NATURAL HISTORY AND OUTCOME IN NON-CONGENITAL SCOLIOSIS PRESENTING BEFORE AGE TEN YEARS.

Abstract

Background: Scoliosis occurring during the growing years of childhood, while less common, has a greater potential for severe deformity than that with adolescent onset. Treatment is therefore more urgent, and the untreated natural history more difficult to determine. Orthotic treatment and the more recently improved surgical techniques may halt or even reverse the natural history, but the length of time needed for adequate follow-up makes this hard to verify. This report examines the outcome for a historical group of these patients, treated and not, to establish a bench-mark against which results can be measured.

Methods: Retrospective analysis of records derived from the scoliosis database. Subjects were patients presenting with non-congenital scoliosis before the age of ten years and who were at least ten years old when last reviewed. Outcome measures were treatment protocols, the age and incidence of surgery, and the radiological and cosmetic outcome.

Results: 243 children were included, being 38 infantile idiopathic scoliosis (IIS: 20 male, 18 female); 86 juvenile idiopathic scoliosis (JIS: 19 male, 67 female); 119 symdromic scoliosis (Syn:46 male, 71 female) Depending on age, perceived progression potential and individual factors, treatment was either jacket and brace, or observation unless surgery was deemed advisable. In all, 81 children were braced and 162 were not; 129 have had surgery (25 IIS, 48 JIS; 56 Syn.). The individual groups showed no statistical advantage to non-operative treatment in preventing surgery, but in the whole group it appears that a significantly greater proportion (Z=2.7269, p< 0.01) of those braced were subsequently operated. Mean age at surgery was 7.3 years for IIS, 12.97 for JIS and 8.3 for Syn. Recurrence of deformity post-operatively was always observed in those operated before puberty, regardless of the surgical technique.

Conclusion: Ten years of age was taken as the minimum for inclusion, although it is significantly earlier than skeletal maturity, because it has been practice to offer surgery well before this age, and some short term effects may already be apparent by the tenth birthday. This was not a trial of treatment between similar groups, so the appearance of increased surgery in the braced children suggests that, while the clinicians were well able to identify those with a worse prognosis, orthotic treatment was not effective in altering this prognosis. A recently published study¹ demonstrated the failure of past surgical techniques to prevent progressive deformity and respiratory compromise in infantile-onset scoliosis. Here it was found that the older the patient at corrective surgery, the better the result, that methods supposed to prevent post-operative recurrence in skeletally immature children failed to do so, and, while non-operative treatment may be effective at least in postponing surgery, even preventing it in some cases, this was not demonstrated statistically. Treatment of spinal deformity in pre-adolescent children warrants debate as a separate subject, and is a more serious problem than that occurring in adolescence.