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ENANTIOMORPHIC DISORDER CONCEPT TO EXPLAIN THE LEFT-RIGHT LENGTH ASYMMETRIES OF PAIRED SKELETAL STRUCTURES IN IDIOPATHIC SCOLIOSIS: IMPLICATIONS FOR ETIOLOGIC THEORY AND PREVENTIVE SURGERY

¹ The Centre for Spinal Studies and Surgery, Queen’s Medical Centre, Nottingham, UK , ² Department of Human Anatomy & Cell Biology & Royal Liverpool Children’s Hospital, University of Liverpool, UK , ³ Department of Orthopaedic Surgery, King’s Mill Hospital, Mansfield, UK (Supported by AO).

In idiopathic scoliosis the detection of extra-spinal left-right skeletal length asymmetries in the upper limbs, ribs, ilia and lower limbs [1–7] begs the question: are these asymmetries unconnected with the pathogenesis, or are they an indicator of what may also be happening in immature vertebrae of the spine? The vertebrate body plan has mirror-image bilateral symmetries (mirror symmetrical, homologous morphologies) that are highly conserved culminating in the adult form [8]. The normal human body can be viewed as containing paired skeletal structures in the axial and appendicular skeleton as a) separate left and right paired forms (e.g. long limb bones, ribs, ilia), and b) united in paired forms (e.g. vertebrae, skull, mandible). Each of these separate and united pairs are mirror-image forms – enantiomorphs. In idiopathic scoliosis, genetic and epigenetic (environmental) mechanisms [9–11] may disturb the symmetry control of enantiomorphic immature bones [12–13] and, by creating left-right endochondral growth asymmetries, cause the extra-spinal bone length asymmetries, and within one or more vertebrae create growth conflict with distortion as deformities (= unsynchronised bone growth concept) [14].

Conclusion: This enantiomorphic disorder concept applied to the axial skeleton during infancy, juvenility and adolescence – through reductionism into the molecular mechanisms of growth plate responses to different hormones at successive phases of development – provides a new theoretical insight to explain the whole body deformity of AIS. The concept suggests preventive surgery on spine and ribs.

Correspondence should be addressed to Jeremy C T Fairbank at The Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX7 7LD, UK