Nghiên cứu điều trị vẹo cột sống vô căn ở trẻ em bằng áo nẹp CAEN tt tiếng anh

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH HA NOI UNIVERCITY IN MEDICINE DO TRONG ANH RESEARCH ON TREATING IDIOPATHIC SCOLIOSIS IN CHILDREN WITH CAEN BRACE Specialization : ORTHOPEDICS AND PLASTIC SURGERY Numeric code: 62720129 SUMMARY OF DOCTORAL THESIS IN MEDICINE HA NOI - 2020 Thesis is completed at: HA NOI UNIVERCITY IN MEDICINE Assoc Prof Nguyen Cong To Instructor : Assoc Prof Pham Van Minh Reviewer 1: Assoc Prof Ha Hoang Kiem Reviewer 2: Assoc Reviewer 3: Prof Ngo Van Toan Assoc Prof Nguyen Trong Luu The thesis is presented at University doctoral thesis evaluation Council held at Ha Noi Univercity in Medicine On Day/ Month / 2020 The Thesis can be found at : - National Library - Central Library of Medical infomation - Library of Ha Noi Univercity in Medicine SCIENTIFIC WORKS RELATED TO THE THESIS HAVE BEEN SUBMITTED Do Trong Anh (2013), “Correction effect of CAEN brace in traetment of idiopathic scoliosis in children” Practical medical Journal, (864) – No 3/2013, pp 171-73 Do Trong Anh (2019), “Survey on some idiopathic scoliosis characteristics in children at HCM City Orthopedic and Rehabilitation Hospital ”, Practical medical Journal, JPM No (1102) pp 13-15 Do Trong Anh (2019), “Survey on related factor on result of treatment idiopathic scoliosis in children at HCM City Orthopedic and Rehabilitation Hospital”,Practical medical Journal, JPM No (1102) pp 53-57 INTRODUTION Scoliosis is a deformity of the spine whose scoliosis is mostly curved to the side along the frontal plane, of which idiopathic scoliosis is the dominant type The treatment for idiopathic scoliosis patients, specialy in puberty is an urgent problem For moderate and mild scoliosis, conservative treatment is always the first mentioned treatment method because of its safety, low cost and good effectiveness, contributing to a significant reduction in the number of patients requiring surgery Conservative treatment of scoliosis with braces has been around for a long time in the world CAEN braces also called night braces are successfully manufactured and put into use for the treatment of scoliosis conservation treatment at the Orthopedic and Rehabilitation Hospital in Ho Chi Minh City In order to contribute to assessing the effectiveness of this type of brace when applied in Vietnam, we conducted research on the topic "Research on treating idiopathic scoliosis in children with CAEN brace" The urgency of the thesis Wearing a brace is a treatment for preserving idiopathic scoliosis in children The effectiveness of wearing a brace for treatment has long been proven However, wearing braces is still inconvenient This inconvenience reduces patient consensus, reducing the number of patients who accept bracing treatment CAEN brace is a relatively new type of brace, which is said to have the ability to adjust and reduce it, so it is effective for treatment even when worn only at night That can help increase consensus, reduce inconvenience, and increase the effectiveness of a brace treatment So far there is only very little research on the effectiveness of this brace In order to widely use this type of brace, more research is needed on the effectiveness of CAEN braces to treat idiopathic scoliosis in children New contributions of the thesis CAEN braces were first made and used in Vietnam by the author of the technology transfer braces, with the name "night braces" - This is the first systematic study on the effectiveness of CAEN brace in the treatment of idiopathic scoliosis in Vietnam - The project has a new feature compared to previous studies, only wear braces 10 hours at night This study used CAEN braces for longer wearing periods (from 10 hours to 16 hours) Assess the effectiveness of treatment, patient consensus and the safety of the brace, when the wearing time is longer than the time recommended by the author of CAEN brace The layout of the thesis: The thesis consists of a thesis with 120 pages, including sections: Background (3 pages), Overview (40 pages), Subjects and research methods (18 pages), Results (27 pages), Discussion (32 pages), Conclusion (2 pages), Recommendation page The thesis has 56 tables, 50 pictures, charts, 124 references including Vietnamese, English and French documents CHAPTER I: OVERVIEW 1.1 ANATOMY AND SPINAL BIOMECHANICAL The spine consists of many vertebrae stacked on top of each other to form a support column of the whole body The vertebrae develop by cartilage growth above and below Most scoliosis begins to develop from softissue This deformity eventually causes growth retardation in the growth place of the vertebrae on the concave side of the curve and produces a wedge-shaped vertebra 1.2 GENERAL CONCEPT OF SCOLIOSIS`  Scoliosis is a deformation of the vertebral spine in the frontal plane and the maximum rotation deformity is at the apex of the curve The spine is called scoliosis when Cobb angle on X- ray > 100  There are basic types:  Scoliosis congenital:  Scoliosis due to neuromuscular causes  Scoliosis is a condition of some other diseases  Idiopathic scoliosis, a scoliosis that has no known cause 1.3 CLASSIFICATION OF SCOLIOSIS 1.3.1 Classification by age, based on time of onset 1.3.2 Classification by position of the curve 1.3.3 Classification by type of curve 1.3.4 Classification by King-Moe and by Lenke 1.4 ETIOLOGY Although the cause of idiopathic scoliosis is still unknown, many studies have been carried out with many theories put forward such as due to genetic factors, disorders of bones, muscles, and intervertebral disc development as well as causes in the nervous system 1.5 EPIDEMIOLOGY Idiopathic scoliosis rate has been reported as 0.5% to 3% Scoliosis rate with curve> 300 is from 0.15% to 0.3% The rate of idiopathic scoliosis in young boys compared to teen females is 1/4 In Vietnam, there are no comprehensive statistics on the epidemiology of idiopathic scoliosis in children 1.6 THE DEVELOPMENT OF SPINE, RISSER SIGN AND SCOLIOSIS 1.6.1 The growth of spine and Risser sign The spine can only grow in height when the cartilage grows of vertebra is unsealed The degree of ossification of the iliac apophysis (Risser sign) coincides with the growth cartilage of the vertebra and can be used to assess the ability to develop the height of the spine Risser's classification system divides the bone maturation process into stages of calcification of the iliac crest: Risser0: no calcification; Risser1: calcification of 25% outside; Risser2: calcification of 50% iliac crest; Risser3: calcification of 75%; Risser4: calcification of most iliac crest without welding with pelvis; and Risser 5: the ilium (bone) is calcified at a level of 100% and the iliac apophysis is fused to iliac crest 1.6.2 Relationship between spinal growth and scoliosis When children are immature, the spine is still developing, scoliosis can be significantly progressive by the Hueter - Volkmann law As the angle curve increases, under the influence of gravity, the difference in pressure between the two sides of the vertebra increases, making the uneven development of the two vertebrae leading to increased scoliosis diformity According to Julius Wolff's law, once the bone has matured, the vertebrae will not deform 1.7 THE NATURAL HISTORY AND COMPLICATION OF SCOLIOSIS 1.7.1 The natural history of idiopathic scoliosis Untreated idiopathic scoliosis will have: -85% of idiopathic scoliosis in infancy can be self-corrected -15% of idiopathic scoliosis in infancy is progressive -The smaller the Risser degree, the greater the risk of progressive of the curve -The curve increases by an average of 150 after the bone stops growing -Scoliosis with curves 100 exclude scoliosis with any reason 1.9 TREATMENT OF IDIOPATHIC SCOLIOSIS 1.9.1 The treatments 1.9.1.1 Physical exercise 1.9.1.2 Stretching 1.9.1.3 Electrical stimulation 1.9.1.4 Surgery 1.9.1.5 Casting 1.9.1.6 Treatment of idiopathic scoliosis with a brace  Treatment principles • Scientific basis of the treatment for scoliosis: The scoliosis corrections are based on points rule; Some braces also create vertical stretches; Some braces help active sefl correction; These correction changes in the pressure on the sides of the vertebra - Types of braces: Some basic types have been used such as Milwaukee, Boston, Wilmington, Cheneau, Charleston - Braces full tieme and braces part time 1.9.2 CAEN brace 1.9.2.1 History of CAEN braces CAEN brace comes from Caen area of France and is also the abbreviation of the phrase "Corset Appuis Electifs Nocturnes segmentaires" (Night brace with selective pressure point) 1.9.2.2 Principle of treatment with CAEN braces: create on three planes in the space of reduction of each scoliosis deformation segment 1.9.2.3 Structure of CAEN braces CAEN brace is made of 3-4mm thick polypropylene, hugging the pelvis to create stability for the body of the shirt, the empty chest creates a physiological chest, the upper body can be folded forward The windows create ventilation that significantly reduces the weight of the brace, the pressure areas are lined with foam 1.10 Domestic and foreign studies on the effectiveness of CAEN brace in the treatment of idiopathic scoliosis Pierrard and colleagues studied CAEN brace treatment for 135 patients with idiopathic scoliosis from 1994 to 1998, showing good results from 75% -79% depending on the type of curve Nathan D studied in 2003, on 78 patients with idiopathic scoliosis, showing a good correction of the CAEN brace was 75% Fauvy and Fillipetit studied 21 patients with idiopathic scoliosis treated with a CAEN brace, showing that no patient had a severe scarring angle greater than CHAPTER SUBJECTS AND METHODS OF THE STUDY 2.1 STUDY SUBJECTS 2.1.1 Criteria for selecting a patient  Patient examinationed and treated at Ho Chi Minh City Orthopedics and Rehabilitation Hospital from March 2014 to July 2017 They have been diagnosed as idiopathic scoliosis:  Ages 10-17 years old  Risser sign ≤3  The curve has a Cobb angle greater than 200 and less than 450  Approve conservative treatment with a brace  Compliance treatment and re-examination regime  Having a clear address, cooperating to monitor the disease  The patient has a clear and complete medical record, and all Xray films taken at the time of treatment, at the time of the first brace and at the end of treatment  Duration of treatment, follow-up and evaluation is 24 months 2.1.2 Exclusion criteria  The patient is not in the study age  Parent or patient does not agree on treatment  Patient does not have a full follow-up, does not follow up regularly  Patient does not wear a brace at least 10 hours /day  The patient did not wear a brace long enough to study  Patients with Cobb angle less than 200 and greater than 450  Patient with Risser sign >3  Inadequate medical records and X-ray films 2.2 RESEARCH METHODS 2.2.1 Study design: Clinical intervention, open, non-controlled, using the pre- after evaluation model (comparing results before and after treatment) 2.2.2 Sample size and method choose a sample: Using the sample size formula with an estimated success rate of 0.6, we have the sample size needed for the study to be 96 patients Sampling: Convenient, no control group 2.2.3 Examination: detection of scoliosis, assessment of scoliosis level and morphology, Using Test Adams, assess balance level with the plumb line Take x-rays of the entire vertebrae frontally and laterally, observing the curves, the shape, the number of curves, the direction of the scoliosis, the head, the end and the apex of the curve - Measure the angle of the curve using Cobb's method - Evaluate the peak rotation by the method of Nash and Moe - Assess the level of bone maturation according to Risser Classification of disease: • Type of curve: • Curve direction is the convex direction of the curve • According to Cobb angle: Light Type Cobb Angle from 20 0-290, Medium Type Cobb Angle from 30 0-390, Severe type Cobb angle ≥400 2.2.4 Treatment:  The time to wear a brace: from 10 to 16 hours  The process of making braces includes the following steps: - Measure the size of the armpit, the tip of sternum, the waist of the hips, the upper anterior pelvis spine and greater trochanter , the height from the waist to the armpit on the sides Take a sample of the brace  Create a negative form  Create the positive form  Repair curves  Shaping braces Creating windows, revealing chest, honing and testing braces  Determine the level of initial correction: take X-ray when wearing the first brace to determine the level of initial correction Instructing the patient to take physical exercise: the treating doctor will guide the patient to take physical exercise in and out of the brace Patients are instructed to practice leaning in braces to create active 10 3.1.2 Characteristics of type and direction of curves Table 3.7 Distribution of curve types Type of curve Thoracic (n= 45) Thoracic- lumbar (n=29) Thoracic (n=8) Double Thoracic and ThoracicLumbar (n=10) Double Thoracic and Thoracic (n=32) Total (n=124) Number of patient 45 29 10 Ratio % 36.3 23.3 6.4 8.0 32 124 25.8 100 Table 3.8 Distribution of curve directions Curve direction Turn right To the left total Number patient 91 33 124 Ratio % 73.3 24.7 100 3.1.3 Distribution of patients according to Risser sign Table 3.9 Distribution of patients by Risser sign Risser Total Number patient 18 22 30 54 124 Ratio % 14,5 17,7 24,2 43,5 100 3.1.4 Distribution of patients according to apical rotation 11 Table 3.10 Distribution of patients according to apical veterbra rotation Rotation of apical Number patient Ratio % veterbra 42 33.9 + 64 51.6 ++ 18 14.5 +++ Total 124 100 3.1.5 Distribution of patients according to Cobb angle Table 3.11 Distribution of patients according to angle of scoliosis Cobb angle Number patient Ratio % 20-29 43 34.7 30-39 66 53.2 40-45 15 12.1 Total 124 100 Balance Male Female Total Table 3.12 Balance of body Standard Average deviation 1.18 0.09 0.91 0.05 0.96 0.61 P >0.05 Table 3.13 Distribution of patients by the hour of bracing Number of hour bracing Number patient Ratio % 10 - 12 hours 89 71.7 13 -16 hours 35 28.3 12 3.2 Treatment results of CAEN braces 3.2.1 Initial correction in CAEN braces Table 3.14 Initial correction results of CAEN braces Level of correction Number patient Ratio % patient 15-19 % 0.8 20-29 % 0.8 30-39 % 5.6 40-49 % 6.5 50-59 % 14 11.3 60-69 % 12 9.7 70-79 % 37 29.8 80-89 % 14 11.3 90-100 % 30 24.2 Total 124 100 3.2.2 Treatment results Table 3.15 Treatment results Result Total Number patient Good (Cobb angle increases below 88 5) Fair (Cobb angle increased by 010 10 ) Moderate (Cobb angle increased 11 above 10 ) Poor surgery 15 Total number of patients 124 Ratio % 70.9 % 8.1 % 8.9 % 12.1% 100% 13 3.2.3 Safety of CAEN braces Table 3.16 Complications of CAEN braces Complication Number Ratio % patient Uncomplicated 111 89.5 Complications 13 10.5 Purple pain in pressure area 11 8.9 Mild ulcers 1.6 Amyotrophy 0 Respiratory failure 0 3.3 Factors related to treatment outcome 3.3.1 Results of treatment related to age and gender Table 3.17 Relationship between results and gender Result Male female N=112 P ( N=12) (50.0%) 82 (73.2%) Good (n=88) 0.05 Fair (n=10) (0.0%) 11(9.8%) >0.05 moderate (n=11) (41.7%) 10 (8.9%) Pour n=15 0.05 15 tuổi 69.2 11.5 3.8 15.7 16 tuổi 88.9 0.0 11.1 0.0 17 tuổi 89.3 10.7 0.0 0.0 TC 70.9 8.1 8.9 12.1 14 3.3.3 Results of treatment are associated with risser sign and rotations of apical veterbrae Table 3.19 Results of treatment related to rotation of apical veterbrae Rotation +; Rotation ++; Rotation +++; n=42 n=64 n=18 Result Numbe Numbe Numbe Ratio Ratio Ratio % r r r % % % patient patient patient Good 38 90,4 46 71,9 22,2 (n=88) Fair 4,8 9,4 11,1 (n=10) Moderat 2,4 14 5,6 e (n=11) Pour 2,4 4,7 11 61,1 (n= 15) P