Rib index is a strong surrogate of scoliometric reading in idiopathic scoliosis.

INTRODUCTION AND AIM: Scoliometry is not always included in the examination protocol of IS patients. The aim of this report is to examine the degree of correlation of Segmental Rib Index (SRI) to scoliometry, in order for SRI to be used as a surrogate of scoliometric angle of trunk rotation (ATR). MATERIAL AND METHOD: 66 Idiopathic Scoliosis (IS) subjects were studied, with a mean age 12.2 ± 2.9 years, 18 boys and 48 girls: 20 thoracic, 22 thoracolumbar and 24 lumbar curves. The standing lateral spine radiographs (LSR) were obtained and the Segmental Rib Index (SRI) from T1 to T12 were assessed. The ATR was documented. RESULTS: In all 66 cases with IS the scoliometer readings (ATR) were significantly correlated to the SRI at the T6, T7 and T8 levels. In the thoracic curves SRI and ATR correlations were significant for the levels T6-T12. DISCUSSION: It was suggested that as long as the patients doesn't have scoliometer measurements, the SRI, could be used as a surrogate for scoliometry. It was also found that in thoracic, thoracolumbar and lumbar level, in both genders, changing from the flexed position to the standing position, the mean trunk asymmetry (TA) decreases. Therefore, if these patients had their TA measured using a scoliometer during the Adams test, their body asymmetry would have been greater than that measured using the SRI method on standing LSR. Consequently, it is evident that the significantly correlated SRI used as a surrogate for the scoliometric assessment of TA is reasonably a strong surrogate.

Are the Spinal Changes in the Course of Scoliogeny Primary but Secondary?

In this opinion article, there is an analysis and discussion regarding the effects of growth on the spinal and rib cage deformities, the role of the rib cage in scoliogeny, the lateral spinal profile in adolescent idiopathic scoliosis (AIS), the genetics and epigenetics of AIS, and the interesting and novel field investigating the sleep impact at nighttime on AIS in relation to the sequence of the scoliogenetic changes in scoliotics. The expressed opinions are mainly based on the published peer-reviewed research of the author and his team of co-authors. Based on the analysis noted above, it can be postulated that the vertebral growth changes in the spine during initial idiopathic scoliosis (IS) development are not primary-intrinsic but secondary changes. The primary cause starting the deformity is not located within the vertebral bodies. Instead, the deformations seen in the vertebral bodies are the secondary effects of asymmetrical loads exerted upon them, due to muscular loads, growth, and gravity.

Maternal age at birth: does it dictate the epigenotypic expression of the trunkal asymmetry of a child?

INTRODUCTION: Trunkal back asymmetry is considered very important for the selection of children at risk of developing scoliosis. Traditionally, this asymmetry as thoracic or lumbar hump is the main indicator for referral of subjects with idiopathic scoliosis (IS) to clinics from school-screening programs. This asymmetry is also used as the most important sign for further assessment at scoliosis clinics. There are reports suggesting that an epigenetic risk factor for IS is maternal age at birth. However, the influence of maternal age on the development of trunkal asymmetry during growth has not been reported. This report aims to assess if maternal age at birth impacts trunkal asymmetry, and how this parameter may dictate the epigenotypic expression of the trunkal asymmetry of a child. MATERIAL AND METHODS: The sample examined: 11832 (5855 males and 5977 females) children and adolescents (5-17 years old, mean age: 11.34±2.79) were screened at their school for back trunkal asymmetry and/or scoliosis. The measurements: The Prujis scoliometer was used to examine the students in standing and sitting forward bending positions. If at least one of child's measured angles was equal to or exceeded 6 or 7 degrees of scoliometer reading, it was labelled as "Asymmetry-6" and "Asymmetry-7" respectively. The age, standing height and body weight of children and maternal age were also documented, among other parameters. The maternal age at birth and children's BMI were subsequently calculated. The statistical analysis: Asymmetries were tested for correlation with maternal age at birth which was transformed to a categorical variable using 5-year intervals. Pearson's χ2 test was used for the univariate analysis, while logistic regression was used for quantitative univariate and multivariate analysis. Statistical significance level was set to p<.05. SPSS and STATA TM v. 11.0 statistical packages were used for the analysis. RESULTS: Univariate analysis: Univariate analysis showed that the prevalence of asymmetry-6 in boys tended to significantly decrease as mother's age at birth increased (mother's age at birth: <19, 20-24, 25-29, 30-34, 35-39, >40 years, % of asymmetry-6: 11.5%, 9.5%, 8.5%, 7.6%, 5.2%, 5.3%, respectively, (p=0.026). This trend, although present, was not significant in girls. The prevalence of asymmetry-7 also showed a decreasing trend, which was only significant in boys (mother's age at birth: <19, 20-24, 25-29, 30-34, 35-39, >40 years, % of asymmetry-7: 8.7%, 5.9%, 5.9%, 4.6%, 2.6%, 3.5%, respectively, p=0.010). Maternal age at birth, as a continuous variable, was inversely associated with the appearance of asymmetry-6 in both boys and girl s (OR: 0.966, 0.982, 95%CIs: 0.947-0.985, 0.965-0.999, p: 0.001, 0.040, respectively). This was also the case for asymmetry-7 only in boys: (OR: 0.961, 0.982, 95%CIs: 0.938-0.985, 0.962-1.003, p: 0.001, 0.088, respectively). Multivariate analysis: The significant and inverse effect of maternal age at birth on the appearance of asymmetry in boys remained even after adjusting for child's BMI and age. For one year increase of maternal age at birth, the odds of the boys being asymmetrical6 were reduced by 2.8% (OR:0.972, 95% CIs: 0.953-0.992, p: 0.005), adjusting for child's age and BMI. For one year increase of maternal age at birth, the odds of the boys being asymmetrical7 were reduced by 3.2% (OR:0.968, 95% CIs: 0.945-0.992, p: 0.010), adjusting for child's age and BMI. However, the aforementioned correlations were not significant for girls in both cases. DISCUSSION AND CONCLUSIONS: The influence of maternal age at birth on the development of trunkal asymmetry during growth has not been previously assessed, as evidenced from literature review. The findings of this report indicate that maternal age as an environmental factor in the general population, may possibly influence epigenetically, the occurrence of the initial presentation of trunkal asymmetry in males more than females, as well as IS during growth. Consistent findings reported from the USA, Edinburgh and Sweden reveal increased maternal age as a risk factor for AIS, suggesting maternal factors can predispose to it. It seems that males are more affected by this factor but, unexpectedly in this study, by younger and not older mothers, as reported for AIS in the literature. Low-birth weight associated with younger parental age may also be associated with increased trunkal asymmetry particularly of boys, an hypothesis that need testing. The importance our findings is based on the belief that the intra-uterine environment is crucial in programming the fetus for various health and disease outcomes throughout life.

Reply to de Reuver et al. 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 [...].

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

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.

Using the Scoliometer and a Surface Topography Apparatus to Check if Back Trunk Asymmetry Changes in Children and Adolescents in the Forward Flexion and Standing Erect Positions.

Background The purpose of this study is to evaluate the effects of the forward bending (FB) test versus the standing erect (SE) position on back trunk asymmetry (TA). The Scoliometer in the FB position and the 4D Formetric (4DF; Diers International, Schlangenbad, Germany) readings in the SE position were assessed. Method The angle of trunk inclination (ATI) was measured at the midthoracic, thoracolumbar, and lumbar levels using the Scoliometer in the FB position and the 4DF in the SE position. A total of 134 subjects attending the scoliosis clinic (86 girls and 48 boys), age ranging from seven to 18 years, were assessed. The children and adolescents were divided into three groups according to the severity of TA, symmetric group 1 (0-2 degrees), asymmetry group 2 (2 to 6 degrees), and group 3 having asymmetry of seven or more degrees. Children with leg length discrepancy were excluded from the study. The IBM SPSS v.20 package (IBM Corp., Armonk, NY) was used for analysis. Results At the midthoracic level comparing the Scoliometer to 4DF readings in males in group 1, the Wilcoxon signed ranks test was p=0.451 while for the Spearman's Rho, it was -0.138; in group 2, p=0.184 and Rho=0.204; and in group 3, p=0.109 and Rho=0.500. For females in group 1, p=0.000 while Rho=0.003; in group 2, p=0.008 and Rho=0.000, and in group 3, p=0.003 while Rho=0.642. At the thoracolumbar level in males for group 1, p=0.004 and Rho=-0.517; in group 2, p=0.006 and Rho=0.000; and in group 3, p=0.043 while Spearman's Rho=0.053. For females in group 1, p=0.000 and Rho=-0.095; in group 2, p=0.000 and Rho=-0.171; in group 3, p=0.001 while Rho= -0.081. At the lumbar level for males in group 1 p=0.000 while Rho=0.149; in group 2, p=0.003 and Rho=0.373; while in group 3, p=0.109 and Rho= (-). For females in group 1, p=0.000 while Rho=-0.072; in group 2, p=0.001 and Rho=0.168; and in group 3, p=0.068 while Rho=0.500. Conclusion The results of this study show that the back TA in children and adolescents is not similar in the FB and SE positions. This phenomenon probably is attributed to the complicated trunkal (spinal, thoracic, and pelvic) anatomy, and the results of this study may be used as a useful foundation for further understanding of torso dynamics.

Idiopathic and normal lateral lumbar curves: muscle effects interpreted by 12th rib length asymmetry with pathomechanic implications for lumbar idiopathic scoliosis.

BACKGROUND: The historical view of scoliosis as a primary rotation deformity led to debate about the pathomechanic role of paravertebral muscles; particularly multifidus, thought by some to be scoliogenic, counteracting, uncertain, or unimportant. Here, we address lateral lumbar curves (LLC) and suggest a pathomechanic role for quadrates lumborum, (QL) in the light of a new finding, namely of 12th rib bilateral length asymmetry associated with idiopathic and small non-scoliosis LLC. METHODS: Group 1: The postero-anterior spinal radiographs of 14 children (girls 9, boys 5) aged 9-18, median age 13 years, with right lumbar idiopathic scoliosis (IS) and right LLC less that 10°, were studied. The mean Cobb angle was 12° (range 5-22°). Group 2: In 28 children (girls 17, boys 11) with straight spines, postero-anterior spinal radiographs were evaluated similarly to the children with the LLC, aged 8-17, median age 13 years. The ratio of the right/left 12th rib lengths and it's reliability was calculated. The difference of the ratio between the two groups was tested; and the correlation between the ratio and the Cobb angle estimated. Statistical analysis was done using the SPSS package. RESULTS: The ratio's reliability study showed intra-observer +/-0,036 and the inter-observer error +/-0,042 respectively in terms of 95 % confidence limit of the error of measurements. The 12th rib was longer on the side of the curve convexity in 12 children with LLC and equal in two patients with lumbar scoliosis. The 12th rib ratios of the children with lumbar curve were statistically significantly greater than in those with straight spines. The correlation of the 12th rib ratio with Cobb angle was statistically significant. The 12th thoracic vertebrae show no axial rotation (or minimal) in the LLC and no rotation in the straight spine group. CONCLUSIONS: It is not possible, at present, to determine whether the 12th convex rib lengthening is congenitally lengthened, induced mechanically, or both. Several small muscles are attached to the 12th ribs. We focus attention here on the largest of these muscles namely, QL. It has attachments to the pelvis, 12th ribs and transverse processes of lumbar vertebrae as origins and as insertions. Given increased muscle activity on the lumbar curve convexity and similar to the interpretations of earlier workers outlined above, we suggest two hypotheses, relatively increased activity of the right QL muscle causes the LLCs (first hypothesis); or counteracts the lumbar curvature as part of the body's attempt to compensate for the curvature (second hypothesis). These hypotheses may be tested by electrical stimulation studies of QL muscles in subjects with lumbar IS by revealing respectively curve worsening or correction. We suggest that one mechanism leading to relatively increased length of the right 12 ribs is mechanotransduction in accordance with Wolff's and Pauwels Laws.

The rib index is not practically affected by the distance between the radiation source and the examined child.

BACKGROUND: All lateral spinal radiographs in idiopathic scoliosis (IS) show a Double Rib Contour Sign (DRCS) of the thoracic cage, a radiographic expression of the rib hump. The outline of the convex overlies the contour of the concave ribs. The rib index (RI) method was extracted from the DRCS to evaluate rib hump deformity in IS patients. The RI was calculated by the ratio of spine distances d1/d2 where d1 is the distance between the most extended point of the most extending rib contour and the posterior margin of the corresponding vertebra on the lateral scoliosis films, while d2 is the distance from the least projection rib contour and the posterior margin of the same vertebra, (Grivas et al 2002). In a symmetric thorax the "rib index" is 1. This report is the validity study of DRCS, ie how the rib index is affected by the distance between the radiation source and the irradiated child. METHODS: The American College of Radiology's (2009) guidelines for obtaining radiographs for scoliosis in children recommends for the scoliotic - films distance to be 1,80 meters. Normal values used for the transverse diameter of the ribcage in children aged 6-12 years were those reported by Grivas in 1988. RESULTS: Using the Euclidean geometry, it is shown that in a normal 12-year old child d1/d2 = 1.073 provided that the distance ΔZ ≈ 12cm (11,84) and EA = 180cm, with transverse ribcage diameter of the child 22 cm. CONCLUSIONS: This validity study demonstrates that the DRCS is substantially true and the RI is not practically affected by the distance between the radiation source and the irradiated child. The RI is valid and may be used to evaluate the effect of surgical or conservative treatment on the rib cage deformity (hump) in children with IS. It is noted that RI is a simple method and a safe reproducible way to assess the rib hump deformity based on lateral radiographs, without the need for any other special radiographs and exposure to additional radiation.