI ,6 6WXGHQWV ZHUH H[DPLQHG ZLWK D SURSULHWDU\ DQRQ\PRXV TXHVWLRQQDLUH FRPSULVLQJ JHQHUDONQRZOHGJHRI,6 VDJLWWDOSODQHFRUUHFWLRQLQ,6 LQIOXHQFHRIYDULRXVSK\VLFDODFWLYLWLHVRQ,6 NQRZQPHWKRGVRIFRQVHUYDWLYHWUHDWPHQW RI,6RSHQTXHVWLRQ

5HVXOWV

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

D. Ciazynski et al. / Knowledge About Idiopathic Scoliosis Among Students of Physiotherapy

)LJXUH 3UHIHUHQFH RI VSRUWVLQ PDQDJHPHQWRI,6

)LJXUH.QRZQDQG SUHIHUUHGPHWKRGVRIFRQVHUYDWLYH WUHDWPHQWLQ,6

283

284

D. Ciazynski et al. / Knowledge About Idiopathic Scoliosis Among Students of Physiotherapy

'LVFXVVLRQ

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± SDWLHQWV DQG SDUHQWV )XUWKHUPRUH PRUH ZLGHO\ DFFHVVLEOH SRSXODU OLWHUDWXUH RI VXEMHFW ZRXOGEHKLJKO\DSSUHFLDWHG $V JHQHUDONQRZOHGJHPRVWVWXGHQWV DJUHHGZLWKWKH'QDWXUHRIVFROLRWLFGHIRUPLW\ +RZHYHUPRUHWKDQRQHWKLUGRITXHVWLRQHGGLGQRWNQRZWKHFRUUHFWFULWHULRQRIGLDJQRVLV RI VFROLRVLV 7KH 656 UHFRPPHQGDWLRQ RI RI &REE DQJOH LV FRQVLGHUHG DV DQ LQWHUQDWLRQDOVWDQGDUGDQGVKRXOGEHNQRZQWRDQ\SK\VLRWKHUDSLVW >@ ([DPLQLQJWKH VWXGHQWVDERXWSUHYDOHQFHFRQVLGHUHGIRUFLEOHH[WHQVLRQH[HUFLVHVRIWKH EDFNDVDQDFWLYLW\ZKLFKVXSSRUWVFRUUHFWLRQRI,6 $WSUHVHQWPRVWDXWKRUVDJUHHWKDWWKLV NLQG RI WUDLQLQJ QRW RQO\ GRHV QRW KHOS WR RYHUFRPH VFROLRVLV EXW PD\ DJJUDYDWH FXUYH SURJUHVVLRQDQGVKRXOGEHDYRLGHG 3DWKRPHFKDQLVPVRI WKH GHYHORSPHQWRI,6SRLQWVRXW WKDW DQ LQLWLDO WKRUDFLF FXUYH LV LQGXFHG DW WKH DSH[ E\ ORFDO ORUGRWLVDWLRQ FDXVHG E\ GLVSURSRUWLRQ EHWZHHQ WKHDQWHULRUDQG SRVWHULRU FROXPQ RI WKH VSLQH 7KLV SRLQW RI YLHZ HPSKDVL]HVWKHLPSRUWDQFHRIVDJLWWDOSODQHFRUUHFWLRQDQGSUHVHUYDWLRQRUUHEXLOWRIQRUPDO WKRUDFLFN\SKRVLV>@ ,Q D TXHVWLRQ UHJDUGLQJ WKH LQIOXHQFH RI YDULRXV VSRUWLQJ DFWLYLWLHV RQ LGLRSDWKLF VFROLRVLV UHVXOWHG LQ VXEVWDQWLDO GLIIHUHQFH RI RSLQLRQ 2QO\ VZLPPLQJ ZDV FRQVLGHUHG DV KDUPOHVV DQG SRVLWLYHO\ DIIHFWLQJ VFROLRVLV ,QWHUHVWLQJO\ HQRXJK UHYLHZ RI WKH OLWHUDWXUH UHYHDOVWKH QHHGRIFRQVHQVXVUHJDUGLQJWKHHIIHFWRIVZLPPLQJDQGRWKHUVSRUWVRQVDJLWWDO SODQH >@ 1RZDGD\V ZKHQ VHGHQWDU\ VW\OH RI OLIH WDNHV RQ WKH SURSRUWLRQV RI FLYLOLVDWLRQ LVVXH WKHUDSLVWV FDQQRW DIIRUG VXFK D GLVVRQDQFH LQ UHFRPPHQGDWLRQV *XLGHOLQHVFRQFHUQLQJYDULRXVVSRUWDFWLYLWLHVVKRXOGEHVSHFLILHGLQYLHZRIVFROLRVLVDQG WKHQ LQGLYLGXDOO\ PRGLILHG LQ UHVSHFW RI SDUWLFXODU SDWLHQW 3K\VLFDO DFWLYLW\ DQG PDLQWHQDQFHRIJHQHUDOILWQHVVLVLPSRUWDQWHLWKHUIRUVFROLRWLFVDQGKHDOWK\SHRSOH 0HWKRGV RI FRQVHUYDWLYH WUHDWPHQW RI VFROLRVLV PHQWLRQHG E\ TXHVWLRQHG VWXGHQWV UHIOHFWHG WKH SURJUDP RI HGXFDWLRQ WKHQ DJDLQ JHQHUDO DYDLODELOLW\ RI FRQWHPSRUDU\ OLWHUDWXUHRQWKHVXEMHFW 6WXGHQWVVHHPWRNQRZDERXWDYDULHW\RIWUHDWPHQWPHWKRGVEXW RQO\DVPDOOSURSRUWLRQ RIWKHVHWKHUDSLHVKDGSURYHQ UDGLRORJLFDOHYLGHQFH ,WVKRXOGEH UHFRJQLVHGDVDIDYRXUDEOHSRLQWWKDWWKHPRVWSRSXODURISUHIHUUHGWKHUDSLHVXVHGPHWKRGV EDVHG RQ WKH ' FRUUHFWLRQ RI WKH VSLQH /HKQHUW6FKURWK:HLVV DQG 'RERVLHZLF] ,JQRUDQFH RI NQRZOHGJHRI WKH 0HWKRGH/\RQDLVH6LGH6KLIWDQG6,5 LVVWULNLQJHVSHFLDOO\ LQYLHZRI WKHLU UHFRPPHQGDWLRQE\626257JXLGHOLQHV>@ 7KH TXHVWLRQQDLUH GLG QRW LQFOXGH DQ\ TXHVWLRQV UHODWLQJ WR EUDFH WUHDWPHQW ZKLFK UHTXLUHVIXUWKHULQYHVWLJDWLRQ

&RQFOXVLRQV 7KH DYHUDJH OHYHO RI NQRZOHGJH RI LGLRSDWKLF VFROLRVLV DPRQJ VWXGHQWV RI SK\VLRWKHUDS\ LV XQVDWLVIDFWRU\ GHVSLWH WKH HGXFDWLRQ SURJUDPPH LQFOXGLQJ 626257JXLGHOLQHV

D. Ciazynski et al. / Knowledge About Idiopathic Scoliosis Among Students of Physiotherapy

285

(GXFDWLRQLQWKH ILHOGRIVFROLRVLVVKRXOGEHERWKZLGH UDQJLQJ DQGFRQVLVWHQWZLWK FRQWHPSRUDU\ VWDQGDUGV

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

This page intentionally left blank

Chapter 8 Treatment of Scoliosis

This page intentionally left blank

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-289

289

Thoracoplasty in the Surgical Treatment of Adolescent Idiopathic Scoliosis T. GREGGI, G. BAKALOUDIS, F. LOLLI, M. DI SILVESTRE, A. CIONI, S. GIACOMINI, G. BARBANTI BRODANO, F. VOMMARO, K. MARTIKOS, P. PARISINi Spine Surgery Department, Istituto Ortopedico Rizzoli, Bologna ,Italy Abstract. A consecutive series of 40 adolescents surgically treated between 1998-2001, by posterior spinal fusion and thoracoplasty were compared with a similar group of 40 adolescents treated in the same period by posterior only segmental fusion. Clinical and radiographic analysis was performed, including the SRS-30 questionnaire and Pulmonary Function Tests (PFT). Minimum five years follow-up was requested. No statistical differences were found between the two groups in PFT’s both pre-operatively and at latest follow up. Our findings suggest that thoracoplasty did not adversely affected long-term PFT’s in AIS patients treated by posterior spinal fusion alone.

1.

Introduction

The primary goal of surgical treatment in adolescent idiopathic scoliosis (AIS) remains the arrest of further curve progression by obtaining a solid arthrodesis mass, long-term balance of the spine in both the sagittal and coronal planes, and preservation of the maximum number of motion segments. Several additional factors, e.g., safety, cost, and morbidity, are important in the surgical decision-making. In recent years, with the advent of modern third-generation segmental posterior instrumentation, in particular pedicle screws only constructs, a significant deformity correction is also desired by both the physician and the patient, whereas preservation or enhancement of pulmonary function is a strong consideration for thoracic curves [1-5]. The association between a spinal deformity and pulmonary impairment has been widely reported [6-13], with more severe curves (>100°) considered to be responsible for a significant decrease in clinical pulmonary function. A recent multicenter study on 631 AIS patients found a moderate or severe pulmonary impairment in association with thoracic curves of <50°, showing that some patients with adolescent idiopathic scoliosis may have clinically relevant pulmonary impairment that is out of proportion with the severity of the spinal deformity [14]. Posterior spinal arthrodesis with thoracoplasty and an open anterior approach, with respect to a posterior only fusion, were found to have a deleterious effect on pulmonary function for as long as five years postoperatively and chest cage preservation was recommended to maximize both absolute and percent-predicted pulmonary function values after surgical treatment of adolescent idiopathic scoliosis [15]. More recently, both anterior open approaches and thoracoplasty were the only variables found to be related to a clinically significant reduction in the predicted 2-year pulmonary function in surgically treated AIS patients. The magnitude of the effects of both these variables, however, was considered modest [16].

290

T. Greggi et al. / Thoracoplasty in the Surgical Treatment of Adolescent Idiopathic Scoliosis

The aim of the present study was to compare two similar groups of adolescents surgically treated for their spinal deformity, the first by means of posterior only segmental fusion (PSF), the second by posterior spinal fusion and thoracoplasty (PSF+T), focusing on the long-term effects of thoracoplasty in the surgical treatment of adolescent idiopathic scoliosis. 2.

Materials and Method

A consecutive series of 40 patients with main thoracic AIS curves (Lenke type 1, 2, 3, and 4), surgically treated between 1998 - 2001 at one institution by PSF+T were compared with a similar group of 40 adolescents treated in the same period by PSF alone. Inpatient and outpatient charts were used for the collection of demographic data, and annotation of any medical and surgical-related complications, including revision surgeries. The Lenke surgical classification of AIS [17] was used to describe curve patterns. Radiographic evaluation on standing postero-anterior and lateral films on long-cassette (90x30 cm) was performed, including Cobb measurements [18] of the major thoracic (MT) curve, and thoracic kyphosis (T5–T12), both preoperatively and postoperatively, and at the latest follow up visit. A radiographic Rib Hump (RH) assessment (Fig.1), as proposed by Potter [19], was also performed. On the final visit, the SRS-30 questionnaire was administered, and a Pulmonary Function Test (PFT) evaluation was performed. A minimum five years’ follow-up was requested for inclusion in the study. During the period considered for the current investigation the same surgical team (three different surgeons) performed all surgeries, with indication for thoracoplasty being a clinically relevant rib hump (i.e > 15° on the scoliometer measurement), or a particular concern of such deformity from the patient or family. Statistical analysis was performed using the t-test (paired and unpaired), the Wilcoxon test for non-parametric paired analysis, and the Mann-Whitney test for nonparametric unpaired analysis. Results are expressed as the mean (SD), with a P value < 0.05 considered as being statistically significant.

Fig. 1 Diagram showing the measurement technique for assessing the RH deformity. The RH is the linear distance between the left and right posterior rib prominences at the apex of the rib deformity on a lateral radiograph.

T. Greggi et al. / Thoracoplasty in the Surgical Treatment of Adolescent Idiopathic Scoliosis

3.

291

Results

We were able to review the entire series at an average clinical follow of 6.2 years (1.3). There were no statistically significant differences between the two groups concerning gender, age (PSF+T:16.3 years vs PSF: 15.2 years), Lenke’s curve type distribution, and Cobb’s preoperative main thoracic (MT) curve magnitude (PSF+T: 66° vs PSF: 63°), whereas both final MT percent correction (PSF+T: 53.03% vs PSF: 51.35%; p<0.03) and RH absolute correction (PSF+T: -2.1 cm vs PSF: -1.5; p<0.01) were superior in the thoracoplasty group (Table 1). We found no statistically significant differences between the two groups in terms of sagittal contour, with thoracic kyphosis (T5–T12) angle similar in each group before surgery (PSF+T 35.32° vs PSF 35.22°), immediate postoperative (26° vs 29.3°), and at final follow-up evaluation (28.4° vs 32.4°). Table 1 Gender (M/F) Age (years) Lenke’s distribution Preoperative main thoracic Cobb Follow-up main thoracic Cobb Percent overall correction Preoperative kyphosis (T5-T12) Follow-up kyphosis (T5-T12) Preoperative Rib hump (cm) Postoperative Rib hump (cm) Overall Rib hump correction (cm)

PSF+T group 6M/34F 16.3 (2) 25 “1”/10 “2”/5 “3” 66 (14) 31 (11.2) 53.03 (12.6) 35.32 (10.1) 28.4 (9.8) 3.45 (0.44) 1.69 (0.77) -2.1 (0.9)

PSF group 5M/35F 15.2 (1.9) 29 “1”/8 “2”/3 “3” 63 (13) 35 (13) 51.35 (12.8) 35.22 (12.5) 32.4 (10.6) 2.96 (0.63) 1.91 (0.4) - 1.5 (1.1)

P n.s n.s n.s n.s n.s n.s n.s n.s n.s n.s < 0.01

With regards to PFT’s, in the PSF+T group both the absolute values of forced vital capacity was unchanged, from 2.87 to 3.1 L (p = 0.16), and those of forced expiratory volume in one second from 2.39 to 2.60 L (p = 0.36), in the pre-operative and last followup evaluation. In the PSF group the forced vital capacity increased from 2.83 to 3.34 L [p < 0.0001] and forced expiratory volume in one second increased from 2.41 to 2.84 L [p < 0.0001]), showing nevertheless no statistical differences both pre-operatively and at latest follow up when the two groups were compared (Table 2). At the latest follow-up visit, SRS-30 scores did not show any statistical differences between the two groups (total score PSF+T: 4.1 vs PSF:4.3; n.s) (Table 2). Table 2 Preoperative FVC (L)/ FVC % Preoperative FEV1 (L)/ FEV1 % Follow-up FVC (L)/ FVC % Follow-up FEV1 (L)/ FEV1 % Follow-up vs Pre-operative FVC (L)/ FVC % Follow-up vs Pre-operative FEV1 (L)/ FEV1 % SRS pain SRS self-image SRS function SRS mental health SRS satisfaction SRS total score

PSF+T group 2.87 (0.75) / 85% (15) 2.39 (0.48) / 82% (12) 3.1 (0.6) / 83% (14) 2.60 (0.36) / 80% (11.5) 4.16 (0.65) 3.84 (0.53) 3.54 (0.71) 4.02 (0.35) 4.3 (0.75) 4.1 (0.25)

PSF group 2.83 (0.8) / 84% (14) 2.41 (0.7) / 80% (13) 3.34 (0.5) / 87% (18) 2.84 (0.4) / 83% (17) < 0.0001 < 0.0001 4.23 (0.54) 3.46 (0.71) 3.25 (0.36) 3.63 (0.46) 4.5 (0.29) 4.3 (0.30)

P n.s n.s n.s n.s n.a n.a n.s n.s n.s n.s n.s n.s

No fatal complications or neurologic injuries, either acute or delayed deep wound infections were observed in this case series. In the PSF+T group 3 surgery-related

292

T. Greggi et al. / Thoracoplasty in the Surgical Treatment of Adolescent Idiopathic Scoliosis

complications (proximal hook disengagement) in 3 patients (7.5%) required 2 revision surgeries in 2 patients (at 3 ½, and 5 years respectively from the index procedure), whereas post-operative thoracoplasty-related pulmonary complications were encountered in 10 patients (moderate pleural effusion in 7, pneumonia secondary to moderate atelectasis in 2, pneumothorax in 1), requiring chest tube placement in 3 patients. In the PSF group a revision surgery with complete removal of the instrumentation was performed in a 19-year-old female patient due to persistent late operative site pain; intra-operative cultures were negative, 4 years after the index procedure. Three post-operative medical complications were observed in this latter group (1 acute cholecistitis, a superior mesenteric artery syndrome, a moderate pneumonia in 1) that did not require any invasive procedure and healed uneventfully by conservative treatment. 4.

Conclusions

According to our findings thoracoplasty did not adversely affect long-term PFT’s in AIS patients treated by posterior spinal fusion alone, as suggested by previous reports. A relatively high incidence of peri-operative complications were observed in the thoracoplasty group when compared to the posterior only fusion group. A trend towards better coronal plain correction and rib hump amelioration was found, not clearly reported by a self-assessment disease specific questionnaire. References [1] [2] [3] [4] [5] [6] [7] [8] [9]

[10] [11] [12] [13] [14] [15]

Bridwell K Surgical Treatment of Idiopathic Adolescent Scoliosis. Spine 24 (1999) 2607-2616. Lenke LG Betz R.et al., Spontaneous Lumbar Curve Coronal correction After Selective Anterior or Posterior Thoracic Fusion in Adolescent Idiopathic Scoliosis. Spine 24 (1999) 1663-1672. Haher TR, Merola A, et al., Metaanalysis of surgical outcome in adolescent idiopathic scoliosis. A 35year English literature review of 11,000 patients. Spine 20 (1995) 1575–1584. Kim YJ, Lenke LG, et al., Comparative Analysis of Pedicle Screw Versus Hybrid Instrumentation in Posterior Spinal Fusion of Adolescent Idiopathic Scoliosis. Spine 31 (2006) 291-298. Suk SI, Lee CK, et al., Segmental pedicle screw fixation in the treatment of thoracic idiopathic scoliosis. Spine 20 (1995) 1399-1405. Aaro S, Ohlund C, Scoliosis and pulmonary function. Spine 9 (1984) 220–222. Leong JC, Lu WW, et al., Kinematics of the chest cage and spine during breathing in healthy individuals and in patients with adolescent idiopathic scoliosis. Spine 24 (1999) 1310–1315. Vedantam R, Crawford AH, The role of preoperative pulmonary function tests in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion. Spine 22 (1997) 2731–2734. Vedantam R, Lenke LG, et al., A prospective evaluation of pulmonary function in patients with adolescent idiopathic scoliosis relative to the surgical approach used for spinal arthrodesis. Spine 25 (2000) 82–90. Wood KB, Schendel MJ, et al., Thoracic volume changes in scoliosis surgery. Spine 21 (1996) 718–723. Weinstein SL, Zavala DC, Ponseti IV, Idiopathic scoliosis: long-term follow-up and prognosis in untreated patients. J Bone Joint Surg Am 63 (1981) 702–712. Upadhyay SS, Mullaji AB, et al., Relation of spinal and thoracic cage deformities and their flexibilities with altered pulmonary functions in adolescent idiopathic scoliosis. Spine 20 (1995) 2415–2420. Kearon C, Viviani GR, et al., Factors determining pulmonary function in adolescent idiopathic thoracic scoliosis. Am Rev Respir Dis 148 (1993) 288–294. Newton PO, Faro FD et al., Results of Preoperative Pulmonary Function Testing of Adolescents with Idiopathic Scoliosis. A Study of Six Hundred and Thirty-one Patients. J Bone Joint Surg [Am] 87 (2005) 1937-1946. Kim YJ Lenke LG et al., Prospective evaluation of pulmonary function in adolescent idiopathic scoliosis relative to surgical approach: minimum 5-year follow-up. J Bone Joint Surg [Am] 87 (2005) 1534-1541.

T. Greggi et al. / Thoracoplasty in the Surgical Treatment of Adolescent Idiopathic Scoliosis [16] [17] [18] [19]

293

Newton PO Perry A et al, Predictors of Change in Postoperative Pulmonary Function in Adolescent Idiopathic Scoliosis: A Prospective Study of 254 Patients. Spine 17 (2007) 1875-1882. Lenke LG Betz R Harms J, et al., Adolescent idiopathic scoliosis: a new classification to determine extent of spinal arthrodesis. J Bone Joint Surg [Am] 83A (2003) 1169–1181. Cobb JR. Outline for the study of scoliosis. AAOS Instructional Course Lecture 5 (1948)261-275. Potter BK Kuklo TR Lenke LG Radiographic Outcomes of Anterior Spinal Fusion Versus Posterior Spinal Fusion With Thoracic Pedicle Screws for Treatment of Lenke Type I Adolescent Idiopathic Scoliosis Curves. Spine 30 (2005) 1859-1866.

294

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-294

3UHOLPLQDU\9DOLGDWLRQRI&XUYH3URJUHVVLRQ 0RGHOIRU%UDFH7UHDWPHQW (/28'+,// (3$5(17 -5$62-0$+22'0025($8'+(''(1

&DSLWDO+HDOWK *OHQURVH5HKDELOLWDWLRQ+RVSLWDO6LWH $YH(GPRQWRQ$%&DQDGD7*% 'HSDUWPHQWRI6XUJHU\8QLYHUVLW\RI$OEHUWD (GPRQWRQ$%&DQDGD7*( 'HSDUWPHQW RI 5HKDELOLWDWLRQ0HGLFLQH 8QLYHUVLW\ RI$OEHUWD(GPRQWRQ$%&DQDGD 7*(

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¶VVNHOHWDOPDWXULW\&REEDQJOHPHDVXUHPHQWSDWLHQW¶VPRWLYDWLRQDQGWKHULVNRI SURJUHVVLRQ >@ ,Q 1RUWK $PHULFD FXUYHV OHVV WKDQ DUH JHQHUDOO\ QRW WUHDWHG EXW PRQLWRUHGXQWLOVNHOHWDOPDWXULW\ $FFRUGLQJWR6FROLRVLV5HVHDUFK6RFLHW\FXUYHVRI WRLQDJURZLQJFKLOGDUHFRQVLGHUHGIRURUWKRWLFEUDFLQJ7KHJRDORIEUDFHWUHDWPHQWLV WR VWRSFXUYHSURJUHVVLRQ 6XUJHU\LVWKHILQDORSWLRQIRUWUHDWLQJVFROLRVLV 7REHHIIHFWLYH VXUJHRQV DQG RUWKRWLVWV VXJJHVW WKH EUDFH PXVW EH ZRUQ IRU XS WR KRXUV SHU GD\ >@ +RZHYHU WKH ZHDU KRXU LV QRW EDVHG RQ H[SHULPHQWDO GDWD LW LV EDVHG RQ UHVHDUFKHUV¶ UHSRUWV>@WKDWWKHPRUHWKHSDWLHQWZHDUVWKHEUDFHDQGWKH EHWWHULV WKHUHVXOW

E. Lou et al. / Preliminary Validation of Curve Progression Model for Brace Treatment

295

$ W\SLFDO EUDFH FDQGLGDWH LV D \HDUROG JLUO ZKR LV DW D VWDJH WKDW VKH SD\V FORVH DWWHQWLRQ WR KHU DSSHDUDQFH DQG GRHV QRW ZDQW WR EH GLIIHUHQW WKDQ KHU SHHUV +RZHYHU ZHDULQJ D EUDFH LV UHVWULFWLYH XQFRPIRUWDEOH DQG GUDZV XQZDQWHG DWWHQWLRQ LW DIIHFWV SDWLHQWV¶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¶VDWWHQWLRQ +RZHYHUGXULQJWKLVVWXG\RXUPRQLWRUV\VWHPZDVRQO\DEOH WR ORJ PRQWK GDWD ZLWKRXW SDWLHQWV¶ LQWHUDFWLRQ 6LQFH EUDFH WUHDWPHQW LV D ORQJ WHUP FRPPLWPHQWHDUO\SUHGLFWLRQRIWUHDWPHQWRXWFRPHPD\KHOSVXUJHRQVWRFKDQJHWUHDWPHQW SURWRFRO PRUH DSSURSULDWHO\ $ SUHGLFWLRQ PRGHO RI EUDFH WUHDWPHQW RXWFRPHV KDV EHHQ GHYHORSHG>@EDVHGRQ$,6SDWLHQWV \HDUV 7KHFXUYHSURJUHVVLRQPRGHOLV &XUYH 3URJUHVVLRQ GHJUHHV 3HWHUVRQ 5LVN 4XDOLW\ 4XDQWLW\ 4XDQWLW\ 4XDOLW\ 7KHULVNVFRUHZDVFDOFXODWHGEDVHGRQ3HWHUVRQ¶VULVNRISURJUHVVLRQIRUPXODZKHQWKH EUDFH ZDV SUHVFULEHG 7KH DJH WKUHVKROG IRU PDOHV ZDV LQFUHDVHG E\ \HDUV RYHU WKH IHPDOHWKUHVKROG LQ3HWHUVRQ VULVNVFRUHDVPDOHVSK\VLFDOO\PDWXUHODWHUWKDQIHPDOHV 7KH TXDOLW\RIEUDFHZHDUZDVDVVHVVHGDVDFRQWLQXRXVYDULDEOHUHODWLYHWRWKHSUHVFULEHGORDG OHYHOV DQGWKHTXDQWLW\ RI EUDFH ZHDU ZDV GHWHUPLQHG E\ KRZ PDQ\ KRXUV SHU GD\ RU WKH SURSRUWLRQRIWKHSUHVFULEHGZHDUWLPH WKDWWKHVXEMHFWVZRUHWKHLUEUDFHV

2EMHFWLYH 7KLV VWXG\ ZDV WR HYDOXDWH WKH DFFXUDF\ RI WKH SUHGLFWLRQ PRGHO RI WKH EUDFH WUHDWPHQW RXWFRPHVEDVHGRQWKHULVNSURJUHVVLRQDQGEUDFHXVDJH

296

E. Lou et al. / Preliminary Validation of Curve Progression Model for Brace Treatment

0DWHULDOV 0HWKRGV 6L[QHZEUDFHVXEMHFWV)0 DJH\HDUV&REEZKRZHUHSUHVFULEHGD 7/62 W\SH RIEUDFH ZHUH UHFUXLWHG LQWR WKLV VWXG\ $OO VXEMHFWV VLJQHG WKH FRQVHQW IRUP EHIRUHWKH\SDUWLFLSDWHGLQWRWKLVVWXG\7KHVHOHFWLRQFULWHULDIROORZHGWKH656EUDFHVWXG\ JXLGHOLQHV 7KH &REE DQJOH RI WKH WUHDWHG FXUYH DW SUHEUDFH DQG LQEUDFH DW WLPH RI PRQLWRULQJZHUH±R DQG ±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

)LJXUH%UDFH0RQLWRU6\VWHP

)LJXUH %UDFH0RQLWRUHPEHGGHGLQVLGHDEUDFHZLWKRXWSDWLHQWLQWHUDFWLRQ

5HVXOWV $OOVXEMHFWV ZHUHIROORZHG IRUDPLQLPXPRI \HDUVEH\RQGILQLVKLQJEUDFHWUHDWPHQWRU XQWLOVXUJHU\ 7KH3HWHUVRQULVNWKHTXDOLW\DQGTXDQWLW\RIWKHEUDFHXVDJH RIHDFKVXEMHFW GXULQJPRQLWRUZDVVKRZQLQWDEOH

E. Lou et al. / Preliminary Validation of Curve Progression Model for Brace Treatment

6XEMHFW

*HQGHU

3HWHUVRQULVN

4XDOLW\

4XDQWLW\

) ) ) 0 ) )

297

7DEOH6XPPDU\RIWKHULVNRISURJUHVVLRQTXDOLW\DQGTXDQWLW\PHDVXUHPHQW

7DEOH VKRZHG WKH SUHGLFWLRQ UHVXOWV DQG WKH DFWXDO EUDFH WUHDWPHQW RXWFRPHV DIWHU WKH WUHDWPHQW$PRQJWKHVHVXEMHFWVVXEMHFWKDGKDGDVXUJHU\ZKHQKHUFXUYHUHDFKHG GHJUHHV 7KH PD[LPXP GLIIHUHQFH EHWZHHQ WKH PRGHO DQG WKH DFWXDO YDOXHV ZHUH GHJUHHV 6XEMHFW

,QLWLDO&REE DQJOH

,QEUDFH&REEDQJOH

3UHGLFWHG &XUYH SURJUHVVLRQ

$FWXDOFXUYH FKDQJHV

7DEOH 7KHSUHGLFWLRQUHVXOWVYHUVXVWKHDFWXDOFXUYHFKDQJHV

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

&RQFOXVLRQV 7KH SUHGLFWLRQ PRGHO GHPRQVWUDWHG WKDW LW LV SRVVLEOH WR SUHGLFW EUDFH WUHDWPHQW RXWFRPH XVLQJTXDOLW\TXDQWLW\RIEUDFHXVDJHDQGDULVNSURJUHVVLRQIDFWRU $FNQRZOHGJPHQWV 7KLVSURMHFWZDVIXQGHGE\WKH6WROOHU\&KLOGUHQ V+RVSLWDO)RXQGDWLRQ5HVHDUFK*UDQW

298

E. Lou et al. / Preliminary Validation of Curve Progression Model for Brace Treatment

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±\HVRUQR"-%RQH-RLQW6XUJ >@ %6 5LFKDUGV 50 %HUQVWHLQ &5 '$PDWR HW DO 6WDQGDUGL]DWLRQ RI FULWHULD IRU DGROHVFHQW LGLRSDWKLF VFROLRVLVEUDFHVWXGLHV656&RPPLWWHHRQ%UDFLQJDQG1RQRSHUDWLYH0DQDJHPHQW6SLQH >@ *1LFKROVRQ0)HUJXVRQ3HOO.6PLWK0(GJDU70RUOH\'HYHORSPHQWRI,QVWUXPHQWHGVSLQDO%UDFH IRU PHDVXULQJ FRPSOLDQFH DQG VNLQ PLFURFOLPDWH LQ WKH FRQVHUYDWLYH WUHDWPHQW RI DGROHVFHQW LGLRSDWKLF VFROLRVLV3URFHHGLQJRI%ULWLVK6FROLRVLV6RFLHW\6LOYHU-XELOHH0HHWLQJ0DUFK ±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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-299

299

%5$&(0$3DSURSRVDOIRUDQHZ FODVVLILFDWLRQRIEUDFHV 61(*5,1,)=$,1$6$7$1$6,2 ,6,&2,WDOLDQ6FLHQWLILF6SLQH,QVWLWXWH 9LD%HOODUPLQR0LODQ,WDO\ ± VWHIDQRQHJULQL#LVLFRLW $EVWUDFW %UDFHV WRGD\ DUH QDPHG DFFRUGLQJ WR WKH DXWKRU¶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

,QWURGXFWLRQ

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

300

S. Negrini et al. / BRACE MAP, a Proposal for a New Classiﬁcation of Braces

SHUVRQDOLVPVSURJUHVVLYHO\GHYHORSVWKDWFRQWUDVWZLWKVFLHQFHPRUHRYHUWKHSRVVLELOLW\WR XQGHUVWDQGEUDFHVDFWLRQVDQGXVHIXOQHVVLVUHGXFHG>@ 7KH DLP RI WKLV SDSHU LV WR SURSRVH IRU WKH ILUVW WLPH DQG LQLWLDOO\ YHULI\ D QHZ FODVVLILFDWLRQRIEUDFHV

0DWHULDOVDQG0HWKRGV

:H WKHRUHWLFDOO\ GHYHORSHG WKH FODVVLILFDWLRQ DQG DSSOLHG LW WR FRQYHQLHQWO\ FKRVHQ EUDFHV (XURSHDQ DQG $PHULFDQ WR SUHOLPLQDULO\ YHULI\ LI LW ZDV SRVVLEOH WR GLVWLQJXLVK EHWZHHQDOORIWKHP7KHEUDFHVFRQVLGHUHGLQWKLVVWXG\FRPHIURPDQGDUHXVHGPDLQO\ LQ GLIIHUHQW FRXQWULHV DQG LQFOXGH %RVWRQ 86 &KDUOHVWRQ 86 &KrQHDX &K /DSDGXOD , /\RQHVH ) 0DJXHORQH , 0LOZDXNHH 86 3$6% , 3URYLGHQFH 86 6IRU]HVFR, 6LELOOD&Kr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• %%XLOGLQJ&&XVWRPPDGH&S&XVWRPSRVLWLRQLQJ3SUHIDEULFDWHGHQYHORSH • 55LJLGLW\66RIW((ODVWLF55LJLG99HU\ULJLG • $$QDWRPLFDOFODVVLILFDWLRQ&&7/6277/62//62 • &( &RQVWUXFWLRQRIWKH(QYHORSH66\PPHWULF$$V\PPHWULF • 0$ 0HFKDQLVP RI $FWLRQ 7 7KUHH 3RLQW ( (ORQJDWLRQ 3 3XVK 0 0RYHPHQW • 3 3ODQH RI DFWLRQ ' ) ' )URQWDO + ' +RUL]RQWDO 6 ' 6DJLWWDO )K &RPELQHG )URQWDO KRUL]RQWDO )V &RPELQHG )URQWDO VDJLWWDO +V &RPELQHG +RUL]RQWDOVDJLWWDO

5HVXOWV

2XW RI WKH EUDFHV FRQVLGHUHG WKH %5$&( 0$3 FODVVLILFDWLRQ GLG QRW DOORZ WR GLIIHUHQWLDWHRQO\WZRRIWKHPWKH&KDUOHVWRQDQG3URYLGHQFH7DEOH

'LVFXVVLRQ

7KHSURSRVHGFODVVLILFDWLRQSURYHGWREHDEOHWRGLIIHUHQWLDWHEUDFHVRQHIURPWKHRWKHU DQGRQO\WZRZHUHVLPLODUO\FODVVLILHG 7KHILUVWSRLQWWREHGLVFXVVHGLVGRZHQHHGDFODVVLILFDWLRQLQWKLVILHOG":HWKLQN WKDWLIZHFRQWLQXHZLWKWKHDFWXDOQDPHVZHFDQQRWFRPSDUHGLIIHUHQWEUDFHVVDPHEUDFHV ZLWK VDPH SULQFLSOHV FDQ KDYH GLIIHUHQW QDPHV DQG VDPH EUDFHV ZLWK VDPH QDPHV DUH DSSOLHG E\ GLIIHUHQW SK\VLFLDQV DFFRUGLQJ WR GLIIHUHQW SULQFLSOHV >@ 0RUHRYHU WR XQGHUVWDQG ZKDW ZH DUH GRLQJ ZH QHHG WR FRPSDUH WKH GLIIHUHQW EUDFHV VWDUWLQJ IURP D FRPPRQEDVLVDFODVVLILFDWLRQRIIHUVVXFKDFRPPRQODQJXDJHDQGZHGHILQLWLYHO\QHHGLW

S. Negrini et al. / BRACE MAP, a Proposal for a New Classiﬁcation of Braces

301

7DEOH&ODVVLILFDWLRQRIWKHEUDFHVFRQVLGHUHG2QO\&KDUOHVWRQDQG3URYLGHQFHEUDFHKDYHQRWEHHQ GLVWLQJXLVFKHGE\WKHSURSRVHGFODVVLILFDWLRQ

% 5 $ &( 0$ 3 %XLOGLQJ 5LJLGLW\ $QDWRPLFDO &RQVWUXFWLRQ 0HFKDQLVP 3ODQH RI $FWLRQ RI FODVVLILFDWLRQ RIWKH DFWLRQ (QYHORSH 3 5 / 6 7 %RVWRQ & 5 7 $ 7 ) &KDUOHVWRQ & 5 7 $ 7 &KHQHDX & 5 / 6 3 /DSDGXOD & 9 7 $ 7 )K /\RQHVH & 9 7 6 7 6 0DJXHORQH & 5 & 6 ( )K 0LOZDXNHH & 5 / $ 0 )K 3$6% & 5 7 $ 7 ) 3URYLGHQFH & 9 7 6 3 6IRU]HVFR & 5 7 6 3 6LELOOD &S ( 7 $ 0 6SLQH&RU ,W¶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± ZZZVRVRUWRUJ ,QFRQFOXVLRQZHQHHGWREHWWHUXQGHUVWDQGEUDFHVDFWLRQDQGWRXQGHUVWDQGZHQHHG WRFRPSDUHWKHGLIIHUHQWRUWKRVLVEXWWRFRPSDUHZHQHHGWRKDYHDFRPPRQEDFNJURXQG DQG D FODVVLILFDWLRQ LV WKH SRVVLEOH VWDUWLQJ SRLQW ,I %5$&( 0$3 ZLOO QRW EH WKH ULJKW FODVVLILFDWLRQLWFRXOGEHFKDQJHG1HYHUWKHOHVVZHQHHGWRDSRLQWWRVWDUW

5HIHUHQFHV >@ >@ >@ >@ >@ >@

6WXFNL**ULPE\ *$SSO\LQJWKH,&)LQPHGLFLQH -5HKDELO0HG ,&) &ODVVLILFD]LRQH,QWHUQD]LRQDOHGHO)XQ]LRQDPHQWRGHOOD'LVDELOLWj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

302 >@ >@ >@ >@ >@ >@ >@ >@ >@

S. Negrini et al. / BRACE MAP, a Proposal for a New Classiﬁcation of Braces &XPPLQJV 5-($/RYHOHVV-&DPSEHOO66DPHOVRQ-00D]XU,QWHUREVHUYHUUHOLDELOLW\DQG LQWUDREVHUYHUUHSURGXFLELOLW\RIWKHV\VWHPRI.LQJHWDOIRUWKHFODVVLILFDWLRQRIDGROHVFHQWLGLRSDWKLF VFROLRVLV -%RQH-RLQW6XUJ$P 'XRQJ /)&KHULHW+/DEHOOH7KUHHGLPHQVLRQDOFODVVLILFDWLRQRIVSLQDOGHIRUPLWLHVXVLQJIX]]\ FOXVWHULQJ 6SLQH 1HJULQL$61HJULQL7KHWKUHHGLPHQVLRQDOHDV\PRUSKRORJLFDO'(02 FODVVLILFDWLRQRIVFROLRVLV SDUW,,UHSHDWDELOLW\ 6FROLRVLV 1HJULQL6$ 1HJULQL7KHWKUHHGLPHQVLRQDOHDV\PRUSKRORJLFDO'(02 FODVVLILFDWLRQRIVFROLRVLV 3DUW,,,FRUUHODWLRQZLWKFOLQLFDOFODVVLILFDWLRQDQGSDUDPHWHUV 6FROLRVLV 3RQFHW3-'DQVHUHDX+/DEHOOH*HRPHWULF7RUVLRQLQ,GLRSDWKLF6FROLRVLV$7KLUG'$QDO\VLVDQGD 3URSRVDOWRD1HZ&ODVVLILFDWLRQ,Q3URFHHGLQJRIWKH6HFRQG%LDQQXDO0HHWLQJRIWKH,QWHUQDWLRQDO 5HVHDUFK6RFLHW\RI6SLQDO'HIRUPLWLHV$PVWHUGDP,26 /HQNH /*55%HW]-+DUPV.+%ULGZHOO'+&OHPHQWV7*/RZH.%ODQNH$GROHVFHQW LGLRSDWKLFVFROLRVLVDQHZFODVVLILFDWLRQWRGHWHUPLQHH[WHQWRIVSLQDODUWKURGHVLV -%RQH-RLQW6XUJ$P $ :HLVV +505LJR7KHFKHQHDXFRQFHSWRIEUDFLQJDFWXDOVWDQGDUGV6WXG+HDOWK7HFKQRO,QIRUP &RLOODUG &$&LUFR&+5LYDUG$QHZFRQFHSWIRUWKHQRQLQYDVLYHWUHDWPHQWRI$GROHVFHQW,GLRSDWKLF 6FROLRVLVWKH&RUUHFWLYH0RYHPHQWSULQFLSOHLQWHJUDWHGLQWKH6SLQH&RU6\VWHP'LVDELO5HKDELO$VVLVW 7HFKQRO 5LJR 061HJULQL+:HLVV7*ULYDV70DUX\DPD7.RWZLFNL 626257FRQVHQVXVSDSHURQEUDFH DFWLRQ7/62ELRPHFKDQLFVRIFRUUHFWLRQLQYHVWLJDWLQJWKHUDWLRQDOHIRUIRUFHYHFWRUVHOHFWLRQ 6FROLRVLV

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-303

303

&OLQLFDODQGSRVWXUDOEHKDYLRXURIVFROLRVLV GXULQJGDLO\EUDFHZHDQLQJKRXUV 61(*5,1,&)86&20520$12)=$,1$6$7$1$6,2 ,6,&2,WDOLDQ6FLHQWLILF6SLQH,QVWLWXWH 9LD%HOODUPLQR0LODQ,WDO\ ±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³FRQFHUWLQDHIIHFW´GXH WR EUDFH ZHDQLQJDQGWKH LPSRUWDQFH RI VWDQGDUGL]LQJFOLQLFDOH[DPLQDWLRQ ZLWKUHVSHFW WR WKHGDLO\EUDFHZHDQLQJKRXUV .H\ZRUGV,GLRSDWKLFVFROLRVLV%UDFHWUHWPHQW(YDOXDWLRQ

,QWURGXFWLRQ

'XULQJEUDFHWUHDWPHQWHYHU\GD\WKHSDWLHQWZHDQWKHEUDFHIRUDPRUHRUOHVVORQJSHULRG RIWLPH7KLVEUDFHZHDQLQJWLPHLVGLUHFWO\UHODWHGWRWKHILQDOUHVXOWVLQIDFWEUDFHVZRUN ZKHQSUHVFULEHGIXOOWLPH>@DQGZKHQFRPSOLDQFHLVKLJK>@,QDQ\FDVHZKDWKDSSHQV WRVFROLRVLVZKHQWKHEUDFHLVZHDQHGLVQRWGHVFULEHGLQWKHOLWHUDWXUHHYHQLIWKLVKDYHD FOLQLFDO LPSDFW 7KH TXHVWLRQUHODWH ERWK WR DVVHVVPHQW LH ZKDWKDSSHQVWR WKH FOLQLFDO VLJQVZHHYDOXDWH" DQGUHVXOWVLHZKDWKDSSHQVWRVFROLRVLV" ,Q WKH SDVW ZH K\SRWKHVL]HG D SRVVLEOH ³FRQFHUWLQD HIIHFW´ )LJXUH >@ WKDW FRXOG H[SODLQWKHLPSRUWDQFHRISDWLHQW¶VFRPSOLDQFH$FFRUGLQJWRWKLVK\SRWKHVLVHDFKWLPHD EUDFHLVZHDQHGWKHGHIRUPLW\JUDGXDOO\PRYHVEDFNIURPWKHPD[LPDOLQEUDFHFRUUHFWLRQ WRWKHRULJLQDORXWRIEUDFHVLWXDWLRQWKLVUHYHUVDOLVGXHWRDSRVWXUDOFROODSVH>@WKDWLV FRUUHODWHGWRWKHOHQJWKRIEUDFHZHDQLQJDQGWKHULJLGLW\IOH[LELOLW\ RIWKHVSLQH>@LWVHOI FRUUHODWHGWRWKHVWDJHRIJURZWKWKHERQHDJHWKHPXVFXODUHQGXUDQFHDQGWKHXVXDOEUDFH ZHDULQJ $FFRUGLQJWRWKH³FRQFHUWLQDHIIHFW´K\SRWKHVLVWKHGHIRUPLW\UHDFKHGDWWKHHQG RI GDLO\ EUDFH ZHDQLQJ JLYHV WKH DOORZHG FRPSUHVVLRQ RI WKH ZHGJHG YHUWHEUDH DQG FRQVHTXHQWO\WKHILQDOUHVXOWV

304

S. Negrini et al. / Clinical and Postural Behaviour of Scoliosis

)LJXUH

7R YHULI\ ZKDW KDSSHQV GXULQJ GDLO\ ZHDQLQJ WLPH DQG WR YHULI\ LI WKH FRQFHUWLQD HIIHFW LV SRVVLEO\ UHDO ZH GHYHORSHG D VWXG\ WR HYDOXDWH VFROLRVLV SRVWXUDO DQG FOLQLFDO FKDQJHVDWEUDFHZHDQLQJ

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

S. Negrini et al. / Clinical and Postural Behaviour of Scoliosis

305

/RFRPRWLRQ DQG 6SLQH D QRQLRQLVLQJ LQVWUXPHQW WKDW DOORZ D ' UHFRQVWUXFWLRQ RI WKH VSLQH >@3DLUHG$129$DQGWWHVWZHUHXVHGIRUVWDWLVWLFDODQDO\VLV

5HVXOWV 0DLQ UHVXOWV DUH UHSRUWHG LQ )LJXUH 7KH + JURXS VKRZHG D VWDWLVWLFDOO\ VLJQLILFDQW 3 ZRUVHQLQJRIRIWKH$75LQKRXUVPPRIWKHSURPLQHQFHLQKRXUDQG PP RI WKH 6DJLWWDO ,QGH[ LQ KRXUV LQ WKH PHDQWLPH ZH KDG D VFROLRVLV ZRUVHQLQJ LQ KRXUV EXW QRW VLJQLILFDQW 2Q WKH FRQWUDU\ WKH JURXS + GLG QRW VKRZ DQ\ VWDWLVWLFDOO\ VLJQLILFDQW FKDQJH LQ KRXUV $OWKRXJK QRW VWDWLVWLFDOO\ VLJQLILFDQW *2$/6 YDULDWLRQ )LJXUH ' VXJJHVW D SRVLWLYH SRVWXUDO UHDFWLRQ LQ *URXS + DQG VWDELOLW\VOLJKW ZRUVHQLQJLQ+

'LVFXVVLRQ *URXS+VKRZHGYDULDWLRQVLQWRKRXUVLQDOOFOLQLFDOSDUDPHWHUVDQGSUHVXPDEO\LQ VFROLRVLV&REEGHJUHHVDVFRXOGEHK\SRWKHVL]HGIURPDVXUIDFHWRSRJUDSKLFPHDVXUHPHQW 7KH YDULDWLRQV REVHUYHG ZHUH ELJJHU WKDQ WKH PHDVXUHPHQW HUURUV RI WKH FRQVLGHUHG SDUDPHWHUV >@ ,QVLGHWKHHYHU\GD\EUDFHZHDQLQJWLPHJURXS+ WKHUHZHUHQRYDULDWLRQVSHUKDSV SRVLWLYHVOLJKWVWUDLJKWHQLQJUHDFWLRQV ZKLOHZKHQRYHUFRPLQJLWJURXS+ DQGLQWKH

$

%

&

'

)LJXUH

306

S. Negrini et al. / Clinical and Postural Behaviour of Scoliosis

FDVHRISURPLQHQFHWKDWDOUHDG\FKDQJHGDIWHUKRXURQO\ VLPSO\UHDFKLQJWKLVWLPHZH REVHUYHG VWDWLVWLFDOO\ DQG FOLQLFDOO\ VLJQLILFDQW ZRUVHQLQJ RI FOLQLFDO SDUDPHWHUV VFROLRVLV FRXOGFKDQJHEXWWKHUHGXFHGVDPSOHGLGQRWDOORZWRUHDFKGHILQLWLYHUHVXOWV$FFRUGLQJWR WKHVH UHVXOWV LW¶V SRVVLEOH WKDW WKH ³FRQFHUWLQD HIIHFW´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¶WEHXVHGIRUUHSHDWHGPHDVXUHPHQWV $FFRUGLQJWRWKHVHUHVXOWVWKHFOLQLFDOHYDOXDWLRQEXWSUHVXPDEO\DOVR[UD\V WLPLQJ VKRXOG EH VWDQGDUGL]HG DQG SHUIRUPHG RU LPPHGLDWHO\ DW EUDFH ZHDQLQJ RU DIWHU WKH HYHU\GD\DOORZHGZHDQLQJWLPH0RUHRYHUWKH³FRQFHUWLQDHIIHFW´VKRXOGEHVWXGLHGPRUH WRXQGHUVWDQGLILWLVUHDODQGLPSRUWDQWLQFOLQLFDOSUDFWLFHIRUILQDOUHVXOWV

5HIHUHQFHV >@ >@ >@ >@ >@ >@ >@ >@ >@ >@

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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-307

307

'RLPEDODQFHVLWXDWLRQVVWLPXODWHDVSLQDO VWUDLJKWHQLQJUHIOH[LQSDWLHQWZLWKDGROHVFHQW LGLRSDWKLFVFROLRVLV" 0520$129=,/,$1,6$7$1$6,2)=$,1$61(*5,1, ,6,&2,WDOLDQ6FLHQWLILF6SLQH,QVWLWXWH 9LD%HOODUPLQR0LODQ,WDO\ ±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

,QWURGXFWLRQ

%DODQFHLVDUHOHYDQWIXQFWLRQLQHYHU\GD\OLIHDQGLQWKHOLWHUDWXUHWKHUHDUHSDSHUVRQLWV LPSDLUPHQW LQ DGROHVFHQW LGLRSDWKLF VFROLRVLV $,6 SDWLHQWV 7KH FRUUHODWLRQ EHWZHHQ EDODQFH DQG $,6 LV VWLOO XQFOHDU DQG WZR QRQ H[FOXVLYH K\SRWKHVHV FRXOG H[SODLQ WKHVH SUREOHPVDELRPHFKDQLFDOK\SRWKHVLVZKLFKJLYHVLPSRUWDQFHWRVXFKIDFWRUVDVWKH VKDSHRI WKH WUXQN DQG WKH FKDQJHV LQ WKH UHODWLRQVKLSV EHWZHHQ ERG\ VHJPHQWV DQG D VHQVRU\ LQWHJUDWLRQ K\SRWKHVLV ZKLFK SUHGLFWV LPSDLUPHQWV LQ WKH G\QDPLF UHJXODWLRQ RI VHQVRULPRWRULQWHJUDWLRQE\WKHLQDSSURSULDWHZHLJKWLQJRIVHQVRU\LQSXWV >@ &HQWHURIERG\PDVVVZD\&20 KDVEHHQGHPRQVWUDWHGLQWKHVHSDWLHQWVDQGFDQEH SUREDEO\DFRQVHTXHQFHRIWKHPLVDOLJQPHQWRIWKHVSLQH>@0RUHRYHUFKLOGUHQZLWK$,6 VKRZSRRUEDODQFHHVSHFLDOO\ZKHQYLVXDODQGVRPDWRVHQVRU\LQSXWLVFKDOOHQJHG>@WKXV VXJJHVWLQJDQLQWHJUDWLRQGHILFLW6RPHVWXGLHVKDYHSRLQWHGRXWWKHSRVVLEOHH[LVWHQFHRID YHVWLEXODUSUREOHPVLQ$,6WKDWFDQVRPHKRZDIIHFWDFRUUHFWEDODQFHDQGSRVWXUDOFRQWURO >@ 3K\VLFDO H[HUFLVHV 3( RXWSDWLHQW DQG LQSDWLHQW UHKDELOLWDWLRQ KDYH EHHQ UHFRPPHQGHGDV WKH ILUVW OLQH RI WUHDWPHQW IRU VPDOO FXUYHV DQG WKRVH ZLWKD ORZ ULVN RI SURJUHVVLRQE\ YDULRXVPRVWO\(XURSHDQFOLQLFLDQV>@7KHUHDUHPDQ\3(DSSURDFKHV WKDWVKRZHGWREHHIIHFWLYHLQ$,6LQUHGXFLQJEUDFHSUHVFULSWLRQDQGDYRLGLQJSURJUHVVLRQ

308

M. Romano et al. / Do Imbalance Situations Stimulate a Spinal Straightening Reﬂex?

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

5HVXOWV 2QDYHUDJHFRPSDULQJ6%WR)6WKHUHZDVDVWDWLVWLFDOO\VLJQLILFDQWUHGXFWLRQRIWKHFXUYHV IURP)6 WR6% 7KLVZDVFRQILUPHGORRNLQJDWWKHDYHUDJHRIWKH FXUYHV RI HDFK SDWLHQW EXWQRW ZKHQORRNLQJ DW WKH ZRUVW FXUYH IURP LQ )6WR LQ 6% ZKHUH VWDWLVWLFDO VLJQLILFDQFH ZDV QRWUHDFKHG /RRNLQJ DW WKH FXUYHV ZRUVHQHG DQG LPSURYHG LQ 6% YHUVXV )6 ORRNLQJ DW WKH SDWLHQWV WKHVH SHUFHQWDJHVZHUHDQGUHVSHFWLYHO\

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

M. Romano et al. / Do Imbalance Situations Stimulate a Spinal Straightening Reﬂex?

309

IHHGEDFNDQGIHHGIRUZDUGUHDFWLRQVZKRVHLPSRUWDQFHLQWKHSRVWXUDOFRQWURORIWKHWUXQN KDVEHHQVWUHVVHG>@

5HIHUHQFHV >@

>@ >@ >@ >@ >@ >@ >@ >@ >@ >@ >@ >@ >@ >@

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

310

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-310

Congenital scoliosis – presentation of three severe cases treated conservatively H-R WEISS Asklepios Katharina Schroth Spinal Deformities Rehabilitation Centre, Korczakstr. 2, 55566 Bad Sobernheim, Germany, [email protected]

Abstract. In view of the very limited data about conservative treatment of patients with congenital scoliosis (CS) available, early surgery is suggested already in mild cases with formation failures in the first three years of life. It is common sense that patients with failures of segmentation will not benefit from conservative treatment at all and the same applies to failures of formation with curves of > 50 degrees in infancy. Materials and Methods. Two patients with rib synostosis denied surgery before entering the pubertal growth spurt. These patients have been treated conservatively with braces and Scoliosis In-Patient Rehabilitation (SIR) and now are beyond the pubertal growth spurt. One patient with a formation failure and a curve of > 50 degrees lumbar has been treated with the help of braces and physiotherapy from 1.6 years on and is still under treatment now at the age of 15 years. Results. Severe decompensation was prevented in the two patients with failure of segmentation, however a severe thoracic deformity is evident with underdeveloped lung function and severe restrictive ventilation disorder. The patient with failure of formation is well developed, now without cosmetic or physical complaints although his curve progressed at the end of the growth spurt due to final mal-compliance. Conclusions. Failures of segmentation should be advised to have surgery before entering the pubertal growth spurt. In case they deny, conservative treatment can at least in part be beneficial. For patients with failures of formation conservative treatment should be suggested in the first place because long-term outcomes of early surgery beyond pubertal growth spurt are not yet revealed. Keywords. Congenital scoliosis, conservative treatment, indication for surgery

1.

Introduction

In view of the very limited data about conservative treatment of patients with congenital scoliosis (CS) available, early surgery is suggested already in mild cases with formation failures in the first three years of life. It is common sense that patients with failures of segmentation will not benefit from conservative treatment at all and the same applies to failures of formation with curves of > 50 degrees in infancy. Purpose of this study was to reveal the effects of conservative treatment in this rare patient population.

H.-R. Weiss / Congenital Scoliosis – Presentation of Three Severe Cases Treated Conservatively

2.

311

Material and Method

Two patients with rib synostosis (Fig. 1 and 2) denied surgery before entering the pubertal growth spurt. These patients have been treated conservatively with braces and Scoliosis InPatient Rehabilitation (SIR) and now are beyond the pubertal growth spurt. One patient with a formation failure (Fig. 3) and a curve of > 50 degrees lumbar has been treated with the help of braces and physiotherapy from 1.6 years on and is still under treatment now at the age of 15 years.

3.

Results

Severe decompensation was prevented in the two patients with failures of segmentation, however a severe thoracic deformity is evident with underdeveloped lung function and severe restrictive ventilation disorder. The patient with failure of formation is well developed now without cosmetic or physical complaints although his curve progressed at the end of the growth spurt due to mal-compliance.

Figure 1: Follow-up from 10 years to 18 years. Progression from 10–12 years, after that stable. At 10 years the patient had 62° and progressed to 71° at the age of 12. Last x-ray: 72°. VC: 650 ml / 19% of the predicted value.

4.

Discussion

So called long-term studies reporting on congenital scoliosis patients treated surgically reveal follow-up periods of 3-6 years with most of the patients being still before the pubertal growth spurt at final follow-up [1-4]. While the complications reported for the entity of congenital scoliosis varies widely between 0 and 48% in short- to mid-term [5-8]. The long-term complication rate for congenital scoliosis patients operated on is not yet reported.

312

H.-R. Weiss / Congenital Scoliosis – Presentation of Three Severe Cases Treated Conservatively

Figure 2: From 2002 (64°) before pubertal growth spurt until 2007 (59°) at Risser 4 (15 years.) no progression has been detected. The ATR has been reduced with the Chêneau braces applied from initially 17° to 9° in January 2008 during the last SIR.VC: 1.640 ml / 33% of the predicted value.

Figure 3: 52° at the age of 18 months, in between the curve without brace on was down to 40°, 58° at final follow-up with Risser 4 after final mal-compliance. The patient had no cosmetic complaints. A small lumbar hump is visible but no decompensation.

To conclude from single case reports that: “The early fusion prevented the customary severe progression of this condition and early death due to cor pulmonale ”, somehow seems biased pro surgery when there could be the possibility that even without surgery cor pulmonale would not necessarily be the consequence of an untreated congenital scoliosis [9,10]. On the other hand the patients reported on in these case reports are not yet beyond 50 years of age and might develop cor pulmonale in the future.

H.-R. Weiss / Congenital Scoliosis – Presentation of Three Severe Cases Treated Conservatively

5.

313

Conclusions

Failures of segmentation should be advised to have surgery before entering the pubertal growth spurt. In case they deny, conservative treatment can at least in part be beneficial. For patients with failures of formation conservative treatment should be suggested in the first place because long-term outcomes of early surgery beyond pubertal growth spurt in adulthood are not yet revealed.

References [1]

Thompson AG, Marks DS, Sayampanathan SR, Piggott H: Long-term results of combined anterior and posterior convex epiphysiodesis for congenital scoliosis due to hemivertebrae. Spine. 1995 Jun 15;20(12):1380-5. [2] Marks DS, Sayampanathan SR, Thompson AG, Piggott H: Long-term results of convex epiphysiodesis for congenital scoliosis. Eur Spine J. 1995;4(5):296-301. [3] Bollini G, Docquier PL, Viehweger E, Launay F, Jouve JL: Thoracolumbar hemivertebrae resection by double approach in a single procedure: long-term follow-up. Spine. 2006 Jul 1;31(15):1745-57. [4] Lazar RD, Hall JE: Simultaneous anterior and posterior hemivertebra excision. Clin Orthop Relat Res. 1999 Jul;(364):76-84. [5] Ayvaz M, Alanay A, Yazici M, Acaroglu E, Akalan N, Aksoy C. Safety and efficacy of posterior instrumentation for patients with congenital scoliosis and spinal dysraphism. J Pediatr Orthop. 2007 Jun;27(4):380-6. [6] Benli IT, Duman E, Akalin S, Kiş M, Aydin E, Un A. [An evaluation of the types and the results of surgical treatment for congenital scoliosis]. Acta Orthop Traumatol Turc. 2003;37(4):284-98. [7] Shono Y, Abumi K, Kaneda K. One-stage posterior hemivertebra resection and correction using segmental posterior instrumentation. Spine. 2001 Apr 1;26(7):752-7. [8] Kahanovitz N, Brown JC, Bonnett CA.The operative treatment of congenital scoliosis. A report of 23 patients. Clin Orthop Relat Res. 1979 Sep;(143):174-82. [9] Winter RB, Lonstein JE. Congenital scoliosis with posterior spinal arthrodesis T2-L3 at age 3 years with 41year follow-up. A case report. Spine. 1999 Jan 15;24(2):194-7. [10] Winter RB, Lonstein JE. Congenital thoracic scoliosis with unilateral unsegmented bar and concave fused ribs: rib osteotomy and posterior fusion at 1 year old, anterior and posterior fusion at 5 years old with a 36year follow-up. Spine. 2007 Dec 15;32(26):E841-4.

314

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-314

Conservative scoliosis treatment in patients with Prader-Willi syndrome H-R WEISS, S BOHR Asklepios Katharina Schroth Spinal Deformities Rehabilitation Centre, Korczakstr. 2, 55566 Bad Sobernheim, Germany, [email protected]

Abstract. Patients with Prader-Willi syndrome often suffer from scoliosis of major degrees. Due to current literature surgical intervention seems the gold standard of treatment although the rate of complications in this condition are reported to be significantly higher than in patients with Adolescent Idiopathic Scoliosis. Purpose of this study was to reveal the effects of conservative treatment in this rare patient population. Materials and Methods. A case series of patients with this condition has been investigated to estimate as to whether Prader-Willi patients with scoliosis may benefit from conservative scoliosis management. 9 Patients with this condition have been found in our out-patient database. 5 of these retarded patients (3 girls, two boys) today are 19 years and older and therefore are without any significant residual growth. Average Cobb angle was 47 degrees (34 – 66 degrees) at 12 years, average observation time was 6.4 years. Results. Two of the five patients progressed. Average Cobb angle after follow-up was 52 degrees. No progression beyond 70 degrees has been found after cessation of growth. In one patient the curve deteriorated clearly after reducing brace wearing time and therefore was due to non-compliance. Conclusions. Stabilisation of scoliosis due to Prader-Willi syndrome is possible by means of conservative management. To expose this patient population to the risks of surgical management seems not to be justified. Keywords. Prader-Willi syndrome, scoliosis, surgery, complications, indications

1.

Background

Children with Prader-Willi syndrome frequently have musculo-skeletal problems such as joint hyperlaxity, hypotonia, delayed bone age, and scoliosis. Their musculo-skeletal problems are magnified by the extreme obesity many of these patients exhibit [1]. Osteopenia, poor impulse control and defiant behaviors, and diminished pain sensitivity are aspects of PWS that may complicate all facets of orthopaedic nonsurgical and surgical management in this patient population. The treating orthopaedic surgeon must plan carefully and proceed with caution when treating children and adults with PWS [2].

315

H.-R. Weiss and S. Bohr / Conservative Scoliosis Treatment

Patients with Prader-Willi Syndrome often suffer from scoliosis of major degrees. Due to current literature surgical intervention [3] seems the gold standard of treatment although the rates of complications in this condition are reported to be significantly higher than in patients with Adolescent Idiopathic Scoliosis. Purpose of this study was to reveal the effects of conservative treatment in this rare patient population.

2.

Material and Methods

A case series of patients with this condition has been investigated to estimate as to whether Prader-Willi patients with scoliosis may benefit from conservative scoliosis management. 9 Patients with this condition have been found in our out-patient database. 5 of these retarded patients (3 girls, two boys) today are 19 years and older and therefore are without any significant residual growth. Average Cobb angle was 47 degrees (34 – 66 degrees), average observation time was 6.4 years.

19 / 17°

30 / 40°

i. Br. 17 / 25°

29 / 37°

24 / 30°

Figure 1. Left: First presentation at the age of 11 years, 2nd. from left: Brace indication at 12 years, middle: In brace correction, 2nd. from right: At weaning at the age of 20 years and on the right: Four years without brace at 24 years. During the last 4 years the woman lost weight.

3.

Results

Two of the five patients progressed. Average Cobb angle after follow-up was 52 degrees. No progression beyond 70 degrees has been found after cessation of growth. In one patient the curve deteriorated clearly after reducing brace wearing time and therefore was due to non-compliance.

316

H.-R. Weiss and S. Bohr / Conservative Scoliosis Treatment

Figure 2. Surface scans of the patient who in the end was progressive due to non-compliance (Start of treatment, intermediate result and final result at the age of 19 years) without significant clinical deterioration.

4.

Discussion

In current literature there is no evidence that scoliosis surgery in patients with PraderWilli syndrome improves signs and symptoms of scoliosis during lifetime.Therefore to expose this patient population to the high risks of surgery [3] seems not to be justified. Conservative management can prevent curve progression in patients with PraderWilli syndrome and has to be regarded to be indicated primarily. On the other hand scoliosis in the case of a Prader-Willi syndrome seems to be less malignant than in other conditions when the results of conservative treatment are good at average in patients usually presenting with significant obesity.

Figure 3. Clinical pictures of the patient who in the end was progressive due to non-compliance (Start of treatment, intermediate result and final result at the age of 19 years) without significant clinical deterioration and in his last brace on the right.

H.-R. Weiss and S. Bohr / Conservative Scoliosis Treatment

317

Figure 4. 24 year old patient (to be seen on the right) next to her mother at the final follow-up. Her curve has improved significantly (see figure 1.) during the four years without brace, however performing physiotherapy regularly.

5.

Conclusions

Stabilisation of scoliosis due to Prader-Willi Syndrome is possible by means of conservative management. To expose this patient population to surgical management seems not to be justified medically.

References [1] [2] [3]

Gurd AR, Thompson TR: Scoliosis in Prader-Willi syndrome. J Pediatr Orthop. 1981;1(3):317-20. Kroonen LT, Herman M, Pizzutillo PD, Macewen GD: Prader-Willi Syndrome: clinical concerns for the orthopaedic surgeon. J Pediatr Orthop. 2006 Sep-Oct;26(5):673-9. Yamada K, Miyamoto K, Hosoe H, Mizutani M, Shimizu K: Scoliosis associated with Prader-Willi syndrome. Spine J. 2007 May-Jun;7(3):345-8.

This page intentionally left blank

Chapter 9 Abstracts

This page intentionally left blank

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-321

321

)%1JHQHSRO\PRUSKLVPVLQDGROHVFHQW LGLRSDWKLFVFROLRVLVSDWLHQWV &$2;LQJELQJ4,8
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

322

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-322

,QYHVWLJDWLRQRQWKHDVVRFLDWLRQ EHWZHHQ HVWURJHQ ȕUHFHSWRUJHQHSRO\PRUSKLVPVDQG WKHVXVFHSWLELOLW\ RIDGROHVFHQWLGLRSDWKLF VFROLRVLV &+(1+DLRX&+(1=KLMXQ4,8
Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-323

323

9LWDPLQ'UHFHSWRUJHQHSRO\PRUSKLVPVQR DVVRFLDWLRQZLWKORZERQHPLQHUDOGHQVLW\LQ DGROHVFHQWLGLRSDWKLFVFROLRVLVJLUOV &+(1:HQ-XQ4,8
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

.H\ZRUGV $GROHVFHQW LGLRSDWKLF VFROLRVLV YLWDPLQ ' UHFHSWRU JHQH SRO\PRUSKLVP ERQHPLQHUDO

324

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-324

([SUHVVLRQDQGVLJQLILFDQFHRI6R[LQ FKRQGURF\WHFHOOVIURPDGROHVFHQWLGLRSDWKLF VFROLRVLVSDWLHQWV $+8$1*< 4,8G681 6SLQH6XUJHU\WKH$IILOLDWHG'UXP7RZHU+RVSLWDORI1DQMLQJ8QLYHUVLW\0HGLFDO6FKRRO 1DQMLQJ&KLQD

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r \ DQG SDWLHQWV ZLWKRXW VFROLRVLVIHPDOV PDOHVPHDQDJHr\ 7KHPHDQFREEDQJOHRI$,6SDWLHQWVZDVrUDQJH IURPWR7KHFKRQGURF\WHV IURPKXPDQLOLDF JURZWKSODWH ZHUHLVRODWHG‫ޔ‬FXOWXUHG DQG SDVVDJHG LQ YLWUR 7KHQ WKH H[SUHVVLYH RI 6R[ RI FKRQGURF\WH IURP JURXSV ZHUH GHWHFWHG E\ XVLQJ 57 3&5 :HVWHUQ EORWWLQJ DW S JHQHUDWLRQ ([SUHVVLRQ RI 6R[ RI FKRQGURF\WHLQFUHDVHGREYLRXVO\LQ$,6JURXSDVFRPSDUHGZLWKFRQWUROJURXS3 QR PDWWHU IURP QXFOHLF DFLG RU SURWHLQ OHYHO 7KH DEQRUPDO H[SUHVVLRQ RI WKH WUDQVFULSWLRQ IDFWRU6R[PD\EHUHODWHGWRWKHPROHFXODUPHFKDQLVPRIWKH SDWKRJHQHVLVRI$,6 .H\ZRUGV ,GLRSDWKLFVFROLRVLV6R[FKRQGURF\WHHWLRORJ\

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-325

325

3URPRWHUSRO\PRUSKLVPRIPDWULOLQJHQH 0$71 LVDVVRFLDWHGZLWKVXVFHSWLELOLW\WR DGROHVFHQWLGLRSDWKLFVFROLRVLVDFDVHFRQWURO VWXG\ 4,8<&+(1=7$1*1 /6&+(1*- &<

6SLQH6XUJHU\6SLQH6XUJHU\WKH$IILOLDWHG'UXP7RZHU+RVSLWDORI1DQMLQJ8QLYHUVLW\

0HGLFDO6FKRRO1DQMLQJ&KLQD 7KH-RLQW6FROLRVLV5HVHDUFK&HQWHURI1DQMLQJ 8QLYHUVLW\ WKH &KLQHVH8QLYHUVLW\RI+RQJ.RQJ'HSDUWPHQWRI&KHPLFDO3DWKRORJ\ 7KH&KLQHVH8QLYHUVLW\RI+RQJ.RQJ&KLQD

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

326

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-326

/HIWULJKWDV\PPHWU\JHQHH[SUHVVLRQ GRPDLQVDUHUHYHUVHGLQDGROHVFHQWLGLRSDWKLF VFROLRVLV $025($8 %$=('',1( '6:$1* +/$%(//( %32,75$6 &+ 5,9$5' **5,0$5' -28(//(7 63$5(17

0ROHFXODU*HQHWLFV/DERUDWRU\ RI0XVFXORVNHOHWDO'LVHDVHV5HVHDUFK&HQWUH &+8 6DLQWH-XVWLQH0RQWUpDO4F&$1$'$ 'HSDUWPHQWRI6WRPDWRORJ\)DFXOW\RI 'HQWLVWU\8QLYHUVLWpGH0RQWUpDO 'HSDUWPHQWRI%LRFKHPLVWU\)DFXOW\RI0HGLFLQH8QLYHUVLWpGH0RQWUpDO /,6' /DERUDWRU\5HVHDUFK&HQWUH&+86DLQWH-XVWLQH0RQWUpDO 2UWKRSHGLF'LYLVLRQ&+8 6DLQWH-XVWLQH8QLYHUVLWpGH0RQWUpDO0RQWUpDO 2UWKRSHGLF'LYLVLRQ7KH0RQWUHDO &KLOGUHQ¶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
Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-327

327

613VDQDO\VLVRI&+'JHQHDQGLGLRSDWKLF VFROLRVLV,6 LQ&KLQHVH 1/7$1*+<<(81*+)$15.:2.9:+81*.0/((73/$0 %:1*<4,8-&&+(1* 'HSDUWPHQWRI&KHPLFDO3DWKRORJ\ 'HSDUWPHQWRI2UWKRSDHGLFV 7UDXPDWRORJ\ /L .D6KLQJ,QVWLWXWHRI+HDOWK6FLHQFHV7KH&KLQHVH8QLYHUVLW\RI+RQJ.RQJ+RQJ.RQJ 'HSDUWPHQWRI 2UWKRSDHGLFV'UXP7RZHU+RVSLWDO1DQMLQJ8QLYHUVLW\&KLQD -RLQW 6FROLRVLV5HVHDUFK&HQWHURI7KH&KLQHVH8QLYHUVLW\RI+RQJ.RQJDQG1DQMLQJ 8QLYHUVLW\

$EVWUDFW &+' JHQH ZDV UHFHQWO\ DVVRFLDWHG ZLWK IDPLOLDO IRUP RI LGLRSDWKLF VFROLRVLV ,6 +RZHYHUWKHKDSORW\SHDQGDOOHOHVVKRZLQJGLVHDVHSUHGLVSRVLWLRQZHUHDOVRFRPPRQ YDULDQWVIRXQGWKHSRSXODWLRQ7KHUHIRUHLWLPSOLHVWKDWWKHVHKLJKULVNDOOHOHVLQ&+'JHQH PD\ DOVR SOD\ D UROH LQ WKH JHQHWLF SUHGLVSRVLWLRQ RI VSRUDGLF IRUP RI ,6 &KLQHVH IHPDOH$,6SDWLHQWV&REE¶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

328

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-328

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

H.Y. Yeung et al. / Collagen I Alpha 2 Gene Polymorphism Association Study ]VFRUHRI

333S

SS

%RG\:HLJKW

SYDOXH

%0,

&RUUHFWHG%RG\+HLJKW

$UP6SDQ

/%0'

/HIW)HPRUDO1HFN%0'

5LJKW)HPRUDO1HFN%0'

1')1%0'

')1%0'

/$UHD

/%0&

329

330

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-330

$*HQHWLF0RGHO)RU6WXG\LQJ7KH (WLRSDWKRJHQHVLV2I/DWH2QVHW,GLRSDWKLF 6FROLRVLV 1/6 7$1*+< <(81*.0/(( ;4,8 <4,8 -&< &+(1* 'HSDUWPHQWRI2UWKRSDHGLFVDQG7UDXPDWRORJ\'HSDUWPHQWRI&KHPLFDO3DWKRORJ\ /HH+\VDQ&OLQLFDO5HVHDUFK/DERUDWRU\ 3ULQFHRI:DOHV+RVSLWDO7KH&KLQHVH 8QLYHUVLW\RI+RQJ.RQJ+RQJ.RQJ6$5

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

.H\ZRUGV JHQHWLFVHVWURJHQUHFHSWRUJHQHPHODWRQLQUHFHSWRUJHQH

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-331

331

3K\VLFDOH[HUFLVHVDQGDGROHVFHQWLGLRSDWKLF VFROLRVLVUHVXOWVRIDFRPSUHKHQVLYH V\VWHPDWLFUHYLHZRIWKHOLWHUDWXUH 0520$12&)86&260,12==,6$7$1$6,2)=$,1$61(*5,1,

,6,&2,WDOLDQ6FLHQWLILF6SLQH,QVWLWXWH 9LD5REHUWR%HOODUPLQR 0LODQ ,WDO\ ,WDOLDQ&RFKUDQH&HQWHU 0LODQ,WDO\

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

332

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-332

,GHQWLILFDWLRQRI656U'RPDLQV8VLQJ )DFWRU$QDO\VLV0HWKRGRORJ\ '&%XUWRQ 60/DL0$$VKHU

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¶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¶VDOSKDRIWKHGRPDLQVZDVIRU3DLQ IRU )XQFWLRQ DQG IRU 6HOI ,PDJH DQG IRU 0HQWDO +HDOWK )LQDOO\ WKH LQWHUQDO FRQVLVWHQF\RIWKH VDWLVIDFWLRQGLVVDWLVIDFWLRQZLWK PDQDJHPHQWGRPDLQZDV )DFWRU DQDO\VLV RI WKH 656U FRQILUPV WKH SODFHPHQW RI WKH QRQPDQDJHPHQW GRPDLQ TXHVWLRQVLQWKHLUUHVSHFWLYHIRXUGRPDLQV,QWHUQDOFRQVLVWHQF\ZDVJRRGWRH[FHOOHQWLQDOO GRPDLQV .H\ZRUGV3V\FKRPHWULFDVVHVVPHQWVFROLRVLV656U

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-333

333

9DULDWLRQVRI6HPLFLUFXODU&DQDOV2ULHQWDWLRQ DQG/HIWULJKW$V\PPHWU\LQ$GROHVFHQW ,GLRSDWKLF6FROLRVLV$,6 &RPSDULQJZLWK 1RUPDO&RQWUROV050RUSKRPHWU\6WXG\ 8VLQJ$GYDQFHG,PDJH&RPSXWDWLRQ 7HFKQLTXHV :&: &+8 / 6+, ':$1* 73$86 5*%85:(// *&: 0$1 $ &+(1* +< <(81*.0/((3$ +(1*-&< &+(1* 'HSDUWPHQWRI'LDJQRVWLF5DGLRORJ\ 2UJDQ,PDJLQJ&RPSXWHU6FLHQFHDQG (QJLQHHULQJ2UWKRSDHGLFV 7UDXPDWRORJ\&KLQHVH8QLYHUVLW\RI+RQJ.RQJ%UDLQDQG %RG\&HQWUH8QLYHUVLW\RI1RWWLQJKDP&HQWUHIRU6SLQDOVWXGLHVDQG6XUJHU\4XHHQ¶V 0HGLFDO&HQWUH1RWWLQJKDP8.

$EVWUDFW%DODQFHG\VIXQFWLRQKDVEHHQUHSRUWHGWREHDVVRFLDWHGZLWKDGROHVFHQWLGLRSDWKLF VFROLRVLV$,6 7KLVVWXG\VRXJKWWRLQYHVWLJDWHIRUDQ\PRUSKRPHWULFGLIIHUHQFHSUHVHQWLQ YHVWLEXODU V\VWHP EHWZHHQ $,6 VXEMHFWV DQG QRUPDO FRQWUROV +LJK UHVROXWLRQ 7: 05 LPDJHVRIYHVWLEXODUV\VWHPVZHUHREWDLQHGIURP$,6JLUOVZLWKQRUPDOSRVWXUDOEDODQFH 3% 3%DEQRUPDO$,6JLUOVDQGPDWFKHGFRQWUROV7KH'YHVWLEXODUV\VWHPVXUIDFHV ZHUH VHJPHQWHG E\ DXWRPDWLF FRPSXWDWLRQDO SLSHOLQH 2QH EHVW ILW FLUFOH ZDV DVVLJQHG WR HDFKRIWKHWKUHHVHPLFLUFXODUFDQDOV6KDSHRIHDFKFDQDOZDVUHIOHFWHGE\WKHUDGLXVRILWV FLUFOHZKLOHVSDWLDOUHODWLRQVKLSDPRQJWKHWKUHHFDQDOV ZDVUHIOHFWHGE\WKHOHQJWKDQGDQJOH IRUPHG EHWZHHQ WKH FRUUHVSRQGLQJ OLQHV FRQQHFWLQJ WKH FHQWHUV RI HDFK SDLU RI FLUFOHV 2ULHQWDWLRQDV\PPHWU\EHWZHHQOHIWDQGULJKWYHVWLEXODUV\VWHPVZDVPHDVXUHGE\WKH(XOHU DQJOHV FDOFXODWHG WR ULJLGO\ UHJLVWHU WKH ULJKW WR OHIW YHVWLEXODU VXUIDFH 6WDWLVWLFDO DQDO\VLV ZDVSHUIRUPHGXVLQJRQHZD\$129$ 7KHUHZDVVLJQLILFDQWJURXSGLIIHUHQFHLQ WKHVKDSH DQG VSDWLDO UHODWLRQVKLS RI WKH VHPLFLUFXODU FDQDOV ,Q JHQHUDO $,6 KDG JUHDWHU RULHQWDWLRQ DV\PPHWU\ EHWZHHQOHIW DQGULJKWYHVWLEXODU V\VWHPVZKHQFRPSDUHGZLWKQRUPDO FRQWUROV S 7KLV GLIIHUHQFH ZDV PRUH H[DJJHUDWHG LQ 3%DEQRUPDO $,6S 0HDQ YDOXHV RI URWDWLRQDO DQJOHV DURXQG \D[LV ZHUH DV IROORZV FRQWURO 3%QRUPDO $,6 3%DEQRUPDO$,6 5RWDWLRQDODV\PPHWU\RIWKHYHVWLEXODUV\VWHP PLJKW EHRQH RI WKHIDFWRUVOHDGLQJ WRSRVWXUDO G\VIXQFWLRQLQ$,6 :KHWKHUWKLV VWUXFWXUDO FKDQJH KDV DQ\ SURJQRVWLF HIIHFW RQ FXUYH SURJUHVVLRQ ZDUUDQWV IXUWKHU ORQJLWXGLQDO LQYHVWLJDWLRQ .H\ZRUGV%DODQFHG\VIXQFWLRQYHVWLEXODUV\VWHPVFROLRVLV

334

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-334

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Į FRQFXUUHQWYDOLGLW\ZDVGRQHE\FRPSDULVRQZLWKWKH6)DQGGLVFULPLQDQWYDOLGLW\XVLQJ $129$RQFOLQLFDOYDULDEOHV 7KH656VKRZHGDJRRGJOREDOLQWHUQDOFRQVLVWHQF\DQG LQ DOO RILWVGRPDLQV 0HDQ VFRUHV DQG VLJQLILFDQWGLIIHUHQFHVFDQEH IRXQGLQWDEOH7KH IDFWRULDO VWUXFWXUH ZDV FRKHUHQW ZLWK WKH RULJLQDO TXHVWLRQQDLUH ZLWK RI H[SODLQHG YDULDQFH +LJK FRUUHODWLRQ FRHIILFLHQWV ZHUH REWDLQHG EHWZHHQ 656 DQG 6) FRUUHVSRQGLQJ GRPDLQV
Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-335

335

7KHXVHRIDGHFLVLRQWUHHLQFUHDVHVDFFXUDF\ ZKHQFODVVLI\LQJDGROHVFHQW LGLRSDWKLF VFROLRVLVXVLQJ/HQNHFODVVLILFDWLRQ 33+$1 10(=*+$1,63$5(17 -$'(*8,6(+/$%(//(

/,6'+RSLWDO6DLQWH-XVWLQH0RQWUHDO4&&DQDGD /,2 &HQWUHGHUHFKHUFKHGX&+800RQWUHDO4&&DQDGD

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

336

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-336

$UHWKHUHVXEW\SHVLQ/HQNHFXUYHV" $3 6$1*2/(&($8%,1,$66WRNHV+/$%(//(

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± 30& ± DQG N\SKRVLV ± 7KH WZR VXUJLFDO JURXSV * FDVHV * FDVHV KDGVLPLODU&REEDQJOHV±± EXWH[KLELWHGGLIIHUHQW30&RULHQWDWLRQV *±*± DQGN\SKRVLV*±*± 3DWLHQWV* ZLWK KLJKHU30&YDOXHVDOVRVKRZHGK\SRN\SKRVLVFKDUDFWHULVWLFV3DWLHQWVZLWKVLPLODUWKRUDFLF VFROLRVLVFXUYHFKDUDFWHULVWLFVLQWKHFRURQDOSODQHPD\H[KLELW YHU\GLIIHUHQWFKDUDFWHULVWLFV LQWKHVDJLWWDOSODQHDVHYLGHQFHGE\GLVWLQFW30&RULHQWDWLRQ&ODVVLI\LQJ$,6XVLQJFOXVWHU DQDO\VLVUHYHDOHGVWUXFWXUDOGLIIHUHQFHVFKDUDFWHUL]LQJLQKHUHQW'FRPSOH[LWLHVLQWKHVSLQH ZKLFKDUHQRWFOHDUO\DSSDUHQWLQDVLQJOHSODQH .H\ZRUGVFOXVWHUDQDO\VLVDGROHVFHQWLGLRSDWKLFVFROLRVLVSDWWHUQUHFRJQLWLRQ

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-337

337

3RVWHULRULQVWUXPHQWHGVFROLRVLVFRUUHFWLRQLQ WKRUDFLFODWHRQVHWLGLRSDWKLFVFROLRVLVWZR \HDUUHVXOWV $$&2/(6$ 4$,0.+$1,66+$50$%1$
338

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-338

&DQVXUJLFDOUHGXFWLRQFRUUHFWVSLQRSHOYLF DOLJQPHQWLQ/6GHYHORSPHQWDO VSRQG\OROLVWKHVLV" +/$%(//( 35286628/< '&+23,1 (%(57+211$8'7+5(6.2 0 2 %5,(1

6DLQWH-XVWLQH8QLYHUVLW\&HQWHU+RVSLWDO0RQWUHDO4&&DQDGD &HQWUHGHV0DVVXHV/\RQ)UDQFH ,QVWLWXW&DORW%HUFN3ODJH)UDQFH &KLOGUHQ V+RVSLWDO%RVWRQ%RVWRQ0$86$ 0LDPL&KLOGUHQ+RVSLWDO0LDPL)/86$

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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-339

339

7KHUHODWLRQVKLSEHWZHHQSHOYLFEDODQFHDQG DGRPHVKDSHGVDFUXPLQGHYHORSPHQWDO VSRQG\OROLVWKHVLV +/$%(//(35286628/
340

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-340

$KLVWRULFDODQGREVHUYDWLRQDOVWXG\WR H[SRVHVRPHHWLRSDWKRJHQHWLFIDFWRUVWKDW PD\EHUHOHYDQWWRDGROHVFHQWLGLRSDWKLF VFROLRVLV$,6 LQVRPHSDWLHQWV 0(0&0$67(5 6FRWWLVK1DWLRQDO3DHGLDWULF6SLQH'HIRUPLW\&HQWUH 5R\DO,QILUPDU\(GLQEXUJK

$EVWUDFW ,QFRQVHFXWLYHVFROLRVLVSDWLHQWVUHIHUUHGWRD6SLQH&HQWUHZHUHUHPRYHG DIWHU WKH VXUJHRQ PDGH D GLDJQRVLV RI LQIDQWLOHMXYHQLOH LGLRSDWKLF VFROLRVLV FRQJHQLWDO VFROLRVLV FRQJHQLWDO N\SKRVLV 6FKHXHUPDQQ¶V GLVHDVH QHXURILEURPDWRVLV PXVFXODU G\VWURSK\ 0DUIDQ¶V RU 0DUIDQRLG V\QGURPH RU VSRQG\OROLVWKHVLV 1H[W ZHUH HOLPLQDWHGIRUVHYHUDOUHDVRQVLQFOXGLQJROGHUSDWLHQWVZKRGLGQRWDWWHQGZLWKWKHLUSDUHQWV $,6SDWLHQWVZKRVHPRWKHURUIDWKHUKDGOHIWWKHIDPLO\KRPHVWUDLJKWVSLQHORZ,4WLSWRH ZDONHUVRWKHUPHGLFDOSUREOHPVEDFNSDLQDQGDIDPLO\KLVWRU\RIVFROLRVLV 7KHUHPDLQLQJ $,6SDWLHQWVZHUHGHHPHG KHDOWK\¶E\VL[FULWHULD0F0DVWHUHWDO DQGFODVVLILHG DV ,QIDQW VZLPPHUV SDWLHQWV JLUOV ER\V WDNHQ WR DQ LQGRRU KHDWHG VZLPPLQJ SRROLQWKHLUILUVWPRQWKV0F0DVWHUHWDO 3RRU GLHW SDWLHQWV JLUOV ER\V 2Q TXHVWLRQLQJ WH[WXUH ZDV WKH SURKLELWLQJ IDFWRU LQ WKH FKLOG¶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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-341

341

)UHQFK&DQDGLDQYDOLGDWLRQRIWKH6SLQDO $SSHDUDQFH4XHVWLRQQDLUH6$4 LQWKH DGROHVFHQWSDWLHQWVDWDVFROLRVLVFOLQLFDQGLWV FOLQLFDODSSOLFDWLRQ 63$5(17 0 52<%($8'5<--21&$6 0%($86e-2850 )25&,(5 6%(.+,&+(* *5,0$5'+ /$%(//(

6DLQWH-XVWLQH8QLYHUVLW\+RVSLWDO&HQWHU &{WH6WH&DWKHULQH5G 0RQWUpDO4XpEHF+7&&DQDGD

'HSWRI0HFKDQLFDO(QJLQHHULQJeFROH3RO\WHFKQLTXHGH0RQWUpDO 32%R[ 6WDWLRQ³&HQWUH9LOOH´ 0RQWUpDO4XpEHF+&$&DQDGD

$EVWUDFW 7KH 6$4 ZDV GHYHORSHGWR PHDVXUH SDWLHQWV¶DQG SDUHQWV¶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¶DQG SDUHQWV¶ VFRUHV ZHUH VLJQLILFDQWO\ PRUHDIIHFWHG ZKHQFRPSDUHG WR RWKHU JURXSVREVHUYDWLRQEUDFHGDQGSRVWRS ,QWKH6$4IYVHFRQGSDUW 44 D8 VKDSHGGLVWULEXWLRQDQGDKLJKHUGLVDJUHHPHQWEHWZHHQSDUHQWVDQG SDWLHQWVZHUHREVHUYHG TXHVWLRQLQJWKHUHVSRQVHVFDOHFRQVWUXFWLRQ 7KH6$4IYVKRZVVDWLVIDFWRU\YDOLGLW\DQG UHOLDELOLW\ LQ VSLQDO GHIRUPLW\ DSSHDUDQFH HYDOXDWLRQ 6LQFH LW LV LQGHSHQGHQW RI SDWLHQW¶V JHQHUDO FKDUDFWHULVWLFV LW FDQ GLVFULPLQDWH EHWZHHQ UHOHYDQW FOLQLFDO YDOXHV DQG SURYLGH XVHIXOLQIRUPDWLRQIRUWKHFOLQLFDOPDQDJHPHQWRI$,6SDWLHQWV

342

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-342

$QHQHUJ\EDVHGPHFKDQRELRORJLFDOJURZWK PRGHOIRUVLPXODWLQJYHUWHEUDOSURJUHVVLYH GHIRUPLWLHVXQGHUPXOWLGLUHFWLRQORDGV +/,1&e$8%,1 ,9,//(085(63$5(17

'HSWRI0HFKDQLFDO(QJLQHHULQJeFROH3RO\WHFKQLTXHGH0RQWUpDO 32%R[ 6WDWLRQ³&HQWUH9LOOH´ 0RQWUpDO4XpEHF+&$&DQDGD

6DLQWH-XVWLQH8QLYHUVLW\+RVSLWDO&HQWHU &{WH6WH&DWKHULQH5G 0RQWUpDO4XpEHF+7&&DQDGD

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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-343

343

86DQG(XURSHDQ5LVVHUJUDGLQJV\VWHPV ZKLFKRQHEHVWSUHGLFWWKHFXUYHDFFHOHUDWLRQ SKDVHLQDGROHVFHQWLGLRSDWKLFVFROLRVLV" 0/1$8/7 63$5(17 +/$%(//(052<%($8'5<0 5,9$5'

6WH-XVWLQH+RVSLWDO0RQWUHDO&DQDGD 6RFLDODQGSUHYHQWLYHPHGLFLQH8QLYHUVLW\RI0RQWUHDO0RQWUHDO &DQDGD

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

344

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-344

'HFUHDVHG/HDQ0DVVLQ$GROHVFHQW ,GLRSDWKLF6FROLRVLV /,:(,*824,8<21* 6SLQH6XUJHU\WKH$IILOLDWHG'UXP7RZHU+RVSLWDORI1DQMLQJ8QLYHUVLW\0HGLFDO6FKRRO 1DQMLQJ&KLQD

$EVWUDFW 6HYHUDO VWXGLHV KDYH UHYHDOHG WKDW DGROHVFHQW LGLRSDWKLF VFROLRVLV $,6 SDWLHQWV KDGORZHU%0,WKDQWKHQRUPDOFRQWUROVDQGVRPHREVHUYDWLRQVVXJJHVWHGWKDWWKHUHPD\EH DUHODWLRQVKLSEHWZHHQ$,6DQGERG\FRPSRVLWLRQ,WKDVEHHQIRXQGWKDWERG\IDWPDVVZDV UHODWHG WR WKH VHYHULW\ RI $,6 GXULQJ SHULSXEHUWDO WLPH EXW WKH GLIIHUHQFH RI ERG\ FRPSRVLWLRQEHWZHHQ $,6DQG QRUPDO FRQWUROV KDV QHYHU EHHQ VWXGLHG $WRWDORI $,6 JLUOV DQG QRUPDOJLUOVZLWK5LVVHU ZHUHUHFUXLWHG7KH FXUYH VHYHULW\ZDV PHDVXUHG XVLQJ&REE¶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

.H\ZRUGVDGROHVFHQWLGLRSDWKLFVFROLRVLVERQHPLQHUDOGHQVLW\ERG\FRPSRVLWLRQ

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-345

345

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a/ DQG SUR[LPDO IHPXU ZDV REYLRXVO\ ORZHU LQ $,6 JURXS WKDQ WKDW RI WKH FRQWURO JURXS ,QFUHDVHG H[SUHVVLRQ RI 5$1./DQGGHFUHDVHGH[SUHVVLRQRI23*ZHUHIRXQGLQ06&VLQ$,6JURXSDVFRPSDUHG ZLWKWKH FRQWURO JURXS3 7KHDEQRUPDO H[SUHVVLRQ RI5$1./DQG23* RI 06&V PD\EHUHVSRQVLEOHIRUWKHPROHFXODUPHFKDQLVPRIWKHGHFUHDVHGERQHPDVVRIDGROHVFHQW LGLRSDWKLFVFROLRVLVSDWLHQWV .H\ ZRUGV㧦$GROHVFHQW LGLRSDWKLF VFROLRVLV %RQH 0LQHUDO 'HQVLW\ 3DWKRJHQHVLV 0HVHQFK\PDO6WHP&HOOV5$1./2VWHRSURWHJHULQ

346

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-346

$VVRFLDWLRQ%HWZHHQ*URZWK+RUPRQH*HQH DQG$GROHVFHQW,GLRSDWKLF6FROLRVLV 4,8 ;X6KHQJ7$1*1HOVRQ/HXQJ6DQJ4<(81*+LX
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¶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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-347

347

([SUHVVLRQRIPHODWRQLQUHFHSWRULQ FKRQGURF\WHRIDGROHVFHQWLGLRSDWKLF VFROLRVLV 681*XDQJTXDQ:$1*:HLMXQ+8$1*$LELQJ&+(1*-DFN&KXQ
6SLQH6XUJHU\WKH$IILOLDWHG'UXP7RZHU+RVSLWDORI1DQMLQJ8QLYHUVLW\0HGLFDO

6FKRRO1DQMLQJ&KLQD'HSDUWPHQWRI2UWKRSDHGLFVDQG7UDXPDWRORJ\ WKH &KLQHVH8QLYHUVLW\RI+RQJ.RQJ&KLQD7KH-RLQW6FROLRVLV5HVHDUFK&HQWHURI1DQMLQJ 8QLYHUVLW\ WKH &KLQHVH8QLYHUVLW\RI+RQJ.RQJ 4,8
348

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-348

P51$ ([SUHVVLRQVRI 7\SH,FROODJHQ 2VWHRFDOFLQDQG2VWHRSURWHJHULQ LQ ,OLDF &DQFHOORXV%RQHIURP *LUOVZLWK $GROHVFHQW ,GLRSDWKLF6FROLRVLV 681;X4,8
Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-349

349

([SUHVVLRQRI5XQ[DQGW\SH;FROODJHQLQ KXPDQYHUWHEUDOJURZWKSODWHRIDGROHVFHQW LGLRSDWKLFVFROLRVLV :$1*6KRXIHQJ4,8
([SUHVVLRQ

GLVFUHSDQF\ RI W\SH ; FROODJHQ DQG 5XQ[ EHWZHHQ FRQYH[ DQG FRQFDYH VLGHV RI WKH YHUWHEUDOJURZWKSODWHLPSOLFDWHDGLIIHUHQWFKRQGURF\WLFNLQHWLFVZKLFKPD\EHDSRVVLEOH HWLRORJLFDOIDFWRURUDVHFRQGDU\FKDQJHLQWKH SURJUHVVLRQ RIDGROHVFHQWLGLRSDWKLFVFROLRVLV

.H\ZRUGV LGLRSDWKLFVFROLRVLV W\SH;FROODJHQ5XQ[JURZWKSODWH

350

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-350

,VFRUWLFRVSLQDOWUDFWRUJDQL]DWLRQGLIIHUHQWLQ LGLRSDWKLFVFROLRVLV" '0LKDLOD %&DODQFLH

'HSDUWPHQWRI1HXURVFLHQFH681<8SVWDWH0HGLFDO8QLYHUVLW\6\UDFXVH1< 'HSDUWPHQWRI1HXURVXUJHU\681<8SVWDWH0HGLFDO8QLYHUVLW\6\UDFXVH1<

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° ,Q DGGLWLRQ ILQJHUDQGKDQGGH[WHULW\ZDVORZHULQ,6VXEMHFWVUHODWLYHWRFRQWUROV7KHVHILQGLQJVVXJJHVW D GLIIHUHQW&67 IXQFWLRQDO RUJDQL]DWLRQ LQ ,6 IXUWKHU XQGHUVFRULQJ WKHLPSRUWDQFH RI QHXUDO IDFWRUVLQWKHHWLRSDWKRJHQHVLVRI,6

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-351

351

(IIHFWVRILQYLYR0HFKDQLFDOORDGLQJRQ H[WUDFHOOXODUPDWUL[FRPSRQHQWVRIWKH JURZWKSODWH 0&DQFHO,9LOOHPXUH)0ROGRYDQ**ULPDUG 'HSWRI0HFKDQLFDO(QJLQHHULQJeFROH3RO\WHFKQLTXHGH0RQWUpDO 32%R[6WDWLRQ³&HQWUH9LOOH´ 0RQWUpDO4XpEHF+&$&DQDGD 6DLQWH-XVWLQH8QLYHUVLW\+RVSLWDO&HQWHU &{WH6WH&DWKHULQH5G 0RQWUpDO4XpEHF+7&&DQDGD )DFXOW\RI'HQWLVWU\6WRPDWRORJ\ 8QLYHUVLWpGH0RQWUpDO 0RQWUHDO4XHEHF+7-&DQDGD

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μPGD\ IRU WKH FRQWURO VKDP DQG ORDGHG JURXSV &RPSUHVVLRQ PRGXODWHG & JURZWK E\ S DQG S< DV FRPSDUHG WR FRQWUROV DQG VKDPV UHVSHFWLYHO\ $W WKH H[WUDFHOOXODU PDWUL[ OHYHO QR FKDQJH ZDV REVHUYHG LQ WKH SURWHRJO\FDQV1HYHUWKHOHVVWKHH[SUHVVLRQRIW\SH;DQG,,FROODJHQVZDVUHGXFHGLQ DQGUHVSHFWLYHO\RIWKHORDGHGUDWV 6WDWLFFRPSUHVVLRQORDGLQJUHGXFHVERQHJURZWK UDWH,QYLYRWKLVJURZWKPRGXODWLRQLQYROYHVUHPRGHOLQJRIWKHH[WUDFHOOXODUPDWUL[ZKLFK FRXOGLQWXUQOHDGWRFKDQJHVLQVXUURXQGLQJFHOOXODUDFWLYLWLHV

352

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-352

7UDQVYHUVH3ODQH3HOYLF5RWDWLRQIROORZLQJ 5RWDWLRQDOO\&RUUHFWLYH,QVWUXPHQWDWLRQRI $GROHVFHQW,GLRSDWKLF6FROLRVLV'RXEOH &XUYHV 0$$6+(5'&%85721 60/$,-/*80%&$5/621

'HSDUWPHQWRI2UWKRSHGLF6XUJHU\8QLYHUVLW\RI.DQVDV0HGLFDO&HQWHU.DQVDV&LW\ .686$ 'HSDUWPHQWRI3UHYHQWLYH0HGLFLQH +HDOWK6FLHQFHV8QLYHUVLW\RI.DQVDV0HGLFDO &HQWHU.DQVDV&LW\.DQVDV86$ 6FKRRORI0HGLFLQH8QLYHUVLW\RI.DQVDV0HGLFDO&HQWHU.DQVDV&LW\.DQVDV86$

$EVWUDFW 1RWLFHDEOH SHOYLFURWDWLRQVRPHWLPHV RFFXUV KRZRIWHQ" 2I FRQVHFXWLYH SDWLHQWVKDGGRXEOHFXUYHV/HQNH 5RWDWLRQDOO\FRUUHFWLYHOXPEDUSHGLFOHVFUHZ LQVWUXPHQWDWLRQZDVXWLOL]HGLQ 7UDQVYHUVHSODQHSHOYLFURWDWLRQ7335 ZDVTXDQWLILHG E\ WKH /5 KHPLSHOYLV ZLGWK UDWLR IURP VWDQGLQJ 3$ VFROLRVLV UDGLRJUDSKV ;UD\V ZHUH RULHQWHG ZLWK WKH WKRUDFROXPEDUOXPEDU 7// DSH[ OHIW 7KH /5 UDWLR LV ! ZLWK OHIW SHOYLV URWDWLRQ >FRXQWHUFORFNZLVH a FOLQLFDOO\ QRWLFHDEOH @ DQG ZLWK ULJKW URWDWLRQ >FORFNZLVH a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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-353

353

$0XOWLYDULDWH5HJUHVVLRQ0RGHOIRU 3UHGLFWLQJWKH77.\SKRVLVLQ $GROHVFHQW,GLRSDWKLF6FROLRVLV 6.DGRXU\)&KHULHW+/DEHOOH

'HSDUWPHQWRI%LRPHGLFDO(QJLQHHULQJ(FROH3RO\WHFKQLTXHRI0RQWUp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± IRU QRUPDO N\SKRWLF FXUYHV VSLQHV N\SKRVLV UDQJH ± DQG IRU K\SHUN\SKRWLFFXUYHV VSLQHVN\SKRVLV ! 7KLV SDSHU SUHVHQWV SURPLVLQJ UHVXOWV IRU D PXOWLYDULDWH UHJUHVVLRQ PRGHO ZKLFK LV DEOH WR SUHGLFW WKH VDJLWWDO WKRUDFLF N\SKRVLV EHWZHHQ 7 DQG 7 EXLOW RQ WKH WKRUDFLF &REE DQG OXPEDU ORUGRVLV PHDVXUHV $OWKRXJKWKHHVWLPDWHLVQRWSHUIHFWO\DFFXUDWHLWIDOOVZLWKLQDUHDVRQDEOHUDQJH WRDVVHVVDGHTXDWHO\ WKHVDJLWWDOFXUYHRIWKHVSLQH

354

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-354

3RRU%RQH0HFKDQLFDODQG6WUXFWXUDO 3URSHUWLHVLQ $,63DWLHQWV±8VLQJ 1RQLQYDVLYH4XDQWLWDWLYH8OWUDVRXQG +XQJ9:<4LQ/
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≥° DQG DJHPDWFKHG QRUPDOFRQWURO JLUOV ZHUHUHFUXLWHG486 PHDVXUHPHQW ZDVSHUIRUPHGDW WKH QRQGRPLQDQW VLGH RI FDOFDQHXP 3DUDPHWHUV PHDVXUHG E\ 486 LQFOXGHG EURDGEDQG XOWUDVRXQG DWWHQXDWLRQ %8$ YHORFLW\ RI VRXQG 926 DQG VWLIIQHVV LQGH[ 6, ,QGHSHQGHQW WWHVW ZDV XVHG IRU DQDO\VLV 5HVXOWV VKRZHG WKDW WKHUH ZHUH QR VLJQLILFDQW GLIIHUHQFH LQ DJH DQG PHQDUFKDO DJH EHWZHHQ $,6 DQG FRQWUROV S! 7KH PHDQ &REE DQJOHIRU$,6JLUOVZDV °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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-355

355

7KH(IIHFWRQWKH ,QWHUYHUWHEUDO3UHVVXUH 'LVWULEXWLRQLQD*RDW6SLQHXSRQ ,PSOHPHQWDWLRQRID6SULQJ/LNH'HYLFH /LX;& 5L]]D5 7KRPHW]-7DVVRQH&/\RQ5

'HSWRI2UWKRSDHGLF6XUJHU\0HGLFDO&ROOHJHRI:LVFRQVLQ 'HSWRI0HFKDQLFDO(QJLQHHULQJ0LOZDXNHH6FKRRORI(QJLQHHULQJ0LOZDXNHH:,

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

356

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-356

6WUHVVVKLHOGLQJZLWKLQWKHVFROLRWLFVSLQHD SURJUHVVLYHULVNIDFWRU" 0'ULVFROO&e$XELQ63DUHQW$0RUHDX eFROH3RO\WHFKQLTXH &+86DLQWH-XVWLQH0RQWUpDO4&

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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-357

357

6XVSHQVLRQLVEHWWHUWKDQVLGHEHQGLQJWR DVVHVVVSLQDOIOH[LELOLW\LQ$GROHVFHQW ,GLRSDWKLF6FROLRVLV 0(/DPDUUH 63DUHQW+ /DEHOOH &($XELQ--RQFDV <3HWLW

6DLQWH-XVWLQH8QLYHUVLW\ +RVSLWDO &HQWHU&{WH6DLQWH&DWKHULQH0RQWUHDO 4XHEHF&DQDGD+7& 'HSDUWPHQWRI2UWKRSDHGLF6XUJHU\8QLYHUVLW\RI0RQWUHDO32%R[6WDWLRQ &HQWUHYLOOH0RQWUHDO4XHEHF&DQDGD+&- 'HSDUWPHQWRI0HFKDQLFDO(QJLQHHULQJeFROHGHWHFKQRORJLHVXSpULHXUH 1RWUH'DPH2XHVW0RQWUHDO4XHEHF&DQDGD+&. &RUUHVSRQGLQJDXWKRU 'HSDUWPHQWRI0HFKDQLFDO(QJLQHHULQJeFROH3RO\WHFKQLTXH32%R[6WDWLRQ &HQWUH9LOOH0RQWUHDO4XHEHF&DQDGD+&$ $EVWUDFW 6SLQH IOH[LELOLW\ LV DGHFLVLYHSDUDPHWHUIRUWKHSODQQLQJRI$GROHVFHQW,GLRSDWKLF 6FROLRVLV$,6 VXUJHU\ 6LGHEHQGLQJLVWKH JROG VWDQGDUGWHVW+RZHYHU LW VXIIHUV IURPD SRRUUHSURGXFLELOLW\ DQGLWPHDVXUHVFXUYH UHGXFLELOLW\UDWKHUWKDQIOH[LELOLW\VLQFHWKHIRUFHV LQYROYHG DUHQRWNQRZQ$IOH[LELOLW\WHVWFRQVLVWLQJLQDFRPSOHWHVXVSHQVLRQRIWKHVXEMHFW E\ D KDUQHVV ZDV SURSRVHG 7KH DLP RI WKLV VWXG\ ZDV WR YHULI\ LI VXVSHQVLRQ LV D EHWWHU PHWKRGWKDQVLGHEHQGLQJWRHVWLPDWHVSLQHIOH[LELOLW\ )LYHSRVWHURDQWHULRUUDGLRJUDSKVRI $,6 VXEMHFWV ZKR XQGHUZHQW VXUJLFDO LQVWUXPHQWDWLRQ ZHUH DQDO\]HG SUHRSHUDWLYH VWDQGLQJ ULJKW DQG OHIW EHQGLQJ FRPSOHWH VXVSHQVLRQ DQG SRVWRSHUDWLYH VWDQGLQJ &REE DQJOHV DQG D[LDO URWDWLRQ RI DSLFDO YHUWHEUDH ZHUH PHDVXUHG WR DVVHVV WKH SUHRSHUDWLYH UHGXFWLRQ ZLWK ERWK WHVWV FRPSDUHG WR WKH VXUJLFDO FRUUHFWLRQ ,Q DGGLWLRQ IOH[LELOLW\ LQGLFHVSHUFXUYHLQWKHFRURQDODQGWUDQVYHUVHSODQHV ZHUHFDOFXODWHGIURP WKHVXVSHQVLRQ GDWD 7KHUH ZDV QR VWDWLVWLFDO GLIIHUHQFH LQ SUHRSHUDWLYH FXUYH UHGXFWLRQ EHWZHHQ WKH VXVSHQVLRQDQGVLGHEHQGLQJWHVWVYV 7KHWZRWHVWVXQGHUHVWLPDWHGWKHVXUJLFDO FRUUHFWLRQ 6XVSHQVLRQSURGXFHGODUJHUSUHRSHUDWLYH D[LDOGHURWDWLRQ WKDQVLGH EHQGLQJ 7KH VXVSHQVLRQ WHVW DOORZHG FDOFXODWLQJ IOH[LELOLW\ LQGLFHV LQ WKH FRURQDO ± 1P DQGWUDQVYHUVH ±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

358

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-358

&ODVVLILFDWLRQRIVFROLRVLVGHIRUPLW\' VSLQDOVKDSHE\FOXVWHUDQDO\VLV ,DQ$)6WRNHV $UFKDQD36DQJROH3K'DQG&DUO(ULF$XELQ

8QLYHUVLW\RI9HUPRQW%XUOLQJWRQ9HUPRQW86$ (FROH3RO\WHFKQLTXH0RQWUHDO4XHEHF&DQDGDDQG6DLQWH-XVWLQH8QLYHUVLW\+RVSLWDO &HQWUH0RQWUHDO4XHEHF&DQDGD

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

7KH JURXS DVVLJQPHQWV FDQ FKDQJH ZLWK UHSHDWHG

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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-359

359

$OWHUDWLRQRI0RELOLW\DQG7UXQN0XVFOH $FWLYDWLRQ'XULQJ:DONLQJDQG%HQGLQJLQ $,63DWLHQWVZLWK3RVWHULRU)XVLRQ &7DVVRQH ;&/LX7-RQHV-7KRPHW] 5/\RQ 'HSWRI2UWKRSDHGLF6XUJHU\0HGLFDO&ROOHJHRI:LVFRQVLQ0LOZDXNHH:,86$ $EVWUDFW 7KHSXUSRVH RIWKLVVWXG\ LVWRLQYHVWLJDWH WKH GLIIHUHQFHV LQ MRLQW PRYHPHQW RI WKH ORZHU H[WUHPLW\ /( SRVWXUDO PRELOLW\ DQG SDUDYHUWHEUDO PXVFOH DFWLYLW\ EHWZHHQ SDWLHQWVZKRKDYHXQGHUJRQHSRVWHULRUIXVLRQSURFHGXUHVIRUSURJUHVVLYHLGLRSDWKLFVFROLRVLV DQG KHDOWK\ YROXQWHHUV .LQHPDWLFV RI WKH /( DQG WUXQN ZHUH DQDO\]HG XVLQJ DQ (OHFWURPDJQHWLF 7UDFNLQJ 6\VWHP 3ROKHPXV ,QF &ROFKHVWHU 97 GXULQJ OHYHO ZDONLQJ DQG PXVFXODU DFWLYLW\ PHDVXUHG GXULQJ VWDWLRQDU\ IOH[LRQ H[WHQVLRQ DQG ODWHUDO EHQGLQJ XVLQJ VXUIDFH (0* 1RUD[RQ 6FRWWVGDOH $= 7KH VWXG\ LQFOXGHG SDWLHQWV ZKR KDG XQGHUJRQH SRVWHULRU VSLQDO IXVLRQ ZLWK LQVWUXPHQWDWLRQ UDQJLQJ IURP 7 WR / DQG KHDOWK\ YROXQWHHUV ZLWKRXW VSLQDO DV\PPHWU\ 0HDQ DJH RI SDWLHQWV ZDV \HDUV DW VXUJHU\ DQG \HDUV DW IROORZXS 6WDQGDUG WWHVW ZDV XVHG WR GHWHUPLQH VLJQLILFDQFH S 7KHUHZDVDWUHQGWRZDUGVLQFUHDVHGJDLWYHORFLW\DQGLQFUHDVHGFDGHQFHLQIXVHG SDWLHQWV 7RUVR GLVSODFHPHQW LQ WKH VDJLWWDO SODQH ZDV LQFUHDVHG ZKHUHDV WUXQFDO URWDWLRQ ZDV GHFUHDVHGSRVWIXVLRQDV FRPSDUHGWRQRUPDOVXEMHFWV 6LJQLILFDQWUHGXFWLRQLQ SHOYLF WLOWDVZHOODVKLSDQGNQHH520LQERWKVWDQFHDQGVZLQJSKDVHZHUHPHDVXUHGSRVWIXVLRQ 3 'UDPDWLF UHGXFWLRQV RI WKH DUHD PHDQ DQG SHDN YDOXHV RI HDFK (0* SKDVH IOH[LRQ DQG UHOD[DWLRQ ZHUH VHHQ LQ WUDSH]LXV ODWLVVLPXV GRUVL DQG PXOWLILGXV DFWLYLW\ GXULQJ IRUZDUG IOH[LRQ H[WHQVLRQ DQGODWHUDO EHQGLQJ LQ SRVWRSHUDWLYHSDWLHQWV3 2YHUDOO SDWLHQWV ZKR KDYH XQGHUJRQH SRVWHULRU VSLQDO IXVLRQ IRU LGLRSDWKLF VFROLRVLV GHPRQVWUDWH DOWHUHG JDLW SDWWHUQV DV ZHOO DV GLPLQLVKHG SDUDVSLQDO PXVFXODU UHFUXLWPHQW GXULQJVSLQDOPRWLRQV

360

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-360

7KUHHGLPHQVLRQDO05,DQDO\VLVRI WKHVNXOO PRUSKRPHWU\LQ DGROHVFHQWLGLRSDWKLF VFROLRVLVJLUOV $ SLORWVWXG\
Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-361

361

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

362

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-362

$1HZ6\VWHPIRU&ODVVLI\LQJ7RUVR 'HIRUPLWLHVLQ6FROLRVLVXVLQJ/RFDOL]HG 6KDSH,QGLFHV 32$MHPED1*'XUGOH DQG9-5DVR

,PDJLQJ7HFKQRORJLHV/DE*(*OREDO5HVHDUFK&HQWUH%DQJDORUH,QGLD

(OHFWULFDODQG&RPSXWHU(QJ8QLYHUVLW\RI$OEHUWD(GPRQWRQ$OEHUWD&DQDGD

'HSWRI5HKDELOLWDWLRQ7HFKQRORJ\*OHQURVH5HKDELOLWDWLRQ+RVSLWDO (GPRQWRQ $OEHUWD&DQDGD $EVWUDFW $FFXUDWHFODVVLILFDWLRQRIWKH VHYHULW\ DQGW\SH RIWRUVR GHIRUPLW\ LV XVHIXOIRU WKH FOLQLFDO PDQDJHPHQW RI VFROLRVLV ([LVWLQJ PHWKRGV RI FODVVLILFDWLRQ DUH EDVHG RQ ODQGPDUNVVWDWLVWLFVDQGPDFKLQHOHDUQLQJ/DQGPDUNLGHQWLILFDWLRQLVGLIILFXOWDQGSURQHWR HUURU 6WDWLVWLFV DQG PDFKLQH OHDUQLQJ RIWHQ \LHOG JHQHULF JOREDO FODVVLILFDWLRQV RI VHYHULW\ VXFK DV PLOG PRGHUDWH DQG VHYHUH 7KLV SDSHU SUHVHQWV D QHZ ORFDOL]HG FODVVLILFDWLRQ V\VWHPIRUWRUVRGHIRUPLWLHVLQVFROLRVLVFRPSULVHGRIDGHIRUPLW\W\SHDQGDVHYHULW\VFRUH 7KH V\VWHP LV EDVHG RQ ORFDO VKDSH LQGLFHV REWDLQHG IURP PDWKHPDWLFDO PRGHOV FDOOHG VWUXFWXUHG VSOLQHV PRGHOV 6WUXFWXUHG VSOLQHV PRGHOV FDSWXUH VKDSH FRPSRQHQWV LQ WKH FRURQDO D[LDO DQG ODWHUDO SODQHV %\ GLYLGLQJ HDFK WRUVR LQWR DSLFDO WKRUDFLF DQG OXPEDU YHUWHEUDUHJLRQVDQGFRQVLGHULQJWKHVKDSHFRPSRQHQWVLQHDFKRIWKHWKUHHSODQHVZHDUULYH DWGHIRUPLW\FODVVHV ([SHULPHQWVRQLPDJHVRIYROXQWHHUVVKRZWKDWWKHV\VWHPLV UREXVW WR YDULDWLRQV GXHWRSRVWXUH DQG SRVLWLRQLQJ5HVXOWV RIWKH DQDO\VLV RI IXOOWRUVR DQG EDFNWRUVR LPDJHVRI VFROLRVLV SDWLHQWV VKRZWKDW PRVW VFROLRVLVWRUVRV RFFXS\ RQO\RIWKH FODVVHV([SHULPHQWV DOVRVKRZWKDWWKH W\SH RIWRUVR GHIRUPLW\VWURQJO\ FRUUHODWHV WR /HQNH¶V VSLQDO GHIRUPLW\ FODVVLILFDWLRQ IRU WKLQ SDWLHQWV EXW QRW IRU SOXPS SDWLHQWV 7KH VHYHULW\ RI WRUVR GHIRUPLW\ VWURQJO\ FRUUHODWHV WR WKH VHYHULW\ RI VSLQDO GHIRUPLW\&REEDQJOH IRUWKLQSDWLHQWV7KHVHYHULW\RIWRUVRGHIRUPLW\VWURQJO\FRUUHODWHV WRFOLQLFLDQV¶VFRUHRIGHIRUPLW\EXWQRWWRFOLQLFLDQV¶VFRUHRISDWLHQWFOLQLFDOKLVWRU\

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-363

363

$QRYHOYLVXDOL]DWLRQVFKHPHIRUPRQLWRULQJ DQGWUDFNLQJRIWRUVRGHIRUPLWLHVLQVFROLRVLV 32$MHPED1*'XUGOH 9-5DVR

,PDJLQJ7HFKQRORJLHV/DE*(*OREDO5HVHDUFK&HQWUH%DQJDORUH,QGLD (OHFWULFDODQG&RPSXWHU(QJ8QLYHUVLW\RI$OEHUWD(GPRQWRQ$OEHUWD&DQDGD 'HSWRI5HKDELOLWDWLRQ7HFKQRORJ\*OHQURVH5HKDELOLWDWLRQ+RVSLWDO (GPRQWRQ$OEHUWD&DQDGD

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j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

364

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-364

$QDO\VLVRIWUXQNH[WHUQDODV\PPHWU\ LQVLGH EHQGLQJ 3$=269DOpULH0,/(')HWKLD'(%$11e3KLOLSSH/$%(//(+XEHUW&+(5,(7 )DULGD

(FROH3RO\WHFKQLTXH3%R[6WDWLRQ&HQWUHYLOOH0RQWUpDO&DQDGD+&$ 5HVHDUFK&HQWHU6WH-XVWLQH+RVSLWDO&{WH6WH&DWKHULQH0RQWUp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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-365

365

6DJLWWDO6SLQR3HOYLF$OLJQPHQWLQ /XPERVDFUDO6SRQG\OROLVWKHVLV -HDQ0DUF0DF7KLRQJ =KL:DQJ -DFTXHV$GH*XLVH +XEHUW/DEHOOH

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

366

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-366

&HUHEURVSLQDO)OXLG&6) )ORZ'\QDPLFVDW WKH&UDQLRFHUYLFDO-XQFWLRQLQ$GROHVFHQW ,GLRSDWKLF6FROLRVLV0RUSKRORJLFDODQG )XQFWLRQDO6WXG\ZLWK3KDVHFRQWUDVW 0DJQHWLF5HVRQDQFH,PDJLQJ &KX:&:0DQ*&:/DP::0
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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-367

367

,V7KHUHDQ\5HJLRQDO'LIIHUHQFHRI%UDLQ 7LVVXH'HQVLWLHV%HWZHHQ $GROHVFHQW ,GLRSDWKLF6FROLRVLV$,6 3DWLHQWVDQG 1RUPDO&RQWUROVD0RUSKRPHWULF6WXG\ZLWK +LJK5HVROXWLRQ05%UDLQ,PDJLQJ &KX:&: 6KL/ :DQJ' 3DXV 7 3LWLRW $ %XUZHOO 5* 0DQ*&:&KHQJ $
'HSDUWPHQWRI'LDJQRVWLF5DGLRORJ\ 2UJDQ,PDJLQJ &RPSXWHU6FLHQFHDQG(QJLQHHULQJ 2UWKRSDHGLFV 7UDXPDWRORJ\&KLQHVH8QLYHUVLW\RI+RQJ.RQJ %UDLQDQG%RG\&HQWUH8QLYHUVLW\RI1RWWLQJKDP 'HSDUWPHQWRI6SLQDO6XUJHU\8QLYHUVLW\RI$GHODLGH$XVWUDOLD &HQWUHIRU6SLQDOVWXGLHVDQG6XUJHU\4XHHQ¶V0HGLFDO&HQWUH1RWWLQJKDP8.

$EVWUDFW 2EVHUYDWLRQ RI VXEFOLQLFDO QHXURORJLFDO DEQRUPDOLWLHV KDV OHG WR SURSRVDO RI QHXURGHYHORSPHQWDO HWLRORJLF PRGHO IRU $,6 /RQJHU ODWHQF\ LQ VRPDWRVHQVRU\ ±HYRNHG SRWHQWLDO66(3 DQG LPSDLUHG EDODQFH FRQWURO KDYHEHHQGHPRQVWUDWHGLQ$,6 VXEMHFWV,Q WKLVVWXG\ZHLQYHVWLJDWHGZKHWKHUUHJLRQDOEUDLQWLVVXHGHQVLWLHVLQ$,6SDWLHQWVGLIIHUIURP PDWFKHG FRQWURO VXEMHFWV 1LQH OHIW WKRUDFLF $,6 JLUOV PHDQ &REEV DQJOH ° DQG PDWFKHGFRQWUROV ULJKWWKRUDFLF$,6JLUOVPHDQ&REEV ° DQG PDWFKHGFRQWUROV XQGHUZHQW 05 LPDJLQJ RI WKH EUDLQ )XOO\ DXWRPDWLF PRUSKRPHWULF DQDO\VLV ZDV XVHG WR DQDO\VH WKH 05 LPDJHVLW LQFOXGHGOLQHDU UHJLVWUDWLRQWRD WHPSODWH EUDLQDQG EUDLQWLVVXH FODVVLILFDWLRQ LQWR JUH\ PDWWHU *0 ZKLWH PDWWHU :0 DQG FHUHEURVSLQDO IOXLG &6) 7LVVXH GHQVLWLHV ZHUH FRPSDUHG EHWZHHQ $,6 VXEMHFWV DQG FRQWUROV 7KHUH ZDV QR VLJQLILFDQWGLIIHUHQFHEHWZHHQ$,6 VXEMHFWVDQG QRUPDO FRQWUROV ZKHQ FRPSDULQJDEVROXWH DQGUHODWLYHLHEUDLQVL]H DGMXVWHG YROXPHV RI JUH\ DQGZKLWH PDWWHU8VLQJ YR[HOEDVHG PRUSKRPHWU\VLJQLILFDQW JURXS GLIIHUHQFHV &RQWUROV ! OHIW $,6 ZHUHIRXQGLQ GHQVLW\RI :0 LQ JHQX RI FRUSXV FDOORVXP OHIW LQWHUQDO FDSVXOHDQWHULRU DUP DQG :0 XQGHUO\LQJ RUELWRIURQWDOFRUWH[RIWKHOHIWKHPLVSKHUH7KH DERYHGLIIHUHQFHZDVQRW REVHUYHG LQULJKW $,6 JURXS &RUSXV FDOORVXP PDMRU FRPPLVVXUDO ILEHU UHVSRQVLEOH IRU FRQWUROOLQJ WKH EDODQFH RI ULJKW DQG OHIW VLGH RI WKH ERG\ ZDV GLIIHUHQW LQ DW\SLFDO OHIW VFROLRVLV ZKLOH VLJQLILFDQW UHJLRQDO EUDLQ FKDQJHV KDYH QRW \HW IRXQG LQ WKRVH ZLWK W\SLFDO ULJKW WKRUDFLF VFROLRVLV)XUWKHULQYHVWLJDWLRQLVZDUUDQWHGWRVHHZKHWKHUWKHDERYHGLVFUHSDQF\LVUHODWHG WRODWHUDOLW\RIWKHVFROLRWLFFXUYH 6XSSRUWHGE\7KH%ULWLVK6FROLRVLV5HVHDUFK)RXQGDWLRQ

368

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-368

$VLJQLILFDQWQXPEHURISDWLHQWVZLWK$,6 H[KLELWWUDQVYHUVHSODQHSHOYLVGHIRUPDWLRQ - (0HXQLHU $XELQ&( + /DEHOOH $6DQJROH5-DFNVRQ//HQNH 31HZWRQ

'HSDUWPHQWRI0HFKDQLFDO(QJLQHHULQJ(FROH3RO\WHFKQLTXH8QLYHUVLW\RI0RQWUHDO 32%R[6WDWLRQ&HQWUHYLOOH0RQWUHDO4&&DQDGD+&$ 5HVHDUFK&HQWUH6DLQWH-XVWLQH8QLYHUVLW\+RVSLWDO&HQWUH8QLYHUVLW\RI0RQWUHDO 0RQWUHDO4&&DQDGD 6SLQH6XUJHU\1RUWK.DQVDV&LW\+RVSLWDO 0286$2UWKRSDHGLF6XUJHU\:DVKLQJWRQ 8QLYHUVLW\6W/RXLV0LVVRXUL86$ 2UWKRSDHGLFV5DG\¶V&KLOGUHQ¶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¶QRUPDO¶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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-369

369

5HGXFLQJUDGLDWLRQH[SRVXUHIRUVFROLRVLV 3$5(176'(6&+Ç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

370

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-370

$EQRUPDO3UROLIHUDWLYH5HVSRQVHRI &KRQGURF\WHVWR0HODWRQLQLQ*LUOVZLWK $GROHVFHQW,GLRSDWKLF6FROLRVLV :DQJ:HL-XQ
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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-371

371

1RUPDOH[SUHVVLRQRIPHODWRQLQUHFHSWRUV 0707 LQ%06&VIURPDGROHVFHQW LGLRSDWKLFVFROLRVLVSDWLHQWVDQGLWV VLJQLILFDQFH /,+DLER :$1*:HLMXQ 681*XDQJTXDQ &KHQJ-DFN&KXQ
6SLQH6XUJHU\6SLQH6XUJHU\WKH$IILOLDWHG'UXP7RZHU+RVSLWDORI1DQMLQJ8QLYHUVLW\ 0HGLFDO6FKRRO1DQMLQJ&KLQD 'HSDUWPHQWRI2UWKRSDHGLFVDQG7UDXPDWRORJ\WKH&KLQHVH8QLYHUVLW\RI+RQJ.RQJ &KLQD 7KH-RLQW6FROLRVLV5HVHDUFK&HQWHURI1DQMLQJ8QLYHUVLW\ WKH&KLQHVH8QLYHUVLW\RI +RQJ.RQJ

$EVWUDFW $ PHODWRQLQ GHILFLHQF\ KDV EHHQ VXJJHVWHG EHLQJ DW WKH VRXUFH RI DGROHVFHQW LGLRSDWKLF VFROLRVLV $,6 +RZHYHU WKH UHOHYDQFH RI PHODWRQLQ LQ WKH HWLRSDWKRJHQHVLV RI WKDW FRQGLWLRQLV FRQWURYHUVLDO7KHUHLV HYLGHQFH VKRZV PHODWRQLQ VLJQDOLQJG\VIXQFWLRQLQ RVWHREODVWIURPDGROHVFHQWLGLRSDWKLFVFROLRVLVSDWLHQWV%XWQRVWXG\LQYHVWLJDWHVPHODWRQLQ VLJQDOLQJSDWKZD\LQ%06&V7RVWXG\PHODWRQLQUHFHSWRUV0707 H[SUHVVLRQDQGWR H[SORUH LWV VLJQLILFDQFH LQ %06&V IURP $,6 SDWLHQWV (LJKWHHQ $,6 SDWLHQWV DQG WHQ YROXQWHHUV ZHUHLQFOXGHG)URPDQWHULRU VXSHULRULOLDF VSLQH WKH KXPDQ ERQH PDUURZ ZDV REWDLQHGZLWKDQWLFRDJXODWLRQE\KHSDULQH$QGWKH06&VZHUHLVRODWHGE\GHQVLW\JUDGLHQW FHQWULIXJH IURPWKH PRQRQXFOHDU FHOOVDQG WKHQ ZHUH FXOWLYDWHGDQGVHULDOVXEFXOWLYDWHGLQ YLWUR ([SUHVVLRQ LQWHQVLW\ RI PHODWRQLQ UHFHSWRUV0707 RI %06&V IURP WKH WZR JURXSV ZDV GHWHFWHG E\ 57 3&5 )ORZ F\WRPHWU\ GHPRQVWUDWHG WKDW WKH H[SDQGHG PRQRQXFOHDU FHOOV H[SUHVVHG PHVHQFK\PDO VWHP FHOO PDUNHUV 7KHUH ZDV QR VWDWLVWLFDO GLIIHUHQFHRIPHODWRQLQUHFHSWRUVH[SUHVVLRQLQ%06&VEHWZHHQ$,6JURXSDQGWKHFRQWUROV 3! 0HODWRQLQ UHFHSWRUV H[SUHVVLRQ LQ %06&V IURP DGROHVFHQW LGLRSDWKLF VFROLRVLV SDWLHQWV LV QRUPDO ZKLFK SURYLGHV IRXQGDWLRQ IRU IXUWKHU VWXG\ RI PHODWRQLQ VLJQDOLQJ SDWKZD\LQ%06&V .H\ZRUGV0HODWRQLQUHFHSWRULGLRSDWKLFVFROLRVLVP51$PHVHQFK\PDOVWHPFHOO

372

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-372

(/(9$7('3/$60$)$&7253,6 ,192/9(',1,',23$7+,&6&2/,26,6 216(7$1'&859(352*5(66,21 $0RUHDX$)UDQFR%$]HGGLQH3+5RPSUp , 7XUJHRQ.0%DJQDOO %3RLWUDV +/DEHOOH &+5LYDUG **ULPDUG-2XHOOHW 63DUHQW*/DURXFKH * /DFURL[

0ROHFXODU*HQHWLFV/DERUDWRU\ RI0XVFXORVNHOHWDO'LVHDVHV5HVHDUFK&HQWUH&+8 6DLQWH-XVWLQH0RQWUpDO4F&$1$'$ 'HSDUWPHQWRI6WRPDWRORJ\)DFXOW\RI'HQWLVWU\8QLYHUVLWpGH0RQWUpDO 'HSDUWPHQWRI%LRFKHPLVWU\)DFXOW\RI0HGLFLQH8QLYHUVLWpGH0RQWUpDO 'LYLVLRQRI$QDWRP\'HSDUWPHQWRI6XUJHU\3HULQDWDO5HVHDUFK&HQWUH8QLYHUVLW\RI $OEHUWD(GPRQWRQ 2UWKRSHGLF'LYLVLRQ&+86DLQWH-XVWLQH8QLYHUVLWpGH0RQWUpDO0RQWUpDO /,6'/DERUDWRU\5HVHDUFK&HQWUH&+86DLQWH-XVWLQH0RQWUpDO 2UWKRSHGLF'LYLVLRQ7KH0RQWUHDO&KLOGUHQ¶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¶V DQJOH ! QJP/ WKDQ $,6 SDWLHQWVZLWKD&REE¶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
Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-373

373

7KH(IIHFWRI0HODWRQLQRQ3UROLIHUDWLRQ DQG 'LIIHUHQWLDWLRQRI 2VWHREODVWVLQ$GROHVFHQW ,GLRSDWKLF6FROLRVLV9V1RUPDO&RQWURO 0DQ*&:
2UWKRSDHGLFV 7UDXPDWRORJ\7KH&KLQHVH8QLYHUVLW\RI+RQJ.RQJ +RQJ.RQJ&KLQD /HHK\VDQ,QVWLWXWHRI&OLQLFDO6FLHQFH7KH&KLQHVH8QLYHUVLW\RI+RQJ.RQJ+RQJ.RQJ &KLQD 6SLQH6XUJHU\WKH )LUVW$IILOLDWHG0LOLWDU\+RVSLWDO 1DQMLQJ

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

374

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-374

$5DQGRPL]HG&RQWUROOHG7ULDORQ7UHDWPHQW 2XWFRPHDQG3DWLHQW¶V$FFHSWDQFHRIWKH 6SLQH&RU9V5LJLG%UDFLQJ6\VWHPIRU$,6 *LUOV /DP73:RQJ061J%.:6LQ6:.ZRN5+./HH:7. 6KXP6/)&KRZ '+.&KHQJ-&<

'HSDUWPHQWRI2UWKRSDHGLFVDQG7UDXPDWRORJ\7KH&KLQHVH8QLYHUVLW\RI+RQJ.RQJ 'HSDUWPHQWRI+HDOWK7HFKQRORJ\DQG,QIRUPDWLFV+RQJ.RQJ3RO\WHFKQLF8QLYHUVLW\ 'HSDUWPHQWRI3URVWKHWLFVDQG2UWKRWLFV3ULQFHRI:DOHV+RVSLWDO6KDWLQ+RQJ.RQJ 'LYLVLRQRI1XWULWLRQDO6FLHQFHV)DFXOW\RI+HDOWK 0HGLFDO6FLHQFHV8QLYHUVLW\RI 6XUUH\8. 'HSDUWPHQWRI3K\VLRWKHUDS\3ULQFHRI:DOHV+RVSLWDO6KDWLQ+RQJ.RQJ

$EVWUDFW 6SLQH&RU ZDV D IOH[LEOH EUDFH IRU WUHDWLQJ $,6 &RLOODUG HW DO DQG :HLVV HW DO VWXGLHG 6SLQH&RU DQG UHSRUWHG GLIIHUHQW UHVXOWV 7R EHWWHU XQGHUVWDQG WKH UROH RI 6SLQH&RU IRU $,6 ZH HYDOXDWHG LWV HIIHFWLYHQHVV DQG SDWLHQW¶V DFFHSWDQFH XVLQJ ULJLG EUDFHV DV FRQWUROV 7KLVZDVDSURVSHFWLYHUDQGRPL]HGFRQWUROOHGWULDORQVNHOHWDOO\LPPDWXUH$,6 JLUOVPDQDJHGE\DGHGLFDWHGWHDPDFFRUGLQJWRDVWDQGDUGL]HGSURWRFRO7KHDYHUDJHIROORZ XS ZDV PRQWKV $OO VXEMHFWV KDYH UHDFKHG VNHOHWDO PDWXULW\ &OLQLFDO DQG UDGLRJUDSKLF DVVHVVPHQWV ZHUH PDGH HYHU\ WKUHH PRQWKV 3DWLHQW¶V DFFHSWDQFH ZHUH DVVHVVHG ZLWK D YLVXDODQDORJVFDOHRQLWHPVDWWKHUGWKDQGWKPRQWKV$QLQFUHDVHRI&REE¶VDQJOH !GHJUHHVZLWKLQEUDFHZDVFRQVLGHUHGDIDLOXUH 7KHPHDQDJHPHDQ5LVVHUDQGPHDQ LQLWLDO &REE¶VDQJOH IRUWKH 6SLQH&RUQ DQG ULJLGEUDFHQ JURXSV ZHUHDQG DQG DQG UHVSHFWLYHO\ 6SLQH&RU DQG ULJLGEUDFH VXEMHFWV GHIDXOWHG IROORZXS7KHUH ZHUH IDLOXUHVLQWKH 6SLQH&RUDQG IDLOXUH LQWKHULJLGEUDFH JURXS S ZLWK WKH /RJ 5DQN WHVW $SDUW IURP RXW RI WKH LWHPV SDWLHQW¶V DFFHSWDQFHDQGVDWLVIDFWLRQZHUHVLPLODUEHWZHHQWKHWZRJURXSV 6SLQH&RUVHHPHGWRJLYH D OHVV IDYRXUDEOH UHVXOW IRU FXUYH FRQWURO ZKHQ FRPSDUHG ZLWK WKH ULJLG EUDFH 3DWLHQW¶V DFFHSWDQFHZDVVLPLODUEHWZHHQWKHWZRJURXSVH[FHSWIRURIWKHLWHPV$ODUJHUVWXG\ ZDVUHTXLUHGIRUGHILQLQJWKHUROHRI6SLQH&RULQWUHDWLQJ$,6

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-375

375

,V)XOO7RUVR,PDJLQJIRUWKH$VVHVVPHQWRI 7RUVR'HIRUPLW\LQ6FROLRVLV:RUWKLWV&RVW" 32$MHPED1*'XUGOHDQG9-5DVR

,PDJLQJ7HFKQRORJLHV/DE*(*OREDO5HVHDUFK&HQWUH%DQJDORUH,QGLD (OHFWULFDODQG&RPSXWHU(QJ8QLYHUVLW\RI$OEHUWD(GPRQWRQ$OEHUWD&DQDGD 'HSWRI5HKDELOLWDWLRQ7HFKQRORJ\*OHQURVH5HKDELOLWDWLRQ+RVSLWDO(GPRQWRQ $OEHUWD&DQDGD

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µPRGHVW\ JDUPHQWV¶WKDW GLVWRUWWKH QDWXUDOWRUVR VKDSH ,Q WKLVSDSHUZH GHWHUPLQHGWKHUHODWLYHLQIRUPDWLRQJDLQREWDLQHGIURPIXOOWRUVRLPDJHVYLVjYLVEDFNWRUVR LPDJHV IURP LPDJHV DFTXLUHG IURP VFROLRVLV SDWLHQWV 7KLV ZDV DFKLHYHG E\ FRPSXWLQJ WKH HQWURS\ RU LQIRUPDWLRQ FRQWHQW RI ORVVOHVV VKDSH PRGHOV RI WKH IURQWDQG EDFN RI WKH WRUVR2XU UHVXOWV VKRZ WKDW DQ LQYHVWPHQW LQ D IXOO WRUVR LPDJLQJ V\VWHP ZRXOG JHQHUDOO\ OHDG WR DLQFUHDVH LQ WKH DYDLODEOH DPRXQWRI LQIRUPDWLRQ7KLV LQFUHDVH FRXOG MXVWLI\ WKH KLJKHU FRVW DQG FRPSOH[LW\ DVVRFLDWHG ZLWK IXOO WRUVR LPDJLQJ LI IXOO WRUVR LQGLFHV DUH XVHGLQWKHFOLQLFDOPDQDJHPHQWRIWKHGHIRUPLW\

376

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-58603-888-5-376

,PSRUWDQFHRIWKHLPPHGLDWHFRUUHFWLRQIRU WKHHIIHFWLYHQHVVRIEUDFHWUHDWPHQWLQ$,6 - &OLQ &e$XELQ 63DUHQW +/DEHOOH

eFROH3RO\WHFKQLTXHGH0RQWUpDO0RQWUpDO&DQDGD 6DLQWH-XVWLQH8QLYHUVLW\+RVSLWDO&HQWHU0RQWUpDO&DQDGD

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

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved.

377

Subject Index 3-D correction 116 adolescent idiopathic scoliosis 116, 133, 321–323, 326, 336, 344–346, 360 aetiology of idiopathic scoliosis 240 aetiology 340 AIS 249 arm 189 asymmetrical 221 asymmetrical growth 33 asymmetry genes 326 back morphology 29 back pain 249 balance 307 balance dysfunction 333 basicranium 360 belief propagation 161 biomechanical model 128 biomechanics 52, 90, 116, 273 body composition 344 body mass index 9 body schema 208 bone mineral 323 bone mineral density 328, 344, 345, 348 brace 299 brace management 294 brace treatment 303 buccal epithelial cells 3 calcaneus 231 calvarium 360 chondrocyte 324, 347 classification 299 cluster analysis 336 Cobb angle 151 Cobb angle improvement 337 complications 314 computer-aided measurement 151 congenital scoliosis 310 conservative treatment 281, 310 conservative treatment of idiopathic scoliosis 33

curve severity 346 cytogenetic abnormalities 3 deformity 273 diet 340 dome shaped sacrum 339 dual kriging 61 education 281 ER β 322 ergonomics 103 estrogen receptor gene 330 etiology 324, 347 evaluation 303 exercises 307, 331 experimental design 116 eye asymmetry 340 faulty posture 107 FBN3 321 femoral anteversion 37, 225 finite element model 111 finite element modeling 90 finite element simulation 85 foot 231 fusionless surgery of idiopathic scoliosis 33 gait 61 gene polymorphism 321–323, 325 genetics 330 growth 85, 273 growth hormone 346 growth plate 37, 225, 349 growth spurt 133 height loss 48 historic studies 52 human evolution 9 human torso 96 hypothalamus 197 idiopathic scoliosis 9, 22, 33, 37, 61, 72, 189, 197, 208, 225, 240, 245, 263, 281, 299, 303, 324, 325, 347–349, 371 image registration 254 image segmentation 161

378

implant configuration 111 improvement of school screening 245 in situ bending 72 in vivo 273 independent component analysis 96 indication for surgery 310 indications 314 instrumentation 128, 294 intensity image registration 96 intermembral index 189 intervertebral disc 33, 273 intervertebral efforts 61 ISIS2 65, 68, 157 juvenile idiopathic scoliosis 29 juveniles 29 kyphosis 52, 68 kyphosis angle 137 laser correlation spectroscopy 3 leg 189, 231 leptin 9, 197 literature review 331 loading 221 lordosis 231 lower limbs 90 lumbar 231 lumbar lordosis 103 machine learning 254 magnetic resonance imaging 360 marker placement 166 MATN1 325 melatonin receptor 347, 371 melatonin receptor gene 330 mesenchymal stem cell(s) 345, 371 metabolic shifts 3 mRNA 347, 348, 371 multibody dynamics 61 musculoskeletal disorders 3 natural history 133 neuro-osseous timing of maturation 208 objectivity 140 occurrence 346 optical trunk molding 22 optimization 116 osteocalcin 348 osteoneural growth 52 osteoprotegerin 345, 348

pathogenesis

9, 37, 189, 197, 208, 225, 263, 345 pathogenesis of idiopathic scoliosis 33 pattern recognition 336 pelvic balance 338 pelvis 9 physical activity 107 physical therapy 307 physiotherapy 103 pixel matching 161 polymorphism 346 posterior surgical instrumentation 337 postural control 140 posture 103 Prader-Willi syndrome 314 progression 85 psychometric assessment 332 quality and quantity of brace usage 294 quality of life 249 Quantec 337 questionnaire 249 radiography 48, 137 RANKL 345 rat model 273 reduction techniques 338 registration 161 rehabilitation 140, 331 retrospective multi-centre study 338 rib hump 65 ribcage 9 ribs vertebral rotation 263 rucksack 221 Runx2 349 sagittal deformity patterns 72 school screening 240, 245 scoliometer 337 scoliosis 52, 65, 85, 90, 111, 128, 151, 157, 161, 166, 254, 294, 307, 314, 328, 332, 333 scoliosis surgery 116 shoulder girdle 9 skeletal growth 208 skeletal maturity 48 Sox9 324 spinal length 48 spinal tension 52

379

spine

9, 37, 90, 128, 166, 189, 197, 208, 225, 231, 263 SpineCor 133 spine modeling 61 spondylolisthesis 338, 339 SRS-22 249 SRS-22r 332 staple 111 stapling of the spine 33 stature 48 style of life 107 surface topography 157 surgery 111, 314 surgery simulator 116 surgical positioning 90 susceptibility 322, 325 swimmers 340

symmetrical sympathetic nervous system thoracic growth thoracolumbar junction thoracolumbar spine tibial torsion trunk asymmetry type I collagen type X collagen ultrasound vestibular system videorasterstereography visualization vitamin D receptor volume VRS

221 197 22 72 52 37, 225 29 328, 348 349 37, 225 333 137, 140 65 323 22 137, 140

This page intentionally left blank

Research into Spinal Deformities 6 P.H. Dangerfield (Ed.) IOS Press, 2008 © 2008 The authors and IOS Press. All rights reserved.

381

Author Index Ajemba, P.O. 362, 363, 375 Alchinova, I.B. 3 Aleschenko, A.V. 3 Anderson, S.I. 197 Aronsson, D.D. 273 Asher, M.A. 332, 352 Atanasio, S. 299, 303, 307, 331 Aubin, C.-É. 61, 90, 111, 116, 128, 336, 342, 356–358, 368, 376 Aujla, R.K. 9, 37, 189, 225, 263 Azeddine, B. 326, 372 Bagnall, K.M. 372 Bakaloudis, G. 289 Barbanti Brodano, G. 289 Bardakos, N. 33 Beaudoin, G. 369 Beauséjour, M. 334, 341 Bekhiche, S. 341 Berryman, F. 65, 68, 157 Berthonnaud, É. 338, 339 Bettany-Saltikov, J. 103, 221 Bohr, S. 314 Bourgin, J.-F. 22 Bowden, G. 157 Bozonnat, M.-C. 22 Breakwell, L.M. 337 Brown, C. 339 Burton, D.C. 332, 352 Burwell, R.G. 9, 37, 189, 197, 208, 225, 263, 333, 367 Calancie, B. 350 Cancel, M. 351 Cao, X.-B. 321, 322, 323 Carlson, B. 352 Chan, C.W. 361 Charles, Y.P. 22, 72 Charron, G. 369 Chen, H.-O. 321–323 Chen, W.-J. 321, 323 Chen, Z.-J. 321–323, 325 Cheng, A. 333, 367

Cheng, J.C.-Y. 325, 327, 328, 330, 333, 346, 347, 354, 360, 361, 366, 367, 370, 371, 373, 374 Cheng, T.H. 360 Cheriet, F. 269, 353, 364 Chevalier, T.L. 166 Chockalingam, N. 166, 231 Chopin, D. 338 Chow, D.H.K. 374 Chu, W.C.W. 333, 360, 366, 367 Ciazynski, D. 281 Cioni, A. 289 Clin, J. 376 Cole, A.A. 9, 37, 189, 225, 263, 337 Crandall, D. 128 Czakwari, A. 107 Czernicki, K. 107, 281 D’Amico, G. 79 D’Amico, M. 79 Dangerfield, P.H. v, 9, 37, 166, 189, 197, 208, 225, 231, 263 Dansereau, J. 90 Davies, N. 157 de Guise, J.A. 335, 365 Debanné, P. 364 Deschênes, S. 369 Detrembleur, C. 61 Di Silvestre, M. 289 Dimeglio, A. 22 Douglas, D.L. 337 Drevelle, X. 85 Driscoll, C. 90 Driscoll, M. 356 Dubois, J. 369 Dubousset, J. 85 Durdle, N.G. 96, 144, 161, 254, 362, 363, 375 Durmala, J. 107, 281 Ebermeyer, E. 85 Elobeidi, N. 137 Elsafi, A.S. 96, 144

382

Fairbank, J. Fan, H. Fisette, P. Forcier, M. Franco, A. Frascarello, M. Freeman, B.J.C.

65, 68, 157 327 61 334, 341 372 79 37, 189, 208, 225, 263, 367 Fusco, C. 303, 331 Giacomini, S. 289 Greenhalgh, A. 231 Greggi, T. 289 Grimard, G. 326, 334, 341, 351, 372 Grivas, T.B. 29, 33, 240, 245 Gum, J.L. 352 Hedden, D. 294 Heng, P.A. 333, 360, 367 Hill, D. 151, 249, 294 Hresko, T. 338 Hu, S. 339 Hu, Y.Y. 361 Huang, A. 324, 347 Hughes, C. 337 Hui, C.F.F. 361 Hung, V.W.Y. 327, 328, 354, 360 Hung, W.Y. 373 Jackson, R. 368 Jobson, M. 103 Joncas, J. 334, 341, 357 Jones, T. 359 Kadoury, S. 269, 353 Karganov, M.Y. 3 Karski, T. 194 Khlebnikova, N.N. 3 Kirby, A.S. 9, 37, 189, 225, 263 Kotwicki, T. 44 Kozhevnikva, M.I. 3 Kumar, A. 161 Kwok, R.H.K. 327, 328, 374 Labelle, H. 90, 116, 128, 269, 326, 334–336, 338, 339, 341, 343, 353, 357, 364, 365, 368, 369, 372, 376 Lacroix, G. 372 Lafon, Y. 85 Lai, S.M. 332, 352 Lalonde, N.M. 111 Lam, T.P. 327, 366, 374 Lam, W.W.M. 366 Lamarre, M.-E. 357

Larouche, G. 372 Lavy, C. 157 Le, L.H. 151 Lee, K.M. 327, 328, 330, 333, 354, 360, 361, 366, 367, 370, 373 Lee, W.T.K. 354, 374 Lenke, L. 368 Leung, K.S. 361 Li, H. 371 Li, W.-G. 322, 344, 348, 349 Lin, H. 342 Liu, X.C. 355, 359 Liu, Z. 322, 345 Lolli, F. 289 Lou, E. 151, 249, 294 Lyon, R. 355, 359 Ma, W. 345, 348, 349 Mac-Thiong, J.-M. 365 Mahood, J. 249, 294 Maier-Hennes, A. 140 Majdouline, Y. 116 Man, C.-W. 360, 370 Man, G.C.W. 333, 366, 367, 373 Marcoul, A. 22 Marcoul, M. 22 Martikos, K. 289 Maziotou, C. 29 McBride, C.A. 273 McMaster, M.E. 340 Meunier, J.E. 368 Meyer, N. 72 Mezghani, N. 335 Mihaila, D. 350 Mihas, C. 29 Miled, F. 364 Minozzi, S. 331 Miron, M.-C. 369 Moldovan, F. 351 Moreau, A. 326, 356, 372 Moreau, M. 294 Moulton, A. 9, 37, 189, 197, 225, 263 Nault, M.L. 343 Naylor, B. 337 Negrini, S. 299, 303, 307, 331 Newton, P. 368 Ng, B.K.W. 327, 328, 360, 366, 370, 373, 374 Noskin, L.A. 3 O’Brien, J.P. 245

383

O’Brien, M. 338 Ouellet, J. 326, 372 Pan, W.M. 361 Paniccia, M. 79 Pannetier, R. 111 Parent, E. 249, 294 Parent, S. 326, 334, 335, 341–343, 356, 357, 369, 372, 376 Parisini, P. 289 Parker, N. 231 Paus, T. 333, 367 Pazos, V. 364 Pelevina, I.I. 3 Petit, Y. 357 Phan, P. 335 Pitiot, A. 367 Poitras, B. 326, 372 Polak, F.J. 9, 37, 189, 225, 263 Pratt, R.K. 9, 37, 189, 225, 263 Püschel, I. 140 Pynsent, P. 65, 68, 157 Qaimkhani, S.A. 337 Qian, B. 345, 348, 349 Qin, L. 328, 354, 361 Qiu, X.-S. 321–323, 330, 346 Qiu, Y. 321–325, 327, 330, 344–349, 370, 371, 373 Quraishi, N. 157 Raison, M. 61 Ramirez, L. 254 Raso, V.J. 96, 151, 161, 254, 294, 362, 363, 375 Rivard, C.-H. 326, 372 Rivard, M. 343 Rizza, R. 355 Rodopoulos, G. 33, 240 Romano, M. 303, 307, 331 Rompré, P.H. 372 Roncoletta, P. 79 Roussouly, P. 338, 339 Roy-Beaudry, M. 334, 341, 343 Samin, J.-C. 61 Sangole, A.P. 336, 358, 368 Schumann, K. 140 Serebranyi, A.M. 3 Shannon, T.M.L. 121 Sharma, S. 337

Shi, L. 333, 360, 367 Shum, S.L.F. 374 Sin, S.W. 374 Skalli, W. 85 Stamp, M. 221 Steib, J.-P. 72 Stokes, I.A.F. 48, 273, 336, 358 Sun, G. 324, 347, 371 Sun, X. 348 Tang, N.L.-S. 325, 327, 328, 330, 346 Tassone, C. 355, 359 Ternovoy, K.S. 3 Thometz, J. 355, 359 Triandafyllopoulos, G. 29 Turgeon, I. 372 Vallasciani, M. 79 van Loon, P.J.M. 52, 170 van Rhijn, L.W. 170 Vasiliadis, E.S. 29, 33, 240, 245 Villemure, I. 111, 342, 351 Vommaro, F. 289 Wang, B. 345, 348, 349 Wang, D.S. 326, 333, 367 Wang, S. 349 Wang, W.-J. 347, 370, 371, 373 Wang, X. 128 Wang, Y. 151 Wang, Z. 365 Warren, J. 103, 221 Webb, J.K. 9, 37, 189, 225 Weiss, H.-R. 133, 137, 140, 310, 314 Wilson-MacDonald, J. 157 Wong, M.S. 374 Yeung, H.Y. 327, 328, 330, 333, 354, 360, 366, 367 Yeung, Hiu-Yan 370 Yeung, Hiu-Yen 346 Yeung, Y.H. 373 Young, M.K. 166 Yu, Y. 345, 348, 349 Zaina, F. 299, 303, 307, 331 Zewail, R. 144 Zhang, J. 151 Zhu, F. 345, 348, 349 Zhu, Z. 345, 348, 349 Ziliani, V. 307 Zubović, A. 157

This page intentionally left blank

This page intentionally left blank

This page intentionally left blank