A scoliotic curve in patients younger than 3 years is termed as infantile idiopathic scoliosis. Infantile idiopathic scoliosis is more frequent in boys than in girls, the curves are primarily in thoracic spine and generally convex to the left.
Infantile idiopathic scoliosis may be progressive, usually increasing rapidly, or resolve spontaneously within a few years with or without treatment. The resolving type occurs in 70% to 90% of patients.
However, till now it is very difficult to differentiate between the two especially when the curve is mild. There are different observations by different researchers that favor the likelihood of resolving type but there is no certain criteria. These observations are
- Deformity noted before 1 year of age
- Smaller curves at presentation
- No compensatory curves.
- Curves associated with plagiocephaly[a condition characterized by an asymmetrical distortion (flattening of one side) of the skull]
Based on measurement of the rib vertebral angle, Mehta developed a method to differentiate resolving from progressive curves and this is quite helpful in predicting curve progression.
Cause of Infantile Idiopathic Scoliosis
Though the exact cause is not yet identified, few researchers suggested that the position in which an infant is laid may be the causative factor for the scoliosis. During the first few months of life, all infants have a natural tendency to turn toward their right side when laid supine and gravity causes plastic deformation of the immature thorax. Making child lie prone has been suggested as a measure to reduce the chances of this development.
Treatment of Infantile Idiopathic Scoliosis
For treatment it is important to identify the progressive type from resolving type.If the rib vertebral angle difference (RVAD) is more than 20 degrees and the curve is not flexible on clinical examination, it is considered progressive until proved otherwise.
Overall, treatment options include
- Sserial casting followed by bracing and later fusion if needed
- Preoperative traction to correct the curve followed by fusion
- Subcutaneous instrumentation without fusion.
Non Operative Treatment
In a very young child, serial casting with general anesthesia may be needed until the child is large enough for fitting an orthosis satisfactorily with a change usually required every 2 to 3 months. When brace is given for full time untill the curve stability has been maintained for at least 2 years and gradually reducing thereafter.
A thoracic-lumbar-sacral orthosis (TLSO) or cervical-thoracic-lumbar-sacral orthosis (CTLSO) are usually required depending upon the size of the curves.
Significant improvement can be obtained with the use of a well-fitting orthosis during the early period of skeletal growth.
If a curve is severe or increases despite the use of an orthosis, surgical stabilization is needed. Effort should be made to delay surgical procedures long as possible to optimize spinal growth, but if the curve progression is substantial, it would need to be operated.
Ideally, surgery should not only stop progression of the curve but also allow continued growth of the thorax. But if fusion is necessary, it should be done spanning short length so as to preserve maximum number of motion segments and growth plates.
Anterior release and fusion followed by posterior spinal fusion with instrumentation is considered to be the functional treatment but If it is technically possible, subcutaneous growth rods should be preferred.
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