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Infantile Scoliosis Workup

  • Author: Palaniappan Lakshmanan, MBBS, MS, AFRCS, FRCS(Tr&Orth); Chief Editor: Dennis P Grogan, MD  more...
 
Updated: Nov 02, 2015
 

Laboratory Studies

See the list below:

  • Scoliosis has been seen in families, and research is ongoing to identify any scoliosis-related genes. [8, 9]
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Imaging Studies

See the list below:

  • 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). [20] 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. [21, 22]
    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.[23]

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.[3]

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.[4]

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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: British Orthopaedic Association, AOSpine

Disclosure: Nothing to disclose.

Coauthor(s)

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, British Scoliosis Society

Disclosure: Nothing to disclose.

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.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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 Orthopaedic Association, Scoliosis Research Society, Pediatric Orthopaedic Society of North America, American Academy of Orthopaedic Surgeons

Disclosure: Received none from OrthoPediatrics for consulting; Received salary from Journal of Pediatric Orthopaedics for management position; Received none from SpineForm for consulting; Received none from SICOT for board membership.

Chief Editor

Dennis P Grogan, MD Clinical Professor (Retired), Department of Orthopedic Surgery, University of South Florida College of Medicine; Orthopedic Surgeon, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa

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

Disclosure: Nothing to disclose.

Additional Contributors

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 College of Sports Medicine, Pediatric Orthopaedic Society of North America, American Association for the History of Medicine, American Orthopaedic Society for Sports Medicine, Massachusetts Medical Society

Disclosure: Received consulting fee from Smith & Nephew Endoscopy for consulting; Received consulting fee from EBI Biomet for consulting; Received consulting fee from OrthoPediatrics for consulting; Received stock from Pivot Medical for consulting; Received consulting fee from pediped for consulting; Received royalty from WB Saunders for none; Received stock from Fixes-4-Kids for consulting.

References
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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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