Colour Doppler ultrasonography for evaluation of anterior chest blood supply: the possible role of arterial blood supply to the costosternal junction in the aetiology of idiopathic scoliosis in female adolescents

Using Photogrammetry to Analyze Anatomical Changes in the Nipple in Juvenile and Adolescent Scoliosis Patients

BACKGROUND

The need for an objective set of anterior trunk measurements, such as nipple and clavicular shoulder joints, is essential to quantify the anterior asymmetry present in scoliosis. This study aims to characterize breast asymmetry (BA) in young individuals with scoliosis using photogrammetry.

METHODS

Digital photographs of the anterior trunk of the 51 scoliosis patients aged 4-20 years were taken from an anterior perspective. These images were then transferred to a computer. Ten parameters were measured using the ImageJ software. The positions of patients' nipples were classified into 6 types based on ratios on the x-axis.

RESULTS

The majority of patients had a right breast that was larger, intensifying the apparent BA due to trunk rotation. The apical vertebra level in patients was found at T8 in 23.6% and T9 in 45.1%. In 92.5% of the patients, the right breast was consistently larger. The lengths between the lateral boundaries and nipples of the right and left breasts and between the medial boundary and nipple of the right breast were statistically significantly higher in males than in females (p < 0.05). Significant differences were found when comparing the values of the lengths between the medial boundaries and nipples of the right and left breasts, the difference in length between the right and left acromioclavicular joint lines, and the angles of the nipple and acromioclavicular joint with the degrees of scoliosis in juvenile and adolescents (p < 0.05). Pearson regression analysis revealed a significant correlation between BA differences and the Cobb angle with a correlation coefficient of 0.901. Factors related to breast aesthetics, like differences in the height of nipples and the distance from the sternal notch to the nipple, represent 30% of the overall score.

CONCLUSION

The study concluded that there is a significant correlation between the severity of scoliosis and BA differences. Augmentation mammaplasty for BA not only decreased the breast difference but also leveled the nipple disparities. Photogrammetry is considered to be an alternative to other methods and is believed to contribute to the follow-up of BA.

LEVEL OF EVIDENCE IV

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The Prevalence of Scoliosis after Fontan Circulation Surgery Followed-Up to Adolescence

Introduction

The advancement of surgical techniques and perioperative management for congenital heart disease (CHD) has increased life expectancy. The surgical creation of the Fontan circulation maintains pulmonary blood flow without relying on an effective pump from the abnormal heart, relying on peripheral vascular resistance to maintain effective flow through the lungs. Unfortunately, this delicate mechanism is compromised when scoliosis restricts ventilation, leading to Fontan failure and a poor prognosis for life. This report describes the prevalence of scoliosis with Fontan completion surgery and the role of screening and surgical correction.

Methods

Ninety-six consecutive Japanese patients undergoing Fontan completion surgery for CHD between 2000 and 2017 were identified in our institutional records. The inclusion criterion was at least 7 years of follow-up after Fontan completion surgery, while the exclusion criteria were congenital, syndromic, and neuromuscular scoliosis. Radiographic and clinical parameters, including cardio-thoracic ratio (CTR) for cardiomegaly and cyanosis saturation, were compared between with and without scoliosis.

Results

There were 23 and 40 patients in the scoliosis and no scoliosis groups, respectively. The mean age at the final follow-up was 18.5 and 16.7 years in the scoliosis and no scoliosis groups, respectively (p=0.02). Mean CTR was 43.7% and 39.4% in the scoliosis and no scoliosis groups (p=0.016), and the mean saturation in room air at the final follow-up was 88.8% and 93.2%, respectively (p=0.036). There were no significant differences to clarify the risk factors with multivariate logistic regression analysis.

Conclusions

The prevalence of scoliosis with Fontan completion surgery was 36.5%. Screening for scoliosis is important for children with Fontan circulation surgery as part of their routine follow-up at least until they reach adolescence.

Evidence Level: 4.

Etiopathogenesis of adolescent idiopathic scoliosis: Review of the literature and new epigenetic hypothesis on altered neural crest cells migration in early embryogenesis as the key event

Adolescent idiopathic scoliosis (AIS) affects 2-3% of children. Numerous hypotheses on etiologic/causal factors of AIS were investigated, but all failed to identify therapeutic targets and hence failed to offer a cure. Therefore, currently there are only two options to minimize morbidity of the patients suffering AIS: bracing and spinal surgery. From the beginning of 1960th, spinal surgery, both fusion and rod placement, became the standard of management for progressive adolescent idiopathic spine deformity. However, spinal surgery is often associated with complications. These circumstances motivate AIS scientific community to continue the search for new etiologic and causal factors of AIS. While the role of the genetic factors in AIS pathogenesis was investigated intensively and universally recognized, these studies failed to nominate mutation of a particular gene or genes combination responsible for AIS development. More recently epigenetic factors were suggested to play causal role in AIS pathogenesis. Sharing this new approach, we investigated scoliotic vertebral growth plates removed during vertebral fusion (anterior surgery) for AIS correction. In recent publications we showed that cells from the convex side of human scoliotic deformities undergo normal chondrogenic/osteogenic differentiation, while cells from the concave side acquire a neuronal phenotype. Based on these facts we hypothesized that altered neural crest cell migration in early embryogenesis can be the etiological factor of AIS. In particular, we suggested that neural crest cells failed to migrate through the anterior half of somites and became deposited in sclerotome, which in turn produced chondrogenic/osteogenic-insufficient vertebral growth plates. To test this hypothesis we conducted experiments on chicken embryos with arrest neural crest cell migration by inhibiting expression of Paired-box 3 (Pax3) gene, a known enhancer and promoter of neural crest cells migration and differentiation. The results showed that chicken embryos treated with Pax3 siRNA (microinjection into the neural tube, 44 h post-fertilization) progressively developed scoliotic deformity during maturation. Therefore, this analysis suggests that although adolescent idiopathic scoliosis manifests in children around puberty, the real onset of the disease is of epigenetic nature and takes place in early embryogenesis and involves altered neural crest cells migration. If these results confirmed and further elaborated, the hypothesis may shed new light on the etiology and pathogenesis of AIS.

Both Bilateral Breast Volume Discrepancy and Asymmetric Anterior Chest Wall Shape Contribute to the Unsightly Breast Contour in Female Right Thoracic Idiopathic Scoliosis

STUDY DESIGN

A retrospective radiographic study.

OBJECTIVE

To evaluate the asymmetry of breast volume (BV) and shape in female adolescent idiopathic scoliosis (AIS) patients and to define their relationship with deformed components of the anterior chest wall and curved spine.

SUMMARY OF BACKGROUND DATA

The higher incidence of asymmetric breast development in AIS was described by prior studies. However, the interplay between scoliosis curve magnitude and severity of breast asymmetry (BA) are unknown.

METHODS

A total of 73 surgically treated female right thoracic AIS patients classified as Lenke type I were enrolled in this study, with the average Cobb angle being 52.08±11.68 degrees. The Image J software was utilized to calculate BV. Both concave and convex radiographic parameters of breast shape were measured including the extraversion angle (EA), the coverage angle (CA), the axial breast height, the vertical breast height (VBH), and the nipple-to-sternum distance. The inclination angles of the concave and convex anterior chest wall were also assessed. BA was calculated according to the formula as follows: BA=(concave-convex)×BV/[(concave+convex)×BV]/2. The measurements of spinal deformity parameters included the Cobb angle, the RAsag angle, and the RAml angle. Paired t test was performed to analyze the asymmetry of breast shape, and Pearson correlation analysis was utilized to define the correlation between the breast shape, spinal deformity, and the inclination of anterior chest wall.

RESULTS

The concave BV, EA, axial breast height, and vertical breast height were significantly larger than those of the convex side (P<0.05), whereas the concave CA and the inclination angle of the anterior chest wall were significantly smaller than those of the convex side (P<0.05). No difference was detected between the concave and the convex nipple-to-sternum distance (P>0.05). The averaged BA was 11.4%, with the ratio of asymmetry beyond 10% being 52.1%. No statistically significant relationships between BA and Cobb angle, RAsag angle, RAml angle were detected (P>0.05). The inclination angle of the anterior chest wall demonstrated significant correlation with EA (P<0.001) and CA (P<0.001), respectively.

CONCLUSIONS

The incidence of BA in AIS is notable, with the concave breast being larger, more extroversive, and more concentrated than the convex breast. The discrepancy between concave and convex anterior chest wall inclination bound to scoliosis could have a major influence on breast orientation and profile, suggesting a synergistic role of anterior chest wall deformity and bilateral BV discrepancy in the formation of BA.

Disturbance of rib cage development causes progressive thoracic scoliosis: the creation of a nonsurgical structural scoliosis model in mice

BACKGROUND

The pathomechanism underlying idiopathic scoliosis remains unclear, and, to our knowledge, a consistent and relevant animal model has not been established previously. The goal of this study was to examine whether a disturbance of rib cage development is a causative factor for scoliosis and to establish a nonsurgical mouse model of progressive scoliosis.

METHODS

To examine the relationship between rib cage development and the pathogenesis of progressive scoliosis, a plastic restraint limiting anteroposterior rib cage development was placed on the chest of four-week-old mice. All mice were evaluated with whole-spine radiographs, and the severity of scoliosis was consecutively measured. The rib cage rotation angle and the anteroposterior chest dimension were measured with use of micro-computed tomography scanning. To examine whether the imbalanced load transmission through the ribs to the vertebral body was involved in our model, we performed a rib-neck osteotomy in a subgroup of the mice.

RESULTS

The thoracic restraint did not provoke spinal curvature immediately after it was applied, but nine of ten mice that wore the restraint but did not have rib osteotomy gradually developed progressive scoliosis. Radiographs and computed tomography images showed a right thoracic curvature, vertebral rotation, and narrow chest in the mice that had worn the restraint for eleven weeks but did not have rib osteotomy even after the restraint was removed. The anteroposterior chest dimension was significantly correlated with both the curve magnitude and the rib cage rotation angle. The progression of spinal deformity was observed only during the adolescent growth spurt, and it plateaued thereafter. The left-side rib osteotomy led to the development of progressive left-thoracic curvature, whereas the bilateral rib osteotomy did not cause scoliosis, even with restraint wear.

CONCLUSIONS

We established a nonsurgical experimental model of progressive scoliosis and also demonstrated that a rib cage deformity with an imbalanced load to the vertebral body resulted in progressive structural scoliosis.

The role of the autonomic nervous system in the etiology of idiopathic scoliosis: prospective electron microscopic and morphometric study

OBJECTS

The exact etiology of scoliosis is still unknown. The main purpose of this study is to search for the possible causation of scoliosis in the development changes of autonomic nervous structures. In this prospective study, we followed-up the changes in peripheral nerve structures and its discrepancies regarding the concavity and convexity of the scoliotic curve.

MATERIALS AND METHODS

We evaluated 12 patients with the idiopathic scoliotic deformity and the control group of 3 patients without any scoliotic deformity. The samples from the peripheral nerves of the convexity and concavity of the scoliotic deformity were drawn during the surgical correction by using the transthoracic approach. The samples were examined by the electron microscopic method and morphometric statistical evaluation.

RESULTS

In samples taken from the scoliotic convexity, 23.71% of myelinized nerve fibers (MNF), 12.21% of unmyelinized nerve fibers (UNF), and 5.0% of Schwann cells (SC) were found by the morphometric measurement. There were 17.36% of MNF, 5.82% of UNF, and 5.27% of SC in samples taken from the concavity and 29.9% of MNF, 19.9% of UNF, and 16.7% of SC in the control nonscoliotic samples. Statistically significant differences between both sides of scoliotic deformity (convexity and concavity) and differences between the scoliotic samples and the nonscoliotic control samples were found. In all scoliotic samples, significant morphologic changes were found, mostly in the myelin sheaths and axon fiber abnormalities compression.

CONCLUSION

There are significant morphologic changes in spinal autonomic nervous structures in scoliotic patients. These findings can help us in the search for the etiology of scoliosis.

Evolution of anterior chest wall blood supply in female adolescents with progressive right-convex thoracic idiopathic scoliosis

Breast asymmetry was believed to be related to the asymmetry of anterior chest wall blood supply and subsequently to etiology of idiopathic thoracic scoliosis in female adolescents. Recent investigations on the anterior chest wall blood supply with colour Doppler ultrasonography in such individuals did not show anatomic and hemodynamic abnormalities. The present study investigated the evolution of anterior chest wall blood supply in these individuals over a 2-year period. Twenty female adolescents with progressive right-convex idiopathic thoracic scoliosis (scoliotics), who were during the study in therapy with thoracolumbosacral orthosis and 20 age-matched girls, without spine deformity (controls) were studied with colour Doppler ultrasonography [internal mammary artery (IMA)] twice within the 2-year period. IMA-anatomic parameters [lumen diameter (D) and cross sectional area (AR)] and also hemodynamic flow parameters [time average mean flow velocity (TAM) and flow volume per minute (FV)] were measured. In the 2-year period of observation, thoracolumbosacral orthosis prevented scoliosis progression (P=0.004), whereas IMA-AR decreased bilaterally in the individuals of both groups (P<0.03). In the last evaluation: in scoliotics right IMA FV decreased (P<0.04), whereas in controls IMA FV decreased bilaterally (P<0.03); left IMA FV was significantly higher (P<0.05) in scoliotics than in controls. The significant, within the 2-year period, decrease of IMA-diameter, cross-sectional area, and flow volume seems to be a physiologic ageing process because it was observed in all individuals (scoliotics and controls) and thus these anatomic and hemodynamic changes seem not to have been affected by bracing. The maintenance of left flow volume of IMA in the prebrace levels in scoliotics was the most significant finding of this investigation. In conclusion, this study provided evidences for abnormalities in the evolution of anterior chest wall blood supply in female adolescents with progressive right-convex female thoracic scoliosis. Further studies are needed to investigate if this asymmetric blood evolution contributes to the development of this pattern of scoliosis in girls.

Asymmetric evolution of anterior chest wall blood supply in female adolescents with progressive right-convex thoracic idiopathic scoliosis

Breast asymmetry was believed to be related to asymmetry of anterior chest wall blood supply and subsequently to aetiology of idiopathic thoracic scoliosis in female adolescents. Recent investigations on the anterior chest wall blood supply with Colour Doppler Ultrasonography (CDU) in such individuals did not show anatomical and hemodynamic abnormalities. The present study investigated the evolution of anterior chest wall blood supply in these individuals over a 2-year period. Twenty female adolescents with progressive right-convex idiopathic thoracic scoliosis (scoliotics), who were during the study in therapy with horacolumbosacral orthosis (TLSO) and 20 age-matched girls, without spine deformity (controls) were studied with CDU [internal mammary artery (IMA)] twice within the 2-year period. IMA-anatomical parameters [lumen diameter (D) and cross sectional area (AR)] as well as hemodynamic flow parameters [time average mean flow velocity and flow volume per minute (FV)] were measured. In the 2-year-period of observation, TLSO prevented scoliosis progression (P = 0.004), while IMA-AR decreased bilaterally in the individuals of both groups (P < 0.03). In the last evaluation: in scoliotics right IMA FV decreased (P < 0.04), while in controls IMA FV decreased bilaterally (P < 0.03); left IMA FV was significantly higher (P < 0.05) in scoliotics than in controls. The significant, within the 2-year period, decrease of IMA-diameter, cross-sectional area, and flow volume seems to be a physiological ageing process because it was observed in all individuals (scoliotics and controls), and thus these anatomic and hemodynamic changes seem not to have been affected by bracing. The maintenance of left flow volume of IMA in the pre-brace levels in scoliotics was the most significant finding of this investigation. In conclusion, this study provided evidence for abnormalities in the evolution of anterior chest wall blood supply in female adolescents with progressive right-convex female thoracic scoliosis. Further studies are needed to investigate if this asymmetric blood evolution contributes to the development of this pattern of scoliosis in girls.