Current Concepts in the Management of Early-onset Idiopathic Scoliosis

Ujjwal K Debnath

Disclosures

Pediatr Health. 2010;4(3):343-354. 

In This Article

How to Assess the Child with Early-onset Scoliosis

Clinical

Clinicians should be able to elicit the birth history and the developmental milestones from the mother. EOS has been known to occur in association with breech presentation as well as in premature low birth-weight male children.[23] A thorough physical examination from head to toe is important to exclude any other causes of the spinal deformity. Physical examination may reveal evidence of chest wall and shoulder height asymmetry, trunk imbalance and pelvic obliquity. Thoracic scoliosis in infants is more common in boys and is to the left in 92% of cases.[3] On the contrary, Goldberg et al. found that there was an absolute association between gender and disease, but no significant correlation between left convexity and disease.[34]

The physicians should assess the flexibility of the curvature by holding the infant prone on their knees with convex side downward. If the child is walking, then one may suspend the child by holding under the arms and assess the correction of curve with lateral pressure. Limb lengths should be measured in supine position. One must look for other associations (e.g., plagiocephaly, dysplastic hip, inguinal hernia and evidence of congenital heart disease). A neurological examination should be carried out at the end to rule out neurological causes of scoliosis (e.g., syringomyelia or Chiari 1 malformation).[35] Gradual progression occurs at 2–3° per year and malignant progression occurs at 10° per year. Curve resolution occurs in 90% children who are diagnosed before the age of 1 year.

Imaging

Imaging studies should include plain radiographs of whole spine in both antero-posterior and lateral plane. The curvature should be measured using Cobb's method[36] and rib–vertebral angle difference (RVAD) is measured using Mehta's method.[37] The RVAD is useful in predicting curve progression. The rib–vertebrae angle is measured by (Figure 1):

Figure 1.

 

Rib-vertebral angle difference measurement at apical vertebra (b – a).

  • Drawing a line perpendicular to the middle of the upper or lower border of the apical vertebrae of the curve;

  • Then measuring the angle this line makes with the medial extension of another line drawn from the mid point of the head to the mid point of the neck of the rib, just medial to the beginning of the shaft of the rib;

  • The difference between the right and the left side (concave and the convex side) is the RVAD.

A whole-spine MRI scan should be performed in all patients to rule out any neural axis abnormalities. Incidence of 17.6% neural axis abnormalities has been observed in a study.[38] Recent evidence suggested 21.7% neural axis abnormalities in patients with Cobb angle more than 20°.[39] A 3D CT scan is required to understand the deformity in all planes as well as the pedicle morphology for choice of the implants (Figure 2A & B).

Figure 2.

A 10-year-old boy who had spinal fusion at the age of 5 years returned for clinico-radiological assessment before the pubertal growth spurt.
(A) Clinical photograph of the back. (B) A 3D CT scan showing the deformity in all planes.

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