Idiopathic Scoliosis Dr. Donald W. Kucharzyk Clinical Assistant Professor University of Chicago...

““Idiopathic Scoliosis”Idiopathic Scoliosis”

Dr. Donald W. KucharzykClinical Assistant Professor

University of ChicagoChildren’s Hospital

““Idiopathic Scoliosis” Idiopathic Scoliosis”

• Defines a common and potentially severe musculoskeletal disorder

• The term scoliosis is derived from the Greek word meaning “crooked” as first used by Galen in 131 A.D.

• References are made to scoliosis since ancient times as seen in ‘Corpus Hippocraticum’


“Etiology”• Remains unknown• Several studies have attempted to

look into this and various factors have been postulated: genetic, tissue deficiencies, vertebral growth abnormalities, and central nervous system theories


“Genetic Factors”• Risenborough found a 11.1%

incidence of scoliosis in first born relatives of patients with idiopathic scoliosis

• Twins show a concordance of scoliosis with an incidence of 92% monozygotic and 63% dizygotic


“Genetic Factors”• Despite this confirming evidence of

a genetic etiology, the gene and gene products responsible for the development of idiopathic scoliosis remains still unknown


“Tissue Deficiencies”• Primary pathology centered in the

structural tissues of the spine• Fibrous Dysplasia results in

dysplastic, mis-shapened vertebrae• Muscle disorders such as Duchene’s

lead to a collapsing scoliosis


“Tissue Deficiencies”• Soft tissue collagen disorders such as

Marfan’s have a clear association with scoliosis (defect in fibrillin)

• Osteopenia has been associated with idiopathic scoliosis…bone mineral density lower in girls aged 12 to 14 than a matched control with scoliosis: mechanism unknown


“Vertebral Growth Abnormality”• Milner and Dickson postulated a

differential growth rates between the right and left sides of the spine

• Results in abnormal biomechanical loading of the spine: Heuter-Volkmann effect


“Vertebral Growth Abnormality”• Dickson postulated a discrepancy

between growths of the anterior and posterior spinal columns

• Irregularities in the sagittal shape of the spine during rapid adolescent growth may contribute to development of scoliosis

• Scoliotic patients are taller and thinner


“Central Nervous System”• Goldberg noted greater asymmetry

of the cerebral cortices• Abnormalities in equilibrium and

vestibular functions have been noted in scoliosis patients

• Melatonin and the pineal gland has been postulated


“Central Nervous System”• Malchida et al, Hilibrand et al, and

Bagnall et al have all looked at melatonin levels in blood and urine

• Paraspinal muscle histology revealed denervation changes, also sarcolemma changes were seen at the myotendinous junction supporting a neuropathic cause


“Natural History”• Understanding this is essential to

determining when treatment is necessary

• Few natural history studies examine curve progression in the untreated skeletally immature population


“Natural History”• Curves under 20 degree’s are are

low risk for progression• Certain factors due influence the

natural history: sex, remaining growth, curve magnitude, and curve pattern


“Natural History”• Sex: females progress the most• Remaining Growth: Risser sign,

Menarchal status, and Peak Height Velocity

• Curve Magnitude: ‘Lonstein et al”• Curve Pattern: Double curves and

thoracic curves likely to progress followed by thoracolumbar and lumbar


“Classification”• Curve Location: cervical apex C2-C6 Cervicothoracic apex C7-T1 Thoracic apex T2-T12 Thoraocolumbar apex T12-L1 Lumbar apex L2-L4


“Classification”• Age at Onset: Infantile: age birth to 3 years Juvenile: age 4 to 10 years Adolescent: age 11 to 17 years Adult: age 18 years up


“Prevalence”• 0.5 to 3 per 100 (curves over 10

degrees)• 1.5 to 3 per 1000 (curves over 30

degrees)• Based upon age types: 0.5%

infantile, 10.5% juvenile, and 89% adolescent


“Prevalence”• When a sibling or parent has

scoliosis: seven fold increase(sibling) and three fold increase(parent) compared to general population


“Clinical Features”• Pain: not a common complaint.• Discomfort can be a common

feature but not severe pain.• ‘Ramirez et al’ noted mild back

discomfort and fatigue in 23% • If severe pain: must question

etiology of the idiopathic curve


“Clinical Examination”• Evaluation of trunk shape, trunk

balance, neurologic system, limb length, skin markings and any skeletal abnormalities

• Adams forward bend test• Radiologic Assessment: standing PA

and lateral


“Interpretation of Scoliosis Film”• Soft tissue abnormalities• Congenital bony abnormalities• Pedicle appearance and width• Curve assessment (Cobb Method)• Vertebral rotation (Nash and Moe)• Skeletal Maturity


“Curve Pattern Classification”• King-Moe Classification: King I: Rt T Lt L lumbar larger King II: Rt T Lt L thoracic larger King III: Rt Thoracic King IV: Long Thoracolumbar King V: Double thoracic


“Curve Pattern Classification”• Lenke Classification: more

comprehensive and considers both frontal and sagittal plane deformity

• Currently being evaluated for practicality and usefulness

• ‘Spine Volume 26 Number 21 Nov. 1, 2001’


“General Treatment Concepts” OBSERVATION• No treatment needed if curve

magnitude under 25 degrees• Repeat evaluation in 3 to 4 months• If 7 to 10 degree change then

considered progression and treatment needed


“General Treatment Concepts” BRACE TREATMENT• Nachemson 1995: effectiveness of

bracing versus observation…bracing better

• Types of braces available: Milwaukee, TLSO(Boston), Charleston Bending Brace, SpineCor

• Brace wear duration


“Types of Braces”• Milwaukee and Boston: data

supports good results with either• Charleston Bending Brace: variable

results; “Price et al” 79% success “Katz et al” Boston vs Charleston and Boston better “Howard et al” compared all three with Boston/TLSO better of the three


“Types of Braces”• Griffet et al: “SpineCor system” worn as an undergarment allows normal spine movement while

applying a dynamic corrective force limitation: progressive curves under 30 degrees initial data is promising


BRACE TREATMENT• Brace treatment is effective• Does change the Natural History• Full-time use better than part-time “Rowe et al: 23 hrs better”• Indications: progressive curves over

25 degrees; initial curve presentation of between 30 and 40 degrees


BRACE TREATMENT• In brace radiographs are important

and obtained in 2 to 4 weeks• 40 to 50% correction for Boston• 70 to 90% correction for Charleston• Insufficient in-brace correction leads

to unsatisfactory outcomes


SURGICAL CORRECTION GOALS• Reduce the magnitude of the curve• Obtain fusion to prevent progression• Create a well-balanced spine


SURGICAL CORRECTION INDICATIONS• Curves over 45 degrees• Trunk deformity(rotation)• Trunk balance• Progressive curves despite bracing


SURGICAL CORRECTION INSTRUMENTATION• Harrington• Luque• Cotrel-Dubousset• TRSH• Isola• Colorado II


SURGICAL CORRECTION MECHANISM OF CORRECTION• Frontal plane realignment through

translation• Distraction increases thoracic

kyphosis and reduces the scoliosis• Compression corrects the scoliosis

and restores maintains lumbar lordosis


SURGICAL CORRECTION “Newer Techniques”• Pedicular screws: Suk et al reported

better frontal plane correction and improved de-rotation

• Hammill et al reported that screws reduced end vertebra tilt better than with hooks


SURGICAL CORRECTION “ANTERIOR APPROACH”• Used to mobilize a large curve in

conjunction with posterior fusion• Limits the number of segments to be

fused in thoracolumbar/thoracic curves

• Allows anterior instrumentation• Eliminates crankshaft phenomenon


SURGICAL CORRECTION “ANTERIOR APPROACH”• Dwyer and Schafer were the first• Kaneda et al: positive results• Betz et al: re-established kyphosis• Picetti and Crawford et al:

endoscopic release and instrumentation resulted in less pain, improved muscle function and smaller incisions


OUTCOME OF SURGICAL INTERVENTION• Harrington: 48% coronal improvement• CD: 61% coronal and sagittal plane

improvement• Anterior correction: 58% improvement


GENERAL GUIDELINES FOR TREATMENT OF SCOLIOSIS• Under 20 degree’s: observe• 20 to 30 degree’s: observe with

frequent follow-up; progression then brace

• 30 to 45 degree’s: brace unless Risser 4/5 then observe

• 45 plus degree’s: instrumentation


THANK YOU

Idiopathic Scoliosis Dr. Donald W. Kucharzyk Clinical Assistant Professor University of Chicago...

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