Casting for Early Onset Scoliosis: Follow-up Questions

The faculty answer follow-up questions from the audience of Casting for Early Onset Scoliosis: Why, When, and How?

If you have a casting question not found below, email [email protected] and we will do our best to have the webinar faculty answer your query.

1. (a) How often do the presenters change the casts and (b) What criteria do they use to stop casting?

• Dr. Johnston: Every 2-3 months. Criteria depends on intent – if going for cure then curve should be 15 degrees or less (a magnitude you would be comfortable onserving).
• Dr. Sanders: 2 and under, q2mo, 3yo q3m, 4+ q4m.
• Dr. D’Astous: I do the same.

2. Someone mentioned a special type of stockinette used under the cast to allow easy removal of foreign objects that get inside the cast. Please explain.

• Dr. Johnston:  It’s a silver impregnated T shirt used by Orthotists as undergarment for TLSO braces, and comes in sizes appropriate for small children getting casted for EOS.
• Dr. Sanders: Charlie mentioned this.  I use a Boston Brace shirt.
• Dr. D’Astous: I use a knit-rite T-shirt/turtleneck and 2 layers of regular stockinette. We used to use silver impregnated Knit-Rite shirts as Charlie mentioned but now we use regular Knit-Rite shirts.

3. What is the oldest patient that can be casted?

• Dr. Johnston: Probably more important is patient weight – upper limit around 30 kg, but not enough experience to give hard and fast rules. I would cast >6 only if family/patient insist, and that is really getting too late.
• Dr. Sanders: Unknown.  I have casted children up to age 10 but rarely have casted age 6 and  up.
• Dr. D’Astous: I have also casted as old as 10 but rarely would initiate casting after the age of 6. 

4. Could you elaborate on the relationship between pulmonary compromise and age of initial treatment?

• Dr. Johnston: Age at initial treatment not correlated with pulmonary function, and pulmonary compromise usually seen in juvenile or older.
• Dr. Sanders: Unfortunately, all our information is anecdotal. Pulmonary compromise is from the interaction of intrinsic pulmonary disease, muscle weakness, neural control, and chest volume.  I don’t believe we can give a good answer on this.
• Dr. D’Astous: I agree with Jim.

5. At what cobb do they consider success/cure and can stop casting?   

• Dr. Johnston:  We use < 15 degrees X 6 months, then go to TLSO or even observation if really straight.
• Dr. Sanders: <10 degrees.
       
   

6. Can you please have the panel describe tips and pearls for casting sagittal plane deformities, like kyphosis?

• Dr. Johnston:  I use regular supine halter – pelvis traction with sling under apex of curve which is progressively tighted to produce extension.  3 point mold with upper sternum or neck piece (depending on apex), apex posterior, and anterior pubic area.
• Dr. Sanders: I have had very limited success casting for kyphosis in young children and no success casting for lordosis.
• Dr. D’Astous: I have had some limited success with kyphosis. I use longitudinal traction with one hand pushing anteriorly just below the apex of the kyphosis and the other hand pushing posteriorly against the manubrium. I have occasionally used an occipito-mandibular extension to the EDF cast mostly to maintain sagittal alignment and support the weight of the head. It seems that this can slow the progression of kyphosis and buy some time. Again this is mostly anecdotal

7. (a) What gives the best predictor for in cast correction and (b) How do we know we have done a good job with the cast?                                                                                                                                                                          

• Dr. Johnston: Unknown but study going on now to correlate flexibility and correction in cast to final outcome.
• Dr. Sanders: Initial curve correction seems a good predictor (Glotsbecker’s article).
• Dr. D’Astous: In our series in Salt Lake City, age of less than 15 months at initiation of casting was a good predictor and flexibility seemed to trend towards a cure but did not prove to be statistically significant.

8. Which types of brace do you use after casting generally?

• Dr. Johnston: TLSO.
• Dr. Sanders: Custom molded TLSO under anesthesia using the same technique as the cast.
• Dr. D’Astous: I do the same and the trim lines on the brace are very similar to the cast. We have a traction table in our P&O department so occasionally, I will mold them there using the same technique as for the EDF cast.

9. How long it is advisable to wear a cast in an early onset scoliosis?  

• Dr. Johnston: Minimum is usually 1 year, especially to obtain “cure”. Casts work as growth modulation, so this amount of time is necessary to guide the spine straight.  We often will cast x 1 year, brace for 6-12 months, and then return to cast if correction lost up to about age 4.
• Dr. Sanders: Until you have the curve resolved (<10 degrees out of the cast) or under control.
• Dr. D’Astous: I do the same.

10. (a) At what Cobb angle do you switch to bracing and (b) do you give a 'cast vacation'?   

• Dr. Johnston: When curve is < 15 and casts have been applied for 1 year = safe to go to brace.
• Dr. Sanders: It is a negotiation. Ideally, under 10 degrees.  Sometimes, the family needs to stop.  I do not typically give a cast vacation but often shift to a waterproof cast for the summers in children where I am aiming for control rather than cure.
• Dr. D’Astous: I do give them a cast vacation with a custom TLSO for the summer if I have no   hope for a cure. If I think a cure is possible, I am more reticent to give them a cast vacation and I explain this to the family.

11. What do you tell the families about the impact on walking in the young infant children?  

• Dr. Johnston: Slows them down but not deleterious.
• Dr. Sanders: It may delay them for a few days. Some kids get up and walk with the casts, and parents have given the cast the credit!
• Dr. D’Astous: I have not seen the cast impair a child’s motor development and indeed, some children walk better with improved truncal balance.

12. I keep hearing that curves under 60 degrees are most likely to resolve. Is this a supine or standing measurement?                                                                    

• Dr. Johnston: Could be either, but if RVAD or rib phase unfavorable in IIS, probably won’t resolve
• Dr. Sanders: We do not have consistency in this.  Curves usually increase about 10 degrees when going from supine to upright.
• Dr. D’Astous: The ones in our series were 60 degrees standing X-rays.

13. How do you know when to stop or change gears in treatment?   

• Dr. Johnston: Stop when curve is “cured” , or no further correction occurring in 6 months for a delaying cast, or when the rib position is being compressed and chest wall being deformed.
• Dr. Sanders:  If I am pushing the ribs to much towards the spine, I do not believe casting is a good continued option.
• Dr. D’Astous: Stop when the ribs are getting too vertical.             

14. Time given between casts? 

• Dr. Johnston: 1-2 days if during treatment period
• Dr. Sanders: Usually the next day after removal. Sometimes a week or so break unless continuing to get further correction.  If this is the case, I do not allow breaks.
• Dr. D’Astous: I do the same.

15. Upper age to not cast?

• Dr. Johnston: None, depends more on patient weight.
• Dr. Sanders: No specific age.  It is unlikely I will start casting in someone 7 and up. Rarely in age 6.
• Dr. D’Astous: Same for me.

16. (a) A couple of other particulars on protocol... how many casts do you plan on initially? (b) When to stop if successful? (c) How much time between casts? (d) Any time off between casts for summer, etc?

• Dr. Johnston: Cast X 1 yr, brace in summer for a “break” if desirable.
• Dr. Sanders: I plan on 1 year minimum.  No time off until after 1 year and then is based on the response.
• Dr. D’Astous: I do the same. I do give them a cast vacation with a custom TLSO for the summer if I have no hope for a cure.

17. Are there any cheaper alternatives to the traction table for developing countries?              

• Dr. Johnston: Unknown.
• Dr. Sanders:  Any table has to allow traction and airway support and a free torso.  There is no reason one cannot be built from local resources.
• Dr. D’Astous: I have seen a good cast applied in South America with 2 cardboard boxes, a 1.5 “ aluminum support bar for the back and many hands to help out.

If you have a casting question that was not answered by these questions, email [email protected] and we will do our best to have the webinar faculty answer your query.