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 .
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
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 .
• 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.
(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
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(
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.
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.
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
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
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 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.
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.
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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