Juvenile Scoliosis (4-9)

Juvenile (4-9) scoli
Approach to Juvenile Idiopathic Scoliosis

Technically speaking, juvenile refers to the curve occurring between 4 and 9 years of age
– represents a part of the continuum between infantile and adolescent scoliosis (two different clinical entities)
– may resemble infantile or adolescent curves
– in the lower end (3-6 years) the female male ratio is nearly 1:1 (more like infantile)
– in the upper ends (7-10 years) the female to male ratio is nearly 4:1 (more like adolescent)
– spontaneous correction is more likely in the younger age group
– left thoracic and left lumbar curves are more likely to improve without treatment in the 3-6 year group (like the infantiles tend to do as well)

– approximately 70% of curves in juvenile patients progress to require some treatment – in 50% of these, the curve progression requires surgery
– curve progression is not surprising, seeing as how much spine growth is left ahead of the child!

Rib Vertebral Angle Difference
– measured in this group as well, but tends not to be as good at predicting progression in the juveniles
– serial RVAD measurements, however, have been used to measure response to brace treatment in this group

Other predictors
– curves greater than 45 degrees at the beginning of brace treatment tend to require surgery eventually
– curves greater than 35 degrees at the beginning of brace treatment have a 50% chance of requiring surgery

Treatment

– curves less than 25 degrees are observed
– curves that progress beyond 25 degrees are braced (Milwaukee brace)

Milwaukee brace
– patients with curves less than 35 degrees and RVADs of less than 20 tend to do well with brace
– patients with curves greater than 45 degrees and RVADs of greater than 20 tend to do poorly with brace
– patients between 35 and 45 degrees were unpredictable

Surgery
– try to delay as much as possible – may let a kid get to about 55-60 before pulling the trigger, to allow for as much spine growth as possible
– DiMeglio – two periods of rapid spine growth – birth to 5 years, and 10 to 16 years
– between 5-10 years: each spinal segment averages 0.05 cm growth per segment per year
– after 10 years: each spinal segment averages .11 cm per segment per year

– a basic formula: cm of shortening = 0.07 x number of segments fused x number of years of growth remaining
– so if you were going to fuse 8 segments in a 7 year old who has 7 more years to grow, the predicted cm of shortening would be 0.07 x 8 x 7 = 3.92 cm

– almost all will be Risser 0
– to avoid crankshaft, should do front and back if doing fusion
– can try subcutaneous growing rod – tends to increase hypokyphosis, and needs changing every 6-12 months though