- Open Access
Is there a body of evidence for the treatment of patients with Adolescent Idiopathic Scoliosis (AIS)?
© Weiss; licensee BioMed Central Ltd. 2007
- Received: 29 November 2007
- Accepted: 31 December 2007
- Published: 31 December 2007
Historically, the treatment options for AIS, the most common form of scoliosis are; exercises; in-patient rehabilitation; braces and surgery. While there is evidence in the form of prospective controlled studies that Scoliosis Intensive Rehabilitation (SIR) and braces can alter the natural history of the condition, there is no prospective controlled study comparing the natural history with surgical treatment.
One aim of the Scoliosis Society (SOSORT) should be; to help develop a body of research regarding the outcomes of conservative and operative treatment as well, and to highlight the problems of treatment indications in patients with AIS and other spinal deformities. Another aim is to help to improve the safety of patients who have surgery. By producing evidence-based information that can be used to develop guidelines that could aid both professionals and patients in making decisions about surgical and conservative options.
Although 'Scoliosis' is the official journal of the SOSORT and is the main forum for experts in the field of conservative management of patients with spinal deformities, there needs to be more wide spread attempt to develop a fuller body of evidence focussing on spine surgery as well.
Today evidence based medicine (EBM) and evidence based practice (EBP) are valuable instruments in the decision making process of professionals in the medical field. Restrictions upon resources of social health care systems have lead to calls for greater efficiency and cost effectiveness of treatment programmes. Therefore good quality evidence studies providing the highest of research are necessary to evaluate effectiveness of treatments.
Smallest evidence is provided by "expert opinion"
Case reports/case series
Randomized controlled studies (RCT) and
Meta analyses from RCT
The quality and types of evidence help to segregate research into levels. They are graded (IV [lowest] – I [highest]) and from those levels recommendations for treatment are derived (Grade D [lowest] – Grade A [highest]).
Grade B recommendations for conservative treatment of scoliosis are justified. There are prospective controlled studies (level II) [2–4] and enough data from level III or IV, which are generally consistent  when taking into account studies from central Europe or Asia [6–9]. These levels of evidence seem not to have been reached in the United States [10, 11].
Although randomised controlled trials (RCT's) provide the highest evidence the application of this study design is unrealistic for complex disorders like scoliosis. While pharmacological studies are the main field for RCT's until now no RCT on treatment outcomes for scoliosis is available.
In pharmacological studies one can easily standardise the treatments (drugs) to be investigated. Body weight of the patients and dosage of drugs can easily be measured .
Additionally to that, there is evidence on level II for the use of the Boston brace [3, 4]. In the SRS multi-centre prospective controlled study  the survival analysis clearly has shown that the Boston brace was superior to observation only and to electrical stimulation. A long term controlled prospective follow-up has also provided evidence that the Boston brace efficiently stops curvature progression . A Meta-analysis  clearly unveils that brace wearing time is one determinant for a successful outcome. But if the brace could not influence the curvature, why would the amount of time spent wearing the brace be an important issue?
In the light of this evidence already available, an RCT is not only a complex task but an unethical one. To allow growing patients to continue without conservative treatment (a control group) until nothing except surgical intervention can help them, is completely unethical. Especially when one considers the problems with surgery, such as; primary risks; a re-surgery rate, which might be higher than 30% in the long-term [17–19] and future complications . This type of approach cannot be regarded as patient-oriented. This is why the SOSORT offers clinicians and scientists to take part in prospective controlled studies on bracing. Within this society there is a unique opportunity to test different bracing approaches against each other in order to find the "Best Practice" of bracing. This will enable clincians in the near future the opportunity to give their conservatively treated patients the best possible advice and offer the best possible treatment in a more standardized way. Research on living patients should only be done in order to develop a useful treatment, this is why we need to be able to measure brace quality. We know that in-brace correction and compliance are the two main determinants of outcome [16, 20, 21]. Therefore in-brace correction might serve as a measure for brace quality and compliance as a measure for quality of management. Efforts have to be made to improve both of these.
Dolan et al.  have found a wide variation of surgical rates for a number of brace types worn 8 to 20 hours per day. The variation in the pool of selected data ranged from a surgical rate of 1% to 43%. After calculating this data the authors concluded: "Based on the evidence presented here, one cannot recommend one approach [bracing] over the other [observation] to prevent the need for surgery in AIS" 
But there are four main weaknesses within this study; the subject (a brace) and the outcome parameter (rate of surgery), are components which are known to contain great ranges of variability and therefore, the only justified conclusion to be drawn from this study would be that 'rate of surgery' cannot be used to generate valid evidence.
Secondly, the authors set the inclusion and exclusion criteria in a way to enable the exclusion of studies that have presented a smaller rate of surgery and also those with the additional use of physiotherapy. Only one  of the four studies from outside the US [6–9] covering this topic is cited (but not included) in their paper, due to their specific choice of inclusion and exclusion criteria.
As Hawes clearly highlighted , a large number of papers from the US containing an undefined number of patients treated by physiotherapy do exist, even in natural history studies. But as physiotherapy historically has been recognized as 'no treatment'  they tend not to be considered within research reviews.
The third main problematic area within this study is that there is no mention of the correction effect of the braces used in this study. When brace quality is not assessed and in-brace correction is the only quality parameter applied, no conclusions about the use of bracing can be made. Braces from Europe have not been included in this paper, although they are of higher standards in terms of in-brace correction [13, 20, 21, 24, 26].
The final and most significant weakness of this study is in relation to 'a need for surgery' for patients with AIS . As signs and symptoms of scoliosis in AIS patients cannot be cured by surgery , there is no indication for surgery other than the cosmetic indication. As Goldberg pointed out in her paper , which can be viewed as the precursor of the paper by Dolan and Weinstein , surgery replaces one pathology (a curved spine) with another (a stiff spine). Therefore, there are no clinical indications for surgery in patients with AIS, when we are dealing with a relatively benign condition [28, 29] and when there is no proof that surgery changes signs and symptoms of scoliosis .
In another paper by Dolan et al , the subject of the 'professional' opinion concerning the effectiveness of bracing was investigated. As could have been expected, a high variability in opinions has been found in the group of surgeons and a small number of other professions. In this study a RCT on braces has also been postulated. One question remains to be answered: Is a surgeon automatically a 'professional' when bracing is the specialised subject?
With respect to surgery, there are no level II or level I studies to support the use of surgery in the treatment of AIS and as previously stated by Hawes , signs and symptoms of AIS cannot be changed by surgery.
But respect should remain for the psychological indication for surgery when a patient with AIS is unable to cope with the deformity.
The assumption that there is an indication for surgery', in spite of the known long-term risks [17–19, 27], however should be made cautiously by those with an ethical responsibility to the patient as it seems that this lacks a scientific evidence base.
To help to develop the body of research regarding the outcome of surgery and to highlight the problems of treatment indications in patients with AIS and other spinal deformities we would like to open the Scoliosis Journal to papers that discuss surgical procedures.
One of our aims is to improve patients' safety in surgery by producing evidence-based information that can be used to develop guidelines that could aid both professionals and patients in making decisions about surgical and conservative options.
Within this society we have well known spinal surgeons who are specialists in conservative management of scoliosis as well. This is why I am confident that to include papers with surgical content, is a step towards an equilibrated and balanced view on scoliosis management.
Tomasz Kotwicki, deputy editor in charge will oversee papers with surgical content from now on.
My very best wishes to my friend and colleague Dr. Tomasz Kotwicki, who surely is both: a dedicated physician and a remarkable pediatric spine surgeon.
The author is thankful to Deborah Goodall for copyediting this paper.
Written informed consent was obtained from the patients for publication of their cases.
- Oxford Centre for Evidence-based Medicine, Levels of Evidence (May 2001). [http://www.cebm.net/?o=1011]
- Weiss HR, Weiss G, Petermann F: Incidence of curvature progression in idiopathic scoliosis patients treated with scoliosis in-patient rehabilitation (SIR): an age- and sex-matched controlled study. Ped Rehab. 2003, 6: 23-30. 10.1080/1363849031000095288.View ArticleGoogle Scholar
- Nachemson AL, Peterson LE: Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. A prospective, controlled study based on data from the Brace Study of the Scoliosis Research Society. J Bone Joint Surg Am. 1995, 77 (6): 815-22.View ArticleGoogle Scholar
- Danielsson AJ, Hasserius R, Ohlin A, Nachemson AL: A prospective study of brace treatment versus observation alone in adolescent idiopathic scoliosis: a follow-up mean of 16 years after maturity. Spine. 32 (20): 2198-207. 2007 Sep 15View ArticleGoogle Scholar
- Weiss HR: Rehabilitation of adolescent patients with scoliosis–what do we know? A review of the literature. Pediatric Rehabilitation. 2003, 6 (3–4): 183-94.View ArticleGoogle Scholar
- Rigo M, Reiter C, Weiss HR: Effect of conservative management on the prevalence of surgery in patients with adolescent idiopathic scoliosis. Pediatric Rehabilitation. 2003, 6: 209-214. 10.1080/13638490310001642054.View ArticleGoogle Scholar
- Maruyama T, Kitagawa T, Takeshita K, Mochizuki K, Nakamura K: Conservative treatment for adolescent idiopathic scoliosis: can it reduce the incidence of surgical treatment?. Pediatric Rehabilitation. 2003, 6 (3–4): 215-9.View ArticleGoogle Scholar
- Weiss HR, Weiss G, Schaar HJ: Incidence of surgery in conservatively treated patients with scoliosis. Pediatric Rehabilitation. 2003, 6: 111-8. 10.1080/13638490310001593446.View ArticleGoogle Scholar
- Edelmann P: Brace treatment in idiopathic scoliosis. Acta Orthop Belg. 1992, 58 (Suppl 1): 85-90.PubMedPubMed CentralGoogle Scholar
- Goldberg CJ, Moore DP, Fogarty EE, Dowling FE: Adolescent idiopathic scoliosis: the effect of brace treatment on the incidence of surgery. Spine. 2001, 26: 42-47. 10.1097/00007632-200101010-00009.View ArticleGoogle Scholar
- Dolan LA, Weinstein SL: Surgical rates after observation and bracing for adolescent idiopathic scoliosis: an evidence-based review. Spine. 32 (19 Suppl): S91-S100. 2007 Sep 1.View ArticleGoogle Scholar
- Hernandez D, Miquel R, Porrini E, Fernandez A, Gonzalez-Posada JM, Hortal L, Checa MD, Rodriguez A, Garcia JJ, Rufino M, Torres A: Randomized controlled study comparing reduced calcineurin inhibitors exposure versus standard cyclosporine-based immunosuppression. Transplantation. 84 (6): 706-14. 2007 Sep 27View ArticleGoogle Scholar
- Weiss HR, Werkmann M, Stephan C: Correction effects of the ScoliOlogiC "Cheneau light" brace in patients with scoliosis. Scoliosis. 2: 2. 10.1186/1748-7161-2-2. 2007 Jan 26.Google Scholar
- Dolan LA, Donnelly MJ, Spratt KF, Weinstein SL: Professional opinion concerning the effectiveness of bracing relative to observation in adolescent idiopathic scoliosis. J Pediatr Orthop. 2007, 27 (3): 270-6.View ArticleGoogle Scholar
- Goldberg CJ, Moore DP, Fogarty EE, Dowling FE: Scoliosis: a review. Pediatr Surg Int. 2007 Sep 22Google Scholar
- Rowe DE, Bernstein SM, Riddick MF, Adler F, Emans JB, Gardner-Bonneau D: A meta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis. J Bone Joint Surg Am. 1997, 79 (5): 664-74.View ArticleGoogle Scholar
- Asher MA, Burton DC: Adolescent idiopathic scoliosis: natural history and long term treatment effects. Scoliosis. 1 (1): 2. 10.1186/1748-7161-1-2. 2006 Mar 31.Google Scholar
- Sponseller PD, Cohen MS, Nachemson AL, Hall JE, Wohl ME: Results of surgical treatment of adults with idiopathic scoliosis. J Bone Joint Surg Am. 1987, 69 (5): 667-75.View ArticleGoogle Scholar
- Dickson JH, Erwin WD, Rossi D: Harrington Instrumentation and Arthrodesis for Idiopathic Scoliosis: A twenty-one year follow-up. J Bone Joint Surg Am. 1990, 72: 678-683.View ArticleGoogle Scholar
- Landauer F, Wimmer C, Behensky H: Estimating the final outcome of brace treatment for idiopathic thoracic scoliosis at 6-month follow-up. Pediatric Rehabilitation. 2003, 6 (3–4): 201-7.View ArticleGoogle Scholar
- Weiss HR: Standard der Orthesenversorgung in der Skoliosebehandlung. Med Orth Tech. 1995, 5: 323-330.Google Scholar
- Castro FP: Adolescent idiopathic scoliosis, bracing, and the Hueter-Volkmann principle. Spine J. 2003, 3: 180-5. 10.1016/S1529-9430(02)00557-0.View ArticleGoogle Scholar
- Braun J: Identification of Progression Genes. Proceedings of the International Research Society of Spinal Deformities Meeting, Ghent. 2006Google Scholar
- Weiss HR, Rigo M: The Chêneau concept of bracing – Actual standards. SOSORT instructional course lectures. Edited by: Grivas TB. IOS press,Google Scholar
- Hawes MC: The use of exercises in the treatment of scoliosis: an evidence-based critical review of the literature. Pediatric Rehabilitation. 2003, 6 (3–4): 171-82.View ArticleGoogle Scholar
- Hopf C, Heine J: [Long-term results of the conservative treatment of scoliosis using the Cheneau brace]. Z Orthop Ihre Grenzgeb. 1985, 123 (3): 312-22.View ArticleGoogle Scholar
- Hawes M: Impact of spine surgery on signs and symptoms of spinal deformity. Pediatric Rehabilitation. 2006, 9 (4): 318-39. 10.1080/13638490500402264.View ArticleGoogle Scholar
- Weinstein SL, Dolan LA, Spratt KF, Peterson KK, Spoonamore MJ, Ponseti IV: Health and function of patients with untreated idiopathic scoliosis: A 50 year natural history study. JAMA. 2003, 289: 559-567. 10.1001/jama.289.5.559.View ArticleGoogle Scholar
- Haefeli M, Elfering A, Kilian R, Min K, Boos N: Nonoperative treatment for adolescent idiopathic scoliosis: a 10- to 60-year follow-up with special reference to health-related quality of life. Spine. 31 (3): 355-66. 10.1097/01.brs.0000197664.02098.09. 2006 Feb 1View ArticleGoogle Scholar
- Hill D, Raso VJ, Moreau K, Moreau M, Mahood J: Long-term follow-up of surgically treated AIS patients. Stud Health Technol Inform. 2002, 91: 477-80.PubMedPubMed CentralGoogle Scholar
- Bettany J: Are Back Shape Changes Following Scoliosis Surgery Stable? A prospective 3 year follow-up of five different surgical procedures. Proceedings of the European Spinal Deformities Society. Birmingham 31 May – 3 June.Google Scholar
- Helenius I, Remes V, Vrjonen T, Ylikoski M, Schlenzka D, Helenius M, Poussa M: Comparison of long-term functional and radiological outcomes after Harrington instrumentation and spondylodesis in AIS: a review of seventy-eight patients. Spine. 2002, 27: 176-180. 10.1097/00007632-200201150-00010.View ArticleGoogle Scholar
- Shapiro GS, Taira G, Boachie-Adjei O: Results of surgical treatment of adult IS with low back pain and spinal stenosis. A study of long term clinical radiographic outcomes. Spine. 2003, 28: 358-363. 10.1097/00007632-200302150-00009.PubMedPubMed CentralGoogle Scholar
- Hamil CL, Lenke LG, Bridwell KH, Chapman MP, Blanke K, Baldus C: The use of pedicle screw fixation to improve correction in the lumbar spine of patients with IS. Is it warranted?. Spine. 1996, 21: 1241-1249. 10.1097/00007632-199605150-00020.View ArticleGoogle Scholar
- Helenius I, Remes V, Yrjonen T, Ylikoski M, Schlenzka D, Helenius M, Poussa M: Harrington and Cotrel-Dubousset instrumentation in AIS. Long term functional and radiographic outcomes. Journal of Bone and Joint Surgery. 2003, 85-A: 2303-2309.View ArticleGoogle Scholar
- Korovessis P, Filos KS, Zielke K: Effects of the combined VDS-Zielke and Harrington operation on the frontal rib cage deformity of double major curves in IS. Spine. 1995, 20: 1061-1067. 10.1097/00007632-199505000-00013.View ArticleGoogle Scholar
- Wood KB, Transfeldt EE, Ogilvie JW, Schendel MJ, Bradford DS: Rotational changes of the vertebral-pelvic axis following Cotrel-Dubousset instrumentation. Spine. 1991, 16: S404-S408. 10.1097/00007632-199108001-00019.View ArticleGoogle Scholar
- Wood KB, Schendel MJ, Dekutoski MB, Boachie-Adjei O, Heithoff KH: Thoracic volume changes in scoliosis surgery. Spine. 1996, 21: 718-723. 10.1097/00007632-199603150-00012.View ArticleGoogle Scholar
- Wood KB, Olsewski J, Schendel M, Boachie-Adjei O, Gupta M: Rotational changes of the vertebral pelvic axis safter sublaminar instrumentation in AIS. Spine. 1997, 22: 51-57. 10.1097/00007632-199701010-00009.View ArticleGoogle Scholar
- Pratt RK, Webb JK, Burwell RG, Cole AA: Changes in surface and radiographic deformity after universal spine system for right thoracic adolescent IS. Is rib hump reassertion a mechanical problem of the thoracic rib cage rather than an effect of relative anterior spinal overgrowth?. Spine. 2001, 26: 1778-1787. 10.1097/00007632-200108150-00009.View ArticleGoogle Scholar
- Bettany J, Partridge C, Edgar M: Topographical, Kinesiological and Psychological Factors in the Surgical Management of Adolescent Idiopathic Scoliosis. Stud Health Technol Inform. 1995, 15: 321-326.Google Scholar
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