Is the routine use of magnetic resonance imaging indicated in patients with scoliosis?

Does intervertebral disc degeneration in adolescent idiopathic scoliosis correlate with patient-reported pain scores? A review of 968 cases

PURPOSE

Report the rate and severity of degenerative disc disease (DDD) in non-surgical adolescent idiopathic scoliosis (AIS) patients and correlate these findings with patient-reported symptomatology scores. Additionally, to quantify the rate of concurrent pathological radiological findings in this group.

METHODS

This was a retrospective chart review study at a single tertiary centre. AIS patients aged 10-16 who had received a whole spine MRI between September 2007 and January 2019 and who had not received surgical intervention to their spine were included. MRI scan reports were screened to extract those who had evidence of DDD. These were then reviewed by a blinded second reviewer who graded every disc using the Pfirrmann grading system. SRS-22 scores were extracted for patients when available.

RESULTS

In total, 968 participants were included in the study. Of these, 93 (9.6%) had evidence of DDD, which was Pfirrmann grade ≥ 3 in 28 (2.9%). The most commonly affected level was L5/S1 (59.1% of DDD cases). A total of 55 patients (5.7%) had evidence of syringomyelia, 41 (3.4%) had evidence of spondylolisthesis (all L5/S1), 14 (1.4%) had bilateral L5 pars defects, and 5 (0.5%) had facet joint degeneration. Spondylolisthesis and bilateral pars defects were more common in patients with DDD identified on MRI scan (p < 0.001 and p = 0.04, respectively). Function (p = 0.048) and pain (p = 0.046) scores were worse in patients with DDD.

CONCLUSION

We present a baseline for the rate and severity of DDD in the non-operative AIS cohort. This should assist in decision-making and counselling of patients prior to surgery.

LEVEL OF EVIDENCE

III.

Entire-spine Magnetic Resonance Imaging Findings and Costs in Children With Presumed Adolescent Idiopathic Scoliosis

BACKGROUND

Patients with adolescent idiopathic scoliosis (AIS) are commonly monitored for curve progression with spinal radiographs; however, the utility of magnetic resonance imaging (MRI) screening is unclear. The purpose of this study was to assess the findings of screening MRI for patients with a nonsurgical curve size ordered during routine clinical care and compare them with MRI ordered for patients with large curves as part of preoperative screening.

METHODS

All consecutive patients with presumed AIS who underwent entire-spine MRI with a presumed diagnosis of idiopathic scoliosis at a single institution between 2017 and 2019 were retrospectively reviewed. Patients were stratified based on MRI indication into the following groups: preoperative evaluation, pain, neurological symptoms, abnormal radiographic curve appearance, rapidly progressive curve, and other. Neural axis abnormalities recorded included concern for tethered spinal cord, syringomyelia, and Chiari malformation. The MRI findings of preoperative patients with large curves were compared with all other patients. The number needed to diagnose (NND) a neurological finding was calculated in patients whose MRIs were ordered during routine clinical care. The amount charged for each patient undergoing entire-spine MRI was determined by review of our institution's Financial Decision Support system.

RESULTS

There were 344 patients included in this study with 214 (62%) MRIs performed for preoperative evaluation. Although MRI abnormalities were found in 49% of patients, only 7.0% (24/344) demonstrated neural axis abnormalities with no difference between preoperative and other indications (P=0.37). For patients with nonsurgical curves undergoing MRI due to a complaint of back pain (n=28), there were no neural axis abnormalities, and a lower rate of disk herniation/degenerative changes detected compared with preoperative MRI (3.6% vs. 18%, P=0.06). Among the 15 patients undergoing MRI for a neurological concern, 1 had a neural axis abnormality that required surgical detethering. The NND for MRI to detect a neural axis abnormality that potentially required neurosurgical intervention in nonpreoperative patients with a neurological concern was 34.4. The average cost for MRI was $17,816 (range: $2601 to $22,411) with a total cost of $2,368,439 for nonsurgical curves.

CONCLUSIONS

Entire-spine MRI for nonpreoperative indications including pain, abnormal radiographic curve appearance, and rapid curve progression has minimal utility for patients with AIS. For patients with neurological complaints, the NND a potentially treatment-altering finding with MRI is 34.4.

LEVEL OF EVIDENCE

Level II-diagnostic.

Whole-Spine Magnetic Resonance Imaging: A Review of Suggested Indications

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The spinal column has a propensity for lesions to manifest in a multifocal manner, and identification of the lesions can be difficult.

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When used to image the spine, magnetic resonance imaging (MRI) most accurately identifies the presence and location of lesions, guiding the treatment plan and preventing potentially devastating complications that are known to be associated with unidentified lesions.

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Certain conditions clearly warrant evaluation with whole-spine MRI, whereas the use of whole-spine MRI with other conditions is more controversial.

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We suggest whole-spine MRI when evaluating and treating any spinal infection, lumbar stenosis with upper motor neuron signs, ankylosing disorders of the spine with concern for fracture, congenital scoliosis undergoing surgical correction, and metastatic spinal tumors.

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Use of whole-spine MRI in patients with idiopathic scoliosis and acute spinal trauma remains controversial.

Incidence and significance of findings on spinal MRIs in a paediatric population with spinal column complaints

PURPOSE

We sought to identify correlations between working diagnosis, surgeon indication for obtaining spinal MRI and positive MRI findings in paediatric patients presenting with spinal disorders or complaints.

METHODS

Surgeons recorded their primary indication for ordering a spinal MRI in 385 consecutive patients. We compared radiologist-reported positive MRI findings with surgeon response, indication, working diagnosis and patient demographics.

RESULTS

The most common surgeon-stated indications were pain (70) and coronal curve characteristics (63). Radiologists reported 137 (36%) normal and 248 (64%) abnormal MRIs. In total, 58% of abnormal reports (145) did not elicit a therapeutic or investigative response, which we characterized as 'clinically inconsequential'. In all, 42 of 268 (16%) presumed idiopathic scoliosis patients had intradural pathology noted on MRI.Younger age (10.3 years versus 12.0 years) was the only significant demographic difference between patients with or without intradural pathology. Surgeon indication 'curve magnitude at presentation' was associated with intradural abnormality identification. However, average Cobb angles between patients with or without an intradural abnormality was not significantly different (39° versus 37°, respectively). Back pain without neurological signs or symptoms was a negative predictor of intradural pathology.

CONCLUSION

Radiologists reported a high frequency of abnormalities on MRI (64%), but 58% of those were deemed clinically inconsequential. Patients with MRI abnormalities were two years' younger than those with a normal or inconsequential MRI. 'Curve magnitude at presentation' in presumed idiopathic scoliosis patients was the only predictor of intrathecal pathology. 'Pain' was the only indication significantly associated with clinically inconsequential findings on MRI.

LEVEL OF EVIDENCE

III.

The rate of intraspinal problems and clinical evaluation of scoliosis: A cross-sectional, descriptive study

Objectives

This study aims to define the chronological, angular, and topographic classes in presumed idiopathic scoliosis and to investigate the frequency of generalized joint hypermobility, pain, neurological deficit, ankle deformity, Risser grade, and magnetic resonance imaging (MRI) findings in these patients.

Patients and methods

This cross-sectional, descriptive study included a total of 36 patients (11 males, 25 females; mean age 13.4±4.6 years; range, 6 to 24 years) with idiopathic scoliosis between January 2015 and January 2019. Data including age, sex, complaint of pain, generalized joint hypermobility (based on Beighton score), neurological deficit, ankle deformity, and definition of scoliosis were recorded. Chronological, angular, and topographic classification were carried out. The Risser grade and MRI findings were noted.

Results

Of all patients, 30 (83.3%) were idiopathic, five (13.9%) were neuromuscular, and one (2.8%) was congenital scoliosis based on MRI findings. Of 13 (36.1%) spine MRI scans, six (46.2%) were intraspinal anomalies, four were syringomyelia (30.8%), one was Chiari type 1 malformation (7.7%), and one was hemivertebrae with diastematomyelia (7.7%). The highest rates of classes according to chronological, angular, and topographical classifications of idiopathic scoliosis were adolescent (17/30, 56.7%), low angular (24/30, 80.0%), and lumbar scoliosis (15/30, 50.0%), respectively. Ten patients (33.3%) complained of pain, while 23 patients (76.7%) had no neurological deficit and seven (23.3%) had hypoesthesia. Seventeen patients (56.7%) had generalized joint hypermobility.

Conclusion

Idiopathic scoliosis with non-severe spinal deformity may present with intraspinal neural axis abnormalities, even when it is neurologically intact. Based on our study results, it seems to be useful to consider whole spine MRI for the evaluation of thoracic and lumbar scoliosis.

Scoliosis in spinal muscular atrophy: is the preoperative magnetic resonance imaging necessary?

PURPOSE

To determine the prevalence of intraspinal alterations in scoliosis due to Spinal Muscular Atrophy (SMA).

METHODS

Cross-sectional, observational, descriptive study. Fifty-six patients with SMA diagnosis required surgical treatment due to scoliosis.

INCLUSION CRITERIA

scoliosis/kyphoscoliosis > 50 degrees in the coronal plane, clinical characteristics of Spinal Muscular Atrophy, accurate diagnosis by means of molecular or genetic study. Prior to the spinal surgery, and to find related intraspinal alterations, MRI of the spine and posterior cranial fossa was performed.

RESULTS

Forty females, 16 males, mean age 11 years (range 6-14 years). 94% of the patients had Spinal Muscular Atrophy type 2. The mean angle value was 81 degrees (range 53-122 degrees) in the coronal plane and 62 degrees (range 35-80 degrees) in the sagittal plane. The prevalence of intraspinal alterations was 1.78%. One patient with cervical hydromyelia and no neurological surgical procedure prior to the spinal deformity surgery was reported.

CONCLUSIONS

In the context of preoperative planning and strategy of patients with scoliosis due to Spinal Muscular Atrophy, MRI may have not to be requested.

The relationship between measures of spinal deformity and measures of thoracic trunk rotation

Background

Adolescent idiopathic scoliosis (AIS) is associated with both asymmetry of the torso (rib hump) and vertebral body rotation (VBR). Current surgical techniques aim to reduce the VBR and rib hump. However, it is not clear how the vertebral rotation and thoracic asymmetry are linked.

Methods

A retrospective cohort study was performed in which all adolescent patients with a diagnosis of AIS (Lenke curve type one to four only), a minimum 2-year follow up and a complete data set of radiographs, Integrated Shape Imaging System 2 (ISIS2) surface topography and axial imaging within a 6-week period were included. The Cobb angle was obtained from the radiograph, the maximum VBR was measured from the axial imaging using the Aaro and Dahlborn technique and the largest maximum skin angle (MSA) was taken from the ISIS2 topography. MSA is the ISIS2 parameter and is similar in nature to a scoliometer.

Results

From the surface topography database of AIS, 51 met the inclusion criteria. There were 6 males and 45 females with a mean age of 14.6 years (SD 1.4, range, 11.2 to 17.7). The mean Cobb angle was 54.4° (SD 13.8°, range, 29° to 92°). Mean MSA was 11.7° (SD 4.0°, range, 4° to 23°). Mean VBR was 14.3° (SD 4.3°, range, 8° to 24°). Through linear regression techniques, the relationships between Cobb angle, MSA and VBR were examined. The R² between Cobb angle and MSA was 9%, between Cobb angle and VBR was 23% and between MSA and VBR was 16%. A multiple regression analysis did not improve these results.

Conclusions

Whilst AIS features both VBR and torso asymmetry, they are poorly related to each other. This may help to explain why surgical de-rotation of the spine does not fully address the rib hump as other factors, yet to be defined, must be involved.

An ontology-based module of the information system ScolioMedIS for 3D digital diagnosis of adolescent scoliosis

BACKGROUND AND OBJECTIVE

Conventional information systems are built on top of a relational database. The main weakness of these systems is impossibility to define stable data schema ahead when the knowledge of the system is evolving and dynamic. The widely accepted alternatives to relational databases are ontologies that can be used for designing information systems. Many research papers describe various methods for improving reliability and precision in generating the type of the Lenke classification based on the image processing techniques or a computer program, but all of them require radiograph images. The main objective of this paper is to demonstrate the development of an ontology-based module of the information system ScolioMedIS for adolescent idiopathic scoliosis (AIS) diagnosis and monitoring, which uses optical 3D methods to determine the Lenke classification of AIS and to avoid harmful effects of traditional radiation diagnosis.

METHODS

For creating an ontology-based module of the ScolioMedIS we used the following steps: specification, conceptualization, formalization and implementation. In the specification and conceptualization phase we performed data collection and analysis to define domain, concepts and relationships for ontology design. In the formalization and implementation stage we developed the OBR-Scolio ontology and the ontology-based module of the ScolioMedIS. The module employs the Protégé-OWL API, as a collection of Java interfaces for the OBR-Scolio ontology, which enables the creating, deleting, and editing of the basic elements of the OBR-Scolio ontology, as well as the querying of the ontology.

RESULTS

The ontology-based module of ScolioMedIS is tested on the datasets of 20 female and 15 male patients with AIS between the ages of 11 and 18, to categorize spinal curvatures and to automatically generate statistical indicators about the frequency of the basic spinal curvatures, degree of progression or regression of deformity and statistical indicators about curvature characteristics according to the Lenke classification system and Lenke scoliosis types. Results are then compared with analysis of the Lenke classification of 315 observed patients, performed using traditional radiation techniques.

CONCLUSIONS

This part of the system allows continuous monitoring of the progression/regression of spinal curvatures for each registered patient, which may provide a better management of scoliosis (diagnosis and treatment).