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Scoliosis in Juveniles

- Discussion:
    - by definition juvenile scoliosis develops before age 10;
    - majority of idiopathic curvatures are right thoracic curves;
    - left thoracic scoliosis is unusual;
    - clinically, juvenile scoliosis shows slow progression prior to age 10, but after age 10 rapid progression may be found;
    - diff dx of non progressive curve:
           - spondyloepiphyseal dysplasia tarda:
           - osteoid osteoma;
           - infection;
           - discitis;
    - diff dx of progressive curve:
           - tethered cord:
           - Arnold Chiari malformation:
           - hydromyelia:
           - hydrocephalus:
           - spinal tumor;
           - syringomyelia:
                   - cervicothoracic syrinx associated with a Chiari type-I malformation at the foramen magnum has a significantly increased 
                           prevalence in patients with idiopathic scoliosis, particularly those who exhibit a juvenile onset of this disorder;
                           - Chiari malformation and the syrinx could be the result of traction on the medulla distally through the foramen magnum;
                   - prevalence of a syrinx may range from 17 to 47 %;
                           - greater prevalence of left-sided thoracic deformity in patients with a syrinx;

- Radiographs:
    - level of most rotated vertabra at the apex of the primary curve is an important predictor of prognosis;
    - relative thoracic lordosis;
    - rib vertebral angle:
          - angle formed by perpendicular line from apical vertebral end plate and a second line from the mid-neck to mid-head of the adjacent rib;
          - the rib vertebral angle difference is the difference between the two RVA on the concave and convex sides of the curve;
                 - a curve greater than 20 is considered progressive;
    - reference:
          The rib-vertebra angle in the early diagnosis betweeen resolving and and progressive infantile scoliosis.

- MRI:
    - may be indicated in patients less than 11 years old, w/ left thoracic scoliosis, w/ neck pain, headaches, or neurologic findings;
    - MRI will help rule out a syrinx, spinal tumor, or dural ectasia;

- Bracing:
    - a good prognosis for successful bracing is a rib vertebral angle difference less than 10 deg in the brace;
    - because juvenile curves are more flexible than their adult counterparts, curves of up to 60 deg can be managed in a brace;
    - once patients enter the adolescent growth spurt, bracing is often ineffective;

- Surgical Treatment Options
    - upto 25% to 50% of children w/ juvenile scoliosis will require fusion;
    - note that posterior fusion in a physiologically young patient may lead to the crankshaft phenomenon

Childhood scoliosis: clinical indications for magnetic resonance imaging.

Routine use of magnetic resonance imaging in idiopathic scoliosis patients less than eleven years of age.

Infantile and juvenile idiopathic scoliosis before skeletal maturity.

MRI of 'idiopathic' juvenile scoliosis. A prospective study.

Orthopaedic aspects of intraspinal tumors in infants and children.

Diastematomyelia and structural spinal deformities.

Juvenile idiopathic scoliosis.

Spinal cord tumor: A cause of progressive neurological changes in children with scoliosis. A report of three cases.