Efficacy and safety of halo-gravity traction in the treatment of spinal deformities: A systematic review of the literature / Eficacia y seguridad de la tracción de halo-gravedad en el tratamiento de las deformidades de columna: una revisión sistemática de la literatura

Objective: To determine, through a systematic review, the effects of halo gravity traction in spinal deformity. Methods: Prospective studies or case series of patients with scoliosis or kyphosis treated with cranial halo gravity traction (HGT) were included. Radiological outcomes were measured in the sagittal and/or coronal planes. Pulmonary function was also assessed. Perioperative complications were also collected. Results: Thirteen studies were included. Congenital etiology was the most frequent etiology observed. Most studies provided clinically relevant curve correction values in the sagittal and coronal planes. Pulmonary values improved significantly after the use of HGT. Finally, there were a pool of 83 complications in 356 patients (23.3%). The most frequent complications were screw infection (38 cases). Conclusions: Preoperative HGT appears to be a safe and effective intervention for deformity that allows correction prior to surgery. However, there is a lack of homogeneity in the published studies.(AU)

Objetivo: Determinar, mediante una revisión sistemática, los efectos de la tracción de halo-gravedad (HGT) en las deformidades de columna. Métodos: Se incluyeron estudios prospectivos o series de casos de pacientes con escoliosis o cifosis tratados con HGT. Los resultados radiológicos se midieron en los planos sagital y/o coronal. También se evaluó la función pulmonar. Finalmente, se recogieron las complicaciones perioperatorias. Resultados: Se incluyeron 13 estudios. La etiología congénita fue la más frecuente. La mayoría de los estudios proporcionaron valores de corrección de la curva clínicamente relevantes en los planos sagital y coronal. Los valores pulmonares mejoraron significativamente tras el uso de HGT. Por último, existieron 83 complicaciones en 356 pacientes, siendo la infección la más frecuente (38 casos). Conclusiones: La HGT mostró ser una intervención segura y eficaz para la deformidad, que permite la corrección antes de la cirugía. Sin embargo, existe una falta de homogeneidad en los estudios publicados.(AU)

[Artículo traducido] Eficacia y seguridad de la tracción de halo-gravedad en el tratamiento de las deformidades de columna: una revisión sistemática de la literatura / Efficacy and safety of halo-gravity traction in the treatment of spinal deformities: A systematic review of the literature

Objective: To determine, through a systematic review, the effects of halo gravity traction in spinal deformity. Methods: Prospective studies or case series of patients with scoliosis or kyphosis treated with cranial halo gravity traction (HGT) were included. Radiological outcomes were measured in the sagittal and/or coronal planes. Pulmonary function was also assessed. Perioperative complications were also collected. Results: Thirteen studies were included. Congenital etiology was the most frequent etiology observed. Most studies provided clinically relevant curve correction values in the sagittal and coronal planes. Pulmonary values improved significantly after the use of HGT. Finally, there were a pool of 83 complications in 356 patients (23.3%). The most frequent complications were screw infection (38 cases). Conclusions: Preoperative HGT appears to be a safe and effective intervention for deformity that allows correction prior to surgery. However, there is a lack of homogeneity in the published studies.(AU)

Objetivo: Determinar, mediante una revisión sistemática, los efectos de la tracción de halo-gravedad (HGT) en las deformidades de columna. Métodos: Se incluyeron estudios prospectivos o series de casos de pacientes con escoliosis o cifosis tratados con HGT. Los resultados radiológicos se midieron en los planos sagital y/o coronal. También se evaluó la función pulmonar. Finalmente, se recogieron las complicaciones perioperatorias. Resultados: Se incluyeron 13 estudios. La etiología congénita fue la más frecuente. La mayoría de los estudios proporcionaron valores de corrección de la curva clínicamente relevantes en los planos sagital y coronal. Los valores pulmonares mejoraron significativamente tras el uso de HGT. Por último, existieron 83 complicaciones en 356 pacientes, siendo la infección la más frecuente (38 casos). Conclusiones: La HGT mostró ser una intervención segura y eficaz para la deformidad, que permite la corrección antes de la cirugía. Sin embargo, existe una falta de homogeneidad en los estudios publicados.(AU)

¿Cómo planifico una cirugía de escoliosis idiopática del adolescente? Sistematización de un método de planificación preoperatoria / How do I plan adolescent idiopathic scoliosis surgery? Systematization of a preoperative planning method

La planificación preoperatoria resulta fundamental en la cirugía de escoliosis idiopática del adolescente (EIA) para determinar los niveles a fusionar y realizar el procedimiento con mayor precisión y diligencia. Sin embargo, su realización protocolizada no está tan extendida entre los especialistas en formación. El objetivo de este artículo es describir en detalle el método de planificación preoperatoria en la EIA empleado en una unidad especializada de raquis infantil y del adolescente de un centro de referencia, así como, la logística y la táctica, apoyado en un software gratuito de medición digital semiautomática y planificación. Se muestran 3 casos representativos de diferentes deformidades vertebrales, intervenidos mediante una artrodesis vertebral posterior tras una planificación preoperatoria según el método descrito. Este método resulta muy adecuado para el cirujano en formación al aunar las ventajas de los métodos tradicionales y los más modernos, y ser sencillo, de bajo coste, accesible, reproducible y con carácter formativo.(AU)

Preoperative planning is essential in adolescent idiopathic scoliosis (AIS) surgery to determine the fusion levels and to perform the procedure with greater precision and diligence. However, the protocolized performance of such planning is not as widespread among specialists in training. The aim of this article is to describe in detail the preoperative planning method for AIS used in a specialized pediatric and adolescent spine unit of a referral center, as well as the logistics and the tactics, supported a free semi-automatic digital measurement and planning software. Three representative cases of different vertebral deformities, treated by posterior spinal fusion after preoperative planning according to the method, are shown. This method is highly suitable for the trainee surgeon as it combines the advantages of traditional and modern methods, and is simple, low cost, accessible, reproducible and with an educational character.(AU)

[Translated article] How do I plan adolescent idiopathic scoliosis surgery? Systematization of a preoperative planning method / ¿Cómo planifico una cirugía de escoliosis idiopática del adolescente? Sistematización de un método de planificación preoperatoria

La planificación preoperatoria resulta fundamental en la cirugía de escoliosis idiopática del adolescente (EIA) para determinar los niveles a fusionar y realizar el procedimiento con mayor precisión y diligencia. Sin embargo, su realización protocolizada no está tan extendida entre los especialistas en formación. El objetivo de este artículo es describir en detalle el método de planificación preoperatoria en la EIA empleado en una unidad especializada de raquis infantil y del adolescente de un centro de referencia, así como, la logística y la táctica, apoyado en un software gratuito de medición digital semiautomática y planificación. Se muestran 3 casos representativos de diferentes deformidades vertebrales, intervenidos mediante una artrodesis vertebral posterior tras una planificación preoperatoria según el método descrito. Este método resulta muy adecuado para el cirujano en formación al aunar las ventajas de los métodos tradicionales y los más modernos, y ser sencillo, de bajo coste, accesible, reproducible y con carácter formativo.(AU)

Preoperative planning is essential in adolescent idiopathic scoliosis (AIS) surgery to determine the fusion levels and to perform the procedure with greater precision and diligence. However, the protocolized performance of such planning is not as widespread among specialists in training. The aim of this article is to describe in detail the preoperative planning method for AIS used in a specialized pediatric and adolescent spine unit of a referral center, as well as the logistics and the tactics, supported a free semi-automatic digital measurement and planning software. Three representative cases of different vertebral deformities, treated by posterior spinal fusion after preoperative planning according to the method, are shown. This method is highly suitable for the trainee surgeon as it combines the advantages of traditional and modern methods, and is simple, low cost, accessible, reproducible and with an educational character.(AU)

Efficacy and safety of halo-gravity traction in the treatment of spinal deformities: A systematic review of the literature.

OBJECTIVE: To determine, through a systematic review, the effects of halo gravity traction in spinal deformity. METHODS: Prospective studies or case series of patients with scoliosis or kyphosis treated with cranial halo gravity traction (HGT) were included. Radiological outcomes were measured in the sagittal and/or coronal planes. Pulmonary function was also assessed. Perioperative complications were also collected. RESULTS: Thirteen studies were included. Congenital etiology was the most frequent etiology observed. Most studies provided clinically relevant curve correction values in the sagittal and coronal planes. Pulmonary values improved significantly after the use of HGT. Finally, there were a pool of 83 complications in 356 patients (23.3%). The most frequent complications were screw infection (38 cases). CONCLUSIONS: Preoperative HGT appears to be a safe and effective intervention for deformity that allows correction prior to surgery. However, there is a lack of homogeneity in the published studies.

Efficacy and safety of halo-gravity traction in the treatment of spinal deformities: A systematic review of the literature. / [Artículo traducido] Eficacia y seguridad de la tracción de halo-gravedad en el tratamiento de las deformidades de columna: una revisión sistemática de la literatura.

OBJECTIVE: To determine, through a systematic review, the effects of halo-gravity traction (HGT) in spinal deformity. METHODS: Prospective studies or case series of patients with scoliosis or kyphosis treated with cranial HGT were included. Radiological outcomes were measured in the sagittal and/or coronal planes. Pulmonary function was also assessed. Perioperative complications were also collected. RESULTS: Thirteen studies were included. Congenital etiology was the most frequent etiology observed. Most studies provided clinically relevant curve correction values in the sagittal and coronal planes. Pulmonary values improved significantly after the use of HGT. Finally, there were a pool of 83 complications in 356 patients (23.3%). The most frequent complications were screw infection (38 cases). CONCLUSIONS: Preoperative HGT appears to be a safe and effective intervention for deformity that allows correction prior to surgery. However, there is a lack of homogeneity in the published studies.

[Translated article] How do I plan adolescent idiopathic scoliosis surgery? Systematization of a preoperative planning method.

Preoperative planning is essential in adolescent idiopathic scoliosis (AIS) surgery to determine the fusion levels and to perform the procedure with greater precision and diligence. However, the protocolized performance of such planning is not as widespread among specialists in training. The aim of this article is to describe in detail the preoperative planning method for AIS used in a specialised paediatric and adolescent spine unit of a referral centre, as well as the logistics and the tactics, supported a free semi-automatic digital measurement and planning software. Three representative cases of different vertebral deformities, treated by posterior spinal fusion after preoperative planning according to the method, are shown. This method is highly suitable for the trainee surgeon as it combines the advantages of traditional and modern methods, and is simple, low-cost, accessible, reproducible and with an educational character.

Comparative Analysis Between Isolated Posterior and Anteroposterior Approaches for Severe Scoliosis Treatment.

Objective To comparatively analyze isolated posterior and double surgical approaches for the treatment of severe scoliosis. Methods We retrospectively analyzed medical records of 32 patients with scoliosis angular value > 70° submitted to surgical treatment in a tertiary hospital between 2009 and 2019. These patients were divided into two groups: PV group with 17 patients submitted to arthrodesis by isolated posterior route (PV) and APV group with 15 patients approached anteriorly and posteriorly (APV). In the PV group, there were 16 female patients and 1 male, with a mean age of 16.86 years old. In the APV group, there were 10 female patients and 5 males, with a mean age of 17.71 years old. Cobb angles were measured by a single spinal surgeon manually on panoramic radiographs, orthostasis before and after surgery. Weight, pre- and postoperative height, and duration of the procedure were also evaluated. Results In the PV group, preoperative and postoperative Cobb angles, verified in the main curve, were 96.06 ± 8.45° and 52.27 ± 15.18°, with an average correction rate of 0.54 ± 0.16, respectively. In the APV group, these values were 83.12 ± 11.60° for preoperative Cobb angle, and 48.53 ± 10.76° postoperatively, with correction rate of the main curve of 0.58 ± 0.11. Conclusion The two forms of surgical approach for the treatment of severe scoliosis were astowed as to the rate of correction of the deformity. Therefore, isolated posterior access has an advantage over the double approach, based on shorter surgical time, shorter hospital stay, and less risk of complications.

La transición posquirúrgica en adolescentes que padecen escoliosis idiopática. Un estudio cualitativo / The post-surgical transition in adolescents who have idiopathic scoliosis. A qualitative study

Objetivo: Conocer el proceso que viven las y los adolescentes que padecen escoliosis idiopática al intervenirse quirúrgicamente para corregir la deformidad física. Método: Estudio cualitativo con enfoque interaccionismo simbólico. Se realizaron 22 entrevistas semiestructuradas a adolescentes intervenidos de fusión espinal posterior en un hospital de tercer nivel de Madrid entre mayo de 2019 y enero de 2021. Se llevó a cabo análisis en progreso de Taylor y Bogdan. Resultados: Los pacientes con escoliosis idiopática del adolescente presentan una transición compleja simultánea de tipo salud/enfermedad y de desarrollo. Las principales condiciones inhibidoras de la transición son los significados sobre: su identidad, sociales, creencias sobre la cirugía, el desconocimiento sobre la patología, el proceso quirúrgico y su recuperación. Como condiciones facilitadoras encontramos: la actitud positiva hacia el cambio físico, estético, social, el nivel socioeconómico y el apoyo familiar. Conclusiones: Los informantes de este estudio refieren que la afectación estética y las limitaciones físicas son los principales elementos que les causan disconfort. La intervención quirúrgica se presenta como la solución a esta situación. La recuperación es un punto crítico en el proceso de transición debido principalmente al dolor. Aceptan el malestar sufrido durante la recuperación porque esperan obtener una mejora en la imagen y las limitaciones físicas. Los cambios y diferencias que experimentan durante la transición les hace pensar que van a poder llevar una «vida normal» a la que se refieren constantemente en los discursos.(AU)

Objective: To know the process experienced by adolescents suffering from idiopathic scoliosis when undergoing surgery to correct the physical deformity. Method: Qualitative study with a symbolic interactionism approach. 22 semi-structured interviews were conducted with adolescents who underwent posterior spinal fusion in a third-level hospital in Madrid between May 2019 and January 2021. Taylor and Bogdan's analysis in progress was carried out. Results: Patients with adolescent idiopathic scoliosis present with a complex simultaneous health/illness and developmental transition. The main inhibitory conditions of the transition are the meanings about: their identity, social, beliefs about surgery, ignorance about the pathology, the surgical process, and their recovery. As facilitating conditions, we find: a positive attitude towards physical, aesthetic, and social change, socioeconomic level, and family support. Conclusions: The informants of this study refer that aesthetic affectation and physical limitations are the main elements that cause them discomfort. Surgical intervention is presented as the solution to this situation. Recovery is a critical point in the transition process mainly due to pain. They accept the discomfort suffered during the recovery because they hope to obtain an improvement in the image and physical limitations. The changes and differences they experience during the transition make them think that they will be able to lead a «normal life» to which they constantly refer in their speeches.(AU)

Comparative Analysis Between Isolated Posterior and Anteroposterior Approaches for Severe Scoliosis Treatment / Análise comparativa entre as abordagens cirúrgicas por via posterior isolada e por via anteroposterior para tratamento de escoliose severa

Abstract Objective To comparatively analyze isolated posterior and double surgical approaches for the treatment of severe scoliosis. Methods We retrospectively analyzed medical records of 32 patients with scoliosis angular value > 70° submitted to surgical treatment in a tertiary hospital between 2009 and 2019. These patients were divided into two groups: PV group with 17 patients submitted to arthrodesis by isolated posterior route (PV) and APV group with 15 patients approached anteriorly and posteriorly (APV). In the PV group, there were 16 female patients and 1 male, with a mean age of 16.86 years old. In the APV group, there were 10 female patients and 5 males, with a mean age of 17.71 years old. Cobb angles were measured by a single spinal surgeon manually on panoramic radiographs, orthostasis before and after surgery. Weight, pre- and postoperative height, and duration of the procedure were also evaluated. Results In the PV group, preoperative and postoperative Cobb angles, verified in the main curve, were 96.06 ± 8.45° and 52.27 ± 15.18°, with an average correction rate of 0.54 ± 0.16, respectively. In the APV group, these values were 83.12 ± 11.60° for preoperative Cobb angle, and 48.53 ± 10.76° postoperatively, with correction rate of the main curve of 0.58 ± 0.11. Conclusion The two forms of surgical approach for the treatment of severe scoliosis were astowed as to the rate of correction of the deformity. Therefore, isolated posterior access has an advantage over the double approach, based on shorter surgical time, shorter hospital stay, and less risk of complications

Resumo Objetivo Analisar comparativamente as abordagens cirúrgicas por via posterior isolada e dupla abordagem para tratamento da escoliose severa. Métodos Analisou-se retrospectivamente prontuários de 32 pacientes com escoliose de valor angular > 70° submetidos a tratamento cirúrgico em hospital terciário entre 2009 e 2019. Dividiu-se estes pacientes em dois grupos: Grupo VP com 17 pacientes submetidos a artrodese por via posterior isolada (VP) e Grupo VAP com 15 pacientes abordados por via anterior e posterior (VAP). O Grupo VP apresentou 16 pacientes do sexo feminino e 1 do masculino, com idade média de 16,86 anos. No grupo VAP, 10 pacientes do sexo feminino e 5 do masculino, com idade média de 17,71 anos. Os ângulos de Cobb foram mensurados por único cirurgião de coluna, manualmente, em radiografias panorâmicas, em ortostase no pré- e pós-operatório. Foram avaliados também peso, altura pré- e pós-operatória e duração do procedimento. Resultados No Grupo VP, o ângulo de Cobb pré-operatório e pós-operatório, verificados na curva principal, foram respectivamente 96,06° ± 8,45° e 52,27 ± 15,18°, apresentando taxa média de correção de 0,54 ± 0,16. No grupo VAP, esses valores foram de 83,12° ± 11,60° para o ângulo de Cobb pré-operatório, 48,53 ± 10,76, pós-operatório, com a taxa de correção da curva principal de 0,58 ± 0,11. Conclusão As duas formas de abordagem cirúrgica para tratamento de escoliose severa se equiparam quanto à taxa de correção da deformidade. Portanto, o acesso posterior isolado apresenta vantagem em relação a dupla via, baseado no menor tempo cirúrgico, menor tempo de internação e menos risco de complicações

Embarazo y ortopedia / Pregnancy and Orthopaedics

Introducción: Son múltiples las afecciones ortopédicas que sufre una mujer embarazada, por ello las demandas de atención por esta causa van en ascenso. Objetivo: Actualizar el tratamiento de las lesiones traumáticas y ortopédicas en la paciente embarazada y coordinar las indicaciones de la cesárea. Métodos: Se utilizan métodos teóricos y empíricos para realizar análisis del conocimiento actualizado sobre estas. Resultados: Se determinó que el parto normal es posible después de una fractura pélvica, siempre que no existan secuelas que dañen el canal del parto. El dolor de espalda fue un síntoma común en las mujeres embarazadas, pero en las que presentaron escoliosis las molestias fueron más frecuentes. La diastasis de la sínfisis del pubis se asoció con la maniobra de McRoberts; y la indicación de cesárea se sugirió a partir de criterios puramente obstétricos, aunque se respetaron las afecciones ortopédicas y traumáticas presentes en las pacientes. Conclusiones: Incrementar los conocimientos del personal que trabaja con la embarazada, a partir de sus factores de riesgo y las posibilidades de mitigación de daño por estas causas.

Introduction: pregnant women suffer from multiple orthopaedic conditions; therefore, care demands for this cause are on the rise. Objective: to update the treatment of traumatic and orthopaedic injuries in pregnant patients and coordinate the indications for cesarean section. Methods: theoretical and empirical methods were used to carry out the analysis of updated knowledge regarding these affections. Results: we determined that normal delivery is possible after a pelvic fracture, as long as there are no sequelae that damage the birth canal. Back pain was a common symptom in pregnant women but in those with scoliosis the discomfort was more frequent. Symphysis pubis diastasis was associated with the McRobert's maneuver; and the indication for cesarean section was suggested based on purely obstetric criteria, although the orthopaedic and traumatic conditions present in the patients were respected. Conclusions: to increase the knowledge of the personnel, who work with the pregnant women, based on their risk factors and the possibilities of mitigating damage due to these causes.

Juvenile scoliosis as the first manifestation of syringomyelia associated with Chiari malformation type I.

BACKGROUND: Scoliosis is a spinal deformity that usually manifests as a structural curve determining a variable deformity of the trunk. According to some published series, 4 to 26% of scoliosis initially classified as idiopathic show neurological alterations when studied with nuclear magnetic resonance, such as syringomyelia and Chiari malformation, among the most frequent. Chiari malformations are characterized by descending herniation of the cerebellar tonsils, brainstem, and IV ventricle into the spinal canal. CASE REPORT: We present the case of a patient whose first symptomatic manifestation was early-onset scoliosis. The overlapping of some physical examination signs, such as postural lateralization and scoliosis, reinforced the active suspicion of neuroaxis alterations. CONCLUSIONS: Early childhood-onset scoliosis should raise a high degree of suspicion for association with neuro-spinal diseases. Although the frequency of Chiari malformation is low, its early approach could reduce the progression of associated comorbidities. An early detection could change the prognosis of the disease.

INTRODUCCIÓN: La escoliosis es una deformidad de la columna que usualmente se manifiesta como una curva estructural que determina una deformidad variable del tronco. Las malformaciones de Chiari se caracterizan por la herniación descendente de las amígdalas cerebelosas, tronco encefálico y IV ventrículo hacia el canal espinal. Según algunas series publicadas, del 4 al 26% de las escoliosis inicialmente catalogadas como idiopáticas muestran alteraciones neurológicas al ser estudiadas con resonancia magnética nuclear, como la siringomielia y malformación de Chiari, dentro de las más frecuentes. CASO CLÍNICO: Se presenta el caso de un paciente cuya primera manifestación sintomática fue escoliosis de comienzo temprano. El solapamiento de algunos signos del examen físico, como la lateralización de la postura y la escoliosis, reforzaron la sospecha activa de alteraciones del neuroeje. CONCLUSIONES: La escoliosis de inicio temprano en la infancia debe despertar un alto grado de sospecha de asociación con enfermedades neuro-espinales. Dentro de este contexto, aunque malformación Chiari es de baja frecuencia, su abordaje precoz permitiría disminuir la progresión de comorbilidades asociadas. La detección temprana podría cambiar el pronóstico de la enfermedad.

The post-surgical transition in adolescents who have idiopathic scoliosis. A qualitative study.

OBJECTIVE: To know the process experienced by adolescents suffering from idiopathic scoliosis when undergoing surgery to correct the physical deformity. METHOD: Qualitative study with a symbolic interactionism approach. 22 semi-structured interviews were conducted with adolescents who underwent posterior spinal fusion in a third-level hospital in Madrid between May 2019 and January 2021. Taylor and Bogdan's analysis in progress was carried out. RESULTS: Patients with adolescent idiopathic scoliosis present with a complex simultaneous health/illness and developmental transition. The main inhibitory conditions of the transition are the meanings about: their identity, social, beliefs about surgery, ignorance about the pathology, the surgical process, and their recovery. As facilitating conditions, we find: a positive attitude towards physical, aesthetic, and social change, socioeconomic level, and family support. CONCLUSIONS: The informants of this study refer that aesthetic affectation and physical limitations are the main elements that cause them discomfort. Surgical intervention is presented as the solution to this situation. Recovery is a critical point in the transition process mainly due to pain. They accept the discomfort suffered during the recovery because they hope to obtain an improvement in the image and physical limitations. The changes and differences they experience during the transition make them think that they will be able to lead a «normal life¼ to which they constantly refer in their speeches.

Mecanismos neurológicos involucrados en la escoliosis idiopática. Revisión sistemática de la literatura / Neurological mechanisms involved in idiopathic scoliosis. Systematic review of the literature

La literatura que explica los mecanismos neurológicos que subyacen al desarrollo o a la compensación de la escoliosis idiopática es limitada. El objetivo del presente artículo es describir e integrar los mecanismos y las vías nerviosas por medio de las cuales se compensa y/o se desarrolla la escoliosis idiopática. Se realizó una revisión sistemática narrativa en diferentes bases de datos sobre los estudios publicados entre el 1 de enero 1967 y el 1 de abril de 2021, empleando los siguientes términos: «scoliosis», «vision», «ocular», «vestibule», «labyrinth», «posture», «balance», «eye movements», «cerebellum», «proprioception» y «physiological adaptation». En la búsqueda se identificaron 1.112 referencias, de las cuales al final se incluyeron 50: 46 estudios clínicos observacionales analítico-descriptivos (entre cohortes, reporte y serie de casos) y 4 estudios experimentales. En la respuesta neurológica a la escoliosis idiopática, la integración sensitivo-cortical de las aferencias visual-oculomotor-vestibular-propioceptiva permite realizar modificaciones a nivel postural con el fin de lograr una compensación inicial sobre el balance sagital y el centro de masa; sin embargo, con el tiempo dicho mecanismo de compensación puede agotarse y causar progresión de la deformidad inicial. (AU)

The literature that explains the neurological mechanisms underlying the development or compensation of idiopathic scoliosis is limited. The objective of the article is to describe and integrate the mechanisms and nerve pathways through which idiopathic scoliosis is compensated and/or developed. A narrative systematic review in different databases of the studies published between January 1, 1967 and April 1, 2021 was performed, using the following terms: «scoliosis», «vision», «eye», «vestibule», «labyrinth», «posture», «balance», «eye movements», «cerebellum», «proprioception», and «physiological adaptation». In the search, 1112 references were identified, of which 50 were finally included: 46 observational analytical clinical studies-descriptive (between cohorts, report and series of cases) and 4 experimental studies. In the neurological response to idiopathic scoliosis, the sensory-cortical integration of the afferences in the visual-oculomotor-vestibular-proprioceptive systems, allows modifications at the postural level in order to achieve an initial compensation on the sagittal balance and the centre of body mass; however, over time these compensation mechanisms may be exhausted causing progression of the initial deformity. (AU)

Neurological mechanisms involved in idiopathic scoliosis. Systematic review of the literature.

The literature that explains the neurological mechanisms underlying the development or compensation of idiopathic scoliosis is limited. The objective of the article is to describe and integrate the mechanisms and nerve pathways through which idiopathic scoliosis is compensated and/or developed. A narrative systematic review in different databases of the studies published between January 1, 1967 and April 1, 2021 was performed, using the following terms: "scoliosis", "vision", "eye", "vestibule", "labyrinth" "posture", "balance", "eye movements", "cerebellum", "proprioception", and "physiological adaptation". In the search, 1112 references were identified, of which 50 were finally included: 46 observational analytical clinical studies-descriptive (between cohorts, report and series of cases) and 4 experimental studies. In the neurological response to idiopathic scoliosis, the sensory-cortical integration of the afferences in the visual-oculomotor-vestibular-proprioceptive systems, allows modifications at the postural level in order to achieve an initial compensation on the sagittal balance and the centre of body mass; however, over time these compensation mechanisms may be exhausted causing progression of the initial deformity.

Effect of progression of adolescent idiopathic scoliosis on gait parameters / Efeito da progressão da escoliose idiopática do adolescente sobre os parâmetros da marcha / Efecto de la progresión de la escoliosis idiopática del adolescente sobre los parámetros de la marcha

ABSTRACT Objectives: To evaluate the influence of the degree of severity of adolescent idiopathic scoliosis (AIS) on the distribution of plantar load on the feet during gait. Material and Methods: 40 patients with AIS were evaluated and divided into severity groups: 13 with mild AIS; 13 with moderate AIS; and 14 with severe AIS. Cobb angles (degrees) were evaluated by radiography. Gait was assessed using the pressure platform at a frequency of 100 Hz. The adolescents walked on a 20-meter track, with their feet resting on the platform, totaling an average of 12 steps. The following were evaluated: contact area, peak pressure, and maximum force on the 4 regions of the feet: hindfoot (medial and lateral), midfoot, and forefoot. Results: Adolescents with moderate and severe AIS showed an increase in peak pressure and maximum force on the medial (p=0.014; p=0.045, respectively) and lateral (p=0.035; p=0.039, respectively) hindfoot and a reduction on the midfoot (p=0.024) when compared to mild AIS. The contact area showed no differences between groups. Conclusion: The moderate and severe degree of AIS severity promoted increased plantar load on the medial and lateral hindfoot (heel) during gait compared to adolescents with a mild degree of scoliotic curvature. In this way, gait training in the milder stages of disease severity can minimize the overload and the increase in force vectors on the spine, preventing the progression of severe scoliotic curvature. Level of Evidence II; Cross-sectional study.

Resumo: Objetivos: Avaliar a influência do grau de severidade da escoliose idiopática do adolescente (EIA) sobre a distribuição da carga plantar dos pés durante a marcha. Material e Métodos: 40 pacientes com EIA foram avaliados e divididos em grupos de severidade: 13 com EIA leve; 13 com EIA moderada; e 14 com EIA grave. Os ângulos de Cobb (graus) foram avaliados pela radiografia. A marcha foi avaliada pela plataforma de pressão, a uma frequência de 100 Hz. Os adolescentes caminhavam sobre uma pista de 20 metros, com o registo do apoio dos pés sobre a plataforma, totalizando em média 12 passos. Foram avaliadas área de contato, pico de pressão e força máxima sobre as 4 regiões dos pés - retropé (medial e lateral), mediopé e antepé. Resultados: Os adolescentes com EIA moderada e grave mostraram um aumento do pico de pressão e força máxima sobre o retropé medial (p=0,014; p=0,045, respectivamente) e lateral (p=0,035; p=0,039, respectivamente) e uma redução sobre o mediopé (p=0,024) quando comparados a EIA leve. Não houve diferenças quanto a área de contato entre os grupos. Conclusão: O grau de severidade moderada e grave da EIA promoveu um aumento da carga plantar sobre retropé medial e lateral (calcanhar) durante a marcha em comparação aos adolescentes com grau leve da curvatura escoliótica. Desta forma, o treino de marcha nos estágios mais leve de severidade da doença pode minimizar a sobrecarga e o aumento dos vetores de força sobre a coluna, evitando a progressão da curvatura escoliótica grave. Nível de evidência II; Estudo transversal.

Resumen: Objetivos: Evaluar la influencia del grado de severidad de la escoliosis idiopática del adolescente (EIA) sobre la distribución de la carga plantar en los pies durante la marcha. Material y Métodos: Se evaluaron 40 pacientes con EIA y se dividieron en grupos de gravedad: 13 con EIA leve; 13 con EIA moderada; y 14 con EIA grave. Los ángulos de Cobb (grados) se evaluaron mediante radiografía. La marcha se evaluó utilizando la plataforma de presión a una frecuencia de 100 Hz. Los adolescentes caminaron sobre una pista de 20 metros, con los pies apoyados en la plataforma, totalizando un promedio de 12 pasos. Se evaluaron: área de contacto, presión pico y fuerza máxima en las 4 regiones de los pies: retropié (medial y lateral), mediopié y antepié. Resultados: Los adolescentes con EIA moderado y severo mostraron un aumento en la presión pico y la fuerza máxima en el retropié medial (p=0,014; p=0,045, respectivamente) y lateral (p=0,035; p=0,039, respectivamente) y una reducción en el mediopié (p=0,024) en comparación con EIA leve. El área de contacto no mostró diferencias entre los grupos. Conclusión: El grado moderado y severo de severidad de la EIA promovió un aumento de la carga plantar en el retropié medial y lateral (talón) durante la marcha en comparación con adolescentes con un grado leve de curvatura escoliótica. De esta manera, el entrenamiento de la marcha en las etapas más leves de la gravedad de la enfermedad puede minimizar el aumento de la sobrecarga y el aumento de los vectores de fuerza en la columna, evitando la progresión de la curvatura escoliótica severa. Nivel de Evidencia II; Estudio transversal.

Complications of prolonged halo-gravitational tractional in spinal deformity surgeries / Complicações da tração halo-gravitacional prolongada em cirurgias de deformidade da coluna / Complicaciones de la tracción halo-gravitacional prolongada en cirugías de deformidad de la columna

ABSTRACT Objective: Spinal traction by a cranial halo is a method with more than half a century of application, presenting the possibility of gradual correction of deformities while the patient is awake, also improving respiratory and nutritional patterns. This study aimed to evaluate the complications of pins and traction during their use in treating severe spinal deformities. Methods: We evaluated 27 patients undergoing surgical treatment using halo-gravitational traction pre or interoperatively between 2014 and 2020. Inclusion criteria were the presence of severe deformity (>100º) in the coronal and/or sagittal plane and traction for at least seven days. Two subgroups were identified: patients presenting only severe coronal deformity (Group 1) and patients with severe deformity in the sagittal plane accompanied by coronal deformity (Group 2). Clinical and radiological data were analyzed retrospectively, evaluating the variables: age, sex, weight, height, etiological diagnosis, number of pins, traction time, sagittal and coronal Cobb angle before and after traction, and complications related to pins and traction. Results: Age and weight showed a significant correlation with the occurrence of complications related to the pins (p=0.007; p<0.001), as well as the congenital etiology of deformity (p=0.001), and those patients in group 2 (p=0.006). There was no significant correlation between the variables studied and the occurrence of neurological complications. Conclusion: Halo-gravitational traction is an important adjunctive method in treating severe spinal deformities. Despite having a considerable complication rate, there were no serious events. Level of evidence IV; Case series.

Resumo: Objetivo: A tração espinhal por halo craniano é um método com mais de meio século de aplicação, apresentando a possibilidade de correção gradual de deformidades com o paciente desperto, além da melhoria do padrão respiratório e nutricional. Este estudo teve como objetivo avaliar as complicações relacionadas aos pinos e à tração durante o seu uso no tratamento de deformidades graves. Métodos: Foram avaliados 27 pacientes submetidos a tratamento cirúrgico com uso de tração halo-gravitacional pré ou inter-operatória, entre 2014 e 2020. Os critérios de inclusão foram a presença de deformidade grave (>100º) coronal e/ou sagital, e duração mínima de 7 dias de tração. Dois subgrupos foram identificados: pacientes com deformidade grave coronal (Grupo 1) e pacientes com deformidade grave sagital acompanhada de deformidade coronal (Grupo 2). Os dados clínicos e radiológicos foram analisados retrospectivamente, incorporando as variáveis: idade, sexo, peso, altura, diagnóstico etiológico, número de pinos, tempo de tração, ângulo de Cobb sagital e coronal pré e pós tração, complicações relacionadas aos pinos e à tração. Resultados: Idade e peso demonstraram correlação significativa com a ocorrência de complicações relacionadas aos pinos (p=0,007; p<0,001), assim como etiologia congênita (p=0,001), e os pacientes incluídos no grupo 2 (p=0,006). Não houve correlação significativa com a ocorrência de complicações neurológicas. Conclusão: A tração halo-gravitacional é um importante método adjuvante no tratamento de deformidades graves da coluna vertebral. Apesar de ter apresentado taxa de complicações considerável, não ocorreram eventos graves. Nível de evidência IV; Série de casos.

Resumen: Objetivo: La tracción espinal por halo craneal es un método con más de medio siglo de aplicación, presentando la posibilidad de corrección gradual de las curvas con el paciente despierto, mejorando el patrón respiratorio y nutricional. Este estudio evaluó las complicaciones relacionadas con los tornillos y la tracción durante el tratamiento de deformidades espinales graves. Métodos: Se evaluó a 27 pacientes sometidos a cirugía con uso de tracción halo-gravitatoria pre o inter quirúrgica, entre 2014 y 2020. Los criterios de inclusión fueron la presencia de deformidad severa (>100º) en el plano coronal y/o sagital y tiempo mínimo de tracción de 7 días. Dos subgrupos fueron identificados: pacientes con deformidad severa en el plano coronal (Grupo 1), y pacientes con deformidad sagital severa acompañada de deformidad coronal (Grupo 2). Los datos clínicos y radiológicos se analizaron retrospectivamente, evaluando edad, sexo, peso, talla, diagnóstico etiológico, número de tornillos, tiempo de tracción, ángulo de Cobb sagital y coronal pre y post tracción, complicaciones relacionadas con los tornillos y tracción. Resultados: Se demostró que la edad y el peso eran factores significativamente correlacionados con las complicaciones de los tornillos (p=0,007; p<0,001), así como la etiología congénita (p=0,001), y los pacientes incluidos en el grupo 2 (p=0,006). No hubo correlación significativa entre las variables estudiadas y complicaciones neurológicas. Conclusión: La tracción halo-gravitacional es un método adyuvante importante en el tratamiento de deformidades espinales severas. A pesar de haber presentado una tasa de complicaciones considerable, no hubo eventos graves. Nivel de evidencia IV; Series de casos.

Evaluation of cervical lordosis in patients with adolescent idiopathic scoliosis / Avaliação da lordose cervical nos pacientes com escoliose idiopática do adolescente / Evaluación de lordosis cervical en pacientes con escoliosis idiopática del adolescente

ABSTRACT: Introduction: In healthy individuals and in patients with adolescent idiopathic scoliosis (AIS), the curvature of the cervical spine varies greatly, with approximately 36-40% of AIS patients having kyphosis of the cervical spine. Aim: To assess the curvature of the cervical spine in AIS patients and subgroups according to Lenke's classification (1 to 6). Methods: 107 patients with AIS were assessed for cervical lordosis (C2-C7) using the Cobb method, subdivided into lordosis and cervical kyphosis. The following parameters were assessed and compared between the subgroups: T5-T12 thoracic kyphosis (TK); L1-S1 lumbar lordosis (LL), pelvic incidence (PI), sagittal vertical axis (SVA), T1 pelvic angle (TPA), C2-C7 cervical lordosis, C1-C2 cervical lordosis, T1 slope (T1s), neck tilt, thoracic inlet angle (TIA) and cervical sagittal axis (CSVA). Results: Kyphosis of the cervical spine was observed in 48% of patients. The Lenke classification curves (1 to 6) showed no difference with regard to the curvature of the cervical spine. In the subgroup with cervical lordosis, thoracic kyphosis, and T1 slope were significantly higher. Neck tilt was significantly higher in the subgroup with kyphosis. Conclusions: Almost half of the patients have kyphosis of the cervical spine, and the curvature of the cervical spine in AIS patients varies widely. Thoracic kyphosis, T1 slope, and neck tilt are significantly different between the subgroups of patients with lordosis or kyphosis. Level of Evidence III; Observational and Retrospective Study.

RESUMO: Introdução: Nos indivíduos saudáveis e nos pacientes com escoliose idiopática do adolescente (EIA) a curvatura da coluna cervical apresenta grande variação, sendo que aproximadamente 36-40% dos pacientes com EIA apresentam cifose da coluna cervical. Objetivo: Avaliar a curvatura da coluna cervical nos pacientes com EIA e nos subgrupos, de acordo com a classificação de Lenke (1 a 6). Métodos: Foram avaliados 107 pacientes com EIA quanto a lordose cervical (C2-C7), pelo método de Cobb, subdivididos em dois grupos: lordose e cifose cervical. Foram avaliados e comparados entre os subgrupos os seguintes parâmetros: cifose torácica T5-T12 (TK); lordose lombar L1-S1 (LL), incidência pélvica (PI), eixo sagital vertical (SVA), ângulo T1 pélvico (TPA), lordose cervical C2-C7, lordose cervical C1-C2, inclinação T1 (T1s), inclinação cervical (neck tilt), ângulo entrada torácica (TIA) e eixo cervical sagital (CSVA). Resultados: A cifose da coluna cervical foi observada em 48% dos pacientes. As curvas de classificação de Lenke (1 a 6) não apresentaram diferença com relação à curvatura da coluna cervical. No subgrupo com lordose cervical a cifose torácica e a inclinação de T1 foram significativamente maiores. A inclinação cervical foi significativamente maior no subgrupo com cifose. Conclusões: Quase a metade dos pacientes apresenta cifose da coluna cervical, sendo amplamente variável a curvatura da coluna cervical nos pacientes com EIA. A cifose torácica, a inclinação de T1 e a inclinação cervical são significativamente diferentes entre os subgrupos de pacientes com lordose ou cifose. Nível de Evidência III; Estudo Observacional e Retrospectivo.

RESUMEN: Introducción: En individuos sanos y en pacientes con escoliosis idiopática del adolescente (EIA), la curvatura de la columna cervical varía enormemente, y aproximadamente el 36-40% de los pacientes con EIA presentan cifosis de la columna cervical. Objetivo: Evaluar la curvatura de la columna cervical en pacientes con EIA y subgrupos según la clasificación de Lenke (1 a 6). Métodos: Se evaluó la lordosis cervical (C2-C7) de 107 pacientes con EIA mediante el método de Cobb, subdivididos en dos grupos: lordosis y cifosis cervical. Se evaluaron y compararon los siguientes parámetros entre los subgrupos: Cifosis torácica (TK) T5-T12; lordosis lumbar (LL) L1-S1, incidencia pélvica (PI), eje vertical sagital (SVA), ángulo pélvico T1 (TPA), lordosis cervical C2-C7, lordosis cervical C1-C2, inclinación T1 (T1s), inclinación del cuello, ángulo de la entrada torácica (TIA) y eje sagital cervical (CSVA). Resultados: Se observó cifosis de la columna cervical en el 48% de los pacientes. Las curvas de clasificación de Lenke (1 a 6) no mostraron diferencias con respecto a la curvatura de la columna cervical. En el subgrupo con lordosis cervical, la cifosis torácica y la inclinación T1 eran significativamente mayores. La inclinación cervical fue significativamente mayor en el subgrupo con cifosis. Conclusiones: Casi la mitad de los pacientes presentan cifosis de la columna cervical, y la curvatura de la columna cervical en los pacientes con EIA varía ampliamente. La cifosis torácica, la inclinación T1 y la inclinación cervical son significativamente diferentes entre los subgrupos de pacientes con lordosis o cifosis. Nivel de Evidencia: III; Estudio Observacional y Retrospectivo.

Sagittal misalignment in adolescent idiopathic scoliosis / Desalinhamento sagital na escoliose idiopática do adolescente / Mala alineación sagital en la escoliosis idiopática del adolescente

ABSTRACT: Introduction: The correlation between sagittal and coronal parameters in patients with adolescent idiopathic scoliosis (AIS) presents contradictory results and is not fully understood. Objective: To evaluate the sagittal vertical axis (SVA) and its correlation with sagittal parameters and the main curve in patients diagnosed with AIS. Methods: 109 patients with AIS and indications for surgical treatment were evaluated. The correlation of the SVA with sagittal parameters (thoracic kyphosis, lumbar lordosis, pelvic incidence, lumbar lordosis, pelvic version, and sacral inclination) and with the main curves (main thoracic and thoracolumbar/lumbar) was evaluated. Results: The SVA ranged from -208 to 66.30 mm (mean -19.64 ± 36.21), above 50 mm in two patients (1.83%). There was no correlation between the sagittal parameters and the magnitude of the main curve and the SVA. Conclusion: The SVA showed great variability in the group of patients with AIS; a small percentage of patients had an SVA greater than 50 mm. The low percentage of patients with sagittal misalignment showed the compensatory capacity of young patients with vertebral deformity. Level of Evidence: III; Observational and Retrospective Study.

RESUMO: Introdução: A correlação entre os parâmetros sagitais e coronais nos pacientes com escoliose idiopática do adolescente (EIA) apresenta resultados contraditórios e não está totalmente esclarecida. Objetivo: Avaliar o eixo sagital vertical (SVA) e sua correlação com parâmetros sagitais e a curva principal de pacientes com diagnóstico de EIA. Métodos: Foram avaliados 109 pacientes com EIA e indicação de tratamento cirúrgico. Foi avaliada a correlação do SVA com parâmetros sagitais (cifose torácica, lordose lombar, incidência pélvica, lordose lombar, versão pélvica e inclinação do sacro) e com as curvas principais (torácica principal e toracolombar/lombar). Resultados: O SVA variou de -208 a 66,30 mm (média -19,64 ± 36,21), ficando acima de 50 mm em dois pacientes (1,83%). Não foi observada correlação dos parâmetros sagitais e da magnitude da curva principal com o SVA. Conclusão: O SVA apresentou grande variabilidade no grupo de pacientes com EIA e pequena porcentagem dos pacientes apresentaram SVA maior que 50 mm. A baixa porcentagem de pacientes com desalinhamento sagital evidenciou a capacidade compensatória dos pacientes jovens e com deformidade vertebral. Nível de Evidência: III; Estudo Observacional e Retrospectivo.

RESUMEN: Introducción: La correlación entre los parámetros sagitales y coronales en pacientes con escoliosis idiopática del adolescente (EIA) presenta resultados contradictorios y no se comprende completamente. Objetivo: Evaluar el eje vertical sagital (SVA) y su correlación con los parámetros sagitales y la curva principal en pacientes diagnosticados de EIA. Métodos: Se evaluaron 109 pacientes con EIA e indicación de tratamiento quirúrgico. Se evaluó la correlación del SVA con parámetros sagitales (cifosis torácica, lordosis lumbar, incidencia pélvica, lordosis lumbar, versión pélvica e inclinación sacra) y con las curvas principales (torácica principal y toracolumbar/lumbar). Resultados: El SVA osciló entre -208 y 66,30 mm (media -19,64 ± 36,21), siendo superior a 50 mm en dos pacientes (1,83%). No hubo correlación entre los parámetros sagitales o la magnitud de la curva principal y el SVA. Conclusión: El SVA mostró una gran variabilidad en el grupo de pacientes con EIA y un pequeño porcentaje de pacientes presentó una SVA superior a 50 mm. El bajo porcentaje de pacientes con desalineación sagital mostró la capacidad compensatoria de los pacientes jóvenes con deformidad vertebral. Nivel de Evidencia: III; Estudio Observacional y Retrospectivo.

Confiabilidade da classificação de nash & moe em pacientes com escoliose idiopática do adolescente / Confiabilidad del método de nash & moe en pacientes con escoliose idiopática del adolescente / Reliability nash and moe s grades in patients with adolescent idiopathic scoliosis

ABSTRACT: Objective: Evaluate the inter and intra-observer reliability of Nash and Moe's grades, used to assess patients diagnosed with Adolescent Idiopathic Scoliosis (AIS). Methodology: Forty-seven representative x-rays of patients with AIS were randomly selected to evaluate the apical vertebral rotation (AVR) using Nash and Moe's grades. The evaluation of the AVR was made independently in two distinct moments by two observers. The inclusion criteria in the study were a patient diagnosed with AIS and an orthostasis radiography with a good-quality image. An agreement study between the evaluations and the inter and intraobserver's reliability was determined using Kappa's statistics with a confidence interval of 95%. Results: The interobservers' Kappa's value in the first evaluation was 0,44 (CI 95%; 0,22-0,66) and 0,37 (CI 95%; 0,17-0,56) in the second. In the intraobservers' evaluations, the Kappa's value for examiner 1 was 0,61 (CI 95%; 0,40-0,81) and 0,46 (CI 95%; 0,22-0,70) for examiner 2. Conclusion: This study's results demonstrated that Nash and Moe's grades are unreliable for evaluating vertebral rotation in patients with AIS. Level of Evidence III; A Cross-Sectional Study.

RESUMO: Objetivo: Avaliar a confiabilidade inter e intraobservador da classificação de Nash & Moe, usada em pacientes diagnosticados com escoliose idiopática do adolescente (EIA). Metodologia: Quarenta e sete radiografias representativas de pacientes com EIA foram selecionadas aleatoriamente para avaliação da rotação da vértebra apical (RVA), usando a classificação de Nash & Moe. A avaliação do RVA foi realizada de forma independente em dois momentos distintos, por dois examinadores. Os critérios de inclusão no estudo foram: paciente com diagnóstico de EIA e radiografia realizada em ortostase, com imagem de boa qualidade. Foi realizado um estudo de concordância entre as avaliações, e a confiabilidade inter e intraobservador foi calculada utilizando a estatística de Kappa com intervalo de confiança (IC) de 95%. Resultados: O valor de Kappa interobservador na primeira avaliação foi de 0,44 (IC 95% de 0,22-0,66) e na segunda de 0,37 (IC 95% de 0,17 -0,56). Nas avaliações intraobservadores, o valor de Kappa para o examinador 1 foi de 0,61 (IC 95% de 0,40-0,81) e para o examinador 2 foi de 0,46 (IC 95% de 0,22-0,70). Conclusão: Os resultados deste estudo demonstraram que a classificação de Nash & Moe apresenta baixa confiabilidade na avaliação do grau de rotação vertebral em pacientes com EIA. Nível de Evidência III; Estudo Transversal.

RESUMEN: Objetivo: Evaluar la confiabilidad inter e intraobservador para la clasificación de Nash & Moe, usada para estudiar pacientes diagnosticados con Escoliosis Idiopática del Adolescente (EIA). Metodología: Cuarenta y siete radiografías representativas de pacientes con EIA fueron seleccionadas aleatoriamente para evaluación de la rotación de la vértebra apical (RVA) usando la clasificación de Nash & Moe. La evaluación fue hecha de modo independiente en dos momentos distintos, por dos evaluadores. Los criterios de inclusión en el estudio fueron: paciente con diagnóstico de EIA y radiografía realizada en ortostasis, con buena calidad de imagen. Se realizó un estudio de concordancia entre las evaluaciones y se calculó la fiabilidad interobservador e intraobservador mediante la estadística de Kappa con un intervalo de confianza (IC) del 95%. Resultados: El valor Kappa interobservador en la primera evaluación fue de 0,44 (IC 95%: 0,22-0,66) y en la segunda de 0,37 (IC 95%: 0,17 -0,56). En las evaluaciones intraobservador, el valor Kappa para el examinador 1 fue de 0,61 (IC 95%: 0,40-0,81) y para el examinador 2 fue de 0,46 (IC 95%: 0,22-0,70). Conclusión: Los resultados de este estudio demostraron que la clasificación de Nash & Moe tiene una baja fiabilidad para evaluar el grado de rotación vertebral en pacientes con EIA. Nivel de Evidencia III; Estudio Transversal.