The correlation between coronal balance and neuroaxial abnormalities detected on MRI in adolescent idiopathic scoliosis

Monitoring Expression of Balance during Therapy in Children with Postural Disorders

In the literature, we find information about the impact of changes in the shape of the spine on the efficiency of equivalent reactions, and we also find information about the methods and effects of physiotherapy in improving equivalent reactions. However, there is a lack of publications showing the process of changes taking place over time and defining their nature at individual stages of treatment. The aim of this study is to present the process of monitoring the expression of balance in patients aged 8-12 years with postural disorders, in the course of the therapeutic process. The shape of the spine and the efficiency of equilibrium reactions in standing posture and during gait were assessed in all the subjects. The subjects were put into two groups: with a shape-of-spine disorder and without one. The recommended set of therapeutic activities in home conditions lasted about 20 min and was performed by the child with a parent's supervision. The therapeutic program was based on elements of neurophysiological methods: Vojta and PNF. The following parameters were measured: the maximum movement of the center of pressure (CoP) in the frontal plane during gait, the maximum movement of the CoP in the sagittal plane, the movement of the CoP in the frontal plane in static conditions and the movement of the CoP in the sagittal plane in static conditions. Six statistically significant differences were recorded, and all of them were related to measurement I. The Friedman test result was statistically significant for all the indexes. Post hoc analyses were performed using the Dunn-Bonferroni test. The children with shape-of-spine disorders had a lower efficiency of equivalent reactions in relation to the children without disorders. The therapy with the application of neurophysiological methods in the treatment of shape-of-spine disorders improved equilibrium reactions in these patients. Long-lasting and thorough observations of the therapeutic process in children with shape-of-spine disorders should include the monitoring of the efficiency of equilibrium reactions.

7.7% Prevalence of neural axis abnormalities on routine magnetic resonance imaging in patients with presumed adolescent idiopathic scoliosis scheduled for spine surgery: a consecutive single surgeon retrospective cohort of 182 patients

PURPOSE

The purpose of this study was to use a Delphi analysis to identify a clinically relevant threshold for the prevalence of neural axis abnormalities (NAAs) that would warrant routine preoperative screening.

METHODS

A panel of experienced physicians specializing in pediatric spine surgery, pediatric neurosurgery, and pediatric neuroradiology was formed to establish consensus using a Delphi process to identify a minimum prevalence of NAAs that would initiate the implementation of preoperative MRIs as standard of care. Following the Delphi analysis, patients scheduled for PSF (Posterior Spinal Fusion) from 2010 to 2018 were retrospectively identified. Patients were included based on the following criteria: (1) 10-18 years old at time of MRI (inclusive), (2) AIS diagnosis prior to preoperative MRI (no concerning curve pattern, rate of progression, or neurologic signs/symptoms to suggest alternative diagnosis to AIS), and (3) standard preoperative MRI of the cervical, thoracic, and lumbar spine undergone. The prevalence of NAAs on preoperative MRI was recorded for all patients.

RESULTS

There were 182 eligible patients. 14 had NAAs on MRI. The prevalence of NAAs was 7.7% [95% CI 4.27-12.57%]. This prevalence was significantly [p < 0.0001] higher than the clinically relevant threshold of 1.3% established by the Delphi panel. Of the 14 patients with NAAs noted on preoperative MRI, neurosurgical intervention was recommended for 4 patients, 2.2% [95% CI 0.6-5.5%] of the total cohort.

CONCLUSIONS

Delphi panelists reported a low tolerance for NAAs among patients undergoing PSF for presumed AIS. Group consensus recommended routine screening should be implemented if the prevalence of NAAs is greater than 1.3%. The prevalence of NAAs in our cohort as well as related studies was significantly higher than this threshold.

LEVEL OF EVIDENCE

Diagnostic-level III.

The use of MRI in the study of patients with idiopathic scoliosis: a systematic review of the literature

Objective. To analyze the frequency of hidden neuraxial pathology in idiopathic scoliosis (IS), to substantiate the need for MRI in IS and to identify promising areas for the use of MRI in the examination of patients with IS.Material and Methods. The literature review was carried out using the PubMed and Google Scholar databases. Of the 780 papers on the research topic, 65 were selected after removing duplicates and checking for inclusion/exclusion criteria. As a result, 49 original studies were included in the analysis. Level of evidence – II.Results. According to modern literature, the main direction of using MRI in idiopathic scoliosis is the search for predictors of latent pathology of the spinal cord and craniovertebral junction. The frequency of neuraxial pathology in idiopathic scoliosis is 8 % for adolescent IS and 16 % for early IS. The main predictors of neuraxial pathology are male sex, early age of deformity onset, left-sided thoracic curve and thoracic hyperkyphosis. MRI in IS may be a useful addition to radiological diagnostic methods to identify risk factors and to study degenerative changes in the spine.Conclusion. MRI of the spine should be performed in the early stages of IS to detect latent spinal cord tethering. In type I Chiari anomalies, there is a possibility that early neurosurgery can prevent the development of scoliosis. The main signs of latent neuraxial pathology in IS are early progression of spinal deformity, left-sided thoracic curve, male gender and thoracic kyphosis over 40° according to Cobb.MRI can be used as an effective non-invasive tool in research aimed at identifying risk factors for IS, including helping to track early degeneration of intervertebral discs.

Evaluation of the association between postural control and sagittal curvature of the spine

Introduction

Balance is key to controlling body posture. Balance is typically assessed by measures of the body’s vertical orientation, obtained by balancing out the forces acting on different body segments. The ability to maintain balance is assessed by evaluating centre of pressure (CoP) displacement; such assessments are typically used to evaluate responses to a treatment process.

Purpose of study

This study evaluated the efficiency of compensatory reactions in children according to the extent of thoracic kyphosis and lumbar lordosis.

Materials and method

The study enrolled 312 children aged 8‒12 years, including 211 patients with postural disorders: thoracic kyphosis outside the 47‒50-degree range and lordosis outside the 38‒42-degree range (study group). A control group was also recruited and comprised 101 children without postural disorders. The DIERS formetric 4D system was used to assess posture and CoP displacement.

Results

Children in the study group showed a significantly greater range of CoP displacement than children in the control group. The kyphosis angle correlated with the maximum CoP displacement in the coronal plane and the maximum CoP displacement in the sagittal plane during gait. The kyphosis angle also correlated with the maximum CoP displacement back in the static test. The size of the lordosis angle correlated with the maximum displacement of CoP in the coronary plane during gait, and with the maximum displacement of CoP toward the left, forward, and backward in the static test. The correlation coefficient of the lordosis angle with displacement of the CoP in the sagittal plane was 0.999.

Conclusions

An analysis of clinical risk factors for adolescent scoliosis caused by spinal cord abnormalities in China: proposal for a selective whole-spine MRI examination scheme

BACKGROUND

Approximately 80% of adolescent scoliosis cases are idiopathic, and some non-idiopathic scoliosis cases caused by spinal cord abnormalities are misdiagnosed as idiopathic scoliosis. This study examined the risk factors for non-idiopathic scoliosis with intramedullary abnormalities, explored the feasibility of whole-spine MRI, and provided a theoretical basis for the routine diagnosis and treatment of adolescent idiopathic scoliosis.

METHOD

The clinical data of adolescent scoliosis patients who were admitted to Shanghai Tongren Hospital and Shanghai Changhai Hospital between July 1, 2013, and December 31, 2018, were reviewed. According to the whole-spine MRI results, the patients were divided into either the idiopathic group or the intramedullary abnormality group. Sex, age, main curvature angle, main curvature direction, kyphosis angle, scoliosis type, coronal plane balance, sagittal plane balance, abdominal wall reflex, sensory abnormality, ankle clonus and tendon reflexes were compared between the two groups. Student's t test was used to evaluate the differences in the continuous variables, and the chi-square test was used to evaluate the differences in the categorical variables. Fisher's exact test was applied to detect the difference in the rate of intraspinal anomalies between the groups. Logistic regression was used to evaluate the correlation between the multivariate risk factors and intramedullary abnormalities.

RESULT

A total of 714 adolescent scoliosis patients with a mean age of 13.5 (10-18 years) were included in the study, and intramedullary abnormalities were found in 68 (9.5%) patients. There were statistically significant differences in the incidence rates of intramedullary abnormalities between males and females, left and right thoracic curvatures, angular scoliosis and smooth scoliosis, and abnormal abdominal wall reflex and ankle clonus (P < 0.01). Logistic regression showed that the ratios for sex, scoliosis direction, scoliosis type, abdominal wall reflex and ankle clonus were 2.987, 3.493, 4.823, 3.94 and 8.083, respectively. The ROC curve showed a sensitivity of 66.18% and a specificity of 89.01%, and the Youden index corresponding to the optimal critical point was 0.5519.

CONCLUSION

Risk factors associated with adolescent scoliosis caused by abnormal intramedullary abnormalities included male sex, thoracic scoliosis on the left side, sharp curvature of the spine, abnormal abdominal wall reflex and ankle clonus. In adolescent scoliosis patients, the incidence of scoliosis caused by intramedullary abnormalities was approximately 9.5%. These clinical indicators suggest that there is a high-risk adolescent scoliosis population who should undergo whole-spinal MRI preoperatively to rule out intramedullary abnormalities.

Clinical Relevance of Preoperative MRI in Adolescent Idiopathic Scoliosis: Is Hydromyelia a Predictive Factor of Intraoperative Electrophysiological Monitoring Alterations?

STUDY DESIGN

This was a prospective cohort study.

OBJECTIVES

The main objectives of this study were to evaluate the prevalence and clinical relevance of neuroaxial anomalies in adolescent idiopathic scoliosis (AIS) patients as well as to evaluate different clinical and radiologic variables as potential predictors of the presence of a magnetic resonance imaging (MRI) abnormality.

SUMMARY OF BACKGROUND DATA

The usefulness of preoperative magnetic resonance imaging in AIS is still debated in the literature as well as the clinical relevance of the neuroaxial anomalies detected.

MATERIALS AND METHODS

We performed an analysis on 88 patients affected by AIS with normal neurological examination undergoing a posterior arthrodesis intervention. Patients were stratified according to the presence and type of neuroaxial abnormalities and were compared by age, sex, Risser grading, Lenke curve type, coronal and sagittal curve parameters, presence of alterations at intraoperative neuromonitoring, and "pain" and "function" scores at the SRS-22 test.

RESULTS

Neuroaxial abnormalities were reported in 23 patients (26.14%): 14 hydromyelias, 7 syringomyelias, 1 case of Chiari I syndrome, and 1 case of spinal ependymoma. Age, sex, Risser grading, curve type, and coronal and sagittal curve parameters did not differ between normal patients and patients with any neuroaxial abnormality. Alterations of motor-evoked potential/somatosensory-evoked potential monitoring during surgery were reported in 23 patients; the difference in their incidence between normal (20%) and hydromyelia (64%) patients was significant (P<0.01). In evaluating the subareas of the SRS-22 test, we found that the "function" scores differed significantly by comparing normal (21.5±1.6) and hydromyelia (20.4±1.8) patients (P<0.05).

CONCLUSIONS

The prevalence of neuroaxial abnormalities in AIS patients is relatively high, but we could not identify any definitive clinical or radiologic predictor of their presence. Hydromyelia was correlated with intraoperative motor-evoked potential/somatosensory-evoked potential electrophysiological alterations.

Prevalence and risk factors for neural axis anomalies in idiopathic scoliosis: a systematic review

BACKGROUND

There is ongoing controversy about the routine use of magnetic resonance imaging (MRI) preoperatively in patients with presumed idiopathic scoliosis (IS). Routine MRI can help identify possible causes for the deformity and detect anomalies that could complicate deformity surgery. However, routine MRI increases health-care costs significantly and may reveal mild variations from normal findings without clinical relevance, which can still lead to anxiety and influence decision-making.

PURPOSE

Given the necessity to make evidence-based decisions both in the light of quality of care and cost control, the aim of this review is to report the prevalence of neural axis anomalies in IS and to identify risk factors associated with these anomalies.

STUDY DESIGN

A systematic review was carried out.

METHODS

An electronic search of PubMed, Embase, Cochrane, and Cinahl until May 2017 was performed. Studies were assessed by two reviewers independently according to predetermined inclusion (MRI in presumed IS) and exclusion criteria (diagnosis other than IS).

RESULTS

Fifty-one studies were included comprising 8,622 patients. In 981 patients, anomalies were found, resulting in an overall prevalence of 11.4%. The prevalence was 10.5%, 9.0%, and 14.2% when screening was performed of all IS patients, preoperative patients, or patients with presumed risk factors. The prevalence of a syrinx (3.7%), an Arnold-Chiari malformation (3.0%), or a combination of both (2.5%) was highest. Less frequent diagnoses included tethered cord (0.6%), an incidental malignancy (0.3%), and split cord malformations (0.2%). Risk factors for intraspinal anomalies included early-onset scoliosis, male gender, atypical curves, thoracic kyphosis, and abnormal neurologic findings such as reflexes and sensation.

CONCLUSIONS

This systematic review shows that a significant number of patients have intraspinal anomalies on preoperative MRI in (presumed) IS. The prevalence of finding spinal axis abnormalities increases in preselected patient groups with specific risk factors.

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.

Preoperative Magnetic Resonance Imaging Evaluation in Patients with Adolescent Idiopathic Scoliosis

Study Design

Retrospective case series.

Purpose

The purpose of this study was to examine the incidence of neural axis abnormalities and the relevant risk factors in patients with adolescent idiopathic scoliosis (AIS).

Overview of Literature

The use of preoperative magnetic resonance imaging (MRI) to assess the whole spine in patients with idiopathic scoliosis is controversial, and indications for such MRI evaluations have not been definitively established. However, we routinely use whole-spine MRI in patients with scoliosis who are scheduled to undergo surgical correction.

Methods

A total of 378 consecutive patients with presumed AIS who were admitted for spinal surgery were examined for neural axis abnormalities using MRI. To differentiate patients with normal and abnormal MRI findings, the following clinical parameters were evaluated: age, sex, menarcheal status, rotation angle (using a scoliometer), coronal balance, shoulder height difference, and low back pain. We radiographically evaluated curve type, thoracic or thoracolumbar curve direction, curve magnitude and flexibility, apical vertebral rotation, curve length, coronal balance, sagittal balance, shoulder height difference, thoracic kyphosis, and the Risser sign.

Results

Neural axis abnormalities were detected in 24 patients (6.3%). Abnormal MRI findings were significantly more common in males than in females and were associated with increased thoracic kyphosis. However, there were no significant differences in terms of the other measured parameters.

Conclusions

Among the patients with presumed AIS who received preoperative whole-spine MRI, 6.3% had neural axis abnormalities. Males and patients with increased thoracic kyphosis were at a higher risk.

The Role of Routine Preoperative Magnetic Resonance Imaging in Idiopathic Scoliosis: A Ten Years Review

Study Design

Prospective study.

Purpose

To determine the role of routine preoperative magnetic resonance imaging (MRI) to detect the incidence and risk factors for intraspinal anomalies in patients with idiopathic scoliosis.

Overview of Literature

The incidence and risk factors for intraspinal anomalies in patients with idiopathic scoliosis are controversial, and the indications for preoperative MRI in these patients vary among centers.

Methods

Information on patients with idiopathic scoliosis who were surgical candidates over 10 years (age at presentation, sex, magnitude and apex of major curve, intraspinal anomalies detected by MRI, and neurological examination results) were recorded, the patients were grouped according to the intraspinal anomaly, and the data were analyzed.

Results

Of the 271 patients with idiopathic scoliosis, 27 had neuroaxial abnormalities (9.9%). Of these 27 patients, 14 (52%) underwent a neurosurgical procedure. Significant differences were observed in the frequency of early disease onset and male sex (p<0.05) between the group of patients with neuroaxial abnormalities on preoperative MRI and those who did not have a cord anomaly. No difference was detected in the magnitude or direction of the curve.

Conclusions

Neuroaxial abnormalities in patients with idiopathic scoliosis and a normal neurological examination were highly frequent (9.9%). Missing these abnormalities before surgery could inflict catastrophic postoperative complications. The incidence of neuroaxial abnormalities was higher in male patients and in those with early onset disease. Thus, MRI is essential for all patients with idiopathic scoliosis who require medical intervention.

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.

Detection of syringomyelia in a pediatric patient with mild scoliosis: a case report

It can be challenging to detect syringomyelia in patients with scoliosis, as some cases are mildly symptomatic with little to no neurological deficits. However, a timely diagnosis of syringomyelia is needed to facilitate important treatment considerations. This case report details an 11-year-old female with mild scoliosis and a two-year history of spinal pain that had short-term symptomatic relief from chiropractic treatment. Subtle neurological signs were detected only at re-evaluation, which prompted further investigation with radiographs and subsequent magnetic resonance imaging (MRI). MRI revealed a non-expansile syrinx measuring 3 mm at its widest diameter that extended from C5 to the conus medullaris. The aim of this case is to heighten awareness of the potential diagnostic challenges in patients with syringomyelia and scoliosis. The incidence, pathogenesis, clinical presentation, and management of syringomyelia will be presented to help primary contact providers with appropriate referral and co-management of these patients.

Indication for preoperative MRI of neural axis abnormalities in patients with presumed thoracolumbar/lumbar idiopathic scoliosis

PURPOSE

The purpose of this study was to investigate the incidence of neural axis abnormalities in patients with presumed "idiopathic" thoracolumbar or lumbar scoliosis by magnetic resonance imaging (MRI) and try to determine which clinical and radiographic characteristics correlate with neural axis abnormalities on MRI in these patients.

METHODS

The database of a single spinal deformity center was retrospectively reviewed to identify all patients with a primary diagnosis of idiopathic scoliosis (IS) between January 2003 and August 2011. A total of 446 patients with main thoracolumbar or lumbar curves were identified. Radiographic parameters including main curve Cobb angles, location of curve apex, span of main curve, thoracic kyphosis (T5-T12), thoracolumbar junction kyphosis (T10-L2), lumbar lordosis (L1-S1), and sagittal and coronal balance were measured.

RESULTS

Neural axis abnormalities were detected in 35 (7.8 %) patients. For patients with neural axis abnormalities, a higher proportion of male gender and long thoracolumbar curves were presented. In these patients, the mean age was smaller and the mean Cobb angle of main curve was larger. Greater thoracic kyphosis (≥ 30°) was more frequently found in those with neural axis abnormalities. The incidences of thoracolumbar junction hyperkyphosis were similar between two groups (P > 0.05). There was no difference between two groups as to lumbar lordosis and coronal and sagittal balance.

CONCLUSION

We recommend the routine use of MRI in the patients with one or more of the following characteristics: right curves, long curve span, apex at thoracolumbar spine and hyperthoracic kyphosis.