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Chapter 26 Congenital Scoliosis 443
vertebral column resection, osteotomies, and guided growth
progression.
Posterior Spine Fusion
Posterior fusion is among the “simplest” and “safest” techniques, but is not without its limitations or complications.91
Ideal candidates for posterior fusion are those with small, relatively short curves who otherwise have limited growth potential in the anterior spine. In general, curves no greater than 25
degrees that are limited to no greater than ve vertebrae may
be considered.
Selection of these curves minimizes the risk of the crank-
sha phenomenon92 that can be seen if the anterior spinal
growth is still active. e cranksha phenomenon occurs
when growth remaining increases the curve. Additionally,
lordosis in the proposed region of fusion is a contraindication
to posterior fusion because anterior growth will worsen lordosis. A review of 54 congenital scoliosis patients reported a
15% cranksha incidence in patients undergoing posterior
fusion before the age of 10 years, especially those with surgery
at an early age and greater than 50-degree curves.
Posterior spinal fusion may cause signicant issues as the
child continues to age. In a large meta-analysis review of
patients with early-onset scoliosis, congenital scoliosis, and
infantile scoliosis who underwent posterior spinal fusion
for presumed denitive fusion in early childhood, revision
surgery has been required in 24% to 39% of cases.93 Additionally, restrictive pulmonary disease occurs in many of these
patients,93 although it should be noted that nonoperative
management and continued curve progression are also likely
to have negative eects on pulmonary function.94 Patients 1 to
4 years old are best suited for this procedure. Posterior fusion
can be considered a prophylactic procedure.
Imaging the spine prior to exposure is useful because the
area of deformity is oen dicult to localize by inspection and
palpation alone. During exposure, failure to recognize the
potentially complex posterior laminar defects can lead to
neurologic injury. Aer exposure of the posterior elements,
the spine should again be imaged to conrm that the targeted
deformity, which may have anterior components, aligns with
posterior elements. Some deformities, particularly anterior
bars or malaligned hemivertebrae, have anterior elements that
do not correspond to the logical posterior elements. Due to
dicult localization of the deformity, there is a risk of extending the fusion past the originally planned surgery. Fusion must
include all vertebrae involved in the congenital curve and
should extend laterally to the transverse processes. Successful
fusion is achieved by thorough facet resection, decortication,
and placement of abundant bone gra. Posterior instrumenta-
tion can be used safely in the pediatric patient to decrease the
risk of pseudarthrosis. Of course, posterior elements may be
deformed, with fused or missing laminae, or thin pedicles that
do not lend themselves well to instrumentation. With advancing age, typically by the age of 2 years, instrumentation
becomes feasible. A postoperative cast or a rigid brace is then
required for 2 to 3 months to achieve fusion and curve
correction.
87
92
Combined Anterior and Posterior Spine Fusion
While the posterior-only approach has shortcomings due to
the risk of anterior growth, the combined anterior and posterior fusion can more eectively prevent progression.84 e
main indications for a combined anterior and posterior fusion
are a deformity with signicant anterior and posterior growth
potential. For example, a unilateral bar with a contralateral
hemivertebra would be appropriate for a combined anterior
and posterior spine fusion.
Performing an anterior approach allows for discectomy
and removal of the vertebral endplates, which augments spine
exibility and the potential for deformity correction. Unlike
the posterior-only fusion, the combined approach, or even
anterior only, is appropriate for lordotic curves. e combined
fusion may decrease the rate of pseudarthrosis, decrease the
cranksha phenomenon, and can also be augmented by
instrumentation. Anterior bone gra is typically placed for
fusion. Depending on surgeon preference and the location of
the deformity, the anterior procedure may be performed either
through an anterior, open technique, thoracoscopically,95 or
through a posterior approach. Accessing the anterior vertebrae
via a posterior approach is most feasible at the thoracolumbar
junction via retropleural dissection, especially if the surgeon
is able to take advantage of a kyphotic element.
Convex Hemiepiphysiodesis
e concept of convex hemiepiphysiodesis is the same as that
commonly employed for deformity of growing long bones.
e surgeon is able to take advantage of this and spare the
patient intraoperative destabilization or growth arrest of the
whole fused spine segment, with convex growth arrest. Convex
hemiepiphysiodesis slows convex-side growth while the
concave curve still grows, allowing for safe and relatively
controlled progressive deformity correction.96 us, failures of
segmentation with little or no growth potential cannot be
successfully treated this way. Ideal candidates for convex
hemiepiphysiodesis are young enough that growth will allow
for signicant correction, a curve less than 70 degrees, have
six or fewer involved vertebrae, and demonstrate signicant
concave growth potential.97 Patients should be 6 years old or
younger because spinal growth is two-thirds complete by this
age.98 Traditionally, pathologic congenital kyphosis or lordosis
has been a contraindication for this procedure.99 For example,
an appropriate deformity for this treatment may be a single or
multiple hemivertebrae in a patient 6 years old or younger.
Convex hemiepiphysiodesis typically requires an anterior
and posterior exposure; however, posterior-only methods are
feasible. e traditional combined anteroposterior approach
allows for the removal of the convex portion of discs and
vertebral endplates and fusion of this convex portion with
bone gra via the anterior approach; removal of the unilateral
facet joints and fusion is completed via the posterior exposure.
Traditional convex hemiepiphysiodesis without instrumentation typically yields modest curve correction, on the order of
0 to 15 degrees by maturity; some patients achieve only an
arrest of progression.
100
Much of the correction with convex
SECTION
IV
444 PEDIATRICS
growth arrest seems to be achieved acutely at the time of the
initial procedure, which is then attempted to be maintained
with postoperative immobilization.
As with the other treatments, instrumentation can be used
to achieve better intraoperative correction—convex posterior
compression is typically utilized with good results in convex
growth arrest.
101,102
Early follow-up analysis of 11 patients with
long, sweeping congenital curves (involving multiple anomalous vertebrae) who underwent this method of concave posterior distraction in convex instrumented hemiepiphysiodesis
yields encouraging results. A posterior-only instrumented
convex growth arrest with pedicle screws at each segment on
the convex side may obviate the need for anterior surgery. A
collection of 13 patients treated with the posterior-only convex
growth arrest procedure described earlier demonstrated that
the procedure is safe and that curves improved by 5 degrees
or greater in nine patients, while two patients’ curves remained
the same.
103
Hemivertebra Excision
Hemivertebra excision is preferred in cases in which a hemivertebra causes progressive curve and deformity with truncal
imbalance. In contrast to fusion and convex epiphysiodesis,
hemivertebra excision acutely corrects the curve and corrects
for truncal imbalance. Excision of the hemivertebra is recommended if the curve progresses signicantly. Instrumented
hemivertebra excision provides the highest degree of correction, particularly if carried out before 3 years of age.
vertebra excision is ideal for a fully segmented hemivertebra
104
Hemi-
at the apex of the curve in the thoracolumbar junction, lumbar
spine, or lumbar sacral spine, and with a xed lateral transla-
tion of the trunk. Cervicothoracic or cervical hemivertebra
excision has been reported but is a more complex procedure
due to the vertebral artery.
105
Hemivertebrae may be resected
by an anteroposterior or posterior procedure only.
e combined anterior and posterior excision of the
hemivertebra allows for the circumferential exposure of the
spine and complete excision of the adjacent discs. Anterior
and posterior exposure can be achieved either by sequential
procedures under a single anesthetic or when performed
simultaneously.
106,107
Aer excision, the unstable spine is
then stabilized with anterior and/or posterior instrumentation typically by utilizing an anterior structural gra, which
is useful on the concave side to maintain a normal sagittal
contour. Instrumentation may then be used both anteriorly
and posteriorly to apply compression and to further stabilize the spine. e need for postoperative immobilization is
determined by the surgeon’s impression of spinal stability
(Fig. 26.12).
Similar to convex hemiepiphysiodesis, hemivertebra excision can also be accomplished via a single posterior approach
due to advances in imaging and monitoring.
108–111
e ideal
indication for a posterior-only approach is a hemivertebra
located at the thoracolumbar junction or in the lumbar spine,
with some associated kyphosis.62 e posterior-only approach
is stabilized with segmental transpedicular instrumentation
aer excision.
111,112
Clinical experience has shown that pedicle
screws even in young children do not cause spinal stenosis. If
needed, hooks can augment the screws.
A
FIG. 26.12 (A–C) Radiographs of a 2-year-old boy with progressive kyphoscoliosis at the level of the L1
hemivertebra. (D–E) The patient underwent hemivertebra resection and anterior and posterior spinal fusion
with posterior spinal instrumentation. He was placed in a cast and maintained good correction postoperatively.
B
C
D
E
Chapter 26 Congenital Scoliosis 445
Osteotomies
Complex curves with multiple fusions, prior instrumentation,
and signicant trunk imbalance may justify multiple anterior
and posterior osteotomies to allow for spinal mobilization.
Patients undergoing osteotomies should have preoperative
imaging of the entire spine to rule out intraspinal anomalies
in the canal. Aer osteotomies are created, correction of the
curve may be achieved at the same stage. Complex deformity
correction may incorporate osteotomies with other types of
procedures. Multiple concave rib osteotomies add exibility.
It can be considered as an alternative in the treatment of rigid
congenital curves involving more than three levels or multiple
curves separated by at least two segments that would otherwise
require multiple vertebral resections.
Vertebral Column Resection
Vertebral column resection (VCR) describes the complete
resection of vertebral segments using either combined anterior
and posterior approaches or a posterior-only approach, which
enables signicant three-dimensional deformity correc-
113,114
tion.
to severe spinal deformities, including those with large rigid
curves, xed trunk translation, or asymmetry between the
length of the convex and concave column of the deformity.
VCR carries signicant risk of neurologic injury
26.13). is high risk is partially secondary to the severe
nature of the deformity eligible for VCR and partially due
to the resulting instability from segmental resection and
instrumentation.
is technique may be applied to correct moderate
114–116
(Fig.
Rigid instrumentation that controls the spinal column
above and below the resection area must be performed in VCR
procedures. Instrumentation is imperative for preventing and
treating the very real risk of spinal subluxation. Anterior
structural gra can be used on the concave side of the con-
struct to maintain a normal sagittal contour. Similarly, a
posterior structural gra, preferably from the patient’s rib, can
be used to cover a laminectomy defect.
115,116
Releases are also
typically performed at the apex of scoliosis or kyphoscoliosis
deformities to facilitate pedicle screw placement.
Guided Growth Procedures
In a young patient with progressive deformity, growing rods
provide progressive correction of the curve and the expansion
of the thorax. is is especially of value for congenital spine
deformities with concomitant rib fusions, which lead to
restrictive pulmonary disease and/or TIS. In general, guided
growth procedures should be considered as an alternative to
long spinal fusion. An important consideration to discuss with
the patient and family is the commitment to undergoing
multiple surgical spinal procedures, typically every 6 months.
Among the potential complications are dri of the spinal
anchors, infection, postoperative pain, device fracture due to
stress fatigue, brachial plexus palsy, and neurologic injury.
Dual growing rods lengthened at 6-month intervals were
shown to achieve greater curve correction and allow for greater
spinal growth when compared to single growing rods.
patients with spondylocostal dysostosis, vertical expandable
prosthetic titanium rib guided growth has more marked
impact on curve progression and chest wall development:
117,118
119
In
SECTION
IV
A
FIG. 26.13 (A–B) Radiographs of severe congenital scoliosis measuring 120 degrees in a 15-year-old girl. (C–D)
The patient underwent posterior spinal fusion instrumentation, right vertebral column resection, and multiple
discectomies.
B
C
D
446 PEDIATRICS
A
FIG. 26.14 (A) Radiograph of severe chest deformity associated with congenital scoliosis and multiple rib
fusions in a symptomatic 4-year-old child. (B–C) The patient underwent multiple rib osteotomies with the use
of vertical expandable prosthetic titanium rib anchored from rib to rib and from rib to spine.
B
increases in thoracic height and width and improvement in
the Cobb angle (Fig. 26.14).
Magnetic controlled growing rods (MCGRs) continue to
expand the possibilities for guided growth procedures. Rather
than continued reoperation with exchange of implants, as is
needed with conventional growing rods, MCGRs can facilitate
curve control, maintain growth along the spine, and spare the
patient multiple reoperations by using nonsurgical distraction
methods. Preliminary data on MCGRs are promising both
from a safety and ecacy standpoint.
120,121
Long-term outcome
studies are needed to better inform surgical decision making
regarding the use of guided growth procedures.
Conclusion
Congenital scoliosis presents immense variation in deformity,
impact, and treatment options. Not all cases benet from
surgery. Regular examination will make clear which patterns
require intervention. Advances in growth-friendly surgery
have provided many other options for treatment. Advances in
imaging, monitoring, and operative techniques will make the
treatment as safe as possible.
KEY POINTS
1. Assessment of vertebral anomalies is best in early childhood.
2. Progressive deformation is due to imbalance in spine growth.
Some vertebral anomalies do not lead to imbalance and are
not likely to produce deformity.
3.
Bracing has almost no eect on congenital spine curves.
C
4. Surgery should be performed as early as is practical to prevent
secondary structural changes.
5.
All patients with congenital scoliosis should be evaluated for
genitourinary anomalies. They should also undergo panspinal
MRI if signicant progression occurs or if surgery is indicated.
6.
The rst available lm should be analyzed and used for
subsequent comparisons.
7.
The measurement error for congenital scoliosis is greater than
idiopathic (approximately 10 degrees).
8.
Neurologic risk of spine surgery is higher for congenital
scoliosis than other types.
9.
Congenital anomalies of the posterior elements do not often
correlate with anomalies of the bodies and may require
three-dimensional CT to previsualize.
10.
The surgeon should be aware of midline laminar defects when
using a posterior exposure.
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2.
McMaster MJ, Ohtsuka K. The natural history of congenital
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Chapter 26 Congenital Scoliosis 447
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treatment of congenital scoliosis.
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71. Riccio AI, Guille JT, Grissom L, Figueroa TE. Magnetic
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73. Facanha-Filho FA, Winter RB, Lonstein JE, et al.
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74. Loder RT, Urquhart A, Steen H, et al. Variability in Cobb
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76. Kawakami N, Tsuji T, Imagama S, et al. Classication
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77. Blake NS, Lynch AS, Dowling FE. Spinal cord
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79. Prahinski JR, Polly DW Jr, McHale KA, Ellenbogen RG.
Occult intraspinal anomalies in congenital scoliosis. J Pediatr
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80. Suh SW, Sarwark JF, Vora A, Huang BK. Evaluating congenital
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81. Basu PS, Elsebaie H, Noordeen MHH. Congenital spinal
deformity: a comprehensive assessment at presentation. Spine.
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82. Klemme WR, Polly DW Jr, Orchowski JR. Hemivertebral
excision for congenital scoliosis in very young children.
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83. Hedequist DJ, Hall JE, Emans JB. e safety and ecacy of
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84. McMaster MJ, Singh H. e surgical management
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85. Weiss HR. Congenital scoliosis: presentation of three severe
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86. Cheneau J, Grivas TB, Engels G, Fritsch HS. Wedged
vertebrae normalization in congenital scoliosis due to
application of external forces by brace. Scoliosis. 2007;2
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87. Burnei G, Gavriliu S, Vlad C, et al. Congenital scoliosis: an
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88. uet ED, Padberg AM, Raynor BL, et al. Increased risk of
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89. Mooney JF III, Bernstein R, Hennrikus WL Jr, et al.
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90. Moroz P, Emans JB, Hedequist DJ, et al. Outcomes of major
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91. Hedequist DJ. Instrumentation and fusion for congenital
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93. Karol LA. Early denitive spinal fusion in young
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94. Bowen RE, Scaduto AA, Banuelos S. Does early thoracic
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95. Newton PO, White KK, Faro F, et al. e success of
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99. Cil A, Yazici M, Alanay A, et al. e course of sagittal plane
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100. ompson AG, Marks DS, Sayampanathan SR, et al.
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101. Shono Y, Abumi K, Kaneda K. One-stage posterior
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103. Demirkiran G, Yilmaz G, Kaymaz B, et al. Safety and
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104. Repko M, Krbec M, Burda J, et al. [Simple bony fusion or
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105. Ruf M, Jensen R, Harms J. Hemivertebra resection in the
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108. Nakamura H, Matsuda H, Konishi S, Yamano Y. Single-stage
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109. Ruf M, Harms J. Hemivertebra resection by a posterior
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113. Bradford DS. Vertebral column resection. Orthop Trans.
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117. Dayer R1, Ceroni D, Lascombes P. Treatment of congenital
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expansion thoracostomy: a surgical technique. Eur Spine J.
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SECTION
27
CHAPTER
Idiopathic scoliosis is the most common cause of spinal
deformity in pediatric patients, encompassing 80% of all
scoliosis. Because its etiology is not known, it is a diagnosis of
exclusion—other causes such as congenital, syndromic, neuromuscular, and positional (leg-length discrepancy) must be
ruled out. e radiographic diagnosis requires a coronal plane
angle, measured by the Cobb method, of 10 degrees or greater.
Patients with curves less than 10 degrees are considered to
have spinal asymmetry.
early-onset scoliosis in 1950. Later, Dickson4 expanded further
on that concept and proposed that idiopathic scoliosis be
divided into early (0–5 years old) and late onset (>5 years old),
based on spinal growth velocity noted in these two age groups.
Currently, idiopathic scoliosis is divided into four categories
based on the age of onset: infantile (birth to 2 years + 11
months), juvenile (3–9 years + 11 months), adolescent (10–17
years + 11 months), and adult (18 years and older).5 Treatments include close observation, bracing, and surgical intervention. Patient safety is imperative and is achieved by
appropriate training, careful patient selection, and adherence
to the principles of deformity surgery. Advanced technology
and procedures have improved surgical treatment, with the
ultimate goals being patient safety, satisfaction, motion preservation, and choosing the optimal fusion levels to prevent the
need for further surgical intervention.
Epidemiology
Infantile and juvenile scoliosis are less prevalent than adolescent idiopathic scoliosis. Infantile idiopathic scoliosis is more
common in Europe, constituting less than 1% of idiopathic
scoliosis cases in the United States. Typically, these are le-
sided thoracic curves, oen occurring among boys. Recent
reviews suggest that there might be a decline in its incidence.6
In contrast, juvenile cases are typically diagnosed at age 5 years
in boys and 7 years in girls, accounting for about 10% to 20%
of idiopathic scoliosis cases.3 Additionally, juvenile cases occur
predominantly in girls; however, between 3 and 6 years of age,
there seems to be a similar distribution between boys and
1,2
Ponseti and Friedman3 rst described
Idiopathic Scoliosis
Lawrence G. Lenke
Fernando E. Silva
Ronald A. Lehman Jr
girls, only to become predominant again in girls aer age 6
years. e curve patterns closely resemble those of adolescents.
Adolescent idiopathic scoliosis (AIS) is the most prevalent
type. Among adolescents, the prevalence of 10-degree curves
is less than 3%, with about 5% of curves showing a progression
of greater than 30 degrees.4 is prevalence decreases as a
function of curve magnitude, however, to about 0.3% to 0.5%
and 0.1% in curves measuring 20 degrees and 40 degrees,
respectively.7 e prevalence of curves greater than 10 degrees
is higher among girls, with a 4 : 1 ratio of girls to boys, increasing to 9 : 1 when curves reach an operative range of about 40
to 50 degrees.
Etiology
Despite decades of research, the specic cause of idiopathic
scoliosis remains elusive and likely multifactorial. Possible
causes of infantile idiopathic scoliosis include intrauterine
molding or postnatal pressure on the spinal column from
supine positioning during sleep. Other etiologies that have
been considered in idiopathic scoliosis include dysfunction in
proprioception to maldevelopment in central pattern generators in the spinal cord, connective tissue disorders, hormonal
issues, and muscle/structural changes.
gests, however, that in the observed deformation of the spine,
the unique mechanics of the fully erect posture, which is
exclusive to humans, as well as genetics, both play important
roles in its development and progression. Kouwenhoven and
Castelein13 concluded that many factors may play a role in the
initiation and progression of AIS at a certain age. e growth
spurt noted among adolescents seems to play a role in progression because, as the spine grows, there seems to be a mechanical inuence as a critical buckling load is reached. Reports in
the literature continue to strongly suggest a genetic link.
Genetics
It is widely accepted that genetics plays a major role in idiopathic scoliosis. In 2008, Kulkarni and colleagues15 mapped a
developmentally critical CHD gene to 15q26.1 and, together
8
9-12
e literature sug-
14
IV
451
452 PEDIATRICS
with CHD7, suggested a possible role of CHD2 in the embry-
onic development of the spine. In eorts to map out the
gene(s) responsible for idiopathic scoliosis, Gao and colleagues16 reported the rst gene (CHD7) in the 8q12 locus to
be associated with a familial idiopathic scoliosis. However,
Tilley and colleagues failed to replicate Gao’s ndings.17 In
contrast, Takahashi et al. detected a strong association between
AIS and rs11190870 near LBX1, noting that this was associated with both susceptibility and curve progression of AIS.18
Hua et al. corroborated the latter ndings as they reported on
the strong association between AIS and rs11190870 near
LBX1 in a Japanese group with AIS.19 In terms of inheritance,
the prevalence is 11% among rst-degree relatives, 2.4%
among second-degree relatives, and 1.4% among third-degree
relatives.20 Concordance among monozygotic and dizygotic
twins has been reported to range from 73% to 92% and 36%
to 63%, respectively.
21,22
Anderson and colleagues23 published
a population-based study taken from the Danish Twin Registry in which 46,418 twins were registered. From the 34,944
respondents, the concordance rate for monozygotic twins was
13% versus 0% for dizygotic twins. Gurnett and colleagues24
published a report of a single multigenerational family in
which AIS and pectus excavatum segregated as an autosomal
dominant condition. rough linkage analysis, the investigators identied a genetic locus for the two conditions on
chromosome 18q. Hence, even though the exact genetic and
hereditary basis of scoliosis remains elusive, several chromosomes appear to play a role. Furthermore, its mode of inheritance remains unclear as both autosomal recessive, autosomal
dominant with variable penetrance, and X-linked dominant
modes of inheritance have been reported.
Natural History
About 90% of infantile curves show spontaneous resolution,
especially among infants who are younger than 1 year at
diagnosis.
with a thoracic component. Insight into curve progression can
be obtained from the rib-vertebral angle dierence (RVAD)
and “phase of the rib head.”26 To calculate the RVAD, a line is
drawn perpendicular to the apical vertebral endplate, another
line is drawn from the mid-neck to the mid-head of the corresponding rib; the angle formed by the intersection of these
lines is the rib vertebral angle or RVA. For calculating the
RVAD, the angle on the other side of the same vertebra is
calculated as well. e dierence between the values of the
RVAs on the concave and convex sides of the curve is the
RVAD. In terms of phase of the rib head, if the head and neck
of the convex rib of the vertebral body at the apex of the curve
does not overlap the vertebral body, it is termed phase I; if it
does overlap, it is termed phase II. It is unnecessary to calculate
the RVAD when a curve is noted to be a phase II type, as those
are almost certain to progress. Curves with RVAD greater than
20 degrees or phase II angles are very likely to progress.
also spontaneously resolve, about 70% of juvenile curve types
tend to progress, with 50% requiring bracing and 50% surgical
6,25
Curves that typically progress are double curves
Although juvenile scoliosis curves less than 25 degrees can
treatment. ese curves tend to progress if idiopathic scoliosis
is diagnosed before age 6 years and/or if they have a Cobb
angle of greater than 30 degrees. Here, the RVAD has not
proven to be a useful predictor of curve progression.
Many factors inuence the natural history of AIS. Growth
potential, skeletal maturity, curve magnitude, and location are
important considerations when assessing progression of AIS.
Family history, gender, and rotation do not seem to inuence
progression. Peak height growth seems to correlate best with,
and is a better predictor of, progression than skeletal maturity.
In terms of biomechanical inuences, this likely is secondary
to attaining a critical vertebral column height, which leads to
a critical buckling load and greater bending moments with
eventual curve progression. In girls, peak height growth seems
to occur 6 to 12 months before the onset of menarche. In boys,
peak height growth seems to correlate with the closure of the
triradiate cartilage. Larger or double curves tend to progress
more than smaller or single curves. Additionally, curves can
progress aer skeletal maturity; thoracic curves greater than
50 degrees and thoracolumbar/lumbar (TL/L) curves greater
than 40 degrees can progress on average 1 degree per year.
27,28
Evaluation
History and Physical Examination
A complete history, including any family history of scoliosis,
is obtained and a physical examination is performed. With
infantile and juvenile cases, in particular, a thorough prenatal,
birth, and developmental history is obtained. In the adolescent, the growth spurt history is noted. Length of time postmenarche is an indication of potential growth remaining. A
girl grows fastest one year before onset of menarche and
usually nishes growing 2 years aer its onset. Voice changes
in boys are noted as well, because when such change has
begun, the growth spurt is in its most intense phase. When
the voice has acquired adult characteristics, the growth rate
has started to decelerate. e duration of voice change varies
between less than 1 year to more than 3 years. is information is imperative in determining peak growth velocity and as
predictors of growth potential and its implications on possible
curve progression.29 Symptoms of pain and/or weakness and
how the patient perceives her or his appearance relative to the
deformity are especially important with AIS.30 During the
examination, height, weight, and age (years plus months since
last birthday) are recorded. e head is examined with special
attention to torticollis and plagiocephaly, given its higher
incidence with infantile scoliosis. Possible conditions and
anomalies that might be present include buccal and palatal
anomalies, café-au-lait spots, and midline dimples or hair
patches, or both, over the lumbodorsal spine, which can be
important clinical clues to the presence of intraspinal pathology. Limb laxity is also checked and, when present, genetic
counseling is requested. Trunk shi, a clinical correlate of
curve rotation, is evaluated as the patient stands with the hips
and knees fully extended. e relationship of the patient’s head
to the pelvis is also noted in evaluating the overall coronal and
sagittal balance. Any shoulder, breast, or pelvic asymmetry is