Objective: Infants introduced to indoor heated swimming pools in the first year of life show an association with progressive adolescent idiopathic scoliosis (AIS). Similarly control children exposed in this way show an association with vertical spinous process asymmetry. A new method of assessment was used on these controls who were standing in an upright position. Overall, our evidence suggests that indoor heated swimming pools contain a risk factor that predisposes some infants to develop spinal asymmetries years later – progressive AIS in a few and off-vertical spinous process asymmetry in the many. What the risk factor may be and its possible portal of entry into the infant’s body are unknown and possibilities are examined. A subsequent new group of control children confirms the association of indoor heated swimming pools and vertical spinal asymmetry.

Risk factors: An irritant gas trichloramine (nitrogen trichloride) has been found to contaminate the air of indoor-chlorinated pools which Bernard et al link to asthma and chronic airway inflammation. Besides the lungs the skin in infants may provide another portal of entry of any chemical risk factors for spinal asymmetries. In connection with a chemical risk factor Nachemson anecdotally noted the development of scoliosis in salmon fry at a fish farm who were exposed to water contaminated after the re-painting of a water regulating dam.

Environmental epigenomics and disease susceptibility: Barker and his colleagues and others have shown that the origins of important chronic diseases of adult life may lie in foetal responses to the intrauterine environment and in infants to early postnatal life. Currently, there are British and US medical research projects to gather information on how human genes and environment interact over the years to cause disease; the British project is called Biobank. Another aspect concerns disease susceptibility by spotting gene variants in people who already have specific diseases. Do the suspected risk factors of indoor-chlorinated pools for spinal asymmetries need to be included in such studies? Is there potential for prevention?

In our earlier study we found 61% of the controls taken swimming in the first year of life had vertical spinous process asymmetry. In the subsequent smaller study the incidence even higher (83%).

Conclusions:

The evidence reported in our earlier paper suggests that infants introduced to indoor heated swimming pools in the first year of life show an association with spinal asymmetries including progressive AIS and in controls vertical spinous process asymmetry.

Background: To our knowledge, there are no publications that have evaluated physical activities in relation to the etiology of AIS other than sport scoliosis (1,2) so we undertook a study to assess the physical activities of patients with progressive AIS from their first year to early teens and compared these with those of a control group.

Methods: All 156 children in this study had to adhere to the following 6 criteria:- born full term, fed well as infants, achieved their milestones, no hospital visits except for sports injuries, no family history of a scoliosis and no back pain (prior to diagnosis in the patient group). We compared 79 consecutive patients (girls 66, boys 13) diagnosed as progressive AIS (62 of whom subsequently had a spinal fusion) with a control group of 77 subjects (girls 66, boys 11) of similar age, gender, race and socioeconomic status. A structured history was obtained from the mother and child of each group average time taken to obtain the history was 47 minutes. Each child was examined for toe touching and vertical symmetry of spinous processes whilst standing. The findings suggest a relation between physical activities or the lack of them and the development of progressive AIS.

Results: There is a significantly increased odds of AIS in those who were introduced to a swimming pool within the first year of life (p=0.001), did not attend gymnastics/ karate classes (p=0.005), did not attend dance classes (girls only, p=0.045), did not have horse riding classes (p=0.003), did not go skating (< 0.001), and who could touch their toes (p=0.011). No association is found with playing football/hockey or regular swimming at the age of 10 years.

Conclusion: Progressive AIS is positively associated with an early introduction to swimming and ability to toe touch. Spinal asymmetry was noted in the controls. AIS is negatively associated with participation in dance, skating, gymnastics/karate and horse riding classes. Is it possible that children who develop AIS have a longstanding proprioception defect which makes them less likely to participate in sporting activities? If so, by encouraging children to participate in sport might we increase their proprioception abilities and make those at risk less likely to develop spinal asymmetry which may progress to a scoliosis requiring surgical correction?

Background: Congenital anomalies of the chest wall and Sprengel’s shoulder are often associated with congenital deformities of the spine. It has been suggested that extensive rib fusions on the concavity of a congenital scoliosis may adversely affect progression of the spine deformity, thoracic function and growth of the lungs, which can lead to a thoracic insufficiency syndrome.

Methods: This is a retrospective study of the medical records and spine radiographs of 620 consecutive patients with congenital spine deformities. The rib anomalies were classified into simple and complex and the presence of a Sprengel’s shoulder was recorded.

Subjects: There were 497 patients (80%) with scoliosis, 88 patients (14%) with kyphoscoliosis, and 35 patients with kyphosis (6%). The mean rate of scoliosis deterioration without treatment, age and curve size at surgery was compared for the different types of vertebral abnormalities in patients with and without rib anomalies.

Results: Rib anomalies occurred in 124 patients. The rib anomalies were simple in 97 patients (78%) and complex in 27 (22%). The most common simple rib anomaly (70 patients; 72%) was a fusion of two or three ribs. The most common complex rib anomaly (20 patients; 74%) was a fusion of multiple ribs associated with a large chest wall defect. Rib anomalies were most commonly associated with a congenital scoliosis (116 patients; 93.6%), and much less frequently with a congenital kyphoscoliosis or kyphosis (8 patients). In those patients with a scoliosis, the rib anomalies were simple in 91 patients (78.5%) and complex in 25 patients (21.5%). Eighty-eight of the 124 patients (76%) with rib abnormalities had a scoliosis due to a unilateral unsegmented bar with or without contra-lateral hemivertebrae at the same level, and 8 patients had mixed unclassifiable vertebral anomalies. In contrast, only 17 patients with a scoliosis and rib anomalies had hemivertebrae alone. The rib anomalies were most frequently associated with a thoracic or thoracolumbar scoliosis (107 patients; 92.2%) and occurred on the concavity in 81 patients (70%), convexity in 27 patients (23%), and were bilateral in 8 patients. Sprengel’s deformity occurred in 45 patients; 43 patients with congenital scoliosis (8.6%), and 2 with kyphoscoliosis or kyphosis. A Sprengel’s shoulder occurred most frequently in association with a thoracic scoliosis due to a unilateral failure of vertebral segmentation (28 patients). The elevated shoulder was on the concavity of scoliosis in 26 patients and on the convexity in 16 patients. We compared the mean rate of curve progression without treatment, the age and curve size at spine surgery for the different types of spine deformities in patients with and without rib anomalies either simple or complex and found no significant difference (p> 0.05); the only statistical difference was that the mean age at surgery was higher for patients with a unilateral unsegmented bar without rib anomalies (p=0.005).

Conclusion: Congenital rib anomalies and Sprengel’s shoulder occur most commonly on the concavity of a thoracic or thoracolumbar congenital scoliosis due to a unilateral failure of vertebral segmentation. However, these anomalies do not have an adverse effect on curve size or rate of progression.

Objective: Idiopathic scoliosis is a complex, three-dimensional deformity. Surgical correction has been assessed by radiographic measurements in the coronal and sagittal planes and vertebral rotation. However the primary concern for the patient is the transverse plane deformity at the skin surface. The purpose of this study was to correlate the surface and radiographic measurements of transverse plane deformity in idiopathic thoracolumbar scoliosis before and after single stage anterior fusion with instrumentation.

Design: A consecutive, prospective study of patients operated upon by a single surgeon.

Subjects: 24 patients (23 female) with idiopathic thoracolumbar scoliosis operated on between 1990 and 1999. Mean age at surgery 14.8 yrs (range 10.9 to 17.5). All had single stage surgery through an anterior thoraco-abdominal approach with anterior release of a mean of 4 discs (range 3 to 6). Anterior instrumentation was inserted using vertebral body screws secured to a single contoured rod with interbody bone grafting using strips of rib autograft.

Outcome measures: All patients were assessed both radiographically and by surface topography using the Integrated Shape Imaging System (ISIS) pre-operatively, post-operatively and during each follow-up visit for a mean 3.1 years (range 1.8–9.1).

Results: Radiographically the mean pre-operative coronal Cobb angle of 49 degrees (range 30 to 74) was reduced to 13 degrees (range 0 to 32) following surgery with a mean 2 degree loss (range −5 to 10) at final follow-up. The Perdriolle rotation was reduced by a mean of 19 degrees (range 5 to 30) with a mean 1 degree loss (range −6 to 6) of correction at final follow-up.

ISIS showed the mean pre-operative Standing Angle of Trunk Inclination (sATI) of 15 degrees (range 7 to 25) was reduced to 5 degrees (range 0 to 15) post-operatively with a further mean improvement of 2 degrees during the follow-up period. The final sATI was within the range of normality for 21 patients (87 percent). Spinal balance in the coronal plane improved from a mean of 24mm to 11mm. Spinal balance in the sagittal plane was unchanged.

Conclusions: Anterior surgery for idiopathic thoracolumbar scoliosis is effective in reducing transverse plane deformity. The Standing Angle of Trunk Inclination is returned to the normal range in 87% of cases. Coronal plane balance is improved by surgery. These corrections occur mainly due to surgery but also continue on follow up (growth).

Objective: Surgical correction of late-onset idiopathic scoliosis (AIS) has been shown to be effective in obtaining correction in the frontal and sagittal planes, but is of questionable benefit in reducing the rib hump in the transverse plane The purpose of this study was to assess the effects of double rod and pedicle screw (AO USS) instrumentation on transverse plane asymmetry (on the convex and concave side of the scoliosis) in a single thoracic curve type (King III).

Design: A consecutive, prospectively studied cohort treated by a single surgeon with either a single-stage or two-stage procedure.

Subjects: Sixty-five patients with a King III adolescent idiopathic scoliosis were studied. There were 53 females and 12 males whose mean age at surgery was 14.5 years (range 11.1 to 17.9). A single-stage posterior fusion with instrumentation was performed in 46 patients whose mean Cobb angle at surgery was 56° (range 35 to 84). A two-stage procedure with thoracotomy and anterior spine release by multiple disc excisions (mean 6 levels) combined with internal costoplasty (mean 6 ribs), followed one week later by posterior spinal fusion with instrumentation, was performed in 15 patients whose mean Cobb angle was 78° (range 40 to 92).

Outcome measures: All patients were assessed both radiographically and by Integrated Shape Imaging System (ISIS) surface topography pre-operatively, postoperatively (mean of 14 weeks) and at follow-up visits for a mean 2.7 years (range 1.5–6.1).

Results: There were no non-unions or instrument failures in either group.

Single-stage group: Post-operative improvement in the Cobb angle was a mean 54% with a mean 2° loss in correction at final follow-up. ISIS showed the angle of rib hump elevation (convexity side) was improved by a mean of 2.1° and the angle of rib depression (concavity side) was unchanged. At final follow-up the angle of rib hump elevation had recurred by a mean of 3.6° beyond the original pre-operative value. The angle of rib depression remained unchanged.

Two-stage group: Post-operative improvement in the Cobb angle was a mean 64% with a mean 1° loss in correction at final follow-up. ISIS showed the angle of rib hump elevation (convexity side) was improved by a mean of 6.2° and the angle of rib depression (concavity side) was improved by a mean of 3.5°, producing a more balanced transverse plane. At final follow-up the angle of rib hump elevation only recurred by a mean 2.2°. This was compensated by a further improvement in the angle of rib depression by a mean of 2.5°, producing a further correction to balance the transverse plane.

Conclusions: Single-stage surgery is not effective in improving the transverse plane deformity. Two-stage surgery improves the transverse plane deformity on both the convexity and concavity producing a more balanced spine with further improvement due to an improvement of the rib depression (concave side) during follow-up (growth).