Morphology, Development and Deformation of the Spine in Mild and Moderate Scoliosis: Are Changes in the Spine Primary or Secondary?

Abstract

Introduction and aim of the study: We aim to determine whether the changes in the spine in scoliogenesis of idiopathic scoliosis (IS), are primary/inherent or secondary. There is limited information on this issue in the literature. We studied the sagittal profile of the spine in IS using surface topography. Material and methods: After approval of the ethics committee of the hospital, we studied 45 children, 4 boys and 41 girls, with an average age of 12.5 years (range 7.5–16.4 years), referred to the scoliosis clinic by our school screening program. These children were divided in two groups: A and B. Group A included 17 children with IS, 15 girls and 2 boys. All of them had a trunk asymmetry, measured with a scoliometer, greater than or equal to 5 degrees. Group B, (control group) included 26 children, 15 girls and 11 boys, with no trunk asymmetry and scoliometer measurement less than 2 degrees. The height and weight of children were measured. The Prujis scoliometer was used in standing Adam test in the thoracic (T), thoraco-lumbar (TL) and lumbar (L) regions. All IS children had an ATR greater than or equal to 5 degrees. The Cobb angle was assessed in the postero-anterior radiographs in Group A. A posterior truncal surface topogram, using the “Formetric 4” apparatus, was also performed and the distance from the vertebra prominence (VP) to the apex of the kyphosis (KA), and similarly to the apex of the lumbar lordosis (LA) was calculated. The ratio of the distances (VP-KA) for (PV-LA) was calculated. The averages of the parameters were studied, and the correlation of the ratio of distances (VP-KA) to (VP-KA) with the scoliometer and Cobb angle measurements were assessed, respectively (Pearson corr. Coeff. r), in both groups and between them. Results: Regarding group A (IS), the average height was 1.55 m (range 1.37, 1.71), weight 47.76 kg (range 33, 65). The IS children had right (Rt) T or TL curves. The mean T Cobb angle was 24 degrees and 26 in L. In the same group, the kyphotic apex (KA (VPDM)) distance was −125.82 mm (range −26, −184) and the lordotic apex (LA (VPDM)) distance was −321.65 mm (range −237, −417). The correlations of the ratio of distances (KA (VPDM))/(LA (VPDM)) with the Major Curve Cobb angle measurement and scoliometer findings were non-statistically significant (Pearson r = 0.077, −0.211, p: 0.768, 0.416, respectively. Similarly, in the control group, KA (VPDM))/(LA (VPDM) was not significantly correlated with scoliometer findings (Pearson r = −0.016, −p: 0.939). Discussion and conclusions: The lateral profile of the spine was commonly considered to be a primary aetiological factor of IS due to the fact that the kyphotic thoracic apex in IS is located in a higher thoracic vertebra (more vertebrae are posteriorly inclined), thus creating conditions of greater rotational instability and therefore greater vulnerability for IS development. Our findings do not confirm this hypothesis, since the correlation of the (VP-KA) to (VP-KA) ratio with the truncal asymmetry, assessed with the scoliometer and Cobb angle measurements, is non-statistically significant, in both groups A and B. In addition, the aforementioned ratio did not differ significantly between the two groups in our sample (0.39 ± 0.11 vs. 0.44 ± 0.08, p: 0.134). It is clear that hypokyphosis is not a primary causal factor for the commencing, mild or moderate scoliotic curve, as published elsewhere. We consider that the small thoracic hypokyphosis in developing scoliosis adds to the view that the reduced kyphosis, facilitating the axial rotation, could be considered as a permissive factor rather than a causal one, in the pathogenesis of IS. This view is consistent with previously published views and it is obviously the result of gravity, growth and muscle tone.

Direct Vertebral Rotation (DVR) Does Not Improve Clinical and Radiological Results Compared to Differential Rod Contouring (DRC) in Patients Treated Surgically for Idiopathic Scoliosis

“…According to many authors, rib hump deformity most likely results from asymmetric rib growth rather than from vertebral rotation, and ATR measurements correlate with apical axial vertebral rotation but only up to a certain point [ 19 , 20 ]. The residual rib hump exists even if significant vertebral derotation is carried out, due to the fixed deformity of the ribs and also the fact that ribs may continue to grow asymmetrically postoperatively if the patient still has growth potential, a phenomenon resulting in the relapse of the thoracic deformity [ 19 , 20 , 21 ]. In clinical papers, authors have not found any beneficial effects of DVR on rib hump reduction compared to methods that include no derotation [ 16 , 22 ].…”

Why Is There Always a Remnant Rib Hump Deformity after Spinal Operations in Idiopathic Scoliosis: Aetiological Implications and Recognition of the Proper Rib Level for Costoplasty

“…The authors' opinion is that "at initiating and mild scoliosis, the patho-biomechanics are probably dissimilar from the biomechanics when the curve is severe". Furthermore, we consider that at initiating and mild IS cases, genetics, epigenetics, and biology have the dominant/protagonistic aetiological role; however, we should not overlook the non-protagonistic role of patho-biomechanics at this stage, which become dominant later for progressive IS [50].…”

“…Grivas et al (2007 and2022) confirmed the role of the RC asymmetry as a leading parameter for the development of IS, concluding that in mild IS, the deformity of the thorax precedes the spinal deformity. They found that there is a lack of correlation between surface topography findings (hump) presented as TA to the Cobb angle in younger girls in mild and moderate IS and that this correlation appears later in older children [27,50].…”

Comment on Grivas et al. Morphology, Development and Deformation of the Spine in Mild and Moderate Scoliosis: Are Changes in the Spine Primary or Secondary? J. Clin. Med. 2021, 10, 5901

“…With great interest, we have read the article entitled “Morphology, Development and Deformation of the Spine in Mild and Moderate Scoliosis: Are Changes in the Spine Pri-mary or Secondary?” by Grivas et al, an incredibly interesting read [ 1 ]. This study covers the important but divided topic of sagittal spinal alignment as a causal factor in the etiology of idiopathic scoliosis, and we would like to compliment the authors on their work.…”