Is Cobb angle an obstacle to the future progress in scoliosis treatment?
The history of scoliosis treatment is well documented over the past almost 500 years (1st metal brace was created in 1575) and dates back to the early writings of the Hippocrates himself (The Father of Medicine). For hundreds of years, if not thousands, scoliosis patients have been immobilized in various types and applications of scoliosis brace treatment without success, and the current clinical data appears the orthopedic community isn’t any closer to scoliosis brace treatment success even today. Dr. Stefano Negrini led a comprehensive review of scoliosis brace treatment and concluded “There is a very low quality of evidence in favor of using braces, making generalization very difficult.” 436 years of attempted scoliosis brace treatment experimentation and “very low quality of evidence” is the best they can come up with? Obviously, we need a better way.
The first scoliosis surgery was conducted (unsuccessfully) in 1865 and subsequently spurred on the first medical malpractice lawsuit in the orthopedic community shortly after. While scoliosis surgery techniques, hardware, and abilities have vastly improved since that time, the long-term negative complications of fusing multiple levels of freely move-able joints in a patient’s scoliosis spine still haunts the procedure; keeping in mind the wide spread agreement that the primary indication for scoliosis surgery is for improving one’s cosmetic appearance and not medical necessity.
The current state of scoliosis treatment appears to be scoliosis brace treatment is worthless and the scoliosis surgery procedure is worse than the condition itself in many cases.
The need for drastic change and over-haul to the scoliosis treatment system is clearly obvious, yet decade after decade, little to no progress is made other that “improvements” to the existing scoliosis brace protocols and scoliosis surgery procedures. The obvious question is simply, why? When the need is so glaringly evident and the technology and thought process is so clearly under-developed; why hasn’t the scoliosis treatment community rushed to meet the needs and demands of a world full of scoliosis patients? In my opinion it can be summed up in two words: Cobb angle.
Cobb angle first appeared on the scene in 1948 and has been adopted as the “common” (not necessarily “gold” standard) for scoliosis evaluation every since. Cobb’s angle is a completely obsolete system of analysis. Idiopathic scoliosis is a very complex condition and the more we learn about idiopathic scoliosis, the more complex it appears to be. Attempting to describe a condition as complex as idiopathic scoliosis purely by the means radiographic lateral flexion is the equivalent to attempting to describe all the features of your new luxury car by only its color. There is so much more to this condition than just a Cobb angle.
The “prognostic” or “predictive” value of Cobb angle in curve progression is only slightly better than the odds of flipping a coin and ALL of the Cobb angle prognostic assumptions are based off a single study by Lonstein and Carlson in 1984, which has never been repeated or re-produced to this very day.
The current treatment schedule for scoliosis (10 degree diagnosis and then “watch and wait”, 25 degrees scoliosis brace treatment recommendation, 40 degrees scoliosis surgery recommendation) was accepted almost entirely on one article in 1977, by one doctor (Dr. William Kane), who openly admits the numbers are arbitrary and based on a cost based analysis to fit a particular healthcare system. It is not necessarily based off science, and more importantly, not necessarily based off the patient’s best interests.
Cobb angle has a generally accepted +/- 5 degree intra-examiner (same doctor measuring) “measurement error” between 2 separate x-rays and up to a 9.8 degree inter-examiner (different doctor) “measurement error” between 2 separate x-rays. This means a scoliosis brace treatment recommendation is essentially being made with an “acceptable” 20% error rate in scoliosis brace treatment recommendations for scoliosis cases of 25 degrees and scoliosis surgery recommendations are being made with a 12.5% error rate for scoliosis cases of 40 degrees. These measurement error rates are simply unacceptable when making recommendations for highly invasive procedures which have life-long lasting impacts (physically, emotionally, and psychologically) on those scoliosis patients unfortunate enough to be subjected to them.
Cobb angle is measured out of tradition, not an updated scientific understanding of idiopathic scoliosis.
So what is the link between an obsolete, un-reproducible, and un-reliable measurement system (Cobb angle) and the stagnant progress of scoliosis treatment (more useless scoliosis braces and more ways to induce spinal fusion through surgery)? All “mainstream” scoliosis treatment protocols (scoliosis brace treatment and scoliosis surgery) are entire predicated on Cobb angle. Remove Cobb angle from the equation and there is no indication for scoliosis brace or scoliosis surgery treatment. It’s really that simple. Cut off the head of the beast and the body dies.
Scoliscore genetic testing and Early Stage Scoliosis Intervention combine to create a new future for scoliosis treatment.
It has been said that one has to “replace” or “break” a current system, before the old one can be replaced. For example, email “broke” and “replaced” the fax machine. Almost overnight the fax machine became completely obsolete. Generally speaking it is easier to “break” the existing system than to “replace” it with something entirely brand new (which is really hard to do and needs to be invented first). In the case of over-hauling and replacing the current scoliosis treatment system it will need to be “broken” AND “replaced”.
Scoliscore genetic testing for idiopathic scoliosis will “break” the current scoliosis treatment system, because it “breaks” the use of Cobb angle as a predictive tool of curve progression. Idiopathic scoliosis a multi-factorial condition (aka: a combination of both genetic pre-disposition and environmental influences) and completely unique to every patient’s individual scoliosis case. No two cases of idiopathic scoliosis will ever have exactly the same genetic pre-disposition and/or environmental influences, so having a “known” variable like the patient’s genetic pre-disposition become invaluable in determining their true curve progression risk. In other words, a low genetic risk scoliosis case with a 20 degree Cobb angle looks exactly the same as a high genetic risk scoliosis case with a 20 degree Cobb angle on an x-ray; and under the current system to scoliosis treatment they would both receive the same scoliosis treatment recommendation (which in this case would be “observation only”).
The Early Stage Scoliosis Intervention program will “replace” the current scoliosis treatment model when used in combination with the genetic predisposition information provided by the Scoliscore test. Again, based on the new understanding that idiopathic scoliosis is a multi-factorial condition with both genetic predisposition and environmental influences resulting in the development of a spinal curvature; the current scoliosis brace and scoliosis surgery treatment protocol only attempts to deal with the end result (the spinal curvature) rather than treating and preventing the spinal curvature from developing by reducing/eliminating the environmental factors (the only variable we can currently control at this time). However, the Early Stage Scoliosis Intervention program is solely targeted towards reduction of the environmental influences and is centered around a neuro-muscular rehabilitation program the specifically targets the automatic postural control centers in the hind brain, which many researchers feel is genetically predisposed to being “under-developed” in idiopathic scoliosis patients.
This “one, two” punch of accurately determining which patients are most genetically predisposed to developing a severe idiopathic scoliosis curvature with Scoliscore genetic testing and immediately implementing an Early Stage Scoliosis Intervention program which re-trains the under-developed postural control centers in the brain, while simultaneously reducing environmental influences for idiopathic scoliosis is the most scientifically advanced approach to scoliosis spine treatment to date.
The current state of scoliosis treatment is deplorable. The Cobb angle system of scoliosis evaluation is antiquated (and thanks to Scoliscore genetic testing, now obsolete as well), and the scoliosis treatment system (scoliosis brace and scoliosis surgery treatment) employed under its (Cobb angle) direction is equally antiquated. In order to “turn the page” to a new day in scoliosis treatment, the scoliosis treatment community will need to embrace Scoliscore genetic testing as a way to “break” the hold Cobb angle has on scoliosis treatment protocols and adopt an Early Stage Scoliosis Intervention program to “replace” the current observation, scoliosis brace treatment, and scoliosis surgery treatment methodology in favor or a more pro-active strategy which prevents the spinal curvature (hence eliminating the need for scoliosis brace and scoliosis surgery treatment) and re-trains the neuro-muscular under-developmental cause of idiopathic scoliosis.
Tags: cobb angle, idiopathic scoliosis, scoliosis brace, scoliosis spine, scoliosis surgery, scoliosis treatment, scoliscore