Introduction: A parameter in surface topography was developed to measure left-right differences in back surface of different scoliosis patterns, and to relate these to biological asymmetry and the evolution of deformity. Because of the close association between scoliosis and growth, the hypothesis that scoliosis is growth, that it affects not just the spine but the whole body and that it falls into well-described biological patterns of asymmetry, was explored.

Methods: The new measure compares the positions of three points (mid way between the first thoracic vertebra and axilla, and one and two thirds from axilla to posterior superior iliac spines) on either side of the mid-line, reflecting right onto left and expressing the displacement along Cartesian axes in millimetres. The purpose is to measure size and growth differences at diagnosis and during follow-up. Statistical analysis was of prospectively collected topographic, radiographic and clinical data. There were three groups, all female: 1. mild asymmetry (N=84, no radiograph); 2. thoracic (N=65, mean Cobb angle 61.4°±19.5) and 3. thoracolumbar or lumbar (N=40, mean Cobb angle was 51.8°±23.0). Comparisons were made between each group and theoretically perfect symmetry (test value zero). Correlations with Cobb angle change over time were analysed.

Results: Groups one and three showed directional asymmetry in the coronal plane only, and were not statistically different from each other. Group two showed directional asymmetry at all levels, the side of the scoliosis convexity being larger in all three dimensions (left-right, antero-posterior and cranio-caudal). Changes in Cobb angle correlated with statistical significance with change in the vertical height of the convex side.

Conclusions: This topographic measure was developed specifically to quantify the asymmetry of the back surface, to assign it to a biological pattern and to observe how it might change during growth and scoliosis evolution. All levels of asymmetry, the minor as well as the true scoliosis, showed directional asymmetry (normal distribution of left-right differences about a mean that is not zero, genetically determined) which suggests an origin of scoliosis lying in the biology of growth and the evolution of morphology, rather than in a particular disease process. This asymmetry does not cause scoliosis: it is the result of asymmetric growth processes, it is scoliosis. The relevance of this view is that it obviates the need for an identifiable disease process, as scoliosis is a non-specific developmental response to physiological stress. It is the destabilising of the genetic control “programme” that operates in the growing organism to produce an adult phenotype which is an accurate expression of its genotype. This interpretation can explain observations of natural history that currently cause problems viz. the association with growth and development, lateralisation, increased incidence with other medical conditions, and female predominance, the recurrence of deformity after surgical correction and perhaps even the difficulty in reaching a final conclusion on the efficacy of brace treatment.

Background: Adolescent idiopathic scoliosis has been intensively studied, but is still not understood. It is the paradoxical co-existence of rude health and gross deformity in the same individual that needs to be explained. The essence of scoliosis is asymmetry, and bilateral asymmetries in many anatomical features have been described in association with it. Measurement of asymmetry in back surface made possible by surface topography can explore this aspect and throw light on the evolution of the deformity as the Cobb angle changes.

Objective: To quantify the asymmetry of the back surface in scoliosis and the lesser non-scoliosis deformities.

Methods: Routine clinical material (patient demographics, radiography and surface topography) was analysed. Changes in body symmetry were quantified, using a topographic measure that calculates the difference, in three dimensions and at three levels, between the left and right sides of the back across the mid-line (natal cleft to first thoracic vertebra). Girls only (to eliminate any effect from sexual dimorphism) with all presenting degrees of deformity from barely failing the forward bend test through mild scoliosis unconfirmed by radiograph (Group 1, N=311) to documented scoliosis (Cobb angle => 10°), apex at T12 or below (Group 2 and apex above T12 (Group 3).

Results: All groups showed significant departures from bilateral symmetry. Groups 1 and 2 were similar, in that the left side was taller but narrower than the left. In Group 3, the side of curve convexity was taller than the concave side. This was reversed in left thoracic scoliosis patterns and was seen to increase over time with progression of the Cobb angle.

Discussion: It has long been acknowledged that scoliosis and growth are inseparable, but studies have failed to demonstrate a disease process or endocrine imbalance. These findings suggest that it is not a disorder superimposed on growth, but that growth itself causes the deformity. The spine, the whole trunk, in fact, is crooked because it grew that way. Only a small discrepancy in left-right symmetry is sufficient, over time and during periods of rapid growth, to produce both the curve and the rotation.

Conclusion: Scoliosis is neither a disease nor a mechanically induced aberration. It results from asymmetrical growth, which occurs at the cellular and molecular level.

A 2002 study by Goldberg et al showed that surgery before age 10 for infantile onset idiopathic scoliosis (diagnosis < 4 years, Cobb angle => 10°) preserved neither respiratory function nor cosmesis, and has not been contradicted. In 2005, Mehta re-emphasised scoliosis correction by serial cast-bracing, while Thompson et al reported satisfactory results with growing rods. An analysis of the status quo of a cohort of patients with infantile idiopathic scoliosis (other diagnoses and syndromes excluded), managed by cast-bracing, was undertaken, asking whether interim progress was acceptable or demanded a change of protocol.

Of 35 patients born between October 1993 and December 2002,15 have completely resolved, age at diagnosis 1.6 ± 0.96 years, Cobb angle 20.3°±11.9, RVAD 11.1°±13.8, latest age 4.1± 2.3. 20 were prescribed cast-bracing, age at diagnosis 1.8±0.9 years, Cobb angle 47.3°±12.6, RVAD 29.6±24.5, age at treatment was 2.1±1.0 years. Cobb angle (p< 0.001) and RVAD (p=0.001) were larger in the treated group, but age at presentation was the same (p=0.473). Surgery was performed on 3 children unresponsive to initial casting, at ages 3.2, 3.6 and 3.7, and in 3 at ages 8.6, 10.1 and 11 years. 3 children, aged 6.0, 8.1 and 11.3 are out of brace with straight spines and 11 are stable in brace.

Infantile idiopathic scoliosis seems programmed to resolve or progress according to initial severity and in line with growth rate. Those who respond to casting in infancy generally remain stable until near puberty when surgery is uncontroversial. Those who progress relentlessly and immediately in cast remain the issue, as reports of newer methods include a wide range of ages and diagnoses and give their outcome in terms of Cobb angle only. It has not yet been shown that any treatment will alter their prognosis so constant analysis of all outcome parameters is essential.

It is customary to analyse scoliosis as a mechanical failure: first there is a straight spine (=normal), then an habitual and collapsing posture (=disease) and finally, structural remodelling (Hueter-Volkmann effect = scoliosis). This hypothesis makes two practical predictions:

There is a disease process causing the pathological posture. The purpose of gatherings such as this is to identify this pathology, thus far without success.

The failure of school scoliosis screening to achieve this end is well documented, but the consequence for the underlying hypothesis has not been analysed. Screening failed, not because it was unable to detect scoliosis, but because scoliosis did not behave as the hypothesis predicted.

Disease process: All theories presume some form of neurological or muscular deficit as the final pathway but while the variety is wide, e.g. (historically) anterior poliomyelitis; more recently proprioceptive defect, melatonin or calmodulin disorder, there is no clear evidence for such a deficit in adolescent idiopathic scoliosis (AIS). Of 1342 screening referrals to this centre, 10 had a neurological diagnosis (most of which were already known to the patients) and 598 had radiologically confirmed AIS. In contrast, 1707 referrals to the general clinics included 410 syndromic cases and 420 AIS. Patients with a neurological problem, by and large, find their own way to medical attention. The hypothesis does not explain the natural history or the aetiology, and awkward observations, such as the association with growth (Goldberg et al Spine.18(5):529–535.1993, Eur Spine J.2:29–36.1993 and, most recently, Ylikoski M. Journal of Pediatric Orthopaedics B.14:320–324, 2005) or the higher incidence in ballet dancers (Warren et al. New England Journal of Medicine.314(21):1348–1353.1986) and rhythmic gymnasts (Tanchev et al. Spine.25(11):1367–1372.2000) are ignored.

Screening: Screening programmes (e.g. Goldberg et al., Spine.20(12):1368–1374, 1995) showed that there was no precise demarcation between “scoliosis” and “normal,” and that there was no benefit in terms of the need for surgical correction from screening or bracing, (Goldberg et al. Spine.26(1):42–47, 2001).

Discussion: his information has been in the public domain for some years and, in the meanwhile, there have been huge advances in biology and medicine which must have relevance. When the predictions of a hypothesis are not confirmed, that hypothesis must at least be re-examined, and it is not necessary to wait until a replacement can be suggested. The undisputed aspects of scoliosis, such as association with growth rate and maturation, lateralisation, gender predominance, normal distribution of Cobb angle and asymmetry over the wider population, essential health and normality of those with even severe deformity, increased incidence in other conditions, all suggest a different model. This is an opportune time to pause and reconsider the underlying model of scoliosis in the light of what we have learned about scoliosis and what is now known in other disciplines about how morphology is determined and evolved.

Background: It is commonly observed that a good correction of the Cobb angle at scoliosis surgery is accompanied by an acute asymmetry of shoulder height. Kuklo et al in 2002 described (Spine. 26(18):1966–1975) spontaneous reversal of this, using radiographic measures and patient questionnaires.

Objective: To determine the incidence and extent of shoulder-imbalance before posterior spinal surgery and to ascertain its outcome, using radiographic and topographic measures.

Methods: Patients with right thoracic adolescent idiopathic scoliosis who had undergone corrective posterior spinal fusion by one surgeon were identified. Pre- and all postoperative spinal radiographs and surface topography were evaluated and correlated. Any effect from concomitant anterior release procedures was sought.

Results: Sixty six patients were identified, 56 girls and 10 boys. Their pre-operative major Cobb angle was 73°±14.0 and mean correction was 38.8°±12.333 (56%). Before surgery, surface topography showed the mid-point of the right shoulder to be at a mean or 18.3mm.±10.9 higher than the equivalent left point; eight days later, the difference was −6.7 mm. ±9.68, a mean change of 25.9mm±11.8. At six months, it was −5.1 ±6.86, statistically unchanged. At two years, it was −2.16 (p=0.051) and at three years, 1.76± 6.53 and indistinguishable from zero or perfect balance. The difference between pre-operative and final shoulder level difference was 19.54mm.±9.09. The Cobb angle of the compensatory upper thoracic curve was not significantly changed throughout. There was no statistically significant difference in shoulder height between patients undergoing single or two-stage surgery, either before or at any stage after.

Discussion and conclusion: Correction of post-operative shoulder imbalance does occur spontaneously, as reported by Kuklo et al. and is not a function of spinal accommodation to the new anatomy.

Background: A sharp, localised, thoracolumbar gibbus is pathognomonic of the mucopolysaccharidosis (MPS) group of disorders, the most common of which is Hurlers syndrome (MPS I). Untreated patients with this disease run an inevitable course of neurological and physical degeneration until death within the first decade. Haemopoietic stem cell transplantation (HSCT) has resulted in considerable improvement in survival with amelioration of many of the symptoms and signs which characterise this disease. Data, however, is disappointing in relation to the impact of HSCT on skeletal dysplasia. This study reviews the natural history of spinal deformity in Hurler’s syndrome after HSCT in infancy.

Methods: Twenty three patients (12 male and 11 female), transplanted at a mean age of 0.9 years ± 0.47, (range 0.27 – 1.8yrs) were investigated, of whom 19 were at least two years post-HSCT and were included. HLA identical donor sources included unaffected or heterozygote family members, unrelated adults or cord blood. Mean age at review was 9.4 years ± 4.57, (range 2.5 – 18.4yrs). Serial measurements of the thoracolumbar spines incorporated clinical records, radiographs and surface topography. The thoracolumbar gibbus was measured on lateral spinal radiograph using the standard adaptation of the Cobb method. Two segments of the spine were documented: the gibbus itself and the thoracic profile above it. Clinical assessment and surface topography were contrasted with this.

Results: At presentation, all showed the characteristic gibbus at the thoracolumbar junction, with a flat and stiff thoracic spine above. Three patients underwent surgery to correct or maintain the gibbus, which was unsuccessful in two; the third is stable, but still young. Two patients have developed scoliosis: one in the juvenile period and one in infancy. Three female patients are now post-menarchal and have shown no progression of their gibbus. One male patient, now aged 19 years, had significant progression of his gibbus at puberty, but is now stable, untreated and cosmetically acceptable. The remainder are still pre-pubertal but their deformities are not currently progressive.

Conclusion: The fate of the spinal deformity in untreated MPS-I has been poorly documented, as the condition was invariably fatal from cardiorespiratory failure during the first decade. These interim results suggest that, while the deformity persists and may become more pronounced during growth and adolescence, it does not significantly impact on quality of life. The considerations which usually dictate intervention in other spinal deformities of childhood may not necessarily apply and should be approached with caution. The more recent availability of recombinant human -L- iduronidase adds further interest to the management of these patients and warrants cautious expectation , in the context of experience gained in these groups of patients. In conclusion atients with MPS I have complex multisystem disorders, independent of their orthopaedic status. While monitoring their spinal deformity is indicated, over-intrusive investigation and treatment may be counterproductive.

Background: In adolescents at or near skeletal maturity, correction of severe scoliosis may be facilitated by first mobilising the spine anteriorly before the definitive posterior fusion and instrumentation. There is no dispute that this is effective, but it is significantly more invasive, and carries greater risks. The benefits have been measured in greater reduction in the Cobb angle, but the patient’s real concern is with cosmesis. Surface topography can measure this aspect.

Methods: Retrospective comparison of topographic parameters (before surgery and at 7 days, 6 months, and 2 years after, and at latest review, if more than two years) after one-stage (Group 5, N=10) and two stage (Group 3, N=39) with normal adolescents (Group 1, N=63). Patients operated for adolescent idiopathic scoliosis by one surgeon (FED) were compared with girls referred and then judged normal from the screening programme. Topographic parameters (spinal angle, saggittal profile, asymmetry and trunk balance) and Cobb angles were compared by t-test.

Results: Prior to surgery, both treatment groups differed significantly from the index group on all parameters except saggittal profile; from each other, they differed only in mean Cobb (Group 3: 73.6°, Group 5: 59°) and spinal angles and Suzuki hump sum. After surgery, both groups showed significant mean reduction in most parameters and in final Cobb angle (Group 3: 32.7° (−40.9°), Group 5: 29° (−30°) postoperatively) excepting rib hump, and were not statistically distinguishable. Over two years, there was continued improvement in trunk balance and re-establishment of lumbar lordosis in both groups. Group 5 (single stage) showed a slight recurrence of some asymmetry parameters that was statistically (but perhaps not clinically) significant. All patients had a solid fusion post-operatively.

Conclusion: Ideally, this study would be done prospectively, on a controlled, double-blind, randomised basis, but the numbers required and time involved make this impractical. These two surgical groups were pre-selected on the basis of curve severity, and these results may show that the anterior procedure is necessary to bring Group 3 to the same end-point as Group 5. Alternatively, while the anterior procedure improves the reduction of the Cobb angle, it might be the posterior fusion that rearranges the shape of the back and hence brings about the cosmetic improvement. In conclusion reducing the Cobb angle has been the standard of surgical assessment, but the cosmetic result does not necessarily correlate with this. The possibility that less invasive surgery may give as good a cosmetic outcome is worth discussing, as the savings in time, money and risk would be enormous.

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.

Objective: To assess the treatment outcome at a minimum age of 15 years in patients who had presented with idiopathic scoliosis in infancy.

Design: Patients were recalled for full pulmonary function testing (spirometry, lung volumes and gas diffusion) and surface topography. Results were correlated with history and clinical radiographs.

Subjects: The records showed 32 patients, of whom 23 could be contacted and agreed to take part in the study. Thirteen had no other abnormality, and 9 had a variety of additional problems not thought to directly precipitate their spinal deformity. There were 13 female and 9 male and age at testing ranged from 15.2 to 30.2 years.

Outcome measures: Spirometry (forced vital capacity (FVC), forced expiratory volume in one minute (FEV₁)), lung volumes ( total lung capacity (TLC), residual volume (RV)) and gas diffusion (carbon monoxide diffusion (DLCO), and alveolar volume (VA)) were correlated with the most recent Cobb angle, surface topography and age at surgery where applicable.

Results: Those who were successfully managed without recourse to surgery (N=6) had normal cosmesis and pulmonary function (mean FEV₁ = 98.7%, mean FVC = 96.6%). When surgery had been postponed until after age 10 (N=6, mean age at surgery 12.9 years) pulmonary function showed some restriction (mean FEV₁ = 79%, mean FVC = 68.3%). Those who underwent corrective surgery before age 10 years (N=11, mean age at surgery 4.1 years) had significant recurrence of deformity and diminished respiratory function (mean FEV₁= 41%, range 14 – 72%, mean FVC = 40.8%, range 12 – 67%). There was statistically significant correlation (p< 0.01 or less) between respiratory measures on the one hand and age at surgery (where applicable), surface topography measures and latest Cobb angle.

Conclusions: It has been reported that only in early-onset scoliosis is the growth of lung tissue and the multiplication of alveoli impeded[1,2] and treatment is directed at preserving both pulmonary function and cosmesis. Early surgery is recommended on the assumption that the Cobb angle can be controlled and normal pulmonary development enabled in those whose scoliosis did not respond to conservative methods. Methods have changed since the earlier cases in this series were treated, and it is hoped that later results will be different. However, caution requires that, in monitoring these patients, cosmesis and, more importantly, respiratory function be considered before a conclusion is drawn.

Objective: It is frequently said that the natural history of adolescent idiopathic scoliosis (AIS) is not understood. This study examines clinical data collected over some years and shows that the information is available and needs only to be generalised and applied.

Design: Retrospective analysis of data, relating basic clinical information (age, Cobb angle, pubertal status, growth) to outcome in the practical terms that are relevant to clinical practice and patient management, Subjects: Two groups of female patients identified from the database: Group 1, girls diagnosed at least one year before the onset of menses and last reviewed at least one year afterwards; Group 2, girls diagnosed at least one day after menarche, followed for at least one year and not having surgery as a first option i.e. within six months.

Outcome measures: Within and between group comparisons as regards age, height and Cobb angle at presentation and at last review and age at menarche. Change in height and Cobb angle of 10°, and the incidence of non-operative treatment and corrective surgery were considered. Statistical analysis was by student’s t test and Fisher’s exact.

Results: Group 1 (N=58) presented at a mean age of 11.6 years SD 1.02, range 10 – 13.9 and reached menarche a mean of 2.1 years later, SD 0.86, range 1.0 – 4.5. Mean Cobb angle was 16.79 SD 8.58. Progression of more than 10° was observed in 24 girls, 11 of whom underwent surgery. Those who progressed had a higher initial Cobb angle (p=0.01) and were taller at discharge (p=0.041), but all other parameters were the same. Group 2 (N=92) presented at a mean age of 13.7 years SD 0.92 with a mean Cobb angle of 23.77° SD 14.52. Progression of 10° or more was observed, one of whom had surgery, her Cobb angle having increased from 48° to 64°. 6 had surgery for cosmetic reasons without further increase in Cobb angle. There was no statistically significant difference between the stable and progressive groups on any parameter other than final Cobb angle.

Comparing Groups 1 & 2, girls in Group 1 were younger and smaller at diagnosis with lower Cobb angles. They were older at menarche, but this was inevitable from the selection criteria, and more likely to progress (p< 0.001), to receive a brace (p=0.047) and to undergo surgery (p=0.043). Age, final Cobb angle and height at discharge were not significantly different.

Conclusions: 1.Girls diagnosed with AIS before puberty are at increased risk of progression but this is not usually clinically significant and does not usually lead to corrective surgery. 2.Girls diagnosed after menarche progress rarely and less. In practice, their deformity can be taken as stable at presentation. 3. In most cases, the course is benign and non-operative treatment had no discernible effect on outcome. As the percentage progressing significantly or requiring treatment at any stage is small, a less interventionist approach is indicated.

Introduction: The arguments for and against school screening for scoliosis are long since over, and centres have continued or ceased as they thought best and as funding allowed. However, the programmes did amass considerable volumes of observations that, being part of the over-all epidemiological picture, could advance our understanding of adolescent idiopathic scoliosis and of minor asymmetries of back shape.

Methods and Results: A retrospective examination of the records from the school screening programme at this centre concentrated on subjects with minor asymmetry, those who at first review did not qualify as ‘scoliosis’ yet were noted to have failed the forward bend test. There were 91,811 examinations on 55,484 girls: 2170 were classified as ‘non-scoliosis asymmetry’. Of these, 1574 were noted but not referred; 360 were reviewed in clinic without radiograph,; 107 had straight spines on radiograph and 221 had Cobb angles < 10°. Eleven are known to have progressed to 10° or more, three passed 25°, two passed 40° and one underwent surgery. This gives an incidence in this subgroup of 0.51% for defined scoliosis. For scoliosis => 25°, it was 0.14%; for scoliosis => 40°, 0.092%; and 0.046% for surgery, none of which shows a significant difference from the equivalent rates for the population as a whole. (0.6% Cobb angle => 10°, 0.2% Cobb angle => 25°, 0.08% Cobb angle => 40°, 0.045% surgery. (Goldberg CJ et al. (1995). Spine. 20(12):1368–1374).

Conclusion: These findings are in accordance with previous reports on school screening, and it is not proposed to re-open the discussion. Their relevance is their relationship to significant scoliosis: since these children are not at increased risk of developing deformity, they cannot be, as has been proposed (Nissinen et al (2000) Spine. 25:570–574) instances of mild or early scoliosis, and they do not need intensive investigation, follow-up or treatment. Non-scoliosis asymmetry is closer to the increased fluctuating asymmetry displayed by this age group (Wilson and Manning. (1996) Journal of Human Evolution. 30:529–537) and begs a more biological approach to spinal deformity, asymmetry and back shape.

Introduction: Historically, the spinal curvature of adolescent idiopathic scoliosis was considered a life-threatening occurrence, which would result in early death from cardio-respiratory compromise. Consequently, corrective surgery had the primary intention of preventing this unacceptable outcome: cosmetic improvement was considered to be certainly important, but not the prime objective of the treatment. More recent work (e.g. Branthwaite MA. (1986) Br.J.Dis.Chest. 80:360–369) has shown that, while significant deformity presenting in early childhood does carry this outlook, those with an adolescent onset should not be significantly affected in this way. Consequently, any surgery recommended is primarily cosmetic, to improve the deformity when it is unacceptable to the patient and her parents. This, of necessity, changes the criteria by which treatment outcome should be assessed. Scoliosis surgery has generally been judged by the correction in Cobb angle and, more recently, the derotation of vertebrae. However, it is well known that neither factor accurately expresses cosmesis, the criterion by which the patient will judge the operation. Surface topography attempts to quantify the external appearance of a patient and so the cosmetic effect of surgery. Since 1995, when a surface topographic system (Quantec) was acquired by this department, 61 patients were operated for adolescent idiopathic scoliosis, of whom 35 underwent anterior release and posterior fusion for rigid thoracic curves.

Methods and Results: Pre- and post-operative radiographs were compared with topographic results from the same periods and with the latest scan at last review. The mean pre-operative Cobb angle was 74.5° and, postoperatively was 40.7°, a mean correction of 45.4% and was statistically significant (p< .001). This was accompanied by statistically significant reductions in upper and middle topographic spinal angles (p=0.001), an increase in thoracic kyphosis (p< 0.05), a decrease in lumbar lordosis (p=0.001), lower rib hump (p< 0.05), Suzuki hump sum (a measure of back asymmetry, p=0.001) and posterior trunk asymmetry score (POTSI, a measure of trunk balance, p=0.003). At final follow-up a mean of 2.2 years later, topographic spinal angles and POTSI maintained their improvement, still being statistically significantly less than their pre-operative values. Thoracic kyphosis, lumbar lordosis, rib hump and Suzuki hump sum had returned towards pre-operative levels and no longer showed statistically significant differences.

Conclusions:This confirms previous reports of the recurrence of the rib-hump. In conclusion, after two-stage spinal fusion for adolescent idiopathic scoliosis, significant improvement in cosmetic appearance can be achieved. However, over time certain aspects of the original deformity, particularly distortion of the back surface (rib hump or asymmetry) recurs.

Surgical correction of spinal deformity in patients with neural axis abnormalities has established risks of causing further neurological injury. It is necessary to identify individuals with a predisposition for such abnormalities before treatment is instituted.

Objective: Examination of the association between idiopathic scoliosis and underlying neural axis abnormalities in the infantile and juvenile age groups.

Design: Retrospective chart and radiographic review.

Subjects: Ninety-four (36 infantile, 58 juvenile) consecutive patients with non-congenital scoliosis under the age of eleven years.

Outcome measures: These consisted of the MRI findings, neurological examination, associated curve morphology and necessity for neurosurgical intervention or surgical curve correction.

Results: Approximately 25% of patients presenting as idiopathic juvenile scoliosis had underlying neural axis abnormalities. No patient with apparent infantile idiopathic scoliosis had an abnormal spinal MRI scan. Using the Z score for independent proportions, there was a statistically significant difference between infantile and juvenile scoliosis and the presence of an underlying neural axis abnormality (Z score of 2.089, equivalent to p< 0.02).

Conclusions: We advocate routine MR spinal imaging in all patients with juvenile idiopathic scoliosis. In infantile idiopathic scoliosis, to avoid unnecessary general anaesthetics, one should image the spinal canal only when clinically indicated