A prospective evaluation of idiopathic left thoracic scoliosis with magnetic resonance imaging

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.

Sagittal spinal morphotype assessment in 8 to 15 years old Inline Hockey players

Background

Physiological sagittal spinal curvatures play an important role in health and performance in sports. For that reason, several scientific studies have assessed spinal morphology in young athletes. However, to our knowledge, no study has assessed the implications of Inline Hockey (IH) practice on sagittal integrative spinal morphotype in adolescent players.

Objectives

The aims of the present study were to describe habitual sagittal spinal posture in young federated IH players and its relationship with training load and to determine the sagittal integrative spinal morphotype in these players.

Methods

An observational analysis was developed to describe the sagittal spinal morphotype in young federated IH players. A total of 74 IH players from the Technification Plan organized by the Skating Federation of the Valencian Community (aged from 8 to 15 years) participated in the study. Thoracic and lumbar curvatures of the spine were measured in a relaxed standing position (SP), in a slump sitting position (SSP) and in maximum flexion of the trunk (MFT) to determine the "Sagittal Integrative Morphotype" of all players. An unilevel inclinometer was used to quantify the sagittal spinal curvatures. The Hip Joint Angle test was used to quantify the Lumbo-Horizontal angle in flexion (L-H fx) of all participants with a goniometer.

Results

When thoracic curvature was analyzed according to normality references, it was found that 64.9% of IH players had thoracic hyperkyphosis in a SSP, while 60.8% and 74.3% of players were classified as normal in a SP and in MFT, respectively. As for the lumbar curve, 89.2% in a SP and 55.4% in MFT were normal, whereas 68.9% of IH players presented lumbar hyperkyphosis in a SSP. Regarding the "Sagittal Integrative Morphotype," only 17.6% of players were classified as "Normal" in the three measured positions for the thoracic curve, while 37.8% had "Thoracic Hyperkyphosis" and 41.8% presented "Functional Thoracic Hyperkyphosis." As for the "Sagittal Integrative Lumbar Morphotype," only 23% of athletes had a normal curve in the three positions, whereas 66.2% presented "Functional Lumbar Hyperkyphosis." When the L-H fx was evaluated, the results showed that only 16.2% of the athletes were classified as normal.

Conclusions

Federative IH practice seems to cause specific adaptations in spinal sagittal morphotype. Taking into account the "Sagittal Integrative Morphotype" only 17.6% IH players presented "Normal Morphotype" with a normal thoracic kyphosis in the three measured positions, while only 23% IH players presented "Normal Morphotype" with a normal lumbar curvature in the three assessed positions. Furthermore, only 16.2% of IH players showed normal pelvic tilt. Exercise programs to prevent or rehabilitate these imbalances in young IH players are needed.

Incidence of Neuraxial Abnormalities Is Approximately 8% Among Patients With Adolescent Idiopathic Scoliosis: A Meta-analysis

BACKGROUND

Several studies have sought to address the role of routine preoperative MRI in patients with adolescent idiopathic scoliosis (AIS) undergoing deformity correction. Despite similar results regarding the prevalence of neuraxial anomalies detected on MRI, published conclusions conflict and give opposing recommendations. Lack of consensus has led to important variations in use of MRI before spinal surgery for patients with AIS.

QUESTIONS/PURPOSES

This systematic review and meta-analysis of studies about patients with AIS evaluated (1) the overall proportion of neuraxial abnormalities; (2) the patient factors and curve characteristics that may be associated with abnormalities; and (3) the proportion of patients who underwent neurosurgical intervention before scoliosis surgery and the kinds of neuraxial lesions that were identified.

METHODS

We performed a search of four electronic databases (PubMed, EMBASE, CINAHL Plus, and SCOPUS) utilizing search terms related to routine MRI and AIS, yielding 206 articles. Studies included had at least 20 participants, patients with ages 11 to 21 years, and a Methodological Index for Non-Randomized Studies (MINORS) study quality score of 8 and 16 points for noncomparative and comparative studies, respectively. Non-English manuscripts, animal studies, and those that did not include patients with AIS solely were excluded. Eighteen articles with 4746 patients were included for analysis of the overall proportion of neuraxial abnormalities, 12 articles with 3028 patients for analysis by sex, eight articles with 1603 patients for right main thoracic curve, eight articles with 665 patients for a left main thoracic curve, and 13 articles with 3063 patients and 230 (7.5%) abnormalities for number of neurosurgical interventions before scoliosis correction. The mean MINORS score for studies included was 14 (range, 10-20). Each study was analyzed for the proportion of patients identified with neuraxial abnormalities and associations with specific demographics. We determined the proportion of patients who underwent surgical interventions before scoliosis surgery as well as the types of neuraxial lesions identified. The articles were assessed for heterogeneity and publication bias. Because all groups were determined to be heterogeneous, a random-effects model was used for each group in this meta-analysis; with this analysis, an overlap of 95% confidence intervals suggests no difference at the p < 0.05 level, but this analytic approach does not provide p values.

RESULTS

The pooled proportion of neuraxial abnormalities detected on MRI was 8% (95% confidence interval [CI], 6%-12%). With the numbers available, we found no difference in the proportion of male and female patients with neuraxial abnormalities (18% [95% CI, 11%-29%] versus 9% [95% CI, 6%-12%], respectively). Likewise, there was no difference in the proportion of pooled neuraxial abnormalities in right and left curves (9% [95% CI, 6%-14%] versus 15% [95% CI, 5%-35%], respectively). In the subset of abnormalities analyzed for number of neurosurgical interventions before scoliosis correction, the pooled proportion showed that 33% (95% CI, 24%-43%) underwent neurosurgical intervention before deformity correction. The most common abnormalities of the 367 found on MRI were syringomyelia in 127 patients (35%), Arnold-Chiari Type 1 malformation with syrinx in 103 patients (28%), and isolated Arnold-Chiari Type 1 malformation in 91 patients (25%).

CONCLUSIONS

The proportion of patients with AIS who have neuraxial abnormalities is high (8%) and a large number undergo surgical intervention before scoliosis reconstruction. We did not find any particular demographic variables that indicated an increased risk of abnormality. Clinicians should consider advanced imaging before surgical intervention in the treatment of a patient with an idiopathic diagnosis. Preventable variables need to be identified by future studies to establish a better working treatment protocol for these patients.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Evaluation of coronal shift as an indicator of neuroaxial abnormalities in adolescent idiopathic scoliosis: a prospective study

Background

In previous studies, many indicator factors have been proposed to select patients who need an MRI screening of the spinal canal. In current study, the clinical and radiologic factors including coronal parameters of the curve were evaluated to find out which indicator is more important.

Methods

A prospective study included 143 consecutive patients with the diagnosis of adolescent idiopathic scoliosis who were treated between 2010 and 2013 at our spinal clinics. Only patients with normal or subtle neurologic findings were included. All patients were evaluated by a total spine MRI protocol for examination of neuroaxial abnormalities. Known indicators and also coronal shift were analysed in all patients with or without abnormal MRI.

Results

The incidence of neuroaxial abnormalities was 11.9% (17 of 143); only 5 patients (3.5%) were operated to treat their neuroaxial problem. The significant indicators of the abnormalities in our patients were: younger age at onset, asymmetric superficial abdominal reflex and, coronal shift more than 15 mm (P = 0.03). Some previously known indicators like atypical curves, male gender, double curves and absence of thoracic lordosis were not different between two groups of the patients.

Conclusions

A total spine MRI is recommended at presentation in patients with younger age, abnormal neurologic findings and severe coronal shift.

Relationship of syrinx size and tonsillar descent to spinal deformity in Chiari malformation Type I with associated syringomyelia

OBJECT

Chiari malformation Type I (CM-I) is a developmental abnormality often associated with a spinal syrinx. Patients with syringomyelia are known to have an increased risk of scoliosis, yet the influence of specific radiographically demonstrated features on the prevalence of scoliosis remains unclear. The primary objective of the present study was to investigate the relationship of maximum syrinx diameter and tonsillar descent to the presence of scoliosis in patients with CM-I-associated syringomyelia. A secondary objective was to explore the role of craniovertebral junction (CVJ) characteristics as additional risk factors for scoliosis.

METHODS

The authors conducted a retrospective review of pediatric patients evaluated for CM-I with syringomyelia at a single institution in the period from 2000 to 2012. Syrinx morphology and CVJ parameters were evaluated with MRI, whereas the presence of scoliosis was determined using standard radiographic criteria. Multiple logistic regression was used to analyze radiological features that were independently associated with scoliosis.

RESULTS

Ninety-two patients with CM-I and syringomyelia were identified. The mean age was 10.5 ± 5 years. Thirty-five (38%) of 92 patients had spine deformity; 23 (66%) of these 35 patients were referred primarily for deformity, and 12 (34%) were diagnosed with deformity during workup for other symptoms. Multiple regression analysis revealed maximum syrinx diameter > 6 mm (OR 12.1, 95% CI 3.63-40.57, p < 0.001) and moderate (5-12 mm) rather than severe (> 12 mm) tonsillar herniation (OR 7.64, 95% CI 2.3-25.31, p = 0.001) as significant predictors of spine deformity when controlling for age, sex, and syrinx location.

CONCLUSIONS

The current study further elucidates the association between CM-I and spinal deformity by defining specific radiographic characteristics associated with the presence of scoliosis. Specifically, patients presenting with larger maximum syrinx diameters (> 6 mm) have an increased risk of scoliosis.

Influence of hamstring muscles extensibility on spinal curvatures and pelvic tilt in highly trained cyclists

The purpose of this study was to determine the influence of hamstring muscles extensibility in standing, maximal trunk flexion with knees extended and on the bicycle in lower handlebar-hands position of highly trained cyclists. Ninety-six cyclists were recruited for the study (mean ± SD, age: 30.36 ± 5.98 years). Sagittal spinal curvatures and pelvic tilt were measured in the standing position, maximal trunk flexion with knees extended (sit-and-reach test) and while sitting on a bicycle in lower handlebar-hand position using a Spinal Mouse system. Hamstring muscles extensibility was determined in both legs by passive straight leg raise test (PSLR). The sample was divided into three groups according to PSLR angle: (1) reduced extensibility (PSLR < 80º; n = 30), (2) moderate hamstring extensibility group (PSLR = 80º - 90º; n = 35), and (3) high hamstring extensibility (PSLR = > 90º; n = 31). ANOVA analysis showed significant differences among groups for thoracic (p < 0.001) and pelvic tilt (p < 0.001) angles in the sit-and-reach test. No differences were found between groups for standing and on the bicycle position. Post hoc analysis showed significant differences in all pairwise comparisons for thoracic angle (p < 0.01) and pelvic angle (p < 0.001) in the sit-and-reach test. No differences were found in lumbar angle in any posture. In conclusion, the hamstring muscles extensibility influence the thoracic and pelvic postures when maximal trunk flexion with knees extended is performed, but not when cyclists are seated on their bicycles.

Sagittal spinal and pelvic postures of highly-trained young canoeists

The objective of this study was to determine the sagittal spinal curvatures and pelvic position in standing and kneeling in the canoe in young canoeists. Forty-four young highly-trained canoeists (mean age: 15.11 ± 0.61 years) were recruited. Thoracic and lumbar curvatures and pelvic inclination were evaluated with a Spinal Mouse system in standing position and in the base position (kneeling on one knee in the canoe) and catch phase of the stroke. The mean thoracic kyphosis, lumbar lordosis and pelvic inclination in standing were 44.66 ± 8.80º, −30.34 ± 8.31º, and 14.20 ± 7.32º, respectively. In the canoe, the thoracic, lumbar and pelvic angles were 39.66 ± 9.52º, −24.32 ± 6.79º, and 15.18 ± 4.34º, respectively, for the base position (p<0.001 with respect to standing, except for pelvic inclination), and 28.93 ± 10.45º, −13.45 ± 10.60º, and 37.61 ± 6.27º, respectively, for the catch phase of the stroke (p<0.001 with respect to standing and base position). A higher percentage of hyperkyphotic postures in standing than in the canoe was found, while thoracic hypokyphosis increased in the catch phase of the stroke. In regards to the lumbar curve, the percentage of hypolordosis postures in the base position was higher than when standing. Lumbar kyphotic postures were detected in the catch phase of the stroke. In conclusion, the standing thoracic hyperkyphosis in young canoeists may be related to factors other than the posture and movement in the canoe. The canoeists adopted a lumbar flexed posture at the catch phase of the stroke, although this position may not affect the sagittal configuration of lumbar spine in standing. Postural training should be included in the training program of canoeists to improve the thoracic posture in the standing position.

The role of routine magnetic resonance imaging in the preoperative evaluation of adolescent idiopathic scoliosis

The routine use of magnetic resonance imaging (MRI) in adolescent idiopathic scoliosis remains controversial, and current indications for MRI in idiopathic scoliosis vary from study to study. The purpose of this study was to demonstrate the prevalence of neural axis malformations and the clinical relevance of routine MRI studies in the evaluation of patients with adolescent idiopathic scoliosis undergoing surgical intervention without any neurological findings. A total of 249 patients with a diagnosis of idiopathic scoliosis were treated surgically between the years 2002 and 2007. A routine whole spine MRI analysis was performed in all patients. On the preoperative clinical examination, all patients were neurologically intact. There were 20 (8%) patients (3 males and 17 females) who had neural axis abnormalities on MRI. Three of those 20 patients needed additional neurosurgical procedures before corrective surgery; the remaining underwent corrective spinal surgery without any neurosurgical operations. Magnetic resonance imaging may be beneficial for patients with presumed idiopathic scoliosis even in the absence of neurological findings and it is ideally performed from the level of the brainstem to the sacrum.

Preoperative radiological and electrophysiological evaluation in 100 adolescent idiopathic scoliosis patients

This is a prospective study of spinal magnetic resonance imaging (MRI), electrophysiological recordings, and neurological examinations of 100 patients admitted for surgery for adolescent idiopathic scoliosis (AIS), which was conducted to assess the prevalence of structural and functional abnormalities within the spinal cord in patients with clinically normal neurologic condition. In all patients the clinical diagnosis and intact neurological condition was ascertained by a spinal orthopedic surgeon. Full-length spinal axis MRI studies (T1/T2 sequences) and somato-sensory evoked potentials of the tibial nerves (tSSEPs) were preoperatively assessed by independent evaluators blinded to the patients' medical histories. Structural spinal cord abnormalities were found in three of 100 AIS patients on MR imaging. In one patient a Chiari malformation type 1 with an accompanying syringomyelia was diagnosed, which required a suboccipital decompression. In the other two patients small thoracic syringomyelias were diagnosed. Abnormalities of spinal cord function were detected in 68% of the 100 patients: tSSEP latencies corrected for body height were increased in 56% of the patients; pathological differences between tSSEPs on the left and right sides were present in 17% (12% in combination with a prolongation of the latency). The findings of this study indicate that MRI and electrophysiological examinations are essential to assess spinal cord abnormalities that are clinically not detectable in AIS patients. Even in patients with intact neurologic condition and clinically typical right-curved thoracic scoliosis, the possibility of intraspinal pathologies should be ruled out by MRI. It is especially important to detect structural pathologies like syringomyelia and Chiari malformation before proceeding with scoliosis surgery, as these conditions are associated with a higher neurological risk during scoliosis surgery. The electrophysiological recordings made in the present study, with the high number of pathological tSSEPs, are indicative of functional abnormalities with a subclinical involvement of the recorded neuronal pathways. The relevance of the latter findings is not yet clear, but pre-operative tSSEP examinations offer the possibility of assessing alterations in spinal cord function that are undetectable by clinical examination.