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ScoliosisScoliosis Abnormal lateral curvature of Abnormal lateral curvature of
spine in which there is spine in which there is deformity in the coronal plane. deformity in the coronal plane.
May alter sagittal plane as May alter sagittal plane as wellwell Thoracic kyphosis normally = 30-Thoracic kyphosis normally = 30-
35 degrees35 degrees Range 10-50 degreesRange 10-50 degrees
Lumbar lordosis normally = 50-Lumbar lordosis normally = 50-60 degrees60 degrees
Range 35-80 degreesRange 35-80 degrees
Spinal rotation causes Spinal rotation causes posterior prominenceposterior prominence
Upto 10 degrees Upto 10 degrees is normal.is normal.
Can be seen as Can be seen as C- curve or S-C- curve or S-curve.curve.
S- curve is S- curve is usually usually compensatory.compensatory.
Demographics :Demographics :
Occurs in 2-3% of population below the age of Occurs in 2-3% of population below the age of 16 years.16 years.
0.1% have a curve greater than 40 degrees.0.1% have a curve greater than 40 degrees. Girls are more affected than boys.Girls are more affected than boys. Those with a curve of more than 30 degrees Those with a curve of more than 30 degrees
are generally girls, outnumbering boys by are generally girls, outnumbering boys by 10:1.10:1.
Generally progresses during the period of Generally progresses during the period of ‘growth spurts’.‘growth spurts’.
Adolescents are more routinely tested for this.Adolescents are more routinely tested for this.
AnatomyAnatomy
All bony elements are alteredAll bony elements are altered Vertebra are wedge shapedVertebra are wedge shaped Rib vertebral angle alteredRib vertebral angle altered Pedicles rotatedPedicles rotated
Discs are wedged as well Discs are wedged as well
Types of ScoliosisTypes of Scoliosis
CongenitalCongenital
NeuromuscularNeuromuscular Cerebral palsyCerebral palsy
Syndrome relatedSyndrome related Marfan’s syndromeMarfan’s syndrome
IdiopathicIdiopathic 80% are this80% are this
Etiological TheoriesEtiological Theories
GeneticGenetic Tissue deficienciesTissue deficiencies Growth abnormalitiesGrowth abnormalities Central nervous system alterationCentral nervous system alteration
GeneticGenetic
11% incidence in first relatives of 11% incidence in first relatives of patientspatients Normal incidence < 3%Normal incidence < 3%
Monozygote twins more commonMonozygote twins more common No gene identified to dateNo gene identified to date
Tissue DeficienciesTissue Deficiencies
Marfan’s syndrome deficient fibrillinMarfan’s syndrome deficient fibrillin Osteopenia noted in girlsOsteopenia noted in girls Elevated calmodulinElevated calmodulin
Involved in contractile properties thru Involved in contractile properties thru actin & myosinactin & myosin
Elevated in platelets Elevated in platelets No consistent findings to dateNo consistent findings to date
Growth AbnormalityGrowth Abnormality
Asymmetrical vertebral growthAsymmetrical vertebral growth Hueter-Volkman effect is suppression of Hueter-Volkman effect is suppression of
growth on concave sidegrowth on concave side Hypokyphosis during growth spurtHypokyphosis during growth spurt No increased incidence with growth No increased incidence with growth
hormonehormone No initiating factor identified No initiating factor identified
Central Nervous SystemCentral Nervous System
Different size cerebral corticesDifferent size cerebral cortices Altered equilibrium Altered equilibrium
Primary or secondaryPrimary or secondary Deficient melatoninDeficient melatonin
Chicken modelChicken model Inconclusive in humansInconclusive in humans
TerminologyTerminology
Named by apexNamed by apex Cervical if between C2-C6Cervical if between C2-C6 Cervicothoracic if between C7-T1Cervicothoracic if between C7-T1 Thoracic if between T2-T11Thoracic if between T2-T11 Thoracolumbar if between T12-L1Thoracolumbar if between T12-L1 Lumbar if between L2 and belowLumbar if between L2 and below
Primary vs secondaryPrimary vs secondary Structural vs non-structuralStructural vs non-structural
ClassificationClassification
Infantile:Infantile: 0-3 years old (.5%)0-3 years old (.5%) Juvenile:Juvenile: 4-11 years old (10.5%)4-11 years old (10.5%) Adolescent:Adolescent: 10-17 years old (89%)10-17 years old (89%) Adult:Adult: >18 years old>18 years old
HistoryHistory
Family historyFamily history Affected sibling 7 times more frequentAffected sibling 7 times more frequent Affected parent 3 times more frequentAffected parent 3 times more frequent
Recent growth historyRecent growth history Sexual maturitySexual maturity PainPain
‘‘Fatigue pain’Fatigue pain’ Post diagnostic painPost diagnostic pain ‘‘Severe pain’Severe pain’
Physical ExamPhysical Exam
Iliac crest heightIliac crest height Leg length Leg length
discrepancydiscrepancy Shoulder heightShoulder height Arm trunk spaceArm trunk space Scapular positionScapular position Trunk shiftTrunk shift Inspection of skinInspection of skin
Café au lait spotsCafé au lait spots
Physical Examination:Physical Examination:
Features suggestive of polio, Features suggestive of polio, neurofibromatosis, Von Reclinghausen neurofibromatosis, Von Reclinghausen syndrome, Down’s, Marfan’s, Hurler’s syndrome, Down’s, Marfan’s, Hurler’s syndrome, neural tube defects and syndrome, neural tube defects and osteogenesis imperfecta.osteogenesis imperfecta.
Forward protrusion of chest wall on affected Forward protrusion of chest wall on affected side.side.
Increased flank creases on opposite side.Increased flank creases on opposite side. Higher ASIS and PSIS on concave side.Higher ASIS and PSIS on concave side. Spinous process turned into concave side.Spinous process turned into concave side.
Tests of flexibility of Tests of flexibility of spine:spine:
Adam’s forward bending test.Adam’s forward bending test.
Pushing the curve from convex side and Pushing the curve from convex side and noting noting
the correction.the correction.
Lifting the patient up from head.Lifting the patient up from head.
Lateral bending. Lateral bending.
Neurologic ExamNeurologic Exam
Observe gaitObserve gait Hop testHop test Heel and toe walkHeel and toe walk Reflexes Reflexes
Early Detection:Early Detection: Visual examination Visual examination
of gait, posture, limb of gait, posture, limb length and lateral length and lateral curvature of spine.curvature of spine.
A posterior view A posterior view taken, bent at 90 taken, bent at 90 degrees at hips.degrees at hips.
Can also be Can also be detected accidently detected accidently when radiographs when radiographs are taken to rule out are taken to rule out other pathologies.other pathologies.
Once scoliosis is Once scoliosis is suspected:suspected:
A scoliosis series is A scoliosis series is ordered.ordered.
AP cervical, AP cervical, thoracic and thoracic and lumbar spine Xrays lumbar spine Xrays collimated to soft collimated to soft tissues needed.tissues needed.
Sometimes lateral Sometimes lateral views may also be views may also be necessary.necessary.
ImagingImaging
Plain x-raysPlain x-rays Need standing 36 inch cassetteNeed standing 36 inch cassette Posterior to anteriorPosterior to anterior
Decrease thyroid and breast exposure 3-7 Decrease thyroid and breast exposure 3-7 foldfold
Note rotationNote rotation Measure deformity by Cobb methodMeasure deformity by Cobb method Skeletal maturitySkeletal maturity
Cobb MethodCobb MethodChoose the most Choose the most tilted vertebrae tilted vertebrae above and below above and below the apex of the the apex of the curve.curve.
Draw a line Draw a line perpendicular to perpendicular to that vertebrae.that vertebrae.
The angle created The angle created between these between these intersecting lines intersecting lines is the Cobb angleis the Cobb angle..
RotationRotation
Spinous process rotates into Spinous process rotates into concavityconcavity
Pedicle positionPedicle position
Skeletal MaturitySkeletal Maturity
Triradiate cartilage fusionTriradiate cartilage fusion
Risser signRisser sign
MRIMRI
Neurologic deficitNeurologic deficit Infantile and juvenile curvesInfantile and juvenile curves
Spinal cord abnormality in younger Spinal cord abnormality in younger childrenchildren Infantile idiopathic scoliosis 50%Infantile idiopathic scoliosis 50% Juvenile 20%Juvenile 20%
Who needs an MRI:Who needs an MRI:
A thoracic curve to the left.A thoracic curve to the left. Painful scoliosis.Painful scoliosis. Abnormal neurological findings.Abnormal neurological findings. Untoward stiffness.Untoward stiffness. Deviation to one side during the Deviation to one side during the
bend test.bend test. Sudden rapid progression of a Sudden rapid progression of a
previously stable curve.previously stable curve.
Will the curve progress?Will the curve progress?
Three factors involved in progressionThree factors involved in progressionpatient’s genderpatient’s gender
future growth potentialfuture growth potential
curve magnitude at time of diagnosiscurve magnitude at time of diagnosis
Females are 10 times more likely to Females are 10 times more likely to have progression than males.have progression than males.
The greater the growth potential and The greater the growth potential and larger the curve = more likely to larger the curve = more likely to progressprogress
Curve ProgressionCurve Progression
Curves 30 to 50 degrees progress an Curves 30 to 50 degrees progress an average of 10 to 15 degrees over a average of 10 to 15 degrees over a lifetime.lifetime.
Curves > 50 at maturity progress Curves > 50 at maturity progress steadily at a rate of 1 degree per year.steadily at a rate of 1 degree per year.
Curves less than 30 at bone maturity Curves less than 30 at bone maturity are unlikely to progress.are unlikely to progress.
Medical complications:Medical complications:
At 100 degrees or greater: At 100 degrees or greater: increased potential for life increased potential for life threatening effects on pulmonary threatening effects on pulmonary function.function.
Psychologic illness: seen in up to Psychologic illness: seen in up to 19% of females with curves great 19% of females with curves great than 40 degrees as adults.than 40 degrees as adults.
Treatment principles:Treatment principles:
Orthotic braces - 74% success Orthotic braces - 74% success rate at halting progressionrate at halting progression
Must be worn 20 hours a day, but Must be worn 20 hours a day, but most pts are not compliant.most pts are not compliant.
Braces do not correct scoliosis.Braces do not correct scoliosis.
Surgical therapy is definitive, but Surgical therapy is definitive, but indicated only for those at 40 indicated only for those at 40 degrees or abovedegrees or above
Infantile TreatmentInfantile Treatment
Must prove idiopathicMust prove idiopathic 90% are left thoracic90% are left thoracic 3 female : 2 male3 female : 2 male 90% resolve spontaneously90% resolve spontaneously Predict progression by RVADPredict progression by RVAD
< 20 degrees 83% resolve< 20 degrees 83% resolve >20 degrees 84% progress>20 degrees 84% progress
Juvenile TreatmentJuvenile Treatment
Younger onset likely to progressYounger onset likely to progress
>30 degree curve almost always >30 degree curve almost always progressprogress
Some adolescent curves are missed Some adolescent curves are missed juvenilejuvenile
Adolescent TreatmentAdolescent Treatment
Most curves <10 degreesMost curves <10 degrees Boys = girls for these curvesBoys = girls for these curves Usually don’t progressUsually don’t progress
More sever curves (>30 degrees)More sever curves (>30 degrees) 8 girls : 1 boy8 girls : 1 boy
Predicting who will progressPredicting who will progress
Risk for ProgressionRisk for Progression Younger onsetYounger onset
Skeletal ageSkeletal age Risser 0-1 at presentation 60-70% progressRisser 0-1 at presentation 60-70% progress Risser 3 only 10% riskRisser 3 only 10% risk
Menses starts after growth spurtMenses starts after growth spurt Female more likely than maleFemale more likely than male Curve patternCurve pattern
Apex above T12Apex above T12 Degree at presentationDegree at presentation
20-29 degrees 68% risk for progression20-29 degrees 68% risk for progression 30-59 degrees 90% risk for progression30-59 degrees 90% risk for progression
Natural HistoryNatural History
If curve <30 degrees at maturityIf curve <30 degrees at maturity No adult consequencesNo adult consequences Unlikely to ever progressUnlikely to ever progress
Curves >45 degrees may progress a Curves >45 degrees may progress a degree/yeardegree/year
Mortality not increased unless curve Mortality not increased unless curve >90 degree>90 degree Right heart failureRight heart failure Decreased pulmonary functionDecreased pulmonary function
Treatment : 10 degrees Treatment : 10 degrees curve or lesscurve or less
This curve is considered normal.This curve is considered normal. No action is taken.No action is taken. Follow up appointments are Follow up appointments are
prescribed to monitor the patient.prescribed to monitor the patient. Usually done every 3-6 months, but Usually done every 3-6 months, but
at the physician discretion.at the physician discretion.
Treatment:10 to 25 Treatment:10 to 25 degree curvedegree curve
Sometimes no treatment needed, if Sometimes no treatment needed, if no progression.no progression.
Begins with simple orthotics(very Begins with simple orthotics(very effective)effective)
daytime/nighttime braces.daytime/nighttime braces. Shoe lifts for leg length Shoe lifts for leg length
discrepancies.discrepancies. Stretches, exercises. Stretches, exercises.
Shoe Lifts:Shoe Lifts:
Used for leg length Used for leg length discrepancies.discrepancies.
Worn in regular Worn in regular shoes.shoes.
Places opposing Places opposing pressure on pressure on scoliosis curvatures.scoliosis curvatures.
Must be worn Must be worn during every during every scoliosis radiograph.scoliosis radiograph.
Treatment: 25 to 35 Treatment: 25 to 35 degree curvedegree curve
Day and night brace worn 20+ Day and night brace worn 20+ hours/day.hours/day.
Shoe lifts may also be needed.Shoe lifts may also be needed.
Stretches and exercises to loosen Stretches and exercises to loosen muscles and to relieve pain if muscles and to relieve pain if present.present.
Treatment: 45 degree + Treatment: 45 degree + curve curve
Almost always treated with surgery.Almost always treated with surgery. Vertebrae are fused using-Vertebrae are fused using- Bone grafts.Bone grafts. Hardware(metal splints)Hardware(metal splints) Still require braces to be worn in post Still require braces to be worn in post
op period.op period. Causes growth to stop.Causes growth to stop. Can cause nerve damage, infection and Can cause nerve damage, infection and
other problems.other problems.
Left untreated:Left untreated:
If progressing, can worsen upto 70 If progressing, can worsen upto 70 degrees + curve.degrees + curve.
Places pressure on vital organs.Places pressure on vital organs.
Can cause cardio-respiratory problems.Can cause cardio-respiratory problems.
Can eventually become untreatable.Can eventually become untreatable.
Non-Operative Non-Operative TreatmentTreatment
<25 degrees monitor every 4-12 <25 degrees monitor every 4-12 monthsmonths Depends on skeletal maturityDepends on skeletal maturity
>25 degrees monitor every 3-6 months>25 degrees monitor every 3-6 months >30 degrees in skeletally immature >30 degrees in skeletally immature
bracebrace Curve change by 10 degrees braceCurve change by 10 degrees brace Curve >40-45 degrees surgeryCurve >40-45 degrees surgery
Braces :Braces :
Made of polypropylene.Made of polypropylene. Contoured to size and Contoured to size and
shape of body.shape of body. Curved to oppose Curved to oppose
specific points of specific points of scoliosis curvature.scoliosis curvature.
Flexible and Flexible and comfortable.comfortable.
Worn under clothing.Worn under clothing. Nighttime/daytime use.Nighttime/daytime use. Must be worn faithfully.Must be worn faithfully.
BracingBracing
Duration and time in braceDuration and time in brace 23 hours per day23 hours per day Wear until skeletally matureWear until skeletally mature
TypesTypes MilwaukeeMilwaukee Underarm orthosisUnderarm orthosis
Electrical stimulationElectrical stimulation
Successful BracingSuccessful Bracing
Prevent curve progressionPrevent curve progression Randomized studyRandomized study
Braced 74% did not progressBraced 74% did not progress Not braced 34% did not progressNot braced 34% did not progress
Electrical stimulationElectrical stimulation 33% did not progress33% did not progress
Charleston brace still controversial Charleston brace still controversial
Problems with BracesProblems with Braces
Argued efficacyArgued efficacy Narrow treatment window to initiateNarrow treatment window to initiate Poor compliancePoor compliance Must have good orthotistMust have good orthotist
Curves corrected by 20 degrees in Curves corrected by 20 degrees in brace do betterbrace do better
SurgerySurgery
Failed bracingFailed bracing Curves >45 Curves >45
degreesdegrees Unbalanced curves Unbalanced curves
>40 degrees>40 degrees Surgery is fusion Surgery is fusion
with with instrumentationinstrumentation
Surgical Options:Surgical Options:
Infantile and juvenile scoliosis:Infantile and juvenile scoliosis: <8 yrs- instrumentation without <8 yrs- instrumentation without
fusion.fusion.
After 8 years- anterior and posterior After 8 years- anterior and posterior spinal fusion.spinal fusion.
After 11 years- posterior spinal fusion.After 11 years- posterior spinal fusion.
Surgical Options:Surgical Options:
Adolescent scoliosis:Adolescent scoliosis:
Posterior spinal fusion with Posterior spinal fusion with instrumentation.instrumentation.
Anterior spinal fusion if younger than Anterior spinal fusion if younger than 11 years and with open triradiate 11 years and with open triradiate cartilage.cartilage.