Intraspinal anomalies in scoliosis: An MRI analysis of 177 consecutive scoliosis patients

Spinal dysraphism in congenital scoliosis and kyphosis: a retrospective analysis in an Indian population

PURPOSE

Early recognition is crucial for occult spinal dysraphism associated with congenital spinal deformities. There is limited literature available on its occurrence in congenital scoliosis and kyphosis in the Indian population.

METHODS

Our study involved a retrospective review of 247 children who presented at a single centre. We analyzed their demographics and clinical and radiological findings, which included the type of deformity, its location, vertebral anomaly, Cobb angle, and MRI findings. The deformities were categorized as congenital scoliosis or congenital kyphosis with failure of formation, failure of segmentation, or both.

RESULTS

A total of 247 cases were examined (congenital scoliosis-229, congenital kyphosis-18). The average age was seven years (range 0.8 to 19 years, SD 4.6). The mean Cobb angle at presentation in the congenital scoliosis group was 49.4° (range 8 to 145°, SD 23.77) for those with abnormal MRI and 42.45° (range 5 to 97°, SD 20.09) for those with normal MRI. For the congenital kyphosis group, the mean K angle at presentation was 47.7° (range 14 to 110°, SD 33.33) for those with abnormal MRI and 47.36° (range 15 to 70°, SD 16.63) for those with normal MRI. Abnormal MRI results were observed in 130 of the patients (congenital scoliosis-53.7%, congenital kyphosis-38.8%). The highest incidence of abnormal MRI findings was observed in the failure of segmentation (66.6%) and mixed (65%) types. Deformities in the dorsal region had the highest incidence (61.9%). The most common dysraphism instances were diastematomyelia and tethered cord. There was a significant correlation between type of deformity and presence of dysraphism.

CONCLUSION

This is the largest case series of congenital scoliosis and kyphosis reported from India. We found a high incidence of occult spinal dysraphism as compared to other published series. Occult spinal dysraphism is more common in the thoracic region. Diastematomyelia followed by tethered cord was the most common anomaly observed. We recommend MRI screening of whole spine and craniovertebral junction.

Clinical Relevance of Painful Congenital Early-onset Scoliosis: A Magnetic Resonance Image-based Study

BACKGROUND

Back pain, as a clinical marker in scoliosis, has been associated with underlying pathology for many years, warranting further magnetic resonance imaging (MRI). Failures of segmentation, mixed defects, female gender, rib anomalies, congenital thoracic anomalies, and neurocutaneous markers are known risk factors for abnormal MRI pathology findings in patients with congenital early-onset scoliosis (Congenital-EOS). Yet, back pain has not been evaluated as a risk factor for underlying MRI pathology in patients with Congenital-EOS. This study aimed to assess back pain as a risk factor for underlying pathology in Congenital-EOS using MRI as a diagnostic tool.

METHODS

A retrospective database review from the Pediatric Spine Study Group (PSSG) of all patients with Congenital-EOS who reported a back pain complaint, and underwent a spinal MRI study before surgical intervention was performed. Patients were divided into those with an underlying MRI pathology and those without. Demographics were compared between groups.

RESULTS

From a total of 2355 patients with Congenital-EOS registered in PSSG, 107 patients reported a back pain complaint, with only 42 patients fulfilling the inclusion criteria (being evaluated with an MRI study). Overall group mean age was 8.1±4.5 years, with 25 of the 42 patients (60%) being females. Twenty-four of 42 patients (57%) had a comorbidity reported such as cardiac problems, musculoskeletal complaints, neurological deficits/myelopathy, gastrointestinal symptoms, developmental delay, respiratory problems, craniofacial abnormalities, and chromosomal conditions. An underlying MRI pathology was found in 21 of 42 patients with Congenital-EOS (50%) with back pain. The underlying MRI pathologies found were tethered spinal cord, spinal canal stenosis, syringomyelia, Arnold-Chiari malformation, and arachnoid cyst.

CONCLUSIONS

Abnormal MRI findings are common in patients with Congenital-EOS who report back pain. Gender, age, major coronal curve angle, thoracic or lumbar predominance deformity, and comorbidities type or amount were not associated with abnormal MRI findings.

LEVEL OF EVIDENCE

Level II-Prognostic study.

The complex treatment paradigms for concomitant tethered cord and scoliosis: illustrative case

BACKGROUND

Scoliosis associated with tethered cord syndrome is one of the most challenging spinal deformities to manage. Multiple surgical approaches have been developed, including traditional staged and concomitant procedures, spine-shortening osteotomies, and individual vertebral column resections.

OBSERVATIONS

A 10-year-old female presented with congenital kyphoscoliosis with worsening curve progression, tethered spinal cord, and a history of enuresis. The scoliosis had progressed to a 26° coronal curve and 55° thoracolumbar kyphosis. Preoperative magnetic resonance imaging of the spine revealed a tethered cord between the levels of L3-4 and a large kyphotic deformity at L1. The patient underwent laminectomy, during which intraoperative motor signals were lost. A planned hemivertebrectomy at L1 was performed prior to an L4 laminectomy, untethering of the filum terminale, and posterior spinal fusion from T11 to L2. After surgery, the patient experienced transient lower-extremity weakness, with her neurological function improving from baseline over the next 2 months. Ultimately, the goal of this surgery was to halt the progressive decline in motor function, which was successfully achieved.

LESSONS

Much remains to be learned about the treatment of this complicated disease, especially in the setting of concomitant scoliosis. This case serves to exemplify the complex treatment paradigms that exist when attempting to manage this clinical syndrome and that more remains to be learned.

Effects of spinal deformities on lung development in children: a review

Scoliosis before the age of 5 years is referred to as early-onset scoliosis (EOS). While causes may vary, EOS can potentially affect respiratory function and lung development as children grow. Moreover, scoliosis can lead to thoracic insufficiency syndrome when aggravated or left untreated. Therefore, spinal thoracic deformities often require intervention in early childhood, and solving these problems requires new methods that include the means for both deformity correction and growth maintenance. Therapeutic strategies for preserving the growing spine and thorax include growth rods, vertically expandable titanium artificial ribs, MAGEC rods, braces and casts. The goals of any growth-promoting surgical strategy are to alter the natural history of cardiorespiratory development, limit the progression of underlying spondylarthrosis deformities and minimize negative changes in spondylothorax biomechanics due to the instrumental action of the implant. This review further elucidates EOS in terms of its aetiology, pathogenesis, pathology and treatment.

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

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

Intra-Operative Neurophysiological Monitoring in Patients with Intraspinal Abnormalities Undergoing Posterior Spinal Fusion

OBJECTIVE

To analyze the intraoperative neurophysiological monitoring (IONM) data of patients with intraspinal abnormalities undergoing posterior spinal fusion and to determine how intraspinal abnormalities influence IONM results.

METHODS

Patients with severe kyphoscoliosis and intraspinal abnormalities who underwent posterior spinal correction and fusion between September 2015 and January 2019 were retrospectively reviewed. Candidate intraspinal abnormalities included Chiari malformation, syringomyelia, split cord malformation, and tethered cord syndrome. Total intravenous anesthesia was administered, and no muscle relaxant or inhalation anesthesia was used for maintenance. IONM data, including somatosensory evoked potentials (SSEP) and motor evoked potentials (MEP), were recorded. The P37 and N50 latencies and amplitude were recorded for SSEP, whereas only the amplitude was recorded for MEP. The possible high-risk factors for abnormal IONM results were analyzed.

RESULTS

The current study included 87 patients (40 men, 47 women) with an average age of 20.2 ± 10.4 years. The etiologies were neuromuscular in 45 patients, idiopathic in four, and congenital in 38. A total of 136 intraspinal abnormalities were detected, including Chiari malformation in 33 patients, syringomyelia in 55, split-cord malformation in 25, and tethered cord syndrome in 23. Forty patients had one intraspinal abnormality, whereas 47 patients had two or three intraspinal abnormalities. The monitorabilities were 87.4% and 97.7% for the SSEP and MEP, respectively. SSEP alerts were reported in five patients and MEP alerts in four patients, and new neurological deficits were observed in three patients postoperatively. The sensitivity and specificity were 100% and 97.3% for SSEP, and 100% and 98.8% for MEP, respectively. A significant difference in MEP amplitude between the concave and convex sides was observed, while significantly higher SSEP latency was observed on the concave side in patients with preoperative neurological deficits. There were 52 (59.8%) patients with abnormal IONM data. Preoperative neurological deficits (χ²  = 7.715, p = 0.005) and more than one intraspinal abnormality (χ²  = 9.186, p = 0.004) indicated a higher risk of abnormal IONM data.

CONCLUSIONS

IONM can be effectively used in patients with intraspinal abnormalities who undergo posterior spinal fusion. Patients with preoperative neurological deficits and more than one intraspinal abnormality have a higher risk of abnormal IONM monitoring.

Treatment of spinal deformity with diastematomyelia type I: one-stage, two-stage surgery and new technique (vertebral column resection through wide bony septum)

STUDY DESIGN

Case series, literature review, and technical note.

OBJECTIVES

To compare two different approaches to treat the spinal deformity with split cord malformation type I (SCM I). To present a new method of one-stage surgical treatment of congenital spinal deformity with wide bony septum (SCM I).

METHODS

Analysis of the literature on the different types of combined surgical treatment of spinal deformities with SCM I was performed. We have provided our own data on 27 patients treated for congenital spinal deformity and SCM I, one of which underwent Schwab IV type osteotomy at the apex of the deformity through the bony septum and pedicles. Inclusion criteria were presence of spinal deformity in combination with SCM 1, performed surgery to correct spinal deformity, and follow-up period of at least 2 years.

RESULTS

The result of the literature review was controversial and requires additional research. The average age of patients was 8.8 ± 6.6 years old. One-stage treatment of SCM I and spinal deformity was performed in 10 patients (group I) and two-stage in 14 patients (group II). Three patients with severe myelodysplasia, SCM I, and congenital kyphoscoliosis underwent correction of spinal deformity without SCM I removing (group III). The group I had the longest surgery duration (mean 289 ± 75 min) and largest blood loss (mean 560 ± 386 ml), a high percentage of deformity correction (mean 69.6%), and the highest rate of complications (60%). The most optimal was the two-stage treatment with the mean surgery duration 191 ± 137 min, mean blood loss 339 ± 436 ml, mean correction rate 63%, and frequency of complications 21%. The average follow-up time was 6.0 ± 2.6 years.

CONCLUSIONS

One stage surgery associated with a large surgical invasion and a large number of complications. It can be used in some cases, for example when the wide bony septum (SCM I) is localized at the apex of the congenital scoliosis or kyphosis. In all other cases, it is worth adhering to a two-stage treatment. Many new works demonstrate the relative safety and effectiveness of deformity correction without removing the SCM. In our opinion, indications for treatment of spinal deformity without SCM I removing can be the need to perform a shortening ostetomy outside the SCM zone. The remaining cases require a thorough assessment and a balanced decision.

Natural History of Scoliosis in Children with NF1: An Observation Study

(1) Background. Scoliosis is the most common musculoskeletal manifestation of Neurofibromatosis type 1 (NF1), and it might be dystrophic (D) or non-dystrophic (ND) depending on the presence of dysplastic changes of the spine. The aim of our study was to describe the characteristics and natural history of patients with NF1 and scoliosis. (2) Methods. We retrospectively reviewed records from patients with NF1 and scoliosis. Scoliosis was classified as D if at least two dystrophic changes were documented at imaging. (3) Results. Of the 438 patients reviewed, 43 fulfilled inclusion criteria; 17 were classified in D group and 26 in ND. The groups did not differ in age and localization of scoliosis curvature. Surgery was needed more often in D group, but the between-group difference was not significant. Male-to-female ratios of 3:1 and 4:1 were reported in surgically treated NF1 patients with ND and D scoliosis, respectively. (4) Conclusions. Our data suggests independently by the presence of dysplastic changes affecting the spine that males with NF1 are more often affected by scoliosis that requires surgery.

Cross-sectional analysis and trend of vertebral and associated anomalies in Chinese congenital scoliosis population: a retrospective study of one thousand, two hundred and eighty nine surgical cases from 2010 to 2019

PURPOSE

The objective of this article is to report associated anomaly incidences of a large CS cohort and analyze interrelationships among vertebral anomaly types and associated abnormalities.

METHODS

We retrospectively searched and extracted medical records of 1289 CS inpatients surgically treated in our institute from January 2010 to December 2019. All patients have taken spine X-ray, CT, MRI, echocardiogram, urogenital ultrasound, and systemic physical examination. We analyzed information on demographics, CS types, and associated anomalies.

RESULTS

CS type was found to be 49.1% for failure of formation (FF), 19.5% for failure of segmentation (FS), and 31.4% for mixed defects (MD). Intraspinal defects were found in 29.4% patients (16.0% for FF, 45.4% for FS, 40.5% for MD), cardiac in 13.7% (12.3% for FF, 14.3% for FS, 15.6% for MD), genitourinary in 5.8% (4.1% for FF, 6.0% for FS, 8.4% for MD), gastrointestinal in 3.6% (4.7% for FF, 1.6% for FS, 3.0% for MD), and musculoskeletal in 16.4% (10.3% for FF, 19.9% for FS, 23.7% for MD). The intraspinal and musculoskeletal defect incidences were significantly higher in patients with failure of segmentation and mixed defects. We also observed a decreasing trend for intraspinal and musculoskeletal defect incidences as well as a tendency for more failure of formation and less failure of segmentation from 2010 to 2019.

CONCLUSIONS

The intraspinal and musculoskeletal defect incidences were higher in patients with failure of segmentation and mixed defects. Strong interrelationships were found between intraspinal and musculoskeletal defects and among cardiovascular, genitourinary, and gastrointestinal defects. From 2010 to 2019, the proportion of patients with failure of formation increased significantly, causing a decrease in the intraspinal and musculoskeletal defect incidences over time. Female sex, failure of segmentation, and mixed defects could be considered risk factors for more associated anomalies in CS individuals, which would help surgeons in medical management and prenatal consultation.

Similar surgical outcomes of the growing rod technique for treatment of early-onset scoliosis with versus without untreated intraspinal anomalies

OBJECTIVE

The aim of this study was to compare the radiological and clinical outcomes of early-onset scoliosis (EOS) patients with or without intraspinal anomalies (IAs) managed with growing rods (GRs), and to evaluate the safety of the GR technique in EOS patients with untreated IAs.

METHODS

EOS patients undergoing GR placement between August 2008 and July 2017 were retrospectively reviewed. Patients with untreated IAs were classified into the EOS+IA group, and those without IAs into the EOS-IA group. The radiographic parameters including Cobb angle of the major curve, T1-S1 height, and apical vertebral translation were measured, and a detailed assessment of the neurological status was performed at each visit.

RESULTS

Seventy-six patients with EOS (32 boys, 44 girls) with an average age of 6.5 ± 2.3 years at initial surgery satisfied the inclusion and exclusion criteria, including 28 patients in the EOS+IA group and 48 patients in the EOS-IA group. The radiographic measurements were comparable between groups preoperatively, postoperatively, and at the latest follow-up. One patient in the EOS+IA group experienced sensory deficit in a unilateral lower extremity after initial surgery, and an intraoperative neurophysiological monitoring event was observed in a patient in the EOS-IA group. No permanent neurological deficit was observed in either group.

CONCLUSIONS

EOS patients with and those without IAs had comparable clinical and radiological outcomes of the GR technique. Repeated lengthening procedures may be safe for EOS patients with untreated IAs.

Incidence of intraspinal abnormalities in congenital scoliosis: a systematic review and meta-analysis

Objective

This is the first systematic review and meta-analysis on the overall incidence of intraspinal abnormalities in patients with congenital scoliosis (CS) and potential influencing factors.

Methods

We searched three large electronic databases (PubMed, EMBASE, and Cochrane Library) for potentially relevant studies. The quality of the included studies was assessed independently by two authors using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Data on the number of CS patients, number of CS patients with intraspinal abnormalities, sex of the patients, and CS types were extracted from the included studies. R software was used to pool and analyze all the extracted data.

Results

This meta-analysis included 10 articles, and 671 of 1863 CS patients undergoing magnetic resonance imaging (MRI) examinations were identified to have intraspinal abnormalities. The overall incidence of intraspinal abnormalities in the patients with CS was 37% (95% CI, 29–45%). Diastematomyelia was the most common intraspinal abnormality and was detected in 45.60% of the patients with intraspinal abnormalities (306/671). The remaining intraspinal abnormalities included syringomyelia (273/671, 40.69%), tethered cord (190/671, 28.32%), low conus (58/671, 8.64%), intraspinal mass (39/671, 5.81%), Chiari malformation (32/671, 4.77%), fatty filum (27/671, 4.02%), spina bifida (occulta excluded) (17/671, 2.53%), tumor (17/671, 2.53%), cyst (12/671, 1.79%), syringomyelus (4/671, 0.60%), dural ectasia (1/671, 0.15%), and undiagnosed cord MRI hyperintensity (1/671, 0.15%). The patient’s sex and CS type were not factors that affected the incidence of intraspinal abnormalities in CS patients (all P > 0.05).

Conclusions

This meta-analysis revealed that the overall incidence of intraspinal abnormalities detected by MRI in CS patients was 37%. Diastematomyelia was the most common intraspinal abnormality. The patient’s sex and CS type were not factors that affected the incidence of intraspinal abnormalities in CS patients.

Scoliosis in spinal muscular atrophy: is the preoperative magnetic resonance imaging necessary?

PURPOSE

To determine the prevalence of intraspinal alterations in scoliosis due to Spinal Muscular Atrophy (SMA).

METHODS

Cross-sectional, observational, descriptive study. Fifty-six patients with SMA diagnosis required surgical treatment due to scoliosis.

INCLUSION CRITERIA

scoliosis/kyphoscoliosis > 50 degrees in the coronal plane, clinical characteristics of Spinal Muscular Atrophy, accurate diagnosis by means of molecular or genetic study. Prior to the spinal surgery, and to find related intraspinal alterations, MRI of the spine and posterior cranial fossa was performed.

RESULTS

Forty females, 16 males, mean age 11 years (range 6-14 years). 94% of the patients had Spinal Muscular Atrophy type 2. The mean angle value was 81 degrees (range 53-122 degrees) in the coronal plane and 62 degrees (range 35-80 degrees) in the sagittal plane. The prevalence of intraspinal alterations was 1.78%. One patient with cervical hydromyelia and no neurological surgical procedure prior to the spinal deformity surgery was reported.

CONCLUSIONS

In the context of preoperative planning and strategy of patients with scoliosis due to Spinal Muscular Atrophy, MRI may have not to be requested.

MRI utilization and rates of abnormal pretreatment MRI findings in early-onset scoliosis: review of a global cohort

STUDY DESIGN

Retrospective review OBJECTIVES: To report the frequency of pretreatment magnetic resonance imaging (MRI) utilization and rates and types of intra-spinal abnormalities identified on MRI in patients with early-onset scoliosis (EOS). MRI can help identify spinal cord abnormalities in patients with EOS.

METHODS

We reviewed data from patients enrolled from 1993-2018 in an international EOS registry. Patients with incomplete/unverifiable data and those with spinal deformities secondary to infection or tumor were excluded, leaving 1343 patients for analysis. Demographic characteristics, pretreatment major curve magnitude, treatment type, and MRI findings were analyzed. Patients were categorized by EOS type (congenital, idiopathic, neuromuscular, syndromic), pretreatment MRI utilization, and presence of intra-spinal abnormality on MRI. Univariate testing and multivariate logistic regression were performed to identify demographic, radiographic, and clinical predictors of MRI utilization and abnormal MRI findings.

RESULTS

MRI was used in 836 patients (62%). Pretreatment MRI utilization rates ranged from 42% in neuromuscular EOS to 74% in congenital EOS. Prevalence of abnormal MRI findings was 24% overall, ranging from 13% in patients with idiopathic EOS to 39% in neuromuscular EOS. Compared with white/Caucasian patients, Asian/Asian-American patients had higher odds of MRI utilization and abnormal MRI findings. Treatment type, pretreatment major curve magnitude, age at MRI, and age at treatment were not associated with abnormal MRI findings. Overall, 249 abnormalities were identified in 197 patients. The most common findings were syrinx and tethered cord. Syrinx with Chiari malformation was the most frequent combination of abnormal findings.

CONCLUSION

In the two-thirds of patients who underwent MRI before EOS treatment, findings were abnormal in 24%. EOS type and race/ethnicity were associated with both MRI utilization and abnormal findings. The most frequent abnormalities were syrinx and tethered cord, and the type of abnormalities appeared to differ by EOS type.

LEVEL OF EVIDENCE

Prognostic, Level III.

Prevalence and clinical relevance of underlying pathological conditions in painful adolescent idiopathic scoliosis: a MRI-based study

STUDY DESIGN

Cross-sectional comparative study.

OBJECTIVES

Evaluate prevalence and clinical relevance of an underlying pathology in painful adolescent idiopathic scoliosis (AIS) patients after a non-diagnostic history, physical examination and spinal X-ray using Magnetic Resonance Image (MRI) as diagnostic tool. Discrepancies regarding indications of routine MRI screening in painful AIS patients are multifactorial. Few studies have investigated relationship and practical importance of painful AIS with an underlying pathology by MRI.

METHOD

A total of 152-consecutive AIS patients complaining of back pain during a 36-month period were enrolled. All patients underwent whole-spine MRI after a non-diagnostic history, physical examination and spinal X-ray. Underlying pathologies were reported as neural and non-neural axis abnormalities based on MRI reports. Variables such as sex, age, constant or intermittent pain, night pain, back pain location (thoracic or lumbar pain), Cobb-angle and follow-up were evaluated as clinical markers to predict presence of underlying MRI pathologies.

RESULTS

The presence of an underlying pathology was found by MRI in 54 painful AIS patients (35.5%). Isolated syringomyelia was the only neural axis abnormality found in 6 patients (3.9%). Non-neural axis abnormalities (31.6%) were composed by: 32 herniated nucleus pulposus, 5 vertebral disc desiccation, 4 ovarian cysts, 3 renal cysts, 2 sacral cysts, and 2 vertebral hemangiomas. There was no association with gender, age of presentation, initial coronal Cobb angle and follow up; with presence of an underlying pathology. Lumbar pain location was identified as an adequate clinical marker that correlated with presence of an underlying pathology (p = 0.01).

CONCLUSIONS

Prevalence of underlying pathologies diagnosed by MRI in painful AIS was found high (35.5%), but it's clinical relevance and implication are debatable. The use of MRI did not affect orthopedic management of painful AIS patients who showed an underlying pathology. A thorough evaluation must be performed by clinicians; and discussed with patients and family prior to undergo further imaging management.

LEVEL OF EVIDENCE

Level III.

Perioperative Halo-Gravity Traction in the Treatment of Scoliosis with Intraspinal Anomalies

OBJECTIVE

To investigate the efficacy and safety of preoperative halo-gravity traction and 1-stage posterior surgery for the treatment of scoliosis with intramedullary anomalies.

METHODS

A total of 11 patients with scoliosis with intramedullary anomalies were evaluated. All patients were treated with preoperative halo-gravity traction and 1-stage posterior surgery. The average age was 11.4 years (range, 7-21 years). All patients were followed-up for at least 2 years (mean, 3.5 years; range, 2-5 years). Their radiologic presentations and complications were reviewed.

RESULTS

The operating time was 7.9 hours, and the intraoperative bleeding amount was 1890 mL. Both the Cobb angle of scoliosis and kyphosis were significantly improved after halo-gravity traction and the operation (P < 0.05). Tethered cords were released, and intraspinal masses (neurofibromatosis and lipoma) were excised. Syringomyelia and split spinal cord malformations were left untreated. None of the patients experienced deterioration in their neurologic status after surgery. No severe complications, such as infection, cerebrospinal fluid leakage, failed internal fixation, or fractured pedicle screws or rods occurred after the operation. There was no deterioration of neurologic function, delayed infection, or pseudoarthrosis during the follow-up visits.

CONCLUSIONS

Preoperative halo-gravity traction and 1-stage posterior surgery provided patients who had scoliosis and intramedullary anomalies an effective and safe treatment option with few complications.

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

BACKGROUND

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

METHOD

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

RESULT

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

CONCLUSION

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

Frequency and characteristics of congenital intraspinal abnormalities in a cohort of 128 patients with congenital scoliosis

OBJECTIVES

The aims of this study were to determine the incidence and main characteristics of associated intraspinal anomalies in patients with congenital scoliosis (CS) and to analyze the different factors that influence the curve progression.

DESIGN

This was a retrospective comparative study.

METHODS

This was a retrospective study of 128 patients with CS.

MAIN OUTCOME MEASUREMENTS

The incidence of the patients with intraspinal anomalies and their demographic, clinical, and radiological values was described.

RESULTS

Intraspinal anomalies were present in 13.3% of the patients. Among them, the most frequent anomaly was syringomyelia. The most frequent curve was the thoracic curve. The main deformity based on McMaster classification was formation failure. The curve progression during follow-up did not show significant differences between vertebral anomalies, syringomyelia, presence of thoracic anomalies, and gender (P > 0.05).

CONCLUSIONS

Our study showed a lower percentage of spinal anomalies compared to other series. As other studies, the progression of the scoliosis curve in patients with spinal anomalies seems primarily to be determined by the type of vertebral malformation.

LEVEL OF EVIDENCE

Level II.

Is It Possible to Correct Congenital Spinal Deformity Associated With a Tethered Cord Without Prophylactic Intradural Detethering?

BACKGROUND

Patients who have a congenital spinal deformity with a tethered cord generally are treated with prophylactic intradural detethering before deformity correction. However, the detethering procedure carries substantial risk, and it is not clear whether deformity correction can be performed without detethering.

QUESTIONS/PURPOSES

To determine the (1) correction rate, (2) proportion of patients who experienced complications after surgery, and (3) neurological status after recovery from surgery in a group of patients with congenital spinal deformity and a tethered cord who were treated either with posterior spinal fusion only (PSF), pedicle-subtraction osteotomy (PSO), or a vertebral column resection (VCR), based on an algorithmic approach.

METHODS

Between 2006 and 2016, we treated 50 patients surgically for a congenital spinal deformity and a tethered cord. We defined a congenital spinal deformity as one that was caused by failure of vertebral segmentation, failure of vertebral formation, or both, and we made the diagnosis of a tethered cord based on a conus medullaris lower than L2 level, or a diameter of the filum terminale greater than 2 mm, as shown on magnetic resonance image. Of those, nine patients were lost to followup before the 2-year minimum, leaving 41 for analysis at a mean followup of 47 months (range, 24 to 92 months) in this single-institution retrospective study. The treatment algorithm involved one of three approaches: PSF, PSO, or VCR. A total of 15 patients underwent PSF; we used this approach for patients with moderate curves (Cobb angle < 80°) and intact neurological status both previously and during a bending and traction test. Eleven patients underwent PSO; we performed PSO when patients had neurological symptoms (in daily life or during the traction/bending test) and a magnitude of the curve less than 80°. Finally, 15 patients underwent VCR, which we used in patients with a magnitude of the curve more than 80° and/or flexibility less than 20%, with/without neurological symptoms. No patient in any group underwent intradural detethering. We report on the correction rate, defined as the ratio between the corrected magnitude and preoperative magnitude of a curve at a given postoperative time point (correction rate = 1- (Cobb angle at a given time point/preoperative Cobb angle) x 100%); complications, that is, postoperative/recurrent neurological symptoms, cerebrospinal fluid leakage, infection, blood loss > 5000 mL, as determined by chart review performed by an individual not directly involved in patient care; and a detailed neurological exam, including evaluations of sensory function, extremity muscle strength, pain, gait, physiological reflexes, and pathological signs, both before surgery and at most recent followup, as performed by the surgeon. All neurologically symptomatic patients were evaluated with a neurologic scoring system.

RESULTS

The overall mean ± SD correction rate in this series was 63% ± 14%. It was 70% ± 12% in the PSF group, 64% ± 17% in the PSO group, and 56% ± 12% in the VCR group. Seven patients in those three groups experienced major complications, including blood loss more than 5000 mL, temporary neurological symptoms, cerebrospinal fluid leakage, and infection. The most severe complications included one patient in the VCR group who had temporarily decreased strength in the lower limb, and one patient in the PSO group with temporary numbness in the lower limb. Finally, no patients in PSF group had postoperative neurological complications, and all patients with neurological symptoms in the PSO/VCR group improved to varying degrees. For neurologically symptomatic patients in PSO group (n = 6), the neurological score improved slightly, from 22.5 ± 1.9 preoperatively to 24.2 ± 0.8 at the most recent followup (p = 0.024) with a mean difference of 1.7. For neurologically symptomatic patients in VCR group (n = 10), the neurological score improved slightly from 23.1 ± 1.1 preoperatively to 24.2 ± 0.6 at most recent followup (p = 0.009) with a mean difference of 1.1.

CONCLUSIONS

Congenital spinal deformity with a tethered cord may be treated without prophylactic intradural detethering. In the current series treated according to this treatment algorithm, good correction and neurological improvement were achieved, and few complications occurred. However, such a small series cannot prove the safety of this treatment; for that, larger, multicenter studies are necessary.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Limited Sequence MRIs for Early Onset Scoliosis Patients Detected 100% of Neural Axis Abnormalities While Reducing MRI Time by 68

STUDY DESIGN

Diagnostic accuracy.

OBJECTIVE

The purpose of this study was to determine if neural axis abnormalities in early onset scoliosis (EOS) patients can be reliably detected with limited magnetic resonance imaging (MRI) sequences (sagittal T1, sagittal T2).

SUMMARY OF BACKGROUND DATA

MRIs are often performed in EOS patients as studies have shown there are neural axis abnormalities in up to 40% of this population. MRIs are expensive, lengthy, and often require general anesthesia. In young children prolonged or repeated exposure to general anesthesia may be associated with neurocognitive damage.

METHODS

A retrospective review of consecutive EOS patients from February to December 2017 who received an MRI of the cervical, thoracic, and lumbar spine was conducted. MRI images were reviewed for neural axis abnormalities. Two sequences (sagittal T1, sagittal T2) of these previously reviewed MRIs were read at a separate time by an attending pediatric neuroradiologist. The imaging findings from these two select sequences were then compared with the prior radiology report based on all of the standard MRI sequences.

RESULTS

Fifty patients met criteria. Ten patients (20%) had neural axis abnormalities detected by the full MRI. All of these neural axis abnormalities were detected on the combination of sagittal T1 + sagittal T2 images. Standard MRIs lasted 66 ± 20 minutes and patients required 90 ± 22 minutes of anesthesia. Sagittal T1 + sagittal T2 sequences lasted 21 ± 7 minutes (P < 0.0001).

CONCLUSION

Limited sequence MRIs with sagittal T1 and T2 sequences for EOS patients had 100% sensitivity for the detection of neural axis abnormalities and would allow for a 68% reduction in the length of MRI and significant reduction in anesthesia time.

LEVEL OF EVIDENCE

3.

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

STUDY DESIGN

This was a prospective cohort study.

OBJECTIVES

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

SUMMARY OF BACKGROUND DATA

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Organ System Anomalies Associated With Congenital Scoliosis: A Retrospective Study of 305 Patients

DESIGN

Retrospective analyses of congenital scoliosis patients at 2 tertiary care pediatric hospitals.

OBJECTIVE

This study objectives were (1) to report the rates of anomalies of 10 organ systems in congenital scoliosis patients and (2) to determine whether the presence of a single organ system anomaly increases the rate of nonspinal organ system defects.

SUMMARY OF BACKGROUND DATA

Intraspinal, cardiac, renal, and gastrointestinal anomalies have been reported to occur at higher rates in congenital scoliosis than the normal population. It is unknown whether the presence of 1 organ system defect increases the risk of nonspinal organ system anomalies.

METHODS

All patients diagnosed, evaluated in the outpatient setting, with congenital scoliosis who were below 18 years of age at time of presentation with available cardiac echo, renal ultrasound, or magnetic resonance imaging were included in this study.

RESULTS

There were 305 patients (161 females, 53%) whose mean age was 7+3 years. In total, 84% of patients were observed to have at least 1 organ defect. Overall, 22% of patients had 1 organ defect, 19% had 2, 18% had 3, and 18% had ≥4 organ defects. There was an average of 2.2 anomalies per patient (range=0 to 8). Intraspinal anomalies were documented in 43% of patients; syrinx occurred most frequently. Urogenital anomalies were documented in 39% of patients; solitary kidney was most prevalent. Cardiac anomalies were documented in 54% of patients; ventricular septal defect was most common. In 12% of patients, the triad of spinal, urogenital, and cardiac defects was observed. Multiple organ systems were found to have significant associations (P<0.05) in anomaly development.

CONCLUSIONS

Cardiac anomalies were the most common defect (54%), and occurred at a rate >2 times higher than previously reported. The high rate of intraspinal, cardiac, and urogenital defects makes magnetic resonance imaging, echocardiography, and renal ultrasound a critical part of evaluation for all congenital scoliosis patients.

LEVEL OF EVIDENCE

Level II.

Magnetic Resonance Imaging in Infantile Idiopathic Scoliosis: Is Universal Screening Necessary?

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

Determine if there is a subset of presumed infantile idiopathic scoliosis (IIS) patients who have a low incidence of neural axis abnormalities (NAAs) such that screening magnetic resonance imaging (MRI) may be delayed.

SUMMARY OF BACKGROUND DATA

Individuals with presumed IIS have an increased incidence of NAA. Because of the increased incidence, screening MRI is recommended for all patients. We follow these guidelines at our institution. However, MRI screening in this age group is not without cost or risk.

METHODS

This is a retrospective study of 53 presumed IIS (onset ≤3 years) patients who had screening MRIs. Demographic and radiographic characteristics were collected. A binary regression using continuous and categorical variables was used to determine if a model could be created to accurately predict MRI necessity. A receiver operating characteristic (ROC) analysis was performed to determine if a threshold Cobb angle exists that is associated with an increased likelihood of NAA.

RESULTS

Of the 53 patients, 13 had NAA findings, resulting in a 24.5% incidence of NAAs. Significantly fewer abnormal MRIs were found in patients with Cobb angles <29.5° than those with Cobb angles >29.5° (13/33 [39%] vs. 0/20 [0%], p = .0008). Patients with Cobb angles >29.5° were 27 times more likely to have NAAs than those with angles <29.5° (odds ratio = 27.0 [95% CI = 1.5-486.0], p = .03). No other parameters have a predictive value for NAA (p > .05).

CONCLUSION

This is the first study in IIS patients to identify a radiographic parameter that helps select out a subgroup for MRI screening. Additionally, we report an incidence of 24.5% NAAs in these patients, which is higher than previously reported.

Incidence of Intraspinal and Extraspinal MRI Abnormalities in Patients With Adolescent Idiopathic Scoliosis

STUDY DESIGN

Retrospective study with follow-up.

OBJECTIVES

The purpose of this study was to determine the incidence of intraspinal and extraspinal MRI abnormalities in a consecutive series of patients with adolescent idiopathic scoliosis (AIS) and to describe the evaluation and management of these abnormalities.

SUMMARY OF BACKGROUND DATA

Indications for preoperative magnetic resonance imaging (MRI) in patients with AIS remain controversial. Previous studies have reported a wide range of abnormality rates; however, the majority of these studies focus on a nonconsecutive series of patients, and none of these studies report the incidence of extraspinal abnormalities.

METHODS

We studied a consecutive series of patients with AIS managed with spinal deformity surgery. All patients underwent a routine neural axis MRI prior to surgery. MRI reports were reviewed, and intraspinal and extraspinal abnormalities were recorded. Additional chart review and follow-up was performed to determine the rates of evaluation and management for these abnormalities. Descriptive statistics were used to describe the incidence and types of abnormalities, as well as the rates of evaluation and management.

RESULTS

This study included a consecutive series of 259 patients with AIS. MRI abnormalities were noted in 115 patients (44%). After excluding patients with degenerative changes, MRI abnormalities were noted in 64 patients (25%). The incidence of Chiari malformation was 4.2% and syringomyelia was 5%. Extraspinal abnormalities were noted in 10% of patients, and these findings ranged from benign cysts to malignant soft tissue tumor. Approximately 10% of patients needed additional evaluation because of their preoperative MRI findings, and 0.7% of patients required surgical management prior to spinal deformity surgery.

CONCLUSIONS

Significant MRI abnormalities were noted in patients with AIS, and some patients required further evaluation prior to surgery. Additional study including cost-effectiveness analysis is needed to better define the role of preoperative MRI in patients with AIS.

LEVEL OF EVIDENCE

Level II.

A comprehensive review of the diagnosis and management of congenital scoliosis

PURPOSE

To provide the reader with a comprehensive but concise understanding of congenital scoliosis METHODS: We have undertaken to summarize available literature on the pathophysiology, epidemiology, and management of congenital scoliosis.

RESULTS

Congenital scoliosis represents 10% of pediatric spine deformity and is a developmental error in segmentation, formation, or a combination of both leading to curvature of the spine. Treatment options are complicated by balancing growth potential with curve severity. Often associated abnormalities of cardiac, genitourinary, or intraspinal systems are concurrent and should be evaluated as part of the diagnostic work-up. Management balances the risk of progression, growth potential, lung development/function, and associated risks. Surgical treatment options involve growth-permitting systems or fusions.

CONCLUSION

Congenital scoliosis is a complex spinal problem associated with many other anomalous findings. Treatment options are diverse but enable optimization of management and care of these children.

Is the routine use of magnetic resonance imaging indicated in patients with scoliosis?

Background

To assess the reliability of the indicators for performing magnetic resonance imaging in patients with scoliosis and assess the incidence of neural axis anomalies in a population with scoliosis referred to a specialist centre.

Methods

A retrospective review of magnetic resonance imaging (MRI) reports of all patients under the age of 18 who underwent a pre-operative MRI for investigation of their scoliosis between 2009 and 2014 at a single institution was performed.

Results

There were 851 patients who underwent an MRI scan of their whole spine with a mean age of 14.08 years. There were 211 males and 640 females. One hundred and fourteen neural axis abnormalities (NAA) were identified. The presence of a left sided thoracic curve, a double thoracic curve, being male nor being diagnosed before the age of 10 were found to be statistically significant for the presence of a NAA. Furthermore, 2.34% of patients were also found to have an incidental finding (IF) of an extraspinal abnormality.

Conclusions

From our series, the reported indications for performing an MRI scan in the presence of scoliosis are not reliable for the presence of an underlying NAA. We have demonstrated that there is a number of intra and extra dural anomalies found on MRI without clinical symptoms and signs. This acts as normative information for this group.

Keywords

Scoliosis; magnetic resonance imaging (MRI); neural axis abnormalities (NAA); adolescent idiopathic scoliosis (AIS).

Intraspinal Anomalies in Individuals with Scheuermann's Kyphosis: Is the Routine Use of Magnetic Resonance Imaging Necessary for Preoperative Evaluation?

STUDY DESIGN

Retrospective study.

PURPOSE

This study aimed to determine the incidence of intraspinal pathologies (ISPs) in individuals with Scheuermann's kyphosis (SK) and to validate whether the routine use of magnetic resonance imaging (MRI) is necessary for preoperative evaluation.

OVERVIEW OF LITERATURE

There are several studies on the necessity of routine MRI screening and prevalence of ISPs related to different types of scoliosis have been conducted. However, despite the well-established association between ISPs and a higher risk for neurological complications there is no any study on the scientific literature concerning the prevalence of ISPs in patients with SK has been conducted.

METHODS

The database of the institution was retrospectively reviewed to identify all patients diagnosed with SK who underwent surgery between 2012 and 2015. Patients were excluded from the study if their hospital database records did not include spinal images, which are routinely collected before surgery. The presence or absence of ISPs, as indicated on magnetic resonance images, was evaluated by a radiologist.

RESULTS

Of the 138 potential participants, 120 were included in the study. Of these, seven patients (5.8%) had ISPs, and all the cases involved syringomyelia. None of the seven patients with ISPs required additional neurosurgical procedures before corrective surgery. No complications were reported during the perioperative period, and none of the patients developed postoperative neurological deficits.

CONCLUSIONS

According to this study, the incidence rate of ISPs in patients with SK was 5.8%, and we recommend that all patients with SK should be evaluated using MRI of the spine before corrective surgery.

Cluster analysis describes constellations of cardiac anomalies presenting in spinal anomaly patients

BACKGROUND

Cardiac anomalies are prevalent in patients with bony spinal anomalies. Prior studies evaluating incidences of bony congenital anomalies of the spine are limited. The Kids' Inpatient Database (KID) yields national discharge estimates of rare pediatric conditions like congenital disorders. This study utilized cluster analysis to study patterns of concurrent vertebral anomalies, anal atresia, cardiac malformations, trachea-esophageal fistula, renal dysplasia, and limb anomalies (VACTERL anomalies) co-occurring in patients with spinal congenital anomalies.

METHODS

Retrospective review of KID 2003-2012. KID-supplied hospital- and year-adjusted weights allowed for incidence assessment of bony spinal anomalies and cardiac, gastrointestinal, urinary anomalies of VACTERL. K-means clustering assessed relationships between most frequent anomalies within bony spinal anomaly discharges; k set to n - 1(n = first incidence of significant drop/little gain in sum of square errors within clusters).

RESULTS

There were 12,039,432 KID patients 0-20 years. Incidence per 100,000 discharges: 2.5 congenital fusion of spine, 10.4 hemivertebra, 7.0 missing vertebra. The most common anomalies co-occurring with bony vertebral malformations were atrial septal defect (ASD 12.3%), large intestinal atresia (LIA 11.8%), and patent ductus arteriosus (PDA 10.4%). Top congenital cardiac anomalies in vertebral anomaly patients were ASD, PDA, and ventricular septal defect (VSD); all three anomalies co-occur at 6.6% rate in this vertebral anomaly population. Cluster analysis revealed that of bony anomaly discharges, 55.9% of those with PDA had ASD, 34.2% with VSD had PDA, 22.9% with LIA had ASD, 37.2% with ureter obstruction had LIA, and 35.5% with renal dysplasia had LIA.

CONCLUSIONS

In vertebral anomaly patients, the most common co-occurring congenital anomalies were cardiac, renal, and gastrointestinal. Top congenital cardiac anomalies in vertebral anomaly patients were ASD, PDA, and VSD. VACTERL patients with vertebral anomalies commonly presented alongside cardiac and renal anomalies.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

A systematic review was carried out.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Incidence of Neuraxial Abnormalities Is Approximately 8% Among Patients With Adolescent Idiopathic Scoliosis: A Meta-analysis

BACKGROUND

Several studies have sought to address the role of routine preoperative MRI in patients with adolescent idiopathic scoliosis (AIS) undergoing deformity correction. Despite similar results regarding the prevalence of neuraxial anomalies detected on MRI, published conclusions conflict and give opposing recommendations. Lack of consensus has led to important variations in use of MRI before spinal surgery for patients with AIS.

QUESTIONS/PURPOSES

This systematic review and meta-analysis of studies about patients with AIS evaluated (1) the overall proportion of neuraxial abnormalities; (2) the patient factors and curve characteristics that may be associated with abnormalities; and (3) the proportion of patients who underwent neurosurgical intervention before scoliosis surgery and the kinds of neuraxial lesions that were identified.

METHODS

We performed a search of four electronic databases (PubMed, EMBASE, CINAHL Plus, and SCOPUS) utilizing search terms related to routine MRI and AIS, yielding 206 articles. Studies included had at least 20 participants, patients with ages 11 to 21 years, and a Methodological Index for Non-Randomized Studies (MINORS) study quality score of 8 and 16 points for noncomparative and comparative studies, respectively. Non-English manuscripts, animal studies, and those that did not include patients with AIS solely were excluded. Eighteen articles with 4746 patients were included for analysis of the overall proportion of neuraxial abnormalities, 12 articles with 3028 patients for analysis by sex, eight articles with 1603 patients for right main thoracic curve, eight articles with 665 patients for a left main thoracic curve, and 13 articles with 3063 patients and 230 (7.5%) abnormalities for number of neurosurgical interventions before scoliosis correction. The mean MINORS score for studies included was 14 (range, 10-20). Each study was analyzed for the proportion of patients identified with neuraxial abnormalities and associations with specific demographics. We determined the proportion of patients who underwent surgical interventions before scoliosis surgery as well as the types of neuraxial lesions identified. The articles were assessed for heterogeneity and publication bias. Because all groups were determined to be heterogeneous, a random-effects model was used for each group in this meta-analysis; with this analysis, an overlap of 95% confidence intervals suggests no difference at the p < 0.05 level, but this analytic approach does not provide p values.

RESULTS

The pooled proportion of neuraxial abnormalities detected on MRI was 8% (95% confidence interval [CI], 6%-12%). With the numbers available, we found no difference in the proportion of male and female patients with neuraxial abnormalities (18% [95% CI, 11%-29%] versus 9% [95% CI, 6%-12%], respectively). Likewise, there was no difference in the proportion of pooled neuraxial abnormalities in right and left curves (9% [95% CI, 6%-14%] versus 15% [95% CI, 5%-35%], respectively). In the subset of abnormalities analyzed for number of neurosurgical interventions before scoliosis correction, the pooled proportion showed that 33% (95% CI, 24%-43%) underwent neurosurgical intervention before deformity correction. The most common abnormalities of the 367 found on MRI were syringomyelia in 127 patients (35%), Arnold-Chiari Type 1 malformation with syrinx in 103 patients (28%), and isolated Arnold-Chiari Type 1 malformation in 91 patients (25%).

CONCLUSIONS

The proportion of patients with AIS who have neuraxial abnormalities is high (8%) and a large number undergo surgical intervention before scoliosis reconstruction. We did not find any particular demographic variables that indicated an increased risk of abnormality. Clinicians should consider advanced imaging before surgical intervention in the treatment of a patient with an idiopathic diagnosis. Preventable variables need to be identified by future studies to establish a better working treatment protocol for these patients.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Simultaneous Surgical Treatment of Congenital Spinal Deformity Associated with Intraspinal Anomalies

Study Design

Prospective case series.

Purpose

To study the safety, efficacy, and long-term outcomes of single-stage surgical intervention for congenital spinal deformity and intraspinal anomalies.

Overview of literature

Congenital spinal deformities associated with intraspinal anomalies are usually treated sequentially, first by treating the intraspinal anomalies followed by deformity correction after a period of 3–6 months. Recently, a single-stage approach has been reported to show better postoperative results and reduced complication rates.

Methods

Thirty patients (23 females and seven males) were prospectively evaluated for the simultaneous surgical treatment of congenital spinal deformity with concurrent intraspinal anomalies from May 2006 to October 2016. The average age at presentation was 9.8±3.7 years, with the average follow-up duration being 49.06±8.6 months. Clinical records were evaluated for clinical, radiological, perioperative, and postoperative data.

Results

The average angle of deformity was 56.53°±25.22° preoperatively, 21.13°±14.34° postoperatively, and 23.93°±14.99° at the final follow-up. The average surgical time was 232.58±53.56 minutes (range, 100–330 minutes), with a mean blood loss of 1,587.09±439.09 mL (range, 100–2,300 mL).

Conclusions

Single stage surgical intervention for intraspinal anomalies with congenital spinal deformity correction, including adequate intra-operative wake-up test, is a viable option in appropriately selected patients and has minimum complication rates.

Relationship between thoracic kyphosis and neural axis abnormalities in patients with adolescent idiopathic scoliosis

PURPOSE

Previous studies have suggested an association between increased thoracic kyphosis and neural axis abnormalities in patients with adolescent idiopathic scoliosis (AIS). However, the basis for this finding is unclear, and this association has been mainly noted in retrospective studies on a non-consecutive series of patients. The purpose of this study was to assess the relationship between thoracic kyphosis and neural axis abnormalities in patients with AIS.

METHODS

We studied a consecutive series of AIS patients treated with spinal fusion. Thoracic kyphosis (T2 to T12) was measured from preoperative lateral radiographs. All patients underwent a spine magnetic resonance imaging (MRI) prior to surgery, and MRI reports were reviewed to determine the presence of neural axis abnormalities. Statistical analyses included descriptive statistics and chi-squared analysis.

RESULTS

This study included 210 patients with AIS. There were no significant differences in age or gender between patients with thoracic hypokyphosis (kyphosis < 20°), normal thoracic kyphosis (kyphosis 20° to 40°) and thoracic hyperkyphosis (kyphosis > 40°) (p > 0.05). Neural axis abnormalities were present in 17.9% of patients with thoracic hypokyphosis, 9.8% of patients with normal thoracic kyphosis and 13.6% of patients with thoracic hyperkyphosis (p = 0.60). There were no significant differences in rates of Chiari malformation, syrinx, intra-spinal masses and other central nervous system abnormalities between groups (p > 0.05).

CONCLUSIONS

Thoracic kyphosis was not associated with neural axis abnormalities in our consecutive series of patients with AIS. Increased thoracic kyphosis may not be a reliable indicator for the presence of neural axis abnormalities in patients with AIS.

LEVEL OF EVIDENCE

IV.

Abnormalities associated with congenital scoliosis in high-altitude geographic regions

PURPOSE

To assess the different characteristics of congenital scoliosis between low-altitude geographic regions and high-altitude geographic regions in Chinese population and discuss the role of hypoxia on those differences.

METHODS

A total of 120 patients with congenital scoliosis who underwent surgical treatment in our Hospital between January 2009 and October 2017 were identified. Complete data were reviewed, including medical records, X-ray, CT, and MRI pre-operatively. According to the patient's birthplace, they were divided into low-altitude geographic regions (low group) and high-altitude geographic regions (high group). Characteristics of vertebral deformities, rib deformities, and intra-spinal malformations in two groups were analyzed.

RESULTS

A total of 397 segments of vertebral deformities were involved in the two groups, of which 136 were involved in high group and 261 in low group. The average segments involved were 4.5 and 2.9, respectively, in two groups. 63.3% patients in high group have rib deformities, which is significantly higher than that of low group (41.1%); and the proportion of patients with complex rib deformities in high group was also higher than that in low group (57.9% VS 24.3%). The incidence of CS associated with intra-spinal malformations in low group was 38.9%, which was similar to those reported previously; however, the incidence of that in high group was 63%, significantly higher than previous reports.

CONCLUSION

Our results suggested that CS patients in high-altitude geographic regions might tend to have higher proportion and more severe of rib deformities, and also be more likely to accompany with intra-spinal malformations. So we supposed that hypoxia not only aggravated the proportion and severity of rib deformities, but also affected the development of spinal cord in humans.

Scoliosis in Dandy-Walker syndrome: a case report and review of literature

This submission presents a case of scoliosis in a patient with established Dandy-Walker anomaly of the brain. A retrospective review of the patient's case notes was undertaken and the limited literature on this subject reviewed. The 13-year-old girl presented with a stiff right thoracic scoliosis typical of adolescent idiopathic scoliosis. The scoliotic segment also presented with significant lordosis. She had facial and truncal dysmorphism characteristic of Dandy-Walker complex and her brain images confirmed the diagnosis. She underwent scoliosis surgery by the posterior approach uneventfully. In conclusion scoliosis is hitherto unreported in the Dandy-Walker complex. The results of intervention appear satisfactory.

Pediatric spine imaging post scoliosis surgery

Many orthopedic articles describe advances in surgical techniques and implants used in pediatric scoliosis surgery. However, even though postoperative spine imaging constitutes a large portion of outpatient musculoskeletal pediatric radiology, few, if any, radiology articles discuss this topic. There has been interval advancement over the last decades of the orthopedic procedures used in the treatment of spinal scoliosis in adolescents with idiopathic scoliosis. The goal of treatment in these patients is to stop the progression of the curve by blocking the spinal growth and correcting the deformity as much as possible. To that end, the authors in this paper discuss postoperative imaging findings of Harrington rods, Luque rods, Luque-Galveston implants and segmental spinal fusion systems. Regarding early onset scoliosis, the guiding principles used for adolescent idiopathic scoliosis do not apply to a growing spine because they would impede lung development. As a result, other devices have been developed to correct the curve and to allow spinal growth. These include spine-based growing rods, vertically expandable prosthetic titanium rods (requiring repetitive surgeries) and magnetically controlled growing rods (with a magnetic locking/unlocking system). Other more recent systems are Shilla and thoracoscopic anterior vertebral body tethering, which allow guided growth of the spine without repetitive interventions. In this paper, we review the radiologic appearances of different orthopedic implants and techniques used to treat adolescent idiopathic scoliosis and early onset scoliosis. Moreover, we present the imaging findings of the most frequent postoperative complications.

Intraspinal anomalies in early-onset idiopathic scoliosis

Aims

In the United Kingdom, lower incidences of intraspinal abnormalities in patients with early onset idiopathic scoliosis have been observed than in studies in other countries. We aimed to determine the rates of these abnormalities in United Kingdom patients diagnosed with idiopathic scoliosis before the age of 11 years.

Patients and Methods

This retrospective study of patients attending an urban scoliosis clinic identified 71 patients satisfying a criteria of: clinical diagnosis of idiopathic scoliosis; age of onset ten years and 11 months or less; MRI screening for intraspinal abnormalities. United Kingdom census data combined with patient referral data was used to calculate incidence.

Results

Mean age at diagnosis was six years with 39 right-sided and 32 left-sided curves. Four patients (5.6%) were found to have intraspinal abnormalities on MRI. These consisted of: two combined Arnold-Chiari type 1 malformations with syrinx; one syrinx with a low lying conus; and one isolated syrinx. Overall annual incidence of early onset idiopathic scoliosis was one out of 182 000 (0.0006%).

Conclusion

This study reports the lowest rates to date of intraspinal anomalies in patients with early onset idiopathic scoliosis, adding to knowledge regarding current incidences of these abnormalities as well as any geographical variation in the nature of the disease. Cite this article: Bone Joint J 2017;99-B:829–33.

MRI Screening in Operative Scheuermann Kyphosis: Is it Necessary?

STUDY DESIGN

Patients with preoperative spine magnetic resonance imaging (MRI) studies from a prospective multicenter study of operative adolescent Scheuermann kyphosis (SK).

OBJECTIVES

To investigate the usefulness of MRI screening in operative planning for SK surgeries.

SUMMARY OF BACKGROUND DATA

Neural axis abnormalities in operative SK have not been previously studied with MRI screening, despite its use.

METHODS

One orthopedic surgeon and two radiologists evaluated all images retrospectively. Radiographs were evaluated for kyphosis apex and magnitude. MRIs were evaluated for spinal cord abnormalities, epidural lipomatosis, location and number of vertebral wedging, Schmorl nodes and posterior disc herniations, frequency of spondylolysis, etc. The relationship of these pathologies to the kyphosis apex was explored. This group was compared to a surgical SK group without preoperative MRIs.

RESULTS

Eighty-six patients with MRIs, mean age 16.3 years, 64% male, and a mean preoperative kyphosis of 75.9° were evaluated. There were 17 spinal cord abnormalities. Low-lying conus was found in 2 patients, and syrinx in 15 (no Chiari malformations). Epidural lipomatosis was found in 49 patients, average of 5.7 levels. Anterior vertebral wedging occurred in all (mean 4.7 levels). Posterior disc herniations averaged 5.2 levels/patient and 1.8 levels caudad to the apex. Spondylolysis was reported in 8.1%. Four cases (4.7%) had the operative plan changed as a result of the preoperative MRI: two due to neural compression, one due to disc herniation and one due to a spinal cord draped over the apex. Thirty-one patients did not receive an MRI; there were no significant differences between the two groups. The rate of postoperative neurologic change was 3.5% in the MRI group and 3.2% in the no-MRI group.

CONCLUSIONS

Based on 4.7% of cases requiring a change in the operative plan as a result of preoperative MRI, the authors recommend considering performing screening MRI in operative SK patients.

Characteristics and Clinical Relevance of the Osseous Spur in Patients with Congenital Scoliosis and Split Spinal Cord Malformation

BACKGROUND

The natural history of split spinal cord malformation (SCM) is still unclear. Knowledge of the characteristics of the osseous spur and its relationship with the spinal deformity may allow early identification of patients with a higher risk of a neurological deficit and enhance surgical decision-making.

METHODS

Eighty-five consecutive patients with congenital scoliosis and type-I SCM who had undergone surgical treatment at our hospital from May 2000 to December 2013 were identified retrospectively. There were 22 male and 63 female patients with an average age of 13.9 years at the time of surgery. Preoperative clinical and radiographic data were collected to investigate the characteristics of the scoliosis and the osseous spur. Two groups were identified on the basis of whether the patients had intact neurological function (Group A) or a neurological deficit (Group B).

RESULTS

There were 52 patients (61%) in Group A (intact neurological function) and 33 patients (39%) in Group B (neurological deficit). There were no significant differences in the demographic distribution, curve magnitude, or length and thickness of the osseous spur between the 2 groups. In Group A, the location of the osseous spur relative to the apex of the major curve was proximal in 13 patients (25%), distal in 28 (54%), and central in 11 (21%). In Group B, the osseous spur was proximal in 7 (21%), distal in 8 (24%), and central in 18 (55%). The 2 groups differed significantly with respect to the location of the osseous spur (chi square = 10.898, p = 0.004). Group-B patients had a higher proportion of patients with kyphotic deformity (42%) than Group A (10%). The ratio of the diameters of the hemicords (concave side divided by convex side) differed significantly between the 2 groups (0.98 for Group A versus 0.89 for Group B, p = 0.030).

CONCLUSIONS

The neurological status in patients with congenital scoliosis and type-I SCM appears to be closely related to the location of the osseous spur relative to the congenital scoliosis. An osseous spur at the apex of the scoliosis may be related to a higher risk of developing a neurological deficit, especially in patients with kyphotic deformity. Asymmetric splitting of the spinal cord may contribute to neurological deficits.

LEVEL OF EVIDENCE

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

Patterns of congenital bony spinal deformity and associated neural anomalies on X-ray and magnetic resonance imaging

PURPOSE

Congenital malformations of the bony vertebral column are often accompanied by spinal cord anomalies; these observations have been reinforced with the use of magnetic resonance imaging (MRI). We hypothesized that the incidence of cord anomalies will increase as the number and complexity of bony vertebral abnormalities increases.

METHODS

All patients aged ≤13 years (n = 75) presenting to the pediatric spine clinic from 2003-2013 with congenital bony spinal deformity and both radiographs and MRI were analyzed retrospectively for bone and neural pathology. Chi-squared analysis was used to compare groups for categorical dependent variables. Independent t tests were used for continuous dependent variables. Significance was set at p < 0.05.

RESULTS

Fifty-five percent of congenital spine deformity patients (n = 41) had associated spinal cord anomalies on MRI. Complex bony abnormalities had a higher incidence of cord anomalies than simple abnormalities (67, 37 %; p = 0.011). Mixed deformities of segmentation and formation had a higher incidence of cord anomalies (73 %) than failures of formation (50 %) or segmentation (45 %) alone (p = 0.065). Deformities in the sacrococcygeal area had the highest rate of spinal cord anomalies (13 of 15 patients, 87 %). In 35 cases (47 %), MRI revealed additional bony anomalies that were not seen on the radiographs.

CONCLUSIONS

As the number of bony malformations increased, we found a higher incidence of cord anomalies. Clinicians should have increased suspicion of spinal cord pathology in the presence of mixed failures of segmentation and formation.

Prenatal diagnosis and assessment of congenital spinal anomalies: Review for prenatal counseling

The last two decades have seen continuous advances in prenatal ultrasonography and in utero magnetic resonance imaging. These technologies have increasingly enabled the identification of various spinal pathologies during early stages of gestation. The purpose of this paper is to review the range of fetal spine anomalies and their management, with the goal of improving the clinician’s ability to counsel expectant parents prenatally.

Vertebral and Intraspinal Anomalies in Indian Population with Congenital Scoliosis: A Study of 119 Consecutive Patients

STUDY DESIGN

Retrospective case study by clinical and radiological data analysis.

PURPOSE

To analyze different types of vertebral anomalies and the incidence of associated intraspinal anomalies in the Indian population.

OVERVIEW OF LITERATURE

This is the largest study of congenital scoliosis and associated intraspinal anomalies in Indian population. Incidence of intraspinal anomaly in this series is 47% which is higher than previous literature. Hemivertebra was the most common anomaly as seen in previous studies.

METHODS

A total of 119 patients with congenital scoliosis who underwent surgery between December 2006 and December 2012 were studied. Data was reviewed with medical records, plain radiographs, and magnetic resonance imaging (MRI) scans.

RESULTS

Thoracolumbar curve was most common, seen in 43.6% of patients. In addition to scoliotic deformity, kyphosis was seen in 26% of patients. Failure of formation, the most common vertebral anomaly, was seen in 51.2% of patients, failure of segmentation was seen in 19.3% of patients, and there were 29.4% patients having both formation and segmentation anomalies. Hemivertebra was the most common vertebral anomaly seen in 66.3% of patients and for whom 63.2% were in thoracic spine. Intraspinal anomalies were associated with 47% of patients with congenital scoliosis. Tethered cord was the most common intraspinal abnormality and was found in 48.2% patients with intraspinal anomalies. The patients with failure of segmentation and mixed deformities were found to have a significantly higher incidence of intraspinal anomalies (65% and 57%, respectively) than those with failure of formation (34%). Out of 31 patients with kyphotic deformity 29% had intraspinal anomalies, and amongst them tethered cord was the most common anomaly seen in 66% patients. Out of 12 patients with neurocutaneous markers, 83% patients had intraspinal anomaly.

CONCLUSIONS

Intraspinal anomalies were seen in 47% of patients with congenital scoliosis in the Indian population. Tethered cord was the most common intraspinal anomaly, seen in 48% cases of congenital scoliosis. Hemivertebra was seen in 66% cases and was the most common vertebral defect. Hence MRI imaging of whole spine should be done in all cases of congenital scoliosis before any surgical intervention. Special attention should be given to physical examination and visualization of any neurocutaneous markers, which are associated with a higher incidence of intraspinal anomalies; absence of a neurocutaneous marker, however, does not rule out intraspinal anomaly.

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

Study Design

Prospective study.

Purpose

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

Overview of Literature

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

Methods

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

Results

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

Conclusions

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

Evaluation of coronal shift as an indicator of neuroaxial abnormalities in adolescent idiopathic scoliosis: a prospective study

Background

In previous studies, many indicator factors have been proposed to select patients who need an MRI screening of the spinal canal. In current study, the clinical and radiologic factors including coronal parameters of the curve were evaluated to find out which indicator is more important.

Methods

A prospective study included 143 consecutive patients with the diagnosis of adolescent idiopathic scoliosis who were treated between 2010 and 2013 at our spinal clinics. Only patients with normal or subtle neurologic findings were included. All patients were evaluated by a total spine MRI protocol for examination of neuroaxial abnormalities. Known indicators and also coronal shift were analysed in all patients with or without abnormal MRI.

Results

The incidence of neuroaxial abnormalities was 11.9% (17 of 143); only 5 patients (3.5%) were operated to treat their neuroaxial problem. The significant indicators of the abnormalities in our patients were: younger age at onset, asymmetric superficial abdominal reflex and, coronal shift more than 15 mm (P = 0.03). Some previously known indicators like atypical curves, male gender, double curves and absence of thoracic lordosis were not different between two groups of the patients.

Conclusions

A total spine MRI is recommended at presentation in patients with younger age, abnormal neurologic findings and severe coronal shift.

In favour of the definition "adolescents with idiopathic scoliosis": juvenile and adolescent idiopathic scoliosis braced after ten years of age, do not show different end results. SOSORT award winner 2014

Background

The most important factor discriminating juvenile (JIS) from adolescent idiopathic scoliosis (AIS) is the risk of deformity progression. Brace treatment can change natural history, even when risk of progression is high. The aim of this study was to compare the end of growth results of JIS subjects, treated after 10 years of age, with final results of AIS.

Methods

Design: prospective observational controlled cohort study nested in a prospective database. Setting: outpatient tertiary referral clinic specialized in conservative treatment of spinal deformities. Inclusion criteria: idiopathic scoliosis; European Risser 0–2; 25 degrees to 45 degrees Cobb; start treatment age: 10 years or more, never treated before. Exclusion criteria: secondary scoliosis, neurological etiology, prior treatment for scoliosis (brace or surgery). Groups: 27 patients met the inclusion criteria for the AJIS, (Juvenile Idiopathic Scoliosis treated in adolescence), demonstrated by an x-ray before 10 year of age, and treatment start after 10 years of age. AIS group included 45 adolescents with a diagnostic x-ray made after the threshold of age 10 years. Results at the end of growth were analysed; the threshold of 5 Cobb degree to define worsened, improved and stabilized curves was considered. Statistics: Mean and SD were used for descriptive statistics of clinical and radiographic changes. Relative Risk of failure (RR), Chi-square and T-test of all data was calculated to find differences among the two groups. 95% Confidence Interval (CI) , and of radiographic changes have been calculated.

Results

We did not find any Cobb angle significant differences among groups at baseline and at the end of treatment. The only difference was in the number of patients progressed above 45 degrees, found in the JIS group. The RR of progression of AJIS was, 1.35 (IC95% 0.57-3.17) versus AIS, and it wasn't statistically significant in the AJIS group, in respect to AIS group (p = 0.5338).

Conclusion

There are no significant differences in the final results of AIS and JIS, treated with total respect of the SRS and SOSORT criteria, in adolescence. Brace efficacy can neutralize the risk of progression.

Scoliosis-Associated Cervical Spine Pathologies

STUDY DESIGN

A total of 126 scoliosis patients admitted to the hospital were screened for concomitant cervical pathologies.

OBJECTIVES

To investigate the prevalence of cervical spine pathologies and the clinical relevance of magnetic resonance imaging (MRI) in the evaluation of patients with neuromuscular, congenital, syndromic, and idiopathic scoliosis.

BACKGROUND SUMMARY

With the development of MRI, upper neural axis abnormalities such as syringomyelia and Chiari malformation are increasingly being found in patients with scoliosis, but no report in the literature describes other pathologies in the cervical area seen concomitant with different scoliosis types.

METHODS

A total of 126 consecutive patients who were classified as having neuromuscular, congenital, syndromic, and idiopathic scoliosis were retrospectively evaluated. Data regarding cervical neural axis abnormalities obtained from the MRI studies were analyzed and classified into each type of scoliosis group.

RESULTS

A total of 126 patients with scoliosis were evaluated for hindbrain and cervical spine anomalies. Patients were divided into 4 groups regarding the type of scoliosis. The cervical spine of all patients was evaluated with MRI and other radiologic methods when needed. The most frequently seen pathology was syringomyelia. Other pathologies found included congenital vertebral anomalies, Chiari malformation, arachnoid cyst, atlanto-axial dissociation, split cord, posterior vertebral fusion, vertebral hypoplasia, neurenteric cyst, myelomalacia, dermoid cyst, and decrease in craniovertebral angle. Cervical pathologies were most frequently seen in neuromuscular scoliosis, followed by congenital and syndromic groups.

CONCLUSIONS

Cervical spinal pathologies vary according to the type of scoliosis. The number of cervical spinal pathologies diagnosed in idiopathic scoliosis patients was least compared with neuromuscular and syndromic groups. The most common pathology was syringomyelia, followed by congenital vertebral anomalies and cerebral tonsillar hernia. Preoperative MRI scan provides vital information regarding cervical spinal pathologies encountered in scoliosis patients.

Abnormalities associated with congenital scoliosis: a retrospective study of 226 Chinese surgical cases

STUDY DESIGN

Retrospective study of a series of 226 consecutive Chinese patients with congenital scoliosis.

OBJECTIVE

To identify the incidence of intraspinal abnormalities and other organ defects in surgical patients with congenital scoliosis in Chinese population.

SUMMARY OF BACKGROUND DATA

Previous studies have revealed high rates of intraspinal anomalies and other organ defects in patients with congenital scoliosis. The incidence of abnormalities in patients with congenital scoliosis in Chinese population has not been reported.

METHODS

A total of 226 patients with congenital scoliosis underwent surgical treatment in Peking Union Medical College Hospital between January 2005 and March 2011 were identified. A definitive diagnosis of congenital scoliosis for all patients was made. Complete data were reviewed, including medical records, plain radiograph, magnetic resonance (MR) image of the whole spine, echocardiography, and renal ultrasound. The incidence of intraspinal abnormalities and other organ defects were analyzed.

RESULTS

Intraspinal abnormalities were found in 99 (43%) patients. Diastematomyelia was identified to be the most common intraspinal pathological anomaly, which was different from the previous reports. The incidence of intraspinal anomaly in patients with failures of segmentation and mixed defects were significantly higher than those with failures of formation. Patients with thoracic hemivertebrae were found to have a higher incidence of intraspinal abnormalities than patients with lumbar hemivertebrae. Patients with intraspinal abnormality had a higher incidence of positive clinical findings than those with normal magnetic resonance imaging. However, the difference between the 2 groups was not statistically significant. Other organic defects were found in 91(40%) patients. Cardiac defects were detected in 18%, urogenital anomalies in 12%, and gastrointestinal anomalies in 5% of the patients in this study.

CONCLUSION

Diastematomyelia was found to be the most common intraspinal pathological anomaly and cardiac defects were the most common extraspinal anomaly in surgical patients with congenital scoliosis in this study. Magnetic resonance imaging, echocardiography, and ultrasound should be part of routine evaluation in all congenital cases before surgery, no matter positive clinical findings were found or not.

LEVEL OF EVIDENCE

3.

Are intraspinal anomalies in early onset idiopathic scoliosis as common as once thought? A two centre United Kingdom study

PURPOSE

Rates of neural axis abnormalities in infantile and juvenile idiopathic scoliosis may be as high as 50 %. We aimed to determine the rates of neural axis abnormalities in early onset idiopathic scoliosis patients in a British population.

METHODS

This retrospective study at two British spinal deformity clinics identified 72 patients satisfying the inclusion criteria of: (1) age at diagnosis of 7 years and younger, (2) idiopathic scoliosis and (3) magnetic resonance imaging of the neuraxis.

RESULTS

The mean age at diagnosis was 3.6 years and the mean Cobb angle was 47° with a near equal distribution of left (32) and right (36) sided curves. Eight (11.1 %) neural axis abnormalities consisting of two syrinxes, one Arnold-chiari Type I malformation and five combined (Arnold-chiari malformation Type I and syrinx) anomalies were identified.

CONCLUSIONS

This multi-centre study on the largest number of British subjects to date helps to establish the rates of neural axis abnormalities.

The use of routine preoperative magnetic resonance imaging in identifying intraspinal anomalies in patients with idiopathic scoliosis: a 10-year review

PURPOSE

This study sought to quantify the frequency of previously unidentified spinal cord anomalies identified by routine preoperative magnetic resonance imaging (MRI), in patients planned for surgical scoliosis correction.

METHODS

Our study group comprised 206 patients with idiopathic scoliosis who underwent deformity correction from 1998 to 2008. Clinical records of all the patients were retrospectively reviewed to ascertain the proportion having a neural abnormality on preoperative MRI scan.

RESULTS

Twenty of 206 patients (9.7 %) were diagnosed with an unexpected intraspinal anomaly on routine preoperative MRI. In all cases, a neurosurgical opinion was sought prior to further intervention. Of the 20 patients, 11 underwent a neurosurgical procedure (de-tethering of cord, decompression of Chiari, decompression of syrinx). There was no statistically significant difference between the group of patients who had intrinsic spinal cord anomalies on preoperative MRI and those did not have a cord abnormality with regard to age at presentation, gender, side of dominant curve and degree of curve (p < 0.05).

CONCLUSION

The high frequency of spinal cord abnormalities unidentified by preoperative neurological examination, and the frequent need for subsequent neurosurgical intervention, suggests that MRI assessment prior to deformity correction is important in the management of idiopathic scoliosis.

Early onset scoliosis: current concepts and controversies

Early Onset Scoliosis (EOS) may be associated with long-term pulmonary morbidity, which is not commonly seen in Adolescent Idiopathic Scoliosis. Initial evaluation is based on determining any underlying etiology related to congenital or syndromic conditions. Assessing the impact of scoliosis on thoracic development may help guide treatment, which is often required at a young age in these children to prevent irreversible pulmonary insufficiency. Treatment is based on multiple factors but may include non-surgical strategies, such as casting or bracing, along with growth-sparing surgical procedures using growing rods or chest wall expansion. Definitive fusion is rarely indicated in young patients. This chapter will cover the diagnosis, evaluation, and treatment of children with EOS.