Risser sign

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Pelvis
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Female type pelvis
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Male type pelvis
Anatomical terms of bone

The Risser sign is an indirect measure of skeletal maturity, whereby the degree of ossification of the iliac apophysis by x-ray evaluation is used to judge overall skeletal development. Mineralization of the iliac apophyses begins at the anterolateral crest and progresses medially towards the spine. Fusion of the calcified apophyses to the ilium then progresses in opposite direction, from medial-to-lateral. [1]

A typical five-point grading scale is as follows:

Risser grading is traditionally used to estimating the future growth potential of the adolescent spine, particularly in the setting of spinal scoliosis. Risser originally recognized that ossification of the iliac apophyses approximately parallels the ossification of the vertebral apophyses. The earlier the stage of growth, the greater the likelihood of a scoliosis progressing and potentially needing intervention. [2] Note that although Risser first described his findings during a 1948 lecture [3] and published the eponymous paper in 1958, [4] formalized staging systems were developed at a later time.

Controversy

The Risser grading system has been criticized as being an inaccurate proxy for skeletal maturity. Comparison of predicted future growth and progression of scoliosis to actual measured changes show that the Risser system is variably accurate. [5] Specifically, because the progression from stages 1 to 4 (apophyseal "excursion") is rapid and only takes an average of approximately 1 year, these stages are of limited value in pinpointing stage of growth. Cessation of trunk growth as predicted by Risser stage is also earlier than actual growth. [5]

In 2008, Sanders et al proposed an alternative system for assessing skeletal maturity, using hand x-rays in a manner similar to "gold standards" (Greulich and Pyle, Tanner-Whitehouse-III) skeletal maturity assessments. [6] Whether the use of the Sanders vs Risser staging for management of scoliosis would lead to different treatment decisions is being debated. [7]

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The neuromechanics of idiopathic scoliosis is about the changes in the bones, muscles and joints in cases of spinal deformity consisting of a lateral curvature scoliosis and a rotation of the vertebrae within the curve, that is not explained by either congenital vertebral abnormalities, or neuromuscular disorders such as muscular dystrophy. The idiopathic scoliosis accounts for 80–90% of scoliosis cases. Its pathogenesis is unknown. However, changes in the vestibular system, a lateral shift of the hand representation and abnormal variability of erector spinae motor map location in the motor cortex may be involved in this disease. A short spinal cord and associated nerve tensions has been proposed as a cause and model for idiopathic scoliosis. Besides idiopathic scoliosis being more frequent in certain families, it is suspected to be transmitted via autosomal dominant inheritance. Estrogens could also play a crucial part in the progression of idiopathic scoliosis through their roles in bone formation, growth, maturation and turnover. Finally, collagen, intervertebral disc and muscle abnormalities have been suggested as the cause in idiopathic scoliosis, although these are perhaps results rather than causes.

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The management of scoliosis is complex and is determined primarily by the type of scoliosis encountered: syndromic, congenital, neuromuscular, or idiopathic. Treatment options for idiopathic scoliosis are determined in part by the severity of the curvature and skeletal maturity, which together help predict the likelihood of progression. Non-surgical treatment should be pro-active with intervention performed early as "Best results were obtained in 10-25 degrees scoliosis which is a good indication to start therapy before more structural changes within the spine establish." Treatment options have historically been categorized under the following types:

  1. Observation
  2. Bracing
  3. Specialized physical therapy
  4. Surgery
Ossification of the posterior longitudinal ligament Medical condition

Ossification of the posterior longitudinal ligament (OPLL) is a process of fibrosis, calcification, and ossification of the posterior longitudinal ligament of the spine, that may involve the spinal dura. Once considered a disorder unique to people of Asian heritage, it is now recognized as an uncommon disorder in a variety of patients with myelopathy.

Anterior vertebral body tethering (AVBT) is a relatively new surgery for the treatment of scoliosis in pediatric patients. Left untreated, severe scoliosis can worsen and eventually affect a person's lungs and heart.

References

  1. Waldt, Simone; Woertler, Klaus (2014). Measurements and Classifications in Musculoskeletal Radiology. Thieme. pp. 126–127. ISBN   978-3-13-169271-9.
  2. Greiner, Allen K. (May 2002). "Adolescent Idiopathic Scoliosis: Radiologic Decision-Making". American Family Physician. 65 (9): 1817.
  3. Risser JC. Important practical facts in the treatment of scoliosis. Instr Course Lect 1948;V:248-260.
  4. Risser, J. C. (1958-01-01). "The Iliac apophysis; an invaluable sign in the management of scoliosis". Clinical Orthopaedics. 11: 111–119. ISSN   0095-8654. PMID   13561591.
  5. 1 2 Little, David G.; Sussman, Michael D. (September 1994). "The Risser Sign: A Critical Analysis". Journal of Pediatric Orthopaedics. 14 (5): 569–75. doi:10.1097/01241398-199409000-00003. ISSN   0271-6798. PMID   7962495. S2CID   46281125.
  6. Sanders, James O.; Khoury, Joseph G.; Kishan, Shyam; Browne, Richard H.; Mooney, James F.; Arnold, Kali D.; McConnell, Sharon J.; Bauman, Jeanne A.; Finegold, David N. (March 2008). "Predicting scoliosis progression from skeletal maturity: a simplified classification during adolescence". The Journal of Bone and Joint Surgery. American Volume. 90 (3): 540–553. doi:10.2106/JBJS.G.00004. ISSN   1535-1386. PMID   18310704.
  7. Minkara, Anas; Bainton, Nicole; Tanaka, Masashi; Kung, Justin; DeAllie, Christopher; Khaleel, Alexandra; Matsumoto, Hiroko; Vitale, Michael; Roye, Benjamin (2018-01-22). "High Risk of Mismatch Between Sanders and Risser Staging in Adolescent Idiopathic Scoliosis: Are We Guiding Treatment Using the Wrong Classification?". Journal of Pediatric Orthopedics. 40 (2): 60–64. doi:10.1097/BPO.0000000000001135. ISSN   1539-2570. PMID   29360659. S2CID   36464009.