Intraspinal anomalies in scoliosis: An MRI analysis of 177 consecutive scoliosis patients

Abstract

Background: The association of intraspinal neural anomalies with scoliosis is known for more than six decades. However, there are no studies documenting the incidence of association of intraspinal anomalies in scoliotic patients in the Indian population. The guide lines to obtain an magnetic resonance imaging (MRI) scan to rule out neuro-axial abnormalities in presumed adolescent idiopathic scoliosis are also not clear. We conducted a prospective study (a) to document and analyze the incidence and types of intraspinal anomalies in different types of scoliosis in Indian patients. (b) to identify clinico-radiological 'indicators' that best predict the findings of neuro-axial abnormalities in patients with presumed adolescent idiopathic scoliosis, which will alert the physician to the possible presence of intraspinal anomalies and optimize the use of MRI in this sub group of patients.

Materials and methods: The data from 177 consecutive scoliotic patients aged less than 21 years were analyzed. Patients were categorized into three groups; Group A - congenital scoliosis (n=60), group B -presumed idiopathic scoliosis (n=94) and group C - scoliosis secondary to neurofibromatosis, neuromuscular and connective tissue disorders (n=23). The presence and type of anomaly in the MRI was correlated to patient symptoms, clinical signs and curve characteristics.

Results: The incidence of intraspinal anomalies in congenital scoliosis was 35% (21/60), with tethered cord due to filum terminale being the commonest anomaly (10/21). Patients with multiple vertebral anomalies had the highest incidence (48%) of neural anomalies and isolated hemi vertebrae had none. In presumed 'idiopathic' scoliosis patients the incidence was higher (16%) than previously reported. Arnold Chiari-I malformation (AC-I) with syringomyelia was the most common neural anomaly (9/15) and the incidence was higher in the presence of neurological findings (100%), apical kyphosis (66.6%) and early onset scoliosis. Isolated lumbar curves had no anomalies. In group-C, incidence was 22% and most of the anomalies were in curves with connective tissue disorders.

Conclusion: The high incidence of intraspinal anomalies in presumed idiopathic scoliosis in our study group emphasizes the need for detailed examination for subtle neurological signs that accompany neuro-axial anomalies. Preoperative MRI screening is recommended in patients with presumed 'idiopathic' scoliosis who present at young age, with neurological findings and in curves with apical thoracic kyphosis.

Keywords: Intraspinal anomalies; MRI scan; neuro-axial anomalies; scoliosis.

Figure 1

11 year old child with right thoracic presumed ‘idiopathic’ scoliosis. Clinically she had an asymmetrical abdominal reflex. (a, b) The radiographs showed a 53° right thoracic scoliosis with a thoracic kyphosis (T4-T12) of 38°. (c) The MRI showed a Arnold Chiari type-I malformation with a cervicothoracic syrinx. This required a foramen magnum decompression followed by posterior corrective instrumentation

Figure 2

A 13 year old girl presented with a recent onset right thoracic scoliosis. Clinical examination was normal. (a, b) The whole spine X-ray showed a minimal coronal plane deformity, however there was a thoracic apical kyphosis. (c) The MRI showed a large cervico-thoracic syrinx