HAL Id: dumas-01755238
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improves the recovery of respiratory function after
arthrodesis of the spine for adolescent idiopathic scoliosis
Pauline André-Poyaud
To cite this version:
Pauline André-Poyaud. How do Intermittent Positive Pressure Breathing device improves the recovery of respiratory function after arthrodesis of the spine for adolescent idiopathic scoliosis. Life Sciences [q-bio]. 2016. �dumas-01755238�
THÈSE D'EXERCICE / UNIVERSITÉ DE RENNES 1
sous le sceau de l’Université Bretagne Loire
Thèse en vue du
DIPLÔME D'ÉTAT DE DOCTEUR EN MÉDECINE
présentée par
Pauline André-Poyaud
Née le 07/05/1988 à Echirolles
Apport du relaxateur
de pression dans la
récupération de la
fonction respiratoire
après chirurgie
d’arthrodèse de la
scoliose idiopathique
de l’adolescent.
Thèse soutenue à Rennes le 17/10/2016
devant le jury composé de :
Isabelle BONAN
Professeur - CHU de Rennes / Présidente du jury
Philippe VIOLAS
Professeur - CHU de Rennes / examinateur
Eric WODEY
Professeur - CHU de Rennes / examinateur
Christophe CHARBONNIER
Docteur – CRF Kerpape / examinateur
Vincent DANIEL
Docteur- CHU de Rennes / examinateur
Rachel HEYMAN
THÈSE D'EXERCICE / UNIVERSITÉ DE RENNES 1
sous le sceau de l’Université Bretagne Loire
Thèse en vue du
DIPLÔME D'ÉTAT DE DOCTEUR EN MÉDECINE
présentée par
Pauline André-Poyaud
Née le 07/05/1988 à Echirolles
Apport du relaxateur
de pression dans la
récupération de la
fonction respiratoire
après chirurgie
d’arthrodèse de la
scoliose idiopathique
de l’adolescent.
Thèse soutenue à Rennes le 17/10/2016
devant le jury composé de :
Isabelle BONAN
Professeur - CHU de Rennes / Présidente du jury
Philippe VIOLAS
Professeur - CHU de Rennes / examinateur
Eric WODEY
Professeur - CHU de Rennes / examinateur
Christophe CHARBONNIER
Docteur – CRF Kerpape / examinateur
Vincent DANIEL
Docteur- CHU de Rennes / examinateur
Rachel HEYMAN
PROFESSEURS DES UNIVERSITÉS –
PRATICIENS HOSPITALIERS
Nom Prénom
Sous-section de CNU
ANNE-GALIBERT Marie Dominique Biochimie et biologie moléculaire
BELAUD-ROTUREAU Marc-Antoine Histologie; embryologie et cytogénétique
BELLISSANT Eric
Pharmacologie fondamentale; pharmacologie
clinique; addictologie
BELLOU Abdelouahab
Thérapeutique; médecine d'urgence;
addictologie
BELOEIL Hélène
Anesthésiologie-réanimation; médecine
d'urgence
BENDAVID Claude
Biochimie et biologie moléculaire
BENSALAH Karim
Urologie
BEUCHEE Alain
Pédiatrie
BONAN Isabelle
Médecine physique et de réadaptation
BONNET Fabrice
Endocrinologie, diabète et maladies
métaboliques; gynécologie médicale
BOUDJEMA Karim
Chirurgie générale
BOUGET Jacques
Thérapeutique; médecine d'urgence;
addictologie
BOURGUET Patrick
Professeur des Universités en
surnombre
Biophysique et médecine nucléaire
BRASSIER Gilles
Neurochirurgie
BRISSOT Pierre
Professeur des Universités en
surnombre
Gastroentérologie; hépatologie; addictologie
CARRE François
Physiologie
CATROS Véronique
Biologie cellulaire
CHALES Gérard
Professeur des Universités émérite
Rhumatologie
CORBINEAU Hervé
Chirurgie thoracique et cardiovasculaire
CUGGIA Marc
Biostatistiques, informatique médicale et
technologies de communication
DARNAULT Pierre
Anatomie
DAUBERT Jean-Claude
Professeur des Universités émérite
Cardiologie
DAVID Véronique
Biochimie et biologie moléculaire
DAYAN Jacques
Professeur des Universités associé
Pédopsychiatrie; addictologie
DE CREVOISIER Renaud
Cancérologie; radiothérapie
DECAUX Olivier
Médecine interne; gériatrie et biologie du
vieillissement; addictologie
DELAVAL Philippe
Pneumologie; addictologie
DESRUES Benoît
Pneumologie; addictologie
DEUGNIER Yves
Professeur des Universités en
surnombre
Gastroentérologie; hépatologie; addictologie
DONAL Erwan
Cardiologie
DRAPIER Dominique
Psychiatrie d'adultes; addictologie
DUPUY Alain
Dermato-vénéréologie
EDAN Gilles
Neurologie
FERRE Jean Christophe
Radiologie et imagerie Médecine
FEST Thierry
Hématologie; transfusion
FLECHER Erwan
Chirurgie thoracique et cardiovasculaire
FREMOND Benjamin
Chirurgie infantile
GANDEMER Virginie
Pédiatrie
GANDON Yves
Radiologie et imagerie Médecine
GANGNEUX Jean-Pierre
Parasitologie et mycologie
GARIN Etienne
Biophysique et médecine nucléaire
GAUVRIT Jean-Yves
Radiologie et imagerie Médecine
GODEY Benoit
Oto-rhino-laryngologie
GUGGENBUHL Pascal
Rhumatologie
GUIGUEN Claude
Professeur des Universités émérite
Parasitologie et mycologie
GUILLÉ François
Urologie
GUYADER Dominique
Gastroentérologie; hépatologie; addictologie
HOUOT Roch
Hématologie; transfusion
HUGÉ Sandrine
Professeur des Universités associé
Médecine générale
HUSSON Jean-Louis
Professeur des Universités en
surnombre
Chirurgie orthopédique et traumatologique
JEGO Patrick
Médecine interne; gériatrie et biologie du
JEGOUX Franck
Oto-rhino-laryngologie
JOUNEAU Stéphane
Pneumologie; addictologie
KAYAL Samer
Bactériologie-virologie; hygiène hospitalière
KERBRAT Pierre
Cancérologie; radiothérapie
LAMY DE LA CHAPELLE Thierry
Hématologie; transfusion
LAVIOLLE Bruno
Pharmacologie fondamentale; pharmacologie
clinique; addictologie
LAVOUE Vincent
Gynécologie-obstétrique; gynécologie médicale
LE BRETON Hervé
Cardiologie
LE GUEUT Maryannick
Médecine légale et droit de la santé
LE TULZO Yves
Réanimation; médecine d'urgence
LECLERCQ Christophe
Cardiologie
LEGUERRIER Alain
Chirurgie thoracique et cardiovasculaire
LEJEUNE Florence
Biophysique et médecine nucléaire
LEVEQUE Jean
Gynécologie-obstétrique; gynécologie médicale
LIEVRE Astrid
Gastroentérologie; hépatologie; addictologie
MABO Philippe
Cardiologie
MALLEDANT Yannick
Anesthésiologie-réanimation; médecine
d'urgence
MOIRAND Romain
Gastroentérologie; hépatologie; addictologie
MORANDI Xavier
Anatomie
MORTEMOUSQUE Bruno
Ophtalmologie
MOSSER Jean
Biochimie et biologie moléculaire
MOULINOUX Jacques
Biologie cellulaire
MOURIAUX Frédéric
Ophtalmologie
ODENT Sylvie
Génétique
OGER Emmanuel
Pharmacologie fondamentale; pharmacologie
clinique; addictologie
PERDRIGER Aleth
Rhumatologie
PLADYS Patrick
Pédiatrie
POULAIN Patrice
Gynécologie-obstétrique; gynécologie médicale
RAVEL Célia
Histologie; embryologie et cytogénétique
RIFFAUD Laurent
Neurochirurgie
RIOUX-LECLERCQ Nathalie
Anatomie et cytologie pathologiques
ROBERT-GANGNEUX Florence
Parasitologie et mycologie
SAINT-JALMES Hervé
Biophysique et médecine nucléaire
SEGUIN Philippe
Anesthésiologie-réanimation; médecine
d'urgence
SEMANA Gilbert
Immunologie
SOMME Dominique
Médecine interne; gériatrie et biologie du
vieillissement; addictologie
SULPICE Laurent
Chirurgie générale
TARTE Karin
Immunologie
TATTEVIN Pierre
Maladies infectieuses; maladies tropicales
THIBAULT Ronan
Nutrition
THIBAULT Vincent
Bactériologie-virologie; hygiène hospitalière
THOMAZEAU Hervé
Chirurgie orthopédique et traumatologique
TORDJMAN Sylvie
Pédopsychiatrie; addictologie
VERGER Christian
Professeur des Universités émérite
Médecine et santé au travail
VERHOYE Jean-Philippe
Chirurgie thoracique et cardiovasculaire
VERIN Marc
Neurologie
VIEL Jean-François
Epidémiologie, économie de la santé et
prévention
VIGNEAU Cécile
Néphrologie
VIOLAS Philippe
Chirurgie infantile
WATIER Eric
Chirurgie plastique, reconstructrice et
esthétique; brûlologie
WODEY Eric
Anesthésiologie-réanimation; médecine
d'urgence
MAÎTRES DE CONFÉRENCES DES
UNIVERSITÉS – PRATICIENS HOSPITALIERS
Nom Prénom
Sous-section de CNU
AME-THOMAS Patricia
Immunologie
AMIOT Laurence
Hématologie; transfusion
BARDOU-JACQUET Edouard
Gastroentérologie; hépatologie; addictologie
BEGUE Jean-Marc
Physiologie
BOUSSEMART Lise
Dermato-vénéréologie
CABILLIC Florian
Biologie cellulaire
CAUBET Alain
Médecine et santé au travail
DAMERON Olivier
Informatique
DE TAYRAC Marie
Biochimie et biologie moléculaire
DEGEILH Brigitte
Parasitologie et mycologie
DUBOURG Christèle
Biochimie et biologie moléculaire
DUGAY Frédéric
Histologie; embryologie et cytogénétique
EDELINE Julien
Cancérologie; radiothérapie
GALLAND Françoise
Endocrinologie, diabète et maladies
métaboliques; gynécologie médicale
GARLANTEZEC Ronan
Epidémiologie, économie de la santé et
prévention
HAEGELEN Claire
Anatomie
JAILLARD Sylvie
Histologie; embryologie et cytogénétique
LAVENU Audrey
Sciences physico-chimiques et technologies
pharmaceutiques
LE GALL François
Anatomie et cytologie pathologiques
LE RUMEUR Elisabeth
Physiologie
MAHÉ Guillaume
Chirurgie vasculaire; médecine vasculaire
MARTINS Raphaël
Cardiologie
MASSART Catherine
Biochimie et biologie moléculaire
MATHIEU-SANQUER Romain
Urologie
MENARD Cédric
Immunologie
MENER Eric
Médecine générale
MILON Joëlle
Anatomie
MOREAU Caroline
Biochimie et biologie moléculaire
MOUSSOUNI Fouzia
Informatique
MYHIE Didier
Médecine générale
PANGAULT Céline
Hématologie; transfusion
RENAUT Pierric
Médecine générale
RIOU Françoise
Epidémiologie, économie de la santé et
ROPARS Mickaël
Anatomie
SAULEAU Paul
Physiologie
TADIÉ Jean-Marc
Réamination; médecine d'urgence
TATTEVIN-FABLET Françoise
Médecine générale
TURLIN Bruno
Anatomie et cytologie pathologiques
VERDIER Marie-Clémence
Pharmacologie fondamentale;
pharmacologie clinique; addictologie
VINCENT Pascal
Bactériologie-virologie; hygiène hospitalière
REMERCIEMENTS
Au Docteur Rachel HEYMAN,
Merci d’avoir accepté de diriger ma thèse, merci pour l’idée originale, merci de
m’avoir soutenue, merci pour les dizaines de relecture, les rendez-vous, les
briefings au téléphone. Et également merci pour ta bonne humeur et tes
encouragements.
Au Professeur Isabelle BONAN,
Merci d’avoir accepté de présider le jury de cette thèse. Merci également pour
votre disponibilité et votre accompagnement bienveillant en tant que
coordonnateur de DES.
Au Professeur Philippe VIOLAS, au Professeur Éric WODEY, au Docteur
Vincent DANIEL,
Merci d’avoir accepté de faire partie du jury de cette thèse, votre expertise dans
les domaines de la chirurgie de la scoliose, de l’anesthésie pédiatrique et des
Epreuves Fonctionnelles Respiratoires sera essentielle pour juger ce travail.
Au Docteur Christophe CHARBONNIER,
Merci d’avoir accepté de faire partie du jury de cette thèse. J’ai la chance
exceptionnelle de pouvoir profiter de tes enseignements avant ton départ de la
rééducation pédiatrique et je te remercie de la disponibilité avec laquelle tu
partages ton savoir et tes jeux de mots.
Un grand merci à Florence GAILLARD et sa maman pour la relecture en anglais.
Merci à Chloé ROUSSEAU pour son travail en statistiques.
Merci à ma famille, dispersée aux quatre coins de la France, mais toujours présente pour les fêtes et les moments importants. Merci Tatie, on peut toujours compter sur toi.
Merci à mes frères.
Merci maman, pour tout. Tout ce que tu as fait pour nous, pour moi, et tout ce qui reste à venir. Merci Hélène, pour ces moments partagés. Des rires, des joies, des découvertes, des voyages et des moments plus durs… Tu m’as fait murir. Un petit bout du chemin qu’il reste à faire… Merci à tous mes amis pour m’avoir accompagnée tout au long chemin.
Petite pensée pour le NC Corenc qui m’a vue grandir… Marzo, Steph, Oriane, Claire, Pauline, Estelle, Charlotte, c’était chouette de partager ces compètes, ces entrainements et tout le reste avec vous…
Merci à Mymy et Nico de s’être installés à Nantes pour garder un œil sur moi ! Myriam, toujours présente et pleine de douceur pour me tirer les vers du nez, c’est un grand privilège de pouvoir te compter dans mes amis. Nicolas, malgré tes phrases chocs pas toujours adaptées et ton amour pour la musique douteuse, tu es l’un des seuls « hommes » acceptés dans ma vie…
Merci à Vérane de nous rappeler tous les jours l’importance du bling bling… Ma grosse, je te kiffe !
Merci à Delphine, Marie et Anne-Cat, votre soutien et votre travail acharné m’ont permis de réussir une difficile 6ème année… Et visiter le Québec avec vous reste parmi mes plus belles vacances !
En espérant que la team Grenoble Forever ait toujours de beaux jours devant elle !
Merci à ceux que j’ai rencontrés pendant mon internat, qui ont rendu ma vie rennaise trépidante…
Merci à Elo, pour tous ces apéros, la découverte de l’Aventure, pour m’avoir accueillie chez toi et n’avoir refait ta cuisine qu’après mon passage…
Merci à Hélène, ta bonne humeur et ton humour ont sauvé nombre de mes journées !
Merci à Cynthia, ces discussions interminables au moment de dicter mes courriers m’ont énormément aidée à supporter des conditions de travail pas toujours faciles… J’attends avec impatience d’être invitée à Tahiti !
Merci à Meriem pour un semestre haut en couleurs !
Merci à Momo et Katoune, la dream team de l’internat vannetais, un bel été dans mes souvenirs…
Un merci particulier à l’équipe de MPRA, première famille dans mon parcours. A l’équipe de MPRE, pour l’accueil toujours chaleureux. A l’équipe de Beaulieu, pour les beaux moments d’échange. A l’équipe médicale de Vannes pour la découverte de la pédiatrie et les apéros-plage. A la neuropédiatrie d’Angers pour leur gentillesse, les nombreux cafés et les parties de rire. A l’équipe de l’HE à La Réunion, en espérant vous retrouver autour d’un verre à l’Hermitage ! A l’équipe de Kerpape, pour un final en apothéose.
Merci à tous les médecins et les équipes paramédicales pour tous les enseignements sur le terrain. Merci à ceux qui m’ont appris le soin et l’écoute, merci à ceux qui m’ont sortie quand je broyais du noir, merci à ceux qui ont égayé mes trop longues et douloureuses journées de travail et nuits de garde d’un sourire, d’une oreille attentive, de bonbons/chocolats ou de mots gentils.
Merci à tous les co-internes, pour le partage, le soutien et les sorties… Thibault, Thomas, Vincent, Augustin, Sarah, Nathalie, Lisa, Nelly, Célia, Pauline, Flore, Augustin, Lorène, Lucie, Lucie, Florence, Emilie, Damien.
16
SOMMAIRE
TITRE ... 17
TITLE ... 17
RÉSUMÉ ... 18
ABSTRACT... 20
MOTS-CLÉS ... 20
KEY-WORDS... 22
LISTE DES ABRÉVIATIONS ... 23
1. INTRODUCTION ... 23
2. MATERIAL AND METHODS ... 27
3. RESULTS ... 30
4. DISCUSSION ... 35
5. CONCLUSION ... 39
RÉFÉRENCES BIBLIOGRAPHIQUES ... 40
LISTE DES TABLEAUX ... 43
LISTE DES FIGURES ... 44
TABLE DES MATIÈRES ... 45
ANNEXES ... I
17
TITRE
Apport du relaxateur de pression dans la récupération de la fonction
respiratoire après chirurgie d’arthrodèse de la scoliose idiopathique de
l’adolescent.
TITLE
How do Intermittent Positive Pressure Breathing device improves the
recovery of respiratory function after arthrodesis of the spine for
adolescent idiopathic scoliosis.
18
RÉSUMÉ
Introduction
La scoliose idiopathique de l’adolescent (SIA) entraine un syndrome restrictif pulmonaire proportionnel à la sévérité de la maladie. Le syndrome restrictif est corrélé à la présence de limitations fonctionnelles. L’arthrodèse rachidienne provoque une diminution des capacités respiratoires de l’ordre de 40 à 50% en post-opératoire immédiat, dont la récupération se fait progressivement entre le premier et le troisième mois post-opératoire.
Notre objectif était d'analyser l'effet d'une rééducation respiratoire par relaxateur de pression sur la récupération de la capacité vitale forcée (CVf) après une chirurgie d'arthrodèse dans la SIA.
Matériel et méthodes
Cette étude pilote, prospective et observationnelle d'un protocole de soins courants a été menée au sein du service de rééducation pédiatrique du CHU de Rennes. Les patients inclus présentaient une SIA pour laquelle une indication d’arthrodèse vertébrale était posée. Les patients exclus étaient atteints d'une scoliose secondaire ou d'une pathologie pulmonaire préexistante et non stabilisée.
Après un bilan initial 45 jours avant la chirurgie (T0), les patients débutaient la rééducation par relaxateur de pression. Après la chirurgie, ils suivaient un protocole de rééducation en hospitalisation en poursuivant l’utilisation du relaxateur de pression. Une spirométrie était effectuée à T0, la veille de la chirurgie (J-1), puis pendant la deuxième (S2), la troisième (S3) et la quatrième (S4) semaine d’hospitalisation. Une dernière spirométrie était réalisée 4 mois (M4) après l’intervention. Le critère de jugement principal était l’évolution de la CVf après la chirurgie.
Résultats
24 patients ont été inclus entre janvier 2011 et avril 2016. L’angle de Cobb moyen était 67,2° ± 16,5°. La CVf moyenne (% de la théorique) était de 69,3% à T0, 77,3% à J-1, 49% à S2, 57,1% à S3, 68% à S4, 74,3% à M4. La CVf à J-1 était plus élevée que la CVf à T0 de façon significative (+8%, p<0,05). Les CVf à S2 et à S3 étaient plus basses que la CVf à T0 de façon significative (respectivement -20,3% et -12,2%, p <0,001). Par contre, les CVf à S4 et à M4 ne différaient pas de la CVf à T0 de façon significative (respectivement -1,3% et 4,9%).
19
Conclusion
Avec notre protocole, à la quatrième semaine post-opératoire la CVf est déjà revenue à la valeur pré-opératoire. Cette étude montre donc que la rééducation par relaxateur de pression accélère la récupération de la CVf après chirurgie d’arthrodèse dans les SIA.
20
ABSTRACT
Introduction
Adolescent idiopathic scoliosis (AIS) leads to a restrictive lung disease, proportional to the severity of the scoliosis. The restrictive lung disease is closely related to functional limitations. Spinal fusion causes respiratory capacities to diminish up to 40 to 50% in the immediate post-operative period, and recovery occurs between the first and the third post-post-operative months. The goal of this study was to analyse the effect of respiratory rehabilitation with an intermittent positive pressure breathing (IPPB) device on the recovery of forced vital capacity (FVC) after spinal fusion in AIS.
Material and methods
This was a pilot prospective and observational study of a standard care protocol. The included patients were adolescents followed at the teaching hospital in Rennes, presenting an AIS with a surgical indication. Excluded patients were presenting secondary scoliosis or anterior and unstable pulmonary disease.
After an assessment 45 days before surgery (T0), patients started using the IPPB device at home. After the surgery, patients underwent the habitual rehabilitation program in a short hospitalization period and kept using the IPPB device. Follow-up spirometries were performed the day before surgery (D-1), and then during the second (W2), the third (W3), the fourth (W4) week of rehabilitation. A last spirometry was performed 4 months (M4) after surgery. The primary judgment criterion was FVC evolution after surgery.
Results
There were 24 patients included (4 boys, 20 girls) between January 2011 and April 2016. The mean Cobb angle was 67.2° ± 16.5 °. The mean adjusted FVC (% of predicted value) was 69.3% at T0. The FVC at D-1 was significantly higher than the FVC at T0 (+8%, (p<0.05). The FVC at W2 and W3 were significantly lower than the FVC at T0 (respectively -20.3% and -12.2%, p<0.001). The FVC at W4 and M4 were not significantly different from the FVC at T0 (respectively -1.3% and 4.9%).
21
Conclusion
With our protocol, in the fourth post-operative week, FVC has already returned to pre-operative value. This study therefore demonstrates that rehabilitation with IPPB device accelerates the recovery of FVC after spinal fusion in AIS.
22
MOTS-CLÉS
Scoliose, adolescent, arthrodèse vertébrale, capacité vitale, respiration en pression
positive intermittente, rééducation et réadaptation
KEY-WORDS
Scoliosis, adolescent, spinal fusion, vital capacity, Intermittent Positive-Pressure
Breathing (IPPB), rehabilitation
23
LISTE DES ABRÉVIATIONS
AARC : American Association for Respiratory Care
AIS : Adolescent Idiopathic Scoliosis
ATS : American Thoracic Society
BTS : British Thoracic Society
CSF : Cerebro Spinal Fluid
D-1 : The Day Before Surgery
FEV : Forced Expiratory Volume in on second
FVC : Forced Vital Capacity
M4 : The fourth month after surgery
PFT : Pulmonary Function Tests
PSE : Physiotherapeutic specific exercises
r
p: Pearson’s correlation coefficient
Sa02 : Oxygen saturation
SEPAR : Sociedad Española de Neumología y Cirugía Torácica
SOSORT : International Society on Scoliosis Orthopaedic and Rehabilitation
Treatment
T0 : The first assessment, 45 days before surgery
TLC : Total Lung Capacity
TV : Tidal Volume
VAS : Visual Analogic Scale
VC : Vital Capacity
VEmax : Ventilatory Efficiency at maximal exercise
VO2max : Maximal Oxygen Consumption
24
1. INTRODUCTION
Scoliosis is the most frequent abnormality of the spine of child and adolescents. It corresponds to a three dimensional deformation of the spine, leading to a lateral curvature, a vertebral rotation and sagittal anomalies with complex effects on the anatomy of the thoracic cage. It is defined by a clinical rib hump and a vertebral curvature measured with Cobb angle. Idiopathic scoliosis is the most frequent form (85% of scoliosis), with a 0.2 to 6% prevalence in the population [1]. Recently, numerous studies tend to prove that there is a multifactorial etiology to this condition, implying different genes and neuroendocrine and biochemical factors such as melatonin and calmodulin [1, 2]. Adolescent idiopathic scoliosis (AIS) is more likely to affect girls with a 3:1 sex ratio, this ratio increasing with the severity of the scoliosis [3].
Scoliosis leads to a multifactorial restrictive lung disease, proportional to the severity of the scoliosis. Above 90° of Cobb angle, there is an important risk of cardio-respiratory insufficiency. Indeed, the thoracic cage mechanic is altered and conformational anomalies restraint the normal pulmonary inflation. On the muscular level, a weakness of respiratory muscles, a bad diaphragmatic conformation, and an intercostal muscles affection were found. Obstructive lung disease can sometimes be found as well [3]. As a consequence, ventilatory parameters are modified with an increased respiratory rate, a diminished total lung capacity (TLC) and a diminished tidal volume (Vt). But the Vt is augmented compared to the vital capacity (VC), which is an expression of the increase of the work of breathing with accessory respiratory muscles recruitment. TLC measure requires a plethysmography, but it is possible to estimate the restrictive lung disease by recording the forced vital capacity (FVC) whose decrease is proportional to TLC [4]. A restrictive lung disease detected on the pulmonary function testing (PFT) is associated with a risk of developing functional limitations [5]. The restrictive lung disease is also frequently associated with dyspnea and effort deconditioning [6]. During exercise, the respiratory response of adolescents with AIS is reduced compared to the norm, even in mild scoliosis. In the 6-minute walk test, there is a significant raise of the respiratory rate, of the heart rate, and of the score on Borg dyspnea scale, and a significant reduction of the blood oxygen saturation and the walking distance for AIS patients compared to the control group [7]. Other authors have demonstrated an impact on maximal exercise
25
tolerance test with a decrease in maximal oxygen uptake (VO2max) and in ventilatory efficiency at maximal exercise (VEmax), in AIS patients even with moderate scoliosis (Cobb angle <45°) [8]. Others confirm those results and report a decrease in global muscular capacities (respiratory and limb muscles) [9, 10]. In severe scoliosis, the increase of arterial pulmonary pressure could play a role in reducing the exercise capacities.
Spinal fusion is the key surgical treatment of progressive AIS. The arthrodesis effect on respiratory function is not clear yet. Several studies have indeed demonstrated that the different arthrodesis techniques could either ameliorate, deteriorate or stabilize the respiratory function. On the other hand, it is generally accepted that the respiratory function drops at the immediate post-operative period. Some authors have indeed demonstrated that FVC decreases to 40 to 50% of pre-operative value and that all PFTs diminish by 60% around the third post-operative day, to rise up progressively to 80 to 100% of pre-operative value from the second post-operative month, in every scoliosis and all types of surgeries [11].
AIS rehabilitation modalities are highly controversial, and the scientific literature does not enable to conclude formally that there is a proof of efficacy. According to the SOSORT (International Society on Scoliosis Orthopaedic and Rehabilitation Treatment) in 2012, physiotherapeutic specific exercises (PSE) are recommended because they seem to limit the worsening of the scoliosis and to improve lung function [12, 13]. More generally, the physical reconditioning training also plays a role in improving respiratory capacity. [14] To our knowledge, no study has evaluated the effect of a specific respiratory rehabilitation after spinal fusion for AIS and especially the effect of the use of an Intermittent Positive Pressure Breathing (IPPB) device in this indication. Yet the IPPB (Alpha 200® 300®, Bird®) has proven its efficacy in the prevention and treatment of restrictive lung disease. This device delivers a positive pressure during inspiration, after triggering by the patient, and causes pulmonary hyper insufflation. It increases the pulmonary alveolar recruitment, it reduces the work of breathing, it improves chest wall compliance and thus increases the VC of patients [15, 16]. Its use is recommended by several scientific societies (AARC, BTS, SEPAR) in the care of neuromuscular diseases and kyphoscoliosis restrictive lung diseases [17, 18, 19].
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The aim of this pilot study was to analyze the effect of a specific respiratory rehabilitation with an IPPB device on the recovery of lung function after spinal fusion in AIS. Recovery of lung function was assessed by the speed of the recovery of the preoperative value of FVC and also by the possible increase in the value of FVC after surgery.
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2. MATERIAL AND METHODS
Study population
We conducted a prospective observational study of a standard care protocol from January 2011 to April 2016 within the Pediatric Physical Medicine and Rehabilitation department in Rennes University Hospital. Patients included were children followed at Rennes University Hospital with AIS, whatever the Cobb angle and the topography of scoliosis, for whom there was an indication of spinal fusion, whatever the type of surgery. Patients with secondary scoliosis, or with a pre-existing and unstablized lung disease were excluded.
This study was approved by the Ethics Committee of the University Hospital of Rennes.
Study protocol
The patients included followed the usual rehabilitation protocol set up in the pediatric physical medicine and rehabilitation department. The protocol was as follows: 45 days prior to spinal fusion surgery, the patients had a preoperative assessment (T0) including a complete clinical examination by a physiotherapist and a rehabilitation physician (measurement of height standing and sitting, measurement the hump in degree with a scoliometer, measure of sagittal balance with a plumb line, measure of the deviation in the frontal plane in centimeters), pain VAS (visual analogic scale); an analysis of recent radiographs (total spine standing face and profile: topography of scoliosis, Cobb angle, vertebral rotation, Risser test, measure of pelvic parameters including pelvic incidence, lumbar lordosis and pelvic tilt, and measure of thoracic kyphosis); spirometry measurements with FVC, FEV (forced expiratory volume in one second), FEV/FVC; a 6-minute walk test performed by a sports educator.
An education to the use of the IPPB device (Alpha 200® or 300®) was given by a physiotherapist trained in the use of the device, who adjusted the ventilatory parameters according to each child. The pressure that was found to be effective was the one that lead to a mobilization of upper ribs. The flow rate was the slowest the child could tolerate. Patients were then asked to use the IPPB device twenty minutes a day seven days a week until the date of the surgery. A timer was set up the day of the beginning of rehabilitation to monitor the compliance of each patient.
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The day before surgery, a new spirometry was performed (D-1) in the same conditions as the previous ones.
8 days after surgery, the children were admitted to the pediatric in-patient rehabilitation service (with return home on weekends) for an average of 3.5 weeks. They all followed the same multidisciplinary rehabilitation program including a medical evaluation, management of pain, physiotherapy (respiratory and global), occupational therapy, psychomotricity, balneotherapy and adapted physical education. Reeducation through IPPB device was continued at the rate of two times twenty minutes a day, every day, including weekends at home.
At hospital discharge around day 28 after surgery (week 4, W4), the IPPB rehabilitation was continued if postoperative FVC was less than 80% of predicted FVC and / or in case the recovery of the preoperative FVC was not completed (twenty minutes sessions per day for 3 months). For these patients, the timer was kept at the hospital discharge to check for compliance.
For all patients, a final assessment was performed 4 months after surgery (M4), including a medical and physiotherapeutic assessment, a spirometry and a 6-minute walk test.
Judgment criteria
The primary judgment criterion of the study was the speed of FVC recovery up to preoperative values.
Spirometry was performed with a spirometer Jaeger, LAB 5.0 software, by physiotherapists or trained technicians. To measure FVC, children were instructed to inspire deeply and blow as quickly as possible all the air from their lungs into the spirometer. Three measurements were made under the same conditions in a sitting position and the best of three values were retained. We also measured FEV and FEV / FVC ratio. In our study, spirometry was performed 45 days before surgery (T0), the day before surgery (D-1), during the second postoperative week (W2), during the third postoperative week (W3), during the fourth postoperative week (W4) and at the fourth post-operative month (M4) to describe the recovery of FVC.
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The secondary criteria were the correlations between the anthropometric parameters of population and the recovery of the FVC, and the evolution of the 6-minute walk test parameters after surgery. The 6-minute walk tests were performed by a sports educator at T0 and M4. The data collected were the distance and walking speed, maximum heart rate during exercise and score in the Borg dyspnea scale.
Statistical analysis
For statistical analysis the parameters measured at different times were compared using parametric paired Student test or non-parametric Wilcoxon signed ranks. The links between FVC (% predicted) at W4 and T0 parameters were sought using univariate linear regression for quantitative parameters, and ANOVA models for qualitative parameters (such analyzes were adjusted on FVC at T0). The links between the effect of surgery on the spinal parameters and improvement in FVC between T0 and W4 and between T0 and M4 (quantitative variables) were sought using Pearson linear correlations (parametric data), or Spearman’s rank monotonic correlations (nonparametric data). A repeated measures model was conducted to see if there was an effect of time on the evolution of post-operative FVC. FVC at various times was compared with respect to T0 adjustment with Dunnett.
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3. RESULTS
Population characteristics
Over the period from January 2011 to April 2016, 24 patients met the inclusion criteria of this study. Table 1 summarizes the characteristics of the population. There were 4 boys (16.7%) and 20 girls (83.3%). The mean Cobb angle for the main curve was 67.2 °± 16.5°. The majority of scoliosis were classified Lenke 4 (56.5%), 26.1% were Lenke 3. 58.3% of patients wore a brace full-time or night wear and 79.2% of patients were receiving physiotherapy.
21 patients underwent posterior spinal fusion. There was an average of 10 thoracic vertebrae included in the arthrodesis. The rate of correction of the Cobb angle was 59.5 +/- 14.7%. The pelvic incidence was not affected, but the lumbar lordosis and thoracic kyphosis were reduced. The rate of complications in surgical suites was 33.3% (surgical site infection, CSF leak, pneumothorax ...). 25% of patients required oxygen therapy for a few hours and up to 2 days after the operation. Furthermore, there was no significant change in pain (VAS) one month after surgery.
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Variable Population (n=24) Difference before and after surgery Sex
Boys 4 (16.7%)
Girls 20 (83.3%)
Known respiratory pathology
No 20 (83.3%) Yes 4 (16.7%) Brace No 10 (41.7%) Yes 14 (58.3%) IPPB No 5 (20.8%) Yes at D-45 19 (79.2%) BMI 19.4 ± 4.5 Age at scoliosis diagnosis
10.4 ± 3.1 Lenke classification 1 1 ( 4.3%) 2 2 ( 8.7%) 3 6 (26.1%) 4 13 (56.5%) 5 1 ( 4.3%) 6 0
Cobb angle, main curve
Before surgery 67.2 ± 16.5
After surgery 28.1 ± 13.5 p < 0.0001 (S app)
Thoracic kyphosis
Before surgery 26.7 ± 14.1
After surgery 17.4 ± 11.9 p < 0.0001 (S app)
Lumbar lordosis
Before surgery 47.8 ± 11.8
After surgery 39.1 ± 8.5 p = 0.0002 (S app)
Type of arthrodesis
Posterior 21 (87.5%)
Anterior + posterior 1 ( 4.2%) Halo traction + posterior 1 ( 4.2%) Anterior + posterrior then halo
traction + posterior 1 ( 4.2%) Surgery complications No 16 (66.7%) Yes 8 (33.3%) Post-operative oxygenotherapy No 18 (75.0%) Yes 6 (25.0%)
Qualitative parameters : Number (%).
Quantitative parameters : Mean ± standard deviation Paired Student tests (S app)
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Evolution of respiratory parameters
The mean FVC at T0 was 2.3 ± 0.7L (70.8 +/- 20.5% of the predicted value). 8 (33%) patients had a FVC <60% of predicted, and 6 (25%) had a FVC between 60% and 80% of predicted. The mean FEV was 1.9 ± 0.7L (67.5 ± 24.4% of predicted). The results of spirometry are summarized in Table 2.
Time of the study
T0 D-1 W2 W3 W4 M4 FVC in L (%pre) 2.3 ± 0.7 (70.8 ± 20.5) 2.7 ± 0.7 (77.5 ± 21) 1.8 ± 0.5 (52.5 ± 15) 2.1 ± 0.6 (61.8 ± 16.2) 2.5 ± 0.6 (69.7 ± 18) 2.7 ± 0.7 (75.9 ± 21.1) FEV in L (%pre) 1.9 ± 0.7 (67.5 ± 24.4) 2.4 ± 0.6 (82 ± 23.2) 1.5 ± 0.5 (51 ± 17.9) 1.7 ± 0.6 (57.8 ± 17.1) 2.1 ± 0.5 (67.8 ± 18.5) 2.1 ± 0.8 (70.7 ± 26.5) FEV/VC 79.5 ± 9.8 88.9 ± 3.4 84 ± 13.4 80.9 ± 12.9 85.2 ± 11.1 77.8 ± 10.7
Values : Mean +/- Standard deviation
Table 2. Values of spirometry according to time
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Changes in FVC over time is shown in Figure 1, the values of FVC are given in Table 3. FVC at D-1 was significantly higher than FVC at T0 (+ 8%, p <0.05). FVC at W2 and W3 were significantly lower than FVC at T0 (respectively -20.3% and -12.2%, p <0.001). However, the FVC at W4 and M4 did not significantly differ from FVC at T0 (-1.3% and 4.9% respectively).
Figure 1. FVC evolution versus time.
A repeated measures model was performed for each of the two groups to see if there was an effect of time. The p-values of the models were shown on the graph, they correspond to the comparison with T0. * P <0.05; ** P
<0.001
Time of the study
T0 D-1 W2 W3 W4 M4 FVC in %pre 69.3 ± 3.99 77.4 ± 4.3 49 ± 4.1 57.1 ± 4.0 68 ± 3.97 74.3 ± 4.0 Difference with FVC at T0 (p-value) 8.0758 (p=0.0426) -20.3221 (p<.0001) -12.2136 (p<.0001) -1.3369 (p=0.9808) 4.9218 (p=0.2190) Values : Adjusted means +/- Standard deviation
Table 3. FVC evolution versus time
* ** ** 0 10 20 30 40 50 60 70 80 90 100 -6 -4 -2 0 2 4 6 8 10 12 14 16 18 C Vf ( %t h é o ri q u e ) Temps (semaines post-opératoires) Début de la rééducation avec relaxateur de pression Arthrodèse rachidienne
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6-minute walk test
Regarding the 6-minute walk test, only 16 of the 24 patients were evaluable. The average walking speed was 5.2 +/- 0.9 km/h at T0 and 5.3 +/- 1km/h at M4, the average walked distance was 497 +/- 103.2m at T0 and 517.8 +/- 112.2m at M4, and the average heart rate was 140 +/- 20.4bpm at T0 and 141.8 +/- 14.9bpm at M4. The differences were not statistically significant.
Correlation analysis
We found a negative correlation between the presence of postoperative complications and recovery of FVC at W4 (β coefficient = -12.4, p <0.05) [Appendix 2]. There was a positive correlation between the reduction of thoracic kyphosis after surgery and the recovery of the FVC between W4 and M4 (rp = 0.7000, p = 0.011 where rp is the Pearson correlation coefficient).
We did not find significant correlation between the reduction of the Cobb angle after surgery and the recovery FVC.
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4. DISCUSSION
The study population differs slightly from that of other studies on respiratory function in this pathology. We found a female predominance with a sex ratio of 5: 1 (from 1: 1 to 3: 1 in other studies), a mean pre-operative Cobb angle of 67° while between 50 and 60° in literature [20, 21, 22, 23, 24]. These differences can be explained by surgical habits that vary from country to country, and by the fact that the sex ratio increases with the severity of scoliosis and therefore with the Cobb angle.
Preoperative FVC of patients in our study is reduced compared to normal (70.8% of predicted FVC), which is consistent with the literature data relating restrictive lung disease in idiopathic adolescent scoliosis, including moderate scoliosis. In other studies on the subject, preoperative FVC was 67 to 87.7% [20, 22, 23, 24].
The decrease in FVC is correlated to the decrease in TLC, reflecting the installation of a restrictive lung disease. Some authors have clearly identified the decrease in FVC as a predictive marker of respiratory failure in adult patients with non-operated AIS: having an FVC<45% of predicted value in adolescence is correlated with the installation of respiratory failure after 20 years of evolution [25]. This was partly explained by the natural evolution of the VC, which increases until the end of the growth phase in young adulthood and then gradually decreases with age.
In addition, the restrictive pattern detected on the PFT is associated with a risk of functional limitations (ability to walk more than 1 mile, carry more than 10 pounds, need of help in activities of daily living) [5]. This restrictive lung disease is commonly associated with dyspnea and effort deconditioning [6]. The American Thoracic Society (ATS) has also defined that a "moderate" deterioration of respiratory function characterized by a FVC between 50% and 59% of the predicted value (or a FEV between 41% and 59% of predicted) was sufficient to decrease patients ability to perform normal work. The deterioration is described as "mild" when the FVC or FEV are between 60% and 79% of the predicted values [6]. In our study, before surgery, 33% of patients had a moderate deterioration of their respiratory capacities as defined by the ATS, and 25% had a mild deterioration. The management of these alterations in respiratory function is essential in the treatment of the AIS. Indeed, the improvement in FVC and its speed is a major issue in the patient’s functional recovery after spinal fusion.
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Adequately, our results suggest a beneficial effect of IPPB device in the respiratory rehabilitation of patients with AIS. Indeed, in the immediate postoperative period, the FVC of our patients fall to 75.6% of the preoperative FVC value, while studies on the subject reported a drop of 40 to 50% of the preoperative FVC value [26].
Our patients also have a recovery of FVC in the post-operative period faster than described in literature (Figure 2). Indeed, a recent meta-analysis shows that in the case of posterior vertebral arthrodesis for AIS, FVC gradually rises to 70% of the predicted value 1 month after surgery, and reaches 100% of the preoperative value 3 months after surgery [20, 21, 22, 26, 27]. Whereas in our study, the recovery occurs from the fourth post-operative week: FVC at W4 corresponds to 98.2% of pre-operative FVC (the difference between predicted FVC at T0 and at W4 was 1.3% and was not statistically significant).
In addition, there is a trend towards more rapid improvement in FVC, since 4 months after surgery it corresponds to 108.9% of the preoperative value (not significant), while literature only puts out a progressive increase in FVC compared to preoperative FVC after 1 post-operative year (gain between 6 and 17% of the predicted FVC or 108 to 125% of the preoperative FVC between 1 and 20 years after surgery) [20, 21, 22, 26, 27]. These results need to be confirmed by a follow-up of postoperative FVC over a longer period.
Figure 2. FVC evolution versus time in our study compared to literature data
0 10 20 30 40 50 60 70 80 90 100 110 120 130 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 F VC in % o f pr e o pe ra ti v e v a lue Time (post-operative weeks)
Population of the study Literature data without rehabilitation Beginning of rehabilitation with IPPB device for the population of the study Spinal fusion
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A decrease in FVC is also associated with the recruitment of accessory respiratory muscles, increased in the effort in these patients often presenting an effort deconditioning [3]. Therefore, one may think that patients in the post-operative catabolism period should, thanks to the IPPB device, improve their FVC recovery speed, which would allow them to recover faster autonomy to moderate effort. For patients in this study, although there was a trend to improved parameters (walking distance, walking speed) in the 6-minute walk test performed 4 months after pulmonary rehabilitation, the latter is not statistically significant. It should be noted that this analysis has a lack of power linked to the low number of subjects who benefited from these assessments.
The conclusions that can be drawn from correlational analysis in our study are limited because of the small size of our population. It was noted that the presence of post-operative complications correlated with poorer recovery of FVC. There was no correlation between the percentage reduction of the Cobb angle and the recovery of the FVC, while studies show that the bigger the Cobb angle was, the lower the FVC was [28]. We did not find a correlation between the percentage of reduction of the thoracic kyphosis and recovery of FVC at W4, but we found a positive correlation between the reduction of kyphosis and recovery of FVC between W4 and M4. This result is not very well explained because literature shows that the lower the thoracic kyphosis is, the lower the FVC is [28].
Pulmonary complications are part of the first causes of morbidity and mortality in the period following the arthrodesis surgery, with an incidence of 0.6 to 1.5% depending on the studies [29, 30]. There is no direct correlation found in literature between pre-operative pulmonary function and the incidence of complications [3]. Moreover, it appears that post-operative oxygen saturation rate is reduced compared to the preoperative value [31]. We have not found studies reporting the percentage of patients requiring postoperative oxygen therapy. In a doctoral thesis with a comparable population, out of the 13 patients with AIS, 4 (30.7%) required postoperative oxygen [32]. Our study was not designed to analyze the links between the preoperative pulmonary rehabilitation and the occurrence of pulmonary complications after surgery. However, although 25% of patients (N = 6) were in need of post-operative oxygen
38
therapy, only one patient had severe pulmonary complications (pneumothorax). Thus, it would be interesting to conduct a study analyzing more specifically this aspect.
Moreover, we noted that beginning the rehabilitation with the IPPB device 45 days before the date of surgery seemed to already increase the FVC (108% of pre-operative FVC, statistically significant result). We could therefore assume that the introduction of the IPPB device may have an interest in other periods of the management of AIS.
This pilot study provides evidence for the first time of the importance of including specific respiratory rehabilitation through IPPB in the management of peri-operative adolescent idiopathic scoliosis.
Thus, this study aiming at investigating the feasibility and interest of such rehabilitation is emerging as a major preliminary study. It opens many research perspectives in order to harmonize practices and develop recommendations for before and after spinal fusion respiratory rehabilitation. Because of its pilot character, it presents bias (small numbers, lack of control group, open-label and single-center). To confirm these results, a randomized controlled multicenter study is needed.
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5. CONCLUSION
Our study shows that pulmonary rehabilitation with Intermittent Positive Pressure Breathing accelerates the recovery of pulmonary vital capacity after spinal fusion in adolescent idiopathic scoliosis. Functional walking capacities also appear to be improved. Finally, the longer term FVC recovery tends to be greater than in the absence of specific pulmonary rehabilitation. Therefore, rehabilitation with IPPB device must be considered more often in the common care of spinal fusion for AIS patients, as it probably ameliorates patients’ functional capacities, and thus their quality of life after surgery.
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6. Renzetti Jr, A. D., Bleecker, E. R., Epler, G. R., et al. (1986). Evaluation of impairment/disability secondary to respiratory disorders. American Review of Respiratory Disease, 133(6), 1205-1209.
7. dos Santos Alves, V. L., Avanzi, O. (2009). Objective assessment of the cardiorespiratory function of adolescents with idiopathic scoliosis through the six-minute walk test. Spine, 34(25), E926-E929.
8. Barrios, C., Pérez-Encinas, C., Maruenda, J. I., et al. (2005). Significant ventilatory functional restriction in adolescents with mild or moderate scoliosis during maximal exercise tolerance test. Spine, 30(14), 1610-1615.
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11. Yuan, N., Fraire, J. A., Margetis, M. M., et al. (2005). The effect of scoliosis surgery on lung function in the immediate postoperative period. Spine, 30(19), 2182-2185.
12. Weiss, H. R. (1991). The effect of an exercise program on vital capacity and rib mobility in patients with idiopathic scoliosis. Spine, 16(1), 88-93.
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13. Negrini, S., Aulisa, A. G., Aulisa, L., et al. (2012). 2011 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis, 7(1), 1.
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15. Dohna‐Schwake, C., Ragette, R., Teschler, H., et al. (2006). IPPB‐assisted coughing in neuromuscular disorders. Pediatric pulmonology,41(6), 551-557.
16. Denehy, L., Berney, S. (2001). The use of positive pressure devices by physiotherapists. European Respiratory Journal, 17(4), 821-829.
17. Sorenson, H. M., Shelledy, D. C. (2003). AARC clinical practice guideline. Intermittent positive pressure breathing--2003 revision & update. Respiratory care, 48(5), 540-546. 18. Bott, J., Blumenthal, S., Buxton, M., et al. (2009). Guidelines for the physiotherapy
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respiratory complications in patients with neuromuscular disease. Archivos de Bronconeumología (English Edition), 49(7), 306-313.
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23. Upadhyay, S. S., Ho, E. K., Gunawardene, W. M., et al. (1993). Changes in residual volume relative to vital capacity and total lung capacity after arthrodesis of the spine in patients who have adolescent idiopathic scoliosis. J Bone Joint Surg Am, 75(1), 46-52. 24. Kim, Y. J., Lenke, L. G., Bridwell, K. H., et al. (2005). Pulmonary function in
adolescent idiopathic scoliosis relative to the surgical procedure. J Bone Joint Surg Am, 87(7), 1534-1541.
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26. Lee, A. C., Feger, M. A., Singla, A., et al. (2016). Effect of Surgical Approach on Pulmonary Function in Adolescent Idiopathic Scoliosis Patients: A Systemic Review and Meta-analysis. Spine.
27. Kumano, K., Tsuyama, N. (1982). Pulmonary function before and after surgical correction of scoliosis. J Bone Joint Surg Am, 64(2), 242-248.
28. Johnston, C. E., Richards, B. S., Sucato, D. J., et al. (2011). Correlation of preoperative deformity magnitude and pulmonary function tests in adolescent idiopathic scoliosis. Spine, 36(14), 1096-1102.
29. Coe, J. D., Arlet, V., Donaldson, W., et al. (2006). Complications in spinal fusion for adolescent idiopathic scoliosis in the new millennium. A report of the Scoliosis Research Society Morbidity and Mortality Committee. Spine-Philadelphia-Harper And Row Publishers Then Jb Lippincott Company Then Lippincott Williams And Wilkins, 31(3), 345.
30. Reames, D. L., Smith, J. S., Fu, K. M. G., et al. (2011). Complications in the surgical treatment of 19,360 cases of pediatric scoliosis: a review of the Scoliosis Research Society Morbidity and Mortality database. Spine, 36(18), 1484-1491.
31. Kinnear, W. J. M., Kinnear, G. C., Watson, L., et al. (1992). Pulmonary function after spinal surgery for idiopathic scoliosis. Spine, 17(6), 708-713.
32. Grein, E. (2013). Intérêt de l'étude de la fonction respiratoire au lit du patient dans la chirurgie du rachis chez l'enfant et l'adolescent. Thèse de doctorat, Faculté de médecine de Nancy.
33. Scoliosis Research Society. (2016). Adolescent Idiopathic Scoliosis [en ligne]. Scoliosis Research Society [Consulté le 5/09/16]. Disponible sur:
http://www.srs.org/professionals/online-education-and-resources/conditions-and-treatments/adolescent-idiopathic-scoliosis
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LISTE DES TABLEAUX
Table 1. Population characteristics ... 31
Table 2. Values of spirometry according to time ... 32
Table 3. FVC evolution versus time ... 33
44
LISTE DES FIGURES
Figure 1. FVC evolution versus time. ... 33
Figure 2. FVC evolution versus time in our study compared to literature data.. 36
45
TABLE DES MATIERES
PROFESSEURS DES UNIVERSITES – PRATICIENS HOSPITALIERS ... 4
MAITRES DE CONFERENCES DES UNIVERSITES – PRATICIENS
HOSPITALIERS ... 10
REMERCIEMENTS ... 14
SOMMAIRE ... 16
TITRE ... 17
TITLE ... 17
RESUME ... 18
ABSTRACT... 20
MOTS-CLES ... 22
KEY-WORDS... 22
LISTE DES ABRÉVIATIONS ... 23
1. INTRODUCTION ... 23
2. MATERIAL AND METHODS ... 27
Study population ... 27
Study protocol ... 27
Judgment criteria ... 28
Statistical analysis ... 29
3. RESULTS ... 30
Population characteristics ... 30
Evolution of respiratory parameters ... 32
46
Correlation analysis... 34
4. DISCUSSION ... 35
5. CONCLUSION ... 39
REFERENCES BIBLIOGRAPHIQUES ... 40
LISTE DES TABLEAUX ... 43
LISTE DES FIGURES ... 44
TABLE DES MATIERES ... 45
ANNEXES ... I
Annexe 1 : Traitement chirurgical de la scoliose ... I
Appendix 1: Scoliosis surgical treatment ... I
Annexe 2 : Analyse des corrélations entre la récupération de CVf et les
paramètres de la population ... II
Appendix 2: Correlation analysis between FVC recovery and the
population’s parameters ... II
I
ANNEXES
Annexe 1 : Traitement chirurgical de la scoliose
Appendix 1: Scoliosis surgical treatment
There is no curative treatment for scoliosis, and the different treatments existing (rehabilitation, orthotics treatment, surgery) aim at preventing it from worsening and at preventing complications (respiratory, functional and esthetical). Spinal fusion is the key surgical treatment of AIS. The surgeon corrects the curvature of the spine and maintains the obtained correction by inducing a vertebral fusion with osteosynthesis devices and bone graft. It is indicated for simple thoracic, thoraco-lumbar or high lumbar AIS with Cobb angle higher than 40-45°, for simple high lumbar AIS with Cobb angle higher than 50-60°, for superior double curvatures AIS with Cobb angle higher than 60-70°, depending on the localization and the intensity of vertebral rotation, and for scoliosis evolving despise the brace treatment. Optimal age for the surgery is around 13 years of bone age for girls and 15 years of bone age for boys, along with appearance of Risser 1 stage, and closing of the Y cartilage [33]. It is at this age that the speed of the spine growth slows down, whereas the worsening of the curvature is still important, therefore arthrodesis is no longer risky for residual growth of the spine.
II
Annexe 2 : Analyse des corrélations entre la récupération de CVf et les paramètres
de la population
Appendix 2: Correlation analysis between FVC recovery and the population’s
parameters
Variable Number β P-value
Cobb angle, main curve 16 0.03 0.8484
Cobb angle, secondary curve 13 -0.00 0.9873
Pelvic incidence 16 0.16 0.3018 Lumbar lordosis 16 0.16 0.4330 Thoracic kyphosis 15 0.00 0.9939 FVC 16 0.76 0.0000 FEV 15 -0.25 0.3413 FEV/FVC 15 -0.22 0.3777 Walking speed 14 1.35 0.6247 Distance walked 14 0.02 0.4260 Heart rate 7 0.08 0.6310
Number of thoracic vertebrae fused 16 0.64 0.7708
Pain VAS > 0 at T0 16 0.01 0.9982
Known respiratory pathology 16 3.92 0.5484
Brace wearing 16 -1.86 0.6771 Anterior physiotherapy 16 2.49 0.7149 Post-operative complications 16 -12.4 0.0138 Post-operative oxygenotherapy 16 -0.22 0.9647 Quantitative parameters : Linear regressions Qualitative parameters : ANOVA
N° ANDREPOYAUD, Pauline. Apport du relaxateur de pression dans la récupération de la fonction respiratoire après chirurgie d’arthrodèse de la scoliose idiopathique de l’adolescent 41 feuilles, 2 figures, 3 tableaux, 2 annexes, 30 cm. Thèse : Médecine ; Rennes 1; 2016 ; N° . Résumé français Introduction La scoliose idiopathique de l’adolescent (SIA) entraine un syndrome restrictif pulmonaire proportionnel à la sévérité de la maladie. Le syndrome restrictif est corrélé à la présence de limitations fonctionnelles. L’arthrodèse rachidienne provoque une diminution des capacités respiratoires de l’ordre de 40 à 50% en post opératoire immédiat, dont la récupération se fait progressivement entre le premier et le troisième mois post opératoire.
Notre objectif était dʹanalyser lʹeffet dʹune rééducation respiratoire par relaxateur de pression sur la récupération de la capacité vitale forcée (CVf) après une chirurgie dʹarthrodèse dans la SIA. Matériel et méthodes Cette étude pilote, prospective et observationnelle dʹun protocole de soins courants a été menée au sein du service de rééducation pédiatrique du CHU de Rennes. Les patients inclus présentaient une SIA pour laquelle une indication d’arthrodèse vertébrale était posée. Les patients exclus étaient atteints dʹune scoliose secondaire ou dʹune pathologie pulmonaire préexistante et non stabilisée. Après un bilan initial 45 jours avant la chirurgie (T0), les patients débutaient la rééducation par relaxateur de pression. Après la chirurgie, ils suivaient un protocole de rééducation en hospitalisation en poursuivant l’utilisation du relaxateur de pression. Une spirométrie était effectuée à T0, la veille de la chirurgie (J1), puis pendant la deuxième (S2), la troisième (S3) et la quatrième (S4) semaine d’hospitalisation. Une dernière spirométrie était réalisée 4 mois (M4) après l’intervention. Le critère de jugement principal était l’évolution de la CVf après la chirurgie. Résultats 24 patients ont été inclus entre janvier 2011 et avril 2016. L’angle de Cobb moyen était 67,2° ± 16,5°. La CVf moyenne (% de la théorique) était de 69,3% à T0, 77,3% à J1, 49% à S2, 57,1% à S3, 68% à S4, 74,3% à M4. La CVf à J1 était plus élevée que la CVf à T0 de façon significative (+8%, p<0,05). Les Cvf à S2 et à S3 étaient plus basses que la CVf à T0 de façon significative (respectivement 20,3% et 12,2%, p <0,001). Par contre, les CVf à S4 et à M4 ne différaient pas de la CVf à T0 de façon significative (respectivement 1,3% et 4,9%). Conclusion
Avec notre protocole, à la quatrième semaine postopératoire la CVf est déjà revenue à la valeur pré opératoire. Cette étude montre donc que la rééducation par relaxateur de pression accélère la récupération de la CVf après chirurgie d’arthrodèse dans les SIA. Rubrique de classement : DIAGNOSTIQUE ET THERAPEUTIQUE Mots-clés : Scoliose, adolescent, arthrodèse vertébrale, capacité vitale, respiration en pression positive intermittente, rééducation et réadaptation Motsclés anglais MeSH : Scoliosis, adolescent, spinal fusion, vital capacity, Intermittent PositivePressure Breathing (IPPB), rehabilitation JURY : Président : Madame le Professeur Isabelle BONAN Assesseurs : Madame le Docteur Rachel HEYMAN [directeur de thèse] Monsieur le Professeur Philippe VIOLAS Monsieur le Professeur Eric WODEY Monsieur le Docteur Christophe CHARBONNIER Monsieur le Docteur Vincent DANIEL