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School scoliosis screening and the United States Preventive Services Task Force. An examination of long-term results.

STUDY DESIGN: Analysis of scoliosis screening in Dublin (1979-1990) of patients who passed significant levels (25 degrees and 40 degrees) and received orthotic treatment or surgery. OBJECTIVES: To reexamine the basis of school scoliosis screening. SUMMARY OF BACKGROUND DATA: The United States Preventive Services Task Force questioned the validity of school screening for adolescent idiopathic scoliosis because there is insufficient scientific evidence to justify it. METHODS: New entrants (1986-87) to the screening program were used to test the validity of the screening methods. The total screened population, proportions reaching significant Cobb angles or undergoing treatment, were compared across the time period. RESULTS: The sensitivity of the forward bend test in detecting or predicting 40 degrees scoliosis was 0.83, the specificity was 0.99, and the predictive value was 0.08. The proportion prescribed braces declined significantly (P < 0.01), but there was no significant change in those with scoliosis greater than 24 degrees (0.18%) or 39 degrees (.08%) nor was there a significant change in the numbers needing surgery (.045%). CONCLUSIONS: The incidence of significant scoliosis and of surgery is low and independent of changes in bracing policy. The validity of screening to cause significant change in prevalence must be challenged.

Adolescent↗

Syringomyelia. A potential risk factor in scoliosis surgery.

STUDY DESIGN: An 18-year-old patient with "idiopathic" adolescent scoliosis is presented. A thoracic syrinx was detected as an incidental finding during magnetic resonance imaging of the spine. OBJECTIVES: Syringomyelia may be a risk factor for neurologic injury during correction of scoliosis, and in these cases, spinal cord monitoring may be of particular value. BACKGROUND DATA: Spinal distraction and instrumentation carry a risk of neurologic damage in patients with scoliosis and associated syringomyelia. Syringomyelia is a cause of scoliosis, and although neurologic problems are the usual symptom, scoliosis may be the only sign at initial examination. A higher risk of neurologic injury has been reported in corrective surgical treatment of patients with syringomyelia. The mechanism of cord damage is unclear. Monitoring of spinal cord function is recommended to detect intraoperative neurological injury, which may be reversed on removing distraction and implants. RESULTS: Intraoperative somatosensory-evoked potential (SSEP) spinal cord monitoring detected possible cord damage during outrigger distraction. Reduction of distraction led to a recovery of SSEPs and a satisfactory operative outcome. CONCLUSION: Syringomyelia may be a risk factor for neurologic injury during correction of scoliosis, and SSEP spinal cord monitoring may identify and prevent intraoperative spinal cord injury.

Adolescent↗

[Imaging of scoliosis].

The majority of scoliosis (80%) and especially the idiopathic scoliosis are simply investigated by plain films of the entire spine with erect frontal and lateral views, and supine frontal view at the initial examination. Repeated erect frontal views are sufficient for the follow-up. The important radiation dose (average of 1.2 mG for the frontal view and 2.2 mG for the lateral views) imposes to reduce the frequency of these radiographs. This radiological study allows: to separate non structural and structural curves; the identification and the measurement of a structural curve, discussion for its etiology, appraisal of its progressiveness, discussion of the operative or non operative treatment, and radiological follow-up. Modern imaging (C.T, C.T myelography, MRI) is indicated only in very particular cases: idiopathic scoliosis with neurological symptoms, congenital scoliosis with structural vertebral abnormalities, especially these with posterior arch abnormalities, and progressive scoliosis in spinal dysplasiae. Painful scoliosis are unusual. If pain is present consideration should be given for diagnosis of an underlying lesion. In this case a relevant strategy using modern imaging becomes useful and will be discussed.

Humans↗

[Application of tuberculosis medical examination radiographs to scoliosis screening in high schools].

The purpose of this study was to assess the utilization of tuberculosis examination radiographs for scoliosis screening in high schools, for early diagnosis and early treatment of adolescent idiopathic scoliosis in the health management of students. We examined 2,068 first year high school students (1,058 males and 1,010 females) in Wakayama Prefecture, who had chest X-ray photographs taken between 1994 to 1996, and 24 cases (3 males and 21 females) were identified with scoliosis of more than 10 degrees Cobb angle. Fifteen of the cases received further examinations in the hospital, and were diagnosed with definite adolescent idiopathic scoliosis, while 6 cases who did not receive hospital examinations had their abnormality of the spine noted in past periodic health examinations. In the remaining 3 students scoliosis could not be confirmed. The correlation coefficient between the Cobb angle measured in the tuberculosis examination radiographs and in the total spinal radiographs taken by the hospital was 0.815 (p < 0.001). These results suggest that the tuberculosis examination radiographs may be useful for scoliosis screening in high schools.

Adolescent↗

Physical exercises in the treatment of idiopathic scoliosis at risk of brace treatment -- SOSORT consensus paper 2005.

BACKGROUND: Based on a recognized need for research to examine the premise that nonsurgical approaches can be used effectively to treat signs and symptoms of scoliosis, a scientific society on scoliosis orthopaedic and rehabilitation treatment (SOSORT) was established in Barcelona in 2004. SOSORT has a primary goal of implementing multidisciplinary research to develop quantitative, objective data to address the role of conservative therapies in the treatment of scoliosis. This international working group of clinicians and scientists specializing in treatment of scoliosis met in Milan, Italy in January 2005. METHODS: As a baseline for developing a consensus for language and goals for proposed multicenter clinical studies, we developed questionnaires to examine current beliefs, before and after the meeting, regarding (1) the aims of physical exercises; (2) standards of treatment; and (3) the impact of such treatment performed by specialists in the field. RESULTS: The responses to the questionnaires show that, in principle, specialists in scoliosis physiotherapy do not disagree and that several features can be regarded, currently, as standard features in the rehabilitation of scoliosis patients. These features include autocorrection in 3D, training in ADL, stabilizing the corrected posture, and patient education.

Journal Article↗

Three-dimensional spinal curvature in idiopathic scoliosis.

Scoliosis is usually considered as a deformity of the spine in the frontal plane, without reference to curvatures in other planes. In this study, the three-dimensional shape of the spine of 104 patients with untreated idiopathic scoliosis (5-55 degrees Cobb) was studied by means of stereo radiographs to determine relationships between curvature of the spine in the frontal plane view, in the lateral view, and in the intermediate views. There was a weak but statistically significant correlation (r = 0.2) relating greater scoliosis with lesser kyphosis or greater lordosis. In the thoracic region, the sagittal plane spinal curvature was less than that measured in a population without scoliosis (mean difference, 7.72 +/- 9.9 degrees). Seventy-four of 76 scolioses in the upper region of the spine with lateral curvature greater than 5 degrees Cobb were kyphotic. Sixty-four of 84 curves greater than 5 degrees Cobb in the lower region were lordotic. Measuring curvatures in the plane of symmetry of the rotated apical vertebra altered these ratios to 69 of 76 kyphotic in the upper region and 68 of 84 lordotic in the lower region. The plane of maximum curvature of sections of the spine with scoliosis was not related to the plane of symmetry of the rotated apical vertebra, for in kyphotic regions of the spine the rotations of these two planes were in opposite directions. In all cases, the magnitudes of the rotations were quite different, i.e., by a factor of -0.22 for curves in thoracic region and by a factor of 0.24 for curves in the lumbar region. This implies that mechanical measures to correct this spinal deformity or to prevent progression should apply different rotations to the apex from those applied to the curve as a whole and, in opposite senses, in curves in kyphotic regions. There was no evidence of an abnormality of sagittal curvature of a magnitude to implicate it in the etiology or in the treatment.

Adolescent↗

Genetic analysis of structural elastic fiber and collagen genes in familial adolescent idiopathic scoliosis.

Adolescent idiopathic scoliosis is a genetic disorder of unknown etiology. Scoliosis is a clinical feature of inherited connective-tissue disorders including Marfan syndrome. Mutations within the gene of FBN1 (fibrillin 15), a component of the extracellular matrix, are now linked to Marfan syndrome and similar clinical phenotypes. This study investigated the potential association of structural genes encoding for extracellular matrix components of FBN1, elastin, and one of the polypeptides of type-I collagen (COL1A2) with familial adolescent idiopathic scoliosis. Eleven pedigrees, including 96 individuals, were identified in which adolescent idiopathic scoliosis segregated in an apparent autosomal dominant pattern. Fifty-two individuals were determined to be affected with scoliosis. Genomic DNA was analyzed by genetic linkage utilizing four intragenic markers for the structural genes of FBN1, elastin, and COL1A2. Collectively, our results exclude the structural genes of FBN1, elastin, and COL1A2 as candidate genes within these families. However, when viewed individually, specific markers cannot be excluded within all of the families. This information complements previously reported data that fibrillin production and matrix incorporation from scoliotic fibroblasts in vitro are normal in more than 80% of patients studied.

Adolescent↗

Forced vital capacity and maximal respiratory pressures in patients with mild and moderate scoliosis.

Lung function and maximal respiratory pressures of 24 adolescent females with mild-to-moderate idiopathic scoliosis (spinal curvature 10-60 degrees) were determined and compared with 38 age- and sex-matched controls. Twelve patients with moderate scoliosis (Cobb angle 35-60 degrees) had significantly reduced mean values for FVC (% predicted) and maximal inspiratory pressure (MIP), as compared to the controls. Twelve patients with mild scoliosis (Cobb angle less than 35 degrees) had normal mean values for FVC and maximal respiratory pressures, but five individual patients had FVC values less than 80% predicted. All but one of the patients with mild scoliosis had normal MIP values. FVC (% predicted) was significantly correlated with the degree of spinal curvature (r = -0.466; P less than 0.05) but was not related to MIP. These results indicate that reduced FVC values do occur in patients with mild-to-moderate idiopathic scoliosis and suggest that these low FVC values can be attributed to the rib cage deformity rather than to an inability to generate adequate inspiratory pressures.

Adolescent↗

Parameter variation in stable scoliosis.

The reliability of scoliosis parameters such as the Cobb angle, the angle of trunk rotation and moir e topography is known from several publications. These studies concern intra- and interobserver variations; they are in general of transversal nature, which means the measurements were performed on the same subject within a short time period. From clinical experience it appears that these variations may be greater when scoliosis patients are followed over several years. In order to determine the parameter variation in the follow-up of children with scoliosis, a retrospective study was undertaken. From among our outpatient population, 41 children with stable scoliosis over a period of at least 2 years were selected. Stable scoliosis was defined as a spinal deformity which, in retrospect, had not deteriorated during at least a 2-year period prior to the end of growth. Hence no indication for treatment was found for this group. The measurements of the angle of external trunk rotation, moiré topography and Cobb angle of these children during the follow-up period were submitted to statistical computations using one-way analysis of variance. Variations in the results of Cobb angle measurement and the measurement of the angle of trunk rotation were found to be no different to the variations in intra- and interobserver measurements as reported mainly from transversal studies. The variation found in moiré topography, in moiré contour lines and in angle moiré determination, was, however, considered too great for measurements to be reliable. In conclusion, only Cobb angle determination and external measurement of trunk rotation can be accepted as valid follow-up parameters from a methodological viewpoint.

Adolescent↗

Progressive senile scoliosis: seven cases of increasing spinal curves in elderly patients.

An increasing scoliosis was documented in seven elderly women. The average curve at the most recent examination was 43 degrees (range 26 degrees-78 degrees). Previous films, from 5 to 26 years before, demonstrated an average increase of 2.3 degrees/year (range 1 degree-4.8 degrees/year). There were three lumbar and four thoracolumbar curves. Three curves were to the right and four were to the left. Only one patient had osteoporotic vertebral body crush fractures. The common underlying mechanism in the progression of senile scoliosis appears to be asymmetric loading of the spine which can be caused by a previously established scoliosis, spondylolysis/spondylolisthesis, lumbosacral anomalies, or leg length discrepancy. Subsequently, factors that can cause a curve to increase include degenerative disc disease with lateral disc space narrowing, soft tissue failure, and osteoporosis. Since even minor scoliosis can potentially progress in the older adult, increased monitoring of scoliosis in patients over age 50 years may be warranted.

Aged↗

Lung function in congenital and idiopathic scoliosis.

The vital capacity (VC) in patients with congenital scoliosis was compared with the VC in idiopathic scoliosis. For any given Cobb angle (a measure of spinal angulation) the loss in VC was approximately 15% greater in congenital scoliosis than in idiopathic scoliosis. The greater impairment of lung function in congenital scoliosis may be due to the associated rib deformity or to an underlying lung anomaly.

Adolescent↗

Adolescent idiopathic scoliosis as developmental instability.

Adolescent idiopathic scoliosis is the most common spinal deformity affecting children, with a prevalence from mass screening programmes of 1-3%. Despite centuries of study, it remains a problem with no generally accepted theory of aetiology, and disagreement on its natural history and management. Because the deformity consists ultimately of gross left-right asymmetry, a study was undertaken to test the hypothesis that it might be a manifestation of developmental instability. Palmar dermatoglyphics in 112 normal subjects, 62 with non-scoliosis trunk asymmetry and 85 with defined adolescent idiopathic scoliosis were examined and both the absolute right-left difference and the ratio of this to the total were considered. There was increased fluctuating asymmetry of atd difference in those with any asymmetry, scoliotic or not, and increased directional asymmetry of ab and cd ridge counts only in those with pure scoliosis. This suggests that, at adolescence, developmental instability may result in a loss of symmetry in growth, and that in the presence of an increased developmental left-right gradient, this may be of sufficient severity to be classified as deformity and come to the attention of orthopaedic surgeons. This interpretation changes the focus of many previous observations on scoliosis and raises the prospect that developmental stability in humans has relevance to problems hitherto restricted to clinical practice.

Adolescent↗

Amino-oxidase and dermal connective tissue in scoliosis.

The amino-oxidase and collagen content of dermal tissue was evaluated in 10 patients with severe idiopathic scoliosis and in a control group of 7 patients with poliomyelitic scoliosis, that were to undergo surgical correction of their skeletal deformity. A greater dermal content of neutral salt souble collagen was found in the patients with idiopathic scoliosis, compared with the control group. Statistically the difference was highly significant. Mono-amino-oxidase activity, however, was found to be significantly decreased in dermal extracts obtained from patients affected by idiopathic scoliosis in comparison with controls. The involvement of mono-amino-oxidase in the crosslinking of collagen and the possible classification of idiopathic scoliosis as a systemic disease of connective tissue are discussed.

Adolescent↗

Resolution of Ga-67 citrate uptake in the left neck mass of Hodgkin's disease and reversion of double scoliosis of cervical-thoracic and lower lumbar vertebrae.

A 6-yr-old boy underwent a total body Ga-67 citrate imaging study because of a large mass of Hodgkin's lymphoma in the left neck and the left anterior chest wall region. The images showed intense uptake in the left neck extending anteroinferiorly to the left upper chest wall corresponding to the left neck and chest region. In addition, there was mild cervical-upper thoracic scoliosis with convexity to the right and mild scoliosis of the lower lumbar scoliosis with concavity to the left. After three cycles of chemotherapy, in the follow-up Ga-67 citrate total body images seven months after his first Ga-67 citrate imaging, the intense uptake in the left neck and the left upper chest wall had been resolved and the scoliosis of the cervical-thoracic and lower lumbar spine had also been reversed to normal. This case shows that a Ga-67 citrate imaging study is useful for first diagnosis and subsequent monitoring of the therapeutic effects in a follow-up imaging. Also Ga-67 citrate imaging provided evidence that the scoliosis had been reversed.

Antineoplastic Combined Chemotherapy Protocols↗

[Conservative treatment of idiopathic scoliosis with physical therapy and orthoses].

Opinions differ in the international literature about the efficacy of conservative approaches to scoliosis treatment. Because this divergence of opinion corresponds to a great discrepancy in the standards applied to conservative treatment methods, it is not astonishing that the results of conservative treatment as described in the literature also differ. Scoliosis normally does not have such dramatic effects that immediate surgery would be indicated.Moreover, it is clear from the published literature that it is the functional and physiological impairments of scoliosis patients--including pain, torso deformity, psychological disturbance, and pulmonary dysfunction--which require therapeutic intervention. In Germany the triad of outpatient physiotherapy, intensive inpatient rehabilitation, and bracing has proven effective in conservative scoliosis treatment.Indication, content, and results of the individual treatment procedures are described and discussed. The positive outcomes of this practice validate a policy of offering conservative scoliosis treatment as an alternative to patients, including those for whom surgery is indicated.

Adolescent↗

Rapidly progredient scoliosis associated with multicore disease.

Multicore disease is a rare congenital myopathy that normally stops or makes slow progress. It starts with delayed motor development and frequent falls. Especially the proximal muscles are involved. Other symptoms include contractures of joints, clubfoot, high arched palate, chest deformities, involvement of eye-muscle, cardiac abnormalities, hyperlordosis and scoliosis that normally does not require surgery. We report a rare case of advanced scoliosis in multicore disease requiring operative treatment in a 15-year-old girl. In this case the scoliosis took a rapidly progredient course in puberty close to the end of skeletal growth. A dorsal spondylodesis with USS instrumentation from T9 to L3 was performed. A significant reduction of the scoliosis was obtained. Scoliosis in multicore disease may take a rapidly progredient course. Frequent checks will lead to the initiation of surgical treatment in time.

Actins↗

Height of girls with adolescent idiopathic scoliosis.

In a Finnish population, the standing height of 1500 consecutive female patients aged 9-24 years (mean 13.9 years) with untreated idiopathic scoliosis of at least 10 degrees in their lateral curves was compared with the standing height of average girls. The mean magnitude of the major curves was 29.4 degrees (range 10 degrees-80 degrees), and that of the minor curves 20.3 degrees (range 0 degrees-66 degrees). A formula for the height loss caused by the lateral curves, and that caused by thoracic kyphosis, was derived. The corrected height of the girls with idiopathic scoliosis was highly significantly (P<0.001) greater than the height of average girls at the age of 11-15, and this high level of significance was present at the age of 11-13, even without correcting for the height loss caused by scoliosis. After maturation, the girls with idiopathic scoliosis were not significantly taller than average girls. On average, the magnitude of thoracic kyphosis did not affect the height of patients with scoliosis as compared with the height of normal girls of the same age.

Adolescent↗

Platelet calmodulin levels in adolescent idiopathic scoliosis (AIS): can they predict curve progression and severity? Summary of an electronic focus group debate of the IBSE.

There is no generally accepted scientific theory for the etiology of idiopathic scoliosis. As part of its mission to widen understanding of scoliosis etiology, the International Federated Body on Scoliosis Etiology (IBSE) introduced the electronic focus group (EFG) as a means of increasing debate of extant knowledge on important topics. This has been designated as an on-line Delphi discussion. The text for this EFG was written by Professor Thomas G Lowe MD and drawn from research carried out by himself and his co-workers on platelet calmodulin levels in patients with adolescent idiopathic scoliosis. To explain the relationship of platelet calmodulin levels to scoliosis curve changes in AIS brought about spontaneously, by brace treatment, or surgery Dr Lowe attributes the platelet calmodulin changes to paraspinous muscle activity and suggests that the calmodulin acts as a systemic mediator of tissues having a contractile system (actin and myosin). Controversy includes: 1) the lack of normal data and the large variability in baseline levels of platelet calmodulin, necessitating the use of the AIS subjects as their own controls; 2) calmodulin is not usually used as a marker of platelet activation; 3) whether the platelet calmodulin changes which appear to reflect an abnormality of a portion of the spine are related to local and/or regional changes in muscles, nervous system, or immature vertebrae. What is not controversial is the need for more research on platelets and the immature deforming skeleton in relation to etiology and prognosis.

Adolescent↗