Scoliosis: Causes and Treatments
Round 1
Reviewer 1 Report
Thank you for the opportunity to review this valuable work.
This study investigated the causes and treatment of scoliosis.
3. Non-surgical treatments section
Please explain why only the orthosis method was included in the non-surgical treatment.
5. Conclusion section
In this review, please describe the causes of scoliosis and your perspective on future treatment.
Author Response
Firstly, we wish to thank the reviewers for the review of our manuscript and his/her kind words. We have addressed the reviewers comments below.
3. Non-surgical treatments section
Please explain why only the orthosis method was included in the non-surgical treatment.
We did focus on bracing, as it is the most widely accepted and studies area in non-surgical. However, the reviewer is correct and we have added the following paragraph within the manuscript to include other non-surgical investigations.
"Presently, there are various braces, and other additional treatment options, such as acupuncture. Although bracing and surgery, which will be discussed below, other approaches have also been evaluated, such as acupuncture [73-75]. From a case report, where acupuncture was performed 3 times a week for 6 weeks, a correction in the curvature was reported at 10 degrees [74]. In another study, 24 AIS patients, between the age of 14-16, received acupuncture treatment lasting approximately 25 minutes. It was concluded that AIS patients with curvature below 35 degrees benefited [75]. However, more research and follow-up investigation are necessary to validate this treatment option."
5. Conclusion section
In this review, please describe the causes of scoliosis and your perspective on future treatment.
Within the text we highlighted many potential causes for scoliosis, however within the conclusion we did not indicate our perspective on the future. Thus we have added the below text within the manuscript to address the reviewers concern.
"As the technology continues to advance, spinal fusion may be more tolerable for patients. Conversely, with improvements in bracing in conjunction with physical therapy, there may be less need for surgery at all, or perhaps less invasive surgeries. Finally, with advancements in pharmacogenomic testing, there are possibility to understand AIS variants to allow for even earlier detection. Although neither bracing nor surgery cure scoliosis, with genetic testing to determine those children at higher risk of AIS, this may open the possibility to preventing its development early with nutritional and physical therapies."
Reviewer 2 Report
Dear authors,
congratulations for Your work, which well describes causes and treatments for scoliosis.
Just few aspects have to be addressed:
- Line 27: “spina bifida” instead of spinal bifida
- Line 55-57: this period refers to the consequences of scoliosis on sports and psychological aspects, it is very interesting but appears incomplete and needs to be investigated. To do this, please use the following reference:
Notarnicola A, Farì G, Maccagnano G, Riondino A, Covelli I, Bianchi FP, Tafuri S, Piazzolla A, Moretti B. Teenagers’ perceptions of their scoliotic curves. An observational study of comparison between sports people and non- sports people. Muscles, Ligaments and Tendons Journal, 2019, 9(2), pp. 225-235
- I suggest to modify the title of paragraph 3, since it well describes just the braces and not also the other conservative treatments, such as kinesitherapy.
- Line 150: “thoracic curves with an apex at” instead of “curves at an apex at”
- Line 212: remove the comma
- Line 226-227: please rephrase the sentence.
Best regards and good luck
Author Response
Firstly, we wish to thank the reviewers for the review of our manuscript and his/her kind words. We have addressed the reviewer's comments below:
1) Line 27: “spina bifida” instead of spinal bifida
The reviewer is correct and we have modified.
2) Line 55-57: this period refers to the consequences of scoliosis on sports and psychological aspects, it is very interesting but appears incomplete and needs to be investigated. To do this, please use the following reference:
Notarnicola A, Farì G, Maccagnano G, Riondino A, Covelli I, Bianchi FP, Tafuri S, Piazzolla A, Moretti B. Teenagers’ perceptions of their scoliotic curves. An observational study of comparison between sports people and non- sports people. Muscles, Ligaments and Tendons Journal, 2019, 9(2), pp. 225-235
Thank you for this excellent suggestion. We have added the below text within the manuscript:
"Young adolescents, as well as their peers and parents, often visualize scoliosis as a body disfigurement, which can lead to negative body image perceptions. This dissatisfaction of appearance can often lead to decreased self-esteem, anxiety, and even depression [76]."
3) I suggest to modify the title of paragraph 3, since it well describes just the braces and not also the other conservative treatments, such as kinesitherapy.
We have made the edit as suggested.
4) Line 150: “thoracic curves with an apex at” instead of “curves at an apex at”
The reviewer is correct and we have corrected.
5) Line 212: remove the comma
The reviewer is correct and we have corrected.
6) Line 226-227: please rephrase the sentence.
We have modified the sentence to now read:
"Data was collected during the bracing period and followed-up to evaluate which brace had better overall success rates between the TLSOs, Charleston, and Milwaukee. It was concluded that TLSOs significantly lowered progression of the curve and thus had highest overall brace success rate compared to other braces [42]."
Reviewer 3 Report
The review article entitled “Scoliosis-overview of causes and treatment” aims to discuss etiology and different treatment modalities for scoliosis (mainly on adolescent idiopathic scoliosis).
This work has collected numerous related references and revealed great detail on the issue of scoliosis. The article seems to be well-prepared and good enough for publication without major revision.
However, I would like to raise only one question about the figure 1 illustrating the Lenke classification of idiopathic scoliosis. In the figure, the spine drawings should be distinguished among lumbar deviation A, B, or C, but the lumbar curve components of the drawings looked similar and could not be differentiated from the three types. Furtherly, if there were some words of figure legends describing the definitions of lumbar deviations (modifiers), the figure could be more comprehensible.
Author Response
Firstly, we wish to thank the reviewers for the review of our manuscript and his/her kind words. We have addressed the reviewer’s comments below.
The reviewer pointed out: "I would like to raise only one question about the figure 1 illustrating the Lenke classification of idiopathic scoliosis. In the figure, the spine drawings should be distinguished among lumbar deviation A, B, or C, but the lumbar curve components of the drawings looked similar and could not be differentiated from the three types. Furtherly, if there were some words of figure legends describing the definitions of lumbar deviations (modifiers), the figure could be more comprehensible."
We are incredibly grateful for the reviewer's careful analysis of the Figure. He/she correct that the image we created made distinguishing the variabilities between the three types difficult. We thank the editor for the extra time to carefully remake many of these individual spinal representations. It is not possible to include the figure below, however within the manuscript the new figure has been included. Likewise, we have expanded upon the figure text to now read:
"Figure 1. Lenke classification for spinal curvature. Modified from [6]. Generally, Type A has the CSVL between the pedicles to the lumbar apex. Type B has the CSVL touching the apical bodies to lumbar apex. Type C has the CSVL completely medial to the apical lumbar vertebrae."
Reviewer 4 Report
The authors present a nice review about bracing and surgical treatment that are effective methods for scoliosis; some other approaches have also been evaluated. However, to make a new contribution to the field, the paper should address the definition of success more clearly and analyze it, making it the review's goal. Otherwise, this is just a list of current treatments. A complete analysis of the findings should be proposed to provide a clear take-home message.
Majors comments:
The conventionally accepted threshold of 5° or the 2.5° SEM of Cobb measurement approach, please use the Cobb angle and perform an analysis to compare the efficiency.
Draw a graph to depict the methods that reach the threshold.
The RCT presented here should be evaluated with the risk of bias currently used for RCT appraisal and the relative risk reduction by using the Cobb angle. Please use the following one: https://www.cebm.ox.ac.uk/resources/ebm-tools/critical-appraisal-tools
Please provide a table of biases to summarize the limitations of each study.
According to the previous works requested, please provide a take-home message that provides the efficient method, the ones that are not efficient, and those on a grey area.
Minors comments:
The authors should not mention the case report about acupuncture in conclusion since it draws attention. Please use another paragraph to present the other methods that have been used and their limitations.
Author Response
Firstly, we wish to thank the reviewers for the review of our manuscript and his/her kind words. We have addressed the reviewer’s comments below.
1) However, to make a new contribution to the field, the paper should address the definition of success more clearly and analyze it, making it the review's goal. Otherwise, this is just a list of current treatments. A complete analysis of the findings should be proposed to provide a clear take-home message.
This is a very valid comment and concern. Throughout we have highlighted limitations, potential biases, successes, and comparisons. As the reviewer accurately pointed out a more thorough analysis was needed, and thus Table 3 has been modified and we have included a new Table 4 (see below) that hopefully provides a cleaner message.
2) The conventionally accepted threshold of 5° or the 2.5° SEM of Cobb measurement approach, please use the Cobb angle and perform an analysis to compare the efficiency. Draw a graph to depict the methods that reach the threshold.
We again thank the reviewer for these comments. We felt that adding a graph would not fit into the style of the manuscript, thus we not only address the Cobb angle comment that the reviewer indicated we have expanded upon our manuscript in the below manner.
"The Scoliosis Research Society (SRS) identifies Cobb angle as a primary outcome that is most used to determine the success and effectiveness of orthosis treatment. The Cobbs angle of 5° or less at the end of treatment or at the time of brace discontinuation is considered as a successful and effective orthosis. Although comparisons have done with different braces, the studies themselves are performed by different groups., Therefore each study has its own set of inclusion and exclusion criteria, which may differ significantly. Thus it is difficult to exactly compare and contrast the different braces. Additionally, individual researchers define success and failure in terms of brace effectiveness, differently. Some studies include compliance and include maturity as a variable in their study. Thus, a uniformity across studies is difficult to compare. Although, there have been specific comparison studies on orthosis treatment for scoliosis, to fully compare and assess the efficacy of each orthosis, specific criteria need to also be included. Factors, such as initiation of bracing period, curve magnitude at the initiation of therapy and years of skeletal maturity differ across these studies. Ideally, there should be more stringent patient characteristic or inclusion criteria among studies to make a true comparison. Additionally, patients who were categorized as being “successful” should be followed-up for a minimum of 2 years after skeletal maturity. Likewise, studies should include patient compliance to decrease bias, even if the report may be subjective."
3) The RCT presented here should be evaluated with the risk of bias currently used for RCT appraisal and the relative risk reduction by using the Cobb angle. Please use the following one: https://www.cebm.ox.ac.uk/resources/ebm-tools/critical-appraisal-tools. Please provide a table of biases to summarize the limitations of each study. According to the previous works requested, please provide a take-home message that provides the efficient method, the ones that are not efficient, and those on a grey area.
Thank you for these excellent suggestion as well as the link. We have modified Table 3 to include the Risser value as well as the "Definition of brace effectiveness". We have also created a new table (Table 4). Although we were unable to calculate Risk Ratio, because studies included in the manuscript for comparison were multicenter trials that had “no treatment group” and were either follow-up research or just studies that had participants who were treated; we have specifically added a column on Limitation/Bias. This in conjunction with our modified Table 3 should provide a numerical "take-home message."
4) The authors should not mention the case report about acupuncture in conclusion since it draws attention. Please use another paragraph to present the other methods that have been used and their limitations.
The reviewer is correct with his/her concern. We have moved discussion on acupuncture to the non-surgical section and we highlighted the lack of follow-up studies within this arena.
Round 2
Reviewer 4 Report
The authors answered my comments. It needs english editing.
Author Response
Thank you for your positive review of our manuscript. We have carefully gone through it focusing on grammar, spelling, punctuation, and formatting; making any changes necessary. We are very appreciative of your time and input.
