Rev. bras. ortop. vol.52 número3

(1)

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

article

Anatomical

and

radiological

characteristics

in

adolescent

idiopathic

scoliosis

with

surgical

indication

夽

Mauro

Costa

Morais

Tavares

Junior

a,∗

,

Felipe

Ribeiro

Ledur

a

,

Olavo

Biraghi

Letaif

a

,

Raphael

Martus

Marcon

b

_,

_Alexandre

_Fogac¸a

_Cristante

b

_,

Tarcisio

Eloy

Pessoa

de

Barros

Filho

b

a_Universidade_de_São_Paulo,_Faculdade_de_Medicina,_Hospital_das_Clínicas,_Instituto_de_Ortopedia_e_{Traumatologia,}_São_Paulo,_SP,_Brazil

b_Universidade_de_São_Paulo,_Faculdade_de_Medicina,_Departamento_de_Ortopedia_e_{Traumatologia,}_São_Paulo,_SP,_Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received15July2016 Accepted18July2016 Availableonline28April2017

Keywords:

Scoliosis/anatomy&histology Scoliosis/radiography Adolescent

Treatmentoutcome

a

b

s

t

r

a

c

t

Objective:Thisstudyaimstoanalyzetheanatomicalandradiologicalcharacteristicsof ado-lescentidiopathicscoliosispatientswithsurgicalindication.

Methods:Retrospective, descriptive study of 100medical recordspertaining to patients includedinthegroupofscoliosiswithsurgicalindicationfromtheyears2008to2015. Descriptivestatisticswereusedforstatisticalanalysis.

Results:28patientsmettheinclusionandexclusioncriteria,andwereselectedforthestudy. Theaverageagewas15.4(SD±1.2years);intheselectedsample,thefemale/maleratio was6:1;thekyphosismeasuredindegreesbyCobbanglebetweenT5–T12hadanaverage 32.10(SD±13.37);accordingtotheLenkeclassification,themostprevalenttypewastype2, representing28.6%ofcases.

Conclusion:Themeanpatientageinthepresentstudywas15.4(SD±1.2years);themost prevalenttypewastype2intheLenkeclassification.Thereisaneedfornewanatomicaland radiologicalstudiestoelucidatethemorphologicalcharacteristicscommoninadolescent idiopathicscoliosispatients.

夽

StudyconductedatInstitutodeOrtopediaeTraumatologia,HospitaldasClínicas,FaculdadedeMedicina,UniversidadedeSãoPaulo, SãoPaulo,SP,Brazil.

∗ _{Corresponding}_author_.

E-mail:maurodiv@hotmail.com(M.C.TavaresJunior). http://dx.doi.org/10.1016/j.rboe.2017.04.002

(2)

Características

anatomorradiológicas

na

escoliose

idiopática

do

adolescente

com

indicac¸ão

cirúrgica

Palavras-chave:

Escoliose/anatomia&histologia Escoliose/radiografia

Adolescente

Resultadodotratamento

r

e

s

u

m

o

Objetivo: Avaliar as características anatomorradiológicas em pacientes com escoliose idiopáticadoadolescentecomindicac¸ãocirúrgica.

Métodos: Estudodescritivoretrospectivode100prontuáriosdepacientesdogrupode esco-liosecomindicac¸ãocirúrgicade2008a2015.Aanáliseusadafoiaestatísticadescritiva.

Resultados: Preencheramoscritériosdeinclusãoeexclusão28pacienteseforam seleciona-dosparaoestudo.Amédiafoide15,4±1,2anosDP;naamostraselecionada,aproporc¸ão menina:meninofoide6:1;acifosefoimedidaemgrauspeloângulodeCobbentreT5-T12e tevecomomédia32,10◦_±_13,37◦_DP;_segundo_a_{classificac¸ão}_de_Lenke,_o_mais_prevalente_foi otipo2,observadoem28,6%doscasos.

Conclusão: Aidademédiadospacientesnopresenteestudofoide15,4anos;omais preva-lente foi otipo2da classificac¸ãode Lenke.Novos trabalhosanatomorradiológicos são necessáriosparaelucidarcaracterísticasmorfológicascomunsnospacientescomescoliose idiopáticadoadolescente.

Introduction

Scoliosisisathree-dimensionaldeformityofthespinal col-umn. The main diagnostic criterion is a spinal curvature exceeding10degreesonaanteroposteriorviewradiographof thespine.1–4_Adolescent_idiopathic_scoliosis_(AIS)_is_a_common

conditionthataffects0.5–5% ofchildren.5 _The_female:male

ratioranges from1.5:1to3:1, substantiallyincreasingwith age.5_The_{co-occurrence}_between_monozygotic_twins_is_higher

than70%.1

Thediagnosis ofAIS ismade byexclusion,when other causesofscoliosis,suchasvertebralmalformationsor neu-romusculardisorders,areexcluded.1,2_The_etiology_of_AIS_is

unknown and multifactorial.1,5–7 _It _is_very _difficult _to

ade-quatelycharacterizethemorphologyofthemostimportant spinalcurvaturesinpatientswithAIS,asthereisagreat vari-abilityamongindividuals.

Someprognosticfactorsfortheprogressionofthespinal deformityare:thoraciccurveormultiplecurves,Cobbangle greater than 25 degrees atdiagnosis, and delayed skeletal maturation.8_The_Lenke_{classification}_is_often_used_to_define

treatment in AIS. However, even within the six standard definedcurves,therearestructuralvariationswithinthesame kindofcurve,9_what_may_interfere_with_the_surgical_treatment.

Newstudiesareimportanttoelucidatetheprevalent clin-icalfeatures in patients withAIS in order toassist in the correctanatomicalandradiologicalunderstandingofthe dis-ease.Therefore,thisstudyaimedtoassesstheanatomicaland radiologicalcharacteristicsofpatientswithAISwithsurgical indication.

Material

and

methods

This was a retrospective descriptive study of 100 medical chartsofpatientsfromtheIOTHC-FM-USPscoliosisgroup,

assessed from 2008 to 2015. The inclusion criteria were: patients withAIS withsurgical indicationand presenceof apanoramicradiographofthespineinanteroposteriorand lateralview.Theexclusioncriteriawere:patientswith incom-plete registers regarding demographic data, non-walking patients,andthosewithdefinedcausesforthescoliosis.

TheclassificationsusedwereCobb angleandthe Lenke classification.Descriptivestatisticswereusedforanalysis.

Thepresent study wasapprovedbytheResearch Ethics Committeeoftheinstitution.

Thefollowingparameterswereassessed:patientage(in years);Cobbangle(measuredindegrees),andthefirst(most cephalad)andthelastvertebra(mostcaudal)oftheCobbangle ofthemaincurveofeachpatient;Lenkeclassificationofeach patient’scurve;neutralcephalad,neutralcaudal,andneutral apicalvertebraeofthemaincurve;andstablevertebra.The resultsareshownincharts,tables,sheets,orfigures.

Results

After 100 medical registers from scoliosis group patients treatedfrom2008to2015wereretrospectivelyanalyzed,28 mettheestablishedinclusioncriteriaandwereselected.The meanageofpatientswas15.4±1.2years(Fig.1).

Ofthe28patientsanalyzed,24weregirlsandfourwere boys,aratioof6:1.Overall,themostprevalentapicalvertebra wastheT8,in35.7%ofthecases,followedbyT9,in25%of cases.In turn,themostprevalent stablevertebraewere L4 andL3,representing25%and21.4%ofthecases,respectively (Tables1and2).Themostprevalentneutralcephaladvertebra wasT5,in32.1%ofthecases,followedbyT6,in25%.Themost prevalentneutralcaudalvertebraewereL1andL2,in35.7% and21.4%ofthecases,respectively(Tables3and4).

(3)

12

10

Frequency

Age

8

6

4

2

0

12.0 13.0 14.0 15.0 16.0 17.0

Fig.1–Patientsage.

Table1–Apicalvertebra.

Frequency Percentage Valid percentage

Accumulated percentage(%)

L3 1 3.6 3.6 3.6

T10 4 14.3 14.3 17.9

T11 2 7.1 7.1 25.0

T12 1 3.6 3.6 28.6

T6 2 7.1 7.1 35,7

T7 1 3.6 3.6 39.3

T8 10 35.7 35.7 75.0

T9 7 25.0 25.0 100.0

Total 28 100.0 100.0

Table2–Stablevertebra.

L1 2 7.1 7.1 7.1

L2 2 7.1 7.1 14.3

L3 6 21.4 21.4 35.7

L4 7 25.0 25.0 60.7

L5 4 14.3 14.3 75.0

T11 4 14.3 14.3 89.3

T12 3 10.7 10.7 100.0

Total 28 100.0 100.0

Table3–Neutralcephaladvertebra.

T10 1 3.6 3.6 3.6

T11 1 3.6 3.6 7.1

T3 1 3.6 3.6 10.7

T4 3 10.7 10.7 21.4

T5 9 32.1 32.1 53.6

T6 7 25.0 25.0 78.6

T7 5 17.9 17.9 96.4

T9 1 3.6 3.6 100.0

Total 28 100.0 100.0

Table4–Neutralcaudalvertebra.

L1 10 35.7 35.7 35.7

L2 6 21.4 21.4 57.1

L4 1 3.6 3.6 60.7

L5 1 3.6 3.6 64.3

T11 5 17.9 17.9 82.1

T12 5 17.9 17.9 100.0

Total 28 100.0 100.0

12

10

Frequency

T5-T12 Kyphosis

8

6

4

2

0 10

5 15 20 25 30 35 40 45 50 55 60 65 70 75

Fig.2–T5–T12kyphosis.

AccordingtotheLenkeclassification,themostprevalent typeofAISinthisstudywastype2,observedin28.6%ofthe cases,followedbytype4,in25.1%.Fig.3showsanexample ofthemeasurementsusedinthestudyofapatientwithAIS.

(4)

Table5–Lenkeclassification.

Cumulative frequency(%)

1−A 1 3.6 3.6 3.6

1−B 1 3.6 3.6 7.1

1NA 2 7.1 7.1 14.3

1NB 1 3.6 3.6 17.9

1NC 1 3.6 3.6 21.4

2−C 1 3.6 3.6 25.0

2NA 3 10.7 10.7 35.7

2NB 3 10.7 10.7 46.4

2NC 1 3.6 3.6 50.0

3+C 1 3.6 3.6 53.6

3NB 1 3.6 3.6 57.1

3NC 3 10.7 10.7 67.9

4+A 1 3.6 3.6 71.4

4+B 1 3.6 3.6 75.0

4NA 1 3.6 3.6 78.6

4NB 1 3.6 3.6 82.1

4NC 3 10.7 10.7 92.9

6NB 1 3.6 3.6 96.4

6NC 1 3.6 3.6 100.0

Total 28 100.0 100.0

Nopatientswereclassifiedastype5inthesampleselected (Table5).

Discussion

Thepresentstudyaimedtoevaluatetheradiographic param-etersofthecurvesandepidemiologicaldataofpatientswith scoliosisinthesurgicalwaitinglistofthisinstitution.Inthe presentstudy,onlytheradiographicmethodforevaluationof theimages,whichremainsthegoldstandardforthediagnosis ofscoliosis,wasused.Regardingtheresults,previous stud-iesindicatedthattheprevalenceandseverityofthisdisease arehigheringirls,andthatthisrelationshipincreaseswith age.10_In_the_present_series,_a_higher_prevalence_of_the_disease

ingirlswasobserved,ataratioof6girls:1boy,inagreement withtheliterature.

Amongthe numerousclassificationsystemsforAIS,the KingandLenkeclassificationsarenoteworthy.In1983,Howard Kingpresentedhisclassificationsystem,inwhichfivetypes ofcurveweredescribed.Hisworkdefinedforthefirsttime someconceptsthatarewidelyusednowadays,suchasstable vertebraandstructuralorcompensatorycurves.11 _However,

alow inter- and intraobserver agreementwas reported for thatclassification.12,13_In₂₀₀₁_Lenke_et_al.14_published_a_new

classificationsystemforAISdefiningsixtypesofcurve;for thefirsttime,thesagittalplanedeformityofthespinal col-umnwastakenintoaccountforAISclassification.Ahigher inter-andintraobserveragreementwasobservedforthisnew classificationwhencomparedwithKing’s.14

In the present study, only the Lenke classification was used,due toits higher interobserveragreement, aiming to minimize biasfrom errors inthe classification oftypes of curvesofpatients. Inthe present sample,Lenke classifica-tion type2 curves were the most prevalent; however, the literaturefeaturestype1asthemostcommonpattern.15

ThemaintreatmentchoicesforAISaretheuseoforthoses and surgery.Themostcommonorthosesusedinthe treat-ment ofAISwithdemonstrated efficacyare theMilwaukee vestandthoraco-lumbo-sacralorthosis.16,17_The_main_surgical

indicationinAISisathoraciccurveof50◦_or_more,_measured bytheCobbangleduringskeletalmaturation.18_Therefore,_the

correctclassificationandmeasurementofthedegreeof scoli-osisisparamountindeterminingthecorrecttreatmentofthe condition.

Therearenorecentstudiesintheliteraturethatindicate the distribution ofanatomical or morphological character-istics in patients with AIS. Thus, the present study has contributed toelucidatetheprevalenceofthesefindingsin the casesofAISinourinstitution, inorder tomoreclearly identifywhattypeofpatientisbeingtreated;withthecorrect diagnosis,abettertreatmentcanbeproposed.

Recentstudieshaveshownthatpelvicincidencemaybe relevantasacompensatoryorcausalfactorinthe develop-mentofscoliosis.19 _These_parameters_were_not_analyzed_in

thisstudy,andmayproveimportantinfutureresearch. Fur-thermore,duetotheretrospectivecharacteristicofthestudy, alackofdataor recordingissues wereobservedinvarious charts.Ofthe100recordsanalyzed,only28mettheinclusion andexclusioncriteria,afactthathasundoubtedlyaffectedthe findingsofthestudy.Thisstudyshouldnotbegeneralizedto otherpopulations,astheselectedsamplecomprisedpatients fromanoutpatientclinicwhoalreadyhadhadsurgical indi-cation,afactthat,byitself,greatlyimpactsthefindings.

Conclusion

Inthepresentstudy,themeanageofpatientswas15.4±1.2 years.Aratioof6girls:1boywasobserved.Themeankyphosis, measuredindegreesbytheCobbanglebetweenT5andT12, was32.10◦_±_13.37._According_to_the_Lenke_{classification,}_the mostprevalenttypeofAISinthisstudywastype2,observed in28.6%ofthecases,followedbytype4,in25.1%.Nopatients wereclassifiedastype5inthesampleselected(Table5).

Newanatomoradiologicalstudiesareneededtoelucidate thecommonmorphologicfeaturesinpatientswithAIS.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

r

e

f

e

r

e

n

c

e

s

1.TrobischP,SuessO,SchwabF.Idiopathicscoliosis.Dtsch ArzteblInt.2010;107(49):875–83.

2.WestrickER,WardWT.Adolescentidiopathicscoliosis:5-year to20-yearevidence-basedsurgicalresults.JPediatrOrthop. 2011;311Suppl.:S61–8.

3.PanchmatiaJR,IsaacA,MuthukumarT,GibsonAJ,LehovskyJ. The10keystepsforradiographicanalysisofadolescent idiopathicscoliosis.ClinRadiol.2015;70(3):235–42. 4.AdoborRD,JorangerP,SteenH,NavrudS,BroxJI.Ahealth

(5)

5. KoniecznyMR,SenyurtH,KrauspeR.Epidemiologyof adolescentidiopathicscoliosis.JChildOrthop.2013;7(1):3–9. 6. GoodbodyCM,SankarWN,FlynnJM.Presentationof

adolescentidiopathicscoliosis:thebiggerthekid,thebigger thecurve.JPediatrOrthop.2017;37(1):41–6.

7. YamanO,DalbayrakS.Idiopathicscoliosis.TurkNeurosurg. 2014;24(5):646–57.

8. WajchenbergM,MartinsDE,LazarM.Whatisthebestwayto determinethecauseofadolescentidiopathicscoliosis?Ann TranslMed.2015;3(4):48.

9. AtmacaH,InanmazME,BalE,CaliskanI,KoseKC.Axialplane analysisofLenke1Aadolescentidiopathicscoliosisasanaid toidentifycurvecharacteristics.SpineJ.2014;14(10):2425–33. 10.SchlösserTP,vanderHeijdenGJ,VersteegAL,CasteleinRM.

Howidiopathicisadolescentidiopathicscoliosis?A systematicreviewonassociatedabnormalities.PLoSOne. 2014;9(5):e97461.

11.KingHA,MoeJH,BradfordDS,WinterRB.Theselectionof fusionlevelsinthoracicidiopathicscoliosis.JBoneJointSurg Am.1983;65(9):1302–13.

12.CummingsRJ,LovelessEA,CampbellJ,SamelsonS,MazurJM. Interobserverreliabilityandintraobserverreproducibilityof thesystemofKingetal.fortheclassificationofadolescent idiopathicscoliosis.JBoneJointSurgAm.1998;80(8):1107–11. 13.BehenskyH,GiesingerK,OgonM,KrismerM,HannesB,

KarlmeinradG,etal.Multisurgeonassessmentofcoronal

patternclassificationsystemsforadolescentidiopathic scoliosis:reliabilityanderroranalysis.Spine(PhilaPa1976). 2002;27(7):762–7.

14.LenkeLG,BetzRR,HaherTR,LappMA,MerolaAA,HarmsJ, etal.Multisurgeonassessmentofsurgicaldecision-makingin adolescentidiopathicscoliosis:curveclassification,operative approach,andfusionlevels.Spine(PhilaPa1976).

2001;26(21):2347–53.

15.LenkeLG,BetzRR,ClementsD,MerolaA,HaherT,LoweT, etal.Curveprevalenceofanewclassificationofoperative adolescentidiopathicscoliosis:doesclassificationcorrelate withtreatment?Spine(PhilaPa1976).2002;27(6):604–11. 16.BlountWP,SchmidtAC,KeeverED,LeonardET.The

Milwaukeebraceintheoperativetreatmentofscoliosis.J BoneJointSurgAm.1958;40(3):511–25.

17.WattsHG,HallJE,StanishW.TheBostonbracesystemforthe treatmentoflowthoracicandlumbarscoliosisbytheuseofa girdlewithoutsuperstructure.ClinOrthopRelatRes. 1977;(126):87–92.

18.WeinsteinSL,ZavalaDC,PonsetiIV.Idiopathicscoliosis: long-termfollow-upandprognosisinuntreatedpatients.J BoneJointSurgAm.1981;63(5):702–12.