Aims

Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of ‘full-time bracing’ versus ‘night-time bracing’ in adolescent idiopathic scoliosis (AIS).

We retrospectively reviewed the records of 16 children treated for spondylodiscitis at our hospital between 2000 and 2007. The mean follow-up was 24 months (12 to 38). There was a mean delay in diagnosis in hospital of 25 days in the ten children aged less than 24 months. At presentation only five of the 16 children presented with localising signs and symptoms. Common presenting symptoms were a refusal to walk or sit in nine children, unexplained fever in six, irritability in five, and limping in four. Plain radiography showed changes in only seven children. The ESR was the most useful investigation when following the clinical course of the disease. Positive blood cultures were obtained in seven children with Staphylococcus aureus being isolated in five. Antibiotics were used in 14 children and spinal bracing in six. Children with spondylodiscitis often present with a confusing clinical picture leading to late diagnosis. The early use of MRI in the investigation of children with an atypical picture may avoid unnecessary delay in starting treatment and possibly prevent long-term problems. All except one of our children had made a complete clinical recovery at final follow-up. However, all six children in the > 24-month age group showed radiological evidence of degenerative changes which might cause problems in the future

Introduction: Haematogenous pyogenic spinal infection encompasses spondylodiskitis, septic discitis, vertebral osteomyelitis and epidural abscess. Management of pyogenic spinal infection can involve conservative methods and surgical intervention. We carried out a retrospective review of 48 cases of pyogenic vertebral osteomyelitis presenting over a twelve-year period to the National Spinal Injuries Unit of the Republic Of Ireland. Our objective was to analyze the presentation, aetiology, management and outcome of 48 cases of non-tuberculous pyogenic spinal infection. Methods: Both the Hospital Inpatient Enquiry (HIPE) System and the National Spinal Injuries Unit Database were used to identify our study cohort. The medical records, blood results, radiologic imaging and bacteriology results of all patients identified were reviewed. Results: The average age of presentation was 59 years with an almost even distribution between males and females. Most patients took between three and six weeks to present to hospital. Diagnosis was confirmed by serological testing of inflammatory markers and radiological imaging. The most frequently isolated pathogen was Staph. aureus (75% of cases). 94% of cases were managed by conservative measures alone, including antibiotic therapy and spinal bracing. However, in 6% of cases surgical intervention was required due to neurological compromise or mechanical instability. Conclusions: With this large cohort of non-tuberculous, pyogenic spinal infections from the NSIU, we conclude that Staph. aureus is the predominent pathogen. In the vast majority, conservative management with antibiotic therapy and spinal bracing is very successful. However in 6% of cases surgical intervention is warranted and referral to a specialist centre is appropriate

Purpose. Congenital insensitivity to pain is a rare autosomal recessive condition that leads to varying degrees of sensory and autonomic neuropathy. The aim of the study was to explore the common orthopaedic presentations of congenital insensitivity to pain and provide guidance on their treatment and complications. Methods. This study presents the results of fifteen patients with congenital insensitivity to pain, which were referred and treated at our supra-regional referral centre. Intradermal histamine tests and quantitative sweat tests were performed on all fifteen patients. Results. The average age of presentation was 13.2 years (range, two to 28 years). Eight patients presented with Charcot arthropathies and joint dislocations, which involved the foot/ankle (n=4), knee (n=2) or spine (n=2). Four patients presented with fractures or avascular necrosis affecting the tarsal bones and three patients presented with recurrent infections of the lower limbs. Patient education regarding appropriate shoe ware, pedal hygiene, periods of non-weight bearing, spinal bracing and close follow-up within the multi-disciplinary team was the mainstay of treatment. Patients with infection underwent cultures, aspiration, magnetic resonance imaging and treatment with antibiotics. Only one patient required joint washout for septic arthritis of the ankle. Conclusions. Congenital insensitivity to pain presents with both acute and chronic pathology affecting the weight-bearing joints. Treatment should be aimed at off-loading the pressure on these joints and preventing the development of further complications. Surgical intervention should be reserved for patients not responding to conservative treatment or those requiring debridement/washout for extensive infection

We reviewed 26 patients with progressive spinal kyphosis due to anterior fusion between the vertebrae. No patient had back pain or any neurological defect. The kyphosis appeared to be progressive until the fusion had included all of the disc. Progression was faster during the adolescent growth-spurt. Kyphosis increased with the number of discs involved, from one to six, and the extent of fusion within each disc. In six of the nine cases treated by spinal bracing, progression of the kyphosis was arrested

Introduction: While bracing may improve the natural history of patients with adolescent idiopathic scoliosis with moderate curves, little attention has been paid to the potential impact of brace treatment on their quality of life. We hypothesized that bracing has a negative affect on the physical and psychosocial health of affected adolescents. Methods: Quality of life (QOL) data was collected from patients with adolescent idiopathic scoliosis and a spinal curvature greater than 10 degrees at our institution. The Child Health Questionnaire (CHQ) and the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collection Instrument (PODCI) were administered to parents to measure their children’s QOL. Multivariate analyses were conducted to determine the effect of gender and treatment on QOL. Results: Our cohort consisted of 214 patients, who were mostly female, with an average curve of 28 degrees and an average age of 13.7 years. One hundred thirty four patients were observed (average curve 25 degrees), while 80 patients were treated with bracing (average curve 34 degrees). There were no significant differences in QOL between these two treatment groups, using the Bonfer-roni multiple comparison test. There were no gender-related differences in QOL. Among 15 children with pre- and intra-bracing data, there were no significant differences in QOL between these two time points. Discussion and conclusion: Our patients who were treated with spinal bracing did not seem to have significantly different health-related QOL, as compared with patients in the observation group. These findings are contrary to our initial hypotheses and merit further study

Introduction: The clinical effectiveness of spinal bracing for the conservative treatment of adolescent idiopathic scoliosis is still not fully understood. Cohort studies on clinical effectiveness fail to adequately measure and control for confounding variables including spine flexibility, curve type, magnitude and maturity, distribution of corrective forces and compliance. This paper presents intermediate findings from a longitudinal study to objectively measure brace wear patterns and compliance in users of custom fitted TLSOs in the UK. Braces are fitted with data logging devices to measure temperature and humidity at the skin/brace interface. Previously reported measures of compliance have been in adolescents wearing Boston Braces using questionnaires, strap tension, interface pressure and skin temperature. They have shown compliance reported by the user can significantly over estimate actual compliance. Methods and results: 20 patients are being studied over 18 months. TLSOs are fitted with data logging devices to measure temperature and humidity at the skin/brace interface. They are discrete sensors inserted into a pocket formed on the posterior of the brace. Measurements are recorded at 16 minute intervals and data downloaded every three to four months. Results clearly demonstrate compliance and daily wear routines. Temperature and humidity at the skin/brace interface during periods of wear are 35°C and > 80%RH respectively. Compliance ranges from 60–98%. Users who stick rigidly to their regime only remove their brace in the evening. Where poorer compliance is evident, the brace is worn sporadically during the day and evening, and worn full time at night. Conclusion: Measurement of temperature and humidity at the skin/brace interface clearly demonstrates compliance and daily wear routines. Compliance varies from 60–98%. Where poor compliance is an issue it is intended to re-interview these individuals and obtain more detailed information about the reasons why they failed to use the brace

Aims

To clarify the asymmetrical ossification of the epiphyseal ring between the convex and concave sides in patients with adolescent idiopathic scoliosis (AIS).

We determined the frequency, rate and extent of development of scoliosis (coronal plane deformity) in wheelchair-dependent patients with Duchenne muscular dystrophy (DMD) who were not receiving steroid treatment. We also assessed kyphosis and lordosis (sagittal plane deformity). The extent of scoliosis was assessed on sitting anteroposterior (AP) spinal radiographs in 88 consecutive non-ambulatory patients with DMD. Radiographs were studied from the time the patients became wheelchair-dependent until the time of spinal fusion, or the latest assessment if surgery was not undertaken. Progression was estimated using a longitudinal mixed-model regression analysis to handle repeated measurements.

Scoliosis ≥ 10° occurred in 85 of 88 patients (97%), ≥ 20° in 78 of 88 (89%) and ≥ 30° in 66 of 88 patients (75%). The fitted longitudinal model revealed that time in a wheelchair was a highly significant predictor of the magnitude of the curve, independent of the age of the patient (p <  0.001). Scoliosis developed in virtually all DMD patients not receiving steroids once they became wheelchair-dependent, and the degree of deformity deteriorated over time.

In general, scoliosis increased at a constant rate, beginning at the time of wheelchair-dependency (p < 0.001). In some there was no scoliosis for as long as three years after dependency, but scoliosis then developed and increased at a constant rate. Some patients showed a rapid increase in the rate of progression of the curve after a few years – the clinical phenomenon of a rapidly collapsing curve over a few months.

A sagittal plane kyphotic deformity was seen in 37 of 60 patients (62%) with appropriate radiographs, with 23 (38%) showing lumbar lordosis (16 (27%) abnormal and seven (11%) normal).

This study provides a baseline to assess the effects of steroids and other forms of treatment on the natural history of scoliosis in patients with DMD, and an approach to assessing spinal deformity in the coronal and sagittal planes in wheelchair-dependent patients with other neuromuscular disorders.

Cite this article: Bone Joint J 2014;96-B:100–5.