Down syndrome and scoliosis: a review of a 50-year experience at one institution

Paediatric syndromic scoliosis: proceedings of the half-day course at the 57th annual meeting of the Scoliosis Research Society

There are some syndromes that present with unique manifestations pertaining to the spinal column. A good working understanding of these common syndromes is useful for the spinal deformity surgeons and related healthcare providers. This review attempts to encompass these unique features and discuss them in three broad groups: hypermobility syndromes, muscle pathology-related syndromes, and syndromes related to poor bone quality. This review explores the features of these syndromes underpinning the aspects of surgical and medical management. This review represents the proceedings of the Paediatric Half-Day Course at the 57th Annual Meeting of the Scoliosis Research Society.

Scoliosis in Adolescent Patients With Down Syndrome: Correlation Between Curve Magnitude and Functional Level

STUDY DESIGN

This is a retrospective, observational comparative study.

OBJECTIVE

The aim of this study is to determine whether a relationship exists between the functional level and spinal deformity in patients with Down syndrome (DS).

SUMMARY OF BACKGROUND DATA

Patients with DS have a higher incidence of scoliosis than the general population; however, it is unknown whether functional level influences the characteristics and severity of the deformity.

MATERIALS AND METHODS

Of 649 patients with DS included in a pediatric referral center database, we identified 59 with a diagnosis of scoliosis (59.32% female; mean age, 14.19±1.82 y); the 46 patients who met the inclusion criteria comprised the study cohort. According to their functional gait skills and gross motor skills, they were classified into 2 levels. Different coronal and sagittal parameters were measured using full-spine standing radiographs. The need for surgical treatment and history of thoracotomy were recorded as well. Finally, a multivariate association analysis was performed between radiologic parameters and functional level.

RESULTS

Twenty-two patients had a functional level consistent with level I and 24 with level II. Twelve curves were thoracic, 10 thoracolumbar, and 24 lumbar. A statistically significant relationship was found between functional level I and II and curve magnitude: 18.9 degrees (6.8) versus 36.9 degrees (20.3) ( P =0.001) with a cutoff point at 22.3 degrees (area under the curve=0.919, P <0.005, sensitivity=0.917 and specificity=0.818). The relationship between patients who required surgery and level II was also significant ( P =0.016). No relationship was found between functional level and coronal and sagittal balance, nor with other radiologic parameters or with curve location, or between the history of thoracotomy and thoracic curves.

CONCLUSIONS

DS adolescents with poorer functional level were associated with larger curves and greater risk for surgery. These findings may provide valuable guidance for the follow-up of scoliosis in patients with DS based on their functional level.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Risk Factors for Surgical Site Infection in Spinal Surgery and Interventions: A Retrospective Study

BACKGROUND

Surgical site infection following spinal surgery causes prolonged delay in recovery after surgery, increases cost, and sometimes leads to additional surgical procedures. We investigated risk factors for the occurrence of surgical site infection events in terms of patient-related, surgery-related, and postoperative factors.

METHODS

This retrospective study included 1000 patients who underwent spinal surgery in our hospital between April 2016 and March 2019.

RESULTS

Patient-related factors were dementia, length of preoperative hospital stay (≥ 14 days), and diagnosis at the time of surgery (traumatic injury or deformity). The one surgery-related factor was multilevel surgery (≥ 9 intervertebral levels), and the one postoperative factor was time to ambulation (≥ 7 days) were statistically significant risk factors for spinal surgical site infection.

CONCLUSION

One risk factor identified in this study that is amenable to intervention is time to ambulation. As delayed ambulation is a risk factor for postoperative surgical site infection, how medical staff can intervene in postoperative ambulation to further reduce the incidence of surgical site infection is a topic for future research.

Effect of hippotherapy on balance, functional mobility, and functional independence in children with Down syndrome: randomized controlled trial

Impaired muscle strength, proprioceptive and vestibular deficits, and orthopedic dysfunction are common disorders associated with Down syndrome (DS). Hippotherapy uses the horses' multidimensional movement to improve posture, balance, and overall function, both motor and sensory. Research evidence supports hippotherapy as an effective, medically recognized intervention for the rehabilitation of gross motor skills. The aim of this study was to determine the effect of hippotherapy on balance, functional mobility, and functional independence in children with DS. Thirty-four children with DS were randomly assigned to the experimental (hippotherapy) and control groups after the initial assessment. Both groups received physiotherapy including balance exercises, and the experimental group also received hippotherapy as an integrative therapy. Pediatric Balance Scale (PBS), Timed Up and Go Test (TUG), and Functional Independence Measure for Children (WeeFIM) were used before and after the intervention. Baseline outcome measures (PBS, TUG, WeeFIM) were statistically similar between groups (p > 0.05). After the intervention, PBS and TUG scores improved in both groups (p < 0.05). On the other hand, WeeFIM scores improved just in the hippotherapy group (p < 0.05).   Conclusion: Therefore, providing hippotherapy as an integrative therapy to physiotherapy will be more effective in improving the functional independence of children with DS.    Trial registration: NCT05297149 (March 2022, retrospectively registered). What is Known: • Hippotherapy has an improvement effect on balance and functional independence in different diseases and age groups, but the evidence is limited in DS. • There is limited evidence about the effect of hippotherapy on functional mobility in different diseases and age groups, but there is no evidence in DS. What is New: • Hippotherapy is a safe and effective approach to support improvement in functional independence in children with DS.

Outcomes of Posterior Spinal Fusion in Pediatric Patients with Down Syndrome

BACKGROUND

Trisomy 21 or Down syndrome is associated with multiple orthopaedic manifestations. Although cervical instability is the most common spinal condition associated with Down syndrome, the prevalence of scoliosis has been estimated at 4.8% to 8.7%. Very few prior studies have documented the role of spinal fusion in this population, and all have included ≤10 patients.

METHODS

An institutional review board-approved multicenter retrospective analysis of patients with Down syndrome treated with spinal fusion between January 2009 and December 2019 was performed by cross-referencing Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth and Tenth Revisions (ICD-9 and ICD-10) codes. Patients were followed for ≥2 years, with a mean follow-up of 3.77 years. Clinical and radiographic outcomes were collected, and complications were documented using the Clavien-Dindo-Sink (CDS) classification.

RESULTS

A total of 23 patients were included: 96% had ≥1 medical comorbidities, including 16 (70%) with congenital heart disease, of whom 88% had previous cardiac surgery, and 10 (44%) with thyroid disorders. All 23 patients underwent posterior spinal fusion. The mean estimated blood loss was 617 ± 459 mL, the mean length of the surgical procedure was 290 ± 92.7 minutes, and the mean length of hospital stay was 6.03 ± 2.91 days. The major Cobb angle measured 61.7° ± 17.6°, which corrected to 19.4° ± 14.8° (68.6% correction; p < 0.001), with well-maintained correction at 2 years of 22.0° ± 10.3° (64.3% correction; p = 0.158). Thirteen (57%) of 23 patients had a change in curve of >5°. There were no intraoperative complications; however, 12 patients (52%) sustained postoperative complications (e.g., need for reoperation, implant failure, and pulmonary complications), including 6 patients with CDS type 3 or 4 (e.g., wound dehiscence, late superficial abscess, pleural effusion, pseudarthrosis, and readmission for hypoxia). Four patients (17%) required a revision surgical procedure. One patient (4%) required an unplanned intensive care unit admission.

CONCLUSIONS

Although instrumented spinal fusion can effectively correct spinal deformity in these patients, complications are more frequent than in children with adolescent idiopathic scoliosis, with over half of patients sustaining a complication.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Circular RNAs in childhood-related diseases and cancers: A review

Research into the diagnosis, treatment and prevention of childhood-related diseases is the key to reducing their morbidity and mortality. Circular RNAs (circRNAs) play critical roles, both in physiology and pathology, and there is ample evidence to show that they play varying roles in tissue development and gene regulation. Studies on circRNAs in different childhood-related diseases have confirmed their great potential for disease prevention and treatment. These breakthroughs highlight the pathological role of circRNAs in cancers, as well as cardiovascular and hereditary childhood illnesses. In this review, we summarize the role of circRNAs in childhood-related diseases and cancer, and provide an update of the possible diagnostic and therapeutic application of circRNAs.

Use of recombinant human bone morphogenetic protein for revision cervical spine fusion in children with Down syndrome: a case series

OBJECTIVE

Patients with trisomy 21 (Down syndrome; DS) often have atlantoaxial instability (AAI), which, if severe, causes myelopathy and neurological deterioration. Children with DS and AAI who undergo cervical spine fusion have a high rate of nonunion requiring revision surgery. Recombinant human bone morphogenetic protein-2 (rhBMP-2) is a TGF-β growth factor that is used to induce bone formation in spine fusion. Although previous studies in the adult population have reported no reduction in pseudarthrosis rates with the use of rhBMP-2, there is a lack of literature in the pediatric DS population. This study describes the use of rhBMP-2 in children with DS and AAI during revision to treat nonunion.

METHODS

A retrospective review of a cervical spine fusion database (n = 175) was conducted. This database included all cervical spine fusions using modern instrumentation at the authors' institution from 2002 to 2019. Patients with DS who underwent a revision utilizing rhBMP-2 were included in the study. The number of prior fusions, use of rhBMP-2 in fusions, length of stay, halo use, and surgical data were collected. Postoperative complications and length of follow-up were also recorded.

RESULTS

Eight patients (75% female) met the inclusion criteria. The average age at revision with rhBMP-2 was 11 years (range 3-19 years). All patients were diagnosed with nonunion after an initial cervical fusion. All revisions were posterior fusions of C1-2 (n = 2) or occiput to cervical (n = 6). All revisions included implant revisions, iliac crest bone grafting, and rhBMP-2 use. One patient required irrigation and debridement of an rhBMP-induced seroma. Another patient required return to the operating room to repair a dural tear. There were no neurological, infectious, airway, or implant-related complications. Revision utilizing rhBMP-2 achieved fusion in 100% (n = 8) of patients. The average length of follow-up was 42.6 months. All patients demonstrated solid fusion mass on the last radiograph.

CONCLUSIONS

This is the first case series reporting the successful use of rhBMP-2 to facilitate cervical spine fusion in patients with DS after previous nonunion. In addition, few rhBMP-2-related postoperative complications occurred.

Syndromic Scoliosis: National Trends in Surgical Management and Inpatient Hospital Outcomes: A 12-Year Analysis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Evaluate the trends in management and inpatient outcomes in patients with syndromic scoliosis undergoing spinal deformity correction.

SUMMARY OF BACKGROUND DATA

Syndromic scoliosis (SS) refers to scoliosis that is most commonly associated with systemic disease including Ehler Danhlos syndrome (EDS), Marfan syndrome (MF), Down syndrome (DS), Achondroplasia (AP), and Prader-Willi syndrome (PWS). Limited data exist evaluating hospital outcomes in patients with SS undergoing spinal deformity correction.

METHODS

The Kids' Inpatient Database (KIDS) was queried from 2001 to 2012 to identify all pediatric patients with scoliosis undergoing spinal fusion. These patients were then sub-divided into two cohorts: (1) patients with idiopathic scoliosis (IS) and (2) patients with syndromic scoliosis. Trends in surgical management, and postoperative morbidity and mortality were assessed. Length of stay and total hospital charges were additionally analyzed. A sub-analysis to characterize outcomes in each syndrome was also performed.

RESULTS

An estimated 1071 patients with SS were identified and compared with 24,989 pediatric patients with IS. MF (36.8%), Down syndrome (16.0%), and PWS (14.9%) were the most common diagnoses among patients with SS. Between 2001 and 2012, there was a significant decline in the number of anterior procedures performed in both cohorts. Conversely, the number of posterior based procedures increased. SS was associated with increased major complications (2.7% compared with 1.0% in IS; P < 0.001) and minor complication rates (41.0% compared with 28.5% in IS; P < 0.001). Patients with AP incurred the highest rate of major complications (10.7%), minor complications (60.8%), and intraoperative durotomies (6.1%). Total hospital charges increased significantly over the 12-year span.

CONCLUSION

Trends in management of syndromic scoliosis have paralleled that of idiopathic scoliosis. Syndromic scoliosis is associated with increased risks with surgical deformity correction. Further prospective studies are warranted to evaluate the reasons for these differences.

LEVEL OF EVIDENCE

3.

Late implant migration with neurologic compromise as a complication of scoliosis surgery

Late neurological deficit following scoliosis surgery is a rare event and any change in the patient's neurological status deserves immediate attention. We report on two clinical cases (at 2 and 6 years of follow-up) where two different types of proximal instrumentation resulted in lateral drift into the spinal canal causing cord compression with neurological deficit. Late neurological compromise in a posterior spinal-fusion setting deserves a prompt and complete spine investigative search for non-union, infection, or implant migration into the spinal canal.

Spinopelvic Alignment in Subjects With Down Syndrome

STUDY DESIGN

This was a cross-sectional study.

OBJECTIVE

The aim of this study was to describe the spinopelvic alignment of subjects with Down syndrome (DS).

SUMMARY OF BACKGROUND DATA

Subjects with DS are known to suffer from a large prevalence of scoliosis. While scoliosis is known to significantly affect postural alignment, there are currently no studies on the spinopelvic alignment of subjects with DS.

MATERIALS AND METHODS

In total, 41 subjects (28 female subjects and 13 male subjects) with DS, age and sex-matched to 41 asymptomatic subjects, underwent biplanar x-rays with 3-dimensional reconstructions of their spines and pelvises, followed by measurement of commonly used spinopelvic sagittal and coronal alignment parameters. Subjects were then classified into one of Roussouly's 4 types of sagittal alignment. Alignment parameters and prevalence of alignment patterns were compared between the 2 groups.

RESULTS

Subjects with DS were found to be relatively hypokyphotic (T4-T12=-29.0 vs. -37.5 degrees; P<0.001) and hyperlordotic (L1-L5=53.8 vs. 44.3 degrees; P<0.001) with larger pelvic incidence (53.2 vs. 45.1 degrees; P<0.001), sacral slope (47.7 vs. 36.8 degrees; P<0.001), Cobb angle (10.2 vs. 8.0 degrees; P=0.005), and axial rotation of the apical vertebra (6.6 vs. 3.7 degrees; P<0.001) but had smaller pelvic tilt (4.9 vs. 8.1 degrees; P<0.001) compared with control subjects. Roussouly's type 4 was found to be the most frequent pattern in DS subjects (68.3% vs. 14.6%; P<0.001).

CONCLUSIONS

Subjects with DS were found to have a peculiar pattern of hypokyphosis, hyperlordosis, large pelvic incidence, and small pelvic tilt. The altered spinopelvic alignment found in DS could predispose these subjects to hip instability and osteoarthritis.

LEVEL OF EVIDENCE

Level III.

Risk Factors for Development and Progression of Scoliosis After Pediatric Cardiothoracic Operations

BACKGROUND

The purpose of this study was to determine the incidence and risk factors for the development and rate of progression of scoliosis and moderate/severe scoliosis in patients undergoing cardiothoracic operations (CTOs).

METHODS

Included were patients aged younger than 12 years who underwent CTOs in 1995 to 2006 with a preoperative chest roentgenogram (CRG) and a CRG at least 8 years after CTOs. Scoliosis and moderate/severe scoliosis were defined as a Cobb angle of 10 degrees or more and an angle of 25 degrees or more or the need for surgical intervention, respectively. Risk factors were analyzed using nonparametric and parametric survival analyses. For patients that developed scoliosis, progression rate was analyzed using linear regression models for repeated measures using CRG at 6-month intervals.

RESULTS

The study included 871 patients (380 girls [44%]). Median CRG follow-up was 11 years (interquartile range, 9 to 13 years). Overall 10-year incidence of scoliosis and moderate/severe scoliosis was 12% and 3%, respectively. Independent predictors for scoliosis included female sex (hazard ratio [HR], 1.7; 95% confidence interval [CI], 1.2 to 2.5), syndrome (HR, 1.9; 95% CI, 1.3 to 2.8), and isolated developmental delay (HR, 2.4; 95% CI, 1.4 to 4.2). For development of moderate/severe scoliosis, independent risk factors included female sex (HR, 2.8; 95% CI, 1.4 to 5.8), syndrome (HR, 3; 95% CI, 1.5 to 6.1), isolated developmental delay (HR, 3.1; 95% CI, 1 to 9.2]), and prematurity for neonates/infants (HR, 2.3; 95% CI, 1 to 5.2). Rate of angle progression was 0.17 times the current angle per year. Age, syndrome, and developmental delay were risk factors for angle progression.

CONCLUSIONS

Patients that undergo pediatric CTO, regardless of the operative approach, are at increased risk for development of scoliosis and moderate/severe scoliosis. Long-term follow-up of these patients is warranted, in particular for girls and patients with genetic syndromes or developmental delay.

Pseudarthrosis in adult and pediatric spinal deformity surgery: a systematic review of the literature and meta-analysis of incidence, characteristics, and risk factors

We conducted a systematic review with meta-analysis and qualitative synthesis. This study aims to characterize pseudarthrosis after long-segment fusion in spinal deformity by identifying incidence rates by etiology, risk factors for its development, and common features. Pseudarthrosis can be a painful and debilitating complication of spinal fusion that may require reoperation. It is poorly characterized in the setting of spinal deformity. The MEDLINE, EMBASE, and Cochrane databases were searched for clinical research including spinal deformity patients treated with long-segment fusions reporting pseudarthrosis as a complication. Meta-analysis was performed on etiologic subsets of the studies to calculate incidence rates for pseudarthrosis. Qualitative synthesis was performed to identify characteristics of and risk factors for pseudarthrosis. The review found 162 articles reporting outcomes for 16,938 patients which met inclusion criteria. In general, the included studies were of medium to low quality according to recommended reporting standards and study design. Meta-analysis calculated an incidence of 1.4% (95% CI 0.9-1.8%) for pseudarthrosis in adolescent idiopathic scoliosis, 2.2% (95% CI 1.3-3.2%) in neuromuscular scoliosis, and 6.3% (95% CI 4.3-8.2%) in adult spinal deformity. Risk factors for pseudarthrosis include age over 55, construct length greater than 12 segments, smoking, thoracolumbar kyphosis greater than 20°, and fusion to the sacrum. Choice of graft material, pre-operative coronal alignment, post-operative analgesics, and sex have no significant impact on fusion rates. Older patients with greater deformity requiring more extensive instrumentation are at higher risk for pseudarthrosis. Overall incidence of pseudarthrosis requiring reoperation is low in adult populations and very low in adolescent populations.

Scoliosis in Down's syndrome

This study reports the recent experience in the management of scoliosis in Down's syndrome. Curve patterns, progression in brace, and surgical outcomes were recorded. Cardiac surgery history was compared between children with and without scoliosis. Out of 581 children with Down's syndrome, 62 children had scoliosis. The mean age of the children was 13.8 years. The mean magnitude was 31°. Bracing was successful in five of seven patients. Ten children had posterior spinal fusion with follow-up of 2.6 years (1-7.3). One deep wound infection was recorded with no revision. No difference was found in cardiac surgery history between children with and without scoliosis.

LEVEL OF EVIDENCE

Type IV - prognostic and therapeutic study.

Complications associated with surgical repair of syndromic scoliosis

Background

There are a number of syndromes that have historically been associated with scoliosis e.g.: Marfan, Down, and Neurofibromatosis. These syndromes have been grouped together as one etiology of scoliosis, known as syndromic scoliosis. While multiple studies indicate that these patients are at high risk for perioperative complications, there is a paucity of literature regarding the collective complication rates and surgical needs of this population.

Methods

PubMed and Embase databases were searched for literature encompassing the surgical complications associated with the surgical management of patients undergoing correction of scoliosis in the syndromic scoliosis population. Following exclusion criteria, 24 articles were analyzed for data regarding these complications.

Results

The collective complication rates and findings of these articles were categorized based on specific syndrome. The rates and types of complications for each syndrome and the special needs of patients with each syndrome are discussed. Several complication trends of note were observed, including but not limited to the universally nearly high rate of wound infections (>5% in each group), high rate of pulmonary complications in patients with Rett syndrome (29.2%), high rate (>10%) of dural tears in Marfan and Ehlers-Danlos syndrome patients, high rate (>20%) of implant failure in Down and Prader-Willi syndrome patients, and high rate (>25%) of pseudarthrosis in Down and Ehlers-Danlos patients.

Conclusions

Though these syndromes have been classically grouped together under the umbrella term “syndromic,” there may be specific needs for patients with each of these ailments. Given the high rate of complications, further research is necessary to understand the unique needs for each of these patient groups in the preoperative, intraoperative, and postoperative settings.

Adolescent idiopathic scoliosis in Down's syndrome

Adolescent idiopathic scoliosis in Down's syndrome individuals has previously been reported in the context of institutionalised individuals and is of an iatrogenic nature, resulting from previous thoracotomy for congenital heart defects. We report the case of a male, non-institutionalised Down's syndrome individual, with no history of previous thoracic surgery and we follow the natural history of the condition, with particular reference to height velocity and curve progression velocity throughout puberty and successful treatment with a Boston thoracolumbosacral orthosis.

Prevalence of complications in neuromuscular scoliosis surgery: a literature meta-analysis from the past 15 years

PURPOSE

Our objectives were primarily to review the published literature on complications in neuromuscular scoliosis (NMS) surgery and secondarily, by means of a meta-analysis, to determine the overall pooled rates (PR) of various complications associated with NMS surgery.

METHODS

PubMed and Embase databases were searched for studies reporting the outcomes and complications of NMS surgery, published from 1997 to May 2011. We focused on NMS as defined by the Scoliosis Research Society's classification. We measured the pooled estimate of the overall complication rates (PR) using a random effects meta-analytic model. This model considers both intra- and inter-study variation in calculating PR.

RESULTS

Systematic review and meta-analysis were performed for 68 cohort and case-control studies with a total of 15,218 NMS patients. Pulmonary complications were the most reported (PR = 22.71 %) followed by implant complications (PR = 12.51 %), infections (PR = 10.91 %), neurological complications (PR = 3.01 %) and pseudoarthrosis (PR = 1.88 %). Revision, removal and extension of implant had highest PR (7.87 %) followed by malplacement of the pedicle screws (4.81 %). Rates of individual studies have moderate to high variability. The studies were heterogeneous in methodology and outcome types, which are plausible explanations for the variability; sensitivity analysis with respect to age at surgery, sample size, publication year and diagnosis could also partly explain this variability. In regard to surgical complications affiliated with various surgical techniques in NMS, the level of evidence of published literature ranges between 2+ to 2-; the subsequent recommendations are level C.

CONCLUSION

NMS patients have diverse and high complication rates after scoliosis surgery. High PRs of complications warrant more attention from the surgical community. Although the PR of all complications are affected by heterogeneity, they nevertheless provide valuable insights into the impact of methodological settings (sample size), patient characteristics (age at surgery), and continual advances in patient care on complication rates.

Incidence of surgical site infection following adult spinal deformity surgery: an analysis of patient risk

Surgical site infection (SSI) following spinal surgery is a frequent complication and results in higher morbidity, mortality and healthcare costs. Patients undergoing surgery for spinal deformity (scoliosis/kyphosis) have longer surgeries, involving more spinal levels and larger blood losses than typical spinal procedures. Previous research has identified risk factors for SSI in spinal surgery, but few studies have looked at adult deformity surgeries. We retrospectively performed a large case cohort analysis of all adult patients who underwent surgery for kyphosis or scoliosis, between June 1996 and December 2005, by our adult spine division in an academic institution to asses the incidence and identify risk factors for SSI. We reviewed the electronic patient records of 830 adult patients. SSI was classified as deep or superficial to the fascia. 46 (5.5%) patients were found to have a SSI with 29 patients (3.5%) having deep infections. Obesity was found to be an independent risk factor for all SSI and superficial SSI (P = 0.014 and P = 0.013). As well, a history of prior SSI was also found to be a risk factor for SSI (P = 0.041). Patient obesity and history of prior SSI lead to increased risk of infection. Since obesity was related to an increased risk of both superficial and deep SSI, counseling and treatment for obesity should be considered before elective deformity surgery.

An unusual case of congenital scoliosis in a patient with Down syndrome

We report on a case of a young infant with congenital scoliosis (multiple hemivertebrae in the thoracic region and an unsegmented bar in the mid-thoracic region) associated with Down syndrome. Although scoliosis has been previously described in relation to Down syndrome, to the best of our knowledge, there has been no prior report of Down syndrome associated with congenital scoliosis. The patient underwent placement of a vertical expandable prosthetic titanium rib implant. He tolerated the procedure well and had no complications. This case highlights that vertebral malformation may be an etiology of scoliosis in Down syndrome.

BRACING FOR SCOLIOSIS

BRACING IS THE oldest treatment known for scoliotic spinal deformity. The relative advantages to the use of bracing have been directly related to the etiology of the deformity and the flexibility of the spine at the time that a decision is made regarding the use of a brace. In skeletally immature patients with adolescent idiopathic scoliosis, the advantages to bracing are clear. In many instances, prompt recognition and appropriate bracing can arrest the progression of this form of deformity, and, in so doing, the need for any surgery may be avoided completely. On the other hand, in skeletally mature adult deformity patients, bracing has almost no proven role in affecting the natural history of the disease. Likewise, infantile and congenital scoliosis routinely requires surgical correction to prevent curve progression. Lastly, although many surgeons use bracing in the postoperative management of patients with spinal deformity, the benefits of postoperative bracing remain debatable. By far, the best indication for bracing is treatment of the skeletally immature adolescent patient with an idiopathic flexible curve of less than 45 degrees magnitude.

Down syndrome: orthopedic issues

PURPOSE OF REVIEW

The purpose of this review is to update the role of the orthopedic surgeon in the management of Down syndrome as these patients are living longer and participating in sporting activities.

RECENT FINDINGS

Approximately 20% of all patients with Down syndrome experience orthopedic problems. Upper cervical spine instability has the most potential for morbidity and, consequently, requires close monitoring. Other conditions such as scoliosis, hip instability, patellar instability and foot problems can cause disability if left untreated. In some of these conditions, early diagnosis can prevent severe disability.

SUMMARY

Surgical intervention in children with Down syndrome has a high risk of complications, particularly infection and wound healing problems. Careful anesthetic airway management is needed because of the associated risk of cervical spine instability.

Scoliosis

Scoliosis is a structural lateral curvature of the spine with a rotatory component. Imaging in scoliosis is important. Most cases of scoliosis are idiopathic, and imaging is used routinely in monitoring the changes of the deformity that take place during growth. Imaging is also crucial in determining the underlying etiology in non-idiopathic cases of scoliosis and is used in pre- and postoperative monitoring.