Thoracic cage volume and dimension assessment by optoelectronic molding in normal children and adolescents during growth

Influence of Paraspinal Growth-Friendly Spinal Implants in Children with Spinal Muscular Atrophy on Parasol Deformity, Rib-Vertebral Angles, Thoracic, and Lung Volumes

INTRODUCTION

Children with spinal muscular atrophy (SMA) and progressive neuromuscular scoliosis often require early growth-friendly spinal implant (GFSI) treatment for deformity correction with implant fixation either through pedicle screws or bilateral to the spine using ribto pelvis fixation. It has been proposed that the latter fixation may change the collapsing parasol deformity via changes in the rib-vertebral angle (RVA) with a positive effect on thoracic and lung volume. The purpose of this study was to analyze the effect of paraspinal GFSI with bilateral rib-to-pelvis fixation on the parasol deformity, RVA, thoracic, and lung volumes.

METHODS

SMA children with (n = 19) and without (n = 18) GFSI treatment were included. Last follow-up was before definite spinal fusion at puberty. Scoliosis and kyphosis angles, parasol deformity, and index, as well as convex and concave RVA, were measured on radiographs, whereas computed tomography images were used to reconstruct thoracic and lung volumes.

RESULTS

In all SMA children (n = 37; with or without GFSI), convex RVA was smaller than concave values at all times. GFSI did not crucially influence the RVA over the 4.6-year follow-up period. Comparing age- and disease-matched adolescents with and without prior GFSI, no effect of GFSI treatment could be detected on either RVA, thoracic, or lung volumes. Parasol deformity progressed over time despite GFSI.

CONCLUSION

Despite different expectations, implantation of GFSI with bilateral rib-to-pelvis fixation did not positively influence parasol deformity, RVA and/or thoracic, and lung volumes in SMA children with spinal deformity directly and over time.

The anatomical growth of the thoracic cage in adolescents with specific reference to axial growth comparing the right and left hemithorax

This study has demonstrated the changing volume of both the anterior and posterior thorax in normal adolescents (without spinal or thoracic deformity), differentiating for both sex and age, to further understand how the thorax grows, along with the differences in growth between the anterior and posterior thorax. The thorax was measured on axial CT slices at every vertebral level from T3 to T12 in a series of scans previous taken for routine clinical care. Measurements taken were the anteroposterior thoracic distance and the area of the anterior and posterior rib prominences on either side of the thorax. Data was analyzed per vertebral level, differentiating for age and sex. There were 486 CT scans analyzed (257 males and 229 females) between the ages of 8 and 18 years. The analysis identified that for the anterior thorax, there are three phases of growth with an initial slow increase in volume, followed by a stabilization of little growth, followed by another phase of a more rapid increase in volume. For the posterior thorax, there was a gradual increase in area with increasing age. This study demonstrates that the shape of the thorax is age and sex dependent, with males having both a greater width and depth of thorax compared to females. Of particular note is the difference in patterns of growth between the anterior and posterior thorax. This information will add to the understanding of normal growth, which will aid in the management of conditions where that growth is disturbed.

Sternum length norms in Han youngsters in central China

The sternum is one of the most important components of the chest wall. However, to the best of our knowledge, at present there is no reference value of the sternum length in normal Han Chinese children that has been published in the literature. The aim of the present study was therefore to establish the reference value of sternum length in a normal Han Chinese population of different ages and sex groups. Chest computed tomography scans and three-dimensional reconstruction images of 1,080 individuals who were younger than 18 years old and without congenital or acquired structural anomalies or congenital metabolic diseases were retrospectively reviewed. The length of the sternum was measured for each individual and comparisons of the sternum length according to sex were conducted using the Mann-Whitney test. Age or region group comparisons were performed using the ANOVA test, and the association between the length of the sternum and age was assessed by regression analysis. A significant association between the age (x) of the individual and the length of the sternum (y) was confirmed, although different regression patterns were identified for the sexes (the regression equation for males was y=5.616x+60.408; P<0.001; R²=0.890, whereas that for females was y=-0.134x²+6.543x+56.805; P<0.001, R²=0.890). No significant differences in sternum length were identified between the sexes for subjects aged 1-13 years old, whereas significant differences were observed comparing the sexes of the subjects aged 14-18 years old. In conclusion, the present study revealed that the length of the sternum in normal Han Chinese children can be precisely estimated by the age of the child using our formulae for the different sexes (where the most-fit formulae for the two sexes are different). This knowledge can be applied clinically in chest wall deformity assessment, and in surgery planning.

Preliminary evaluation of sagittal and transverse plane cross-sectional variations of the trunk during quiet and deep breathing by optical reflective motion analysis in patients with scoliosis

Trunk movements during quiet and deep breathing in untreated and in operated patients with scoliosis are not well defined. To evaluate sagittal and transverse plane cross-sectional variations of the trunk during quiet and deep breathing by optical reflective motion analysis (ORMA) in children with scoliosis. Twenty-one patients were divided into three groups: normal subjects (A; n = 6), subjects with untreated scoliosis >50° (B; n = 7) and operated patients (C; n = 8). Standing and sitting height, T1-T12 and L1-L5 length, arm span, chest perimeter, weight and BMI were recorded. Trunk movements of all patients, during quiet and deep breathing, were measured with a 10-camera 3D ORMA system (82 markers) with the subjects in a standard standing position. Groups were comparable with respect to age, sex, height, arm span and weight (P > 0.05). Significant differences were found in Cobb angle, chest perimeter and BMI (P < 0.05). Trunk sagittal and transverse plane movements during quiet and deep breathing decreased significantly in group B and group C when compared to group A (P < 0.05). Surgery does not completely eliminate sagittal and transverse plane kinematics, although the spine is rendered more rigid. This preliminary study involving a relatively limited number of patients outlines ORMA is a useful tool for analyzing sagittal and transverse plane motion abnormalities of the trunk. Trunk kinematics was altered during breathing in unoperated patients with scoliosis >50°. Operated subjects had sagittal plane trunk kinematics closer to normal subjects, although changes were less pronounced at the level of the convex side.

A 10-Week Program of Combined Hippotherapy and Scroth's Exercises Improves Balance and Postural Asymmetries in Adolescence Idiopathic Scoliosis: A Randomized Controlled Study

Introduction: The most frequent type of spine abnormality throughout adolescence was adolescent idiopathic scoliosis (AIS). Hippotherapy improved posture, balance and gait of different musculoskeletal conditions. Therefore, this study aims to see how hippotherapy combined with Schroth exercises affected postural asymmetry and dynamic balance in AIS compared to traditional physiotherapy (Schroth exercises) alone. Materials and methods: In this randomized controlled trial, fifty-two patients with AIS (10–18 years, 37 girls and 15 boys) participated. They were arbitrarily allocated into two groups: experimental (19 female/8 male; aged 14.74 ± 1.79 years; Cobb angle 18.59 ± 2.66 degrees) and control (18 female/7 male; aged 15.04 ± 1.81 years; Cobb angle 19.32 ± 2.69 degrees) groups. Both groups received Schroth exercises for 10 weeks, three days/week. The experimental group additionally received hippotherapy training. Pre-treatment and post-treatment assessment for the scoliotic, kyphotic angle, pelvic obliquity, pelvic torsion and vertical spinal rotation and the anteroposterior, mediolateral and overall stability indices were assessed using the formetric system 4D and Biodex Balance System, respectively. Results: After intervention, both groups illustrated significant improvements in all examined variables (p < 0.05). The experimental group illustrated significant improvements in scoliotic angle, kyphotic angle, pelvic obliquity, pelvic torsion and vertical spinal rotation and the stability indices compared to the control group (p < 0.05). Conclusion: In adolescence idiopathic scoliosis, hippotherapy training combined with Schroth exercises improves posture asymmetry and balancing ability more effectively than Schroth exercises alone.

The morphological changes of thorax in pediatric microtia patients after costal cartilage harvesting

BACKGROUND

The surgical treatment of microtia generally starts in childhood, and costal cartilage is the most widely used material for auricular reconstruction. However, multiple costal cartilage harvests lead to local cartilage defects, which may influence the growth of the hemithorax, that need close attention by doctors. In this study, morphological changes of the thorax were measured and analyzed in different follow-up groups.

METHODS

Twenty-eight adolescent microtia patients underwent auricular reconstruction using 6th-8th costal cartilage. Thoracic computed tomography (CT) with three-dimensional reconstruction was performed preoperatively and during follow-up. Comparison of the hemithorax on the operated and unoperated sides was performed by measuring several thoracic parameters using Mimics software (Materialise, Belgium). The data were further analyzed by a paired-samples t-test.

RESULTS

In the operated hemithorax, the costochondral junction midpoints moved medially (6th-8th), posteriorly (6th-7th) and descended less (6th-9th) with significant differences as P < 0.05 compared to the unoperated hemithorax. In addition, height differences indicated local depressions in the chest wall in the areas of cartilage defects (6th-9th, P < 0.05). Following local depression of the chest wall and migration of the ribs, the operated hemithorax also had a smaller area than the unoperated hemithorax (6th-9th, P < 0.05). The differences in the hemithorax were more significant in the midterm group (5-10 y) than in the other follow-up groups, while most parameters showed no significant differences in the long-term group (10-15 y). No significant differences were found in the modified Haller index.

CONCLUSION

Multiple costal cartilage harvests caused morphological changes and asymmetry of the thorax in adolescent patients. As indicated by thoracic CT, significant changes occurred in the local area of cartilage defects, which did not affect the overall thorax. In the long term, more than 10 years after harvesting, the differences in the hemithorax between the operated and unoperated sides decreased significantly. This study provides an important reference for thoracic changes when applying auricular reconstruction in the pediatric microtia patients.

Alterations of sagittal alignment and thoracic cage parameters after long-term bracing in adolescents with idiopathic scoliosis

BACKGROUND

Sagittal alignment and thoracic cage parameters are correlated with the surgery success rate and life quality of adolescents with idiopathic scoliosis (AIS). However, the effects of the long-term bracing on sagittal and thoracic cage parameters have not been clearly recognized.

HYPOTHESIS

Long-term brace treatment could compromise sagittal balance and thoracic development in patients with AIS.

PATIENTS AND METHODS

Two hundred and seventy-five patients with AIS were included in this study. The radiographs when AIS was diagnosed and 2 years after Chêneau bracing treatment were collected. Sagittal, cervical, pelvic, and thoracic cage parameters were evaluated. In addition, 32 patients finishing brace treatment with complete radiograph data were selected from included 275 patients and the data of CL, TK and LL at five different time points was collected.

RESULTS

CL (average: from 14.13° to 8.94°, p=0.012), TK (average: from 24.35° to 19.02°, p=0.001) and LL (average: from 38.44° to 32.13°, p=0.004) underwent observably decline after two-year brace treatment. No statistically significant alteration of pelvic parameters was shown. The vertical parameters of thoracic cage including T1-12 height, left and right thorax height and thoracic transverse diameter increased significantly. Thoracic anteroposterior diameter at the T7 vertebral level (average: from 11.49 to 10.57cm, p=0.001) and diaphragm level (average: from 11.89 to 10.74cm, p=0.001) decreased significantly after bracing.

DISCUSSION

CL, TK and LL decreased after long-term bracing treatment, which lead to the aggravation of "flat back" in AIS patients. In addition, the thoracic anteroposterior diameters declined after two-year bracing, which may result from reduced TK and contribute to further pulmonary function impairment.

LEVEL OF EVIDENCE

IV.

Dynamic 3D Reconstruction of Thoracic Cage and Abdomen in Children and Adolescents With Scoliosis: Preliminary Results of Optical Reflective Motion Analysis Assessment

BACKGROUND

In patients with untreated scoliosis or in those with posterior spinal instrumented fusion (PSF), the movements of neither the thoracic cage (ThC) nor the abdomen (ABD) during quiet and deep breathing have been well defined in the literature. The purpose of this study was to evaluate kinematic variations in the ThC and ABD during quiet and deep breathing by optical reflective motion analysis (ORMA) in children with scoliosis.

METHODS

The study included 6 healthy children (group A), 7 subjects with untreated scoliosis over 50 degrees (group B), and 8 patients with scoliosis treated by PSF (group C). After anthropometric measurements (standing height, sitting height, arm span, chest perimeter, body weight, body mass index, T1-T12, and L1-L5 length) were obtained, the movements of subjects during quiet and deep breathing were measured with a 10-camera 3-dimensional ORMA system (82 markers) with the subjects in a standard standing position.

RESULTS

No significant differences were observed in sex, age, weight, height, or arm span (P>0.05). Significant differences were observed in the chest perimeter, Cobb angle, and body mass index (P<0.05). ThC and ABD movements during quiet and deep breathing decreased significantly in group B and C when compared with group A (P<0.05). Group B showed decreased expansion of the ThC (-52.4% to -58.3%) and relatively increased motion of the ABD compared with groups A and C (P<0.001). However, ABD expansion remained lower in group B than in groups A and C (-32.8% and -5.7%). PSF does not completely eliminate transverse plane kinematics, although a greater reduction was observed at instrumented than noninstrumented levels (-60.8% vs. -35.1%; P<0.05).

CONCLUSIONS

ORMA is a useful tool for assessing alterations in the kinematics of the ThC and ABD caused by severe scoliosis and/or PSF. Compared with normal subjects, patients with severe scoliosis had poorer and less effective kinematics of the ThC and ABD. In contrast, operated subjects had better and more effective kinematics of the ThC and ABD, breathing curves, thoracic expansion, and abdominal movements closer to normal compared with patients with severe, untreated deformity.

LEVEL OF EVIDENCE

Level III.

Serial elongation derotation flexion casting in children with infantile and juvenile scoliosis

Infantile (IS) and juvenile scoliosis (JS) are among the most challenging conditions pediatric orthopedic surgeons are facing in the present days. However, the best treatment of IS and JS is still debated and it remains controversial, at least for some aspects. Untreated early onset spinal deformities may lead to pulmonary and heart compromise. Growth friendly surgical techniques imply multiple distractions with increased risk of auto-fusion, infection and curve stiffening. Serial casting has been proven to be a valuable option to treat children with early onset scoliosis (EOS) in an attempt to delay surgery (in most cases) or to cure the disease (in few cases). More than five decades ago, Cotrel and Morel from France, introduced the Elongation-Derotation-Flexion (EDF) casting technique. EDF cast is a custom-made thoracolumbar cast that corrects the deformed spine three-dimensionally. Serial EDF casting is able to modulate spinal growth and it can-at least in some cases-prevent the progression of the spinal deformity. Today, serial EDF casting technique has become one of the accepted treatment options for the management of children with IS and JS. The main objective of this work is to describe the EDF serial casting technique for the treatment of children with IS and JS, as well as to highlight its advantages and its limits by providing a review of the most recent literature.

The immature spine: growth and idiopathic scoliosis

Untreated progressive scoliosis can have negative effects on the growing spine as asymmetrical forces will act on the growth plates of the vertebral column (>130 growth plates). Spinal growth can be considered as a mixture of hierarchy, synchronization, and harmony: the slightest error can lead to a complex malformation; it is also a very dynamic process although it does not progress linearly: periods of acceleration are followed by periods of deceleration. Remaining growth is a determining factor for the worsening of idiopathic scoliosis (IS): the younger is the child, the higher is the risk of progression, and the more severe will be the disease. After birth, growth of the spine is not linear, and three periods can be identified: (I) between birth and age 5 years; (II) between age 5 and 10 years of age; (III) between age 10 and skeletal maturity. Spine and thoracic cage growth are correlated, although their growth is not synchronous. Timely control of the spinal deformity and its correction are mandatory to restore-as soon as possible-the harmony and the hierarchy of growth between the different growth plates. If action is delayed, the abnormal growth and the subsequent anatomical modifications will lead to a progressive, evolutive, and irreversible clinical picture. This article aims to provide a comprehensive review of how spinal deformities can affect the normal spine and thoracic cage growth.