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Scoliosis

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Objectives

Know the etiology and natural history of

scoliosis

Describe how and when to examine for

scoliosis

Know how to determine the magnitude

and pattern of spinal curvature

Be familiar with treatment options

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Epidemiology

Scoliosis is a lateral curvature of

the spine greater than 10 degrees.Idiopathic vs. Secondary

Idiopathic is the most common type.

Secondary causes include connectivetissue, neurologic, and musculoskeletal

disorders.

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Classification

Idiopathic Scoliosis - defined by the

age of onsetInfantile - birth to 3 years

Juvenile - 3 to puberty

Adolescent - after pubertyAdolescent Idiopathic Scoliosis is

the most common type.

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Etiology: AIS

No direct cause has yet been

isolated.

Leading theory: Multigenedominant condition with variable

phenotypic expression

Studies of twins have shown

greater risk in monozygotic than

dizygotic, and the rate of curve

progression was nearly identical

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Prevalence: AIS

Scoliosis is present in 2 to 4% of

children between 10 and 16 years

of age.Girls tend to have more severe

curves.

F:M ratio 1:1 in those with smallcurves (10 degrees)

F:M ratio increases to 10:1 in those

with curves greater than 30 degrees

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Diagnosis

Need to exclude secondary causes.

History:

family history

presence of pain and neurologic changes

bowel and bladder dysfunction

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Physical Exam

Complete neurologic examTanner staging - curve progression

occurs most rapidly during stage 2 or 3

Adams forward bend test

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Adams Bend TestPt bends forward,spine horizontal to thefloor, while holdingpalms together, armsextended.

Examine from sideand behind thepatient.

Look for a rib hump

Rib hump is ahallmark of a scolioticcurve greater than 10degrees.

Make sure pelvis is not dipping on

one side AND leg length is symmetric

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Imaging

Imaging is ordered for any patientwith a lateral thoracic or lumbar spine

curvature > 10 degrees. It should be

considered in all patients with

cervical curvature!

A single standing PA plain film of the

spine is needed.

The degree of the curve is measured

by the Cobb method.

90% of curves are to the right!

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Red Flagsneed MRI

A thoracic curve to the left

painful scoliosis

abnormal neurologic findingsuntoward stiffness

deviation to one side during the bend

testsudden rapid progression in

previously stable curve

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The Cobb method

Choose the mosttilted vertabrae

above and below

the apex of the

curve.Draw a line

perpendicular to that

vertabrae.

The angle createdbetween these

intersecting lines is

the Cobb angle.

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When do you observe vs.

treat or refer?

What is the likelihood the curve willprogress?

What degree of curvature leads to

medical complications?

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Will the curve progress?

Three factors involved in progression

patients 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

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How to determine growth potential?

Tanner staging - pts in

stage 2 and 3 more

likely to progress

Risser grade

based on ossification of

iliac apophysisgraded from 0 (no

ossification) to 5

(complete bony fusion)

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The magic # is... 30

Data from multiplestudies has yieldedthe Risk of CurveProgression table.

The table assists inpredicting progressionand hence guidingtreatment.

What is the risk for an11 yo girl with a 25degree curve and

Risser grade 1?

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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.

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Medical Complications

At 100 degrees or greater: increased

potential for life threatening effects onpulmonary function

Psychologic illness: seen in up to 19%

of females with curves great than 40degrees as adults.

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Does Screening help?

AAOS recommends screening girls at

ages 11 and 13; boys once at 13 or 14.

AAP recommends at 10, 12, 14, and 16.

But in fact... in 1996 the US Preventative

Task Force found insufficient evidence

for or against screening in asymptomaticpts. This was updated again in June

2004 with the same conclusion.

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Treatment

Orthotic braces - 74% success rate

at halting progression

Must be worn 20 hours a day, butmost pts are not compliant.

Braces do not correct scoliosis.

Surgical therapy is definitive, butindicated only for those at 40

degrees or above

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Conclusion

Adolescent Idiopathic Scoliosis is the

most common type.

Overall, females more prone and tendto have more severe curves (to the

right!).

Screening is of limited value.There are extensive research based

guidelines for predicting curve

progression and treatment