Long-term observation and management of resolving infantile idiopathic scoliosis a 25-year follow-up

Scoliosis in patients with Chiari malformation type I

The literature about the association between Chiari malformations (CMs) and scoliosis has been growing over the last three decades; yet, no consensus on the optimal management approach in this patient population has been reached. Spinal anomalies such as isolated syrinxes, isolated CM, and CM with a syrinx are relatively common among patients with presumed idiopathic scoliosis (IS), a rule that also applies to scoliosis among CM patients as well. In CM patients, scoliosis presents with atypical features such as early onset, left apical or kyphotic curvature, and neurological deficits. While spinal X-rays are essential to confirm the diagnosis of scoliosis among CM patients, a magnetic resonance imaging (MRI) is also recommended in IS patients with atypical presentations. Hypotheses attempting to explain the occurrence of scoliosis in CM patients include cerebellar tonsillar compression of the cervicomedullary junction and uneven expansion of a syrinx in the horizontal plane of the spinal cord. Early detection of scoliosis on routine spinal examination and close follow-up on curve stability and progression are essential initial steps in the management of scoliosis, especially in patients with CM, who may require full spine MRI to screen for associated neuro-axial anomalies; bracing and spinal fusion may be subsequently pursued in high-risk patients.

Nonsurgical Management of Early-onset Scoliosis

Early-onset scoliosis is potentially fatal if left untreated. Although surgical management with growing instrumentation may be necessary, this is not a panacea and is associated with high complication rates. Recent evidence has demonstrated that nonsurgical treatment can be an effective early management strategy in delaying or even precluding the need for surgery, especially surgery with growing instrumentation. The goal of both nonsurgical and surgical management is to control or correct the spinal curve to allow appropriate pulmonary development while delaying definitive fusion until an appropriate skeletal age. Although more commonly used to delay surgery, serial cast correction using the Cotrel and Morel elongation-derotation-flexion technique may result in complete correction in patients with infantile idiopathic scoliosis and smaller curve magnitudes.

Epidemiology of adolescent idiopathic scoliosis

Adolescent idiopathic scoliosis is a common disease with an overall prevalence of 0.47-5.2 % in the current literature. The female to male ratio ranges from 1.5:1 to 3:1 and increases substantially with increasing age. In particular, the prevalence of curves with higher Cobb angles is substantially higher in girls than in boys: The female to male ratio rises from 1.4:1 in curves from 10° to 20° up to 7.2:1 in curves >40°. Curve pattern and prevalence of scoliosis is not only influenced by gender, but also by genetic factors and age of onset. These data obtained from school screening programs have to be interpreted with caution, since methods and cohorts of the different studies are not comparable as age groups of the cohorts and diagnostic criteria differ substantially. We do need data from studies with clear standards of diagnostic criteria and study protocols that are comparable to each other.

Early onset idiopathic scoliosis

Children with early onset scoliosis typically present before age 5 years. Radiographic criteria help to distinguish progressive cases from those that will spontaneously resolve. Severe cardiopulmonary problems may occur in untreated progressive cases. A comprehensive evaluation should be performed to identify commonly associated conditions, such as plagiocephaly, congenital heart disease, inguinal hernia, and hip dysplasia. For curves >20 degrees , magnetic resonance imaging of the neural axis is indicated to rule out occult central nervous system lesions. Surgical management should be considered when nonsurgical measures, including bracing and casting, fail to arrest progression. Surgical methods continue to evolve and are primarily directed at obtaining and maintaining curve correction while simultaneously preserving spinal and trunk growth.

Idiopathic infantile asymmetry, proposal of a measurement scale

To evaluate the development of idiopathic infantile asymmetry and the efficacy of therapeutic interventions, spinal scoliosis can be quantified on the basis of radiographs. For obvious reasons, use of this technique is limited. Here we present a clinical method to describe and quantify infantile asymmetry. For item selection, spontaneous movements (SMs), reactive movements (RMs) and length differences were video recorded in 30 infants (median age 10 weeks, range 6-16) with variable degrees of asymmetry. Within these three categories, reactive movements elicited by head turns to the right and left side in the prone and supine position emerged as reliable parameters reflecting trunk convexity and cervical rotation deficits. Six-point scales were developed for both measurements and added to form final scales. Consistency and interobserver reliability were evaluated in another 20 infants (median age 9 weeks, range 6-15) with variable degrees of asymmetry. Statistical analysis indicated good reliability and consistency of the testing method with an intraclass correlation coefficient of 91.5% (Cronbach alpha 0.84).

CONCLUSION

During the first months of life, idiopathic infantile asymmetry can be clinically assessed using a highly consistent and reliable measurement scale describing degrees of trunk convexity and cervical rotations deficit.