Serial derotational casting in congenital scoliosis as a time-buying strategy

Current Concepts in the Treatment of Early Onset Scoliosis

Despite many surgical advances in the treatment of early onset scoliosis (EOS) over the past two decades, this condition remains a challenge to address. While otherwise healthy children can have EOS, many of these patients have complicated comorbidities making proper treatment algorithms extraordinarily difficult. Non-operative measures can be successful when initiated early, but are many times utilized as a delay tactic until growth-friendly operative procedures can be safely performed. This article will summarize the current concepts in the treatment of EOS with a focus on the surgical advances that have recently been made.

The efficacy of bracing in the treatment of progressive early-onset scoliosis

Serial casting as one of the applications to treat early-onset scoliosis has been reported efficiently to improve deformity, but no report has focused on the efficacy of braces in the treatment of congenital early-onset scoliosis and comparison with progressive idiopathic early-onset scoliosis. Patients with progressive EOS treated with braces in our institution with a minimum of 4 years follow-up were reviewed. Two groups according to the etiological diagnosis were analyzed and compared: the congenital scoliosis (CS) group and idiopathic scoliosis (IS) group. The success cases and the failure cases were also compared. 27 patients with an average main Cobb angle of 38.19° (20-55) underwent initial bracing at an average age of 55.7 months (24-108), the average follow-up time was 76.19 months (49-117). In IS group the main Cobb angle was corrected to 18.69 ± 12.06° (48.61%) following the first bracing; the final Cobb angle was 23.08 ± 22.15°(38.76%) after brace removal. In CS group the main Cobb angle was corrected to 33.93 ± 10.31°(17.1%) following the first bracing and 37.93 ± 14.74°(3.53%) after brace removal. Both coronal chest width and T1-T12 height increased dramatically from pre-bracing to the last follow-up. Patients diagnosed as IS tended to have a better result in main Cobb angle correction than that of CS (P = 0.049). By the time of last follow-up, 8 patients had undergone surgery, and the operation time was postponed by 68.88 ± 26.43 months. For patients with progressive early-onset scoliosis, bracing is an efficient nonsurgical alternative to casting, and some of them can be cured; if not, eventual surgical intervention can be delayed for a period of time without restrictions on the thoracic cavity.

Diagnostic and therapeutic strategies in early onset scoliosis: A current concept review

Substantial advances in the treatment of early onset scoliosis (EOS) over the past two to three decades have resulted in significant improvements in health-related quality of life of affected children. In addition to classifications that address the marked heterogeneity of this patient population, increasing understanding of the natural history of the disease, and new implants and treatment techniques have resulted in innovations unlike any other area of pediatric orthopedics. The growing understanding of the interaction between spinal and thoracic growth, as well as dependent lung maturation, has had a lasting impact on the treatment strategy of this potentially life-threatening disease. The previous treatment approach with early corrective fusion gave way to a growth-friendly concept. Despite the steady development of new growth-friendly surgical treatment options, whose efficacy still needs to be validated, as well as a revival of conservative growth control with serial casts and/or braces, the psychosocial burden of the long lasting and complication-prone treatments remains high. As a consequence, EOS still represents one of the greatest pediatric orthopedic challenges.

Physician collections are 71% less for early onset scoliosis casting than for growing rod instrumentation: A retrospective cohort study

Growing rod (GR) instrumentation and the elongation, derotation, and flexion (EDF) casting technique are 2 alternatives for the treatment of early-onset scoliosis. Our purpose was to investigate the cost of these treatment options. This was a retrospective cohort study of patients with early-onset scoliosis treated at 2 institutions from 2007 to 2014 with either GR instrumentation or EDF casting. Patients with <2 years of follow-up were excluded. Physician and hospital charges and collections, total procedures, and procedure times until final follow-up or time of fusion were compared. Nineteen patients met the inclusion criteria; 8 in the GR group and 11 in the EDF casting group. There were no significant differences between the groups in age (P = .23), public versus private insurance (P = 1.0), or major curve (P = .21) at the initiation of treatment. Excluding final fusion, the EDF casting patients had an average of 2.1 (range: 0.7-6.6) procedures/year while the GR patients had an average of 1.5 (range: 0.8-2.7) procedures/year. The average procedure time for the EDF group was 104.2 minutes; the average procedure time for the GR group, excluding the index procedure, was 62.40 minutes (P = .001). Physician charges were 85% less for the EDF group (EDF= $1892.75, GR= $12,354.53, P < .001). Physician collections were 71% less for the EDF group (EDF= $731.10, GR= $2554.88, P = .001). Hospital charges and collections were similar between the groups (P = .82, P = .42). Physician charges for casting were approximately 18% of that of GRs. Compared to GRs, physician collections were 71% less for EDF casting patients per year.

Does Transitioning to a Brace Improve HRQoL After Casting for Early Onset Scoliosis?

BACKGROUND

Serial casting is favored for the initial treatment of early onset scoliosis (EOS), but there is concern about significant morbidity and caregiver burden. Studies have examined the utility of bracing as an alternative to casting, but little is known about differences in health-related quality of life (HRQoL) between treatments. We hypothesized that patients with a diagnosis of idiopathic EOS experience an improvement in HRQoL when transitioning from serial casting to bracing as measured by the 24-Item Early Onset Scoliosis Questionnaire (EOSQ).

METHODS

Subjects with idiopathic EOS were retrospectively identified from a multicenter database. EOSQ scores were compared before treatment, after index casting, after transition out of cast to brace, and at the most recent follow-up. Available major curve magnitudes were also compared during these time points. Data were compared using repeated-measures ANOVA with post hoc Bonferroni correction.

RESULTS

Sixty-six subjects met the inclusion criteria. Thirty-seven (56%) subjects were male and the average age at the time of index treatment was 1.9 (0.37-6.4) years. The average follow-up was 3.2 (0.90-6.8) years. In 57 subjects, the major curve magnitude improved from a mean of 33 (CI 28-37) degrees before treatment initiation to 27 (CI 23-30) degrees after casting and to 24 (CI 20-29) degrees at the most recent follow-up. The HRQoL subdomain showed a significant decrease in HRQoL during casting treatment 75.7 (CI 72.9-78.5) from pre-index treatment 84.9 (CI 81.4-88.5), during brace treatment 84.8 (CI 81.8-88.0) and at most recent follow-up 87.0 (CI 83.6-90.3) ( P <0.001). The parental impact subdomain improved from the beginning to the end of treatment (77.7 to 87.7, P =0.001) (n=64). Satisfaction improved from casting to bracing (73.4 to 86.7, P <0.001) (n=63) and to the most recent follow-up (73.4 to 87.9, P <0.001).

CONCLUSION

Patients treated with casting for EOS experience reversible declines in HRQoL. After patients transition from casting to bracing, EOSQ scores recover to pretreatment baseline levels and are maintained at follow-up. This information must be balanced with the effectiveness of treatment for EOS with either method and customized for each patient.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Diagnosis and treatment of congenital scoliosis

Background: Congenital scoliosis is caused by anomalies of the vertebra, such as hemivertebra or unsegmented bar, which result in asymmetric growth of the spine. The disruption of vertebra development during embryogenesis may be accompanied by other congenital multi-organ anomalies. The progression of the scoliotic curve may also hinder the development of other organs.Current Concepts: Hemivertebra excision and short spinal fusion have demonstrated favorable outcomes. However, the need for spinal growth and lung development has led to new treatment modalities. Growth-friendly surgeries, such as with a growing rod or vertical expandable rib-based distraction device, have demonstrated good results with curve correction while maintaining spinal growth. Although the outcome of conservative treatment for congenital scoliosis is questionable, casting may be effective as a “time-buying strategy” to delay the need for surgery.Discussion and Conclusion: It is essential to decide on a treatment plan considering the progression of the curve and growth of the spine and lungs through an individualized approach.

Clinical Results of Corrective Cast and Brace Treatment for Early-onset Scoliosis: The Effectiveness of Long-term Cast Treatment That Extends into Children's Schooldays

BACKGROUND

Cast and brace treatment is a conservative treatment for early-onset scoliosis (EOS). We analyzed the clinical results of this treatment when extended into patients' schooldays.

METHODS

Twenty-two children with EOS underwent alternatively repetitive cast and brace treatment (ARCBT). Cast was applied under general anesthesia and remained for some weeks, and the brace was continuously worn, which was repeatedly applied when scoliosis progressed. The change in the major curve angle, requirement for surgical intervention, and complications of ARCBT were analyzed.

RESULTS

Six patients had idiopathic scoliosis (IS), 9 had syndromic scoliosis (SS), and 7 had neuromuscular scoliosis. Cast treatment started at 4.9±2.1 years of age, and the patients were followed up for 8.3 years. The average total number of cast applications was 5.5 per patient. The mean major scoliosis angle was 45.4±12.5 degrees at the first visit; this was corrected to 26.5±8.7 degrees at the first cast application and progressed to 75.4±22.1 degrees at the final visit. Nine patients whose scoliosis progressed finally underwent surgery. The mean age at surgery was 11.0 years (range, 8.8 to 13.1 y), and the mean period from first cast application to surgery was 6.1 years (range, 5.0 to 8.9 y). Four patients' IS rapidly progressed after 9 years of age, and all of them underwent final fusion surgery with a correction rate of 56.9%. Among patients with SS, 1 final fusion, and 2 growth-friendly surgeries were performed at a mean age of 9.2 years; the correction rate was 21.5%. Among patients with neuromuscular scoliosis, 2 final fusion surgeries were performed at a mean age of 11.3 years; the correction rate was 30.7%. The cast-related complication rate was 5.0%, and most complications were skin problems.

CONCLUSIONS

Long-term ARCBT extended into schooldays might be effective for IS. This should be considered as a time-saving treatment option for EOS.

LEVEL OF EVIDENCE

Level IV-case series.

A report of two conservative approaches to early onset scoliosis: serial casting and bracing

PURPOSE

Previous reports have demonstrated the effectiveness of casting for EOS. Brace treatment for EOS has not been studied. The purpose of this multicenter retrospective study was to compare radiographic outcomes, complications, and rates of conversion to surgery in children with EOS treated with casting or bracing.

METHODS

Children aged 2-6 years with idiopathic or neuromuscular EOS treated with casting or bracing with minimum follow-up of 2 years were identified.

RESULTS

68 patients (36 cast, 32 brace) were analyzed. Diagnosis, age at start of treatment, and duration of follow-up were similar. Although the cast patients had a larger pre-treatment major curve magnitude (50° vs 31°, p < 0.001), both groups had a similar major curve magnitude at most recent follow-up (36° vs 32°, p = 0.456). T1-T12 and T1-S1 length increased in both groups. The cast and brace patients had similar complications and conversions to surgery. Sub-analysis showed that while casting resulted in curve improvement regardless of etiology, bracing was able to prevent curve progression in patients with idiopathic EOS but not in patients with non-idiopathic EOS (Δ- 15° vs 27°, p = 0.006). Regression analysis (significance p = 0.10) controlling for baseline age, major curve magnitude, and T1-T12 and T1-S1 length showed that treatment method was associated with difference in major curve magnitude (p = 0.090) and T1-T12 length (p = 0.024).

CONCLUSION

In our study, serial casting led to curve improvement in children with idiopathic and neuromuscular EOS, whereas brace treatment appeared to prevent curve progression in patients with idiopathic EOS but did not appear to control the curve in neuromuscular EOS.

Serial casting for early onset scoliosis and its effects on health-related quality of life during and after discontinuation of treatment

INTRODUCTION

Serial body casting plays an important role in the treatment of early onset scoliosis (EOS), serving as a safer method compared to surgical intervention. There is no published evidence documenting the impact of casting on health-related quality of life (HRQoL) of patients and their caregivers. The purpose of this study was to utilize the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24) to compare the HRQoL of patients with EOS and the burden of care for their caregivers before, during, and after treatment with Mehta casting.

METHODS

In this multicenter retrospective cohort study, two EOS databases were queried for patients with EOS who underwent serial casting from 2005 to 2016. Patients who had treatment prior to their initial cast application, including bracing or surgical intervention, were excluded from the study. Patients were stratified into two subgroups and analyzed separately: those with idiopathic etiology, and those with non-idiopathic etiology. HRQoL and burden of care were assessed using the EOSQ-24 completed before, during, and after cast treatment.

RESULTS

91 patients were identified in this study (mean age at the index casting: 2.1 ± 1.2 years, mean age at final cast removal: 4.1 ± 1.3 years). 59 (64.8%) had EOS of idiopathic etiology, while 32 (35.2%) had EOS of non-idiopathic etiology, including 10 congenital, 6 neuromuscular, and 16 syndromic. Idiopathic patients and non-idiopathic patients experienced an improvement in the coronal deformity from 45° pre-cast to 26° post-cast, and from 59° pre-cast to 34° post-cast, respectively. Patients with idiopathic scoliosis experienced a decrease from baseline in nearly all EOSQ-24 sub-domain scores except for general health. Furthermore, even after the removal of the cast, patients with idiopathic etiology suffered residual negative effects of casting on emotion and transfer sub-domains. Among patients with non-idiopathic etiology, decreased scores from baseline were observed only in transfer and emotion sub-domains during the casting intervention. After brace removal, patients with non-idiopathic etiology had increased scores compared to their baseline scores in most sub-domains.

DISCUSSION

Serial body casting can prevent curve correction in patients with EOS. However, the psychosocial stresses secondary to this non-operative intervention can have significant negative impacts on HRQoL for both idiopathic and non-idiopathic patients during the course of treatment. Although non-idiopathic patients experience improved HRQoL following treatment, idiopathic patients do not seem to exhibit much improvement in HRQoL from baseline even years after the final cast removal.

Diverse approaches to scoliosis in young children

Management of scoliosis in young children needs a comprehensive approach because of its complexity. There are many debatable points; however, only serial casting, growing rods (including traditional and magnetically controlled) and anterior vertebral body tethering will be discussed in this article.Serial casting is a time-gaining method for postponing surgical interventions in early onset scoliosis, despite the fact that it has some adverse effects which should be considered and discussed with the family beforehand.Use of growing rods is a growth-friendly surgical technique for the treatment of early onset spine deformity which allows chest growth and lung development. Magnetically controlled growing rods are effective in selected cases although they sometimes have a high number of unplanned revisions.Anterior vertebral body tethering seems to be a promising novel technique for the treatment of idiopathic scoliosis in immature cases. It provides substantial correction and continuous curve control while maintaining mobility between spinal segments. However, long-term results, adverse effects and their prevention should be clarified by future studies. Cite this article: EFORT Open Rev 2020;5:753-762. DOI: 10.1302/2058-5241.5.190087.

Nonanesthetized Alternatively Repetitive Cast and Brace Treatment for Early-onset Scoliosis

BACKGROUND

Use of cast is a standard treatment (Tx) choice for early-onset scoliosis. Recently, toxicity from repetitive use of general anesthesia has received attention by the Food and Drug Administration (FDA). We introduce a nonanesthetized cast Tx protocol called alternatively-repetitive-cast-and-brace (ARCB) that we have used since 1995 and have conducted an extensive follow-up on these patients to verify the efficacy of this protocol.

STUDY DESIGN

This is a retrospective cohort study.

METHODS

Of a consecutive series of 155 patients who have undergone cast Tx at a single institution, 98 patients (male: 36, female: 62) have been identified under the following criteria: (1) Initial age before ARCB of ≤6; (2) Follow-up period of ≥2 years; (3) Initial scoliosis ≥35 degrees. Patients consisted of the following: congenital/structural: 45, idiopathic: 23, neuromuscular: 6, syndromic: 24. Precast, postfinal cast, minimum in-cast Cobb, as well as thoracic and T1-S1 heights were measured. Fifty-six of these patients had available pulse oximetry on days before and after initial cast, and these were also evaluated to assess cardiopulmonary effects that the cast have on the patients.

RESULTS

Patients were casted 6.6 times, with a mean initial Cobb of 56.5 degrees and a final follow-up Cobb of 57.1 degrees. Follow-up period was 5.0 years. Mean curve progression per follow-up period was 0.5 degrees/y. Minimum in-cast Cobb was 25.6 degrees. Initially patients had a thoracic and T1-S1 height of 12.6 and 22.5 cm, respectively. At final cast, these were 15.3 and 27.2 cm, respectively. Of these patients, 39 had progression >1 degree/y, of which 83.1% had resulted in surgical correction, while this was true for only 37.3% of those that did not show such progression. Idiopathic patients had the greatest correction rate by cast (69%) and had shown an overall progression rate of -2.3 degrees/y. Pulse-oximetry results were not significant amongst patients before and after cast placement.

CONCLUSIONS

ARCB is a versatile and practical Tx choice. It is an effective delaying method in sparing time until surgery with no apparent cardiopulmonary compromise. Curve control was most effective in Idiopathic patients while some curve control was achieved in other etiologies which may have spared time until their eventual surgery.

SIGNIFICANCE

Cast Tx without the need of general anesthesia is an increasingly important topic since anesthesia toxicity from its repetitive use has become apparent. This study exemplifies safe and efficacious use of such cast with effective suppression on cast progression in different etiologies at various degrees.

Vertical Expandable Rib-based Distraction Device for Correction of Congenital Scoliosis in Children of 3 Years of Age or Younger: A Preliminary Report

BACKGROUND

This study was designed to evaluate the treatment outcome of very young children with congenital scoliosis aged 3 years or under after surgery with a vertical expandable prosthetic titanium rib (VEPTR)-based distraction device.

METHODS

A retrospective study of 13 children undergoing implantation of a vertical expandable rib-based distraction device. From September 2007 to June 2018, 13 children (7 male and 6 female patients) with congenital scoliosis were followed after treatment with a VEPTR. The outcome parameters were complications, thoracic height, kyphosis, lordosis, and coronal major scoliosis curve. In addition, the American Society of Anaesthesiologists (ASA) score, assisted ventilation rating, and hemoglobin and body mass index were analyzed. Data were examined separately by 2 investigators.

RESULTS

The mean age at initial surgical treatment was 24.4±10.6 months, follow-up was 91.5±23.1 months. The mean number of surgical procedures per patient was 14±3.9 (total 182 operations). Apart from planned operations every 6 months, 5 unplanned operations (2.7%) were performed. The major scoliosis curve improved significantly from 55.2±21.9 degrees to 40.5±18.7 degrees, thoracic spine height T1-T12 significantly from 111±12 mm to 137±23 mm, T1-S1 height significantly from 211±13 mm to 252±36 mm and space available for the lung from 80.9%±11.3% to 84.4%±8.8% (preoperatively and at 5-y follow-up, respectively). Kyphosis increased significantly from 30±21.4 degrees to 42.6±23.5 degrees and lordosis from 32.4±20.9 degrees to 37.6±10.4 degrees. Hemoglobin levels were virtually unchanged. Weight increased from 10.6±2.8 kg to 20.2±5.0 kg at final follow-up, but body mass index decreased from 16.6±3.7 kg/m² to 15.7±2.9 kg/m².

CONCLUSIONS

The expandable rib-based distraction device is an effective method to treat severe congenital scoliosis in very young children. It can control the deformity and promotes spinal and thoracic growth.

LEVEL OF EVIDENCE

Level IV.

What Is the Cost of a "Cast Holiday" in Treating Children With Early Onset Scoliosis (EOS) With Elongation Derotation Flexion (EDF, "Mehta") Casting?

INTRODUCTION

Serial casting of children with early onset scoliosis (EOS) is an established treatment option. A break from cast treatment often called a "cast holiday," (CH) is often allowed by some centers, particularly over the summer months. The impact of CHs on treatment duration or outcome has not been examined.

METHODS

Institution review board approved retrospective review of children treated for EOS with elongation derotation flexion ("Mehta") casting at a children's hospital between 2001 and 2016 with a minimum of 2 years' follow-up. A CH was defined as a minimum of 4 weeks out of the cast, braced, or unbraced.The analysis was performed to determine the impact of a CH within the first 18 months of treatment. Separate analyses were performed for the entire cohort of children castedduring the study period, and then separately looking at idiopathic EOS in isolation. The impact of a CH was assessed in terms of the likelihood of achieving scoliosis <15 degrees at the final follow-up ("success"). Odds ratios were used to assess group differences between "success" ratios, and Student t tests assessed group differences for parametric data.

RESULTS

Ninety children met inclusion and exclusion criteria, 31 of whom took a CH during the first 18 months of treatment (34%). This included 59 patients with idiopathic EOS (66%), 18 with syndromic EOS, 5 congenital, and 1 neuromuscular. There were no statistically significant differences between CH and no CH groups.Forty-four percent of the no CH group achieved scoliosis <15 degrees at final follow-up, as opposed to 13% of the CH group, an odds ratio of 5.3 for success without a CH. When limited to children with idiopathic EOS, 56% achieved success in the no CH, versus only 22% in the group that took a CH, an odds ratio of 4.4 for success with no CH.

CONCLUSION

This study demonstrates that children treated for EOS with serial casting who take a CH within the first 18 months of treatment are less likely to achieve scoliosis <15 degrees than those who persist with treatment.

LEVEL OF EVIDENCE

Level III.

Evolution of casting techniques in early-onset and congenital scoliosis

Casting is being utilized as a therapeutic strategy in some mild to moderate cases obviating surgical intervention for management of early-onset scoliosis (EOS). Bracing, another conservative modality, applies comparable correcting forces on chest wall and axial skeleton. But cast application carries additional advantage of sustained restorative force which bypasses issue of compliance seen with brace wear. There is no specific blanket treatment, conservative or surgical, for the early-onset spinal deformities. Serial cast application provides near total correction of less severe curves (less than 500 to 600) if treatment is initiated before age of 2 yrs. In this review article, we will assess the evolution of plaster cast application in management of EOS and also describe technique of EDF (Elongation- Derotation- Flexion) casting.

Magnetic Controlled Growth Rods in the Treatment of Scoliosis: Safety, Efficacy and Patient Selection

Early-onset scoliosis is defined as a spinal curvature greater than 10° in children prior to 10 years of age. Untreated EOS may lead to progressively severe spinal deformity, impaired pulmonary development, restrictive lung disease, and both increased morbidity and mortality. Limitations of established conservative treatments include inability to correct severe deformity, as well as challenges with compliance when casting and bracing is applied. In addition, surgical treatment in the form of traditional growing rods requires regular surgical lengthenings and is associated with complications inherent with repeated invasive procedures and exposure to general anesthesia. MAGEC is an evolving magnetically controlled growing rod system for the treatment of EOS. After initial implantation, lengthening is achieved non-invasively by using magnetic external remote control. MAGEC offers the potential to control moderate and severe EOS, while avoiding repeated surgical procedures and associated complications. In this review, we examine the results from clinical, radiological and explant studies following the use of MAGEC, in the context of other established and emerging treatments for EOS.

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.

Health-related quality of life in early-onset-scoliosis patients treated with growth-friendly implants is influenced by etiology, complication rate and ambulatory ability

BACKGROUND

Progressive Early-Onset Scoliosis (EOS) in children may lead to surgical interventions with growth-friendly implants, which require repeated lengthening procedures in order to allow adequate growth. Quality of life was studied using the validated German version of the EOS-Questionnaire (EOSQ-24-G) in surgically treated EOS children with different lengthening modalities.

METHODS

EOSQ-24-G and the KINDLR questionnaire were given to families with EOS children who had been treated by either vertical expandable prosthetic titanium rib implants and repetitive lengthening surgeries every 6 months or children who had received a magnetically expansion controlled implant, which was externally lengthened every 3 months. Results were compared according to differences between the two tests, and with possible influencing factors such as surgical method, severity of scoliosis, relative improvement of curvature, etiology, weight, age, travelling distance, complications, ambulatory ability and others.

RESULTS

56 children with an average curve angle of 69° corrected to 33° (52%; average age 5.6 yrs) answered the EOSQ-24-G and the KINDLR after an average follow-up of 3.9 years. Health-related quality of life (HRQoL) was not affected by the initial scoliosis correction, the number of surgeries or the implant type. However, there was a negative correlation with non-ambulatory status, complications during treatment and for children with a neuromuscular scoliosis.

CONCLUSION

Using the validated EOSQ-24-G, no statistically significant differences were found between the group of children receiving repetitive surgeries and children with external lengthening procedures without surgery. However, results were influenced by the etiology, complication rate or ambulatory ability.

LEVEL OF EVIDENCE/CLINICAL RELEVANCE

Therapeutic Level IV.

Serial casting in early onset scoliosis: syndromic scoliosis is no contraindication

BACKGROUND

Serial casting is a treatment for early onset scoliosis (EOS) in young children to achieve curve correction before bracing or to postpone initial surgical treatment until the patient is older. Good results have been reported for patients with idiopathic early onset scoliosis (IS). However, there are few reports of results in non-idiopathic cases, and the benefits of non-surgical methods in the syndromic-associated early onset scoliosis subgroup are unknown.

METHODS

Retrospective single-institution study of patient charts and X-rays of all cases of sustained serial casting for EOS. Staged correction was obtained by applying three consecutive casts under general anaesthesia. These were changed every 4 weeks, followed by the implementation of a custom-made full-time Chêneau brace. Correction was measured by Cobb angle (CA) and rib-vertebra angle difference (RVAD) on whole spine anterior-posterior radiographs. Statistical analysis was performed via ANOVA.

RESULTS

The study group consisted of 6 patiens with IS and 10 with non-idiopathic scoliosis (NIS) - exclusively syndromic-associated. The mean age at onset of treatment was 35 months (±15). The mean follow up was 21 months (±15). In IS patients average CA/RVAD before treatment was 46°(±8)/20°(±12). In NIS patients average CA/RVAD before treatment was 55°(±15)/24°(±14). After application of the third cast, the CA/RVAD was reduced to 20°(±11)/11°(±10) in IS patients. Whereas in NIS patients average CA/RVAD after the thrid cast was 28°(±12)/18°(±13). At latest follow-up the CA/RVAD was 16°(±7)/9°(±8) in IS patients and 31°(±11)/17° (±15) in NIS patients.

CONCLUSION

Syndromic etiology is not a contraindication for serial casting in EOS. Our results show a curve correction, measured in CA, of 65% in IS patients and 44% in NIS patients. Significant reduction in the morphologic deformity, measured in RVAD, was achieved in the IS cohort, but not in the NIS cohort. In all cases surgical treatment could be delayed.

Minimum 5-Year Follow-up of Mehta Casting to Treat Idiopathic Early-Onset Scoliosis

BACKGROUND

With the exception of Mehta's 2005 report on her experience treating early-onset scoliosis with serial casting, all subsequent studies have had limited follow-up. This current study sought to assess the results of serial casting at a minimum 5-year follow-up and to identify the predictors of the sustained resolution of scoliosis.

METHODS

This study is a retrospective review of children treated for idiopathic early-onset scoliosis with serial casting at a children's hospital between 2001 and 2013 with a minimum 5-year follow-up. A Cobb angle of ≤15° and a decrease in the Cobb angle of >20° at the most recent follow-up were separately assessed. The differences between groups based on these criteria were tested with Student t tests with alpha = 0.05.

RESULTS

Fifty-four children were treated during the study period; of these, 38 had at least 5 years of follow-up and comprised the study sample. The mean follow-up (and standard deviation) was 8 ± 2 years (range, 5 to 13 years). The mean patient age at the time of the first cast was 24 ± 15.1 months (range, 9 to 63 months), with a mean Cobb angle of 56.2° ± 20.1° (range, 22° to 109°). Forty-nine percent of children had scoliosis of ≤15° at the time of the most recent follow-up, and 73% of children were improved by at least 20°. Children with ≤15° scoliosis, compared with children with >15° scoliosis, had significantly lower initial Cobb angle (48.2° compared with 63.7°; p = 0.016), supine traction Cobb angle (22.5° compared with 33.2°; p = 0.048), first-in-cast Cobb angle (24.1° compared with 37.6°; p = 0.01), and first-in-cast rib-vertebral angle difference (12.8° compared with 26.2°; p < 0.01). Age at the time of the first cast, initial rib-vertebral angle difference, flexibility, and body mass index were not significantly different (p > 0.05) between the groups. Three children who initially achieved scoliosis of ≤15° after casting substantially relapsed.

CONCLUSIONS

At a minimum follow-up of 5 years, the initial Cobb angle, first-cast Cobb angle, rib-vertebral angle difference, and traction Cobb angle were all predictive of sustained scoliosis of ≤15°. However, with continued growth, relapse of scoliosis was seen in 3 patients.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Brace treatment can serve as a time-buying tactic for patients with congenital scoliosis

Background

Infantile patients with congenital scoliosis (CS) can be confronted with increasing risk of mortality and morbidity. To date, the effectiveness of conservative treatment in CS has not been sufficiently investigated. We aimed to evaluate the bracing outcome in patients with CS and to investigate whether wearing brace can effectively delay the surgical procedures.

Methods

A total of 39 braced CS patients including 25 boys and 14 girls were reviewed for the eligibility to be included in this study. Radiographic parameters including curve magnitude and T1 to T12 height were evaluated for each patient at the initiation of the treatment and at the final follow-up (FU), respectively. Duration of the follow-up and requirement of surgical interventions were also recorded. The student t test was used to compare the radiographic parameters between the initial visit and the last FU.

Results

The mean initial age at bracing was 4.1 ± 2.3 years, and 7.5 ± 1.8 brace modifications were performed during a mean FU period of 42.1 ± 26.5 months. The mean curve magnitude before bracing was 44.1 ± 12.2°, which was corrected to 41.3 ± 13.5° at the final visit (p = 0.33). T1-T12 height increased from 13.4 ± 2.5 to 17.1 ± 2.8 cm during the treatment (P < 0.001). Nine patients underwent surgical intervention due to the curve progression more than 5°, with the time of surgery delayed for 32.1 ± 18.2 months.

Conclusions

Brace treatment is an effective time-buying modality for CS patients, which may help maintain the body growth and delay the surgical intervention.

[Congenital spine deformities during growth : Modern concepts of treatment]

BACKGROUND

Congenital malformations of the spine can produce scoliosis, kyphosis, lordoscoliosis or kyphoscoliosis. Deformities may progress slowly or fast or may even be stable without progression. Knowledge of the natural history of such deformities is of utmost importance. Besides deformities of the spine and the thorax, a number of associated anomalies have to be taken into account, like thoracic, intraspinal, cardiac and urogenital abnormalities. Special examinations, including MRI of the entire spinal canal need to be ordered prior to beginning of treatment.

TREATMENT

Conservative treatment, including physical therapy and bracing, will not control progression of the curve. Serial casting may be offered for some types of congenital malformations in early childhood. An isolated hemivertebra is best resected by a posterior approach only at age 5 to 6. Growth guiding anterior or posterior procedures like growing rods are currently indicated for very few cases. However, the VEPTR procedure is well indicated for complex congenital deformities with or without thoracic malformations, preserving the growth potential of the spine and the thorax.

KYPHOTIC DEFORMITIES

Kyphotic deformities can not be treated with growth preserving surgery, so that early correction with short fusion is usually indicated. The most severe deformities may have to be treated with complex osteotomies, including VCR (vertebral column resection).

Treatment of early onset spinal deformities with magnetically controlled growing rods: a single centre experience of 30 cases

PURPOSE

The treatment of early onset scoliosis continues to be a major challenge, even when using motorized growth-sparing implants. We report on 30 cases operated on with magnetically controlled growing rods (MCGRs) at our institution, analyzing radiological parameters and complications, comparing our results with the literature and presenting a special implant fixation technique. A separate focus highlights the challenges of conversion from previous non-motorized implants.

METHODS

Consecutive case series. The nature and effects of complications were recorded for all patients. Radiographic evaluations were performed for patients with a minimum follow-up of two years. Separate analyses were carried out for patients who were previously treated with non-motorized growth-sparing implants.

RESULTS

There were 12 documented complications in 11/30 (37%) patients leading to 13 unplanned returns to the operating room. In all, 18/30 patients had a minimum follow-up of two years. Major curve and main kyphosis, as well as T1 to T12 and T1 to S1 distances significantly improved with MCGR implantation, however, less in patients converted from previous growth-sparing surgical treatment. While the achieved correction of the major curve was maintained, there was a loss of kyphosis correction with subsequent implant lengthening. Gain in implant length decreased with increasing number of extensions.

CONCLUSION

Despite improved patient's comfort, MCGR show a considerable complication rate. Coronal plane deformities can be well controlled, but diminished implant lengthening is already apparent within two years after MCGR implantation. Central databases should help to clarify unresolved aspects and optimize the treatment of these young patients.

LEVEL OF EVIDENCE

IV.

Reliability and validity of the Arabic version of the Early Onset Scoliosis 24 Items Questionnaire (EOSQ-24)

Introduction: Early Onset Scoliosis (EOS) is a complex pathology that covers a variety of etiologies, with onset before the age of 10 years. Surgical treatment of EOS should have the objectives of fulfilling maximum pulmonary function, spine length, with minimal hospitalizations, complications, and family burden. Radiographic parameters are an important standard in assessing treatment outcomes. However, the Early Onset Scoliosis Questionnaire-24 (EOSQ-24) was developed to measure the wider dimensions of outcomes involving the quality of life of patients and caregivers post-treatment. The aim of this study was to evaluate the validity and reliability of culturally adapted Arabic version of the EOSQ-24.

Methods: Translation and cross-cultural adaptation, based on published guidelines, were performed on the original English EOSQ-24 by a committee. The Arabic version of EOSQ-24 was applied to the caregivers of all 58 EOS patients who were treated surgically after signing a consent form. Reliability was assessed using Cronbach’s α and item-total statistics for the whole questionnaire initially and for the each domain separately. Data quality was assessed by mean, median, percentage of missing data, ceiling and floor effects. Discriminative validity was examined using non parametric tests.

Results: The response for all items was excellent with only 1.7% (0–1) of responses missing. The floor effect ranged from 0% to 36.2% of patients and the ceiling effect ranged from 0 to 46.6%. Cronbach’s α test reliability was found excellent (0.919), as was the internal consistency of all domains, with Cronbach α ranging from 0.903 to 0.918. Corrected item-total correlations were good for all domains (>0.3). Only one item (Question 21) showed low corrected item-total correlations (r = 0.222). However, Cronbach’s α did not increase significantly when this item was deleted (0.920).

Conclusion: The first adapted Arabic version of EOSQ-24 is found to have good validity and reliability, and it can be used to assess children in Arab societies with EOS.

Infantile Idiopathic Scoliosis: Factors Affecting EDF Casting Success

STUDY DESIGN

IRB-approved retrospective single cohort study.

OBJECTIVES

To review our ten-year history with EDF (Elongation Derotation Flexion) casting in patients with infantile idiopathic scoliosis (IIS) to better understand which factors predict successful outcomes.

SUMMARY OF BACKGROUND DATA

Numerous studies have demonstrated the efficacy of EDF casting in the treatment of progressive infantile idiopathic scoliosis. But none have reproduced the success of Mehta's even with early intervention.

METHODS

Patients with IIS treated with EDF casting with a minimum 24-month follow-up were included. Radiographs and clinical records were reviewed. Age, sex, and curve type were documented. Precast, traction, in cast, in brace, and final Cobb angles were measured and recorded. Outcomes were defined by Cobb angle at final follow-up out of cast or brace. Patients were considered cured if the final Cobb angle was <10°, palliated at 10°-45°, and failed if they required surgical treatment.

RESULTS

Sixty-three patients with IIS were reviewed. Thirty-two were excluded for incomplete records or insufficient follow-up, leaving 31 patients. No patients progressed to surgical intervention during the study. Patients with a Cobb angle >10° in the final cast were 7.3 times more likely to fall into the palliative range at the most recent follow-up than if their Cobb angle was 10° or less even when adjusted for age. Earlier age at onset of casting (14.9 vs. 21.1 months) was not statistically significant (p=.073). Magnitude of initial curvature, flexibility, initial correction, sex, and curve type were also not found to be significant.

CONCLUSION

EDF casting is a valid treatment option for IIS with a high cure rate. Major Cobb angle at the end of casting is most predictive of outcome. Cobb angles >10° at the end of casting had a 7.3 times greater risk of falling into the palliated category versus Cobb angles less than or equal to 10° even when adjusted for age. Initial curve magnitude, curve flexibility, sex, and curve type were not predictive.

LEVEL OF EVIDENCE

Level IV.

Survey to describe variability in early onset scoliosis cast practices

PURPOSE

To investigate paediatric orthopaedists' cast practices for early onset scoliosis regarding patient selection, cast application, radiographic evaluation, treatment cessation and adjunctive bracing.

METHODS

A casting survey was distributed to all paediatric orthopaedists in Children's Spine and Growing Spine Study Groups (n = 92). Questions included physician and patient characteristics, technique, treatment, outcomes, radiographic measurements and comparison to other treatments. A total of 55 orthopaedists (60%) responded, and descriptive statistics were calculated on the subset who cast (n = 45).

RESULTS

A majority of respondents use cast treatment for idiopathic and syndromic scoliosis patients, but not for neuromuscular or congenital scoliosis patients. Major curve angle ranked most important in orthopaedists' decision to commence cast treatment, in comparison with rib-vertebra angle difference or clinical observations. The major curve angle threshold to initiate casting was a median of 30° (20° to 70°), and the minimum patient age was median ten months (3 to 24). First in-cast and out-of-cast radiographs are taken standing, supine, awake, under anesthesia and/or in traction. In all, 58% consistently cast over or under the arm, while 44% vary position by patient. Respondents were divided about the use of a brace after cast treatment: 22% do not prescribe a brace, 31% always do and 36% do in some patients.

CONCLUSIONS

Future multicentre research studies must standardize radiographic practices and consider age and major curve angle at cast initiation and termination, scoliosis aetiology, shoulder position and treatment duration. Practices need to be aligned or compared in these areas in order to distinguish what makes for the best cast treatment possible.Level of Evidence: V, Expert opinion.

What's New in Congenital Scoliosis?

BACKGROUND

Congenital scoliosis is a failure of vertebral formation, segmentation, or a combination of the 2 arising from abnormal vertebral development during weeks 4 to 6 of gestation. The associated spinal deformity can be of varying severity and result in a stable or progressive deformity based on the type and location of the anomalous vertebra(e). Bracing for congenital scoliosis is rarely indicated, while recent reports have demonstrated the utility of serial derotational casting for longer curves with multiple anomalous vertebrae as an effective "time buying strategy" to delay the need for surgery. Earlier hemivertebra excision and short-segment posterior spinal fusion have been advocated to prevent future curve progression of the deformity and/or the development of large compensatory curves. It has been shown in recent long-term follow-up studies that growth rates of the vertebral body and spinal canal are not as dramatically affected by pedicle screw instrumentation at a young age as once thought. Growth friendly surgery with either spine-based or rib-based anchors has demonstrated good results with curve correction while maintaining spinal growth. Rib-based anchors are typically more commonly indicated in the setting of chest wall abnormalities and/or when spinal anatomy precludes placement of spinal instrumentation. Recently, magnetically controlled growing rods have shown promising results in several studies that include a small subset of congenital scoliosis cases.

METHODS

A literature search was performed to identify existing studies related to the treatment of congenital scoliosis published from January 1, 2005 to June 1, 2016. Databases included PubMed, Medline, and the Cochrane Library. The search was limited to English articles and yielded 36 papers. This project was initiated by the Pediatric Orthopaedic Society of North America Publications Committee and was reviewed and approved by the Pediatric Orthopaedic Society of North America Presidential Line.

RESULTS

A total of 36 papers were selected for review based upon new findings. Classic manuscripts on congenital scoliosis are also included to provide sufficient background information.

CONCLUSIONS

Congenital scoliosis represents a wide range of pathology from the simple, stable hemivertebra to the complex, progressive spinal deformity with chest wall abnormalities and associated cardiac, renal, and neural axis anomalies. This paper reviews the natural history and associated anomalies with congenital scoliosis as well as the most up-to-date classification schemes and various treatment options for the care of this challenging patient population.

LEVEL OF EVIDENCE

Level 5.

Serial Casting for Infantile Idiopathic Scoliosis: Radiographic Outcomes and Factors Associated With Response to Treatment

BACKGROUND

Serial casting for early-onset scoliosis has been shown to improve curve deformity. Our goal was to define clinical and radiographic features that determine response to treatment.

METHODS

We retrospectively reviewed patients with idiopathic infantile scoliosis with a minimum of 2-year follow-up. Inclusion criteria were: progressive idiopathic infantile scoliosis and initial casting before 6 years of age. Two groups were analyzed and compared: group 1 (≥10-degree improvement in Cobb angle from baseline) and group 2 (no improvement).

RESULTS

Twenty-one patients with an average Cobb angle of 48 degrees (range, 24 to 72 degrees) underwent initial casting at an average age of 2.1 years (range, 0.7 to 5.4 y). Average follow-up was 3.5 years (range, 2 to 6.9 y). Sex, age at initial casting, magnitude of spinal deformity, and curve flexibility (defined as change in Cobb angle from pretreatment to first in-cast radiograph) were not significantly different between groups (P>0.05). Group 1 had a significantly higher body mass index (BMI) than group 2 at the onset of treatment (17.6 vs. 14.8, P<0.05). Univariate analysis of demographic, radiographic, and treatment factors revealed that only BMI was predictive of Cobb improvement (P=0.04; odds ratio=2.38). Group 1 (n=15) had a significantly lower Cobb angle (21 vs. 56 degrees) and rib vertebral angle difference (13 vs. 25 degrees) compared with group 2 at latest follow-up (P<0.05). A significantly larger proportion of children who were casted at less than 1.8 years of age had a Cobb angle <20 degrees at latest follow-up (P=0.03). Group 2 maintained stable clinical and radiograph parameters from pretreatment to most recent follow-up.

CONCLUSIONS

To maintain a homogeneous cohort, we excluded patients with syndromes and developmental delays. We believe that analyzing a homogeneous group provides more meaningful results than if we studied a heterogeneous sample. BMI was significantly associated with outcome such that for each unit increase in BMI, there is a 2.38× increase in the chance of improvement. Curve flexibility was similar between groups, which suggest that the amount of correction obtained at initial casting does not confirm treatment success. Key aspects of treatment that may determine success include age of less than 1.8 years at initiation of casting and derotation of the spine to correct rib vertebral angle difference of <20 degrees.

LEVEL OF EVIDENCE

Level IV-Therapeutic.

Current Concepts - Congenital Scoliosis

Background:

Congenital scoliosis is one of the ‘difficult to treat’ scenarios which a spine surgeon has to face. Multiple factors including the age of child at presentation, no definite pattern of deformity and associated anomalies hinder the execution of the ideal treatment plan. All patients of congenital scoliosis need to be investigated in detail. X rays and MRI of spine is usually ordered first. Screening investigations to rule out VACTERL (Visceral, Anorectal, Cardiac, Tracheo-esophageal fistula, Renal and Lung) abnormalities are required. They are cardiac echocardiography and ultrasonography of abdomen and pelvis. CT scan is required to understand the complex deformity and is helpful in surgical planning.

Methods:

A comprehensive medical literature review was done to understand the current surgical and non surgical treatment options available. An attempt was made to specifically study limitations and advantages of each procedure.

Results:

The treatment of congenital scoliosis differs with respect to the age of presentation. In adults with curves more than 50 degrees or spinal imbalance the preferred treatment is osteotomy and correction. In children the goals are different and treatment strategy has to be varied according to the age of patient. A single or two level hemivertebra can easily be treated with hemivertebra excision and short segment fusion. However, more than 3 levels or multiple fused ribs and chest wall abnormalities require a guided growth procedure to prevent thoracic insufficiency syndrome. The goal of management in childhood is to allow guided spine growth till the child reaches 10 - 12 years of age, when a definitive fusion can be done. The current research needs to be directed more at the prevention and understanding the etiology of the disease. Till that time, diagnosing the disease early and treating it before the sequels set in, is of paramount importance.

Conclusion:

The primary aim of treatment of congenital scoliosis is to allow the expansion of chest and abdominal cavity, while keeping the deformity under control. Various methods can be categorized into definitive (hemivertebrectomy) or preventive (guided growth). Casting, Growth rods, Convex Epiphysiodesis are all guided growth measures. The guided growth procedure either ‘corrects the deformity’ or will have to be converted to a final fusion surgery once the child completes the spinal growth which is preferably done around 10 - 12 years of age. Future directions should aim at genetic counselling and early detection.

The therapeutic characteristics of serial casting on congenital scoliosis: a comparison with non-congenital cases from a single-center experience

Background

The therapeutic efficacy of serial casting on idiopathic scoliosis has been gradually documented. However, literatures on serial casting for congenital scoliosis (CS) remain extremely rare. This paper aimed to compare the treatment outcomes of serial casting between CS and non-CS patients to comprehensively evaluate the therapeutic characteristics of serial casting on CS patients.

Methods

A total of 23 early-onset scoliosis cases were included and divided into congenital scoliosis (CS, n = 8) and non-congenital group (non-CS, n = 15). Therapeutic outcomes including the major curve Cobb angle, thoracic kyphosis angle, lumbar lodosis angle, and thoracic spine growing rate were compared between groups at precast, after the first cast, and at the latest follow-up, respectively.

Results

All patients received the first cast at the age of 3.25 ± 1.20 years and 5.70 ± 1.18 times of cast corrections. The average casting time was 17.17 ± 3.38 months, and the mean follow-up time was 23.91 ± 12.28 months. Both CS and non-CS groups had significant decrease in Cobb angle after the first cast and at the latest follow-up (all P < 0.05). Cobb angle was significantly lower in non-CS group than in CS group at both time points (all P < 0.01). The correction rate of Cobb angle was significantly higher in non-CS group than in CS group (around 50 vs. 20%, both P < 0.01). The mean thoracic growth rate was significantly lower in CS group than in non-CS group (0.72 ± 0.20 vs. 1.42 ± 0.22 cm/year, P < 0.001). At the latest follow-up, there are 2 cases receiving growing rod surgery, 8 cases wearing a brace, and 13 cases continuing serial casting.

Conclusions

Although the therapeutic efficacy of casting on CS patients is not as good as that on non-CS patients, casting is still an efficient treatment option for CS patients to delay the need for initial surgery.

Advances in growing rods treatment for early onset scoliosis

PURPOSE OF REVIEW

The goal of treatment in early onset scoliosis is to correct the deformity while allowing the thoracic growth for optimal cardiopulmonary functions. Growing rods treatment is a distraction-based, growth-friendly method that is commonly used in treatment of early onset scoliosis with its specific indications. Magnetically controlled growing rods (MCGR) method has been introduced to avoid morbidity of recurrent lengthening procedures. In this review, recent developments in traditional growing rods and MCGR are summarized.

RECENT FINDINGS

As the experience with growing rods increased and favorable results were reported, its indications have expanded. Recent studies focused on patient outcomes and complications. Another area of interest is the effects of growing rods in the sagittal spinal alignment. Midterm results demonstrated that MCGR treatment is promising but not free of complications. In MCGR, there is no consensus on the frequency and amount of distraction per session. Rod contouring and behavior of the magnet under MRI are major issues.

SUMMARY

Growing rods treatment successfully controls the deformity while preserving the growth of spine and thorax, despite high complication rates. Magnetically controlled systems are introduced to avoid repetitive surgical lengthening procedures. Although preliminary results are promising, there are still significant challenges and unknowns for MCGR.

A brief history and review of modern casting techniques in early onset scoliosis

PURPOSE

Body casts have a long history in the treatment of spinal deformity. Currently the use of body casts is limited to early onset scoliosis. Here, we aim to provide a brief narrative of the evolution of cast application for the management of spinal deformity.

METHODS

A history of cast application is provided with a brief review of the orthopedic literature. The current indications for cast application and the authors' preferred technique are described.

RESULTS

Serial casting is an effective treatment method for early onset scoliosis. It may be definitive for most idiopathic curves or used to delay surgical intervention in more severe idiopathic, syndromic and even congenital curves.

CONCLUSIONS

Surgeons who treat children with early onset scoliosis should familiarize themselves with serial cast application techniques.

[Congenital malformations of the growing spine : When should treatment be conservative and when should it be surgical?]

Congenital malformations of the spine are caused by genetic and teratogenic factors. By means of asymmetrical longitudinal growth of the spine they can lead to deformity, most commonly to scoliosis. The malformations can be classified as failure of formation, failure of segmentation and mixed-type malformations. The extent of the deformity and its progression are determined by the remaining growth potential and the location and type of malformation. Up to one third of such deformities are associated with some sort of cardiac or urogenital malformation. The treatment concept is typically determined on an individual basis. Mild deformities often remain undetected. Conservative treatment using a brace has no substantial effect on the primary curve but might be helpful in the treatment of long sweeping, flexible, secondary curves. If rapid progression is documented or expected, surgical intervention as early as possible is warranted to prevent secondary structural changes. The surgical treatment should be focused on and limited to the site of malformation. The aim of surgery is the correction of the deformity at the site of asymmetrical growth. This can be achieved either by resection of a hemivertebra or by performing a vertebral column resection or other type of osteotomy. If notable compensatory, secondary curves are present, these can be corrected with growing rod constructs. The aim of all types of treatment is the correction of existing deformity or the prevention of its progression, in order to ensure balanced growth of the healthy regions of the spine. The present paper discusses the conservative and surgical treatment modalities available to achieve these aims.

Reliability and Validity of the Adapted Spanish Version of the Early-onset Scoliosis-24 Questionnaire

STUDY DESIGN

Translation and validation of the Early Onset Scoliosis-24 Questionnaire (EOSQ-24).

OBJECTIVE

To cross-culturally adapt the American English version of the EOSQ-24 into Spanish language, and to assess its reliability and discriminative validity.

SUMMARY OF BACKGROUND DATA

Treatment of early-onset scoliosis (EOS) seeks to improve natural history and health-related quality of life in children, but radiographic parameters are insufficient to evaluate the severity and efficacy of treatment in these patients. EOSQ-24 was developed to assess the health-related quality of life of EOS children; however, it has not been transculturally adapted and validated for Spanish subjects.

METHODS

Translation and cross-cultural adaptation of the original EOSQ-24 was performed according to published guidelines by an expert committee. The Spanish version of the EOSQ-24 was applied to 44 EOS patients. Reliability was assessed by internal consistency using Cronbach α, item-total correlations, and inter-item correlations. Data quality was assessed by mean, median, percentage of missing data, and ceiling and floor effects. For discriminative validity, comparisons between categorical variables were made by using non-parametric (Kruskal-Wallis and/or Mann Whitney U) tests, and Spearman correlation coefficients were used for continuous variables.

RESULTS

In our study, all items and domains showed very good global internal consistencies (Cronbach α 0.897 and 0.836, respectively). Corrected item-total correlations were good for all domains (>0.3). Two of 24 items showed low corrected item-total correlations (r = 0.179 and r = 0.254), but Cronbach α did not increase when these items were removed. Inter-item correlations were acceptable (>0.2). EOSQ-24 was found capable to discriminate patients with different curves severity (P = 0.001), diagnosis (P = 0.006), and ambulatory status (P = 0.053).

CONCLUSION

The Spanish version of the EOSQ-24 is reliable and a valid tool for the psychometric assessment of children with EOS, and can be applied in routine clinical practice and for research purposes.

LEVEL OF EVIDENCE

2.

Early-Onset Scoliosis: A Review of History, Current Treatment, and Future Directions

Early-onset scoliosis (EOS) is defined as curvature of the spine in children >10° with onset before age 10 years. Young children with EOS are at risk for impaired pulmonary function because of the high risk of progressive spinal deformity and thoracic constraints during a critical time of lung development. The treatment of EOS is very challenging because the population is inhomogeneous, often medically complex, and often needs multiple surgeries. In the past, early spinal fusion was performed in children with severe progressive EOS, which corrected scoliosis but limited spine and thoracic growth and resulted in poor pulmonary outcomes. The current goal in treatment of EOS is to maximize growth of the spine and thorax by controlling the spinal deformity, with the aim of promoting normal lung development and pulmonary function. Bracing and casting may improve on the natural history of progression of spinal deformity and are often used to delay surgical intervention or in some cases obviate surgery. Recent advances in surgical implants and techniques have led to the development of growth-friendly implants, which have replaced early spine fusion as the surgical treatment of choice. Treatment with growth-friendly implants usually requires multiple surgeries and is associated with frequent complications. However, growth-friendly spine surgery has been shown to correct spinal deformity while allowing growth of the spine and subsequently lung growth.

Serial elongation-derotation-flexion casting for children with early-onset scoliosis

Various early-onset spinal deformities, particularly infantile and juvenile scoliosis (JS), still pose challenges to pediatric orthopedic surgeons. The ideal treatment of these deformities has yet to emerge, as both clinicians and surgeons still face multiple challenges including preservation of thoracic motion, spine and cage, and protection of cardiac and lung growth and function. Elongation-derotation-flexion (EDF) casting is a technique that uses a custom-made thoracolumbar cast based on a three-dimensional correction concept. EDF can control progression of the deformity and - in some cases-coax the initially-curved spine to grow straighter by acting simultaneously in the frontal, sagittal and coronal planes. Here we provide a comprehensive review of how infantile and JS can affect normal spine and thorax and how serial EDF casting can be used to manage these spinal deformities. A fresh review of the literature helps fully understand the principles of the serial EDF casting technique and the effectiveness of conservative treatment in patients with early-onset spinal deformities, particularly infantile and juvenile scolisois.