Approach to a Approach to a case of Scoliosiscase of Scoliosis

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.

Forward Bend TestForward Bend TestAdam’s signAdam’s sign

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

BracesBraces

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

Treatment Algorithm Treatment Algorithm

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.

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