Purpose. Spinopelvic parameters describe the orientation, shape, and morphology of the spine and pelvis. In children without spinal deformity, these parameters have been shown to change during the first ten years of life; however, spinopelvic parameters have yet to be defined in children with significant Early Onset Scoliosis (EOS). The purpose of this study is to examine the effects of EOS on sagittal spinopelvic alignment. Method. Standing, lateral radiographs of 82 untreated patients with EOS greater than 50 degrees were evaluated. Sagittal spine parameters (sagittal balance, thoracic kyphosis (TK), lumbar lordosis (LL)) and sagittal pelvic parameters (pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), modified pelvic radius angle (PR)) were measured. These results were compared to those reported by Mac-Thiong et al (Spine, 2004) for a group of asymptomatic (i.e. without spinal deformity) children of similar age. Results. These patients had a mean age of 5.17 years and mean scoliosis of 73.3 17.3. Mean sagittal spine parameters were: sagittal balance (+2.4 4.03 cm), TK (38.2 20.8), and LL (47.8 17.7). These values were similar to those reported for asymptomatic subjects. Mean sagittal pelvic parameters were measured for PI (47.1 15.6), PT (10.3 10.7), SS (35.5 12.2), and PR (57.1 21.2). Although PI was similar to age-matched normals, PT was significantly higher and SS trended lower in the study population. Conclusion. Sagittal plane spine parameters in children with EOS were similar to those found in children without spinal deformity. Likewise, pelvic parameters (PI, SS, PR) were similar; however, those children with EOS signs of pelvic retroversion (increased pelvic tilt). This data may be useful as a baseline in determining prognosis for children with EOS who are treated with growing systems

Objective: Examination of treatment outcome in a mixed group with early onset scoliosis.

Design: Retrospective review of patient data in order to plan a meaningful prospective study of treatment protocols.

Background: Scoliosis presenting before age 10 years, whatever the classification, has potentially significant consequences for morbidity and mortality, yet is discussed less than the more benign adolescent form.

Subjects: Patients with early onset idiopathic or syndromic scoliosis who were at least 15 years old at last review.

Outcome measures: Cobb angle change and the incidence of non-operative treatment and of surgery.

Results: There were 44 male and 74 female patients (19 IIS, 44 JIS and 55 syndromic) with follow-up 12.3 years SD 4.35 and mean Cobb angle progression from 26.6° to 47.21°. Non-operative treatment did not reduce the incidence of surgery either over-all (66.1%) or in individual groups (84.2% IIS, 63.6% JIS and 61.8% syndromic). Surgery in conservatively treated patients was at a later age (11.8 years SD 3.72) in comparison to those without (9.1 years SD 4.53), suggesting some advantage.

Conclusion: While orthotic treatment cannot be shown to prevent surgery in this series, achievement of the more modest aim of delay until nearer the pubertal growth spurt would be an undoubted benefit. Further study is necessary to determine whether this is a therapeutic effect or artefact.

The use of serial casting in the management of early onset scoliosis (EOS) has been well described. Our aim was to evaluate outcomes of plaster jacket therapy in patients with EOS from a tertiary referral centre.

A retrospective review of hospital records and PACS images of 27 patients to identify patients treated with serial casting over a five year period. The primary outcome measure was the need for surgical intervention, with change in Cobb angle used as a secondary outcome measure

Mean age at presentation was 14 months (range 10 – 42), including 14 male and 13 female patients, with an average follow-up of 34 months. Curves were categorised according to aetiology: 16 idiopathic, 6 syndromic, 3 congenital and 2 neuromuscular curves. The mean Cobb angle at diagnosis was 43.7° (range 22 – 115) and mean rib vertebral angle difference (RVAD) was 22.2° (8 – 70). Duration of treatment was 9.9 months (range 3 – 27), with an average of two plaster jacket changes per child. At the time of review, patients fell into one of three groups. Group one (10 patients) failed conservative treatment due no improvement in Cobb angle (mean 48.4° compared with pre-op 53.9°, p value 0.55) and either had insertion of growing rods or had been listed for this procedure, at a mean age of 51.8 months. Group two (12 patients) had a mean Cobb angle of 38.9° pre-treatment which improved to 23.5° (p value <0.05) and were either treated in a brace or had discontinued treatment. The mean RVAD at initial diagnosis was 36.6° in group 1 compared with 13.8° in group 2 (p<0.05). All patients in group one requiring surgical treatment had an RVAD of greater than 20°. Serial casting is on-going for five patients (group three). Complications occurred in 30% of patients including pressure sores, chest infection and respiratory compromise requiring intubation.

Current NICE guidance recognises that serial casting ‘rarely corrects scoliosis’ but recommends it may be used ‘to allow growth before a more permanent treatment is offered’. In our experience, serial casting did not allow any patients with a progressive scoliosis (determined by an RVAD of greater than 20°), to reach a single definitive fusion. However serial casting appeared to halt to curve progression until the child was suitable for the insertion of a growing rod system.

Aim:

To determine the efficacy and safety of the Magec system in early onset scoliosis (EOS).

Objective: Assessment of the outcome for spinal surgery in early onset deformity.

Design: Prospectively collected data on surface topography and respiratory function was analysed.

Subjects: Patients who underwent anterior and posterior spinal surgery before the age of 10 years for non-congenital deformity with special regard to cosmesis and respiratory function.

Outcome measures: Surface topography and respiratory function.

Results: In 10 children with pre-operative surface topography, surgery produced only an apparent reduction in the spinal angle. In the larger group, N=25, who have serial topography post-operatively (mean topographic follow-up 3.5 yrs, SD 1.55), the Suzuki hump sum (a measure of rib hump and back asymmetry) had increased significantly by a mean of 6.9 (SD 14.3, t=2.424, P=0.023). Respiratory function declined. Cobb angles varied in stability but usually increased initially. Trunk balance was maintained.

Conclusion: Surgery in early onset spinal deformity offers mechanical correction of deformity and a promise of no further progression, while also intending to preserve respiratory function into adult life, thus reducing morbidity and early mortality. Initial findings suggest that this is not so: while Cobb angle and trunk balance may be stabilised, the rib hump continues to increase and respiratory function to decline.

Introduction

The aim of the treatment of children with early onset scoliosis is controlling growth of the spine. Whatever the etiology, early progressive deformations require multiple stages of surgery usually performed every 6–12 months. One have to be reckoned with complications requiring additional surgical intervention.

Background: To assess the potential for Quantec imaging to save radiographs in the follow-up of patients with early onset scoliosis. This is a group of patients who often have many radiographs due their age at diagnosis.

Methods: This is a prospective cohort study. Twenty-four children with early onset scoliosis are identified. They all have a minimum of three simultaneous radiographs and Quantec scans as part of routine follow up for their scoliosis curves. There are 15 males and 9 females (22 thoracic, 1 thoracolumbar, 1 lumbar). Mean age at diagnosis is 3 years (range 1–4.8 years). The Cobb angle of the major curve is measured from each radiograph and compared with the Q-angle using Bland-Altman plots and linear regression analysis.

Results: The mean Cobb angle was 30° and the mean Q-angle 19°. The correlation coefficient was 0.68 (p< 0.05). In curves with Cobb angle < 30°, The Bland-Altman plots show a close scatter with a mean difference of 3.4°. It was calculated that this could have safely saved 18 radiographs in 14 patients. In curves > 30°, there was a large scatter and a mean difference between Cobb angle and Q-angle of 20.1°.

Conclusion: In early onset scoliosis, curves with Cobb angle less than 30° can be safely followed clinically and with the Q-scan reducing the number of radiographs required. Curves with Cobb angle greater than 30° cannot be reliably observed with Quantec scans alone.

Background: To assess the use of subcutaneous rodding with sequential lengthening procedures to control progressive early onset curves not responding to conservative treatment modalities.

Methods: A retrospective study reviewing the notes and plain radiographs of all children with early onset scoliosis treated by growth rod insertion over a seven year period (two paediatric spinal surgeons using similar techniques at two major centres). Subjects were children with early onset scoliosis unresponsive to conservative management. Outcome measures – curves at time of instrumentation, curve progression, number of lengthenings, curve magnitude and age at time of definitive fusion, spinal growth achieved and complications encountered.

Results: Majority of children treated uneventfully with satisfactory control of curvature until age at which definitive fusion acceptable. However our results do suggest a number of cases and circumstances where simple growth rod instrumentation is not sufficient and augmentation with anterior apical fusion is required (will discuss these on an individual basis).

Conclusion: The management of early onset progressive scoliosis by means of growth rod instrumentation and sequential lengthenings is safe and effective.

Aim:

To measure truncal parameters for patients treated with growing rod systems for early onset scoliosis (EOS).

Introduction:

Due to absence of fusion in guided-growth devices for EOS (growing rods, Shilla, LSZ) movement of the rods against their attachment is possible resulting in wear debris formation. It is important to understand the wear resistance of materials used in these devices under appropriate conditions.

Purpose

The aim of this study is to assess the safety and efficacy of a remote-operated magnetic growth rod in the treatment of 11 patients with progressive early onset scoliosis (EOS).

Summary Statement

Novel radiopaque UHMWPE sublaminar cables may be a promising alternative to gliding pedicle screws or titanium sublaminar cables within a growth-guidance system for the surgical treatment of early onset scoliosis.

Study Design: Long-term retrospective case review of function in children with early onset scoliosis managed by selective anterior epiphysiodesis and posterior ‘Luque trolley’ growing instrumentation

Method: spinal and clinical function was assessed utilising SRS-22 and SF-36 outcome measures. The rates of secondary surgical procedures and further definitive fusion were recorded. Pulmonary function was assessed by standardised and averaged spirometric data at follow up.

Results: 25 patients have been clinically reviewed and functionally assessed (age range 6–35 years) mean age 17.7 years at follow up. 16 patients have reached skeletal maturity (8males, 8females) with mean follow up 11.8 years, to a mean age of 22.4 years. clinically 80% of cases were well balanced. At maturity the average loss of axial spinal growth measured 10.25cm (arm span- standing height) (range +4 cm to −21cm). In the immature cohort still growing, median shortening was 0.75%, with average height loss 1.63% of predicted. SRS- 22 and SF-36 questionnaires indicated moderate – good functional outcomes in 80% of patients. Spirometric data, with one case incapable of test compliance, demonstrates 24 % of patients had normal spirometric functional parameters, 32% had mild restrictive deficits, 12% had moderate and 28% had severe restrictive deficits. Poor spirometric function did not correlate with poor outcome measures. Over 50% had required further surgery.

Conclusions: Poor functional outcomes occurred in patients requiring early and multiple surgical revision procedures associated with loss of control or fixation of primary and secondary spinal deformities.

Purpose: To report long-term results (with a minimum follow-up of 13 years) of GR construct [Luque-trolley (LT)] in EOS, to identify factors predictive of curve progression and to establish the timing of definitive fusion.

Method: The study cohort consisted of 37 patients (22M & 15F) who had primary LT between 1983–1995 were reviewed. Group I: 7 patients had LT alone and Group II: 30 had LT with convex fusion. Cobb at initial presentation, after first surgery, before definitive fusion and at the latest follow-up was recorded. Other radiological curve parameters recorded were rib spinal angle difference (RSAD), end vertebral tilts (EVT), apical vertebral rotation (AVR) and T1-S1 length. Complications with respect to development of junctional/apical kyphosis, implant failure, pseudoarthrosis (PA), sagittal/coronal profile and instrumented spinal segment growth at maturity were evaluated.

Results: The mean age at definitive fusion for study cohort was 12.5 years. Group I: Mean age at first surgery was 7.4 years (3.3–9.5y). Mean pre-op Cobb angle of primary curve was 600 (310–710) which was corrected to 280 (200–360). They underwent definitive segmental spinal instrumentation(SSI) with fusion at 13.9 years (9.8–15.1y) when the curve had worsened to 480 (400–650). Group II: Mean age at index surgery was 3.6 years (1.6–8.8y). Mean pre-op Cobb of primary curve was 580 (300–900) which corrected to 300 (100–620). 16/30 patients underwent definitive SSI with fusion at 11.5 years (8.5–14.2y) when the curve deteriorated to 600 (530–770). Instrumented segmental spinal growth was 3.2cms (SD±1.45; range 1–5cms). 14/30 maintained their correction till skeletal maturity. JK was observed in 8 cases [proximal(3), distal(2) & apical(3)] which were corrected at the time of definitive SSI. There was a linear relationship between Cobb angle at definitive fusion with concaveRSA and upperEVT.

Conclusion: Correlation and regression statistics revealed predictive factors of curve progression to be concave RSA (®=0.91 & p=0.001) and upper EVT (®=0.81 & p=0.0004). Patients with high concave RSA and upper EVT should be closely monitored for deterioration. Spinal growth that exceeds the capacity of LT to elongate leads to apical kyphosis. Timing of definitive fusion is influenced by growth velocity, clinico-radiological factors and complications.

Objective: To report on the long-term follow-up (mean 14.2 years) of patients with early onset idiopathic scoliosis treated with convex epiphysiodesis (CE) and Luque trolley instrumentation (LTI) without fusion. To evaluate factors influencing curve progression during the adolescent growth spurt in such patients.

Methods: Thirty-one cases of early onset idiopathic scoliosis with documented progression were surgically treated with CE and LTI without fusion between 1984 and 1992. Twenty-three (14 male, 9 female) of 31 cases had reached a minimum of 16 years of age at follow-up. These 23 cases were reviewed. The overlapped ‘L’ configuration of Luque trolley was used for the first 14 cases (prior to 1988), the overlapped ‘U’ configuration was used subsequently in the following 9 cases.

Results: Mean age at operation was 4.3 years (range, 1.5 – 9 years). Mean pre-operative Cobb angle was 65° (range 30° – 95°), and immediate post-operative Cobb angle was 28° (range 10° – 60°). Mean follow-up was 14.2 years (range, 7–19 years). Four cases required insertion of longer Luque rods (mean age of 7.5 years).

Definitive spinal fusion was required in thirteen cases at a mean age of 14.5 years (range 12–23 years), due to progression of scoliosis in 9 cases (mean Cobb angle 55°), and the development of junctional kyphosis in 4 cases. In ten cases the correction obtained was maintained through skeletal maturity (mean Cobb angle at final follow-up 33°). These cases did not require definitive spinal fusion.

The mean growth within the instrumented segment was 3.2 cm (42% of the expected growth). Progression of scoliosis was predicted by pre-operative apical convex rib-vertebra angle (RVA) (p=0.002). Excessive growth within the instrumented segment was predictive of junctional kyphosis but not of scoliosis progression. Age at operation and initial curve magnitude were not found to be significant predictive factors. 72% of overlapped ‘L’ rod construct (10 cases), and 33% of overlapped ‘U’ rod construct (3 cases) had documented curve progression within the adolescent growth spurt and required definitive spinal fusion.

Conclusions: CE and LTI was effective in controlling early onset idiopathic scoliosis, whilst still allowing significant growth. Pre-operative convex RVA was predictive of curve progression. The overlapped ‘U’ rod construct was more effective than the overlapped ‘L’ rod construct in preventing curve progression.

Aims

Magnetically controlled growing rods (MCGR) have been gaining popularity in the management of early-onset scoliosis (EOS) over the past decade. We present our experience with the first 44 MCGR consecutive cases treated at our institution.