1. Scoliosis Idiopathic Scoliosis In Adolescents NEJM Feb 28, 2013: 368:9
Brown Bag #1

2. Scoliosis
Definition: 10 degrees or greater lateral curvature of the spine (Cobb Angle, XR)
Etiology
Congenital (vertebral anomaly)
Neuromuscular (Brain – spastic quadriplegia; Cord – syringomelia, Periph– SMA, MD, NF
Connective Tissue Disorder (Marfan, Ehlers Danlos)
Idiopathic – any age possible, FH (10% in 1st degree relative - no specific gene)

3. PREVALENCE of IDIOPATHIC SCOLIOSIS
Of 2000 adolescents screened with shoulder, hip, forward bend testing
Asymmetry is exceedingly common, > 98% had asymmetric posture
Diagnosis requiring treatment is not
~4% screened positive for scoliosis (n = 80)
~2% had idiopathic scoliosis (> 10 degree curvature on XR) (n = 40)
0.4% required treatment (n = 8)

4. The Dangerous Curve - CONSEQUENCES
Disfigurement #1 concern
Rarely pain in adolescents or adults – Proceed with separate evaluation for BACK PAIN
Only affects lung volumes if > 70 degrees

5. Scoliosis Treatment Most do not need treatment
Goal to prevent progression
Limited data on PT other modalities
Cast for children < 3 years old if significant curve
Bracing for children > 3 yo with curves 25-45º
Observational data supports bracing
Ongoing RCT BrAIST: bracing vs. watchful waiting
Spinal fusion if > 45º with immature skeleton or progression after maturity

6. Screening guidelines
USPTF – no screening as screening has not demonstrated improved outcomes
AAP/ AAOS / SRS / POSNA – visual inspection at set ages
Girls 5th grade (age 10-11) & 7th grade (13-14)
Boys in 8th grade (13-14)

7. Scoliosis Evaluation Physical exam Asymmetry Assessment
shoulder and scapula,
rib prominence on forward bend (Adams Test)- usually left lumbar, right thoracic
waist and trunk
Scoliometer Measurement
<7º is associated with a 95% probability of curve < 30 degrees on XR
RULE OUT OTHER POTENTIAL ETIOLOGIES
Skin: café au lait spots, axillary freckles, subcutaneous fibromas
Neurologic exam and midline spinal deformities
Musculoskeletal – joint laxity, spider digits, leg length discrepancy

8. Scoliosis Imaging X-RAY MRI
SCOLIOSIS FILMS with Cobb Angle: C7 to iliac crest PA standing and lateral
Bone age if serial heights not available (to predict skeletal maturity)
MRI
<10 years of age
True kyphosis
Clinically significant pain
Abnormal neurologic exam or midline neurocutaneous defects
*Left thoracic curve is less common, but not sufficient condition for MRI

9. SUMMARY of Proposed Algorithm for IDOPATHIC SCOLIOSIS
Physical exam / screen at set ages*
XR if scoliometer > 7º
Then use XRAY results to determine f/u and referral needs
Other considerations
MRI if neurologic concerns or < 10 yo / Neurosurgery consult
Cardiology and Genetics consults if c/f Connective Tissues Problem
Separate back pain evaluation if child has significant back pain

10. Summary of Proposed Algorithm
Refer immediately
> 30 degrees at any age
25-29 degrees and early puberty
20-24 degrees before puberty
Increase in 5 degrees on XR at any interval
Follow-up 3 months
15-24 degrees and early puberty
Follow-up 6 months
15-29 degrees and late puberty
Follow-up in 1 year
< 14 degrees but not yet done with puberty
Follow-up in 5 years
Post puberty and Cobb angle degrees
Do not monitor
Normal exam, scoliometer < 7
Scoliosis < 19 degrees and done with puberty

11. The “Dangerous Curve” by Numbers
7º on scoliometer = GET INITIAL X-RAY
10º Cobb Angle on XR = DIAGNOSIS
< 14º on XR = F/U IN 1 YEAR if still growing, otherwise stop
15-29º = F/U and REFERRAL GUIDELINES BASED ON PUBERTY STAGE & CHANGE
30º at end of puberty = UNLIKELY TO PROGRESS, get f/u film in 5 years
>50º at end of puberty may progress 1º/year
>70º affects lung volumes
>100º symptomatic restrictive lung disease