1. The Pediatric Spine Normal Spine Development Thoracic Kyphosis =
20-45 deg
Lumbar lordosis =
20-55 deg
By age 4-5 usually 10-20
Cervical
Mild truncal asymmetries common
10% of population
School screen controversial
Threshold of 7 deg. scoliometer suggested

2. Spinal Flexion and Extension
Cerebral Palsy
Tightness:
Cervical and capital flexion
Thoracic extension
Lateral flexion
Lumbar flexion

3. Kyphosis Postural Congenital Failure of formation and/or segmentation
Apex of curve between T10 and L1 most common
Failure of formation lead to paraplegia
Progressive under deg. – post. Fusion
More than 60 deg – ant. and post.

4. Scheurermann Disease Familial disorder of thoracic spine
Hx of heavy physical loading from work or athletics
Vertebral wedging and kyphosis >45 deg
<60 – encourage activity
>60 - brace
Mild scoliosis
Tx: NSAIDs, rest, stress reduction, TSLO for pain

6. Lordosis Variations common in typical prepubescent child Functional
Compensation for fixed deformity above or below LS level
Structural hyper/hypo
Arrest growth of post lumbar vert with shunting or rhizotomy
Muscular dsytrophy = hypo
Fractures = hypo or hyper

7. Cervical Problems Basilar impression Congenital or acquired
Cervical spine extends into the formamen magnum
May be due to osteopenia:
rickets
osteogenesis imperfecta

8. Occipital-atlantal instability
Rare but sometimes in Down Syndrome
Atlantoaxial instability
Due to abnormalities of odontoid or to ligamentous laxity
Down Syndrome, Rheummatoid arthritis,
Sx: gait disturbance, ex. Intolerance, neck pain
Mild weakness and hyperreflexia
Avoid cervical spine stress

9. Can have instability until the epiphysis closes
X-rays recommended at age 2 y.r. in the case of Down Syndrome
Case example:
7 year old high functioning child with Down Syndrome, in a regular classroom who can ride a tricycle independently. He/she falls off and becomes a paraplegic due to an unstable AA joint

10. Neurological Abnormalities
Progression of scoliosis
Chiari malformation
Tethered cord
Tumors
Unresolved torticollis
Clumsiness
UE weakness
MRI studies helpful

12. Abnormal skin lesions in midline
Dimples
Hemangiomas
Hair patches
Cavus feet
Leg atrophy
Café au lait spots

13. Back Pain Referral important if Evaluate for: Onset before age 4 years
Symptoms persist longer than 4 weeks or increases
Pain interferes with function
Recent onset of scoliosis
Evaluate for:
Mobility and symmetry
Tenderness
Neurological signs – especially asymmetry
Xray, SPECT scan or MR imaging

14. Spondylolysis and Spondylolisthesis
(B) or unilat defects of pars interarticularis = Sphondylolysis
4% of 4 yo, 6% by maturity
If this displaces = spondylolisthesis
Most common form of back pain in children and adults and in children with abnormal bone or connective tissue
Usually due to stress fracture
Tenderness over L5-S1
Limited SLR and forward bending
Pain aggravated by activity, especially competitive sports
Usually pain decreases as child becomes an adult due to decreased activity

15. Benign Back Pain in Children and Adolescents
over ½ in this category
Limit back pack weight (< 20% of body wt
Not EBP
Encourage healthy lifestyle, activity, weight reduction
Disc Herniation
Rare unless family hx, recent trauma, facet asymmetry, spinal stenosis, transitional vertebrae and spondylolisthesis
Usually L4-5 or L5-S1 with radicular pain and secondary spinal deformity
Tx: NSAID, rest, limited activity, TLSO
MR and disc excision if persists

16. Idiopathic Scoliosis Unknown origin Most common
Infantile: birth to 3 yrs
Juvenile: 3-10 yrs
Adolescent: >10 yrs
Prevalence:
2-3% for curves <10 deg
.2 to .3% for curves >20 deg

17. Nonstructural and Structural
Correct on lateral trunk bending
Causes:
Pelvic Obliquity
LLD
Tumor
Muscle spasm
Fixed and do not correct
Rotary component present and visible with forward bending
Primary and compensatory curves

18. Neurofibromatosis
Mutation of neurofibromatosis (Type 1) or schwannomin (Type 2) gene
Type 2 has fewer peripheral but more intracranilal lesions
Scoliosis is idiopathic or dystropic
Dystropic involves short and sharp angulation and spinal instability
Fusion is indicated because of risk of boney dysplasia

20. School Screenings Examine posture anteriorly and posteriorly
Forward bend test
MD and RN do this and often miss some cases
Assess for asymmetries:
Shoulders, nipple, scapula, pelvic heights
Asymmetrical folds of trunk
Curvature of spine

21. Treatment for Scoliosis
Young adolescents prepuberty will most likely progress
Curves <25 deg: observe
Curves deg: non-surgical methods
Goal is to maintain with exercise and brace
TLSO hours per day until skeletal maturity
PT: donning orthosis, schedule, skin care, exercise for ROM (hip flexors) and strength (abdom, gluts, paraspinals)
Curves >40 deg: surgical intervention

22. Surgery for Scoliosis Indications: Instrumentation: PT:
Curve >40 deg
Curve is progressing
Decompensation of spine or thoracic cavity
Instrumentation:
Distract and compress the curve
Correct or minimize the rotory component
Stabilize and maintain
Harrington rods
PT:
Preop and postop for ROM, trunk strengthening, deep breathing and coughing
Early transfers and gait