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 Spine Test 6: Spine February 2005
CME 4: October, November, December 2004
Pediatrics Test 6: Topics in Pediatric Orthopaedic Surgery
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The Journal of Bone and Joint Surgery (American) 86:2187-2195 (2004)
© 2004 The Journal of Bone and Joint Surgery, Inc.

Indications for Magnetic Resonance Imaging in Presumed Adolescent Idiopathic Scoliosis

Jon R. Davids, MD1, Eric Chamberlin, MD2 and Dawn W. Blackhurst, PhD3

1 Motion Analysis Laboratory, Shriners Hospital for Children, 950 West Faris Road, Greenville, SC 29605. E-mail address: jdavids{at}shrinenet.org
2 Pittsburgh Bone and Joint Surgeons, 1321 5th Avenue, McKeesport, PA 15132
3 Department of Biomedical Research, Greenville Hospital System, 701 Grove Road, Greenville, SC 29605

Investigation performed at the Shriners Hospital for Children, Greenville, South Carolina

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: The use of magnetic resonance imaging has led to the diagnosis of abnormalities of the central nervous system associated with apparent idiopathic scoliosis. The indications for magnetic resonance imaging for presumed adolescent idiopathic scoliosis have not been established.

Methods: One thousand, two hundred and eighty children with presumed adolescent idiopathic scoliosis were evaluated over a ten-year period. Magnetic resonance imaging of the central nervous system (brainstem and spinal cord) was performed for specific patients, on the basis of the presence of selected indicators determined from the clinical history, physical examination, and plain radiographic examination of the spine. The medical records were reviewed to determine the specific indicators, the results of the imaging studies, and the subsequent treatment.

Results: Magnetic resonance imaging was ordered for 274 (21%) of the 1280 children who were evaluated. Abnormal findings were seen in twenty-seven (10%) of the 274 patients who underwent imaging, or 2% of the entire cohort. The most valuable single indicator of an abnormal finding on magnetic resonance imaging was absence of thoracic apical segment lordosis: eight of thirty-nine patients with that indicator had an abnormal finding on magnetic resonance imaging. The optimal diagnostic yield for a single category of indicators occurred when an atypical curve pattern was the only indicator: six of fifty-eight patients in whom this was the case had an abnormal finding on magnetic resonance imaging. None of the twenty children in whom pain was the only indicator category had an abnormal imaging study. The optimal diagnostic yield occurred when both an atypical curve pattern and neurological indicators were present: thirteen (25%) of fifty-three patients in whom this was the case had an abnormal finding on magnetic resonance imaging. Thirteen of the twenty-seven patients received surgical treatment for the abnormality of the central nervous system revealed by the imaging.

Conclusions: The correct use of diagnostic tests is an important component of effective medical practice. An abnormality of the central nervous system is present in approximately 10% of patients with presumed adolescent idiopathic scoliosis in whom only subtle abnormalities are identified on the basis of the clinical history, physical examination, or radiographic examination. Knowledge of the diagnostic value of the specific clinical indicators, considered individually and in combination, can help the clinician to determine more effectively when advanced imaging of the central nervous system should be performed.

Level of Evidence: Diagnostic study, Level III-1 (study of nonconsecutive patients [no consistently applied reference "gold" standard]). See Instructions to Authors for a complete description of levels of evidence.


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