This study provides an outlook of the end of MCGR treatment. Although this is a fusionless procedure, instrumented segments do experience stiffness limiting further correction and length gain during final surgery whether fusion or rod removal is performed.
Background Successful brace treatment entails good control of scoliosis with avoidance of surgery. However, achieving curve regression may be an even better radiological result than prevention of curve progression for patients with adolescent idiopathic scoliosis. Vertebral remodeling may occur with well-fitted braces. Better in-brace curve correction may influence the likelihood of vertebral remodeling and the chance of curve regression. Only a few reports have evaluated curve regression with brace treatment, and the factors associated with these events are unknown. Questions/purposes (1) What changes in curvature are observed with brace treatment for adolescent idiopathic scoliosis? (2) What factors are associated with curve improvement? (3) What factors are associated with curve deterioration? (4) Is curve regression associated with improvements in patient-reported objective outcome scores? Methods Between September 2008 and December 2013, 666 patients with adolescent idiopathic scoliosis underwent underarm brace treatment and were followed until skeletal maturity at 18 years old. Among these patients, 80 were excluded because of early discontinuation of brace treatment (n = 66) and loss to follow-up (n = 14). Hence, 586 patients were included in this study, with a mean brace-wear duration of 3.8 ± 1.5 years and post-weaning follow-up duration of 2.0 ± 1.1 years. The mean age at baseline was 12.6 ± 1.2 years. Most patients were female (87%, 507 of 586) and up to 53% (267 of 507) of females were post-menarche. Bracing outcomes were based on changes in the Cobb angle measured out of brace. These included curve regression, as indicated by at least a 5° reduction in the Cobb angle, curve progression, as indicated by at least a 5° increase in the Cobb angle, and unchanged, as indicated by a change in the Cobb angle of less than 5°. We studied the pre-brace and supine Cobb angles, curve flexibility (pre-brace Cobb angle – supine Cobb angle / pre-brace Cobb angle x 100%), correction rate (pre-brace Cobb angle – in-brace Cobb angle / pre-brace Cobb angle x 100%), location of apical vertebrae, apical ratio (convex vertebral height/concave vertebral height), change in the major curve Cobb angle, and apical ratio post-bracing. The refined 22-item Scoliosis Research Society questionnaire was used for patient-reported outcomes and is composed of five domains (function, pain, appearance, mental health and satisfaction with treatment). Its minimum clinically important difference, based on a scale from 0 to 5, has been quoted as 0.2 for pain, 0.08 for activity and 0.98 for appearance domains. Mental health has no quoted minimum clinically important difference for the adolescent idiopathic scoliosis population. Satisfaction with treatment is described based on improvement or deterioration in domain scores. Intergroup differences between bracing outcomes were evaluated with the Kruskal Wallis test. Univariate analyses of bracing outcomes were performed with a point-biserial correlation coefficient for continuous variables and Pearson’s chi-square test for categorical variables. Multivariate logistic regression models were created for improved and deteriorated outcomes. P values < 0.05 were considered significant. Results In all, 17% of patients (98 of 586) had an improved angle and 40% of patients (234 of 586) had curve deterioration. In patients who improved, the mean reduction in the Cobb angle was 9 ± 4°, while in patients who deteriorated, the mean increase in the Cobb angle was 15 ± 9°, and this was maintained at the latest post-brace weaning follow-up. Despite a trend for patients with curve regression to have higher baseline flexibility and correction rate, after controlling for age, Risser staging, radius and ulnar grading, and Sanders staging, we found no clinically important differences with increased correction rate or flexibility. We did find that improvement in the Cobb angle after bracing was associated with reduced apical ratio (odds ratio [OR] 0.84 [95% CI 0.80 to 0.87]; p < 0.001). Curve progression was associated with younger age (OR 0.71 [95% CI 0.55 to 0.91]; p = 0.008), pre-menarche status (OR 2.46 [95% CI 1.31 to 4.62]; p = 0.005), and increased apical ratio (OR 1.24 [95% CI 1.19 to 1.30]; p < 0.001) but no clinically important differences were observed with less flexible curves and reduced correction rate. Improvements in scores of the refined 22-item Scoliosis Research Society domains of function (mean difference on a scale from 0 to 5: 0.2; p = 0.001 versus 0.1; p < 0.001) and pain (mean difference on a scale from 0 to 5: 0.2; p = 0.020 versus 0.0; p = 0.853) were greater in the post-brace improvement group than in the deterioration group and fulfilled the minimum clinically important difference threshold. The appearance domain did not fulfill the minimum clinically important difference. Satisfaction with treatment domain score minimally improved with the curve regression group (mean difference on a scale from 0 to 5: 0.2) but deteriorated in the curve progression group (mean difference on a scale from 0 to 5: -0.4). Conclusions Curve regression occurs after underarm bracing and is associated with superior patient-reported outcome scores. This possible change in Cobb angle should be explained to patients before and during bracing. Whether this may help improve patients’ duration of brace-wear should be addressed in future studies. Patients with well-fitting braces may experience curve improvement and possible vertebral remodeling. Those braced at a younger age and with increased vertebral wedging are more likely to have curve progression. Level of Evidence Level III, therapeutic study.
Introduction: Ability to achieve successful MCGR distraction is crucial for gradual spine lengthening. Rod slippage has been described as a failure of internal magnet rotation leading to a slippage and an inability to distract the rod. However, its onset, significance and risk factors are currently unknown. In addition, how this phenomenon pertains to actual distracted lengths is unknown. Hence, the aims of this study are to identify the factors that are associated with rod slippage and to study the pattern of achieved length gain with a standard distraction methodology. Methods: A total of 22 patients with MCGR implantation with at least 6 distraction episodes were prospectively studied. Patients with rod slippage occurring ≤6 distraction episodes were considered early rod slippage while those >6 or have yet not slipped were grouped as late rod slippage. The association of parameters including body habitus, maturity status, age of implantation, total number of distractions, months of distraction from initial implantation, initial and postoperative Cobb angle, T1-T12, T1-S1, T5-T12 kyphosis, curve flexibility, fusion block length, and distance between magnets in dual rods and between the magnets and apex of the 2 curve with early or late onset of rod slippage was studied. Differences between expected and achieved distraction lengths were assessed with reference to rod slippage episodes and rod exchanges to determine any patterns of diminishing returns. Results: Patients had mean age of 7.1 years at diagnosis with mean follow-up of 49.8 months. A mean 32.4 distractions were performed per patient. Early rod slippage occurred in 14 patients and late rod slippage occurred in 8 patients. Increased height, weight, body mass index, older age, increased T1-12 and T1-S1 lengths, and less distance between magnets were significantly associated with early rod slippage. Expected distraction lengths did not translate to achieved distraction lengths. Reduced length gains were observed after achieving one-third of the allowable distracted length in the first MCGR implanted. However, this rate returned to its original baseline after rod exchange with another reduction observed after half of the total achievable length was obtained in the second MCGR. Conclusion: This is the first study to specifically analyze the impact of rod slippage on distraction lengths and the risk factors associated with its onset and frequency. Increased body habitus and reduced distance between internal magnets significantly influenced rod slippage events. In addition, mismatching between expected and achieved distraction lengths was illustrated. Diminishing returns in distracted length gains were only observed after a certain usage of the MCGR rather than the number of distractions and overall length gain. * indicated statistical significance Early slippage indicates a slippage ≤6 distractions. Late slippage indicates no slip or slippage >6 distractions BMI: body mass index; DRU: distal radius and ulna classification; FBCI: fulcrum bending corrective in...
Delayed antibiotic treatment of M marinum infections and steroid injections were associated with unsatisfactory outcome. Clinicians must have a high index of suspicion for this condition and avoid inappropriate management such as intralesional steroid injections. Public awareness to this condition should be raised.
The use of a rigid collar after laminoplasty leads to less axial neck pain in the first 2 wk after surgery. However, there is no additional benefit with regards to range of motion, quality of life, and complication risk.
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