Early Onset Scoliosis Guidelines for Management in
Resource Limited Settings - 1st Edition
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ISBN: 9780367370312 (hbk)
ISBN: 9780429352416 (ebk)
Typeset in Times
by Deanta Global Publishing Services, Chennai, India
To all the children with spine deformities I treated in Palestine and
globally, and to their families, who motivate me to provide better care.
To my wife, Fatima, and my children, Amal and Azmi, for their love and support.
—Alaa
Dedicated to the children around the world who deserve conscientious care and
the opportunity to heal and flourish. I hope the result of this work will ultimately
help in our unified goal of providing young patients with better care and reduced
morbidity. As Bob Brown said, ‘The future will either be green or not at all.’
—Aakash
Contents
Preface............................................................................................................................................ viii
Acknowledgments..............................................................................................................................ix
Editors.................................................................................................................................................x
List of Contributors...........................................................................................................................xii
List of Abbreviations........................................................................................................................ xv
Chapter 1 Introduction................................................................................................................... 1
Alaaeldin Azmi Ahmad
Chapter 2a Economics and Implementing Early-Onset Scoliosis in Limited-Resources
Facilities........................................................................................................................ 5
Ahmed Shawky Abdelgawaad
Chapter 2b Mismatch in Expectations between Industry and Countries with Limited
Resources.................................................................................................................... 13
Aakash Agarwal
Chapter 2c Organisational Deficiencies in Developing Countries and the Role of Global
Surgery........................................................................................................................ 23
Amal Ahmad
Chapter 3a Blended Learning in Training Paediatric Deformity Surgeons.................................. 33
Emre Acaroglu and Alpaslan Senkoylu
Chapter 3b Evidence-Based Medicine in Low- and Middle-Income Countries............................ 41
Patrick Thornley, Devin Peterson and Mohit Bhandari
Chapter 4 Normal and Abnormal Development and Growth of Spine and Thoracic Cage........ 49
Federico Canavese, François Bonnel, and Alain Dimeglio
Chapter 5 Pulmonary Evaluation and Management of Early-Onset Scoliosis............................ 59
Laura Ellington, Mary Crocker, and Gregory Redding
Chapter 6 Conservative Management of Early-Onset Scoliosis.................................................. 69
Muhammad Tariq Sohail and Shahid Ali
Chapter 7 Anaesthetic Management of Early-Onset Scoliosis.................................................... 79
Damarla Haritha and Souvik Maitra
v
vi Contents
Chapter 8a Biomechanics of Surgical Intervention Associated with Early-Onset Scoliosis......... 93
Aakash Agarwal
Chapter 8b Principles of Surgical Management.......................................................................... 107
Michael Grevitt
Chapter 8c Preoperative Diagnosis and Management................................................................. 123
Mohamed Fawzy Khattab
Chapter 8d Principles of Intraoperative Management of Early-Onset Scoliosis......................... 131
Ashok N. Johari, Rashid Anjum, and Vrushali Ponde
Chapter 8e Postoperative Management for EOS Children.......................................................... 143
Kaustubh Ahuja, Bhavuk Garg
Chapter 8f Principles of Management of Long-Term Complications in EOS............................. 151
Meric Enercan, and Azmi Hamzaoglu
Chapter 8g Management of Spinal Tuberculosis in Young Children.......................................... 161
S. Rajasekaran, Sri Vijay Anand KS, Ajoy Prasad Shetty, and Rishi Mugesh Kanna
Chapter 9a Guidelines for Management in Limited-Resource Settings: Pakistan Experience...... 179
Amer Aziz and Abdullah Shah
Chapter 9b China Experience...................................................................................................... 191
Yong Hai and Aixing Pan
Chapter 9c Egyptian Experience of Surgical Management of Early-Onset Scoliosis................. 195
Mohammad M. El-Sharkawi and Amer Alkot
Chapter 9d Mozambique Experience...........................................................................................207
Alaaeldin Azmi Ahmad
Chapter 9e Chile Experience....................................................................................................... 215
Samuel Pantoja
Chapter 9f Evolution of Experience and Practise in Two Nations.............................................. 223
Ujjwal Kanti Debnath,
Contents vii
Chapter 9g Experience of EOS Management in Two Worlds-II.................................................. 237
Fernando Rios, Behrooz A. Akbarnia, and Gregory M. Mundis, Jr.
Chapter 9h Cross-Border Spine Surgical Treatment: Issues to Consider.................................... 247
Harwant Singh
Chapter 10 Future Considerations............................................................................................... 255
Alaaeldin Azmi Ahmad
Index............................................................................................................................................... 261
Preface
Early-onset scoliosis (EOS) is a deformity of programmes in limited-resources economies. It
the growing spine in children, usually 10 years will explain the difference between short-term
of age and younger, with potentially life-threat- volunteer missions and long-term educational
ening consequences if left untreated. Over the programmes and advocate for the latter as an
past 2 decades, EOS management has evolved to important vessel of EOS service provision in
try to understand the cause, identify coexisting developing countries.
problems and morbidities, and surgically man- The book is not meant to provide formulaic
age the issue while maintaining the growth of solutions for all problems related to the spine
the spine and lung. Numerous protocols have in regions with limited resources but, rather,
been established within a multidisciplinary to draw attention to the particular problems
framework, and growth-friendly implants have facing developing countries in this regard and
been developed to achieve the best results with to provide rough roadmaps based on previous
the fewest complications. successful experiences for interested actors. It
Unfortunately, the science of EOS manage- is meant to promote an understanding of the
ment has centred on case studies in advanced clinical, educational, and organisational prob-
economies and has largely sidestepped the par- lems for the surgeons, global organisations, and
ticular issues of regions with limited resources, local governments dealing with paediatric spine
where many, if not most, children with EOS deformity in limited-resources regions, as well
cannot access treatment because of a lack of as an appreciation for the importance of context-
experts and weak organisational frameworks. based solutions to these problems.
This book is a humble effort to provide guide- This book is possible owing to the valuable
lines to implement this important service contributions of our authors, from various parts
within a limited-resources setting, by high- of the world, who are drawing on their knowl-
lighting realistic, on-the-ground experiences edge and experience to explain how to best over-
of pioneering spine surgeons from developing come the difficulties of promoting EOS service
and developed countries who have succeeded in developing regions. In these times that high-
in establishing EOS programmes that not only light the connectivity of global public health, as
serve patients directly, but also educate young well as the importance of equal rights for all,
spine surgeons and promote EOS research in it is our collective hope that this book contrib-
developing countries. Besides addressing sur- utes to a more egalitarian world where children
geons, the book will also provide guidelines from all social and economic backgrounds can
to global organisations interested in paediat- receive quality care and where surgeons and
ric spine deformity programmes and highlight organisations, especially in the advanced econo-
the issues that must be prioritied and tackled mies, use their various privileges to help materi-
to enable the development of sustainable EOS alise such a vision.
viii
Acknowledgments
This book is possible owing to the valuable con- in developing regions. I also sincerely acknowl-
tributions of our authors, who are drawing on edge the invaluable help of the publishing team
their knowledge and experience from various Shivangi Pramanik and Himani Dwivedi for
parts of the world to explain how to best over- their support and hard work to get this book
come the difficulties of promoting EOS services published.
ix
Editors
Dr Alaaeldin Azmi Ahmad, M.D is a member of the orthopaedic committee of
A paediatric orthopaedic surgeon by train- the Palestinian Board for nine years. He also
ing, Dr Ahmad entered the field of paediatric became head of the orthopaedic programme at
orthopaedic surgery 18 years ago following a the Palestine International Cooperation Agency
1-year fellowship at Shriner’s Hospital in Los (PICA), in charge of developing a paediatric
Angeles, California. Since then, he has initi- spine surgery programme in Mozambique and
ated paediatric spine surgery and education Nicaragua as well as paediatric spine missions in
services in Palestine as well as other countries Pakistan and Rwanda. Globally, he is a member
with limited resources. In his role as a sur- of Scoliosis Research Society’s Growing Spine
geon and professor, he holds the position of Committee, the North American Spine Society’s
Professor at An-Najah Medical School, Head International Outreach Work Group, and the AO
of The Pediatric Orthopedic and Spine Unit Spine’s Education Strategy Task Force; he also
at An-Najah University Hospital, Consultant serves as the Spine Committee chair and sec-
Paediatric Orthopaedic Surgeon at Saint Joseph retary general of World Orthopaedic Concern-
Hospital, Jerusalem, Palestine, and Visiting International Society of Orthopaedic Surgery
Consultant Paediatric Spinal Surgeon in Abdali and Tramautology, and an international fellow
Hospital, Amman, Jordan. He also holds an at the College of Surgeons of East, Central, and
adjunct faculty appointment at the Orthopedic Southern Africa (COSECSA). In addition, he is
Department in University of South Carolina in involved in the Weil Cornell Spine education
Charleston and in the biomedical engineering programme in Tanzania. He possesses a global
department at the University of Toledo in Ohio. vision and a drive to collaborate with colleagues
As a paediatric orthopaedic surgeon, toward the development of education and train-
Dr Ahmad possesses extensive experience in ing programmes that can improve spine surgery
the management of children with spine defor- services in countries with limited resources.
mity, with a special interest in early-onset sco-
liosis (EOS) cases. He invented a new surgical Dr Aakash Agarwal
technique that is more affordable than prevail- Aakash Agarwal, PhD, is the Director of
ing techniques that avoids current surgeries for Research at Spinal Balance Inc., in Toledo, Ohio,
the growing spine through posterior tethering and an Adjunct Professor of Bioengineering at
called active apex correction (APC). Dr Ahmad University of Toledo in Ohio. Dr Agarwal is a
has presented this technique in numerous inter- prolific researcher in the field of preventive and
national congresses and has published papers in predictive science of spinal pathology and post-
peer-reviewed journals discussing its efficiency operative complications, such as spinal defor-
in the surgical management for children with mity, surgical site infection, hardware failure,
EOS. Currently, this technique is being used in and spinopelvic imbalance. Dr Agarwal’s pri-
Palestine, Jordan, India, and Mozambique with mary expertise lies in new preventative mea-
positive results. Overall, Dr Ahmad has been sures to combat spinal surgery complications,
published in more than 35 international journals including surgical site infection and implant
and books, most of them related to EOS man- failures associated with EOS. His major inter-
agement. He shares editorial responsibilities ests include translational research with immedi-
as editorial board member in JOP B and as a ate bench-to-bedside applicability. He has been
reviewer board member in GSJ, SICOT J, and a major contributor to several important proj-
Journal of Clinical Orthopaedics and Trauma. ects that have been recognised as significant.
Dr Ahmad has been active in spinal ortho- He uses combinatory knowledge of biomedi-
paedic education initiatives, both locally and cal engineering, clinical medicine, mechanical
globally. In Palestine, he has trained residents engineering, and biomechanics to study sur-
in the orthopaedic residency programme and gical failures and new treatments to mitigate
x
Editors xi
the risk of complications and infections. He is of certain distraction-based rods and growth-
the inventor of a two-step asepsis process that guided systems and provided guidelines on how
involves providing spinal implants in an individ- to reduce such failure modes. Dr Agarwal holds
ual sterile tube and a preloaded intraoperative several national and international patents. He
sheath allowing implants to be handled hygieni- is an editorial board member for the journals
cally that aims to reduce surgical site infection Clinical Spine Surgery and Spine by Lippincott
and biofilm formation. Dr Agarwal has also Williams & Wilkins. Dr Agarwal also serves
extensively explored the mechanism behind the as an advisory board member for the Center
failure of scoliosis spinal implants in children. for the Disruptive Musculoskeletal Innovation
Through human trial studies and biomechanical (CDMI) under the aegis of the National Science
simulations, he identified the high failure rate Foundation (NSF).
List of Contributors
Ahmed Shawky Abdelgawaad Shahid Ali
Spine Center Doctors Hospital & Medical Centre
Erfurt, Germany Lahore, Pakistan
and and
Assiut University Hospitals Orthopaedic Unit 1
Assiut, Egypt Jinnah Hospital
Lahore, Pakistan
Emre Acaroglu
Ankara Spine Center Amer Alkot
Ankara, Turkey Al-Azhar University, Assiut Branch
Assiut, Egypt
Aakash Agarwal
Department of Bioengineering Sri Vijay Anand
University of Toledo Department of Spine Surgery
Toledo, Ohio Ganga Hospital
and Coimbatore, India
Colleges of Engineering
University of Toledo Rashid Anjum
Toledo, Ohio Acharya Shri Chander College of Medical
Sciences and Hospital
Alaaeldin Azmi Ahmad Jammu, India
An-Najah University
Nablus, Palestine Amer Aziz
and Ghurki Trust Teaching Hospital
Medical University of South Carolina Lahore, Pakistan
Charleston, South Carolina
and Mohit Bhandari
Biomedical Engineering Department Division of Orthopaedic Surgery
University of Toledo McMaster University
Toledo, Ohio Hamilton, Ontario, Canada
Amal Ahmad François Bonnel
Department of Economics Laboratory of Anatomy
University of Massachusetts University of Montpellier
Amherst, Massachusetts Montpellier, France
Kaustubh Ahuja Federico Canavese
Department of Orthopaedics Pediatric Surgery Department
All India Institute of Medical Sciences University Hospital Estaing
New Delhi, India Clermont-Ferrand, France
Mary Crocker
Behrooz A. Akbarnia
Pulmonary and Sleep Medicine Division
San Diego Spine Foundation and Global Spine
University of Washington School of Medicine
Outreach
and
San Diego, California
Department of Pediatrics
University of Washington School of Medicine
Seattle, Washington
xii
List of Contributors xiii
Ujjwal Kanti Debnath Damarla Haritha
Fortis Hospital Department of Anaesthesiology, Pain Medicine
Kolkata, India and Critical Care
and All India Institute of Medical Sciences
AMRI Hospitals New Delhi, India
Kolkata, India
Ashok N. Johari
Alain Dimeglio Enable – International Centre for Paediatric
Pediatric Orthopedic Department Musculoskeletal Care
Clinique St. Roch Mumbai, India
Montpellier, France
Rishi Mugesh Kanna
Laura Ellington Department of Spine Surgery
Pulmonary and Sleep Medicine Division Ganga Hospital
University of Washington School of Medicine Coimbatore, India
and
Department of Pediatrics Mohamed Fawzy Khattab
University of Washington School of Medicine Ain Shams University,
Seattle, Washington Cairo, Egypt
Mohammad M. El-Sharkawi Souvik Maitra
Assiut University Department of Anaesthesiology, Pain Medicine
Assiut, Egypt and Critical Care
All India Institute of Medical Sciences
Meric Enercan New Delhi, India
Istanbul Spine Center
Istanbul Florence Nightingale Hospital Gregory M. Mundis, Jr.
Istanbul, Turkey San Diego Spine Foundation and Global Spine
Outreach
Bhavuk Garg San Diego, California
Department of Orthopaedics
All India Institute of Medical Sciences Aixing Pan
New Delhi, India Department of Orthopedic Surgery
Beijing Chaoyang Hospital
Michael Grevitt Beijing, China
Nottingham University Hospitals
Nottingham, United Kingdom Samuel Pantoja
Clinica Las Condes Private Hospital
Yong Hai and
Department of Orthopedic Surgery Dr. Roberto Del Río Children’s Hospital
Beijing Chaoyang Hospital Santiago, Chile
Beijing, China
Devin Peterson
Azmi Hamzaoglu Division of Orthopaedic Surgery
Istanbul Spine Center McMaster University
Istanbul Florence Nightingale Hospital Hamilton, Ontario, Canada
Istanbul, Turkey
xiv List of Contributors
Vrushali Ponde Alpaslan Senkoylu
Children’s Anaesthesia Services Department of Orthopaedics and Traumatology
Children’s Ortho Centre Gazi University
Surya Children Hospital Ankara, Turkey
Hinduja Healthcare Surgical Hospital
and Abdullah Shah
Holy Spirit Hospital Ghurki Trust Teaching Hospital
Mumbai, India Lahore, Pakistan
and
Holy Family Hospital Ajoy Prasad Shetty
New Delhi, India Department of Spine Surgery
Ganga Hospital
S. Rajasekaran Coimbatore, India
Department of Spine Surgery
Ganga Hospital Harwant Singh
Coimbatore, India Spine and Joint Centre
Pantai Hospital
Gregory Redding Kuala Lumpur, Malaysia
Pulmonary and Sleep Medicine Division
University of Washington School of Muhammad Tariq Sohail
Medicine Pakistan Academy of Medical Sciences
and Islamabad, Pakistan
Department of Pediatrics and
University of Washington School of Medicine Doctors Hospital & Medical Center
Seattle, Washington Lahore, Pakistan
Fernando Rios Patrick Thornley
San Diego Spine Foundation and Global Spine Division of Orthopaedic Surgery
Outreach McMaster University
San Diego, California Hamilton, Ontario, Canada
List of Abbreviations
Accelerated discharge (AD) Forced expiratory volume in the
Acid-fast bacilli (AFB) first second (FEV1)
Acquired immunodeficiency syndrome (AIDS) Forced vital capacity (FVC)
Active apex correction (APC) Foundation of Orthopedics and
Acute normovolemic haemodilution (ANH) Complex Spine (FOCOS)
Adolescent idiopathic scoliosis (AIS) Functional residual capacity (FRC)
Alanine aminotransferase (ALT) Global outreach programmes (GOPs)
Annual progression ratio (APR) Global Spine Care Initiative (GSCI)
Anteroposterior (AP) Global Spine Outreach (GSO)
Antidiuretic hormone (ADH) Gross domestic product (GDP)
Anti-retroviral therapy (ART) Gross national income (GNI)
Anti-tubercular chemotherapy (ATT) Growth guidance system (GGS)
Apical vertebra rotation (AVR) Growth rods (GRs)
Apical vertebral distance (AVD) Halo-gravity traction (HGT)
Artificial intelligence (AI) Health-related quality of life (HRQoL)
Bispectral index (BIS Index) Hemoglobin A1c (HbA1C)
Blended learning (BL) High-dependency unit (HDU)
Bone mineral density (BMD) High-income countries (HIC)
Breath holding time (BHT) Human immunodeficiency viruses (HIV)
C-reactive protein (CRP) Intensive care unit (ICU)
Central sacral vertical line (CSVL) International classification of
Central sterile services department (CSSD) diseases (ICD)
Cerebral palsy (CP) International normalised ratio (INR)
Classification for early-onset scoliosis (C-EOS) Intraoperative neuromonitoring (IOM)
Closing opening wedge osteotomy (COWO) Intravenous (IV)
College of Surgeons of East, Learning management system (LMS)
Central and Southern Africa (COSECSA) Learning outcomes (LO)
Compound muscle action potential (CMAP) Leg length discrepancy (LLD)
Computerised tomography (CT) Limited resources (LR)
Countries with limited resources (CLRs) Low- and middle-income countries (LMICs)
Diagnosis-related groups (DRGs) Magnetic Expansion Control MAGEC
Disc bone osteotomy (DBO) Magnetic growth rod (MGR)
Distal junctional kyphosis (DJK) Magnetic resonance imaging (MRI)
Early-onset scoliosis (EOS) Magnetically controlled
Electrocardiogram (ECG) growing rods (MCGR)
Elongation, derotation, and flexion (EDF) Managed care (MC)
End tidal carbon dioxide (ETCO2) Maputo Central Hospital (MCH)
Endotracheal (ET) Maximum expiratory pressures (MEP)
Epsilon-aminocaproic acid (EACA) Maximum inspiratory pressures (MIP)
Erythrocyte sedimentation rate (ESR) Mean arterial pressure (MAP)
Estimated blood loss (EBL) Memorandum of agreement (MOA)
Evidence-based medicine (EBM) Methicillin-resistant Staphylococcus
External remote controller (ERC) aureus (MRSA)
Face to face (F2F) Minimum alveolar concentration (MAC)
Fellow of College of Physicians Ministry of Health (MOH)
and Surgeons Pakistan (FCPS) Motor evoked potentials (MEP)
xv
xvi List of Abbreviations
National Health Services (NHS) Rib vertebral sternal complex (RVSC)
Neural axis abnormality (NAA) Scoliosis Research Society (SRS)
Neurofibromatosis (NF) Scoliosis Research Society Global
Neurophysiologic monitoring (NM) Outreach Mission Programs (SRS-GOP)
Nongovernmental organisations (NGOs) Scoliosis Research Society
Noninvasive blood pressure (NIBP) questionnaire (SRS-22r)
Nonprofit organisations (NPOs) Self-contained surgical platforms (SCSPs)
Nonsteroidal anti-inflammatory Self-sliding growth guidance (SSGG)
drugs (NSAIDs) Selling, general, and administrative (SG&A)
North American Spine Society (NASS) Shared decision-making (SDM)
Occult spinal dysraphism (OSD) Short-term surgical mission trips (STSMs)
Online learning (OL) Slipped capital femoral epiphysis (SCFE)
Operating time (OT) Society on Scoliosis Orthopaedic
Operation Straight Spine (OSS) and Rehabilitation Treatment (SOSORT)
Outpatient department (OPD) Somatosensory evoked potentials (SSEP)
Oxygen saturation (SPO2) Space available for lung (SAL)
Palestine International Cooperation Spring distraction system (SDS)
Agency (PICA) Syndrome of inappropriate
Partial thromboplastin time (PTT) antidiuretic hormone release (SIADH)
Patient controlled analgesia (PCA) Target controlled infusion (TCI)
Patient-reported outcomes measures (PROMs) Three dimensional (3D)
Pedicle subtraction osteotomy (PSO) Total intravenous anaesthesia (TIVA)
Physical medicine and rehabilitation (PM&R) Total lung capacity (TLC)
Polyvinyl chloride (PVC) Traditional growth rod (TGR)
Posteroanterior (PA) Triradiate cartilage (TRC)
Postoperative nausea vomiting (PONV) Tuberculosis (TB)
Postoperative pain management (POPM) Two dimensional (2D)
Preoperative autologous donation (PAD) U.S. Food and Drug Administration (FDA)
Prothrombin time (PT) United Nations Development
Proximal junctional failure (PJF) Programme (UNDP)
Proximal junctional kyphosis (PJK) University Hospital of Wales (UHW)
Pulmonary functional tests (PFT) Vertebral column resection (VCR)
Queens Medical Centre (QMC) Vertical expandable prosthetic
Randomised controlled trials (RCTs) titanium rib (VEPTR)
Rapid eye movement (REM) Virtual reality (VR)
Red blood cells (RBCs) World Health Organization (WHO)
Research and developmental (R&D) World Spine Care (WSC)
Resource-limited settings (RLS)
Rib vertebral angle difference (RVAD)
1 Introduction
Alaaeldin Azmi Ahmad
CONTENTS
Introduction......................................................................................................................................... 1
Discussion........................................................................................................................................... 2
Why Is This Book Necessary Now?..............................................................................................2
What Makes This Book Important?............................................................................................... 2
Conclusion.......................................................................................................................................... 3
References........................................................................................................................................... 4
INTRODUCTION 1. The treatment two decades ago for
EOS was similar to the management
Early onset scoliosis (EOS) includes all scoliotic
undertaken for adolescent deformity,
deformity for children under 10 years of age. It
i.e. correction and fusion under the
is a life-threatening disease, unlike adolescent
idiopathic scoliosis, which makes early interven- concept that a straight, shorter spine
tion crucial. Most of the patients in this category is better than a long, crooked spine.
have complex spine problems with associated Accordingly, there was no need to
comorbidities. These patients require a multidis- explore and write about EOS as a sepa-
ciplinary approach in a resource abundant facil- rate problem that demands a specific
ity with management subspecialised in spine management, until it became known
deformity. Ironically, the incidences of EOS are that pulmonary function would be
higher and more widespread in countries with compromised unless certain nonfusion
limited resources (CLRs), and except for a very techniques were employed.
sporadic provision of exemplary management of 2. The heterogenicity of this population
such patients in Asia, Africa, and Latin America, with different etiological backgrounds
these patients have no access to solutions with presented unique challenges in man-
which developed nations are equipped. None of agement for these patients. Many
the previously published books on EOS has a authors refrained from writing about
theme dedicated to this problem and the accom-
the management of this particular
panying solutions to this vacuum. This book
problem because there is still a lack of
will be the first to give guidelines based on the
consensus as too few evidence-based
successful programmes run by the most experi-
enced doctors and global thinkers. The upcom- studies have been conducted.
ing chapters will lay out a roadmap on how to 3. A long-standing myth that a very small
implement this service within the context of a number of children suffer from this
limited-resource region, unlike the past publica- problem; we know now that 20% of
tions dealing with the assumption that you have adolescent children with scoliosis had
all the resources within your reach and the only juvenile idiopathic scoliosis, which is a
missing link is the surgical technique; clearly part of EOS. If we now calculate 20%
this is not the case here. Below are several rea- of adolescent idiopathic scoliosis cases
sons explaining why there is a lack of publica- in the United States, for example, juve-
tions about EOS services in CLRs. nile idiopathic scoliosis refers to 20%
