The works of King, Coonrad, Lenke, and subsequent researchers has been instrumental in creating an understanding of curve patterns and developing treatment methods for AIS.13–16 The differences between IEOS and AIS, however, have not been thoroughly investigated or statistically analyzed in a manner that might begin to elucidate variation in causes and preferred treatment methods. One of the barriers to such analysis has been the inability to apply the Lenke system to younger patients, who often do not have bending radiographs. Mishiro et al17 proposed a modified Lenke system for IIS and JIS using only upright coronal and lateral radiographs, but this new system has not been widely adopted as of the time of submission. Because of this limitation, we analyzed and compared parameters measurable on standard coronal and sagittal radiographs. We limited the comparison to the latest preoperative radiographs to ensure that the groups were being compared at points of greatest equivalence, thus minimizing analysis at differing stages of curve progression.
Overall, compared with patients with AIS, those with IEOS exhibited larger curves, a more caudal stable vertebra, larger kyphosis, and a unimodal pattern of primary curve apex distribution centered closer to the thoracolumbar/lumbar junction (vs. the bimodal distribution seen in AIS). When we limited the comparison to patients with thoracic primary curves, we found that those with IEOS had a more caudal apical vertebra, more caudal proximal and distal Cobb end vertebra, larger curve magnitude, a higher percentage of left curves, and a higher percentage of lumbar deformity in which the CSVL stayed between the lumbar pedicles. When we limited the comparison to patients who had thoracolumbar/lumbar primary curves, those with IEOS also had a larger curve magnitude. The larger curve magnitude in IEOS may partially represent the desire to delay surgery as long as possible in these skeletally immature patients.
The recurring patterns of a lower apical vertebra and a lower stable vertebra in IEOS may suggest that children with IEOS require more distal fusion than those with AIS. Such action comes with multiple drawbacks, including limited flexibility and potential stress concentration. In addition, the greater kyphosis seen in IEOS increases pullout stress on proximal anchors (Figure 4A and B). Although several studies have shown casting to be effective in treating less severe IEOS curves,18–21 these results have not been shown to extend to more severe curves such as those in this study. In these severe curves and in more moderate curves that fail nonoperative treatment, multiple established and experimental surgical treatments exist.22
Radiographical curve characteristics in idiopathic scoliosis have been well examined,23–34 and many of our findings reflect reports in the literature that have characterized primary curve sidedness, Lenke type, thoracic kyphosis, and apical vertebra in idiopathic scoliosis. Primary curves are predominantly left-sided in patients with IIS23 and early-onset scoliosis,24 but right-sided patterns predominate in JIS25,28,33 and AIS.28 Our study illustrates these findings: primary thoracic curves were primarily left sided in IEOS (66%) and right sided in AIS (95%). Current literature indicates that patients with primary thoracic curves in EOS and IIS have more pronounced kyphotic tendencies than in patients with JIS and AIS, who tend to exhibit thoracic kyphosis that is less than or equal to normal.10,26,27,30,33,35,36 In our study, the magnitude of T2 to T12 kyphosis was significantly higher in patients with IEOS (40°± 15°) than in those with AIS (31°± 13°). Our study is somewhat less reflective of existing literature on the modal apex of the primary thoracic curve. In our IEOS group, the modal apex of the primary thoracic curve was T10, followed by T9. Two previous studies reported T9 as the modal apex of the primary thoracic curve in IIS29 and JIS,25 although these studies included patients treated both nonoperatively and surgically. Modal apex in our AIS group was T9 followed by T8, which agrees with the T8/T9 average of 1 study32 but differs slightly from the T8 mode in another study.31 Reports of stable vertebra could not be found for comparison.
The primary limitation of our study was the size of the IEOS group compared with the size of the AIS group. AIS is a much more common disorder. As a result, the IEOS group was significantly smaller despite sourcing data from a large, multicenter study group. However, we think the similarities with existing literature show our IEOS group to be representative and suitable for comparison.
A second limitation was that patients were retrospectively identified in the study groups' records based on whether or not they had surgery. Consequently, rather than comparing “operative” IEOS and “operative” AIS as defined by a homogenously used standard of “operative,” we actually compared IEOS and AIS in the children considered as operable by the array of surgeons. This methodology has the potential to introduce bias because many factors play a role in a surgeon's decision. For instance, it is possible that the greater curve magnitude in IEOS results from a desire to postpone surgery in all but the most severe deformities. To address such possibilities fully, we would need to also examine the deformity in patients in each database who have not been considered for surgical intervention.
Our study shows significant differences in radiographical characteristics of IEOS and AIS. Deformity in the younger population exhibits greater kyphosis, larger curve magnitude, and a more distal curve apex, all of which present treatment challenges that are less prevalent in adolescent patients.
* To our knowledge, no previous studies have statistically compared the radiographical characteristics of large cohorts of operative IEOS and operative AIS.
* Patients with IEOS showed larger curve magnitude, more severe kyphosis, less curve compensation, more caudal curve apex, and a more caudal highest stable vertebra.
* The clinical significance of these findings include the need for more distal instrumentation and carefully planned proximal anchors in IEOS secondary to the more caudal and kyphotic curve characteristics.
* Future research may include a classification system applicable to early-onset scoliosis and comparison of the levels and types of instrumentation used in IEOS and AIS.
The authors thank Elaine P. Henze, BJ, ELS, for her editorial work, and Tracey Bastrom, MA, for her statistical analysis. The authors also thank the Growing Spine Study Group and the Harms Study Group, for contribution of data for this study. The Harms Study Group (HSG) is a collaborative cohort of worldwide distinguished surgeons dedicated to the advancement of treatment for children and adolescents with spine deformity. Through comprehensive, multicenter prospective research studies, questions regarding treatment approach and techniques to achieve desired outcomes are studied with a commitment to be internationally recognized for the highest quality published research on new spinal deformity surgery techniques.
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idiopathic; scoliosis; early-onset; infantile; juvenile; adolescent; Lenke