“Idiopathic Scoliosis” Dr. Donald W. Kucharzyk Clinical Assistant Professor University of Chicago Children’s Hospital

“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’

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” “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

“Idiopathic 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

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” “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

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

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” “Prevalence” When a sibling or parent has scoliosis: seven fold increase(sibling) and three fold increase(parent) compared to general population

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” “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’

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” “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

“Idiopathic Scoliosis” 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

“Idiopathic Scoliosis” 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

“Idiopathic Scoliosis” SURGICAL CORRECTION GOALS Reduce the magnitude of the curve Obtain fusion to prevent progression Create a well-balanced spine

“Idiopathic Scoliosis” SURGICAL CORRECTION INDICATIONS Curves over 45 degrees Trunk deformity(rotation) Trunk balance Progressive curves despite bracing

“Idiopathic Scoliosis” SURGICAL CORRECTION INSTRUMENTATION Harrington Luque Cotrel-Dubousset TRSH Isola Colorado II

“Idiopathic Scoliosis” 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

“Idiopathic Scoliosis” 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

“Idiopathic Scoliosis” 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

“Idiopathic Scoliosis” 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

“Idiopathic Scoliosis” OUTCOME OF SURGICAL INTERVENTION Harrington: 48% coronal improvement CD: 61% coronal and sagittal plane improvement Anterior correction: 58% improvement

“Idiopathic Scoliosis” 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

“Idiopathic Scoliosis” THANK YOU