alid is little

Reviewed by the doctors at The Cleveland Clinic Department of Rheumatic and Immunologic Diseases.
Arthritis treatment may include physical therapy and/or occupational therapy.
People with arthritis often have stiff joints - largely because they avoid movements that can increase pain. By immobilizing arthritic joints, however, the stiffness and pain only get worse. Therefore, people with arthritis often benefit from physical therapy. A physical therapist can teach you how to work out stiffness without further damaging your joint. Physical therapy also is useful after an injury, such as from a fall, and after joint surgery, especially for artificial joint replacement.
Occupational therapy can teach you how to reduce strain on your joints during daily activities. Occupational therapists can show you how to modify your home and workplace environments to reduce motions that may aggravate arthritis. They also may provide splints for your hands or wrists, and recommend assistive devices to aid in tasks such as driving, bathing, dressing, housekeeping and certain work activities.
What Is the Goal of Physical Therapy?
The goal of physical therapy is to get a person back to the point where he or she can perform normal, everyday activities without difficulty.
Preserving good range of motion is key to maintain the ability to perform daily activities. Therefore, increasing the range of motion of a joint is the primary focus of physical therapy. Building strength in the involved muscles surrounding the joint also is extremely important, since stronger muscles can better stabilize a weakened joint.
Physical therapists provide exercises designed to preserve the strength and use of your joints. They can show you the best way to move from one position to another and can also teach you how to use walking aids such as crutches, a walker or a cane, if necessary.
What Are Some Benefits of Occupational and Physical Therapy Programs?
There are many benefits to participating in a physical and occupational therapy program, including:
You gain education about your type of arthritis, so that you can be well informed.
If you are overweight, a dietary plan can be created to reduce the stress of excess weight on supporting joints of the back, legs and feet. (As yet, no specific diet -- other than a diet designed for weight loss -- has proved helpful for arthritis.)
You gain foot-care advice, including choice of well-fitting shoes with shock-absorbing outer soles and sculptured (orthotic) insoles molded exactly to the contour of each foot.
You will learn therapeutic methods to relieve discomfort and improve performance through various physical techniques and activity modifications.
What Techniques Will I Learn?
You'll learn several techniques, including:
Rest. Bed rest helps reduce both joint inflammation and pain, and is especially useful when multiple joints are affected and fatigue is a major problem. Individual joint rest is most helpful when arthritis involves one or only a few joints. Custom splints can be made to rest and support inflamed joints and a soft collar can support the neck while you are sitting or standing.
Thermal modalities. Applying ice packs or heating pads, as well as deep heat provided by ultrasound and hot packs, can help relieve local pain. Heat also relaxes muscle spasm around inflamed joints. Heating joints and muscles with a warm bath or shower before exercising may help you exercise more easily.
Exercise . Exercise is an important part of arthritis treatment that is most effective when done properly every day. Your doctor and therapist will prescribe a program for you that may vary as your needs change.

What Therapy Is Offered for People Recovering From Joint Replacement?
Preoperative programs of education and exercise, started before surgery, are continued at home. They may be changed in the hospital after surgery to fit new needs during the rehabilitation period. These exercises may be added to your usual exercise regimen, and you may find your ability to exercise has improved after surgery.
What Joint Protection Techniques Are Offered?
There are ways to reduce the stress on joints affected by arthritis while participating in daily activities. Some of these include:
Controlling your weight to avoid putting extra stress on weight-bearing joints such as the back, hips, knees and feet.
Being aware of body position, using good posture to protect your back and the joints of your legs and feet. When possible, sit down to do a job instead of standing. Change position often since staying in one position for a long time tends to increase stiffness and pain.
Conserving energy by allowing for rest periods, both during the workday and during an activity.
Respecting pain. It is your body's way of telling you something is wrong. Don't try an activity that puts strain on joints that are already painful or stiff.
An occupational therapist can show you ways to do everyday tasks without worsening pain or causing joint damage. Some joint protection techniques include:
Using proper body mechanics for getting in and out of a car, chair or tub, as well as for lifting objects.
Using your strongest joints and muscles to reduce the stress on smaller joints. For example, carrying a purse or briefcase with a shoulder strap rather than with your hand.
Distributing pressure to minimize stress on any one joint. Lifting dishes with both palms rather than with your fingers and carrying heavy loads in your arms instead of with your hands.
If your hands are affected by arthritis, avoid tight gripping, pinching, squeezing and twisting. Ways to accomplish the same tasks with alternate methods or tools can usually be found.
What Are Assistive Devices?
Many assistive devices have been developed to make activities easier and less stressful for the joints and muscles. Your therapist can suggest devices that will be helpful for tasks you may find difficult at home or at work.
A few examples of helpful devices include a bath stool for use in the shower or tub, grab bars around the toilet or tub and long-handled shoehorns or sock grippers. Your therapist can show you catalogs that have a wide variety of assistive devices.

What Are the Treatments for Arthritis?
Arthritis treatment generally includes occupational or physical therapy, exercise, drugs, and sometimes surgery to correct joint damage. Treatments for osteoarthritis can help relieve pain and stiffness, but the disease may continue to progress. The same was true for rheumatoid arthritis in the past. But treatments in recent years have been able to slow or stop progression of joint damage.
The duration and intensity of pain and discomfort depend on the type of arthritis and the degree of severity.
Conventional Medicine
In the case of localized pain, stiffness, and immobility, the typical three-stage arthritis treatment consists of medication to relieve pain and inflammation, rest to let injured tissues heal themselves, and exercise to rebuild mobility and strength.
Joint Protection
Learning to protect your joints is an important part of arthritis treatment. With the help of an occupational therapist, you can learn easier ways to do your normal activities, such as avoiding positions that strain your joints, using your strongest joints and muscles while sparing weaker ones, wearing braces or supports for certain joints and using grab bars in the bath, modified door knobs, canes or walkers, as well as using devices to help you with tasks such as opening jars or pulling up socks and zippers.
Your doctor may recommend pain relievers combined with regimens of heat, rest and exercise, physical therapy, and controlled application of deep heat to soothe affected joints.
Arthritis Medication
To reduce pain and inflammation in mild cases of rheumatoid arthritis and osteoarthritis, your doctor will probably prescribe aspirin or another nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen. Your doctor may also suggest acetaminophen for osteoarthritis.
In more advanced cases, your doctor may recommend corticosteroid joint injections - strong anti-inflammatories - to ease the pain and stiffness of arthritic joints. Depending on the individual, results range from temporary relief to long-lasting suppression of symptoms. Doctors are also using hyaluronate gel-like solutions in joint injections to further restore the cushion and lubricating properities of normal joint fluid thereby minimizing pain. Some examples are Hyalgan, Synvisc, Supartz, and Orthovisc.
In the early 1900s, researchers discovered that certain compounds containing gold, given orally or by injection, gave relief to some people who have rheumatoid arthritis and caused total remission in others.Note, however, that because the side effects of gold treatment can range from minor skin rash to severe blood and kidney disorders, this treatment is generally approached with caution.
Newer treatments using low doses of chemotherapy medications (methotrexate) have produced dramatic improvements in severe rheumatoid arthritis, and these treatments show great promise of preserving joint function. Other strong medications that have come along since methotrexate are Arava, Azulfidine, Enbrel, Imuran, Neoral, Plaquenil, Remicade, Humira, Kineret, Rituxan, and Orencia. In general, they work by suppressing the overactive immune system. Apheresis is another treatment for rheumatoid arthritis that removes antibodies from the blood.
Specific arthritis treatment will depend on the nature and seriousness of the underlying condition. The major concern is for healing the affected area before more serious problems occur. Treatment of infectious arthritis typically involves large intravenous doses of antibiotics as well as drainage of excess fluid from the joints.

Surgery for Arthritis
Various forms of surgery may be needed to reduce the discomfort of arthritis or to restore mobility or joint function. Synovectomy is the removal of damaged connective tissue lining a joint cavity, and allows the body to regenerate new, healthy tissue in its place. This operation is most common in the knee. In cases of severe arthritic damage to the neck or foot, bones can be surgically removed or fused. Although movement is limited after such surgery, the operations relieve excruciating pain and help prevent further damage to nerves or blood vessels.
If arthritis pain and inflammation become truly unbearable, or arthritic joints simply refuse to function, the answer may lie in surgical joint replacement. Today, hip and shoulder joints - as well as smaller joints in elbows, knees, and fingers - can be replaced with reliable artificial joints made of stainless steel and plastic. This type of surgery can dramatically improve function and mobility.
Arthritis Pain Management
Because one of the most trying aspects of this disease is learning to live with arthritis pain, many doctors recommend training in pain management, including cognitive therapy. The National Institutes of Health has found that cognitive behavioral therapy, using education and behavior modification alongside relaxation techniques, is better than routine care for relieving arthritis pain. Such programs focus on improving patients' emotional and psychological well-being by teaching them how to relax and conduct their daily activities at a realistic pace. Learning to overcome mental stress and anxiety can be the key to coping with the physical limitations that may accompany chronic rheumatoid arthritis and osteoarthritis. Cognitive therapy may include various techniques for activity scheduling, imaging, relaxation, distraction, and creative problem-solving.
Alternative Medicine for Arthritis
A variety of alternative therapies are used for arthritis. Let your doctor know if you're considering them.
Some studies suggest that glucosamine and chondroitin supplements are as effective as NSAIDs for reducing pain, swelling, and stiffness in osteoarthritis. Studies in 2001 show some promise that they may slow the progression of osteoarthritis as well. More studies are underway to further investigate this. Typical doses are 1500 mg for glucosamine and 1200 mg for chondroitin daily. Glucosamine can raise blood sugar, so be sure to talk to your doctor before taking it, especially if you have diabetes. The antibiotic doxycycline may also show some potential in delaying the progression of osteoarthritis by inhibiting enzymes that break down cartilage. More research is needed to confirm these results.
The National Institutes of Health considers acupuncture an acceptable alternative treatment for osteoarthritis. Studies have shown that acupuncture helps reduce pain, may significantly lessen the need for painkillers, and can help increase range of motion in affected joints.
Available over-the-counter since 1999, the supplement SAMe has been shown in some studies to be as effective against osteoarthritis pain as NSAIDs, with the added benefit of fewer side effects.

Alternative Medicine for Arthritis continued...
Homeopathy may improve pain, joint tenderness, stiffness, and grip strength, especially when used in conjunction with NSAIDs.
Fish oil has been shown to reduce arthritis inflammation, lessen the need for painkillers, and possibly decrease joint stiffness. A diet low in animal and dairy fats may have similar effects. Excellent sources of fish oil include EPA/DHA capsules and oily fish such as salmon and mackerel.
At least a dozen different herbs have been used to ease the symptoms of both osteoarthritis and rheumatoid arthritis; most are considered anti-inflammatories. Ask your doctor about using any herbs, since they can interact with each other or with medication you are taking. In most cases, lack of careful studies means little is known about long-term effects. Herbs that have been used for arthritis are powdered ginger, borage seed oil, or devil's claw to reduce pain and swelling. Stinging nettles or turmeric may also lessen arthritis pain, stiffness, and inflammation.
Ayurvedic medicine uses herbal compounds internally and externally for arthritis symptom relief. Topical curcumin may help relieve the inflammation of rheumatoid arthritis; if taken in capsule form, it can reduce morning stiffness and boost endurance. In one study, a combination of Withania somnifera, Boswellia serrata, and Cucurma longa caused a significant drop in pain and disability for people with osteoarthritis.
At-Home Remedies for Arthritis
Heat and rest - traditional remedies for arthritis pain - are very effective in the short run for most people with the disease. Overweight sufferers should lose weight, especially when arthritis affects the lower back, knees, and legs. Consult a registered dietician who can help you plan a healthy weight-loss program.
In addition to treatments recommended by your doctor, you can use dry heat from a heating pad or moist heat in the form of a hot bath or a hot-water bottle wrapped in a towel to help relieve arthritis pain and stiffness. Regular exercise is important to keep the joints mobile. People with weakened, badly deformed fingers from rheumatoid arthritis benefit from specially designed utensils and door and drawer handles; people suffering weakness in the legs and arms can use special bathroom fixtures, especially tub rails and elevated toilet seats.
Though arthritis is not preventable, many people are able to prevent disability with a well-designed treatment program, including medications, exercise, and physical therapy when needed.

Thomas Kuivila, M.D.
Pediatric Orthopaedic Surgeon
Cleveland Clinic
Cleveland, OH

What is scoliosis?
Scoliosis is a lateral (toward the side) curvature in the normally straight vertical line of the spine. The normal spine curves gently backward (kyphosis) in the upper back and gently inward in the lower back (lordosis). When a person with a normal spine is viewed from the side, a mild roundness is normally present in the upper back and a degree of swayback is present in the lower back. When a person with a normal spine is viewed from the front or back, the spine appears to be straight. When a person with scoliosis is viewed from the front or back, the spine appears to be curved.

Is scoliosis a recently discovered condition?
No, scoliotic spinal deformities have been depicted in the cave art of the Stone Age. Hippocrates, the father of medicine who lived in Greece around 400 B.C., is credited with coining the term "skoliosis" to describe this spinal abnormality. While the condition has been around for thousands of years, it was not until this century that effective surgery (1914) and effective bracing (1946) were first performed. Our ability to treat the condition has made dramatic advances even in the last 10 years.

What causes scoliosis?
There are many types of scoliosis and many causes for curvature. Congenital scoliosis is a result of a bone abnormality which is present at birth. Neuromuscular scoliosis is a result of abnormal muscles and/or nerves and is frequently seen in patients with spina bifida, cerebral palsy or those with various paralytic-type conditions. Degenerative scoliosis may result from traumatic bony collapse, previous major back surgery or osteoporosis. Certain types of spinal cord abnormalities can also cause scoliosis. The most common type of scoliosis, called idiopathic scoliosis, has no specific identifiable cause. Many theories have been formulated but none have found to be all-encompassing. There is, however, definitely a strong genetic link in idiopathic scoliosis.

Many signs of scoliosis can be physically noticed in a person and may include the following:

• Difference in shoulder height when standing

• Prominence in one part of the back of the chest (thorax)

• Prominence in the lower back when standing or bent over

• Appearance of an S-shaped curve in the back while standing

Who is affected by scoliosis?
The prevalence of scoliosis in the American population at age 16 is 2 to 3%. Less than 0.1% have curves measuring greater than 40 degrees, which is the magnitude of curvature when surgery becomes a consideration. Girls are affected overall 3.6 times more commonly than boys. Girls with curves over 30 degrees outnumber boys ten to one. Idiopathic scoliosis is most commonly a condition of adolescence affecting ages 10 through 16. Idiopathic scoliosis may progress during the "growth spurt" years, but usually will not progress in adulthood in most cases.

How is scoliosis diagnosed?
Most curves are initially detected on school scoliosis screening exams, by a child's pediatrician or family doctor, or by a parent when summer swim season (bathing suit time) starts. The diagnosis of scoliosis and the determination of the type of scoliosis is then made by a careful orthopaedic exam and an x-ray to evaluate the magnitude of the curve.

What is the treatment for scoliosis?
The majority of adolescents with idiopathic scoliosis are observed at regular intervals (usually every 4 to 6 months) by a physical exam and a low radiation x-ray. Bracing is the usual treatment choice for adolescents who have a spinal curve over 25 to 30 degrees - particularly if their bones are still maturing and if they have at least two years of growth remaining. Those who have or develop curves beyond 45 to 50 degrees are often candidates for surgery.

What do bracing and surgery do for the curvature?
The purpose of bracing is to halt progression of the curve. It may provide a temporary correction but usually the curve will assume its original magnitude when bracing is eliminated. Surgery utilizes metallic implants to correct some of the curvature and hold it in the correct position until bone graft placed at the time of surgery consolidates and creates a rigid fusion in the area of the curve.

In recent years, effective minimally invasive surgery has also been used to treat scoliosis. This surgery eliminates painful, abnormal motion, reduces nerve irritation and increases function in most patients. A thin, telescope-like instrument called a laparoscope, and spinal cages (hollow, metal cylinders) are placed between the vertebrae through puncture incisions in the abdomen to fuse the spine. Most patients having this surgery can leave the hospital in 2-3 days.

Do electrical stimulation, exercise programs or manipulation help?
Many studies have shown that electrical stimulation, exercise programs and manipulation are of no benefit in preventing the progression or "curing" scoliosis. Patients should be encouraged to be active and stay fit, however. Like many other disorders, understanding and education about scoliosis is the most important tool with which to manage and prevent complications. The following organizations can provide more information about scoliosis:

The Scoliosis Research Society
555 East Wells Street, Suite 1100
Milwaukee, WI 53202-3823
(414) 289-9107
www.srs.org

The Scoliosis Association, Inc.
P.O. Box 811705
Boca Raton, FL 33481-1705
(800) 800-0669, (561) 994-4435
www.scoliosis-assoc.org

This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition.

Scoliosis Research Institute

Ronald Blackman M.D.

1073 Hubert Road


Oakland, CA. 94610

For curriculum vita and photo Dr. Blackman.

NOTE: Here and at the end of this page is a link to the technique of minimally invasive spine surgery for scoliosis. Please read the entire page prior to clicking onto just this technique.IT IS IMPORTANT TO NOTE THAT I NO LONGER RECOMEND THIS TECHNIQUE except for a few specific instances which includes removal of ligaments and disc for loosening up a stiff curve prior to posterior fusion. DESPITE my DEVELOPMENT OF THE TECHNIQUE I BELIEVE BETTER APPROACHES (posterior pedicle screws) HAVE OCCURRED WITH BETTER CORRECTION,and LOWER FAILURE RATES

Scoliosis is the medical term for curvature of the spine. This paper deals primarily with the surgical treatment of scoliosis. Xray pictures of scoliosis before and after treatment are shown. The thumbnail pictures of scoliosis can be enlarged by clicking on them.

Scoliosis occurs in approximately 2% of women and less than 1/2% of men. It usually starts in the early teens or pre-teens and may gradually progress as rapid growth occurs. Once rapid growth (puberty) is over then mild curves often do not change while severe curves nearly always progress.

There is a fine line between the term scoliosis and a very mild curve in a normal spine. Curves are measured in degrees. Persons with a curve of ten degrees or less are often thought to have just an asymmetry of the spine - but in children who end up with significant curves we have to consider that they started with a straight spine so even a ten degree curve can progress to a fifty degree curve and a significant deformity, if there is enough growing time remaining. Persons with curves measuring under thirty degrees entering adulthood are considered having a mild curve while those over 60 degrees are considered severe.

The treatment options depend on the severity and the age of the person. We can, of course, make up a long list of treatments; only a few have actually been shown to affect the outcome of scoliosis. Numerous studies have failed to show any benefit from exercise, manipulation, meditation or drugs. While exercise is beneficial to maintaining good muscle tone and a healthier heart and lungs, there is no evidence that it affects, one way or the other, the curve progression. It may help in reducing discomfort.

Option 1. Do nothing. The decision to do nothing may be a reasonable decision depending on the age of the person and the predicted outcome. If the person is a teen or pre-teen and the prediction is that this curve will worsen then doing nothing may not be appropriate. Increasing curves usually give an increase in the deformity. That is the chest twists throwing the shoulder blade off in back causing a rib hump and the chest in front rotates as well causing unevenness to the breasts. At the same time the hips at the waist become more uneven. So doing nothing in the teen years may be disastrous.

On the other hand, if the person has reached maturity ( physical at least!) then if the curve is mild, below forty degrees, it may not increase any more. So not doing anything may be okay.

Option 2. Wear a brace. Bracing has been shown to be an effective method to prevent curves from getting worse. From a practical aspect though this treatment is reserved for children and adolescents in whom the prediction of a rapid increase in the curve needs to be thwarted. A brace worn 16 or more hours per day has been shown to be effective in preventing 90% or more of the curves from getting worse. Unfortunately, a brace worn 23 hours per day and worn properly does not guarantee that the curve will not continue to increase. Still, in curves that are mild i.e. between 20 and 35 degrees a brace may be quite effective.

In adults, the curve may progress slowly over the years, bracing is not a practical solution to prevent curves from increasing. Mild curves under 30 degrees do not usually progress; severe curves over 60 degrees usually progress and scoliosis between 30 and 60 degrees may or may not progress.

It must be remembered that a brace for a teenager is not an easy treatment. The brace is hot, hard, uncomfortable, ugly and while it normally can't be seen under the clothes definitely makes a teenager more selfconscious.

We tend to use a brace for 23 hours per day. Using it part time seems to create problems of when to put it on, when to take it off, and for how long; whereas if it becomes part of the routine it becomes a standard function. Additionally, logic supported by data shows that the more the brace is on the better the chance of maintaining correction.

NOTE HOWEVER THAT A BRACE USUALLY DOES NOT CORRECT A CURVE. AT BEST IT WILL STOP IT FROM WORSENING.

There are numerous anecdotes from many kinds of practitioners, including ourselves, who have seen curves straighten both spontaneously and while using a brace. In medicine there are always exceptions. 

The inset shows such an exception


of a teenager in a brace for 18 months.


On the left is an X-ray of the person


before starting brace treatment.


On the right is the same person


18 months after wearing a brace


23 hours per day.

Option 3. SURGERY: For those persons who already have a significant curve with a significant deformity surgery can reduce the curve and significantly reduce the deformity. Usually surgery is reserved for teen and pre-teens who already have a curve around 40 degrees or more. In our practice we tend to be more aggressive than many in doing surgery around 40 degrees while there are many excellent surgeons who defer to 45 or 50 degrees. In the adult age range the reasons for doing surgery are less well defined but include an increasing discomfort or pain in a curve that appears to have increased. For many women the deformity in the hip line and the increasing discomfort combine to make surgery a reasonable option. Many persons note the increasing deformity in the chest coupled with an increase in the rib hump. For those persons surgery can ( not always and certainly not guaranteed) reduce the deformity and the discomfort or pain.

Surgery however is a big deal and not to be undertaken lightly. We invariably use metal rods and screws to help straighten and hold the spine in the corrected position.

There are three major types of curves each with their own method of correction. However, what we do may not be what someone else would do. Surgeons base their procedures on many different factors including their experience with techniques and their outcomes.

The usual scoliosis curve is a thoracic curve ( i.e. at the level of the chest.) In these curves the procedure is a posterior spinal fusion. A fusion is a procedure where the individual bones are made solid each to the one above and below. Typically 10 or more segments are included. In order to first get as much correction of the curve, screws are attached to both sides of the back of the individual vertebra and then these are connected to two metal rods which have been pre-bent to the desired contour. The rod is then coerced into the head of each of the screws on each side so that there is a line of screws with a rod attached on each side of the curve. After the correction is done, little bits of bone are flaked off the back of the vertebra so that when healing occurs the flakes of bone cross and become solid. Some surgeons use extra bone obtained from the back of the pelvis. The metal rod hopefully holds the correction until it is solid approximately in one year.

Showing the curve before surgery

and after surgery with rods in place.


Click on picture to see an


enlarged view.

Scoliosis is a three dimensional problem. It is easy to think of the curves from looking at the back or the front; but the side view also must be considered. Flattening of the normal roundness to the side view of the back affects the general look of the back and the person. One of the aims of surgery is to try to restore the normal contour of the back from both the front view and the side view.

Note the increase

in the roundness.

We have developed a technique to assist us in getting a maximum of correction with a minimum of scar and morbidity. We have developed the use of the endoscope to go into the chest (similar to the way surgeons take out gallbladders now) in front where the actual vertebra are and take out the discs in front thus loosening up the spine so we can get better correction when we do the fusion in back. This is called ENDOSCOPIC DISCECTOMY SURGERY.

This method goes in through the chest using three or four small incisions to reach the front of the spine. Once inside the chest the spine is clearly visible and "soft" tissues can be cleaned off exposing the spine. The discs are easily seen and can be removed.

 These are four views of the spine

as seen through the endoscope.


The views are taken through the chest


Click on this to enlarge the picture.

ANTERIOR APPROACH: For those curves which present more as a distortion of the waistline or hips going in through the front of the abdomen can reach the vertebra and using screws the spine can be exceedingly well corrected ( again not always though). Going in through the front can often allow us to fuse fewer vertebra and get better correction. So we "save a level" and get better motion remaining and usually better correction than posteriorly.

The spine is actually in the middle of the body and the larger weight bearing part of the vertebra is in the front. To correct the curve by going in front,the incision is across the chest in line with a rib and down the front of the abdomen for a short distance. It sounds like a big approach ( and it is ) but the actual incision is no longer than the one in back. The chest is entered and the area of the curve is identified. The discs are removed so that the curve becomes much more mobile and screws are then placed in the vertebra and connected together with a metal rod. Bone graft is placed in the space where the discs were so that later fusion between each adjacent vertebra will occur.The screws are then compressed together, shortening the distance on the outside of the curve and so straightening the curve. Usually fusion occurs in a shorter time than the posterior method and the number of vertebra fused are usually less.

This was a teenager

with an increasing curve


out of balance. Note the


return of the center of gravity.

This is a side view or lateral view. It shows the bodies of the vertebra with the screws and rod in place. Note the slight sway back which is built into the correction.

And for those who have a double curve then often a combination of any of the above may be needed. That is, we may just go in from the back and fuse a long segment of the curves or we may go in from the front and fuse the lower curve and correct it and then fuse from the back or we may do all three procedures, to try to get the maximum correction possible.

Option 1 - Do nothing

Option 2 - Bracing

Option 3 - Surgery

A discussion of our present techniques of minimally invasive anterior endoscopic surgery. We have performed corrective surgery using screws and rods in sixty two children and three adults using three to five half inch incisions. There is minimal cutting of muscle tissue and so far no person has had sufficient blood loss to need a transfusion. We also have used one 4 inch incision and one or two small incisions. Either way, the correction appeared excellent initially but lost correction over time, pain is far less than with major open techniques, most patients stay four or five days in the hospital and many get out sooner. But, newer techniques of pedicle screw fixation appear to give even better result with greater maintenance of correction and stronger fixation, so that the endoscopic anterior technique appears less promising in its present stage of development

Theodoros B Grivas , Elias S Vasiliadis , Constantinos Mihas and Olga Savvidou

Orthopaedic Department, "Thriasio" General Hospital, G. Gennimata Av. 19600, Magoula, Attica, Greece

author email corresponding author email

The electronic version of this article is the complete one and can be found online at: http://www.scoliosisjournal.com/content/2/1/11

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Numerous studies have attempted to quantify the correlation between the surface deformity and the Cobb angle without considering growth as an important factor that may influence this correlation. In our series, we noticed that in some younger referred children from the school-screening program there is a discrepancy between the thoracic scoliometer readings and the morphology of their spine. Namely there is a rib hump but no spinal curve and consequently no Cobb angle reading in radiographs, discrepancy which fades away in older children. Based on this observation, we hypothesized that in scoliotics the correlation between the rib cage deformity and this of the spine is weak in younger children and vice versa.

Methods

Eighty three girls referred on the basis of their hump reading on the scoliometer, with a mean age of 13.4 years old (range 7–18), were included in the study. The spinal deformity was assessed by measuring the thoracic Cobb angle from the postero-anterior spinal radiographs. The rib cage deformity was quantified by measuring the rib-index at the apex of the thoracic curve from the lateral spinal radiographs. The rib-index is defined as the ratio between the distance of the posterior margin of the vertebral body and the most extended point of the most projecting rib contour, divided by the distance between the posterior margin of the same vertebral body and the most protruding point of the least projecting rib contour. Statistical analysis included linear regression models with and without the effect of the variable age. We divided our sample in two subgroups, namely the younger (7–13 years old) and the older (14–18 years old) than the mean age participants. A univariate linear regression analysis was performed for each age group in order to assess the effect of age on Cobb angle and rib index correlation.

Results

Twenty five per cent of patients with an ATI more than or equal 7 degrees had a spinal curve under 10 degrees or had a straight spine. Linear regressions between the dependent variable "Thoracic Cobb angle" with the independent variable "rib-index" without the effect of the variable "age" is not statistical significant. After sample split, the linear relationship is statistically significant in the age group 14–18 years old (p < 0.03).

Conclusion

Growth has a significant effect in the correlation between the thoracic and the spinal deformity in girls with idiopathic scoliosis. Therefore it should be taken into consideration when trying to assess the spinal deformity from surface measurements. The findings of the present study implicate the role of the thorax, as it shows that the rib cage deformity precedes the spinal deformity in the pathogenesis of idiopathic scoliosis.

Background

Numerous studies have attempted to quantify the correlation between the surface deformity and the Cobb angle in patients with idiopathic scoliosis (IS), [1-10].

Several non-invasive methods have been introduced and mathematical models have been developed, all attempting to predict the Cobb angle from the surface deformity. The use of scoliometer, the Moire topography, the Integrated Shape-Imaging System (ISIS) [8], the more advanced 360° torso scanners, [4,11] and the artificial neural networks (ANNs) [12] are examples of such attempts. All have been developed because repeated radiographs which are currently used for scoliotic patients' follow up can increase the risk of cancer as a consequence of increased ionizing radiation [13].

In a recent report Bunnel states that "It has become apparent from many reports that although there is a significant correlation between clinical deformity and radiographic measurement, the standard deviation is so high that it is not possible to reliably predict the degree of curvature from surface topography in any given patient by any technique" [14,5-18,9]. Bunnel also states that, in general, clinical deformity is disproportionately greater than expected for the degree of Cobb angle in the early stages of the development of scoliosis [14].

Although IS is considered a lateral curvature of the spine with concordant vertebral rotation [19], asymmetry involves some other structures like the rib cage, the muscles, the viscera, the fat and the skin in a manner that is unique to each patient and changes over time as the deformity progresses [12]. It is interesting that most of the studies that correlate the surface deformity with the Cobb angle are quantifying this correlation without looking into other elements of the torso asymmetry and their possible aetiologic implications.

While the surface deformity appears to correlate with spinal deformity in most of the studies, we monitored that in some younger referred children from school screening there is a discrepancy between the thoracic scoliometer readings and the Cobb angle [20]. Although these children had a notable thoracic asymmetry, they were found to have straight spines in their standing posteroanterior spinal radiographs. Based on the above observation, we hypothesized that in scoliotics the correlation between the rib cage deformity and this of the spine is weak in younger children and vice versa.

Methods

The posteroanterior and lateral spinal radiographs of 83 referred girls from the "Thriasio" school screening program were evaluated in order to determine the influence of age in the correlation between the rib cage and the spinal deformity. The mean age of the examined girls was 13.4 years (range 7–18). All had trunk asymmetry ≥ 7° in any of the three examined regions of the spine (thoracic, thoracolumbar, or lumbar), as it was measured by the scoliometer and expressed as Angle of Trunk Inclination (ATI).

The spinal deformity was assessed by measuring the Cobb angle from the postero-anterior spinal radiographs. The rib cage deformity was quantified on the lateral spinal radiographs by measuring the rib-index at the apex of the thoracic curve. The rib-index is defined as the ratio of two distances (d1/d2). The first (d1) is the distance between the posterior margin of the vertebral body and the most extended point of the most projecting rib contour, while the second (d2) is the distance between the posterior margin of the same vertebral body and the most protruding point of the least projecting rib contour [20], (Figure 1).

Figure 1. A drawing of a lateral spinal radiograph describing the rib-index. The rib-index is the ratio d1/d2. d1 is the distance between the posterior margin of the vertebral body and the most extended point of the most projecting rib contour. d2 is the distance between the posterior margin of the same vertebral body and the most protruding point of the least projecting rib contour.

The normality of the data was verified with the Shapiro-Wilk test for normal data. No variable deviated from normal distribution. The magnitude of the correlation between the dependent variable "Cobb angle" and the independent variables "rib index" and "age" was estimated by calculation of Pearson's correlation coefficients. After calculating the median age, we divided our sample in two subgroups, consisting of younger and older participants. Separate univariate linear regression analysis was then performed for each age subgroup in order to assess the effect of age on Cobb angle and rib index correlation. The overall significance of the models was based on the calculation of F statistic. All statistics were two-sided and considered significant if p-value was less than 0.05. Analysis was performed using STATA™ (Version 9.0, Stata Corporation, College station, TX 77845, 800-782-8272).

Results

Fourteen out of the 83 girls had straight spines. Seven were found with a curve less than 10°, while 31 had thoracic curves, 10 had thoracolumbar curves and 21 had lumbar curves. The descriptives of the examined girls are shown in Table 1.

Table 1. Descriptives of the age, the rib-index, the thoracic, thoracolumbar and lumbar Cobb angle of the examined girls (n = 83) with different curve types

The correlation between the dependent variable "Thoracic Cobb angle" and the independent variable "rib-index" without adjusting for age was not statistically significant (Pearson's correlation coefficient r = 0.197, p = 0.077). This was also the case for the correlations between Thoracolumbar Cobb angle and rib-index and between lumbar Cobb angle and rib-index (r = 0.105, p = 0.350, r = 0.052, p = 0.642, respectively), Table 2.

Table 2. Pearson's correlation coefficients (r) between the dependent variable "Cobb angle" and the independent variable "rib-index" with and without the effect of the (predictor) variable "age"

After calculating the median age (14 years), two subgroups were created; group A (7–13 years old, 37 subjects, 44.58%) and group B (14–18 years old, 46 subjects, 55.42%). Following the split, the results of the univariate linear regression models of various Cobb angles and rib index for each age group, are presented in Table 3. The only linear association was the one between Thoracic Cobb Angle and rib-index in the age group of 14–18 years (Predicted Thoracic Cobb Angle = -6.357 + 7.974*(Rib-Index). The linear relationship between Thoracic Cobb angle and rib-index is shown graphically in (Figure 2).

Table 3. Univariate linear regression models by age group. Thoracic Cobb angle, Thoracolumbar Cobb angle and Lumbar Cobb angle are the dependent variables. Rib-index is the independent variable

Figure 2. The only linear association was the one between Thoracic Cobb Angle and rib-index in the age group of 14–18 years. (Predicted Thoracic Cobb Angle = - 6.357 + 7.974 × (Rib-Index).

Discussion

The detection of spinal deformities through the various screening programs is a challenging issue. Initially the forward bending test and later the use of back shape analysis methods, such as scoliometer and Moire topography were followed by an increased number of false positive results and an increased number of referrals and unnecessary radiographs [17]. The more advanced 3-D computer assisted systems and the various body scanners are quantifying more accurately the surface morphology of the trunk and efforts have been made to correlate these findings with the spinal deformity.

The present study shows that in younger children the concordance of the surface and spinal deformity is weak and it becomes stronger as the children are growing up. Therefore, in younger children with surface trunk asymmetry, the prediction of the spinal deformity alone from the surface topography is inaccurate, simply because surface topography reveals the thoracic cage and the spinal deformity together. Furthermore the Cobb angle alone cannot explain the whole of the surface deformity [10]. Fourteen out of 83 girls (16.9%) in our study had straight spines, although the scoliometer readings were ≥ 7°. When adding the 7 girls with spinal curves <10°, it is interesting that 21 girls (25%) with an ATI ≥7° had a spinal curve under 10° or had a straight spine.

The rib-index clearly demonstrates the thoracic cage deformity and when its value is above 1, it displays the existence of surface asymmetry, which is the main indicator for referral during school screening for scoliosis [20]. The rib-index is a radiological sign and thus it is not obtainable by the screening programs, but is more meaningful when studying the correlation between the surface and the spinal deformity.

The role of the rib cage in the pathogenesis of idiopathic scoliosis has been implicated in the past [21-27].

The growth of the thoracic spine and the growth of the rib cage are directly related and that a growth disturbance of one induces deformity in the other [28]. Either unilateral rib or spine tethering produces both a scoliosis and rib cage deformity [29]. The deformity induced by unilaterally tethering the ribs is much greater than the deformity induced by unilaterally tethering the transverse processes of the spine. This may be a consequence of the longer moment arm provided by the ribs, thereby producing a larger bending moment to deform the thoracic spine [28].

The spine and ribs work together efficiently at respiration as a dynamic biomechanical structure only under specific conditions [30]. When the thorax is affected by significant deformity, the dynamics of this system change, interfering with normal respiration and lung development [28]. Sevastik et al induced scoliosis experimentally in young New Zealand rabbits either by performing rib osteotomies and interposing a metallic ring into the osteotomy gap to asymmetrically elongate the ribs or by unilaterally segmenting three intercostal nerves [31,32]. In addition, abnormalities in the evolution of anterior chest wall blood supply were implicated in the pathogenesis of progressive right-convex female thoracic scoliosis [27]. On the contrary, young children suffering thoracic insufficiency syndrome and undergoing spine fusion for scoliosis may continue to develop significant thoracic hypoplasia, restrictive lung disease and respiratory insufficiency by early adulthood with early death [30]. A clearer understanding of this reciprocal association between the growth of the rib cage and the thoracic spine has never been quantified. The findings of the present study, which includes mild scoliotic curves, correlate the growth of the rib cage and the thoracic spinal deformity, supporting the hypothesis that the rib cage deformity precedes the spinal deformity in the pathogenesis of idiopathic scoliosis, but can not exclude that pathogenesis might be in the vertebral column.

Age is a very important factor and has a definite effect, since it influences the correlation between the surface and the spinal deformity. In younger children this correlation is very weak, while it is stronger in older children. This important finding of the existence of remarkable rib cage deformity without simultaneous spinal deformity in younger school screening referrals requires further research. A longitudinal study ought to be conducted to discriminate the percentage of children that will in time develop scoliosis and the possible responsible factors.

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.

One more interesting outcome from this study is that screening younger children for scoliosis is beneficial, at least for the purpose of scoliosis aetiology research. This study could not be completed and the above findings couldn't be resulted unless younger children were screened in our scoliosis school screening program.

These findings may also have implications for the conservative treatment in younger scoliotics with braces when indicated. The correction of the more pronounced rib cage deformity which is addressed by the brace could easily prevent the deterioration of the less deformed "central axis" that is the spinal column at an earlier stage.

In conclusion growth seems to have a significant effect in the correlation between the rib cage and the spinal deformity in girls with IS. The findings of the present study support the hypothesis that the correlation between thoracic surface and spinal deformity is weak in younger children, implicating that the thoracic cage deformity precedes that of the spine in the pathogenesis of idiopathic scoliosis.

Authors' contributions

TBG conceived the idea of the study, performed part of the literature review, performed the statistical analysis, interpreted the data and contributed in drafting of the manuscript. EV contributed in manuscript drafting and in the interpretation of data, performed part of the literature review and part of the statistical analysis. CM contributed in the statistical analysis. The authors have read and approved the final manuscript.

Acknowledgements

Parental consent was obtained prior to the examination of children at school.

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The electronic version of this article is the complete one and can be found online at: http://www.scoliosisjournal.com/content/2/1/12

© 2007 Bago et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

The Walter Reed Visual Assessment Scale (WRVAS) was designed to measure physical deformity as perceived by patients with idiopathic scoliosis. Previous studies have shown that the instrument has excellent internal consistency and a high correlation with the radiological magnitude of scoliotic curves. Nonetheless, it is not known whether the scale can discriminate between the various curve patterns of the deformity, or whether the deformities represented in the scale's drawings relate to the corresponding radiological deformities.

Methods

This study included 101 patients (86 women and 15 men; mean age 19.4 years) with idiopathic scoliosis. In a single visit, patients underwent standing PA radiography of the spine and completed the WRVAS. X-ray measurements included: 1) magnitude (Cobb angle) of the proximal thoracic curve (PT), main thoracic curve (MT), and thoracolumbar/lumbar curve (TL/L); 2) difference in shoulder level; 3) T1 offset from the central sacral line (T1-CSL); 4) apical vertebra (apV) rotation at the MT and TL/L curves and 5) apical vertebra offset of the MT and TL/L curves from the central sacral line. A variable designated Cobbmax was defined as the largest angle of the three curves (PT, MT or TL/L). Patients were grouped onto three patterns: Thoracic (TH Group)(n = 30, mean MT 42.1°, TL/L 20.9°); double major (DM Group) (n = 39, mean MT 38.6°, TL/L 34.4°) and thoracolumbar (TL Group)(n = 32, mean MT 14.3°, TL/L 25.5°). The magnitude of the curves in the TL Group was significantly smaller than in the other groups (P < 0.05). The Spearman partial correlation coefficient was determined between the score for each WRVAS question and the curve pattern, adjusting for the Cobbmax variable. The Spearman correlation coefficient was determined between the WRVAS items and shoulder imbalance, T1-CSL offset, MT Cobb angle, MT apV rotation, MT apV offset, PT Cobb, TL/L Cobb, TL/L apV rotation and TL/L apV offset.

Results

The median (interquartile range) of the total WRVAS score was 14 (IQR 6). No correlation was found between the curve pattern and the various scores on the scale (partial correlation coefficients ranged from -0.16 to 0.12). WRVAS drawings for items 1, 2, 4 and 7 correlated satisfactorily with the corresponding radiological measurements (correlation coefficients, 0.62, 0.3, 0.48 and 0.53, respectively). Items 3, 5 and 6 did not correlate with the radiological measurements (correlation coefficients -0.06, -0.07 and 0.05, respectively).

Conclusion

The profile of the individual WRVAS scores does not differentiate among specific curve patterns (thoracic, double major and thoracolumbar/lumbar). Moreover, some of the drawings (items 3, 5 and 6) do not correlate with the radiological deformity they were designed to measure.

Background

The Walter Reed Visual Assessment Scale (WRVAS) (Fig. 1) was designed to measure physical deformity as perceived by patients with idiopathic scoliosis. The scale assesses seven aspects of the deformity: spinal curvature, rib prominence, flank prominence, deformity/alignment of the thorax with respect to the pelvis, trunk imbalance, shoulder asymmetry and scapular asymmetry. In the initial publication, it was demonstrated that the WRVAS scores correlated with the magnitude of the curve and were clearly different in relation to curves less than and greater than 30 degrees. Moreover, the instrument differentiated between patients stating that they "noticed" the deformity from those stating that they "did not notice" it [1].

Figure 1. The Walter Reed Visual Assessment Scale (used with permission from Sanders et al [1]).

Following that publication, our group performed an in-depth evaluation of the metric characteristics of the scale [2]. The internal consistency was found to be excellent, with no differences observed between patients more or less than 18 years of age. Analysis of the distribution of the scores showed a somewhat elevated floor effect in some of the questions, a fact indicating that perception of the deformity is inconsequential for small curves. In keeping with the findings of Sanders et al [1] the correlation between the WRVAS scores and the radiological magnitude of the curves was high. The analysis of convergent validity demonstrated a significant correlation between the WRVAS questions and the self-image scale in the SRS-22 questionnaire. Along this line, the correlation between the WRVAS and the SRS-22 pain, function and mental health scales was only marginal, an indication that the WRVAS is a specific scale for assessing physical aspects if the deformity in patients with idiopathic scoliosis.

At completion of this analysis, we formulated a series of questions related to the practical utility of the scale. First, it seemed interesting to determine whether the test would be able to discriminate between the various scoliotic curve patterns. The hypothesis formulated was that patients with different curve patterns (thoracic vs. lumbar. vs. double curves) should have different scores for some of the items on the scale. Second, we wanted to determine the relationship between the various figures comprising the scale and the corresponding radiological deformities. Thus, the aims of the present study were to assess the impact of curve pattern on the WRVAS scores and establish the relationships between the scores for the various questions and the corresponding radiological measurements.

Methods

This a cross-sectional, observational study, approved by the Medical Ethics Committees of the participating hospitals. The study included patients with idiopathic scoliosis, 10 to 40 years of age, consecutively enrolled in two centers. Patients who had undergone surgical treatment were excluded. The sample included 101 patients (86 women and 15 men) with a mean age of 19.4 years (range 12–40 years). After giving informed consent for participation, all patients completed the Walter Reed Visual Assessment Scale [1] (Fig. 1). This instrument includes a group of drawings representing seven aspects of the scoliotic deformity: item 1 (WR1), spinal deformity (Fig. 1a); item 2 (WR2), rib prominence (Fig. 1b); item 3 (WR3), flank prominence (Fig. 1c); item 4 (WR4), thoracic deformity (Fig. 1d); item 5 (WR5), trunk imbalance (Fig. 1e); item 6 (WR6), shoulder asymmetry (Fig. 1f); and item 7 (WR7), scapular asymmetry (Fig. 1g). Each aspect of the deformity is shown with five levels of increasing severity that are scored from a minimum of 1 to a maximum of 5. Results are presented as the sum of the seven questions (Wr total). During the same visit, a standing PA radiograph of the spine was obtained for each patient, which was used to carry out the following measurements: 1) magnitude (Cobb angle) of the proximal thoracic curve (PT), main thoracic curve (MT), and thoracolumbar/lumbar curve (TL/L); 2) T1 tilt; 3) difference in shoulder level (a line perpendicular to the central sacral line was drawn from the point where the clavicle crossed the chest cage, and the difference in height between the right and left was recorded) [3]; 4) T1 offset from the central sacral line (T1-CSL); 5) apical vertebra (apV) rotation at the MT and TL/L curves, as determined by the trigonometric method of Stokes et al [4]; and 6) apV offset of the MT and TL/L curves from the central sacral line [5]. The right-hand axis convention (right-hand rule) was used to determine the signs of these angles in the frontal and transversal planes [6]. A variable designated Cobbmax was defined as the largest angle of the three curves (PT, MT and TL/L).

Patient grouping

Based on the radiological data, the type of curve was classified according to Lenke's classification [7]: 25 were Type 1, 8 Type 2, 35 Type 3, 4 Type 4, 11 type 5, and 21 Type 6. Departing from this basis, three groups were established: the first included Lenke types 1 and 2 and was labeled thoracic pattern (Th Group, n = 30); the second included patients with a double major curve (DM Group), classified as Lenke 3 and 4 (n = 39), and the third had a thoracolumbar pattern (TL Group) and consisted of patients with curves classified as Lenke 5 and 6 (n = 32).

To assure that patient grouping was accurate, the ratio of the MT curve to the TL/L curve (Th/TL ratio) was determined. The hypothesis was that if the patient grouping were correct, the Th/TL ratio should be close to 1 for the DM pattern, greater than 1 for the TH pattern and less than 1 for the TL pattern. Mean Cobb angle was 31.9° for the MT curve, 27.6° for the TL/L curve and 36.1° for the Cobbmax. The Th/TL ratio was 2.00 for the TH group, 1.08 for the DM group and 0.54 for the TL group (ANOVA, F = 207, P = 0.0001), thereby confirming that patient grouping was accurate. The mean magnitude of the MT and TL/L curves, and the Th/TL ratio for each pattern are shown in Table 1.

Table 1. Mean magnitude (± standard deviation) of the main thoracic curve and thoracolumbar/lumbar curve and the Th/TL ratio for each of the three curve patterns

Statistical Analysis

Impact of curve pattern on the WRVAS

The median of the three groups were compared with Westenberg-Mood median test. To assess the relationship between the curve pattern and WRVAS scores, eliminating the influence of curve magnitude, we determined the Spearman partial correlation coefficient between the score for each WRVAS question and the variable Th/TL ratio (as an indicator of the curve pattern), controlling for the Cobbmax variable.

Relationship between the WRVAS and radiological variables

The non-parametric Spearman correlation coefficient was determined between the WRVAS items and the following radiological variables: shoulder imbalance. T1-CSL offset, MT Cobb angle, MT apV rotation, MT apV offset, PT Cobb, TL/L Cobb, TL/L apV rotation and TL/L apV offset. Significance was determined with Student-t test. Data were analyzed using SPSS for Windows, version 11.5. To determine the Spearman partial correlation coefficient SAS Program was used. Significance was set at < 0.05.

Results

The mean and range of the radiological measurements in the frontal plane are summarized in Table 2. The median of the total WRVAS score was 14 (interquartile range IQR 6). The median (and IQR) for each of the seven questions were: item 1, 3 (1); item 2, 2 (1); item 3, 2(0); item 4, 2(1); item 5, 2(1); item 6, 2(1) and item 7, 2(1).

Table 2. Means and range of values obtained for the radiological measurements in the frontal plane

Impact of the curve pattern

The median for each WRVAS question and the sum of all the scores are shown in Table 3. The TL group showed significantly lower values for questions 2, 3, 6, 7 and the total score. This result, however, coincides with the finding that the Cobbmax in this group was significantly lower then in the others (ANOVA, P < 0.05)(Table 1). Because of the influence of the Cobbmax on the scores for the various questions (Table 4), it was necessary to adjust for the effect of curve magnitude when analyzing the impact of curve pattern on WRVAS scores. To this purpose, we determined the Spearman partial correlation coefficient between the score for each WRVAS question and the variable Th/TL ratio (as the indicator of curve pattern) controlling for the Cobbmax. The partial Spearman correlation coefficients obtained were not significant for any of the seven questions or for the total score (partial rho value -0.16 to 0.12). This indicates that the various scores in the TL group were influenced by the magnitude of the curve and that the impact of the curve pattern was null.

Table 3. Medians of WRVAS questions for each curve pattern

Table 4. Correlation coefficient (Spearman) matrix among WRVAS items and radiologic measurements

Relation between radiologic parameters and WRVAS scores

Spearman correlation coefficients between each WRVAS question and the radiologic measurements are shown in Table 4. Item 1. This question refers to the spine deformity. A strong correlation was found between MT Cobb (rho = 0.62), TL/L Cobb (rho = 0.60) and PT Cobb (rho = 0.49). Item 2. Refers to the magnitude of the rib prominence. This item correlated with MT Cobb (rho = 0.53), and to a lesser degree with MT apV offset, (rho = -0.47) and MT apV rotation (rho = 0.30). Item 3. Assesses magnitude of the flank prominence. A moderate correlation was found with MT Cobb (rho = 0.42) and TL/L Cobb (rho = 0.36); in contrast, no significant correlation was found with TL/L apV rotation or offset. Item 4. Refers to deformity/asymmetry of the rib cage. This item correlated satisfactorily with the MT curve variables (Cobb rho = 0.48; apV offset rho = -0.31). Item 5. Refers to head-pelvis alignment; hence the radiological variable to assess this aspect would be T1 offset from the central sacral line. This item correlated with the magnitude of MT Cobb (rho = 0.41) and TL/L Cobb (rho = 0.42) curve variables, but there was no significant correlation with T1-CSL offset (rho = -0.07). Item 6. Assesses shoulder level imbalance. A moderate correlation was found with magnitude of the MT curve (rho = 0.4), but there was no correlation with the shoulder level imbalance (rho = 0.05). Item 7. Refers to scapular asymmetry. A significant correlation was found with the components of the MT curve (Cobb rho = 0.53, apV offset rho = -0.44 and apV rotation rho = 0.33). The sum of all the scores correlated with the magnitude of the PT curve (rho = 0.44), MT curve (rho = 0.61), and TL/L curve (rho = 0.51) and the variable Cobbmax (rho = 0.62).

Discussion

The WRVAS is a valid test for recording the subjective perception scoliosis patients have of their deformity [1,2]. Nevertheless, according to the results of the present study, the profile of scores obtained with the WRVAS does not allow differentiation among the various curve patterns occurring in this condition. What is more, some of the deformities represented in the figures comprising the instrument do not correspond with the radiological measurements of the deformity depicted. These facts generate some doubt as to the full validity of the scale.

Limitations of the study

Stratification of the patient sample in this study was based on the curve pattern. Patients were categorized according to the classification of Lenke [7] because this system allows classification of the scoliotic curves in broad terms into thoracic (types 1 y 2), double curves (types 3 and 4) and thoracolumbar/lumbar (types 5 and 6). This method of grouping the patients may be debatable. It could be argued that it would have been preferable to have enough cases to represent all six types of curves. This would have considerably lengthened patient enrollment for the study, however, since the prevalence of some curve patterns (e.g., type 4) is quite low. Moreover, in our opinion, it is difficult for a patient to perceive the visual difference between, for example, Lenke types 5 and 6. The grouping applied seems to have been effective since the relationship between the magnitudes of the thoracic and thoracolumbar/lumbar curves between the three groups was dissimilar. Nevertheless, stratification by curve pattern led to an undesired effect: the magnitude of the main curves was different between the groups, specifically the mean magnitude of the curve in the group with the thoracolumbar/lumbar pattern was significantly smaller than that of the other groups.

Relationship between the WRVAS and curve pattern

Our results show that the WRVAS cannot discriminate between the various curve types. The crucial variable that determines the score on the WRVAS is the magnitude of the curve and not the pattern of the curve (thoracic, thoracolumbar or double major). As is seen on Table 3, the profiles of the scores among the groups are virtually identical. If the scale were able to discriminate, it would be expected that the profiles would be different. For example, in the TL group, we would expect that the score for item 3 (flank prominence) would be higher than the score for item 2 (rib prominence), whereas in the TH group the opposite should occur; or, we might expect that in the TL group, item 3 would be clearly higher than item 7 (scapular asymmetry). Our data contradict the impression voiced by some experts that the aesthetic impact of double curves would be less than that of single curves.

Relationship between the WRVAS figures and the radiological variables

One problem we faced when designing the study was to establish a gold standard pattern to be used for determining the validity of each of the seven figures. Classically, spine deformity is assessed by clinical examination and radiological measurements. The textbooks usually recommend that data on shoulder, scapula and waist asymmetries, trunk imbalance, and the angle of trunk inclination be determined from the clinical examination [8,9]. Nevertheless, the maneuvers for performing the examination are not well-standardized and, in general, their reliability is uncertain. The only such maneuver that seems to have acceptable reliability is measurement of the angle of trunk inclination with a scoliosis inclinometer (scoliometer)[10,11]. The reliability of C7-plumbline deviation has been assessed [12] and seems to be less dependable than the scoliometer measurement. We were not able to gather information on the reliability of other examinations, such as the difference in shoulder height or waist crease. The position of the scapulas can be reliably measured with the Lennie test [13]. However, this has only been tested in individuals without spine deformity.

The radiological measurements seem to have undergone a more thorough evaluation. Recent studies have shown that most of the parameters usually determined on PA radiographs of the spine (Cobb angle, apical vertebral offset) have excellent interobserver and intraobserver reliability [5,14,15]. Apical vertebra rotation was measured in the present study with a trigonomic method that has shown good precision [4], whereas differences in shoulder level were determined with an adequately reliable method [3]. Thus, we opted to correlate the WRVAS measurements with several radiological parameters that describe the deformity because they seemed more reliable than clinical assessment.

Questions 1 and 2 correlated satisfactorily with the corresponding radiological variables. Question 3, which refers to flank prominence, should have correlated with the magnitude and apV rotation of the lumbar curve. We found, however, that Question 3 related with the main thoracic curve and that the correlation was weak with lumbar curve magnitude and non-existent with lumbar apV rotation. Hence, we are led to consider that Question 3 does not assess the deformity it is designed to assess.

The deformity that Question 4 attempts to evaluate is somewhat uncertain. In the original description [1], the question is labeled "Head Rib Pelvis". Attending to the figures, this item seems to refer to the alignment between the head, rib cage and pelvis. However, the lungs are also drawn in, giving the impression that the figure attempts to evaluate the rib cage deformity. According to the orientation of the scoliosis, it seems to be a frontal view, although the patient's face is not depicted. Thus, we are led to consider that Question 4 assesses the deformity of the thoracic area. Nevertheless, we have the impression that the face validity of this question is debatable.

Question 5 focuses on trunk imbalance and should relate with offset of T1 to the central sacral line. Nevertheless, the correlation between these two variables was not significant, casting doubts on the validity of the question. Question 6 centers on shoulder imbalance and, logically, should relate with its radiological counterpart. However, once again, there was no correlation between the score and the radiological measurements. Lastly, Question 7 refers to scapular asymmetry, for which a radiological equivalent has not been determined. In bivariate analysis, the scores for this item correlated significantly with the magnitude of the MT curve; thus, it can be considered a good estimation of thoracic deformity.

To summarize, items 1, 2, 4 and 7 of the WRVAS showed a satisfactory relationship with the deformity of the thoracic area, which is what they were designed to measure. Items 3 and 6 exhibited a clear absence of correlation with the deformity they should be measuring and can be considered to have questionable validity. In fact, these items showed the weakest correlation with the Cobbmax variable (Table 4). Question 5 did not relate with its radiological counterpart (T1-CSL offset) but showed a good correlation with the Cobbmax. We have the impression that patients relate this question with waist asymmetry, an aspect that is not specifically covered by any of the figures provided.

The results of this study indicate that the WRVAS is lacking in some aspects. First, it seems clear that the scale mainly assesses the deformity of the thoracic area, whereas the lumbar deformity (both flank prominence and waist asymmetry) are poorly represented. Second, the WRVAS represents the various deformities in only one direction. For, example shoulder imbalance is depicted as a range from normal to maximum elevation of the right shoulder. The possibility that the left shoulder might be elevated is not contemplated. This fact would undoubtedly explain the lack of correlation between the radiological measurement and the score for item 6. This problem is repeated for virtually all the questions. The solution is difficult because it would require the use of different questionnairs according to the direction of the deformity or the requirement that each item range from the maximum left deformity to the maximum right deformity. This might very well compromise the practical utility of the scale. Finally, the scores for various questions do not seem to correspond to what the patient "sees in the mirror". Rather, they seem to correspond more to the subjective impression patients have of their back (which they usually do not see), and this impression is mainly based on the spinal x-rays.

Most authors agree that it is necessary to record the body image disturbance caused by scoliosis [16,17]. Hence, the efforts to improve the available instruments for this purpose should continue. The SRS-22 body image scale is valid, but shows a weak correlation with the magnitude of the curve. The WRVAS is an improvement in this regard. Based on the known data for the scale (internal consistency, discriminant validity), it seems appropriate to use it for overall assessment of the subjective perception patients have of their deformity. Nevertheless, the validity of the instrument to describe a patient's deformity is clearly insufficient. One potential focus of future work might be to modify some of the WRVAS items that are less valid in this regard. We advocate changes that will yield information on the frontal vision of the body and improve the representation of waist asymmetry. On the other hand, if the total sum of the scale is considered sufficiently valid, it might be worthwhile investigating whether some questions that do not seem to provide valid information (such as items 3 and 6) might be excluded.

Conclusion

The WRVAS is a valid questionnaire for assessing the subjective perception patients have of their deformity. Nonetheless, the profile of the individual scores did not differentiate among the various curve patterns studied (thoracic, double major and thoracolumbar/lumbar). Moreover, some of the scale's figures (items 3, 5 and 6) did not correlate with the radiological deformity they were designed to measure. These findings indicate that the WRVAS is not valid to describe the actual deformity a patient has.

Competing interests

The author(s) declare that they have no competing interests.

Authors' contributions

JB contributed in analysis, interpretation of data and drafting the manuscript

JMC contributed in analysis, interpretation of data and drafting the manuscript.

SP contributed in acquisition of data

CG contributed in revising the manuscript

All authors have read and approved the final manuscript

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