Juvenile idiopathic scoliosis appears between the ages of 4 and 10 years. Usually the convexity of the curve is towards right in thoracic region. Juvenile idiopathic scoliosis is considered to be more progressive than adolescent idiopathic scoliosis. The risk of progression increases if the curve has an angle greater than 20 degrees.
There is a high incidence of neural axis [Brain and spine] abnormalities in children of juvenile idiopathic scoliosis.
Anteroposterior and lateral xrays are the basic investigations to know types of curves and the severity. Magnetic resonance imaging is able to reveal neural axis abnormalities which have been reported as high as abut 27% in patients considered for surgery and who were considered neurologically normal preoperatively.
MRI has been recommended as part of a preoperative workup in any juvenile idiopathic scoliosis. Other reasons for ordering an MRI are
- Rapid progression
- Deformity of left thorax
- Neurological abnormalities
If the Rib vertebral angle difference angle of the curve is less than 20 degrees, it is recommended for observation and follow up with an xray every 4-6 months. A progression is indicated by change in angle. A change by 5-7 degrees needs treatment by bracing like Milwaukee brace or thoracolumbosacral orthosis.
Initially, the brace is worn at least 22 hours of 24 hours [called full time bracing].If the curve shows improvement after one year of full time bracing, the time of wearing of brace is decreased gradually to only night time bracing. However, if the progression is noted after decreasing the brace time, a full-time brace program is resumed.
If the curve is not progressing, observation is continued until skeletal maturity.
Part time Milwaukee bracing program has been found successful in patients with curve curvature less than 35 degrees and rib vertebral angle difference of less than 20 degrees had excellent prognoses with treatment in a part-time Milwaukee brace program. Part-time brace treatment may afford these children the social and psychological benefits not provided by a full-time Milwaukee brace program.
The part-time brace program consisted of wearing the brace after school and all night for approximately a year. The patients were then kept in the brace at night only for another 2.5 years. The brace was at that point worn every other night for an average of 1.2 years. Individually, however, the numbers of hours spent wearing the brace depended on the amount of improvement and stability of the curvature.
Bracing is discontinued at skeletal maturity.
If the rib vertebral angle difference progresses above 10 degrees during brace wear, progression can be expected.
However, even if the curve progresses, bracing should be continued as it may slow progression and delay surgery until the child is older.
In case of failure of treatment by orthosis, surgery is considered type of which would depend on the age of the child.
If the child is younger than 8 years and small, the ideal treatment is subcutaneous rod insertion, also termed as growing rod instrumentation..
If the child is larger and 9 or 10 years of age, instrumentation and fusion may be done, but combined anterior and posterior spinal fusions should be considered to avoid a crankshaft phenomenon.
Surgery For Juvenile Idiopathic Scoliosis
There are two kinds of surgeries for Juvenile idiopathic scoliosis.
- Growing rod instrumentation
- Instrumentation with fusion of vertebrae
Growing rod instrumentation allow growth of vertebral column as the vertebrae are not fused and gain in length acquired by natural growth is maintained whereas fusion is contemplated in older children or where the conditions/requirements of growing rod instrumentation cannot be met with.
Growing Rod Instrumentation
This technique isconsidered in a cooperative patient and whose family is able to understand the procedure and its demands.
A multihook segmental instrumentation system is used.
Surgery is required every 6 months to lengthen the construct. A TLSO is needed for at least the first 6 months to protect the instrumentation.
The orthosis can be discontinued if the hook sites are solidly fused. The rods are lengthened every 6 months. At a point where no further distraction can be achieved, final arthrodesis is done and usually instrumentation is removed.
Instrumentation with Fusion
Instrumentation and spinal fusion is considered for children older than 9 or 10 years or are non cooperative.
A combined anterior and posterior procedure should be considered if the patient is deemed at risk for the crankshaft phenomenon.
A multihook segmental system is used or pedicle screw fixation can be considered if it is feasible.
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