Epidemiology
< 4 years by definition
M : F
75% left thoracic
Actually very uncommon
- likely most patients once had spinal dysraphism (Arnold-chiari / syrinx / tethered cord)
- reduced by prenatal folate
Progression
Age < 1
- 90 % spontaneously regress
- very important
- 10% progress to severe deformities
Age > 1
- 80% progress
- more likely to cause cardio / respiratory compromise
- alveoli not developed til age 8
- lungs need room to develop
- high associated with other abnormalities
Progression Risk
1. Mehta Angle / Rib-vertebral angle difference / RVAD
Difference in angle at which rib meets spine at Apex of curve on either side on AP x-ray
- > 20° likely to progress
Phase one and phase two
- phase 2 : rib head overlaps and angle cannot be measured
- risk of progression high
- indicative of rotation
2. Degree of Curve
Likely to progress if curve > 25°
CT
Exclude congenital scoliosis
MRI
Mandatory
- 20% incidence intraspinal pathology
- syrinx / tethered cord / diastematomyelia / ACM
Management
Non operative
Indications
Curve < 25o and RVAD < 20o
- resolve spontaneously
- no need for treatment
Curve > 25o and RVAD > 20o
- brace
Bracing
Serial cast < 1 year
Brace > 1 year
- Milwaukee brace can be curative
- younger age group more likely to tolerate this brace than adolescents
- brace must be worn until curve maximally & permanently corrected
- infantile growth spurt continues till ~ age 4-5
Operative
Indications
Curves > 35o
Progressive curves 5o in 6/12
Issue
Patient < 10 years or before PHV
- high risk crankshaft effect
- fusions must be anterior and posterior
Options
1. Posterior growing rods
- obtain correction whilst maintaining truncal growth
- subcutaneous Harrington rod / Growth Rods / Luque rods
- spine exposed at ends for hook insertion with submuscular or subcutaneous rod insertion
- requires surgical adjustment every year (can be done up to 5 times)
- surgery each time adds to scar and increases risk of problems including infection and cut out
- posterior fusion at later age
2. Hemiepiphyseodesis
- fusion of convex side of apical vertebrae
- is difficult to obtain half disc fusion
- may be used supplementary to growing rods
3. Staples / guided growth hemiepiphyseodesis
- can be done endosopically
4. Posterior instrumented fusion
- not indicated in young children as causes crankshaft effect due to anterior growth continuing
- can be safely performed at age 12 (girls) or 14 (boys)
5. Anterior & Posterior instrumented fusion
- avoids crankshaft effect
- inhibits truncal growth