1. Approach to a case of Scoliosis

2. Scoliosis
Abnormal lateral curvature of spine in which there is deformity in the coronal plane.
May alter sagittal plane as well
Thoracic kyphosis normally = degrees
Range degrees
Lumbar lordosis normally = degrees
Range degrees
Spinal rotation causes posterior prominence

3. Upto 10 degrees is normal.
Can be seen as C- curve or S-curve.
S- curve is usually compensatory.

4. Demographics : Occurs in 2-3% of population below the age of 16 years.
0.1% have a curve greater than 40 degrees.
Girls are more affected than boys.
Those with a curve of more than 30 degrees are generally girls, outnumbering boys by 10:1.
Generally progresses during the period of ‘growth spurts’.
Adolescents are more routinely tested for this.

5. Anatomy All bony elements are altered Discs are wedged as well
Vertebra are wedge shaped
Rib vertebral angle altered
Pedicles rotated
Discs are wedged as well

6. Types of Scoliosis Congenital Neuromuscular Syndrome related
Cerebral palsy
Syndrome related
Marfan’s syndrome
Idiopathic
80% are this

7. Etiological Theories Genetic Tissue deficiencies Growth abnormalities
Central nervous system alteration

8. Genetic 11% incidence in first relatives of patients
Normal incidence < 3%
Monozygote twins more common
No gene identified to date

9. Tissue Deficiencies Marfan’s syndrome deficient fibrillin
Osteopenia noted in girls
Elevated calmodulin
Involved in contractile properties thru actin & myosin
Elevated in platelets
No consistent findings to date

10. Growth Abnormality Asymmetrical vertebral growth
Hueter-Volkman effect is suppression of growth on concave side
Hypokyphosis during growth spurt
No increased incidence with growth hormone
No initiating factor identified

11. Central Nervous System
Different size cerebral cortices
Altered equilibrium
Primary or secondary
Deficient melatonin
Chicken model
Inconclusive in humans

12. Terminology Named by apex Primary vs secondary
Cervical if between C2-C6
Cervicothoracic if between C7-T1
Thoracic if between T2-T11
Thoracolumbar if between T12-L1
Lumbar if between L2 and below
Primary vs secondary
Structural vs non-structural

13. Classification Infantile: 0-3 years old (.5%)
Juvenile: years old (10.5%)
Adolescent: years old (89%)
Adult: >18 years old

14. History Family history Recent growth history Sexual maturity Pain
Affected sibling 7 times more frequent
Affected parent 3 times more frequent
Recent growth history
Sexual maturity
Pain
‘Fatigue pain’
Post diagnostic pain
‘Severe pain’

15. Physical Exam Iliac crest height Shoulder height Arm trunk space
Leg length discrepancy
Shoulder height
Arm trunk space
Scapular position
Trunk shift
Inspection of skin
Café au lait spots

16. Physical Examination:
Features suggestive of polio, neurofibromatosis, Von Reclinghausen syndrome, Down’s, Marfan’s, Hurler’s syndrome, neural tube defects and osteogenesis imperfecta.
Forward protrusion of chest wall on affected side.
Increased flank creases on opposite side.
Higher ASIS and PSIS on concave side.
Spinous process turned into concave side.

17. Tests of flexibility of spine:
Adam’s forward bending test.
Pushing the curve from convex side and noting
the correction.
Lifting the patient up from head.
Lateral bending.

19. Forward Bend Test Adam’s sign

20. Neurologic Exam
Observe gait
Hop test
Heel and toe walk
Reflexes

21. Early Detection:
Visual examination of gait, posture, limb length and lateral curvature of spine.
A posterior view taken, bent at 90 degrees at hips.
Can also be detected accidently when radiographs are taken to rule out other pathologies.

22. Once scoliosis is suspected:
A scoliosis series is ordered.
AP cervical, thoracic and lumbar spine Xrays collimated to soft tissues needed.
Sometimes lateral views may also be necessary.

23. Imaging Plain x-rays Note rotation Measure deformity by Cobb method
Need standing 36 inch cassette
Posterior to anterior
Decrease thyroid and breast exposure 3-7 fold
Note rotation
Measure deformity by Cobb method
Skeletal maturity

24. Cobb Method
Choose the most tilted vertebrae above and below the apex of the curve.
Draw a line perpendicular to that vertebrae.
The angle created between these intersecting lines is the Cobb angle.

25. Rotation
Spinous process rotates into concavity
Pedicle position

26. Skeletal Maturity
Triradiate cartilage fusion
Risser sign

27. MRI Neurologic deficit Infantile and juvenile curves
Spinal cord abnormality in younger children
Infantile idiopathic scoliosis 50%
Juvenile 20%

28. Who needs an MRI: A thoracic curve to the left. Painful scoliosis.
Abnormal neurological findings.
Untoward stiffness.
Deviation to one side during the bend test.
Sudden rapid progression of a previously stable curve.

29. Will the curve progress?
Three factors involved in progression
patient’s gender
future growth potential
curve magnitude at time of diagnosis
Females are 10 times more likely to have progression than males.
The greater the growth potential and larger the curve = more likely to progress

30. Curve Progression
Curves 30 to 50 degrees progress an average of 10 to 15 degrees over a lifetime.
Curves > 50 at maturity progress steadily at a rate of 1 degree per year.
Curves less than 30 at bone maturity are unlikely to progress.

31. Medical complications:
At 100 degrees or greater: increased potential for life threatening effects on pulmonary function.
Psychologic illness: seen in up to 19% of females with curves great than 40 degrees as adults.

32. Treatment principles:
Orthotic braces - 74% success rate at halting progression
Must be worn 20 hours a day, but most pts are not compliant.
Braces do not correct scoliosis.
Surgical therapy is definitive, but indicated only for those at 40 degrees or above

33. Infantile Treatment Must prove idiopathic 90% are left thoracic
3 female : 2 male
90% resolve spontaneously
Predict progression by RVAD
< 20 degrees 83% resolve
>20 degrees 84% progress

34. Juvenile Treatment Younger onset likely to progress
>30 degree curve almost always progress
Some adolescent curves are missed juvenile

35. Adolescent Treatment Most curves <10 degrees
Boys = girls for these curves
Usually don’t progress
More sever curves (>30 degrees)
8 girls : 1 boy
Predicting who will progress

36. Risk for Progression Younger onset Female more likely than male
Skeletal age
Risser 0-1 at presentation 60-70% progress
Risser 3 only 10% risk
Menses starts after growth spurt
Female more likely than male
Curve pattern
Apex above T12
Degree at presentation
20-29 degrees 68% risk for progression
30-59 degrees 90% risk for progression

37. Natural History If curve <30 degrees at maturity
No adult consequences
Unlikely to ever progress
Curves >45 degrees may progress a degree/year
Mortality not increased unless curve >90 degree
Right heart failure
Decreased pulmonary function

38. Treatment : 10 degrees curve or less
This curve is considered normal.
No action is taken.
Follow up appointments are prescribed to monitor the patient.
Usually done every 3-6 months, but at the physician discretion.

39. Treatment:10 to 25 degree curve
Sometimes no treatment needed, if no progression.
Begins with simple orthotics(very effective)
daytime/nighttime braces.
Shoe lifts for leg length discrepancies.
Stretches, exercises.

40. Shoe Lifts: Used for leg length discrepancies. Worn in regular shoes.
Places opposing pressure on scoliosis curvatures.
Must be worn during every scoliosis radiograph.

41. Treatment: 25 to 35 degree curve
Day and night brace worn 20+ hours/day.
Shoe lifts may also be needed.
Stretches and exercises to loosen muscles and to relieve pain if present.

42. Treatment: 45 degree + curve
Almost always treated with surgery.
Vertebrae are fused using-
Bone grafts.
Hardware(metal splints)
Still require braces to be worn in post op period.
Causes growth to stop.
Can cause nerve damage, infection and other problems.

43. Left untreated: If progressing, can worsen upto 70 degrees + curve.
Places pressure on vital organs.
Can cause cardio-respiratory problems.
Can eventually become untreatable.

44. Non-Operative Treatment
<25 degrees monitor every 4-12 months
Depends on skeletal maturity
>25 degrees monitor every 3-6 months
>30 degrees in skeletally immature brace
Curve change by 10 degrees brace
Curve >40-45 degrees surgery

45. Braces : Made of polypropylene. Contoured to size and shape of body.
Curved to oppose specific points of scoliosis curvature.
Flexible and comfortable.
Worn under clothing.
Nighttime/daytime use.
Must be worn faithfully.

46. Bracing Duration and time in brace Types Electrical stimulation
23 hours per day
Wear until skeletally mature
Types
Milwaukee
Underarm orthosis
Electrical stimulation

47. Braces

48. Successful Bracing Prevent curve progression Electrical stimulation
Randomized study
Braced 74% did not progress
Not braced 34% did not progress
Electrical stimulation
33% did not progress
Charleston brace still controversial

49. Problems with Braces Argued efficacy
Narrow treatment window to initiate
Poor compliance
Must have good orthotist
Curves corrected by 20 degrees in brace do better

50. Treatment Algorithm

51. Surgery Failed bracing Curves >45 degrees
Unbalanced curves >40 degrees
Surgery is fusion with instrumentation

52. Surgical Options: Infantile and juvenile scoliosis:
<8 yrs- instrumentation without fusion.
After 8 years- anterior and posterior spinal fusion.
After 11 years- posterior spinal fusion.

53. Surgical Options: Adolescent scoliosis:
Posterior spinal fusion with instrumentation.
Anterior spinal fusion if younger than 11 years and with open triradiate cartilage.

54. THANK YOU…