Infantile Scoliosis Workup
- Author: Palaniappan Lakshmanan, MBBS, MS, AFRCS, FRCS(Tr&Orth); Chief Editor: Dennis P Grogan, MD more...
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Scoliosis has been seen in families, and research is ongoing to identify any scoliosis-related genes. [8, 9]
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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. [21, 22]
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.
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.
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.
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