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PubMed1991

Idiopathic scoliosis and asymmetry of form and function.

This report investigates dimensions of hand and foot preference in 159 girls with idiopathic scoliosis diagnosed after the age of 8 years, 1,522 girls with clinically straight spines, and 132 with minor truncal asymmetry. It was found that, although there was no significant difference in hand or foot preference for individual items between scoliotic groups and controls, there was a statistically significant tendency for children with any degree of asymmetry to show uniform lateralization in the sense of consistency of side preference. Another, smaller group showed a tendency for scoliosis to be associated with clearly visible facial asymmetry, which itself correlated with handedness. It was concluded that theories of scoliosis need to include the frequently ignored minor observations, such as the well-known fact of lateralization of the curve, if they are to describe the condition completely. Because the asymmetry of cerebral lateralization is known to be genetically determined and because it is thought to result in other skeletal asymmetries, such as skull and limb inequality, it seemed reasonable to investigate the primary cause of that gross asymmetry, idiopathic scoliosis.

Adolescent↗
PubMed1991

Effectiveness of nonsurgical treatment for idiopathic scoliosis. Overview of available evidence.

To define further the effectiveness of nonsurgical therapy for idiopathic scoliosis, predefined criteria were established for selection and data retrieval from studies of therapy and natural history, and the results were synthesized quantitatively. Only studies of patients with no more than a 50 degree Cobb angle scoliosis were considered. Twenty-four reports were eligible. There was a fivefold proportion of failures among patients with scoliosis greater than 30 degrees at the start of therapy but no difference in progression between different kinds of nonsurgical therapies or between treated and untreated patients; these were the main findings of this quantitative analysis. These data cannot be used to prove the effectiveness or ineffectiveness of nonsurgical therapy for idiopathic scoliosis, and experimental controlled studies of different therapies seem to be justified both on ethical and scientific grounds. The findings of this overview can be used for their planning.

Adolescent↗
PubMed1991

Magnetic resonance imaging of the brain stem in adolescent idiopathic scoliosis.

The cause of adolescent idiopathic scoliosis remains an enigma. Several studies have demonstrated abnormalities of posture, proprioception, and equilibrium control in patients with adolescent idiopathic scoliosis. These functions are integrated by structures in and around the brain stem. Twenty-seven patients with adolescent idiopathic scoliosis were studied with magnetic resonance imaging to delineate the anatomy of the brain stem in such patients. Imaging was conducted from the hypothalamus to the spinal cord at C3 in 26 patients; the remaining patient underwent an incomplete study because of a claustrophobic reaction. The study group consisted of 25 females and 2 males with an average age of 16 + 5 years. There were 19 right thoracic curves, 5 thoracolumbar curves, and 3 left lumbar curves. The mean primary curve size was 27 degrees at the most recent clinical evaluation. Seven patients were treated with observation, 14 with bracing, and 6 with surgery. The magnetic resonance imaging studies were read independently by three attending radiologists in a randomized, blinded fashion along with the magnetic resonance imaging studies of 11 controls. Asymmetry in the ventral pons or medulla in the area of the corticospinal tracts was noted in seven study patients and one control; one study patient had an enlarged cisterna magna and one an inconclusive (incomplete) study. These findings may support previous studies that have suggested a central nervous system abnormality as a cause of adolescent idiopathic scoliosis.

Adolescent↗
PubMed1991

A biomechanical analysis of Zielke, Kaneda, and Cotrel-Dubousset instrumentations in thoracolumbar scoliosis. A calf spine model.

A biomechanical study was performed in order to evaluate the initial stability of three spinal instrumentation systems, applied to a scoliosis model. Five calf spines (T11-L2) were destabilized anteriorly, and, by inserting a wedge-shaped resin disc within each destabilized intervertebral space, a thoracolumbar scoliosis was created. Three spinal instrumentation systems (Zielke anterior instrumentation, Kaneda anterior multisegmental fixation device, and Cotrel-Dubousset posterior instrumentation) were applied to correct the simulated scoliotic condition. Mechanical nondestructive cyclical testing in axial compression, rotation, flexion, and extension was performed on each spinal construct. The Kaneda device was the most stable instrumentation in all four loading conditions. Zielke instrumentation failed to restore the stability to the level of the intact spine in rotation, and was the least rigid instrumentation in flexion and extension. The Cotrel-Dubousset instrumentation demonstrated favorable stability in flexion and extension, but became the least rigid instrumentation in axial compression and rotation. This study suggests that a one-stage procedure with Zielke instrumentation and a two-stage procedure (anterior release with bone graft and posterior stabilization) with Cotrel-Dubousset instrumentation applied for the correction of scoliosis, should be supplemented with additional external or internal supports. The Kaneda device may offer enough stability with an anterior procedure alone in the correction of scoliosis.

Animals↗
PubMed1992

Rib hump and supine angle as prognostic factors for mild scoliosis.

A retrospective study was conducted on 262 patients with minor idiopathic scoliosis, having supine angles of less than 30 degrees and rib humps of less than 30 mm at the first examination. The initial radiographic measurement of the Cobb supine angle and rib hump height, recorded during a bending test performed on subjects in a sitting position, was correlated with the rate of scoliosis progression. Scoliosis progression was estimated graphically from an angle diagram established by monitoring untreated patients for 7 months to several years, depending on the rate of progression before treatment. More than 95% of the patients with initial supine angles of more than 17 degrees or rib humps greater than 11 mm suffered from progressive scoliosis. The importance of the size of the supine angle, rib-hump height, scoliotic pattern, and state of maturation for the progression rate are analyzed. Knowledge of these parameters can be used to make individual prognoses for approximately 95% of these subjects.

Adolescent↗
PubMed1992

Respiratory failure in scoliosis and other thoracic deformities. A survey of patients with home oxygen or ventilator therapy in Sweden.

Registers covering Swedish patients with home ventilator or long-term oxygen therapy were used to study respiratory failure caused by thoracic deformities. In all, 107 patients were studied. Postpolio scoliosis was found in 47 patients. The age of starting therapy varied between 28 and 80 years. Fourteen patients had thoracic deformities other than scoliosis. The mean scoliotic angle was 135 degrees among the patients with scoliosis, and the mean vital capacity was 26% (range, 13-54%) of predicted normal. The yearly demand for home ventilator or oxygen therapy is calculated to three per million inhabitants. No operated patients had respiratory failure, and no patients were found with idiopathic scoliosis and respiratory failure younger than 30 years of age, which may indicate a preventive effect of corrective surgery on the development of respiratory failure.

Aged↗
PubMed1992

Routine use of magnetic resonance imaging in idiopathic scoliosis patients less than eleven years of age.

The purpose of this study was to determine the incidence of intraspinal pathology presenting as idiopathic scoliosis in children less than 11 years of age and otherwise neurologically normal. Twenty-six consecutive patients (5 boys, 21 girls) with idiopathic scoliosis measuring at least 15 degrees were studied with magnetic resonance imaging. Five children (19.2%) were diagnosed by magnetic resonance imaging to have Chiari-I malformations with hydromyelia (two patients), syringomelia (one patient), intramedullary tumor (one patient) and terminal lipoma (one patient). Only two of the five patients had left thoracic curves. Intramedullary spinal cord pathology can present as scoliosis without neurologic signs. Scoliosis can be the initial neurologic sign suggesting intraspinal pathology, and magnetic resonance imaging is indicated in routine evaluation of children less than 11 years of age.

Arnold-Chiari Malformation↗
PubMed1992

Cotrel-Dubousset instrumentation in idiopathic scoliosis.

Although well accepted in the patient undergoing Harrington instrumentation, the validity of King's criteria in patients undergoing correction of idiopathic scoliosis using the Cotrel-Dubousset system has been questioned. The cases of 64 patients with Type II (N = 40) and Type III (N = 24) idiopathic scoliosis treated with Cotrel-Dubousset instrumentation were reviewed. The average curve correction for Type II spinal curvature was 69.4% after surgery and 57.8% at follow-up examination. Decompensation was evident in 40% of the curves that were fused beyond the stable vertebra. However, the patients were only aware of their trunk decompensation if it was larger than 10 mm, and this was found in 35% of the patients. Decompensation occurred in 60% of those that were fused short of or to the stable vertebra. Only 42% of this group were aware of their decompensation. Decompensation was measured to the left of the spine in all patients. The difference between the subgroups based on the choice of distal fusion levels was not statistically significant (P greater than 0.05). The average curve correction for Type III scoliosis was 62.9% after surgery and 54.6% at the time of follow-up examination. There was no correlation between caudal fusion levels and the incidence of decompensation with Type III curves. It was concluded that there was no statistically significant relationship between choice of distal fusion level and the amount of decompensation, thereby indicating that the use of King's criteria for the selection of fusion levels in patients undergoing correction of idiopathic scoliosis using the Cotrel-Dubousset instrumentation may not be useful.

Adolescent↗
PubMed1992

Rotation vector, a new method for representation of three-dimensional deformity in scoliosis.

Rotation vector for three-dimensional deformity, a new concept in scoliosis, is presented. This vector quantifies three-dimensional deformity in scoliosis. Rotation vectors are calculated between pairs of end plates. Any three-dimensional malalignments (scoliosis, lordosis [or kyphosis] and rotation) existing between a pair of end plates should be cancelled perfectly by rotating one end plate against the other about an axis represented by the rotation vector. A rotation vector suggests how the deformity in scoliosis should be corrected three-dimensionally.

Adolescent↗
PubMed1993

Adolescent idiopathic scoliosis and joint laxity. A study with somatosensory evoked potentials.

To assess the existence of disturbances in proprioception in adolescent idiopathic scoliosis and an hypothetical relationship with generalized joint laxity, a blind comparative study of short-latency somatosensory evoked potentials by posterior tibial nerve stimulation was designed. One hundred twenty-one subjects were included: fifty-two were diagnosed as having adolescent idiopathic scoliosis, thirty-two met criteria for generalized joint laxity, twenty-one had curvatures with Cobb angles less than 10, and twenty-eight were matched control subjects; twelve subjects were initially seen with both adolescent idiopathic scoliosis and generalized joint laxity. We failed to find alterations in somatosensory evoked potentials in patients with adolescent idiopathic scoliosis that could suggest proprioceptive disturbances as a causative factor; however, in a subgroup of thoracolumbar curvatures we were able to demonstrate a functional alteration in somatosensory evoked potentials that could represent a neurologic basis for some curves considered as idiopathic thus far; generalized joint laxity seems to be implicated in this situation.

Adolescent↗
PubMed1994

Low-dose radiography of scoliosis in children. A comparison of methods.

STUDY DESIGN: Records of 1,582 conventional and computed radiographic examinations performed to evaluate scoliosis were reviewed and compared to determine differences in total radiation burden. OBJECTIVE: This study evaluated the impact of computed radiographic imaging (CRI) on radiation exposure in children undergoing serial spinal radiographs for scoliosis assessment and compared exposure from CRI with that of low-dose film-screen combinations. SUMMARY OF BACKGROUND DATA: CRI permits diagnostic radiographic studies to be performed with a dose reduction of 80%-95% compared to conventional film-screen systems. High speed film-screen systems also permit a significantly lower exposure. Each approach has unique advantages and disadvantages. METHODS: Over 6 years, we performed 1,582 spinal examinations in children 4-14 years old using reduced dosage techniques with computed radiography. The images were obtained with Fuji FCR 101 and Philips PCR/SP systems. The adequacy of diagnostic image quality in the serial evaluation of scoliosis at different exposure levels was evaluated and compared with regular and film-screen systems with speeds ranging from 250 to 1,200. RESULTS: Diagnostic-quality images for evaluating scoliosis can be obtained with doses of 5% or less than required with conventional film-screen systems. Computed radiography provides image quality and dose reduction comparable to a 1,200-speed film-screen system. CONCLUSION: CRI gives satisfactory images at 5% reduction of the standard film-screen dose. Based on comparison with a 1,200 speed film-screen system, CRI provides equal or better image quality at a similar radiation dose. The cost of CRI is higher than for film-screen radiography, but wide latitude and the ability to tailor dose with requirements for image quality are significant advantages for CRI.

Adolescent↗
PubMed1994

Left thoracic scoliosis configurations. Why so different?

STUDY DESIGN: Patients in the scoliosis screening database were analyzed with respect to curve convexity, severity, and outcome, using standard statistical methods. OBJECTIVES: This study assessed whether left thoracic scoliosis is always pathologic and inquired why this is the case. SUMMARY OF BACKGROUND DATA: Left thoracic scoliosis is more significant than the usual right thoracic pattern, but evidence in the literature is circumstantial. METHODS: Prospectively collected data from 1979-1990 was analyzed in the natural history database of the school screening program. RESULTS: Right thoracic pattern was observed in 421 girls, and left thoracic pattern was present in 125 girls. The minimum age at diagnosis was 10 years and the Cobb angle was > 4 degrees. Primary left thoracic patterns were statistically smaller and less progressive. CONCLUSIONS: The left pattern of scoliosis in the absence of overt neuropathology carries a benign prognosis. This contradictory observation is examined in the light of biological asymmetry.

Adolescent↗
PubMed1995

Progressive scoliosis in Dubowitz syndrome.

STUDY DESIGN: This case report describes a 17-year-old male with Dubowitz syndrome in whom a progressive left thoracic scoliosis developed that required surgical correction. OBJECTIVE: Scoliosis associated with Dubowitz syndrome had not been previously described among the orthopedic manifestations of this rare syndrome. A review of the literature and the surgical treatment of this patient is presented. SUMMARY OF BACKGROUND DATA: Dubowitz syndrome is a rare autosomal recessive disorder characterized by microcephaly, craniofacial abnormalities, eczematous skin rash, delayed skeletal maturation, and shortness of stature. The orthopedic manifestations of this condition primarily involve the hands and feet with brachyclinodactyly of the fifth finger and syndactyly of the second and third toes. Spinal deformity in these individuals is not well described in the literature. METHODS: Over a 2-year period, the patient's scoliosis progressed to 88 degrees, resulting in severe truncal imbalance without neurologic sequelae. A posterior spinal fusion with segment instrumentation alone was used to correct the deformity. RESULTS: After surgery, excellent restoration of spine sagittal and coronal plane alignment was achieved, resulting in improved sitting and standing balance. CONCLUSION: Patients with Dubowitz syndrome may be at risk of having a progressive, rigid scoliosis. These individuals may need to be observed over a prolonged period for the development of spinal deformity because of the potential for extended delay in skeletal maturation.

Abnormalities, Multiple↗
PubMed1996

Scoliosis in cerebral gigantism, Sotos syndrome. A case report.

STUDY DESIGN: This retrospective study reviewed five patients with scoliosis associated with cerebral gigantism (Sotos syndrome). OBJECTIVE: To clarify the clinical characteristics and progression of scoliosis in patients with cerebral gigantism. SUMMARY OF BACKGROUND DATA. Little has been reported about spinal deformity in this syndrome. METHODS: The records and radiographs of five patients were reviewed. RESULTS: Scoliosis was first noticed at the age of 5 years in one case and at 6-16 months in the others. Their curve patterns were not consistent. Cobb's angles increased rapidly by 4 years of age and after 8 years of age despite attempts at bracing. CONCLUSIONS: Excessive growth in infancy and growth-spurt period after 8 years of age may be related to the rapid progression of scoliosis in the same period.

Brain↗
PubMed1997

Rotational changes of the vertebral pelvic axis after sublaminar instrumentation in adolescent idiopathic scoliosis.

STUDY DESIGN: The authors studied the rotational effect of sublaminar wiring on the spinal pelvic axis on 20 patients who were being treated for adolescent idiopathic scoliosis. OBJECTIVES: To determine if sublaminar wiring effectively derotates the scoliotic spine. SUMMARY OF BACKGROUND DATA: The correction of the rotational deformity in adolescent scoliosis via sublaminar wiring is not well quantified in the literature. The derotation maneuver of Cotrel-Dubousset has been shown to produce variable and unpredictable amounts of axial derotation. METHODS: Twenty patients who underwent posterior spine fusion for adolescent idiopathic scoliosis were evaluated using computed tomography scans and plain radiography before and after surgery and at a subsequent follow-up examination (average time of follow-up examination, 35 months after surgery). The degree of angle of vertebral rotation about the sagittal plane and that relative to the pelvis were measured before and after surgery and at a follow-up examination. RESULTS: The primary thoracic curves were not derotated significantly relative to the pelvis with sublaminar wiring. Primary thoracolumbar curves instrumented on the convexity with pedicle screws were derotated significantly relative to the pelvis (P = .001). The average initial correction was 57%. On final follow-up examination, the correction was 24% (18 of 20 twenty individuals lost axial correction by an average of 34%). In nine of 20 patients the spine was more rotated, relative to the pelvis, than it had been before surgery. No coronal or sagittal decompensation was seen in any curve type. CONCLUSIONS: Coronal and sagittal plane correction of scoliotic curves may be achieved with sublaminar instrumentation. The ability to derotate axially the scoliotic spine appears to be variable, however, and, in most cases, curve-type dependent. Over time, much correction appears to be lost, and in many patients the scoliosis actually becomes worse than it was before surgery. Nonetheless, the apical derotation that takes place appears to be reasonably true: the percent correction of angle of rotation about the sagittal plane and the percent correction of angle of rotation about the sagittal plain relative to the pelvis were closely correlated. Derotation forces applied to the instrumented spine do not appear to be transmitted to more distal segments.

Adolescent↗
PubMed1997

Changes in the unfused lumbar spine in patients with idiopathic scoliosis. A 5- to 9-year assessment after cotrel-dubousset instrumentation.

STUDY DESIGN: Postoperative changes in the lumbar spine were studied retrospectively in patients with adolescent idiopathic scoliosis who had been treated with Cotrel-Dubousset instrumentation. OBJECTIVE: To examine middle-term changes in the unfused lumbar segments below an instrumented scoliosis fusion. SUMMARY OF BACKGROUND DATA: Scoliosis fusion by the Harrington method is known to be associated with a flat back in the fused area and subsequent degenerative changes in the segments below the fusion. No data have yet been published concerning a segmental instrumentation system. PATIENTS AND METHODS: Thirty patients with idiopathic scoliosis, between the ages of 14 and 22 years at the time of surgery, were observed for 5-9 years after surgery. Activity, pain, complications, and 21 radiographic parameters were assessed. RESULTS: The prevalence of low back pain increased from 3% before surgery to 20% at the final follow-up visit, although in none of the patients was the pain so severe that specific treatment was required. Radiographically, uninstrumented lumbar segments generally were realigned successfully in the frontal plane. Analyses in the sagittal plane revealed tendencies to a gradual increase in lumbar lordosis, anterior-upward tilting of the lowest instrumented vertebra, and posterior shift of the sagittal spinal balance. During the follow-up period, seven patients (23%) developed degenerative changes, including mild junctional kyphosis, retrolisthesis, narrowing of disc spaces, or osteophytes. CONCLUSION: Whereas the overall clinical and radiographic results of surgery were satisfactory, the unfused lumbar segments required careful surveillance, especially in the sagittal plane.

Activities of Daily Living↗
PubMed1997

Operative treatment of scoliosis with Cotrel-Dubousset-Hopf instrumentation. New anterior spinal device.

STUDY DESIGN: This study analyzes the effects of a new anterior spinal instrumentation system and the results of use in 50 patients with scoliosis. OBJECTIVES: Anterior spine systems are reviewed. The principles of a new anterior spinal instrumentation system allowing for postoperative care without external support are discussed. SUMMARY OF BACKGROUND DATA: Numerous different implants have been presented in the literature for anterior spinal surgery. Nevertheless a primary stable anterior instrumentation was not available for multisegmental procedures until now, and the restoration of lordosis in the lumbar spine was very difficult with the common devices. The development of more stable devices that also allow a restoration of lordosis in combination with derotation and compression is discussed. METHODS: Fifty patients with scoliosis of different etiologies (neuromuscular: n = 33; idiopathic: n = 16; congenital: n = 1) underwent anterior spinal surgery at the thoracic, thoracolumbar, and lumbar spine. During follow-up, no revision operation was necessary after the monosegmental and multisegmental application of this method, and there were no vessel complications. The results were controlled with a mean follow-up of 26.6 (range 12-41) months. RESULTS: Clinical and radiologic follow-up and complications are reported. Statistical data obtained show a different average blood loss and operation time depending on the different etiology of the scoliotic deformity. The mean corrections for the scolioses by etiology are as follows: myelomeningocele (MMC) (mean preoperative angle 89 degrees, mean correction 54%); neuromuscular (81 degrees, 46%); and idiopathic (55 degrees, 69%). The mean lordosis of the lumbar spine was 29.2 degrees (measured between T12-S1) and could be corrected to 45.2 degrees depending on the etiology of the curvature, whereas the angle of the thoracic kyphosis did not show an essential change. The segmental measurement in idiopathic scoliosis did not show a kyphosization in the lumbar spine. Derotation of the apical vertebra in 15 patients in relation to the sagittal plane was 37%. CONCLUSIONS: The study shows the effect of a new anterior device allowing the application of three-dimensional correction forces to the spine. Particularly in scoliosis derotation, compression and restoration of lordosis are possible. Primary stability is obtained by anchoring the implants with a new wedge-locking technique, which makes postoperative external support unnecessary.

Adolescent↗
PubMed1997

Magnetic resonance imaging evaluation of the adolescent patient with idiopathic scoliosis before spinal instrumentation and fusion. A prospective, double-blinded study of 140 patients.

STUDY DESIGN: This was a prospective, double-blinded study of the magnetic resonance imaging findings in the neural axis of 140 neurologically normal typical adolescents with idiopathic scoliosis who were scheduled for scoliosis surgery. OBJECTIVE: To detect the prevalence of spinal cord and neural axis abnormalities in this select population. SUMMARY OF BACKGROUND DATA: No similar study exists, although a few related studies were published. METHODS: Full-length neural axis magnetic resonance imaging studies were reviewed independently by two radiologists who specialize in the spine. RESULTS: Only four patients had a definite abnormality-one a small thoracic syrinx and the other three with a Chiari malformation. None of these required neurosurgery. All 140 patients had their scoliosis surgery without necrologic compromise. CONCLUSION: Routine magnetic resonance imaging evaluation of neurologically normal, typical adolescents with idiopathic scoliosis is not warranted, based on this study.

Adolescent↗