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Since its original description by Mehta, the rib vertebra angle difference (RVAD) and, in particular, a threshold of 20° have become an accepted and widely utilised prognostic indicator in the assessment of patients presenting with an infantile idiopathic scoliosis (IIS). However, uncertainty in the utility of the RVAD in the prognosis of IIS remains. The aims of this study were to investigate the prognostic significance of the RVAD and to describe the changes in RVAD over long-term follow-up of patients with progressive and resolving IIS. This was a retrospective analysis of patients presenting with IIS at a tertiary spinal deformity unit in the UK. Serial patient radiographs were reviewed and a logistic regression model using the patients index RVAD was created to predict the likelihood of curve progression. At both index presentation and over long-term follow-up, patients with a progressive curve had significantly greater mean Cobb angle and RVAD measurements than those with resolving curves. The RVAD and Cobb were found to correlate positively in both groups, reflecting the underlying costovertebral pathoanatomy. The logistic regression model demonstrated that the optimal RVAD threshold in predicting IIS progression was lower at 17.1° than the 20° cut-off previously advocated. This study describes the utility of the RVAD in predicting IIS evolution. From this analysis, we would advise caution in predicting outcomes based on the index RVAD at presentation. II.

It is a retrospective cohort study. To compare the radiographic and clinical outcomes of serial body casting for infantile idiopathic scoliosis (IIS) with versus without the use of general anesthesia (GA). Serial body casting for IIS has traditionally been performed under GA. However, reports of neurotoxic effects of anesthetics in young children have prompted physicians to consider instead performing these procedures while patients are awake and distracted by electronic devices. Patients from a multicenter registry who underwent serial casting for IIS were included. The patients were divided into asleep (GA) and awake (no GA) cohorts. Comparisons were made between pre-casting, first in-cast, and post-casting radiographic measures in each cohort. The rates of successful casting (≥ 10° major CA improvement), curve progression, and incidence of casting abandonment for surgical intervention were also compared. One-hundred and twenty-one patients who underwent serial casting for IIS were included. Ninety-two (76%) patients were asleep during casting procedures, while 29 (24%) were awake. Patients in the awake cohort were older (p

Retrospective chart review.Determine if there is a subset of presumed infantile idiopathic scoliosis (IIS) patients who have a low incidence of neural axis abnormalities (NAAs) such that screening magnetic resonance imaging (MRI) may be delayed.Individuals with presumed IIS have an increased incidence of NAA. Because of the increased incidence, screening MRI is recommended for all patients. We follow these guidelines at our institution. However, MRI screening in this age group is not without cost or risk.This is a retrospective study of 53 presumed IIS (onset ≤3 years) patients who had screening MRIs. Demographic and radiographic characteristics were collected. A binary regression using continuous and categorical variables was used to determine if a model could be created to accurately predict MRI necessity. A receiver operating characteristic (ROC) analysis was performed to determine if a threshold Cobb angle exists that is associated with an increased likelihood of NAA.Of the 53 patients, 13 had NAA findings, resulting in a 24.5% incidence of NAAs. Significantly fewer abnormal MRIs were found in patients with Cobb angles29.5° than those with Cobb angles29.5° (13/33 [39%] vs. 0/20 [0%], p = .0008). Patients with Cobb angles29.5° were 27 times more likely to have NAAs than those with angles29.5° (odds ratio = 27.0 [95% CI = 1.5-486.0], p = .03). No other parameters have a predictive value for NAA (p.05).This is the first study in IIS patients to identify a radiographic parameter that helps select out a subgroup for MRI screening. Additionally, we report an incidence of 24.5% NAAs in these patients, which is higher than previously reported.

PURPOSE The purpose of this case report is to describe physical therapy (PT) for a child with infantile idiopathic scoliosis and motor delay. KEY POINTS A 10-month-old boy with a 28° left thoracolumbar scoliosis was referred for PT and was seen weekly in his home over a 6-month period following a diagnosis of scoliosis and delayed gross motor milestones. Before the initiation of PT, the child was scheduled to undergo serial casting for correction of the spinal curve and was not yet rolling or transitioning in or out of sitting. By the end of the 6-month intervention period, the spinal curve had resolved to 12° without the need for serial casting and the child was walking independently. CONCLUSION PT appeared to have a positive effect on reduction of the spinal curve and achievement of gross motor milestones.

Over the past decade, casting for scoliosis has become increasingly popular, likely because surgical methods still fall short of a perfect solution. Casting is a useful technique for treating progressive early-onset scoliosis, because the treatment often results in either a cure for younger children with smaller curves or a delay in the need for surgery in others. Proper technique focuses on the rotational component of the curve and avoids pushing the convex ribs further into the chest.

Early-onset scoliosis is potentially fatal if left untreated. Although surgical management with growing instrumentation may be necessary, this is not a panacea and is associated with high complication rates. Recent evidence has demonstrated that nonsurgical treatment can be an effective early management strategy in delaying or even precluding the need for surgery, especially surgery with growing instrumentation. The goal of both nonsurgical and surgical management is to control or correct the spinal curve to allow appropriate pulmonary development while delaying definitive fusion until an appropriate skeletal age. Although more commonly used to delay surgery, serial cast correction using the Cotrel and Morel elongation-derotation-flexion technique may result in complete correction in patients with infantile idiopathic scoliosis and smaller curve magnitudes.

Although many cases of infantile idiopathic scoliosis (IIS) resolve with observation or nonoperative treatment, some severe and/or progressive deformities may benefit from surgical intervention. We present a case of a patient with IIS who was treated initially with bracing. After documented curve progression despite bracing, he was treated with a unilateral rib to spine VEPTR construct. This construct was distracted over a 4-year interval. At most recent follow-up, the VEPTR construct has maintained control of his spinal deformity while preserving thoracic growth and avoiding spinal fusion.

BACKGROUND Cast treatment for infantile idiopathic scoliosis patients ultimately corrects deformity in varying amounts. As the reasons for these differential outcomes are not fully elucidated, the aim of this study was to identify clinical and radiographic variables correlated with better cast correction. METHODS Patients in the Children's Spine Study Group and Growing Spine Study Group registries who underwent cast treatment for idiopathic scoliosis between 2005 and 2013 with 1-year minimum follow-up were included. Data including major curve and rib-vertebra angle difference before cast, initial in-cast application, after cast treatment, and at most recent follow-up were collected. Univariable and multivariable regression analyses were used to identify factors associated with lower major curves at most recent follow-up. RESULTS A total of 68 patients were identified and followed for a mean of 2.5 (range, 1.1 to 5.4) years after cast treatment. Cast treatment lasted an average of 16.7 months, with a median of 6 cast applications (range, 2 to 19). Twenty-five subjects (37%) had a most recent major curve 15 degrees (unresolved). Multivariable linear regression determined that younger age (P=0.02), smaller precast major curve (P

Study Design IRB-approved retrospective single cohort study. Objectives To review our ten-year history with EDF (Elongation Derotation Flexion) casting in patients with infantile idiopathic scoliosis (IIS) to better understand which factors predict successful outcomes. Summary of Background Data Numerous studies have demonstrated the efficacy of EDF casting in the treatment of progressive infantile idiopathic scoliosis. But none have reproduced the success of Mehta’s even with early intervention. Methods Patients with IIS treated with EDF casting with a minimum 24-month follow-up were included. Radiographs and clinical records were reviewed. Age, sex, and curve type were documented. Precast, traction, in cast, in brace, and final Cobb angles were measured and recorded. Outcomes were defined by Cobb angle at final follow-up out of cast or brace. Patients were considered cured if the final Cobb angle was Results Sixty-three patients with IIS were reviewed. Thirty-two were excluded for incomplete records or insufficient follow-up, leaving 31 patients. No patients progressed to surgical intervention during the study. Patients with a Cobb angle >10° in the final cast were 7.3 times more likely to fall into the palliative range at the most recent follow-up than if their Cobb angle was 10° or less even when adjusted for age. Earlier age at onset of casting (14.9 vs. 21.1 months) was not statistically significant (p=.073). Magnitude of initial curvature, flexibility, initial correction, sex, and curve type were also not found to be significant. Conclusion EDF casting is a valid treatment option for IIS with a high cure rate. Major Cobb angle at the end of casting is most predictive of outcome. Cobb angles >10° at the end of casting had a 7.3 times greater risk of falling into the palliated category versus Cobb angles less than or equal to 10° even when adjusted for age. Initial curve magnitude, curve flexibility, sex, and curve type were not predictive. Level of Evidence Level IV.

Retrospective review.To determine the rate of abnormal magnetic resonance imaging (MRI) findings in patients with presumed infantile idiopathic scoliosis (IIS) and the rate of neurosurgical intervention in those patients, and to develop a guideline concerning when to obtain an MRI.The reported rate of intrathecal anomalies associated with presumed IIS varies in the literature (12% to 50%). Conclusions have led to conflicting recommendations concerning when an MRI is indicated.After appropriate internal review board approval, the authors retrospectively reviewed the medical records of patients from a single institution meeting the inclusion criteria: presumed idiopathic curve with a magnitude of ≥20°, age36 months at diagnosis, normal neurologic examination, and presentation between 2002 and 2010. The authors reviewed the MRI findings, whether neurosurgical intervention took place, and the orthopedic treatment course (observation, brace, cast, or surgery).A total of 56 patients were identified and reviewed; 43 had had an MRI. Seven of 43 patients were found to have an anomaly (16.2%). A fatty filum was identified in 2 patients, a syrinx in 3, Chiari I malformation in 2, and a tethered cord in 1 (this patient also had a syrinx). Two of the 7 patients required neurosurgical intervention (28%). Patients who did not have an MRI were statistically younger, had smaller Cobb angles, and required less orthopedic treatment.The incidence of intrathecal anomalies (16.2%) at the authors' institution was similar to previously published reports; however, the need for neurosurgical intervention was significantly lower in this study (28%). For younger patients with small curves (30°) who do not require orthopedic treatment, MRI under sedation can be delayed or avoided. Clinical judgment should be the determinant for whether to use MRI when evaluating patients with presumed IIS.

Nonoperative management of juvenile idiopathic scoliosis (JIS) has been reported to be less effective than that of infantile idiopathic scoliosis. The goal of this study was to analyse the results of casting and/or bracing in JIS. Clinical data from seven patients with JIS, treated with casting followed by bracing (n=3) or by bracing alone (n=4), were retrospectively collected, and curve severity was measured before, during and after treatment. The median Cobb angle decreased from 37° to 25°. No patient needed surgery at a median follow-up of 4.6 years (3.4-9.1 years). Casting and/or bracing is effective for the management of JIS.

Background Though several studies have reported the incidence of intraspinal neural axis abnormalities in infantile and juvenile “presumed idiopathic” scoliosis, there has been a varying prevalence ranging from 11.1 to 26.0 % based on a limited sample size. Therefore, such inconclusive findings have resulted in some questions on the MRI-associated role in the management of these patients. We aimed to investigate the prevalence and distribution of intraspinal anomalies in the infantile and juvenile patients with “presumed idiopathic” scoliosis and to explore the radiographic and clinical indicators with large sample size. Methods A total of 504 infantile and juvenile patients diagnosed with “presumed idiopathic” scoliosis were examined for potentially-existing neural axis abnormalities by MRI. Patients were grouped into two cohorts according to the presence of neural axis abnormalities. Radiographic parameters including curve magnitude, curve pattern, location of apex, degree of thoracic kyphosis, and span of curve were recorded and compared between the two groups. The prevalence of the neural abnormalities between the infantile-age group and juvenile-age group was also compared. The student t test was used to evaluate the differences of continuous variables and the chi-square test was used to evaluate the difference of categorical variables. Fisher exact test was applied to detect the difference of the rate of intraspinal anomalies between the “infantile idiopathic scoliosis” and “juvenile idiopathic scoliosis” group. Results Involving the spinal cord, 94 patients (18.7 %) were found to have a neural abnormality: Arnold-Chiari malformation alone in 43 patients, Arnold-Chiari malformation combined with syringomyelia in 18 patients, isolated syringomyelia in 13 patients, diastematomyelia in six patients, tethered cord combined with diastematomyelia in six patients, tethered cord alone in four patients, and other uncommon intraspinal abnormalities in the remaining four patients. Totally Arnold-Chiari malformation with or without syringomyelia accounted for 64.8 % (61/94) among all these abnormalities. Male gender, left thoracic curve and right lumbar curve were found to be significantly associated with the presence of neural axis abnormalities on MRI. Conclusions The incidence of neural axis abnormalities in the presumed IIS and JIS was 18.7 %. Thus a routine MRI evaluation appears warranted for those “presumed idiopathic” scoliosis patients if aged less than 10 years, being male or having left thoracic or right lumbar curve.

INTRODUCTION: Infantile idiopathic scoliosis (IIS) is a rare orthopaedic condition. Braces and casts are popular options in the treatment of IIS but there is a paucity of studies commenting on the outcome of non-operative treatment. The purpose of this study was to analyse failure and success after non-operative treatment for severe forms of IIS. METHODS: We retrospectively reviewed the data of all children who had been treated for IIS between 2003 and 2009 at a single institution. After calculating the failure and success rates, we additionally performed a risk factor analysis for patients who failed non-operative treatment. Chi (2) and T tests were used for statistical analysis with significance set at p

Study Design: Vertebral rotation was systematically analyzed in the normal, nonscoliotic thoracic spine of children aged 0 to 16 years. Subgroups were created to match the infantile, juvenile, and adolescent age groups according to the criteria of the Scoliosis Research Society. Objective. To determine whether a distinct pattern of vertebral rotation in the transverse plane exists in the normal, nonscoliotic infantile, juvenile, and adolescent spine. Summary of Background Data. We assume that, once the spine starts to deteriorate into a scoliotic deformity, it will follow a preexisting rotational pattern. Recently, we identifi ed a rotational pattern in the normal nonscoliotic adult spine that corresponds to the most common curve types in adolescent idiopathic scoliosis. In infantile idiopathic scoliosis, curves are typically left sided and boys are affected more often than girls, whereas in adolescent idiopathic scoliosis, the thoracic curve is typically right sided and predominantly girls are affected. The present study is the fi rst systematic analysis of vertebral rotation in the normal children’s spine. Methods. Vertebral rotation in the transverse plane of T2–T12 was measured by using a semiautomatic method on 146 computed tomographic scans of children (0–16 years old) without clinical or radiologic evidence of spinal pathology. Scans were mainly made for reasons such as recurrent respiratory tract infections, malignancies, or immune disorders. Vertebral rotational patterns were analyzed in the infantile (0–3-year-old), juvenile (4–9-year-old), and adolescent (10–16-year-old) boys and girls. Results. In the infantile spine, vertebrae T2–T6 were signifi cantly rotated to the left (P ! 0.001). In the juvenile spine, T4 was signifi cantly rotated to the left. In the adolescent spine, T6–T12 were signifi cantly rotated to the right (P " 0.001). Rotation to the left was more pronounced in infantile boys than in the girls (P # 0.023). In juvenile and adolescent children, no statistical differences in rotation were found between the sexes. Conclusion. These data support the hypothesis that the direction of the spinal curve in idiopathic scoliosis is determined by the built-in rotational pattern that the spine exhibits at the time of onset. The well-known predominance of right-sided thoracic curves in adolescent idiopathic scoliosis and left-sided curves in infantile idiopathic scoliosis can be explained by the observed patterns of vertebral rotation that preexist at the corresponding age.

Object There are few data on treatment results for patients with idiopathic infantile scoliosis (IIS). Thus, the authors have performed a retrospective review of their experience with treating these patients, particularly as newer technologies, such as the vertical expandable prosthetic titanium rib (VEPTR), emerge. Methods This retrospective study was conducted to evaluate the methods of treatment used to manage IIS at a single institution. The authors reviewed 31 consecutive patients with a primary diagnosis of IIS. Patients were screened to ensure that there were no confounding congenital anomalies or comorbidities that may have contributed to the spinal deformity. The average age at the time of initial treatment was 25 months. Treatment modalities included bracing, serial body casting, and VEPTR. Pretreatment, posttreatment, and most recent Cobb angles were compared to assess the overall curve correction, and patient charts were reviewed for the occurrence of complications. Results Of the 31 patients, 17 were treated with a brace, 9 of whom had curve progression and went on to other forms of treatment. Of the 8 who did respond, there was an overall improvement of 51.2%. The 10 patients who received body casts, who had a mean preoperative Cobb angle of 50.4°, demonstrated an average correction of 59.0%, with only a few skin irritations reported. The 10 patients treated with VEPTR devices demonstrated a mean preoperative Cobb angle of 90.0°, and an average correction of 33.8% was attained. Three of the VEPTR-treated patients (33%) experienced minor problems. Conclusions The authors' results suggest that body casting has utility for appropriately selected patients; that is, those with smaller, flexible spinal curves. Bracing had limited utility, with high levels of progression and the need for secondary treatments. The VEPTR device appears to be a viable alternative for large-magnitude curves.

Retrospective case series of magnetic resonance imaging (MRI) findings in patients with presumed infantile idiopathic scoliosis (IIS).To identify the prevalence of intraspinal anomalies in patients with presumed IIS at a single, large volume institution and further define the role for a screening MRI.Idiopathic scoliosis in patients less than 10 years of age has been shown to carry a higher prevalence of concordant intraspinal anomalies, up to 20%, in juveniles, when compared to the adolescent age group. Few studies exist assessing the prevalence of intraspinal anomalies in the IIS patient population. Dobbs et al (2002) reported a 21.7% prevalence of neural axis abnormalities in 46 patients with presumed IIS across 3 combined spinal deformity clinics and recommended a screening MRI for all IIS patients with a curve20 degrees.A retrospective review of the medical records of 54 patients at a single institution with a presumed diagnosis of IIS was performed. All patients satisfied the strict inclusion criteria of: curveor =20 degrees, age36 months at diagnosis, normal neurologic examination (i.e., normal tone, motor strength, reflexes, etc.), absence of any concomitant syndromes or congenital anomalies, and an MRI of the spine from skull to coccyx.MRI revealed a neural axis abnormality in 7 (13%) of 54 patients who underwent an MRI. In this subset of 7 patients, 5 (71.4%) required neurosurgical intervention. Tethered cord requiring surgical release was identified in 3 patients, Chiari malformation requiring surgical decompression was found in 2 patients, and a small nonoperative syrinx was found in 2 patients.This study represents the largest evaluation of intraspinal anomalies in IIS to date. Our patient population exhibited a smaller percentage (13%) of neural axis abnormalities than previously reported. On the basis of these findings, the close observation may be a reasonable alternative to an immediate screening MRI in patients presenting with presumed IIS and a curve20 degrees.

Mehta cast utilization has gained a considerable momentum as a nonoperative treatment modality for the initial management of infantile idiopathic scoliosis (IIS). Despite its acceptance, there is paucity of data that characterize the radiographic parameters associated with Mehta casting and the factors correlated with a sustained curve correction.A retrospective review of IIS patients who underwent Mehta casting was performed with a mean 2-year follow-up. X-rays were evaluated at each visit for the Cobb angle, focal deformity, rib-vertebral angle difference, and height of concavity and convexity of the apical 3 vertebrae. Concave-to-convex height ratios were calculated and tracked for each patient. Radiographic parameters were compared from precasting to after final casting, and from final casting to most recent follow-up.A total of 45 patients were identified, of whom 18 (40%) were male and 27 (60%) were female, with a mean age of 18.8±9.5 months at first casting and a mean follow-up of 37.7±19.7 months. Following final casting, the mean Cobb angle (25.6 vs. 52.7 degrees), focal deformity (17.4 vs. 30.5 degrees), rib-vertebral angle difference (18 vs. 32.3 degrees), and the concave-to-convex height ratios improved relative to precast parameters, respectively (P0.001). At final follow-up, mean Cobb angle (16.2 vs. 25.6 degrees) and concave-to-convex height ratios progressively improved when compared with final cast measurements, respectively (P0.001). Five (11%) patients did not demonstrate sustained curve correction at final follow-up, whereas 4 (9%) required growing-rod placement. Lastly, the regression analysis demonstrated improvements in the focal deformity (17.4 vs. 30.5) and the concave-to-convex height ratios of the +1 and -1 apical vertebrae from the precast to last cast periods (P0.001). These findings were correlated with sustained Cobb angle correction from cast removal to the most recent follow-up.Radiographic parameters associated with control of progressive deformity for IIS include improvements in focal deformity and concave-to-convex height ratios for +1 and -1 apical vertebrae after final casting. Mehta casting is an effective treatment for symptomatic IIS and continues to provide IIS patients with significant curve correction.Level IV.

CME Educational Objectives 1. Define scoliosis, including the three major types of scoliosis and the age breakdown for idiopathic scoliosis. 2. Utilize an algorithm for scoliosis screening and the appropriate use of imaging modalities. 3. Understand the appropriate management for adolescent idiopathic scoliosis, including indications for bracing and referral for surgery. Scoliosis is defined as a lateral curvature of the spine greater than 10 degrees on radiography that is typically associated with trunk rotation. The three major types of scoliosis are congenital, idiopathic, and neuromuscular. Idiopathic scoliosis is divided into three subcategories based on the age of onset. Infantile idiopathic scoliosis affects patients younger than 3 years, juvenile idiopathic scoliosis appears in children between 3 and 10 years, and adolescent idiopathic scoliosis (AIS) occurs in skeletally immature patients older than 10 years. AIS is the most common form of idiopathic scoliosis. Approximately 2% to 4% of children aged 10 to 16 years have some degree of spinal curvature. Although some researchers view routine screening for AIS as controversial, well-child examinations and sports physicals are an optimal time to evaluate for AIS in the clinical setting. In 2008, the American Academy of Orthopaedic Surgeons, the Scoliosis Research Society, the Pediatric Orthopaedic Society of North America, and the American Academy of Pediatrics convened a task force to review the issues related to scoliosis screening and issued an information statement concluding that although screening has limitations, the potential benefits that patients with idiopathic scoliosis receive from early treatment can be substantial. Recommendations are now that females are screened twice, at age 10 and 12 years, and males once at age 13 or 14 years. Screening during routine well-child examinations and/or school-based evaluations will help identify patients who need ongoing monitoring. The evaluation of curvatures in conjunction with the level of skeletal maturity will help to guide the management of the curvature.

A consecutive series of infantile idiopathic scoliosis patients with a minimum 5 years follow up were retrospectively reviewed to study the pattern and velocity of spine growth. We found that the initial growth spurt of the spine in early onset idiopathic scoliosis is in the first three years of life. The growth velocity of the lumbar vertebra was greater than the middle thoracic which was greater than the upper thoracic vertebra during first 3 years of age.

Materilas and methods Age of onset was in between 4th and 36th month of life. Initial treatment consisted of physiotherapy and Chenau corrective bracing in all patients. Duration of conservative treatment was from 4 to 5.5 years. The age at surgery was: from 7 to 12 years (table 1). Finally patients underwent surgical treatment: anterior and posterior fusion in 2 patients (3 curves), posterior instrumentation (2 growing rods) in one patient, and VEPTR device in one case. All have led to clinical improvement.

Objectives Few studies exist on the management of progressive curves in the setting of infantile idiopathic scoliosis. We have performed a retrospective review of our experience treating those patients unresponsive to conservative management with the vertical expandable prosthetic titanium rib. Methods We reviewed 8 consecutive patients with infantile idiopathic scoliosis treated at our institution between 2000 and 2009. All patients were screened to ensure that no confounding congenital anomalies or comorbidities contributed to the spinal deformity. Pretreatment, posttreatment, and most recent Cobb angle, sagittal balance, and spinal length, were measured to assess overall curve correction. Patient charts were reviewed for the occurrence of complications. Results The average age at the time of surgery was 45.8 months (range: 24 to 84 mo). The average preoperative Cobb angle was 84 degrees (range: 50 to 119 degrees) and showed mean curve correction of 35.1% (range: 20% to 60%) over an average follow-up of 32 months (range: 14 to 45 mo). Spinal height increased a mean of 71 mm (range: 51 to 98 mm) over an average of 4 lengthenings (range: 2 to 7). Three of the patients (37%) experienced minor hardware complications, none experienced a neurologic deficit. Conclusions Our results suggest that the vertical expandable prosthetic titanium rib device is a safe and effective treatment option for large-magnitude curves in this unique patient population. Level of evidence IV--case series.

Thirteen patients with progressive early onset scoliosis have been managed operatively in an attempt to achieve correction without bracing and to allow the spine to grow. All had posterior segmental spinal instrumentation (SSI) without fusion and 9 of 13 had anterior apical growth arrest as a separate additional procedure. At 2-year follow-up, curve correction averaged 46%. Patients who had anterior apical growth arrest and SSI without fusion had less curve deterioration than those who had SSI alone. New methods are described for 1) measuring growth of the instrumented segment of the spine and 2) calculating the predicted growth of the instrumented segment. Eight of the 13 had more than 50% of predicted growth, three had 30-50% of predicted growth, and two had less than 30% of predicted growth. Operative treatment has been successful in the short term in all but the most malignant form of infantile idiopathic scoliosis.

This is a case report of a 48-year-old-woman with scoliosis since early childhood. Recent radiographic spinal assessment revealed the presence of distinctive spinal abnormalities. To the best of our knowledge this is the first clinical report describing a constellation of unusual changes in an elderly woman with a history of infantile idiopathic scoliosis.

Seven cases with severe scoliosis (three adult idiopathic scoliosis, one neurofibromatosis, two Marfan's syndrome, one infantile idiopathic scoliosis) were treated using Cotrel-Dubousset Instrumentation (CDI). Preoperatively, the major curves measured an average of 101 degrees, and on the best side bend they average 74 degrees, a 27% degree of flexibility. Postoperatively, curves improved to an average of 57 degrees, a correction of 44%. Four of seven cases were treated by two-staged anterior and posterior spinal fusion. A correction of 50% was obtained in this group. Three curves less than 60 degrees were treated with derotation manuever and four curves more than 60 degrees were treated by the 3 rod method. We concluded that two stage anterior and posterior fusion is of value for the treatment of cases with severe rigid curves.

Study design The authors monitored a father and his six children, all of whom had idiopathic scoliosis for more than 13 years. Objective To analyze the similarities and differences in curve pattern between the family members. Summary of background data The etiology and pathogenesis of idiopathic scoliosis are not well understood. Genetic factors play an important role, as is shown by the high concordance in monozygotic twins. Methods Radiographs from all family members were analyzed. Location and direction of the curve, Cobb angle, location of the apex, and rib-vertebra angle difference were compared. Results A father and his six children had idiopathic scoliosis. The curves differed within the family and changed during follow-up. The father had a left convex thoracic scoliosis of 42 degrees. Only three of the children had a curve of similar severity, and only four children had a left convex thoracic scoliosis. In three children the curve pattern changed during follow-up. Conclusions This report of idiopathic scoliosis in a father and six children supports the present theories on a genetic origin of the disorder but also stresses the importance of dynamic processes in the development of scoliosis.

We have reviewed 7 patients (5 boys and 2 girls) with infantile idiopathic scoliosis which was present at birth and was diagnosed at ages from 1 day to 1 month. The mean follow up was 16 years. The objectives were to discover whether intrauterine forces play a role in the aetiology and to determine whether early treatment of a potentially progressive curve can induce resolution. Two infants were male conjoined twins and were united by skin over the posterior sacrum. Six infants had a rib vertebral angle difference greater than 20 degrees in the first radiograph and 5 had stiff curves. In 2 with flexible curves, the deformity disappeared by the end of the first year. The 5 with stiff curves were treated conservatively for 6 to 24 months. Growth has now been completed in 5; 4 have a straight spine and one developed an adolescent curve of 26 degrees. The 2 who are still growing have no scoliosis. Intrauterine moulding was only demonstrated in the conjoined twins. There was a correlation between the rib vertebral angle difference above 20 degrees and the rigidity of the curve. Early treatment of a potentially progressive curve can lead to resolution.

Analysis was made of the results of two methods of treatment of progressive infantile idiopathic scoliosis: a group of forty-eight children treated by rib resection, localiser jackets and Milwaukee brace were compared with a 'control' group of nineteen children treated by localiser jackets and Milwaukee brace alone. This failed to show any significant difference between the two groups. Carefully controlled splintage was effective in slowing the rate of progression of most curves which was not significantly affected by the addition of rib resection.

1. The natural history and prognosis of progressive infantile idiopathic scoliosis are reviewed and twenty-eight cases are reported. 2. Resolving infantile idiopathic scoliosis is described and seven cases are reported. 3. The length of the curve, the degree of rotation, the age of onset of deterioration, and the rate of progression are the important factors in determining the type and severity of the deformity. 4. Infantile idiopathic scoliosis is briefly compared with congenital scoliosis.

1. Resolving infantile scoliosis is transient and unimportant; progressive infantile idiopathic scoliosis can be catastrophic. 2. To be able to differentiate the two at an early stage is a considerable advance. This is important for many reasons, but particularly for parents who are anxious for the future of an infant with a small curve which looks so innocent but which can be so malignant. 3. With the new observations reported by Mehta on the difference of the angles between the apical vertebra and its two ribs, and on the radiological relationship of these rib heads to the vertebral body, the prognosis is now almost wholly reliable. 4. Our former clinical impression that all cases with compensatory curves are progressive has now been verified. 5. At last an early distinction between progressive and resolving scoliosis can be made with confidence.

The incidence of congenital dislocation of the hip in 156 children with infantile idiopathic scoliosis was 6.4 per cent, approximately 10 times its frequency in the general population. In both of these deformities there was a predominance of girls (eight girls: two boys). In unilateral dislocation of the hip the convexity of the thoracic scoliosis was on the same side as the dislocation. Eight out of the 10 children with both deformities also had plagiocephaly.

1. A family study of sixty-one children with infantile idiopathic scoliosis to determine the relationship of other developmental anomalies to the behaviour of the curve is reported. 2. Of the thirty-nine children with resolving curves only one had another defect. 3. Twelve out of twenty-two children with non-resolving curves had at least one other developmental anomaly. 4. The presence of such defects may indicate that the curve is likely to progress.

The changing incidence of idiopathic scoliosis in 672 patients who attended the Edinburgh Scoliosis Clinic between 1968 and 1982 inclusive is reported. Of these patients, 144 had infantile, 51 juvenile and 477 adolescent idiopathic scoliosis. Thirty-seven of the infantile curves progressed and 107 resolved. The relative frequency of both progressive and resolving infantile idiopathic scoliosis (given as a percentage of the total number of patients with idiopathic scoliosis) declined from 41.75 per cent in the four years from 1968 to 1971, to four per cent in the three years from 1980 to 1982. It is suggested that infantile idiopathic scoliosis is a preventable deformity and that the position in which the infant is laid may be a causative factor.

A review was performed of 86 cases of infantile idiopathic scoliosis treated between 1962 and 1979. The single primary curves were classified as resolving, stable, progressive with a low rib--vertebra angle difference (RVAD) and progressive with a high RVAD. Two single primary curves subsequently developed a second curve and 17 were double when first diagnosed. Prognosis was difficult to establish before the age of five years. Only 18 per cent of curves showing progression beyond 50 degrees reached that point before the age of four. Conversely, if a scoliosis of 50 degrees or more was present before the age of four it always progressed. A more favourable outcome was indicated by male sex, a left-sided curve, a low initial curve measurement, an RVAD of less than 20 degrees in the initial radiograph, and the onset of scoliosis in the first year of life.

Infantile idiopathic scoliosis is a structural scoliosis seen in infants, usually boys, with the major curve to the left in almost all cases, and almost invariably in the mid-or lower thoracic region. It occasionally disappears, but in general the curve tends to increase. In the absence of any discoverable etiology it is termed "idiopathic" and it is believed not to differ in essentials from the more common adolescent scoliosis. Lumbar idiopathic scoliosis has a good prognosis as to deformity, but leads more often than any other curvature to degenerative arthritis and pain in later life.

Infantile idiopathic scoliosis is unique in that it differs considerably from idiopathic scoliosis seen in the older child. Early recognition of the progressive type is essential if serious deformity is to be prevented. Treatment must be aimed at controlling the curvature by serial casts and the Milwaukee brace to support the spinal column without interference with the local mechanics of growth. Most children eventually require spinal fusion, but this should be delayed until early adolescence. If a curvature cannot be controlled satisfactorily, however, surgical fusion may be indicated earlier than desired. Never should a curve be allowed to progress beyond 60 degrees. Two cases are presented to illustrate these principles.

The components of Mehta's empirical rib-vertebra angle difference (RVAD) were observed as indicators of the prognosis in infantile idiopathic scoliosis (IIS). The following components were investigated in a retrospective study of 169 children with IIS: (1) convex rib-vertebra angle (RVA); (2) concave RVA; (3) RVAD; (4) initial spinal curve angle; and (5) age at diagnosis. The convex RVA, but not the concave RVA, was found to correlate significantly with the initial spinal curve angle. This is consistent with the hypothesis that factors that determine spinal curve progression in IIS are related to those that lead to drooping of the ribs on the convexity of the thoracic spinal curve. In terms of prognosis, the convex RVA, which entailed one measurement, was as accurate as the RVAD, which entailed two measurements and a calculation. A convex RVA of less than 68 degrees on the initial radiograph usually indicates that a spinal curve will progress.