Scoliosis: Brace treatment - from the past 50 years to the future.

OBJECTIVE: This paper deals with scoliosis treatment over the past 50 years. The review of the literature from the point of view of the current formation of opinion. From conservative forms of treatment, the pendulum has swung to surgical measures. To visualize this temporarily rejection of conservative treatment is the goal of this article. MATERIALS AND METHODS: A review of the literature over the last 50 years was performed from the perspective of current opinion, this with a pinch of personal experience in bracing and scoliosis surgery since 1972. The MESH terms (scoliosis, idiopathic scoliosis, adolescent idiopathic scoliosis) are presented in their number in a flow diagram and the publications on conservative therapies (brace, physiotherapy) are compared to surgical therapies (surgery).Opinions of "eminences" in the 1980s have been replaced by the rules of evidence-based medicine (EBM) at end of the 1990s. This transition will be visualized in the graph of PubMed statistics. In a statement, the future scoliosis treatment is derived from history. RESULTS: The total number of publications shows a ratio of brace to surgery of 13.9% and physiotherapy to surgery of 6.7% for the MESH terms "scoliosis". When "scoliosis" is supplemented with "idiopathic", the brace to surgery ratio changes from 24.5% and physiotherapy to surgery 8.2%. Focusing on adolescent scoliosis the addition of "adolescent" changes the brace to surgery ratio from 24.8% and physiotherapy to surgery 8.1%. In the total number of publications, "adolescent idiopathic scoliosis" is treated by 25.26%. The patient numbers of our own scoliosis outpatient clinic (1482 patients) over the last 15 years show a ratio of brace (Cobb angle 20°-50° brace-indication) to surgery (Cobb angle >50° indication to surgery) of 1 to 0.06. The scientific focus on surgical therapy is evident from the figures of PubMed mentioned. The number of conservative publications shows a depression in the 1990s. In the remainder of this article, opinion-forming developments are outlined and supported by literature citations, responsible for the recovery of publications on conservative scoliosis treatment. New technologies provide additional treatment options. CONCLUSIONS: In this sense, brace therapy is a success story with a future in the digital world of AI (artificial intelligence), mathematical model calculations, and production perhaps from the 3D printer. The central message from the history of the last 50 years is: "The scientific review of treatment results is essential for the further acceptance of brace treatment."

A recurrent single-amino acid deletion (p.Glu500del) in the head domain of ß-cardiac myosin in two unrelated boys presenting with polyhydramnios, congenital axial stiffness and skeletal myopathy.

BACKGROUND: Alterations in the MYH7 gene can cause cardiac and skeletal myopathies. MYH7-related skeletal myopathies are extremely rare, and the vast majority of causal variants in the MYH7 gene are predicted to alter the rod domain of the of ß-cardiac myosin molecule, resulting in distal muscle weakness as the predominant manifestation. Here we describe two unrelated patients harboring an in-frame deletion in the MYH7 gene that is predicted to result in deletion of a single amino acid (p.Glu500del) in the head domain of ß-cardiac myosin. Both patients display an unusual skeletal myopathy phenotype with congenital axial stiffness and muscular hypertonus, but no cardiac involvement. RESULTS: Clinical data, MRI results and histopathological data were collected retrospectively in two unrelated boys (9 and 3.5 years old). Exome sequencing uncovered the same 3-bp in-frame deletion in exon 15 (c.1498_1500delGAG) of the MYH7 gene of both patients, a mutation which deletes a highly conserved glutamate residue (p.Glu500del) in the relay loop of the head domain of the ß-cardiac myosin heavy chain. The mutation occurred de novo in one patient, whereas mosaicism was detected in blood of the father of the second patient. Both boys presented with an unusual phenotype of prenatal polyhydramnios, congenital axial stiffness and muscular hypertonus. In one patient the phenotype evolved into an axial/proximal skeletal myopathy without distal involvement or cardiomyopathy, whereas the other patient exhibited predominantly stiffness and respiratory involvement. We review and compare all patients described in the literature who possess a variant predicted to alter the p.Glu500 residue in the ß-cardiac myosin head domain, and we provide in-silico analyses of potential effects on polypeptide function. CONCLUSION: The data presented here expand the phenotypic spectrum of mutations in the MYH7 gene and have implications for future diagnostics and therapeutic approaches.

Endogenous anandamide and self-reported pain are significantly reduced after a 2-week multimodal treatment with and without radon therapy in patients with knee osteoarthritis: a pilot study.

Multimodal therapies comprising spa applications are widely used as non-pharmaceutical treatment options for musculoskeletal diseases. The purpose of this randomized, controlled, open pilot study was to elucidate the involvement of the endocannabinoid system in a multimodal therapy approach. Twenty-five elderly patients with knee osteoarthritis (OA) received a 2-week spa therapy with or without combination of low-dose radon therapy in the Bad Gastein radon gallery. A 10-point numerical rating scale (pain in motion and at rest), WOMAC questionnaire, and the EuroQol-5D (EQ-5D) questionnaire were recorded at baseline, and during treatment period at weeks one and two, and at 3-month and 6-month follow-ups. Plasma levels of the endocannabinoid anandamide (AEA) were determined at baseline and at 2 weeks, and serum levels of several cartilage metabolism markers at all five time-points. A significant and sustained reduction of self-reported knee pain was observed in the study population, but no further significant effect of the additional radon therapy up and above base therapy. This pain reduction was accompanied by a significant reduction of AEA plasma levels during treatment in both groups. No significant differences were seen in serum marker concentrations between the groups treated with or without radon, but a small reduction of serum cartilage degradation markers was observed during treatment in both groups. This is the first study investigating AEA levels in the context of a non-pharmacological OA treatment. Since the endocannabinoid system represents a potential target for the development of new therapeutics, further studies will have to elucidate its involvement in OA pain.

[Not Available]. / Gluteussehnensyndrom.

Gluteal tendinopathy as well as partial and full-thickness tears of gluteal tendons (gluteus minimus and/or medius tendon) were underestimated as a cause of chronic pain in the past, and treatment was most commonly based on the diagnosis of trochanteric bursitis. Tendinous pathologies can either stay asymptomatic or cause pain and muscular dysfunction, not necessarily being associated with osteoarthritis of the hip 1. As the terminus "rotator cuff tear of the hip" was published in 1997 2, its aetiopathogenesis was reconsidered, resulting in improvements in diagnosis and treatment. Nevertheless the adoption of those findings into clinical daily routine took time 3. Ultrasound and magnetic resonance imaging (MRI) as well as histopathologic examination questioned the relevance of acute bursitis being the only cause of greater trochanteric pain 4, 5, 6, while emphasizing degenerative tendinopathy causing those symptoms 6, 7, 8. The terminus "greater trochanteric pain syndrome" (GTPS) should hereby also include further pathologies, e.g. calcific tendinitis 1, 5. GTPS affects about 10-25 % of the adult population 5. Ultrasound and MRI are reliable, non-invasive methods for detecting tendinous and bursal pathologies 7, 8, 9; in 88 % of all patients with trochanteric pain, MRI gives pathological findings 10. Nevertheless, in 50 % of suspicious pertrochanteric pathologies, patients are free of symptoms 1, 10. In patients undergoing total hip arthroplasty, the incidence of intraoperative macroscopically identified gluteal tendon tears reaches up to 22 % 2, 11, 12, 13. Tendinous tears cause pain and constrained muscular function. Sole traumatic tears are rare, most commonly they are based on pre-existing defects. Tendinosis and partial tears are primarily treated conservatively. Hereby, therapeutic options are similar to those for rotator cuff pathologies of the shoulder. Topical infiltration of corticosteroids and physical therapy offer good results especially in early stages. The effectiveness of extracorporeal shock wave therapy has also been proven 14. Surgical intervention is necessary in case of non-responsiveness to treatment or loss of gluteal muscular function. Hereby, the open gluteal repair always represented the method of choice, whereas recently, users of endoscopic systems reported similar or even better outcomes 15, 16, 17, 18, 19, 20, 21.

Cost-effectiveness of universal ultrasound screening compared with clinical examination alone in the diagnosis and treatment of neonatal hip dysplasia in Austria.

Between 1978 and 1997 all newborns in the Austrian province of Tyrol were reviewed regarding hip dysplasia and related surgery. This involved a mean of 8257 births per year (7766 to 8858). Two observation periods were determined: 1978 to 1982 (clinical examination alone) and 1993 to 1997 (clinical examination and universal ultrasound screening). A retrospective analysis compared the number and cost of interventions due to hip dysplasia in three patient age groups: A, 0 to < 1.5 years; B, ≥ 1.5 to < 15 years; and C, ≥ 15 to < 35 years. In group A, there was a decrease in hip reductions from a mean of 25.2 (SD 2.8) to 7.0 (SD 1.4) cases per year. In group B, operative procedures decreased from a mean of 17.8 (SD 3.5) to 2.6 (SD 1.3) per year. There was a 75.9% decrease in the total number of interventions for groups A and B. An increase of €57,000 in the overall cost per year for the second period (1993 to 1997) was seen, mainly due to the screening programme. However, there was a marked reduction in costs of all surgical and non-surgical treatments for dysplastic hips from €410,000 (1978 to 1982) to €117,000 (1993 to 1997). We believe the small proportional increase in costs of the universal ultrasound screening programme is justifiable as it was associated with a reduction in the number of non-surgical and surgical interventions. We therefore recommend universal hip ultrasound screening for neonates.

[Orthoses in the treatment of neuromotor diseases: mechanism of action of novel aids for positioning, sitting, standing and walking]. / Orthesenversorgung bei neuromotorischen Erkrankungen: Wirkungsweise neuer Hilfsmittel für Lagerung, Sitzen, Stehen und Fortbewegung.

The main indication of orthoses is compensation of malposition, prevention of malalignment and the balance of motion to improve function. Orthoses support current concepts of therapy and are not forms of therapy in their own right. From this point of view orthoses are often used too late to prevent deformities. Efforts to standardize individual ortheses production and orthoses indication are showing initial success. The use of new materials has radically changed orthoses and further advances are expected with the use of electronic components, although this is still at early stages. For some years, particular attention has been paid to the evaluation and objective measurement of the effectiveness of orthoses. The future of orthotics lies in further specialization, standardized indication and objective measurement of acute and long-term results.

Motion in lumbar functional spine units during side bending and axial rotation moments depending on the degree of degeneration.

STUDY DESIGN: Human lumbar spine specimens were tested in axial rotation and side bending. Motion was related to the grade of degeneration. OBJECTIVES: To determine the degree to which degeneration with fissure formation in the disc affects axial rotation of the lumbar functional spine unit. SUMMARY OF BACKGROUND DATA: There is controversy in the literature regarding the influence of severe degeneration and fissures of the disc on the range of axial rotation. METHODS: Thirty-six lumbar spine specimens were tested in axial rotation and side bending, by applying pure moments in an unconstrained setting. The motion in 6 df was recorded by dial gauges. The grade of degeneration was established by the grading schemes of Nachemson, Thompson, Adams, and Mimura. RESULTS: A significant increase of axial rotation and lateral translation under torque was found. This increase mainly took place between Grade 3 according to the schemes of Nachemson, Thompson, and Adams (no fissure formation) and the higher grades of degeneration (defined by fissure formation). Reduced disc height was always associated with fissures. CONCLUSIONS: A reduced lumbar disc height in radiographs seems to be associated with fissure formation in the disc. In this case, the range axial rotation after torque is increased in comparison with cases with less degeneration.

Foot deformities in adolescents and young adults with spina bifida.

Spina bifida is generally accompanied by a high incidence of foot deformities. The goal of management is to achieve a plantigrade foot. Deformities are related to the level of the lesion. With thoracic lesions, the most frequent deformity is an equinus lesion (55%), a club foot with mid-lumbar lesion (87%) and a calcaneal foot with sacral lesions (34%). No deformity was present in 56% of feet in sacral lesion children. Club foot surgery before the age of 2 years entails a high rate of recurrence (78%), necessitating redo surgery. A calcaneo-valgus deformity developed in 45% of ambulating patients with sacral lesions requiring operative stabilization of the foot. Patients with sacral lesions were almost the only ones who remained ambulators. Ambulation was not seen to be related to foot deformities in adolescents and young adults.

Pelvic tilt in neuromuscular disorders.

The pelvic tilt is part of a complex deformity in which both the spine and the hip are involved. By viewing the different planes and analyzing the deforming forces, four different types of pelvic tilt in combination with spinal and hip deformities can be identified. In spina bifida patients congenital deformities of the spine may add to the progression of scoliosis. Analyzing our own patients we found that certain types of pelvic tilt can be related to certain neuromuscular diseases. Moreover our results show that the pelvic tilt can be effectively corrected by spinal surgery, whereas no effect of hip surgery could be demonstrated.

Conservative treatment of tuberculous spondylitis: a long-term follow-up study.

A retrospective follow-up study was performed on 40 patients, in which tuberculous spondylitis was treated conservatively between 1969 and 1985 with orthotic supports for an average of 16 months (range, 10-30 months) and with anti-tuberculous agents. All had persistent back pain, but none had neurological deficits. The mean follow-up period was 17 years (range, 10-26 years). Diagnosis was confirmed histopathologically. The spinal segments involved ranged from T5 to L5. The kyphotic angle was calculated according to Cobb. At final follow-up, 22 patients were pain free, 11 had occasional pain, 6 complained of pain in the morning, and 1 had chronic pain and needed frequent analgesics. Solid bony union was found in 75% of patients. The kyphotic deformity occurred in the thoracic spine with a mean angle of 20 degrees (range, 13-28 degrees) and in the lumbar spine with a mean angle 12 degrees (range, 5-26 degrees). The long-term follow-up of conservative treatment showed only slightly increased kyphosis. Conservative treatment is an alternative to surgical intervention in cases with kyphosis < 35 degrees.

[Minimally invasive approach and surgical procedures in the lumbar spine]. / Minimal-invasive Zugänge und Operationsverfahren an der Lendenwirbelsäule.

The history of minimally invasive lumbar spine surgery began in 1963 with the introduction of chemonucleolysis. Like this technique, the later development of mechanical nucleotomy and lasernucleotomy aimed primarily at reduction of the disc pressure. Miniature optical systems offered the opportunity for more specific decompression by discoscopy or, more recently, by transforaminal epiduroscopy. Initially, nucleotomy was the only feasible minimally invasive procedure. In recent years, however, minimally invasive spinal fusion became possible due to the development of new devices (Cages) and advanced transperitoneal (laparoscopic) and retroperitoneal approaches.

Ammoniagenesis in renal cell culture. Lack of extracellular ammoniagenesis at the apical surface of LLC-PK1 epithelia.

In renal ammoniagenesis, two major pathways of glutamine metabolism have been described: (i) intracellular metabolism by phosphate-dependent glutaminase (PDG) and glutamate dehydrogenase and (ii) extracellular metabolism by phosphate-independent glutaminase. The latter has been identified as the hydrolytic activity of the apically membrane-bound gamma-glutamyl transpeptidase (gamma-GT). The growth properties of cultured renal epithelia enable the study of in vitro extracellular metabolic properties occurring at the apical epithelial surface in the culture dish. Therefore, confluent epithelia of the LLC-PK1 renal epithelial cell line were used to elucidate the role of extracellular (apical) hydrolysis of glutamine by gamma-GT in LLC-PK1 ammonia production. To distinguish between intra- and extracellular metabolism of glutamine, confluent LLC-PK1 epithelia were incubated with either D-glutamine as substrate, which cannot be metabolized intracellularly by PDG, or with L-glutamine and hippurate to stimulate, and AT-125 (acivicin) to inhibit gamma-GT activity, respectively. In addition, cellular uptake of the glutamate, extracellularly formed by gamma-GT, was inhibited by D-aspartate. D-Glutamine (2 mM) did not increase ammonia formation above endogenous production levels, indicating the negligible role of extracellular hydrolysis of glutamine by gamma-GT. After modulating gamma-GT activity by hippurate or AT-125, almost identical ammonia production rates were found within the various experimental protocols, further confirming that extracellular metabolism of glutamine does not significantly contribute to LLC-PK1 ammoniagenesis.

Ammoniagenesis in LLC-PK1 cultures: role of transamination.

The LLC-PK1 renal epithelial cell line has been used as a model system to study renal ammoniagenesis and its regulation by metabolic acidosis in vitro. Experiments were performed on confluent LLC-PK1 epithelia grown for 10-14 days in conventional monolayer technique. After the medium pH was changed from 7.6 to 7.0 for 24-72 h by lowering the bicarbonate concentration in culture medium, LLC-PK1 cells responded with an adaptive increase in glutamine consumption and ammonia production. The rates of glutamine uptake and ammonia generation displayed a ratio of 1:1, i.e., 1 mol ammonia was produced per mole of glutamine consumed. Glutamine consumption and ammonia formation were paralleled by an equimolar production of L-alanine, indicating that transamination appears to be the main ammoniagenic pathway in LLC-PK1 cells. Analysis of the key enzymes of renal ammoniagenesis, phosphate-dependent glutaminase (PDG) and glutamate dehydrogenase (GDH), revealed no changes in enzyme activities up to 72 h of adaptation. Alanine aminotransferase (ALT) activity in LLC-PK1 cells also remained unchanged during the adaptation period. Because transamination seems to play a crucial role in channeling the metabolic flux in LLC-PK1 ammoniagenesis, experiments were performed in which transamination was inhibited by (aminooxy)acetate (AOA). After incubation of control and pH 7.0-adapted LLC-PK1 cultures for 24-72 h in 0.2 mM AOA, no alanine production was found, but 2 mol of ammonia were formed per mole of glutamine consumed, again, without adaptive changes in PDG and GDH activities.(ABSTRACT TRUNCATED AT 250 WORDS)