Infantile Scoliosis Workup

  • Author: Palaniappan Lakshmanan, MBBS, MS, AFRCS, FRCS(Tr&Orth); Chief Editor: Dennis P Grogan, MD   more...
 
Updated: Sep 14, 2011
 

Laboratory Studies

  • Scoliosis has been seen in families, and research is ongoing to identify any scoliosis-related genes.[7, 8]
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Imaging Studies

  • Radiographs of the spine in infants are taken with the child held up by the arms. As the patients are very young, radiographs usually are obtained either with a parent holding the child or with use of a pediatric immobilizer and positioner such as the Pigg-O-Stat. The severity of the scoliosis is established by calculating the rib-vertebral angle difference (RVAD) in the radiographs (see Indications). Radiographs and RVAD calculations should be repeated every 2-3 months to determine whether the curve is progressing or regressing.
  • Anteroposterior radiographs may also be used to evaluate the severity of the curve; however, they may not be accurate, as they assess a 3-dimensional deformity in a 2-dimensional projection. Still, they provide a reasonable estimation of severity and, hence, are used commonly in the evaluation of scoliosis. The angle between the superior endplate of the superior end vertebra and the inferior endplate of the inferior end vertebra is assessed. As lines drawn along these endplates normally pass beyond the edge of the radiograph, a second set of lines is drawn perpendicular to these lines and the angle subtended between them is measured; this is called the Cobb angle, as seen in the image below. The end vertebrae are the most superior and inferior vertebrae in the curve; they are differentiated by the opening of the intervertebral disk space caused by crowding on the concave surface. These vertebrae are theleastdisplaced and rotated, and havemaximally tilted endplates.[16, 17] Preoperative scoliogram showing the Cobb angle. Preoperative scoliogram showing the Cobb angle.
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Other Tests

CT scanning can be used to get a detailed picture of the scoliosis curve. Because spinal fusion is a major surgical treatment modality, patients need to be assessed with respect to their ability to withstand a major surgical procedure and need to have tests done for hemoglobin level and respiratory function.[18]

MRI scanning is necessary in moderate to severe infantile scoliosis, because the neural axis abnormalities associated with infantile scoliosis have been reported to range from 21-50%. The common abnormalities are Arnold-Chiari type I malformation and syringomyelia. Hence, whole-spine MRI is indicated before surgery. The current recommendation is for patients with infantile scoliosis with a Cobb angle greater than 20º.

A retrospective case series, of magnetic resonance imaging (MRI) findings in patients with presumed infantile idiopathic scoliosis, reviewed the medical records of 54 patients. MRI revealed a neural axis abnormality in 7 (13%) of 54 patients who underwent MRI. Of these 7 patients, 5 (71.4%) required neurosurgical intervention. Tethered cord requiring surgical release was identified in 3 patients, Chiari malformation requiring surgical decompression was found in 2 patients, and a small nonoperative syrinx was found in 2 patients. The authors concluded that on the basis of these findings, close observation may be a reasonable alternative to an immediate screening MRI in patients presenting with presumed infantile idiopathic scoliosis and a curve greater than 20º.[2]

A recent study reviewed the frequency of asymmetric lung perfusion and ventilation in children with congenital or infantile thoracic scoliosis before surgical treatment and the relationship between Cobb angle and asymmetry of lung function. The authors found that asymmetric ventilation and perfusion between the right and left lungs occurred in more than half of the children with severe congenital and infantile thoracic scoliosis, but the severity of lung function asymmetry did not relate to Cobb angle measurements. Asymmetry in lung function was influenced by deformity of the chest wall in multiple dimensions and could not be ascertained by chest radiographs alone.[3]

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Contributor Information and Disclosures
Author

Palaniappan Lakshmanan, MBBS, MS, AFRCS, FRCS(Tr&Orth)  Consultant Spinal Surgeon, Department of Trauma and Orthopaedics, Sunderland Royal Hospital, UK

Palaniappan Lakshmanan, MBBS, MS, AFRCS, FRCS(Tr&Orth) is a member of the following medical societies: AO Spine International and British Orthopaedic Association

Disclosure: Nothing to disclose.

Coauthor(s)

Jeetender Pal Peehal, MBBS, MS, MRCS  Knee Research Fellow, Positional MRI Centre, Woodend Hospital, UK

Jeetender Pal Peehal, MBBS, MS, MRCS is a member of the following medical societies: Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Sashin Ahuja, MBBS, FRCS, MSc, MS  Consultant Spinal Surgeon, Department of Orthopedics, University Hospital Of Wales, Cardiff, UK

Sashin Ahuja, MBBS, FRCS, MSc, MS is a member of the following medical societies: British Association of Spine Surgeons and British Scoliosis Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mininder S Kocher, MD, MPH  Associate Professor of Orthopedic Surgery, Harvard Medical School/Harvard School of Public Health; Associate Director, Division of Sports Medicine, Department of Orthopedic Surgery, Children's Hospital Boston

Mininder S Kocher, MD, MPH is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the History of Medicine, American College of Sports Medicine, American Orthopaedic Society for Sports Medicine, Massachusetts Medical Society, and Pediatric Orthopaedic Society of North America

Disclosure: Smith & Nephew Endoscopy Consulting fee Consulting; EBI Biomet Consulting fee Consulting; OrthoPediatrics Consulting fee Consulting; Pivot Medical Stock Consulting; pediped Consulting fee Consulting; WB Saunders Royalty None; Fixes-4-Kids Consulting

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

George H Thompson, MD  Director of Pediatric Orthopedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, and MetroHealth Medical Center; Professor of Orthopedic Surgery and Pediatrics, Case Western Reserve University School of Medicine

George H Thompson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society

Disclosure: OrthoPediatrics None Consulting; Journal of Pediatric Orthopaedics Salary Management position

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Dennis P Grogan, MD  Clinical Professor, Department of Orthopedic Surgery, University of South Florida College of Medicine; Chief of Staff, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa

Dennis P Grogan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association, Irish American Orthopaedic Society, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society

Disclosure: Nothing to disclose.

References

  1. Smith JR, Samdani AF, Pahys J, Ranade A, Asghar J, Cahill P, et al. The role of bracing, casting, and vertical expandable prosthetic titanium rib for the treatment of infantile idiopathic scoliosis: a single-institution experience with 31 consecutive patients. J Neurosurg Spine. Jul 2009;11(1):3-8. [Medline].

  2. Pahys JM, Samdani AF, Betz RR. Intraspinal anomalies in infantile idiopathic scoliosis: prevalence and role of magnetic resonance imaging. Spine (Phila Pa 1976). May 20 2009;34(12):E434-8. [Medline].

  3. Redding G, Song K, Inscore S, Effmann E, Campbell R. Lung function asymmetry in children with congenital and infantile scoliosis. Spine J. Jul-Aug 2008;8(4):639-44. [Medline].

  4. Harrenstein RJ. Die Skoliose bei Sauglingen und ihre Behandlung. Z Orthop Chir. 1930;52:1-40.

  5. Kumar K. Spinal deformity and axial traction. Spine. Mar 1 1996;21(5):653-5. [Medline].

  6. James JI. Two curve patterns in idiopathic structural scoliosis. J Bone Joint Surg [Br]. 1951;33-B:399-406. [Medline].

  7. Browne D. Congenital postural scoliosis. Br Med J. Sep 4 1965;5461:565-6. [Medline].

  8. Dunn PM. Congenital postural scoliosis. Arch Dis Child. Aug 1973;48(8):654. [Medline].

  9. Wynne-Davies R. Familial (idiopathic) scoliosis. A family survey. J Bone Joint Surg Br. Feb 1968;50(1):24-30. [Medline].

  10. Lincoln TL. Infantile idiopathic scoliosis. Am J Orthop. Nov 2007;36(11):586-90. [Medline].

  11. McMaster MJ. Infantile idiopathic scoliosis: can it be prevented?. J Bone Joint Surg Br. Nov 1983;65(5):612-7. [Medline].

  12. Wynne-Davies R. Infantile idiopathic scoliosis. Causative factors, particularly in the first six months of life. J Bone Joint Surg Br. May 1975;57(2):138-41. [Medline].

  13. Mehta MH. The rib-vertebra angle in the early diagnosis between resolving and progressive infantile scoliosis. J Bone Joint Surg Br. May 1972;54(2):230-43. [Medline].

  14. Mehta MH. Growth as a corrective force in the early treatment of progressive infantile scoliosis. J Bone Joint Surg Br. 2005;87(9):1237-1247. [Medline].

  15. Jarvis J, Garbedian S, Swamy G. Juvenile idiopathic scoliosis: the effectiveness of part-time bracing. Spine. May 1 2008;33(10):1074-8. [Medline].

  16. Grivas TB, Burwell GR, Vasiliadis ES, Webb JK. A segmental radiological study of the spine and rib--cage in children with progressive infantile idiopathic scoliosis. Scoliosis. Oct 18 2006;1:17. [Medline].

  17. Gstoettner M, Sekyra K, Walochnik N, Winter P, Wachter R, Bach CM. Inter- and intraobserver reliability assessment of the Cobb angle: manual versus digital measurement tools. Eur Spine J. Oct 2007;16(10):1587-92. [Medline].

  18. Alotaibi S, Harder J, Spier S. Bronchial obstruction secondary to idiopathic scoliosis in a child: a case report. J Med Case Reports. May 22 2008;2:171. [Medline].

  19. Akbarnia BA., Marks DS, Boachie-Adjei O, et al. Dual growing rod technique for the treatment of progressive early-onset scoliosis: a multicenter study. Spine. 2005;30(17 Suppl):S46-57. [Medline].

  20. Bridwell KH. Spinal instrumentation in the management of adolescent scoliosis. Clin Orthop Relat Res. Feb 1997;64-72. [Medline].

  21. Cotrel Y, Dubousset J. A new technic for segmental spinal osteosynthesis using the posterior approach [in French]. Rev Chir Orthop Reparatrice Appar Mot. 1984;70(6):489-94. [Medline].

  22. Dwyer AF, Newton NC, Sherwood AA. An anterior approach to scoliosis. A preliminary report. Clin Orthop Relat Res. Jan-Feb 1969;62:192-202. [Medline].

  23. Harrington PR. Treatment of scoliosis: correction and internal fixation by spine instrumentation. June 1962. J Bone Joint Surg Am. Feb 2002;84-A(2):316. [Medline].

  24. D'Astous JL, Sanders JO. Casting and traction treatment methods for scoliosis. Orthop Clin North Am. Oct 2007;38(4):477-84, v. [Medline].

  25. Motoyama EK, Deeney VF, Fine GF, et al. Effects on lung function of multiple expansion thoracoplasty in children with thoracic insufficiency syndrome: a longitudinal study. Spine. 2006;31(3):284-90. [Medline].

  26. Asher M, Lai SM, Burton D, Manna B, Cooper A. Safety and efficacy of Isola instrumentation and arthrodesis for adolescent idiopathic scoliosis: two- to 12-year follow-up. Spine. Sep 15 2004;29(18):2013-23. [Medline].

  27. Kesling KL, Lonstein JE, Denis F, Perra JH, Schwender JD, Transfeldt EE, et al. The crankshaft phenomenon after posterior spinal arthrodesis for congenital scoliosis: a review of 54 patients. Spine. Feb 1 2003;28(3):267-71. [Medline].

  28. MacEwen GD, Bunnell WP, Sriram K. Acute neurological complications in the treatment of scoliosis. A report of the Scoliosis Research Society. J Bone Joint Surg Am. 1975;57(3):404-408. [Medline].

  29. Yang JS, Sponseller PD, Thompson GH, et al. Growing Rod Fractures: Risk Factors and Opportunities for Prevention. Spine (Phila Pa 1976). Sep 15 2011;36(20):1639-1644. [Medline].

  30. Hoppenfeld S, Gross A, Andrews C, Lonner B. The ankle clonus test for assessment of the integrity of the spinal cord during operations for scoliosis. J Bone Joint Surg Am. 1997;79(2):208-12. [Medline].

  31. Mau H. The changing concept of infantile scoliosis. Int Orthop. 1981;5(2):131-7. [Medline].

 
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RVAD (rib-vertebral angle difference) measurement at apical vertebra: RVAD = b-a (concave - convex side).
Preoperative scoliogram showing the Cobb angle.
Postoperative scoliogram after correction with the pediatric Isola system.
Preoperative and postoperative radiographs show an increase in the space available for lung (SAL) after correction of scoliosis by VEPTR (vertical expandable prosthetic titanium rib).
Preoperative and postoperative radiographs show an increase in the space available for lung (SAL) after correction of scoliosis by VEPTR (vertical expandable prosthetic titanium rib).
 
 
 
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