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Get back in action: managing Idiopathic Scoliosis: mild curves don't need surgery.

MIAMI BEACH -- Scoliosis is a descriptive term, not a diagnosis, Dr. Carl Stanitski said at a pediatric update sponsored by Miami Children's Hospital.

Treatment decisions should be based on a combination of factors, not simply the numerical degree of the curve. Children must be followed to document curve stability vs. progression, said Dr. Stanitski, professor of orthopedic surgery at the Medical University of South Carolina, Charleston.

Idiopathic scoliosis is the most common type. "It's a diagnosis of exclusion," he said.

Not all cases of scoliosis deformity in very young children are congenital. Early-onset idiopathic scoliosis, occurring from birth to 3 years, is more common in boys than girls, is usually a left-sided curve, and almost always resolves over time without bracing or surgery

The juvenile types of idiopathic scoliosis appear between 4 and 6 years and be tween 6 and 9 years, and approximately two-thirds of the cases are progressive.

"We've found that many children with juvenile scoliosis have intradural and extradural MRI changes, including syrinxes, lipomas, and tethered cords.

"If there's been a rapid change in curve size, especially if there are associated changes in neurologic status, I request an MRI of the entire neuraxis,'" Dr. Stanitski said.

Approximately 3% of children undergoing school screening have scoliosis. Of these, fewer than 10% require any treatment, including observation, and fewer than 0.1% require surgery

Trunk asymmetry is a common and normal finding and is generally related to hemihypertrophy due to hand dominance.

Trunk asymmetry per se, even in a child, does not automatically mean that there is a serious problem, Dr. Stanitski emphasized.

In children older than 9 years, the prevalence of a 10-degree curve is 1%-3% and the prevalence of a curve greater than 20 degrees is only 0.3%.

At least a 10-degree curve is required for a scoliosis diagnosis.

When conducting the clinical exam on a child with idiopathic scoliosis, ask when the parents noticed it.

The curve may have been present all winter but was not noticed until the child put on a swimsuit in the summer. Ask about back pain. Many children with idiopathic scoliosis complain of backache, but beware of children who complain of chronic, constant pain. They need further evaluation.

Ask about night pain in curve, particular--it could indicate a tumor.

Assess leg length, gait, and Tanner stage. If a child is still growing, the odds are greater that the curve will progress. Dr. Stanitski said that he finds scoliometers to be inconsistent.

"The radiograph you want to get, and that you need to insist on, is an erect posterior-anterior view of the thoracolumbar spine on a long cassette," he said. "One should not do a scoliosis 'series' of radiographs."

Although pediatricians can assess the size of the curve, whether it is structural or not, and how it affects the trunk balance, they should not attempt to measure scoliotic radiographs without specific training, he added in an interview.

Risser grading is helpful in evaluating skeletal maturity in children.

The Risser scale grades childhood bone development: A low grade means that the skeleton has more potential for growth, and more potential for curve progression, while a high grade means that growth is nearly complete and the potential for curve progression is less likely

A child with a Risser grade of 0-2 who is premenarchal and has a curve of 20-29 degrees has a two in three chance that the curve will progress.

If the child has a Risser grade of 2-4 and is postmenarchal, the odds of progression are approximately one in four, he said.

Common sense is involved. If the child has a large curve at a young age, the curve is more likely to worsen over time. If a child develops the curve at an older age, progression is less likely.

Approximately two-thirds of thoracic curves more than 50 degrees progress to adulthood, Dr. Stanitski noted.

When a patient has a 40- to 49-degree curve, some physicians advocate surgery if the trunk balance is inadequate.

However, the number of degrees in a curve is "only one factor in the complex equation regarding the type of treatment, and this number can't be considered in isolation from other factors," he said in an interview.

Treatment of idiopathic scoliosis is based on the three O's: observation, orthoses, and operation.

Consider the child's age, potential for growth, cosmesis, and the location and magnitude of the curve.

A Boston brace or Charleston brace can be helpful for an immature child with a 25-to 40-degree curve.

Compliance is a problem, however, since children often consider back braces socially unacceptable, especially in the socially challenging times of middle school.

In addition, debate continues over how many hours children should wear the braces.

If a child has a thoracic curve of more than 50 degrees, progression is likely. Surgery is designed to prevent progression. The fusion and instrumentation procedure uses pedicle screws and/or hooks and rods in the thoracic and lumbar spine to correct the deformity; improve cosmesis; and, along with bone grafting, prevent progression.

Intraoperative and postoperative complications are relatively uncommon and may include pneumonia, urinary tract infection, wound infection, and neurologic compromise.

With modern surgical methods, patients are rapidly ambulatory without casts or braces after short hospital stays. Children usually return to school full time within 1 month of the procedure.
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Title Annotation:Clinical Rounds
Author:Splete, Heidi
Publication:Pediatric News
Geographic Code:1USA
Date:Apr 1, 2004
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