Lyon Brace. 1 Clinique du Parc : 84 boulevard des Belges Lyon (FR)

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1 Lyon Brace Jean Claude de MAUROY a.1, Paule FENDER 2, Biagio TATO 3, Piera LUSENTI 4, Gioacchino FERRACANE 5 a MD President of the European Spine Center Abstract. During 60 years, the impressive progress of the scoliosis surgery have hidden the development of the conservative orthopedic treatment. The stabilization of the scoliosis, which implies the safeguarding of a spine as mobile as possible, remains a valid objective. The Lyon Brace management combines 3 techniques A reduction of the scoliosis using a plastered brace fixed on an EDF (Elongation Derotation Flexion) frame by Cotrel. It carries through a flow of the musculoligamentar structure of the concavity. A contention by Lyon Brace. The orthesis without any cervical superstructure is adjustable, symmetric, see through and active. The elongation between the two scapular and pelvic girdle leads to a disc decompression which makes easier the 3D correction of the curves. The individual moulding (custom made) is actually electronic using a full 3D imaging system by Orten. To every 14 types of Lenke s classification matches a specific blue print. A specific physiotherapy combining the consciousness of the deformity, suppling up of the retracted elements of the concavity, compensatory suppling up of the girdles, improvement of the vital capacity based on exhalation, reharmonisation of the static, static strengthening in order to facilitate the ability to be still in a corrected position, kyphotisation proprioceptiv exercises to stimulate the maturation of the postural system. We advise to practice sport during all the treatment. The long term follow up confirms a global effectiveness indication of 0,89 with the rib hump declining by half. When we take care of the scoliosis below 45, we can avoid the surgery in 98% of the cases. In France 60% of the families agree with this stringent treatment which becomes easier thanks to its ambulatory realization and the excellent formation of the partners, the physiotherapists and the orthesist. 1 Clinique du Parc : 84 boulevard des Belges Lyon (FR) 2 CHR de Mulhouse : 20 rue Laennec Mulhouse (FR) 3 Medicasud : Via della Resistenza Bari (I) 4 Studio Lusenti : Stradone Farnese Piacenza (I) 5 Centre Lionese : Via Ricasoli Palermo (I)

2 Introduction The Lyon Brace was created by Pierre Stagnara in [8][10] It is an adjustable rigid brace, without any collar. (figure 1) Figure 1. Milwaukee and original Lyon brace The brace is : Adjustable on seven centimeters of growth, it s efficient. We do not need to change the brace every six months. Active: Because of rigidity of the plexidur structure, the child is stimulated. The active axial auto correction decreases the pressures. Disc decompression: It is the consequence of the Adjustable. The effect of extension between the two pelvic and scapular girdles decreases the pressure on the intervertebral disc and allows a better effectiveness of the pushes. Symmetrical: In addition to the esthetic aspect, the brace is much easier to build. Stable: The stability of both shoulder and pelvic girdles facilitates the intermediate corrections. Transparent: Usually, it is not necessary to use the pads, we can thus control directly on the skin the pushes, stops, drives and reliefs. The Lyon brace management consists of: a time of reduction by one or two braces realised in an EDF frame (Elongation, Derotation, Flexion) by Cotrel. [1] a contention thanks to the Lyon Brace a specific rehabilitation complementary to the pursue of a sport activity almost normal

3 1. THE PLASTER CAST: The plastered brace is nowadays realized in ambulatory (day hospital). It provides many advantages. The plaster cast: - gets the skin ready to improve the tolerance to the orthesis, - allows a maximal reduction when the child is more flexible, - enables to predict the success of the conservative orthopedic treatment when the reducibility is more than 50%, - realizes a flow of the musculo-ligamentar structures of the scoliotic concavity, - cannot be taken off the child, that avoids all the conflict with the parents. The brace experience will therefore be more positive. Figure 1. Plaster cast in Cotrel s frame The technique was described by Marc Ollier. [6] It is carried out in an Cotrel s frame of reduction allowing the Elongation, Derotation and Flexion (EDF). [1] This frame comprises in longitudinal axis, a system of pelvic traction independent for each hemi pelvis and a system of cervical traction with dynamometer. Laterally one has on the right and on the left 3 adjustable bars of inflexion and derotation, 2 low bars, 2 medial bars in the plane of the child and 2 high bars. On each bar, mobile cursors facilitate the fixing of the soft tapes. The child is prepared with the physical therapist by supplings. The thorax of the child is covered with 2 jerseys; the first jersey of 20 cm is wider to cover the edges, the 2 nd jersey of 15 cm encloses the child well and makes it possible to avoid the creases. One slips at the pelvic level between the 2 jerseys 2 beveled square felts of 15 cm side to protect the iliac crest. The child is placed in the frame lengthened in a lying position on a strong removable ticking band. A transverse metal bar is placed at the lower end of the sacrum, and another under the head of the child. Pelvic traction then is installed and one sets up the cervical traction. Axial traction is controlled by a dynamometer. This traction will always be weak, approximately 12 Kilograms (twice the weight of the head). An excessive traction makes lateral bending difficult, derotation and especially kyphotisation; it is interesting only for one important angulation exceeding 40. Installation of the ticking tapes: If we take the example of a right thoracic and left lumbar double-major scoliosis, the technique with 4 tapes is used. The first tape from 20 to 25 cm wide is placed under the thoracic rib hump, its horizontal lower segment leaves on the left concave side, it is rolled up upwards i.e. from the spine towards the anterior part of the thorax, it is reflected in an oblique way on the higher bar of the frame on the left concave side.

4 The second tape, about 20 cm wide is placed on the level of the lumbar rib hump in reverse order, i.e. that the lower horizontal segment leaves of the right concave side and is rolled up upwards, carefully marking the iliac crest and the fold of the waist protected by the pelvic felt. It reflected at the level of the abdomen in an oblique way on the higher bar of concave right side of the frame. It can be also reflected vertically if one seeks a lordosis effect. The third tape, about 15 cm wide is placed on the axillary right level; it produces a counter-push and rebalances the spine. It is symmetrical with the lumbar tape. The fourth tape, about 5 cm wide is placed on the level of the pelvis. It is essential each time there exists a coronal pelvic tilt. It is a tape of purely horizontal shift which surrounds the right hemi-pelvis. One makes a node on the level of the left trochanter for reasons of facility of rolling out the tapes and one fixes it on the left medial horizontal bar. One puts in partial tension the ticking tapes to balance the child, and then we place 2 beveled longitudinal felts of 5 cm thickness, 25 cm broad and 60 cm length under the ticking tapes. The felts must largely overflow on the axillary level. Then one carries out the setting in final tension while being progressive, by alternating inflexion-derotation and axial traction without exceeding 12 kilos, and while making sure the spine is kept balanced in axial plane. When the spine is well balanced, the plaster tapes are unrolled in a derotation way i.e. like the ticking tapes. One uses initially 2 circular tapes of 20 cm broad to cover completely the ticking tapes. Then, 4 plaster splints of 30 cm broad are placed forward, backward and laterally. We cut out the circular tapes carefully all around the ticking tapes. 3 Circular tapes of 20 cm stabilize the cast definitively. Making the plaster cast, one carefully models the counter anterior rib hump on the left and one try to improve kyphosis on the level of the rib hump by raising a little the shoulder girdle, this is why we prefer on the axillary level a ticking tape reflecting itself on the high bar. One can also raise a little the bar of cervical traction to carry out an effect of hammock. The plaster cast dries in the frame during approximately 10 minutes, then the child is standing up and the first cuts are carried out in upright position. The physician delineates trim lines according to the X-rays. On the level of the pelvis, one largely releases the inguinal fold to allow a 90 flexion of the thighs. On the level of the shoulder girdle, cutting is asymmetrical to release the right arm of the child and to allow him more functional independence, but especially to facilitate the rehorizontalisation of the upper limit vertebra. On the level of thoracic and lumbar concavities, one cuts out a window intended to facilitate maintenances of skin and to allow a possible felting of the rib humps. At the abdominal level, a triangular window with xiphoidean peak facilitates maintenances of skin and makes it possible to check the stomach in the event of gastric dilatation. At the thoracic level, one releases the chest by reinforcing the stabilization of the chondro-costal band and the sterno-clavicular support.

5 2. THE LYON BRACE 2.1. Description type The Lyon brace for a thoracic scoliosis or double major scoliosis. Figure 2. Lyon Brace - Frontal view Figure 3. Lyon Brace - Back view It is made from top to bottom : - a pelvic basis insuring the optimal stability of the orthesis, - a lumbar shell T12-L4 either independant, or extending at the abdominalchondro-costal level, - a thoracic shell at the level of the scoliotic convexity, - an opposite thoracic shell used as a counter push, - we can eventually use little crutch to balance on the side of the scoliotic convexity. The shells are fixed on two masts, the posterior and the anterior one. They have some hem made for the adjustement and this enables an adaptation of 7 cm during the growth. The plexidur shells realise according to the application : - a stop, - a drive, - a push. For esthetical and mechanical reason, we avoid as much as we can the pads under the shells.

6 We realise a lumbo-sacral lordosis in order to favor the thoracic kyphotisation Force couples Rotational deformity is an important component of scoliosis. In addition to emphasizing lateral curve correction, the Lyon Brace emphasize correction of rotational deformity. We believe that the application of rotational forces is potentially much more effective when force couples are used. Thus, for every rotational force applied another force opposite the desired center of rotation, in the same rotational direction, is applied to enhance the rotational force. Thus an anteriorly directed derotating force in the lumbar spine is counter balanced by (coupled with) a posteriorly directed force in the anterior abdomen. (figure 4) Figure 4. Derotating force couples Figure 5. Medial gibbosity pad At the thoracic level, it s possible to add a pad on the medial side of the rib hump. (figure 5) 2.3. THE VARIANTS Lyon Brace for a lumbar scoliosis. He was created by Michel & Allègre. [5] It is made of three components: - An ilio-lumbar push (T11-L4) on the convexity, the illiac support is horizontal and enables an extension effect - A tochanterian semicircle at the concavity level. - A thoracic push (T6-T12) on the concavity side. (figure 6) Figure 6. Lyon brace for a lumbar curve Lyon Brace for a thoraco lumbar curve It is only made of one large thoraco lumbar push T6-L2 at the level of the convexity. No lumbar shell.

7 Soft Lyon Brace The material use is polyethylen for a neuro-muscular scoliosis Elastic Lyon Brace The thoracic plastic shells are replaced by elastic strap. They are used in case of major obesity. 3. PHYSIOTHERAPY 3.1. The principles - No complex material. All the exercices have to be repeated at home. - No sportive counter indication. The sport practiced by the child must be continued by adapting if necessary the sportive gesture (avoid the deep quick inspiration, and the flexion of the trunk forward) and by completing if necessary the sportive activity thanks to physiotherapy. - The exercices are symmetric in the frontal plane. - No chapel and miracle exercice. Choosing the best technical way for every child, at every age, and every therapeutic sequence. - No revolution, therefore but an evolution in the exercices which are repeated few minutes a day at home. - We treat a child and not a scoliosis or an X-ray. The look of the child is fundamental. [9] 3.2. Objectives, means, obstacles Table 1. Physiotherapy during the Lyon Brace treatment OBJECTIVES MEANS DANGER-CARE Modification of the spoiled body image of the scoliotic When we first see the patient, back and vertical height difference pictures are shown to the child He has to be conscious of the deformity thanks to the mirror or a video tape The cortical representation of the back is weak and damaged by the fast growth, but let s be careful not to devalorate and depreciate the image of the body Suppling up of the retracted elements of the concavity Stretching posture (Mézières, RPG) The rigidifying scoliosis curve may be a natural element of stability. An excess of the suppling up can lead to a progressive revival of the scoliosis.

8 Dynamical mobilization In some double curves case, the mobilisation is the same on the right and on the left, in fact the bendings show us that 80% of the movement happen in the correction sense and 20% in the worsening sense. Manual modeling of the vertical height difference Suppling up of the griddles Segmentar and analytical correction of the deficit of the extension of the hip measured by Biot at 43%, since the youngest time of the patient Be careful not to favour the flat back. The support has to happen on the internal side of the rib hump. A cushion is put under the left chondro costal canopy and the transversal movement leads to exhalation. The girdles have to compensate Improvement of the vital capacity Saving of the spine Diminution of the mechanical constraint on the axis Reharmonisation of the static Strengthening of the muscle in order to make the behavior in a corrected position easier Highering of the VEMS Blow a balloon every night Development of the compensation at the girdle level and the limbs on a trunk which is still close to vertical Repositioning of the head on the gravity line in the frontal and sagittal plane. Exercice to carry big charges. We look for the global balance, the sand pack must stay on the head, the harmony and the movement coordination. The walk must be synchronised with breathing. For lumbar scoliosis and thoracolumbar: learning of the shift. Reinforcing of the fibers of the deep paravertebral muscle structure and muscles stabilizing the girdle such as the psoas, the abdominals and the pectorals by powerful slow static contraction supported in a corrected position. The deep inspiration favours the rotation (Geyer) thus slow inspiration and quick exhalation. A pelvis unbalance or of the scapular girdle can compensate a scoliosis, we have to respect them. All types «C» of Lenke, the opening of the illio-lumbar angle goes in the direction of the accentuation of the lumbar curve. In the sagittal plane, we have to avoid favouring the lordosing vertebral rear. «The brain ignore the muscles and only know the movement» In the frontal plane, The exercices are symmetric because we do not know the role of the asymmetry concavity convexity. In the sagittal plane, the anterior flexion increase the rotation, therefore we have to strengthen in a neutral position. No body building which concerns the superficial muscle structure.

9 The 24 hours of the back : adaptation of the scoliosis to the environment and of the environment to the scoliosis Stimulate the maturation and the balancing postural system Physiological valorisation Stimulate the global mobilisation of the spine in an automatic way Psychological valorisation Well being and self confidence Control of the sitting position when listening and writing according to the morphotype Dealing with the school bag Proprioceptiv rehabilitation kyphotisation from : Feet sensors, ocular sensors, cutaneous sensors Sport practice Coordination of the gesture, harmony of the move To be upbeat with the scoliosis «The scoliosis is not a disease but a symptom» Some patients have a postural reflex when there is an unbalance situation, which leads to a worsening of the scoliosis 3.3. Lyon Brace Indications Magnitude of the curves : - 20/30 a reducer plastered brace during a month, the orthesis must be wore at night. Weaning at the end of the statural growth. - 31/40 two plastered braces lasting one month and wearing of the orthesis 20 hours a day. Weaning one year after the end of the statural growth. - 41/50 Two plastered brace lasting two months each and wearing of the orthesis 23 hours out of 24. Weaning 18 months after the end of the statural growth. - > à 50 it is possible to realise a Lyon treatment waiting for surgery. Weaning two years after after the end of the statural growth Children age: The fragility of the thorax before the ephebic growth leads us to choose the Milwaukee barce. The best indication concerns the infantile and juvenile scoliosis. When the statural growth is over and waiting for the bony maturity we can use non adjustable Chenau brace Contra indications to bracing Juvenile and infantile scoliosis to avoid a tubular thorax. Sever thoracic lordosis which treatment is usually surgical. The waiting treatment with Lyon barce will be focalized on the lumbar curve to limit the more we can the fusion of the lumbar vertebras. Major psychological reactions.

10 The Lyon conservative treatment is the most elitist, but when the child and the family accept the plastered brace, The compliance is maximal. 4. Brace design blue print. We will use Lenke s classification. To every 14 types of curves one specific blue print is going to match. In a case of electronic moulding according to Orten s process, the specific blue print are corrected automatically. (table 2) The specific modifications: erase, cut, surfacing, reload, smoothing, are done automatically. The bending of the bars in the sagittal plane will be suitable according to the sagittal pattern. Table 2. Blue print according to Lenke s classification 1A Lyon thoraco-lumbar 3 points high Without axillary balance support Right Thoraco-lumbar Push T5-L2 Left Thoracic Push T4-T7 1B With lumbar stop Without axillary balance support Right Thoraco-lumbar Push T5-L1 Left Lumbar stop L1-L4 Left Thoracic Push T4-T8 1C With lumbar drive Without axillary balance support Right Thoraco-lumbar Push T5-L1 Left Lumbar Drive L1-L4 Left Thoracic Push T4-T8 2A Lyon thoraco-lumbar 3 points high Right Thoraco-lumbar Push T8-L2 Left Thoracic Push T5-T7 Right axillary balance support

11 2B With lumbar stop Right Thoracic Push T8-L1 Left Lumbar Stop L1-L4 Left Thoracic Push T5-T8 Right axillary balance support 2C With lumbar drive Right Thoracic Push T8-L1 Left Lumbar Drive L1-L4 Left Thoracic Push T5-T8 Right axillary balance support 3A With lumbar stop Without axillary balance support Right Thoracic Push T5-T12 Left Lumbar Stop L1-L4 Left Thoracic Push T4-T7 3B With lumbar drive Without axillary balance support Right Thoracic Push T5-T12 Left Lumbar Drive L1-L4 Left Thoracic Push T4-T7 3C With lumbar push Without axillary balance support Right Thoracic Push T5-T12 Left Lumbar Push L1-L4 Left Thoracic Push T4-T7 4A With lumbar stop Right Thoracic Push T8-T12 Left Lumbar Stop L1-L4 Left Thoracic Push T4-T7 Right axillary balance support

12 4B With lumbar drive Right Thoracic Push T8-T12 Left Lumbar Drive L1-L4 Left Thoracic Push T4-T7 Right axillary balance support 4C With lumbar push Right Thoracic Push T6-T12 Left Lumbar Push L1-L4 Left Thoracic Push T4-T7 Right axillary balance support 5C Lyon lumbar 3 points low Left Ilio-lumbar Push T12-L4 Right Thoracic Push T7-T12 Right Trochanteric Hemi Circle 6C With thoracic drive Without axillary balance support Left Lumbar Push T12-L4 Right Thoracic Drive T6-T12 Left thoracic Drive T4-T8 5. Long term follow up results Main results We bring forward the results of 1228 complete treatments checked 2 years after the weaning of the brace. [2][3][4][7] The most frequent curves are Lenke s 3 and 4 : 35% The curves Lenke 5 : 30%. The curves Lenke 1 and 2 thoraco-lumbar : 25%. The curves Lenke 1 et 2 thoracic : 10%. During the treatment of a scoliosis the height growth is in average of 11 cm. The weight taken is usually around 5 kgs. The vital capacity gets 10% better during the treatment.

13 Figure 7. Angular stabilization Figure 8. Effectiveness of Lyon Brace 11% of the curves get worse by more than 5 according to the initial curves, that is to say an Effectivity Index of (figure 7 & 8) Those global results can be modulated according to the localization of the curves: - At the thoracic level the Effectivity Index: 0,8 - At the thoraco-lumbar level: Effectivity Index: O,88 - At the lumbar level : Effectivity Index : 0.97 The rib hump is reduced by 50% on average with, as for the curve, a better moulding for the lumbar curves. (figure 9) Figure 9. Aurélia 14 years at the beginning of the treatment rib hump 30mm Cobb T11-L4 35 Last follow up at 28 years : 12 years after weaning rib hump 10 mm Cobb 23

14 We isolated a group of 117 scoliosis which treatment was started with a Risser 0. The global progressive angular curve can be superimposed on the statistic general curve. The Effectivity Index is 0,74. (figure 10) Figure 10. Mean angular results when Lyon brace begins before Risser The failures. We will consider as real failures the curves which have been operated or which justify a surgical indication. It is 2% concerning scoliosis with an initial curve below 45 It is 4% concerning scoliosis with a treatment which started with a Risser 0. It is 22% concerning scoliosis with an initial angle above Brace evaluation and critic The patient is checked up every six months during the treatment. The control is made of: - Size, weight, vital capacity thanks to the spirometer. - Classical clinical check up used for scoliosis without any orthesis. - The radiography of the spine in standing full frontal position is realized without any brace 6 months after the start of the orthesis. The precise tightening of the shell is indicated during the control and so is the wearing of the orthesis. The physiotherapy is adapted according to the progression of the clinical check-up.

15 Conclusion Almost sixty years after the beginning of the Lyon Brace management, we can confirm its effectiveness. Little by little, we precised the indications related to the Lyon Brace and we managed to make the all treatment ambulatory even for the realization of the plastered brace. Nowadays, the electronic moulding enables a precise realization according to Lenke s classification. The Lyon Brace Management seems to give the best chances to the child and the success seems guaranteed for the medical team References [1] Cotrel Y, Morel G. - La technique de l' E.D.F. dans la correction des scolioses. Rev. Chir. Orthop., (1964); 50 (1): [2] de Mauroy JC, Stagnara P. - Résultats à long terme du traitement orthopédique lyonnais des scolioses inférieures à 50. in Journées de la Scoliose. ALDER édit. Lyon, (1979); [3] de Mauroy JC. La scoliose : traitement orthopédique conservateur. Sauramps édit. Montpellier, 279 pp, (1996) [4] de Mauroy JC, Fender P, Cerisier A. Résultats 2 ans après l ablation de 1228 orthèses PMM. Med. Phys. Readapt.,( 2006) ;22(1) :18-21 [5] Michel CR, et coll. - Appareillage des scolioses en période évolutive. Rev. Chir. Orthop., (1970); 56 (5): [6] Ollier M. - Technique des plâtres et corsets de scoliose. Masson édit., Paris,(1970) ;130 pp. [7] Stagnara P, de Mauroy JC. - Résultats à long terme du traitement orthopédique lyonnais. in Actualités en rééducation fonctionnelle et réadaptation. Masson, Paris, (1977); 2 série [8] Stagnara P, Desbrosses J. - Scolioses essentielles pendant l'enfance et l'adolescence : résultats des traitements orthopédiques et chirurgicaux. Rev. Chir. Orthop., (1960); 46: [9] Stagnara P, Mollon G, de Mauroy JC. - Rééducation des scolioses. Expansion scientifique, (1978). [10] Stagnara P. - Les déformations du rachis. Masson édit, Paris, (1985).