Prevention of limb ischemia.
\r\n\tThis book will be a self-contained collection of scholarly papers targeting an audience of practicing researchers, academics, PhD students and other scientists. The contents of the book will be written by multiple authors and edited by experts in the field. The area of interest and scope of the project can be described with (but are not limited to) the following keywords: Alcoholism, Depression, Addiction, Blackouts, Relapse, Binge Drinking, Genetic basis, Neurological Aspects, Treatment, Organ Damage.
\r\n\r\n\tAuthors are not limited in terms of topic, but encouraged to present a chapter proposal that best suits their current research efforts. Later, when all chapter proposals are collected, the editor will provide a more specific direction of the book.
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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"4816",title:"Face Recognition",subtitle:null,isOpenForSubmission:!1,hash:"146063b5359146b7718ea86bad47c8eb",slug:"face_recognition",bookSignature:"Kresimir Delac and Mislav Grgic",coverURL:"https://cdn.intechopen.com/books/images_new/4816.jpg",editedByType:"Edited by",editors:[{id:"528",title:"Dr.",name:"Kresimir",surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"67307",title:"Isn’t Limb as Precious as Life?",doi:"10.5772/intechopen.86391",slug:"isn-t-limb-as-precious-as-life-",body:'\nExtra-corporeal life support (ECLS) for the last 2–3 decades has become an indispensable tool in the armamentarium of physicians and surgeons dealing with patients suffering severe cardio-pulmonary failure [1]. Over the period of time, its utilisation has seen a broadening in terms of indications, age limits and condition of patients [2, 3, 4, 5, 6, 7, 8, 9]. Familiarisation with technique, continuous improvement of equipment and changes in strategy in favour of early intervention have helped to improve the survival of patients supported on the ECLS [10, 11]. However, unfortunately, a significant number of patients still suffer and succumb to complications instigated by the ECLS. In fact, not very uncommonly, ECLS related complications play a decisive role in the clinical outcome of the patient. For the purpose of this discussion, we use the term ECLS as a synonym for extra corporeal veno-arterial membrane oxygenation. Alternative technologies such Impella® or short term left ventricular assist (VAD) are not discussed. Initial ECLS in the acutely presenting patients is often implemented via femoral cannulation. Alternative approaches such as via the subclavian, axillary or carotid artery are used less commonly in adults and the incidence of limb ischemia in these scenarios is negligible compared to femoral artery. Therefore, for all practical purposes we will discuss lower extremity limb ischemia in this chapter. Late or chronic limb ischemia, sometimes occurring months after de-cannulation although symptomatic, seldom threatens limb survival and will not be discussed either.
\nLimb ischemia in patients supported on peripheral ECLS is one of the most dreaded complications and presents with a wide spectrum of clinical symptoms and outcomes. Interestingly enough, this specific complication can be almost totally avoided with a protocol-based approach and precautions taken during the ECLS support; and if it occurs, it can be managed without significant consequences if detected and addressed immediately.
\nECLS, although offered by specialised units only, is becoming more and more adopted for treatment of patients presenting with a variety of problems. Recent developments in technology have resulted in easier implantation and maintenance, ability to implement directly at the bedside, complete cardiopulmonary support and cost-effectiveness when compared to other mechanical circulatory support devices.
\nIn surgery, ECLS is utilised as a rescue in post-cardiotomy cardiogenic shock (PCCS) or as a temporary prolongation of cardiopulmonary bypass (CPB) to allow for an extensive weaning. Historically, the ECLS circuit was connected to the central CPB cannulation following unsuccessful weaning attempts of CPB. Recent years have seen a paradigm shift in preference to peripheral access. It is because peripheral cannulation allows for chest closure and avoids bleeding from high pressure aortic and thin-walled right atrial cannulation site and thus, multiple re-explorations for bleeding-temponade. Furthermore, the risk of formation of a positional thrombus on the intraluminal part of the aortic cannula, which may be dislodged at the time of decannulation and result in a catastrophic embolic event is avoided. And lastly, peripheral access obviates reopening of chest at the time of explantation of ECLS [2, 3]. Cannulation is either performed percutaneously or open, depending on the situation and the presenting patient.
\nA second group experiencing a significant increase in the utilisation of ECLS are patients during primary coronary intervention (PCI) [4, 5], although recent developments may lead to a shift in the technology used, such as Impella®. In this particular clinical setting, the expertise of interventional cardiologists and availability of fluoroscopy obviously lends itself to direct percutaneous implementation of ECLS. Bed-side, emergency direct ECLS implantation in intensive care units is a last and only resort to resuscitate patients after cardiopulmonary arrest undergoing prolonged efforts to re-establish life sustaining cardiac and pulmonary function (e-CPR) [6, 7]. In this situation, percutaneous peripheral access to the groin vessels is the preferable approach in view of the continuation of chest compressions and limited equipment available (e.g. fluoroscopy, surgical set).
\nIn patients with advanced cardiac failure ECLS may be used as a bridge to decision, recovery or heart transplantation. In some of these patients, particularly those awaiting transplantation or long-term VAD implantation it is used in a ‘semi-elective emergency situation’ where patients are destabilising and showing signs of rapidly deteriorating end-organ function and impending cardiogenic shock. In this particular scenario ECLS is used to re-perfuse and stabilise end-organ function such as liver and kidney to allow for a non-emergency long-term VAD implantation at significantly less perioperative risk in a more stable patient. In this complex group of patients, peripheral access is favoured as it does not necessitate a sternotomy or thoracotomy leaving the chest ‘virgin’ or which may be complex due to previous, often multiple, surgical interventions. At the time of subsequent surgery ECLS can then easily be converted to CPB and continuation of ECLS post-surgery, if required [8, 9], can be achieved simply by switching back to an ECLS circuit.
\nIn essence, peripheral access for the ECLS has become popular due to its flexibility of implantation outside operation theatre, reduced cannula site bleeding, the option of chest closure, avoidance of chest re-exploration and explantation without chest intervention. With the overall increase in the utilisation of ECLS in PCCS, post-PCI, e-CPR and as a bridge to transplant or ventricular assist devices and even as a bridge-to-lower risk surgery as a preparational tool, ECLS related complications including limb ischemia are being seen more often than ever before.
\nECLS, essentially being temporary mechanical circulatory support requires an exit strategy with a sustainable solution, namely short or long-term ventricular assist device or transplant. Until then, an uninterrupted and uncomplicated distal limb perfusion is essential for the continuation of peripheral ECLS for more than a few hours. Any complications during the period on ECLS support potentially hinder patients’ progress to recovery or long-term solutions. Of these, limb ischemia is one of the notorious and unfortunately- most commonly encountered complications in patients supported. As with other complications, limb ischemia remains underreported in institutional audits and the literature and reported incidence of ECLS related limb ischemia vary significantly. The Extra-corporeal Life Support Organisation (ELSO) in its latest report shows 1% incidence of limb ischemia [12]. Whereas, a recent metanalysis reviewing 20 studies comprising 1886 patients revealed a pooled estimate of rate of limb ischemia as high as 16.9% (12.5–22.6%); compartment syndrome at 10.3% (7.3–14.5%) and amputation at 4.7% (2.3–9.3%) [13]. Other contemporary, smaller reviews report limb ischemia in range of 4.4–19% and 11–52% [14, 15]. The variation among published literature in incidence of limb ischemia and related complications may be due to difference in inclusion criteria of patients, difference in definition of limb ischemia and publication bias.
\nLimb ischemia has a broad spectrum of presentation ranging from hypothermia to muscle necrosis. In patients on ECLS it may occur for a number of reasons. Of these, the first and foremost is, of course, the simple complete obstruction of the femoral artery by the systemic perfusion cannula, which is inserted in a retrograde fashion, either percutaneously or open. The second is the requirement of extensive vasoconstrictor and inotropic support, which may restrict the ‘residual’ flow to the limb to the point of induction of clinically relevant ischemia. The third is the result of a deterioration of remaining cardiac output and loss of pulse wave, as the limb may be perfused—adequately—during the systolic ejection and be completely ischemic should pulse-wave be lost. Finally, insertion of the venous cannula on the ipsilateral side may result in clinically relevant venous congestion by itself and thus exacerbate any arterial perfusion deficit. Thus, careful monitoring and adjustment of several variables is essential in the prevention of ischemia and the treatment must be aimed at not only correcting the underlying causation but also to mitigate the resulting effects as in necrosis or reperfusion induced injury.
\nThe signs and symptoms of acute limb ischemia are classically described with the 6 Ps- Pain, Pallor, Pulselessness, Paraesthesia, Poikilothermia, and Paralysis [16]. In this context, Rutherford’s grading of acute limb ischemia depending upon the clinical examination namely viable, threatened (salvageable if promptly treated) and irreversible (major tissue loss or permanent nerve damage inevitable) is helpful to determine the timing and type of intervention. The onset of fixed mottling of the skin usually implies irreversible changes but does not allow for an estimation as to the extent. Compartment syndrome results from increased pressure (greater than 30–45 mmHg) in the muscle compartments often due to ischemia or reperfusion related swelling which further decreases blood supply leading to a vicious cycle of swelling-ischemia-swelling, rapidly progressing to irreversible necrosis of the affected muscles. Diagnosis is essentially clinical with findings of swelling, stiffness, pain, and loss of pulse. It is a limb and life-threatening emergency and is usually fatal unless immediate action is undertaken, almost always including four compartment fasciotomies [17].
\nLimb ischemia compromises survival not only of the involved limb but also the patient. The ischemic process, multiple procedures, and transfusions exacerbate the systemic inflammatory response related to ECLS, resulting in increased risk of death [18]. Tanaka et al. report a higher number of procedures per patient and an increased frequency of disseminated intravascular coagulation in patients with vascular complications [19]. They also found the rate of survival to discharge as 18 vs. 49% in patients with and without vascular complications, respectively, demonstrating vascular complications as an independent factor of survival in patients on VA ECLS [19]. While some authors did not find any correlation between limb ischemia and patient mortality [20, 21, 22], it is widely accepted that apart from severity of the underlying condition, neurological uncertainty, and eligibility for substantive therapy, the limb ischemia plays a seminal role in deciding fate of the patient supported on ECLS.
\nSeveral authors highlight the role of concurrent, prophylactic, selective distal limb perfusion from the time of femoral arterial cannulation for systemic perfusion in the prevention of limb ischemia. In one series, the authors claim no occurrence of limb ischemia in patients with prophylactic distal perfusion via selective cannulation (DPC) compared to a 21% incidence of ischemia in patients without DPC [21]. Tanaka et al. demonstrated that the absence of DPC was a significant predisposing factor for vascular complications, while other factors including medical history or risk factors like peripheral vascular disease and severity of baseline condition were not significantly associated with vascular complications [19]. However, from the review of published literature it is difficult to ascertain whether the elective avoidance of DPC or the presence of factors preventing its use (e.g. peripheral artery disease, vessel spasm, vessel injury due to attempted cannulation) are the underlying cause of the vascular complication.
\nIn a comparative study, no limb ischemia was encountered in patients undergoing pro-active DPC in contrast to 9.3% incidence of limb ischemia in patients who underwent re-active DPC as a rescue strategy. They concluded that the delayed distal cannulation not only increased the extent of cannulation site bleeding, but also failed as a rescue therapy as it failed to improve the ischemia [23] whereas pro-active DPC prevented its occurrence. In addition, patients in the pro-active group demonstrated a significantly better weaning rate as well as survival.
\nHowever, despite extensive literature advocating DPC as being preventive to limb ischemia, there is no class I evidence about its efficacy. Understandably, it is difficult to design a randomised trial to identify actual protection offered by prophylactic DPC given the multiple factors responsible for mortality and morbidity and grave condition of patients supported on VA-ECMO.
\nAlthough DPC offers incessant perfusion to the distal limb, its insertion and maintenance are not always smooth, and it is not devoid of complications. The DPC due to their small calibre, slow and low flow, acute angles, multiple connections are prone to bending, thrombogenesis, and peripheral embolization. It is important to note that DPC blockage due to thrombosis may go unnoticed in absence of continuous monitoring of its flow and result in complete thrombo-embolism and obstruction of the femoral artery. In order to avoid this scenario and assess whether limb perfusion remains adequate in the absence of DCP, Huang et al. measured the pressure in the superficial femoral artery distal to the systemic cannula and introduced the DPC only when this pressure was less than 50 mmHg [24]. In their cohort of 26 patients, only 9 patients fulfilling this criterion required the DPC and authors report no limb ischemia in any patients, with or without DPC. These findings are interesting and warrant further evaluation of their technique and confirmation by other study groups.
\nCompared to open cut-down DPC related complications are more common after percutaneous cannulation, often due to multiple cannulation attempts causing vessel injury, extravasation, hematoma and inadvertent cannulation of the profunda femoris. In contrast, while not ubiquitously feasible, technically more challenging and more time consuming, the open cut-down allows visualisation of the artery to ensure an adequate size of the cannula, proper placement, good haemostasis and the abandonment of the site without failed attempts in case of arterial calcifications [15]. Not surprisingly, a significantly higher incidence of limb ischemia was found in patients with a percutaneous DPC compared to patients with no DPC and open cut-down DPC in a series published by the Philadelphia group [25]. In this context, it is worth mentioning the ‘chimney graft construction’ approach on the femoral artery in which a small vascular graft is placed end-to side onto the main femoral artery, thus allowing for bi-directional perfusion without obstruction of the vessel. This avoids the more complex V-A-DPC-ECLS circuit, the DPC itself and its complications [26]. However, while avoiding ischemia and advocated for small femoral arteries, in bigger vessels it may lead to distal limb hyper-perfusion [15] (Table 1).
\nPrevention of limb ischemia | \n
Implantation | \n
Cut down and under vision cannulation whenever feasible | \n
Percutaneous cannulation only with USG/Fluoroscopy | \n
Use of small calibre systemic arterial cannula | \n
Use of Prophylactic distal arterial perfusion cannula | \n
Use of Prophylactic distal venous drainage cannula | \n
Utilise contralateral limb for venous drainage cannula | \n
Maintenance | \n
Bear high suspicion for ischemia | \n
Accept low ECLS flow when possible to reduce cannula size | \n
Maintain left ventricular ejection | \n
Maintain pulsatile flow | \n
Wean vasopressors as soon as possible | \n
Selective infusion of prostacyclin via distal perfusion cannula | \n
Keep patient awake- can complain of limb pain (ischemia) | \n
Suspect limb ischemia if serum Lactate levels high | \n
Achieve and maintain good anticoagulation | \n
Monitoring | \n
Near infra-red spectroscopy in distal limb | \n
Continuous measurement of DPC flow | \n
Doppler Ultrasound of distal limb arteries | \n
Temperature | \n
Explantation | \n
Prefer open cut-down and repair of vessels | \n
Perform balloon thrombo-embolectomy | \n
Avoid groin compression | \n
Prevention of limb ischemia.
A generalised and enthusiastic approach for prophylactic DPC should be carefully reviewed and implemented only in cases with high risk for limb ischemia. These include patients with a history and signs of peripheral vascular disease, atherosclerosis, previous utilisation of groin vessels for access and female gender due to smaller vessel size as they are more prone to develop limb ischemia. In addition, young age may be an independent risk factor due to the absence of collateral vascularisation [21]. Also, there are several variables influencing the of risk of development of limb ischemia which can be addressed separately. These include low or no cardiac output resulting in loss of the pulse wave, although in patients with failure to oxygenate blood via the lung a low or absent biological output may be intended to prevent a watershed phenomenon and ensure cerebral oxygenation. High vasopressor support, peripheral shut-down and big calibre flow-occlusive systemic femoral cannulation are other factors influencing perfusion to distal limb and the development of limb ischemia.
\nAs the principal role of the ECLS is temporary cardio-pulmonary support and preservation of organ perfusion, sufficient ‘biomechanical’ output can be provided often at a reasonable mechanical flow rate without complete replacement of the biological cardiac output. Cannulation with a small calibre systemic cannula may therefore provide enough flow and preserve a pulse wave allowing for sufficient perfusion of the distal limb. A 17F systemic cannula easily provides 4–5 L/min flow with a driving pressure of around 100 mmHg. Takayama et al. compared outcome in patients based on the size of the systemic cannula and showed that a 15F size cannula, while allowing for significantly less blood flow when compared to bigger (17–24F) cannulas, resulted in no difference in use of vasoactive medication, hemodynamic parameters or laboratory values measured [27]. On the other hand, significantly less cannulation-related adverse events were observed in the 15F group.
\nPatients on ECLS support may develop severe vasoplegia requiring high dose vasopressor support to sustain arterial blood pressure for satisfactory end-organ perfusion. Efforts to maintain a negative fluid balance to reabsorb peripheral and pulmonary oedema in a bid to wean ECLS may intensify vasopressor requirement further. While maintaining central blood pressure levels, capillary perfusion of end organs, specifically the intestine as well as the limbs may be significantly reduced in such a scenario. Therefore, it is important to strike a balance between vasopressor delivery dependent blood pressure management, maintenance of fluid balance, arterio-venous perfusion pressure delta and capillary delivery, prioritising vasopressor weaning over ‘drying up the lungs’. Maintenance of good intravascular volume also allows better ECLS flow and cardiac output along with pulsatility.
\nIn essence, utilisation of a small calibre systemic femoral cannula, when possible, acceptance a biomechanical output with low ECLS flow, continued pulsatile flow and avoidance of high dose vasopressors obviate the need for prophylactic DPC insertion in patients, potentially protecting them from DPC related complications. With this conservative management and a protocol of continuous, diligent monitoring, patients that develop limb ischemia can then be detected at an early stage and treated with subsequent DPC, if necessary.
\nThe individual approach of ECLS implantation heavily depends upon the place (out of the hospital, floor, bedside or operation theatre), urgency (elective or emergency), and aetiology (PCCS, post-PCI, primary graft failure or bridge to transplant) of the cardio-respiratory failure. In patients with cardiopulmonary arrest under resuscitation or peri-arrest patients, quick introduction of ECLS through is of utmost importance in order to sustain the patient’s life. In this situation, the primary goal is the insertion of systemic arterial and venous cannulas and there may not be time for simultaneous DPC insertion. Such emergency bedside ECLS implantation in the intensive therapy unit is a scenario that usually does not offer facilities of an operation theatre making percutaneous insertion of peripheral cannulas necessary (Figure 1), often without availability of sonography to appropriately size for the smallest cannulae or fluoroscopy for intravascular positioning. In this context, it is important to note that percutaneous insertion of the DPC can be challenging in the presence of a systemic arterial cannula already in place, either due to the reduction or even absence of blood flow distal to the cannulation site or vasospasm and vessel injury during primary cannulation. Nevertheless, if it is attempted, ultrasound guidance during insertion is helpful and angiographic confirmation of DPC tip position in the superficial femoral artery should be obtained [25, 28].
\nPercutaneous cannulation.
PCCS is a scenario usually encountered after complex and long operations and has an extreme mortality. While ECLS is the only treatment option for these patients, it is important to make the decision to use it as early as possible and avoid repeated and prolonged attempts to wean the patient of CPB as these cause considerable collateral damage. ECLS should not be viewed as a last resort after all else has failed and the patient is in a catastrophic state but rather as a tool to be proactively used to ensure protection of organ function, continuous, uninterrupted sufficient perfusion and maintenance of a functioning coagulation system, thus preventing the well-known ICU exsanguination of these patients and offering both the heart as well as the patient a reasonable chance to recover.
\nFor this, CPB can be converted directly to central ECLS, using the established cannulation or to peripheral ECLS. Peripheral ECLS allows the chest to be fully closed and no re-opening is needed for explantation of the ECLS system or for cannula-site bleeding especially in these patients on anti-coagulation therapy. With the patient stable on CPB it is safe and easy to perform a cut down to the groin vessels and placement of the cannulas under direct vision (Figure 2). If necessary, DPC can be introduced simultaneously. If the myocardial function is somewhat preserved, ECLS flows should be kept at a level allowing for blood flow through the heart to maintain left ventricular ejection in order to prevent its dilatation, stasis of blood and possible atrial and ventricular thrombus formation. In severe myocardial injury, the heart can be rested with full ECLS flow without ejection. In this case, the need for ventricular decompression should be discussed. With biological no-flow, a case of high vasopressor requirement or expected longer duration of support, the DPC can introduced at the same time.
\nOpen cut-down cannulation.
Peri or post-PCI, with fluoroscopy readily available, all ECLS cannulas can be introduced percutaneously and their position be confirmed before the patient leaves the cath-lab. ECLS as a bridge to transplant in awake patients is a recent trend that offers early ambulation and avoids ventilator-associated complications [29]. However, bedside ECLS can be challenging as a cut down is not comfortable in such patients and difficult outside the environment of the operating theatre. In these patients, the systemic arterial and venous cannulae are introduced percutaneously under local anaesthesia or the patient undergoes a short analgo-sedation as full sedation may be too high risk. As a general principal, contralateral femoral arterial and venous cannulation should be encouraged, as the venous stasis and possible limb oedema caused by the venous cannula may intensify any ipsilateral arterial cannula related compromised distal limb perfusion [15].
\nContinuous diligent monitoring of the limb for any signs of ischemia is a key to allow for timely and appropriate intervention. One elegant and inexpensive method of continuous monitoring is placing an additional pulse-oximetry probe on the toes of the cannulated limb. Its reading and waveform can be compared with the probe placed on the normal limb. However, hypothermia and non-pulsatile flow may not offer reliable pulse-oximetry reading. Near infra-red spectroscopy (NIRS), routinely used and established in transcranial cerebral oximetry can be helpful in such cases and is an alternative method for continuous monitoring. It involves application of sensor pads on the legs that detects regional oxygen saturation (rSO2) continuously, representing adequacy of tissue oxygenation. It should be applied as soon as ECLS is started. The rSO2 of the cannulated limb is compared with that of the opposite limb as well as with the baseline rSO2 providing live evidence of a drop in limb perfusion (Figure 3). A reduction in rSO2 values in the cannulated limb to less than 40 or more than 25% from baseline suggest inadequate limb perfusion and mandates urgent intervention [30, 31]. Technical glitches, however, like improper sensor pads attachments should be addressed before attempting to improve distal limb perfusion. Dong and colleagues utilised the NIRS successfully in a group of ECLS patients to detect and successfully treat limb ischemia with DPC in all patients having NIRS whereas 13.9% of the cohort not monitored required a fasciotomy [31]. Indeed, NIRS may reliably detect limb ischemia before it becomes clinically evident [31, 32]. Lamb et al. suggest continuous monitoring of limb utilising NIRS and evaluation of pedal doppler signals in case of a drop in baseline NIRS values to ensure adequate distal limb perfusion [33]. If available, we suggest that NIRS should be part of the protocol for peripheral ECLS.
\nNIRS continuous monitoring.
In presence of DPC, continuous monitoring of its trans-canullar flow is the gold standard in monitoring distal limb perfusion (Figure 4). The DPC flow is dependent on a variety of factors, namely total ECLS flow, mean arterial pressure and systemic and peripheral vascular resistance, and possible thrombo-embolic occlusion in the DPC or distal artery. Therefore, any drop in the DPC flow must be correlated with these factors before any intervention. A drop in the DPC flow should also be cross-checked with the clinical signs of limb ischemia and drop in NIRS rSO2. An hourly record of the DPC flow along with other ECLS parameters should be maintained and perfusionists should be alerted if there is a significant change. Cannula or connecting line bending, thrombosis and dislocation are common non patient related reasons for decreased DPC flow. Both antegrade and retrograde blood flow should be checked by clamps on either side of DPC side-port [10]. In the absence of a side-port, the DPC may have to be disconnected to assess for backflow through the cannula and appropriate flow in the proximal line. Thrombosis in the DPC is usually accompanied by embolization into the distal femoral artery and mandates embolectomy and DPC replacement. Only in the minority of cases it can be addressed by aspiration of the thrombotic material.
\nContinuous DPC flow monitoring.
Despite continuous monitoring of limb perfusion by means of NIRS and DPC flow, hourly inspection for skin colour change, palpation for temperature, capillary return at toe tips, calf palpation and calf girth measurement for compartment syndrome is of paramount importance. Pedal pulses should be checked in the dorsalis pedis and posterior tibial artery and when not palpable a hand-held ultrasound Doppler should be utilised to confirm the flow. The flow may be graded for documentation as palpable- strong pulsatile, palpable- weak pulsatile, doppler- pulsatile, doppler- continuous flow and absent flow. Hourly recording of continuously monitored variables namely DPC flow, NIRS rSO2 are necessary to establish trends and detect limb ischemia before it is clinically apparent. Numbers and signs that may be missed during continuous monitoring can be caught in a vigilant hourly survey. Ischemia in toes is seen not uncommon, even in the presence of well-maintained DPC flow due to peripheral micro thrombo-embolization and/or vasospasm due to peripheral shut down or high dose vasopressors.
\nEarly detection of inadequate limb perfusion allows for immediate intervention to avoid its catastrophic consequences. In absence of the DPC, continuous NIRS monitoring supplemented by an hourly survey by means of clinical examination and Doppler ultrasound flow check in the distal arteries is usually adequate to detect limb ischemia at an early stage. NIRS rSO2, clinical signs and ultrasound Doppler flow in the cannulated limb should be compared with opposite limb, not to confuse ischemia with peripheral shut down and peripheral vasospasm. In patients with a prophylactic or therapeutic introduction of DPC, it is important to remember that the DPC does not guarantee adequate perfusion. Thus, continuous measurement of DPC flow, maintenance of adequate anticoagulation and monitoring of actual limb perfusion remains essential. Awake non-intubated, non-sedated patients supported on ECLS may complain of pain, tingling- numbness or stiffness with the onset of limb ischemia. An increase in lactate levels without an attributable source and acute kidney failure may be signs of subclinical rhabdomyolysis and should immediately raise suspicion of ischemia. Finally, signs of ischemia may be seen only in the toes, even with a good DPC flow due to peripheral embolization through DPC.
\nECLS is a lifesaver for patients with compromised cardiopulmonary function; however, it may instigate life-threatening complications and the incidence of complications increases with increase in duration of the ECLS. Yoe et al. found the duration of ECLS more than 7 days is a factor associated with the development of limb ischemia [23]. Therefore, weaning of ECLS should begin with recovery of vital organ function with the aim of its explantation as soon as possible. Extra caution is mandated during weaning of patients with the DPC, as the decrease in total ECLS flow decreases DPC flow that may lead to inadequate limb perfusion as well as thrombosis of the DPC. In this situation, the DPC flow should be maintained around at least 300 ml/min by applying a gate clamp on the retrograde arterial cannula. Explantation of ECLS at the end of successful weaning should be performed as an elective case in the operation theatre. The vessels are exposed and controlled with slings before removal of cannulas. Embolectomy is attempted multiple times with balloon tip catheters till satisfactory retro and antegrade blood flow is achieved. The artery is then repaired with or without a patch or an interposition graft to maintain its original calibre without flow limitation. The limb is monitored for at least 48 hours following ECLS explantation for any signs of residual or fresh ischemia.
\nTraditionally, 6 hours are recommended as a golden period for intervention in limb ischemia. In a series analysing limb ischemia in ECLS patients an additional retrograde reperfusion within 6 hours of onset of symptoms avoided amputations completely, whereas the same procedure after that period was burdened with a 20% amputation rate or permanent neurological deficit [34]. Therefore, every attempt should be made to re-establish adequate blood supply in the ischemic limb as soon as possible to avoid catastrophic consequences and residual damage (Table 2).
\nManagement of established limb ischemia | \n
Introduce distal perfusion cannula (DPC)- cut down | \n
Percutaneous DPC- Check position with fluoroscopy | \n
Continuous Epoprostenol in DPC | \n
Thrombo-embolectomy | \n
Change of cannulation site | \n
Decompression compartment fasciotomy | \n
Amputation | \n
Management of limb ischemia.
Limb ischemia due to inadequate flow in the distal artery detected at early stage ideally should be treated with the introduction of the DPC if not placed at ECLS implantation. Apart from conscious avoidance, reasons for not introducing prophylactic DPC are among others: failed percutaneous insertion, atherosclerotic plaque palpated in open cut-down and need to return to the intensive care unit for patient stabilisation. In a metanalysis reviewing 22 retrospective studies comparing peripheral ECLS with or without DPC, the presence of a DPC was associated with at least a 15.7% absolute reduction in the incidence of limb ischemia; although without any impact on the patient survival [35].
\nSeveral cannulas from an introducer sheath up to a paediatric arterial cannula are recommended in the literature for this purpose. An ideal is the one that is resistant to bending and thrombosis and offering a least resistance to flow. We found the incidences of limb ischemia and limb ischemia requiring surgical intervention were significantly higher for the introducer sheath compared with the 10–12F Bio-Medicus® paediatric seldinger cannula utilised for distal limb perfusion (30.6 vs. 15.6% and 15.4 vs. 6.25%, respectively) [11].
\nTo introduce the DPC percutaneously, the superficial femoral artery may be visualised distal to the systemic cannula via Ultrasound. If this is not possible, a cut-down insertion should be performed. If introduced bedside, especially percutaneously, the position of the DPC should be confirmed via x-ray.
\nAny ECLS circuit exposes blood to non-biological surfaces and is in itself thrombogenic. Therefore, adequate anticoagulation, usually achieved by continuous intravenous delivery of unfractionated heparin is essential to prevent complications such as thrombus formation and clotting of the circuit and stroke, limb and bowel ischemia. Conventionally heparin is delivered via a central venous catheter. As the small arteries of the distal limb are specifically at risk of micro-thrombotic clotting complications a targeted delivery of anticoagulants may offer a strategy to prevent distal ischemia. Continuous heparin delivery in the ECLS circuit before oxygenator at beginning of ECLS should be considered in any institutional protocol.
\nDue to the discrepancy in size of the aorta and distal superficial femoral artery as well as resistance between the systemic cannula and the DPC, there is a significant discrepancy in the flow rate between them, sometimes resulting in very little or almost no flow through the for DPC. In these cases, a gate clamp on the systemic arm can be helpful; however, it may cause flow turbulence, is potentially thrombogenic and increases driving pressure in the system.
\nAlternatively, and already mentioned above, Epoprostenol, a potent vasodilator, which is established in the treatment of peripheral vascular disease, can be delivered directly into the limb via DPC side-port in order to induce peripheral vasodilatation and increase perfusion. Some paediatric aortic cannulas have a side-port that can be readily used for this purpose [10]. Otherwise, a 3/8–3/8″ connector with a side-port can be inserted into the arm feeding the DPC. In some patients this may result in an increased requirement of vasopressors to maintain central arterial pressure. As a word of caution, selective infusion of vasodilators may also result in hyper-perfusion and clinically relevant oedema, especially in presence of an ipsilateral venous cannula.
\nPeripheral access for ECLS seek mainly due to urgency or bedside scenario is converted to central access once patient is stabilised or develops complication due to peripheral cannulation. One of the strategies in suspected or established limb involves shifting the arterial cannulation site followed by embolectomy and, if necessary, repair of the vessel. In many cases this may be the ascending aorta, as this offers certain advantages such as oxygenated blood supply to coronaries and avoidance of any watershed phenomenon, even in patients with compromised lung function. Also, the opposite superficial femoral artery or axillary artery may be utilised if the treating physician wants to avoid sternotomy or cannulation of the aorta is difficult. In patients with acceptable lung function and compromised cardiac function, ECLS can be converted into a uni- or bi-ventricular short-term ventricular assist device at this time avoiding the further use of the oxygenator and thus allowing for a less stringent anticoagulation regime and easier mobilisation of the patient.
\nFasciotomy is a decompression manoeuvre performed on the limb with acute compartment syndrome, a surgical emergency. Release of pressure allows reperfusion of the ischemic muscles potentially avoiding amputation. A recent metanalysis consisting 1886 patients found 10% incidence of compartment syndrome requiring fasciotomy [13]. Several authors confirm that the procedure is effective provided it is performed as soon as the diagnosis of compartment syndrome is established. It can be performed bedside under local anaesthesia [36, 37]. Four chamber fasciotomies essentially involve decompression of anterior and posterior compartment of the thigh and anterolateral and posteromedial compartments of lower leg. Primary closure of these wounds can be performed following explantation of ECLS and decrease of limb swelling.
\nA last and unfortunate resort in the management of advanced limb ischemia to save a life is to give up a limb. Irreversible ischemic damage to skin and muscles causes rhabdomyolysis, acute kidney injury, and metabolic acidosis. In such cases, amputation of the limb remains the only option to save the patient’s life. Contemporary retrospective observational studies report incidence of lower limb amputation in patients supported with ECLS between 1 to 10% [11, 13, 15, 20, 21, 38]. However, some prospective studies with utilisation of newer technology and ideas such as NIRS for early detection of ischemia and distal arterial pressure based or pre-emptive introduction of DPC reported no amputations [23, 24, 31]. However, apart from the obvious benefit of these newer techniques, patients in studies focusing on limb ischemia may have received significant additional attention and care to prevent and treat limb ischemia at early stage. This in itself may have had a profound effect, further corroborating that early detection of limb ischemia with expectant monitoring and protocol-based prompt intervention may avoid its catastrophic consequences (Figure 5).
\nProtocol for management of limb ischemia.
Care of the cannulated limb with maintenance of adequate perfusion to avoid ischemia is as important as the preservation of vital organ function. Limb ischemia plays a seminal role in the fate of a patient supported on ECLS. Vascular complications, particularly limb ischemia negatively affect survival in patients on ECLS. Expectant continuous monitoring utilising NIRS, if used, a flow monitored distal perfusion cannula and hourly surveys of flow in distal arteries and signs of ischemia are key in timely detection of limb ischemia. A prophylactic distal perfusion cannula should always be used in patients with risk factors for development of limb ischemia and can most likely be avoided in others if a small calibre systemic cannula is used. Acceptance of lower ECLS flow, maintenance of pulsatility and avoidance of vasopressors are additional important elements. Prompt intervention to re-establish adequate blood supply after suspicion of limb ischemia is essential to avoid its catastrophic consequences. The safest method of prophylactic or therapeutic introduction of a distal perfusion cannula remains the open cut-down and exposure. Percutaneously inserted distal perfusion cannulas should be checked for their position by fluoroscopy. Also, change of cannulation site and bridging ECLS to a substantive therapy should be part of any strategy for patients on ECLS. If properly integrated into an institutional protocol and adhered to, these strategies allow for successful treatment of patients in need of extracorporeal life support with low complication and high success rates.
\nAuthors are not funded for preparation of this manuscript. Authors thank Olaf Maunz for helping with manuscript editing.
\nAuthors do not have any conflicts of interest.
Lyon has always had a great tradition of orthopedic, and Charles Gabriel Pravaz was not only the inventor of the syringe, but he also created in Lyon a great orthopedic institute to treat scoliosis 200 years ago. The first Lyon brace, which was made of leather and steel, was created by Stagnara 70 years ago. It undergone a first change with the replacement of leather by polymethacrylate. This brace was used in adults in addition to surgery while waiting for the graft fusion, at a time when osteosynthesis did not have the current quality. In 2013, the use of adult ARTbrace in Europlex’O in polyamide and asymmetry allowed to avoid the plaster cast which has always been the characteristic of the Lyon management. The use of polyamide and digital allows treatment of thoracic and double major curves.
\nVanderpool et al. [1] shows that the frequency of scoliosis in adults increases steadily with age, from 6% of scoliosis after the patient reaches 40 years until it reaches 10% of the population at age 65. The sex ratio was 2 females to 1 male. It is women who have the most painful instabilities and imbalances. Their bone mass is lower than that of men with a vertebral fracture threshold at age 65. Pregnancy and menopause could be also aggravating factors [2].
\nAkbarnia et al. [3] described the key features as curve stiffness, degeneration of the discs, osteoporosis, spinal imbalance both coronal and sagittal, rotary subluxation, spinal stenosis, and higher rate of complications (pulmonary, etc.). The esthetic aspect is not negligible, and even surgery performed during adolescence does not solve everything. Edgar and Mehta [4] has shown that self-image representation and social life is different after surgery in adolescence. 82% of adult scoliosis without surgery was married compared to 60% of scoliosis operated in adolescence. O’Brien [5] analyzes the consequences of scoliosis in adulthood. He noted that for adult scoliosis abnormal physical appearance and diminished self-esteem may always be present, but breathing limitations, inability to function, and other quality of life issues generally become the driving forces for clinical examination, diagnosis, and treatment.
\nThe complications were analyzed by many authors. For Baron and Albert [6] the incidence of medical complications ranges between 40 and 86%. Local complications include infection, pseudarthrosis or failure of instrumentation, and neurological and adjacent-level degeneration or instability. Common medical complications include pneumonia, atelectasis, ileus, delirium, and cerebrovascular incidents. Smith et al. [7] studied the incidence of complications according to age. His conclusions were the following: the oldest age group (65–85 years) has nearly four times the number of minor complications and nearly five times the number of major complications when compared with the youngest age group (25–44 years). As invasive surgical therapy needs a perfect understanding of risk/benefit, Ogilvie [8] suggests that the decision to proceed with surgical treatment even if justified in many cases must be based on a thorough understanding of the anticipated benefits from surgical treatment and the risk of serious complications. These potential complications lead to multiple surgeries with results that can be less desirable than the original condition. The results of conservative orthopedic treatment are more difficult to assess. Kluba et al. [9] compares surgical and conservative treatment for degenerative lumbar scoliosis. He finds a significantly higher rate of spinal stenosis and degenerative spondylolisthesis in the group of patients with surgery. However no significant difference was evident between the two groups in terms of lumbar back pain after 4 years, respectively.
\nEverett and Patel [10] conducted a systematic review of non-operative treatment. There is indeterminate, level III/IV evidence on the effectiveness of any conservative option; level IV evidence on the role of physical therapy, chiropractic care, and bracing; and level III evidence for injections in the conservative treatment of adult deformity. The use of rigid or hard bracing in adult scoliosis is generally not recommended. This is due to the risk of muscle weakening effects from hard bracing and the fact that this could accelerate the degenerative process in some cases. Chuah et al. [11] notes that bracing may sometimes help the symptoms, but it has no effect on curve progression.
\nPain is not synonymous with deformity progression. Some stable scoliosis patient report pain, and others evolve without pain. It will be necessary to try to make the difference between the “physical” pain and the “emotional” suffering when the patient does not support his deformation anymore.
\n\n
Thoracolumbar pain often corresponds to minor joint instability.
The pain of convexity is of muscular origin.
The pain of the concavity is posterior: facet syndrome.
The lumbosacral pain is of ligament origin.
These pains respond perfectly to physiotherapy.
\nWhen scoliosis progresses, it is either (1) the evolution in adulthood of an adolescent idiopathic scoliosis, (2) a de novo scoliosis usually of discal origin, or (3) a camptocormia of muscular origin. In all cases, there may be a disc disease with sometimes rotatory dislocation, postural impairment with imbalance, extrapyramidal muscle involvement, and bone involvement (osteoporosis). In these progressive cases of instability, bracing or surgery may be necessary.
\n\n
From 20 to 30 years old, the main problem is the anatomical pain.
From 30 to 50 years old, the main problem is the discal decompensation.
After 50 years old, there are two main problems: degenerative scoliosis very rigid with arthrosis and camptocormia reducible with paravertebral muscular atrophy.
Early works on scoliosis progression in adulthood were pessimistic [12], but at this time, idiopathic scoliosis, especially rachitic infantile, is mixed with neurological poliomyelitis that no longer exists.
\nIn 2003 Weinstein published the spontaneous evolution of 117 idiopathic scolioses over more than 50 years [13]. Thoracic curves of more than 50 degrees at skeletal maturity progressed with an average of 29.4 degrees. Thoracolumbar curves between 50 and 75 degrees increased with an average of 22.3 degrees. Lumbar curves had the most progression, especially when the L5 vertebra was not well seated and when the apical rotation was greater than 33%. He does not observe a functional respiratory or painful repercussion below 70°. This angulation could be currently the functional surgical Cobb limit. Pregnancy does not change the progression of scoliosis in adulthood, except in cases of twin pregnancy.
\nIn 2007 Marty-Poumarat [14] describes two specific adult scoliosis entities: adolescent scoliosis in adult (ASA) and degenerative de novo scoliosis (DDS).
\nGroup A (ASA) = adult progression of AIS > 40° with first dislocation at 45 years. The progression can be sometimes regular, sometimes chaotic.
\nGroup B (DDS) = de novo scoliosis with low Cobb after 50°, first dislocation at 52 years after menopause. DDS is more progressive than AIS. Because DDS is a result of degenerative disc instability, it is almost always progressive. Lumbar and thoracolumbar are the most progressive degenerative curves. Duval-Beaupere and Dubousset [15] have first described the mechanism of rotatory subluxation. Following their work, many authors have insisted on the importance of the lumbo-pelvic parameters [16, 17, 18].
\nThe radiological risk factors for instability are (1) rotatory dislocation with lateral olisthesis (Figure 1), (2) L3–L4 inclination, (3) hypolordosis, and (4) increased thoracolumbar kyphosis [19, 20].
\nDe novo scoliosis with constitution of a rotatory dislocation in 2 years, then scoliosis worsening by osteoporotic cuneiformization.
The physical activity and fracture rate of adult scoliosis is identical to that of the general population, except for operated patients who have less physical activity [21]. Unlike adolescence, when bracing is systematic when scoliosis progresses, the corrective bracing indication in adults is less related to Cobb angulation but more to the instability which results in pain, abnormal angular evolution, or imbalances (Figure 2).
\nClinical imbalances in the frontal and the sagittal planes.
From a database started in 1998, we selected all adult scoliosis in which conservative orthopedic treatment has been proposed to, even if the treatment had not been achieved by the patient. Scoliosis treated during adolescence and monitored in adulthood were excluded [22]. In this case series study, we analyzed 779 patients referred for nonsurgical treatment, and we correlated three parameters: the etiology, age, and Cobb angulation (Table 1).
\nIndications ARTbrace adult (n = 779) | \nRate % | \nMean age | \nMean angulation | \n
---|---|---|---|
Rotatory dislocation (n = 361) | \n46.5% | \n59.73 y ± 13.50 | \n39.08° ± 16.56 | \n
Segmental instability (n = 150) | \n19% | \n46.03 y ± 15.49 | \n25.29° ± 12.29 | \n
Instability post-surgery (n = 86) | \n11% | \n53.09 y ± 12.91 | \n40.49° ± 15.38 | \n
Camptocormia (n = 68) | \n9% | \n69.78 y ± 12.19 | \n38.09° ± 14.23 | \n
Kyphosis (thoracolumbar) (n = 62) | \n8% | \n60.73 y ± 15.51 | \n43.34° ± 21.48 | \n
Disabling pain (n = 33) | \n4% | \n48.36 y ± 13.73 | \n36.45° ± 21.48 | \n
Spondylolisthesis and spinal stenosis (n = 19) | \n2.5% | \n\n | \n |
Main indications for adult scoliosis bracing with frequency classification.
The rate of dropout patients not wearing the brace is 17% which is not excessive, especially since the plaster cast at that time was made before the brace discouraged patients.
\nA tentative classification according to etiology, age, and angulation is proposed (Figure 3).
\nIndications of nonsurgical treatment by etiology (n = 739).
More than half of the indications concern the rotational dislocation, which is the specific complication of adult scoliosis. The rotary dislocation is visible on the CT scan with subluxation and joint narrowing on the sliding side and widening of the articular space on the opposite side.
\nOne-fourth of the indications concern disc instability, which can be considered as the early stage of rotational dislocation.
\nThe other etiologies are less frequent: lumbar-pelvic-femoral kyphosis, secondary instability under arthrodesis, root pain, and rarely spinal stenosis which requires neurosurgery. Camptocormia is linked to weakness of the deep posterior musculature [23]. The patient increases kyphosis gradually to tighten his weak paravertebral muscles. There is often an extrapyramidal context of Parkinson’s disease [23]. MRI cross sections highlight the fatty degeneration. Some authors have mentioned paravertebral myopathy [24].
\nAccording to age, there is no Cobb angle difference between patients aged 39 and 80 years old, even if we notice a slight worsening between patients aged 80 and 90 years old. It can be concluded that after 40 years, for the same angulation, the risk of decompensation does not depend on age [22].
\nIf we examine in more detail the distribution of patients according to Cobb angle, we find that Cobb angle is not a discriminating factor like aging.
\nOne of the bracing eligibility tests especially for camptocormia is self-correction by using the hands on the thighs, even if this self-correction does not last long in time. The second test of reducibility is carried out in supine position. The occipital patient must rely on the plane of the examination table. The placement of the ARTbrace is performed by the patient who stabilizes the brace at the pelvic level then unrolls the spine using the rigidity of the posterior bar and finally blocks the upper part. As for children, the “mayonnaise tube” effect of the two lateral hemi-valves completes the correction in the sagittal plane.
\nAdult scoliosis bracing is performed only in technically equipped medical clinics. Hospitalization is not essential because the use of the brace must be integrated into the patient’s environment. On the other hand, physiotherapy scoliosis-specific exercises (PSSE) is mandatory.
\nThe brace wearing time protocol is a total time of 24 hours a day during 3 weeks with a plaster cast (or digital cast) to adjust the length of the ligaments with plastic deformation and, then, at least 4 hours per day for a minimum of 6 months, including systematically for 2 hours after the practice of sports activity (Table 2).
\nManagement | \nWearing time | \nParticularity | \nFollow-up examination | \n
---|---|---|---|
First 3 weeks | \nTotal time 24/24 | \nOnly 10′ for shower, no work interruption | \nAt the end of total time without X-ray | \n
First 6 months | \n4 hours/24 | \nSystematically for 2 hours after physical activity | \nAt 6 months with X-ray | \n
6 m to 2 years | \nOn demand and 2 hours after sport | \nIn case of pain, in prevention before major efforts | \nAt 2 years with X-ray | \n
After 2 years | \nNo specific indication | \nBrace is kept for safety | \nAT 5 years with X-ray, then every 5 years | \n
Adult bracing management (Lyon ARTbrace).
Wearing the brace for a “total time” allows the patient to relearn all the gestures of daily living in a good posture, for example, the sitting writing posture with feet behind the chair and buttocks in front of the seat. The lower part of the chest touches the anterior edge of the table, and the forearms rest on the desktop.
\nThe digital cast is made in three blocks according to the deviations as in the teenager, but in deep inspiration. In many cases, only a scan in maximum corrective posture perfectly balanced is performed. The corrective posture is derived from Schroth. The sagittal plane and the frontal plane are simultaneously corrected, ensuring the overall balance of the spine. The spine is placed in maximum extension to promote lumbar lordosis and reduce thoracic hyperkyphosis. The convex hand is placed on the vertical support, the concave hand is placed on the head, and the operator supports the patient’s elbow (Figure 4).
\nDigital cast with simultaneous correction in the frontal and in the sagittal planes.
The thickness of Europlex’O used in adults is 3 mm. The digital cast is made in blocks according to the deviations as in the teenager, but in deep inspiration. The advantages are manifold: (1) The patient can maintain the maximum corrected position for a few seconds while standing; (2) breathing is controlled, and the patient can be asked to perform maximum inspiration; and (3) the accuracy of the eight structure sensors is less than 1 mm. The 3 mm Europlex’O with very high rigidity can be used instead of polyethylene. It is possible to work bare skin, but the thin optical vest in jersey allows the use of landmarks for the superposition of the three blocks. The processing with a specific software allows the creation of a positive which will be milled by a digital milling machine. The CPO has all the tools to rework on the captured shapes. After a period of 3 weeks of “total time,” the brace is worn for a minimum of 4 hours/24 for 6 months, then on demand.
\nInstability pain management is obtained by:
A skin contact of the brace like a massage.
A discharge of the lumbar discs and vertebral body by the “composite beam effect.” The discharge of 30% is provided by the waist grip in the frontal plane, while the sagittal plane is free to prevent an excessive abdominal pressure.
A rebalancing spine in the frontal and sagittal plane.
A limitation of extreme postures.
The rigid brace is an active brace. The patient spontaneously tends to contract the paravertebral musculature in the sense of self-active axial elongation. Associated physiotherapy is however essential.
\nThe brace can reshape the waist. It can also symmetrize the body for the largest scoliotic curves by the adjunction of a foam cushion in the concavity.
\nThe lock automatically performed by the brace facilitates motion and strengthens the musculature of the lower limbs. There is also a better mobility of shoulder girdle because of the stabilization of shoulder blades in a more physiological position.
\nThe wearing of a rigid brace is obligatorily supplemented by physiotherapy scoliosis-specific exercises. The ideal is to act when the spine begins to disrupt or becomes painful, indicating instability. The therapeutic progression is usual:
\n\n
Analgesia.
Preventing muscle atrophy lumbo-abdominal strengthening in isometric and improving paravertebral deep muscles (Figure 5).
Promoting more flexible self-active axial elongation (Figure 6).
Correcting 3D spine balance: in the frontal plane, rebalance of the occipital axis; in the sagittal plane, restoration of sagittal lumbar and pelvic curvatures (pelvic anteversion and lumbar lordosis (strengthening of the iliopsoas)); and in the horizontal plane, dissociation of pelvic and shoulder girdles.
Developing compensation at the lower and upper limbs: relaxation under pelvic extension (hamstring stretching) (Figure 7).
Stimulating the mechanisms of postural correction with reharmonization of the paravertebral tensions (muscular chains) (Figure 8).
Isometric strengthening of the deep front line with correction of thoracolumbar kyphosis.
Self-active axial elongation in closed kinetic chain (hands/espalier).
Posture of stretching posterior chains of the lower limbs.
Reharmonization of paravertebral tensions with mirror control.
The main differences between adolescent and adult scoliosis are demonstrated in Table 3.
\nPhysiology and biomechanics | \nAdolescent | \nAdult | \n
---|---|---|
No specific pain in adolescents. Painful instability in adults | \nNo pain relief techniques | \nPain relief techniques, massage, and others | \n
Flat back in the teenager. Loss of lordosis and hyperkyphosis in adults | \nRestoration of physiological sagittal curves (arms projected forward) | \nPhysiotherapy in lumbar lordosis (hands crossed in the back) | \n
The brace aims to stiffen the spine (rust the spring). Spine mobilization in adults can lead to curve progression | \nSpine mobilization during cast and brace in all the amplitudes | \nNo spine mobilization beyond the corrected posture | \n
Strengthening muscle fibers (adult sarcopenia) | \nReinforcement of the reticulospinal system (aerobic) | \nReinforcement of voluntary musculature in anaerobic metabolism. | \n
Translation along the vertical axis | \nActive axial self-elongation in standing position (grand porter) Open kinetic chain | \nActive axial self-elongation trunk bent at 90°, hands resting on the espalier. Closed kinetic chain | \n
Lumbo-pelvic region | \nOpening the iliolumbar angle | \nAnterior lumbo-pelvic strengthening (iliopsoas, abdo, quad) | \n
Lower limbs | \nNo specific stretching. Global training without excessive resistance | \nStretching of the posterior chain at the level of the lower limbs | \n
One-third of the thorax volume develops after the end of the stature growth | \nResistance breathing exercises (inflating a balloon) | \nBreathing exercises in forced expiration | \n
Main differences between adolescent and adult scoliosis Lyon method physiotherapy.
First week. Physiotherapy is for analgesic purposes and is performed in the supine position by soft traction and a muscular work with irradiation of the short external rotators. Breathing is controlled because of the limitation of the abdominal expansion. The thoracic breathing is facilitated by the mobilization of the intercostal muscles.
\nSecond week. The iliolumbar angle is mobilized to adjust tension at the iliolumbar level. The hump can be modeled with progressive closure of the ratcheting buckle. Physiotherapy is performed in sitting position.
\nThird week. Physiotherapy is more global, more general, more tonic, and stronger. The lever arm of shoulder and pelvic girdles is used. The sessions are made in standing position.
\nWe first determine the sagittal direction of muscular work, usually lordosis for lumbar and thoracolumbar scoliosis. For each session there is a progression from supine to sitting and standing position.
\nRib hump erasing. Having refocused the spine from the vertical in the sagittal plane and in the frontal plane, the patient is asked to lengthen from the brace at the rib hump level. The movement is controlled manually. The trapezius muscle is relaxed.
\nSagittal tensioning girdles. The aim is to relax the posterior chain muscles while avoiding cervical lordosis. The exercise is made with control of inspiration breathing.
\nSelf-axial lengthening. The patient straightens his head, his hands resting on the anterosuperior part of the brace. It can be done in a sitting position using a proprioceptive system. When the head is at the correct high position, a sound and a light stimulate the patient. If the spine is close to a wall, a cushion at the cervical level must be stabilized by the patient. This exercise can be completed with the upper limb extension.
\nPosture memorization. Exercise can be more complete with the work of the lower limbs. The starting position is knees bent for self-axial elongation of the spine; the upper limbs are fixed on the espalier. The patient is asked to stand up to a position of global extension. This exercise improves the quadricep muscle that will be key to saving the spine.
\nStrengthening of weak muscles: quadriceps and abdominals. The exercise will be started in a supine position. The pelvis is locked in the brace posture. This work is associated with an isometric tension of the posterior chain and expiration. This exercise is completed by a stabilization of the shoulder girdle with a stick and control of the rotation of the hip by a ball between the knees. The solicitation is obtained by an oblique manual push on the side of the patient. By gradually lowering the legs, it also seeks the rectus femoris. The anterior chain has been stretched, and it is in this posture of extension that strengthening is performed with isometric contract-relax muscular work.
\nStretching strong muscles: hamstrings and short external rotators. It starts at the lumbosacral junction with pelvic-femoral, tricep, and hamstring stretch in lumbar lock controlled by the brace. It also stretches the psoas and rectus femoris. We can stimulate muscular work by manual push on the pelvis. The buttocks and the latissimus dorsi are solicited in the prone position, emphasizing the control of the cervical lordosis. When sitting, it stretches the anterior chain by adjusting the hip. Stretching can also be controlled at home on a stair. The exercise at the bar also allows global stretching.
\nProprioceptive rehabilitation. On a Klein Vogelbach ball, it transfers the body weight in all plans, with emphasis on relaxation of tone and breathing control. The muscle tonicity is improved by changes in posture, standing, and lying and by the addition of loads. The global proprioceptive work prepares the patient for the definitive weaning of the brace.
\nIn case of major disc degeneration, physiotherapy will be conducted in physiological lordosis, rather than in a standing position.
\nIn case of major facet joint degeneration, physiotherapy will be conducted in physiological lordosis in prone position, legs bent or in a sitting position.
\nIn case of leg length discrepancy, the feet imbalances adjustment with a shoe lift of 5 mm if it improves both pelvic and spine alignment.
\nIn the sagittal plane, one can use small high heel stubs from 3 to 5 cm to reduce a lumbar kyphosis.
\nThe food control helps to reduce overweight.
\nThe postural control concerns mainly the workstation.
\nThe regular practice of physical activity outside is essential. It is necessary to insist on the strict brace wearing during 2 hours after the sports activity.
\nExcessive mobilization of passive structures may lead to a progression of scoliosis, so the hyper flexibility is avoided and a position closest to that of the brace is better.
\nHigh thoracic breathing is less efficient than the usual abdominal breathing, and we must insist on improving the vital capacity for thoracic or double major curves. If lumbar scoliosis is treated, the risk of an increase of scoliosis during inspiration is low; however, breathlessness is to be avoided.
\nAs the brace can be asymmetrical in the direction of the rebalancing of the spine, it will, however, always ensure the balance of the shoulder girdle.
\nWhen the body is fully developed, we advise high-impact sports such as running and dance, to favor the fixation of the calcium on the bone and the constitution of an important bony mass.
\nIn a specific way when ribs are asymmetric, we recommend avoiding deep and quick inhalation which favors the vertebral rotation and therefore the breathlessness during the practice of sports.
\nFor lumbar curves, we advise, as well, against the quick flexions of the trunk forward or the position extending with an anterior flexion of the trunk.
\nDuring the period of maximal tensegrity up to 40 years, all sports can be performed at a high level as long as the spine is straight.
\nAfter 40 years, decreased intervertebral disc height and sarcopenia reduce the body’s performance.
\nAfter 65 years, osteoarthritis is predominant. Swimming avoids overloading the lower limbs and helps maintain lumbar lordosis (Table 4).
\nAge (girls) | \nPhysiology | \nActivity (example) | \n
---|---|---|
15–21 years | \nBefore complete bone mass | \nJogging and running Axial impact and spiral chains | \n
21–40 years | \nBefore sarcopenia and osteopenia (tensegrity) | \nFitness, sports reinforcing spiral chains | \n
40 to retirement | \nBefore extrapyramidal weakness (postural system) | \nNordic walking, cycling | \n
Retirement | \nOsteoarthritis, Pisa syndrome | \nSwimming | \n
Sports activity according to the age.
Immobilization braces made of polyethylene have been used for more than 50 years in case of mechanical pain. They complement classical physiotherapy by reducing load by 30% at the lumbar spine. We specifically studied the 158 patients with 5-year follow-up from our prospective database [25].
\nThe principle of bracing is completely different from that of adolescent scoliosis. Indeed, we try to:
Decompress the discs with the “sandglass effect” lifting the trunk under the ribs and transferring the load on the pelvis.
Rebalance the spine in both the frontal plane and in the sagittal planes, mostly by recreating lumbar lordosis.
Relieve pain by the analgesic effect of rigid low back brace.
A specific frame is used to stabilize the patient in the most corrective posture in the frontal and the sagittal plane.
\nFor those patients who had a progressive scoliosis, Cobb angle is stabilized or improved by more than 5° in 80% of cases, and only 20% of scoliosis remain candidates for surgery [25].
\nThe frontal and horizontal clinical parameters are improved, but not the sagittal parameters with the forward trunk projection (Figure 9).
\nInsufficient correction in the sagittal plane.
The sternoclavicular support is poorly tolerated, and due to reduced dexterity in the older person, lateral closure is a handicap for elderly patients, even if adaptations are possible, that is why we currently use the 3 mm Europlex’O.
\nInstability in adulthood is frequent, and surgery is the most frequently offered solution despite the high rate of complications, as there was no alternative to date for thoracic and thoracolumbar curves. Only overlapped bivalve polyethylene braces were used for lumbar scoliosis with good frontal stabilization but no control in the sagittal plane (Figure 9). The ARTbrace in Europlex’O which allows an average reduction of 70% for the children has been used since 2015 in the adult for all the deviations.
\nThe results of a consecutive series of 62 patients (6.2% of all ARTbrace patients) were treated between 2015 and 2016, as an alternative to surgery.
\nNine patients (15%) which constitute the dropout were not seen at 6 months, which is very little considering the general condition and age of patients. The percentage of dropouts is identical to the previous series of lumbar curves treatments. Despite the very high rigidity, Europlex’O which needs a precision of 1 mm is therefore as well tolerated as polyethylene.
\nIn the frontal plane, the average in-brace reduction is 27%, slightly higher for lumbar and thoracolumbar curvatures. The reduction to 2 years without brace is 15%, and especially the symptomatology of instability disappears. It is now possible to stabilize all thoracolumbar, thoracic, and double major scoliosis (Figure 10).
\nReduction in the frontal plane after decompensation upon arthrodesis.
In the sagittal plane, the average in-brace reduction is 32% and at 2 years without brace of 25% (Figure 11).
\nCorrection of kyphosis in the sagittal plane.
In the horizontal plane, some characteristic case study with EOS 3D confirms that adult ARTbrace is indeed, as in the child, a detorsion brace. Adult ARTbrace is the only brace to correct kyphosis and thus compensate for the insufficiency of polyethylene whose sternoclavicular support was not tolerated (Figure 12).
\nEOS 3D confirms thoracolumbar spine detorsion in ARTbrace.
Adult deformity is a major demographic health issue in the geriatric population. Surgeons are often very conservative in the treatment of adult scoliosis because of the complication rates associated with the surgeries and the marginal bone quality endemic to this population. Medical complications are a major concern in adult spinal deformity surgery [26]. The incidence ranges between 40% and 86%, but there is indeterminate level III/IV evidence on the effectiveness of any usual conservative care option. There is currently a lack of consensus on the most efficacious conservative treatments for adult deformity.
\nVery few results have been published concerning scoliosis adult bracing. Most of them only concern low back pain [27, 28]. Pain is the usual reason of medical consultation. Pain means instability when combined with the following clinical signs:
Frontal and sagittal Imbalance. The lumbar kyphoscoliosis is due to pelvic retroversion. The hips are extended under a retroverted pelvis, femurs were oriented downward and forward, and knees and ankles compensate with flexion deformity. Pelvic retroversion is limited by osteoarthritis of the hip, flexion deformity of the knee is poorly tolerated, and the patient will use a walking stick to walk. The thorax can enter in conflict with the pelvis at the concavity level pushing the viscera down. The patient suffers from breathing difficulty; digestive disorders are common and promote abdominal hypertension and sphincter disorders. The loss of lumbar lordosis has multiple causes: a decrease in the anterior height of the disc, hypertrophy of the facet joints and spinous process increasing the posterior height, and loss of extensors muscle strength [29].
In the horizontal plane, there is a rotation of the shoulder girdle as if the patient looks on the concave side of thoracic scoliosis. The pelvis is drawn by lumbar scoliosis. The convex hemi-pelvis moves back, and the hip is placed in internal rotation, while the concave hemi-pelvis moves forward, and the hip is placed in external rotation.
On each occasion when examining a patient at least every 5 years, verification X-ray is necessary in order to define a progression while being aware that in many cases the progression is chaotic.
The most characteristic sign of decompensating is the disc height loss that can sometimes exceed 10 mm. The disc corruption results in loss of physiological lordosis and ligament instability by hypermobility.
The losses of the gluteal muscles are very distinct when we make the plaster cast. It explains in part the pelvic retroversion; the spine tends to relocate along the line of gravity.
Muscular atrophy is a common criticism for rigid braces. In fact, the conservative orthopedic treatment does not suffer approximation. Its teamwork incorporates a specific physical therapy, the continuation of normal activity, and the practice of regular physical activity. No patient is wearing the brace for pleasure. The risk of overtreatment is zero.
\nUsually the total time bracing relieves pain, and the partial time bracing extends the improvement obtained. When the patient is not relieved, we can discuss the surgery with better arguments. The nonsurgical treatment treats the cause of lumbar instability mainly by discharging the pressure in the disc and stabilizing the lumbar area in lordosis to restore the tensegrity of the spine.
\nThe esthetic improvement of the rib hump and asymmetrical waist is logical; the orthopedic brace is the best way to remodel a trunk. The cosmetic result continues 5 years after starting the treatment, with improvement of the rib hump measured with the plumb line and the Bunnel angle of trunk rotation (Figure 9).
\nThe nonsurgical treatment can fit into a therapeutic progression. The indications may be progressive: observation, physiotherapy, medicine, conservative orthopedic Treatment, and surgery.
\nThe good surgical indications concern the degenerative scoliosis not relieved by bracing, or relieved by total time, but insufficiently by partial time and especially if there is a spinal stenosis. It can also be used to complete surgery if remaining instability.
\nThe Greek study [30] associating Schroth and Chêneau brace shows that patients have great difficulty to follow the protocol. For the quarter of patients following the protocol, the results are correct on pain and posture, but in 39% of patients, Cobb angle continues to increase.
\nJosette Bettany [31] confirms that for adult scoliosis, there are only a few studies on the effectiveness of PSSEs and a conclusion cannot yet be drawn. Recently a RCT proves the effectiveness of a motor and cognitive rehabilitation [32].
\nThe motivation of the patient is fundamental. The brace should be designed as a tool to facilitate physiotherapy.
\nThe use of an instantaneous and accurate CAD/CAM is better because the adult patient can only maintain the corrected position for a few seconds.
\nThe scan is made in deep inspiration to not limit the vital capacity.
\nThe management is 4 hours a day including systematically for 2 hours after any physical activity. Physiotherapy is even more important than during adolescence [33].
\nThe frequency of adult scoliosis makes it a public health problem. The new digital technologies have changed the adult scoliosis bracing, and conservative care in general may be a helpful option for adult deformity, but evidence for this decision was lacking. Lyon nonsurgical treatment is effective and offers new perspectives to adult scoliosis bracing. Not only does the brace relieve pain and support the spine, but for the first time, it corrects deviations in the frontal, sagittal, and horizontal planes. Immobilization braces in polyethylene allow a treatment of the cause of pain without side effects. Worn a few hours in the day, they complement physiotherapy. The first results confirm the excellent tolerance of Europlex’O adult ARTbrace with its ease of implementation and corrections unmatched to date in adults. These corrections make it possible to restore stability of the deviations without surgery. Adult scoliosis bracing as an alternative to surgery could be possible. Initially reserved for the most severe cases, this management deserves to be more widely used for adult scoliosis. The increasing number of CPO using the most modern CAD/CAM technologies should facilitate research in the field of very high rigidity.
\nThanks to my daughter Agnès Thornton de Mauroy, for proofreading in English.
\nARTbrace | asymmetrical rigid torsion brace |
ASA | adolescent scoliosis in adult |
CAD/CAM | computer-aided design/computer-aided manufacturing |
CPO | certified prosthetist/orthotist |
CT scan | computed tomography scan |
DDS | degenerative de novo scoliosis |
EOS | low-dose X-ray imaging |
MRI | magnetic resonance imaging |
PSSE | physiotherapy scoliosis-specific exercises |
RCT | randomized controlled trial |
IntechOpen publishes different types of publications
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