SCOLIOSIS

Dr. Eman Baraka

Lecteurer of Rheumatology, Physical Medicine&

RehabilitationBenhaUniversity

SCOLIOSIS

Dr. Eman Baraka

Lecteurer of Rheumatology, Physical Medicine&

RehabilitationBenhaUniversity

Normal Spinal Curves

Each section of the

spine has a natural

curve .

Viewed from the side :

1.The cervical and

lumbar spines have

lordotic, or slight

concave curves .

2.The thoracic spine has

a kyphotic, or gentle

convex curve .

The normal thoracolumbar

spine is relatively straight

in the sagittal plane and

has a double curve in the

coronal plane. As shown

below, the thoracic spine

in convex posteriorly

(kyphosis) and the lumbar

spine is convex anteriorly

(lordosis). Normally there

should be no lateral

curvature of the spine

•Scoliosis – lateral

•(side-to-side )curve

•of the spine.

Scoliosis is a complicated deformity

that involved lateral curvature of the

spine greater than 10o accompanied

by vertebral rotation, excluding

mobile scoliosis .

.11-Lateral deviation of the spine

2 .Longitudinal rotation of the vertebrae(torsion: procesus spinosus rotates

toward the concavity, while the body of the vertebrae rotates toward the

convexity.)

The body of the vertebrae are wedged on the side of the concavity.

The spine changes its shape and way of functioning.

- - SIMPTOMSSIMPTOMS

3.When the vertebrae rotates, the ribs also rotates, therefore we find a rib hump.

- - SIMPTOMSSIMPTOMS

4 .The intercostal space is reduced on the concav side (ribs are getting

closer) .

5 .The intervertebral space is narrower on the concav side, and wider on the

convex side.

- - SIMPTOMSSIMPTOMS

6 .The vertebral canal is narrower on the convex side .

- - SIMPTOMSSIMPTOMS

7 .Constriction of the vertebrae (the wedge of the vertebrae is situated on the concav side; the bigger wedge is

located in the apex of the deformation).

- - SIMPTOMSSIMPTOMS

• The apical vertebra – in a curve, the vertebra most deviated laterally from the vertical axis that passes through the patient's sacrum, i.e. from the central sacral line

• Structural - usually combined with a rotation of the vertebrae.

• Non structural – scoliotic poor posture

• Classification of scoliosis

• Nonstructural scoliosis postural scoliosis resolves when the child is recumbent compensatory scoliosis caused by leg-length discrepancy;

there is no fixed rotation of the vertebrae

• Transient non structural scoliosis

sciatic scoliosis hysterical scoliosis inflammatory scoliosis

• Structural scoliosis idiopathic (70 - 80 % of all cases) congenital neuromuscular

TYPES OF structural SCOLIOSISTYPES OF structural SCOLIOSIS

1. IDIOPATHIC – the cause is unknown.

2. NEUROMUSCULAR – is due to loss of control of the nerves or

muscles that support the spine. The most common causes of

this type of scoliosis are cerebral palsy and muscular dystrophy.

3. DEGENERATIVE – may be caused by breaking down of the discs

that separate the vertebrae or by arthritis in the joints that link

them.

4. CONGENITAL – due to abnormal formation of the bones of the

spine and is often associated with other organ defects.

Idiopathic scoliosis accounts for about 80 %

of all cases of the disorder, and has a

strong female predilection (7:1).

It can be subclassified into .1INFANTILE – Curvature appears before age

three2-JUVENILE – Curvature appears between

ages three and ten.

3-ADOLESCENT– Curvature usually appears between ages of ten and 13, near the

beginning of puberty .4-ADULT - Curvature begins after physical

maturation is completed .

Infantile Idiopathic

Scoliosis of 20 month-old boy

Young boy with juvenile idiopathic scoliosis

• Adolescent Idiopathic Scoliosis )AIS(

• Definition:)10x10)

• Adolescent Idiopathic Scoliosis (AIS) is a deformity that involved lateral curvature of the spine greater than 10o accompanied by vertebral rotation and occurs in children aged 10 years to maturity.

• AIS may start at puberty or during an adolescent growth spurt. 5 % of adolescents will be found to have some form of scoliosis.

• The incidence of AIS of females to males is about 9:1 3% of these girls usually develop more severely progressive curves than males that require treatment.

Assessment of the scoliotic child

(I) CLINICAL HISTORY of AISThe following is a list of questions that may ask to cover causes and important risk factors:1. The of age 2. The family history3. History suggesting any underlying medical conditions to exclude individuals who have 2ry scoliosis.

This will help us to determine the number of years that remain before the child reaches skeletal maturity. The curve mainly continue to progress throughout adulthood.

(A) Symptoms of scoliosis1.Deformity is the first symptoms:2.PainMany patients are asymptomatic while others

complain of muscle aches in the lower back after sitting or standing a long time ا

a. The pain is mechanical in nature mainly at night and is probably caused by disc and/or facet joint degeneration.

The pain becomes worse the longer they are ambulatory and the symptoms are rapidly relieved upon lying down

b. In sometimes, the pain is radicular in nature; due to nerve root compression.

(B) Neurological complain

(II) The clinical examination of AISThis clinical assessment provides the physician

with a “baseline” from which future curve progression can be measured & determines the

strategies of ttt.

•Complete general & neurological examinations:

During the physical and neurological examinations the physician has to evaluate the

patient’s health and general fitness.

•. Cardiopulmonary assessment:Checking for medical complications and testing of

functions of the heart and lungs •Neurological examination:

To exclude other neurological causes of scoliosis

.Physical assessment for the back:Physical assessment for the back in 3

positions: standing, lying & suspending. Back exam : Inspection, palpation & ROM2. Physical assessment for the

extremities:3. Physical assessment for the chest4. Assessment for the gait5. Special diagnostic tests. • Plumb line• Adam’s forward bending test• Scoliometer

Lowered shoulder

Lowered shoulder blade

Curvature of the spine

Inequality of the Lorent`s triangle

Lowered pelvis

EXAMINATIONEXAMINATION

Standing posture shows an elevated Rt shoulder and scapular asymmetry

Forward bend demonstrates the large right rib hump. Forward bend test brings out the rib prominence and is a vital part of

the clinical examination. The rib hump that is often noticeable in scoliosis is due to rotation of the rib cage.

AIS leads to lateral curvature of the spine, a twisting )rotation( of the spinal column and rib hump.

The scoliosis is determined accordingto the convex side.

The scoliosis is determined according to the convex side.

RIGHT SCOLIOSIS LEFT SCOLIOSIS

Scoliosis may develop:• In the whole spine )total scoliosis(• Only in one part of the spine )partial scoliosis(

Scoliosis may be: Simplex Duplex Triplex

– with the primary and compensatory

curves

• Cervical

• Cervicotoracal

• Toracal

• Toracolumbar

• Lumbar

• Lumbosacral

ScoliometerIt is quite accurate in identifying the degree of

trunk rotation done by a physician, school nurse & Parents. Children with reading of 5 or more

have a curve measuring less than 20.

Imaging evaluation1.The radiological

assessment• The radiographic assessment of the scoliosis patient begins with erect anteroposterior and lateral views of the entire spine (occiput to sacrum).

• In addition, the examination should include a lateral view of the lumbar spine to look for the presence of spondylolysis or spondylolisthesis (prevalence in the general population is about 5 %). The scoliotic curve is then measured from the AP view

Components of the curve

•Apical vertebra: It is the vertebra at the summit of the curve.•End vertebrae: Are the last vertebrae of the curve.•Neural vertebra: It is the vertebra at the junction of two primary curves and it is part of both curves; it is both the lowest vertebra in the upper curve and the highest in the lower curve.

The shape of the spinal curves are usually S or C-shaped.

The scoliotic curve is named according 1.To side of the convex side. (Right or left scoliosis). 2- to the location of the apex of the curve, as shown below.

1.Cobb’s method To use the Cobb method, one must first decide which vertebrae are the end-vertebrae

of the curve. These end-vertebrae are the vertebrae at the

upper and lower limits of the curve which tilt most severely toward

the concavity of the curve. Once these vertebrae have been selected, one then draws a line along the upper endplate of the upper body and along the lower endplate of the lower body as shown below.

X-ray 53° Rt thoracic curve

1.Determination of the severity of rotation

• Mild scoliosis: curves between 0-69 • Severe scoliosis: curves between 70-99 • Very severe scoliosis: curves 100 or over.

• 2. Assessment of functional state of the back

• If the spine is compensated or uncompensated.

• An uncompensated spine as in Paralytic, congenital scoliosis & AIS

(1) The primary curve (structural, fixed):It is identified by persistence of lateral curvature with fixed rotation on forward bending. This curving may be progress until epiphysial closure is completed & the end of skeletal maturity.(2) The secondary curves =Compensatory curves: 2nd curves develop to counter balance 1ryThey may be early mobile, by progression of the condition, they may become fixed.

The aim of the presence of the 2nd

curves:

To maintain & develop a balance of the

body by keeping the head of the patient in

vertical level with the horizontal level of

ocular vision i.e. to maintain the alignment

of the body with the center of gravity.

lateral bending films are often taken to assess the rigidity or flexibility of the

curves

2. The Harrington factor This method is used to measure the

severity of spine curvature & to follow progression. The angle of the curvature is divided by the number of the vertebrae forming the curve and the resultant is the Harrington factor. A value 5 or more is a significant of severe deformity.

3. The method of Nash and Moe This technique is used to measure vertebral

rotation related to rotation of the vertebral pedicle & by dividing the vertebral body into 4 segments.Grades 1 and 2: The convex pedicle is visible on AP view. Grades 3 and 4: The convex pedicle has twisted out of view.

2-Estimate the degree of rotation of the vertebra at the apex of the curve by looking at the relation of the pedicles to midline.

3-The presence of any vertebral or rib anomalies should be reported

X-ray 53° Rt thoracic curve

2. MRI MRI scan of the spine can be requested to rule out an

intracanal spinal lesion that can result in scoliosis.If there are any neurological deficits that would

indicate impingement of the spinal cord )e.g. hyperactive reflexes(

Laboratory investigations Laboratory tests are normal in-patients with AIS

Prognosis of AIS 1. The curve pattern. 2. Age of recognition

3. Skeletal age4. Status of ossification pattern of the iliac apophysis and

the vertebral ring5. Stage development of the physical characteristics of

puberty

Coronal images

Scoliotic deformity

Risser SignThe Risser Sign looks at the iliac crest

growth plate, a fan-shaped part of the pelvis that fuses with the pelvis at maturity. When the

ossification of the iliac apophysis is complete also the vertebral ring apophysis is closed----

skeletal maturation. Vertebral growth usually ceases at bone

age of 16 years in girls and 18 years in boys.

At skeletal maturity, Progression may stop in a curve is less than 45

Progression continue in a curve is greater than 50So, the treatment objective is to try to get the child into adulthood with less than 50 curvature. The girls skeletal maturity rarely continues more than 18 months after the menarche.

Risser's sign

• Risser grade: Each grade from 1-4 corresponds with a 25% increment of iliac crest ossification. A low grade indicates that the skeleton still has considerable

growth. A Risser grade 5 corresponds to skeletal maturity. The lower the Risser

grade at the time of curve detection, the greater the risk of progression

One can also look for evidence of maturation in

the vertebral bodies themselves at the endplates,

as shown below When the plates blend in with the

vertebral bodies to form a solid union, maturation

is complete .

determination of vertebral maturity

Treatment

Physical training:Therapeutic exercises for scoliosis & complications

Back braces

Surgical interventions

Patient & family education -Principles of anatomy of the spine,

body mechanics & posture.Nature of the disease

Applications of orthosisModified life style

Management of scoliosis

Three treatment options for AIS: • Follow up (observation) &Alternative

treatment• Orthosis & Physical programs • Scoliosis surgery.

Main aims of treatment• . Maintaining balanced spine and

preventing more deformity until skeletal maturity.

• Prevent more complications. • Change the child's life style.

•Observation Observation is generally for patients whose curves are less than 25-30º who are still growing, or for curves less than 45º in patients who have completed their growth. Scoliosis surgeons often wish to observe the scoliosis every few years after patients complete their growth to make sure it does not progress into adulthood.

• Alternative TreatmentAlternative treatments to prevent curve progression or prevent further curve progression such as chiropractic medicine, physical therapy, yoga, etc. have not demonstrated any scientific value in the treatment of scoliosis. However, these and other methods can be utilized if they provide some physical benefit to the patient such as core strengthening, symptom relief, etc. These should not, however, be utilized to formally treat the curvature in hopes of improving the scoliosis.

Most curves can be treated nonoperatively if they are detected before they become too

severe. However, 60 % of curvatures in rapidly growing prepubertal children will progress. Therefore, scoliosis screening

should be done. This screening is probably not necessary until the fifth grade. Beyond

that point, boys and girls should be examined every 6 - 9 months. Generally, curvatures less than 30 degrees will not

progress after the child is skeletally mature. Once this has been established, scoliosis screening and monitoring can usually be

stopped. However, with greater curvatures, the curvature may progress at about 1

degree per year in adults. In this population, monitoring should be continued .

The indications of back Orthosis:1.All preadolescent children when the

curve measures 25-40 degrees in a skeletally immature patient.

Since the majority of curve progression happens during a child's growth phase, bracing treatment is continued until the end of growth to keep the correct the spinal alignment.2. To relief the pain by reduction of

axial loading.Contraindication of back orthosis:

1. Growing children + the curve is 45-50 2. Child with already skeletally mature +

the curve 50 or more.

Back OrthosisBiomechanics of orthosis :

Orthosis does not reduce the amount of angulation already present but it is designed to stop the progression of the spinal curve.

Orthosis can successfully prevent curve progression in the majority of patients(80%).

Orthosis applies three-point pressure to the curvature to prevent its progression: end point control, transverse loading & curve correction.

So, the back orthosis is a kinetic, not a static brace in treatment of AIS.

Types of back Orthosis

(I) High profile orthosis Cervico – thoracolumbo - sacral orthosis

(CTLSO): Milwaukee orthosis: It is the ideal brace for AIS.

(II) Low profile orthosis Thoracolumbo -sacral orthosis (TLSO) :

Boston orthosis. Charleston bending orthosis.

(III) Recently computer aided design (CAD) using the (Insignia technique)

It is 3 dimensional image of body parts transmitted to the computer for more accuracy of the measurements.

Milwakee Brace

Milwakee brace

Boston Brace

Boston Brace (low profile brace)

Boston Brace

What is the protocol for wearing the orthosis? 1. Full time protocol: 23 hours a day. It can be taken off to swim or to play sports as Boston & Milwaukee. Most patients start wearing the orthosis at nighttime and then gradually extend the time into the day. 2. Part time protocol: It is worn only at night while the child is asleep as Charleston3. After 4 -5 weeks: the patient will return to the scoliotic clinic for an x-ray in the orthosis and a follow-up examination to ensure that the brace is correcting the curve effectively.4. The child is skeletally mature and finished growing.

Boston Brace in X-ray

Response of curves to bracing 1 .Most curves substantially improved :

Most curves will appear substantially improved (80%) while the brace is worn; however, the great majority will return to the original pre-

treatment magnitude shortly after brace discontinuance.

2.Some spinal curves will continue to progress.

Unfortunately, even with appropriate bracing, some spinal curves will continue to progress .

Many times it is very difficult to predict which curves will continue to progress and need

surgery later, especially if the child is young and skeletally immature..

Disadvantages of back bracingBraces can be uncomfortable, unattractive, hot,

and can make a child self-conscious even though well disguised under clothing.

It is recommended that a cotton T-shirt be worn underneath the brace so that the brace does not

have direct contact with the skin.

Also it is important during removing of the orthosis to check the skin for any signs of

breakdown

Children may loose weight from the brace, due to increased pressure on the abdominal area.

Surgical treatment is recommended for patients whose curves are greater than 45o while still growing, or are continuing to progress greater than 45o when growth stopped .

The goal of surgical treatment is two-fold: first, to prevent curve progression and secondly to obtain some curve correction Surgical management of scoliosis is generally intended to prevent future consequences of progressive deformity .

Surgical Management

Although most adolescents have little impairment or

symptoms related to their deformity, future

consequences include the possible :

• development of progressive pain

• pulmonary or cardiac compromise

• progressive deformity and

unacceptable appearance

• neurological deterioration

• Surgical treatment today utilizes metal implants that are attached to the spine, and then connected to a single rod or two rods. Implants are used to correct the spine and hold the spine in the corrected position until the instrumented segments fuse as one bone.

• The surgery can be performed from the back of the spine (posterior approach) through a straight incision along the midline of the back or through the front of the spine (anterior approach)

Although there are advantages and disadvantages to both approaches, the posterior approach is utilized most often in the treatment of AIS and can be utilized for all curve types. The anterior approach is an option when a single thoracic curve or a single lumbar curve is being treated. Following surgical treatment, no external bracing or casts are used. The hospital stay is generally between 3 and 6 days. The patient can perform regular daily activities and generally returns to school in 3-4 weeks. Depending on the activities of the patient, full participation is allowed between 3 and 6 months after surgery. Most children will not need pain medications 10-14 days after surgery.

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