Orthopedic Treatment of Idiopathic Scoliosis
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
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.
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."
Dr Jean Claude de Mauroy (Médecine Orthopédique)
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