Centre Européen de la Colonne Vertébrale - TELEMEDECINE

Clinique du Parc - Lyon (France)    GKTS 2012


EBM & Orthopedic Treatment of Idiopathic Scoliosis

Evidence Based Medicine represents a new paradigm initially for integrating an objective assessment of patient's clinical expertise and not to supplant experience.
40 years ago, no one orthopedist would discuss the indication of conservative orthopedic treatment and physical therapy in scoliosis; today everyone doubts and it is interesting to understand why.
One of the major problems is the difficulty to objectively assess the prognosis of progressive scoliosis. We know now the default of the Gi protein that prevents the signaling of melatonin at the cellular level. This defect is induced by SNPs (Single Nucleotide Polymorphism) corresponding to minor variations in the genome of a population. A single nucleotide is changed. Jim Ogilvie was able to isolate 53 SNPs associated with the most progressive scoliosis. Retrospectively studying the evolution of progressive scoliosis genetically at risk, it seems that with or without orthopedic treatment, evolution is almost identical.
A second prospective randomized study began in 2007 (BRAIST) including scoliosis of 20° to 40°. Rejection of randomization was found in 83% of cases. When the patient has a preference, 70% chose the conservative orthopedic treatment. So the second difficulty is the EBM ethics.
In our department since 1998 all patients were included in a prospective database. To avoid any discussion with the risk of progression, we selected scoliosis of more than 40° which are universally considered as progressive, so the two precedent pitfalls are avoiding.
The third difficulty concerns the protocol of conservative orthopedic treatment. Unlike the majority of Anglo-Saxon teams, the standard protocol with reduction by a plaster cast made before the rigid adjustable Lyon brace (plaster cast first) is still used. The reason is biomechanical as we seek a creep of paravertebral structures.
This long and heavy treatment explains that nearly 20% of our patients are directed initially to surgery.
When the treatment is accepted, 65% of scoliosis is improved or stable.
35% loss of more than 5 ° from the initial angulation is for boys, who have a higher proportion of infantile and juvenile scoliosis and patients with retreatment, usually the first brace without prior plaster cast.
When we have a follow up of more than 10 years we observe an evolution in adulthood identical to that of the general population of scoliosis.

In conclusion, the plaster cast first seems to be a key factor for the success of conservative orthopedic treatment which, despite its apparent heaviness should be discussed with the patient as part of the "informed consent."

Auteur : Dr Jean Claude de Mauroy (Médecine Orthopédique)

Cette page a été mise à jour pour la dernière fois le : 13 octobre 2012

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