PAEDS ORTHOPAEDIC

(SCOLIOSIS)
Nur Adzyan Ruhaizad
1001335975

LEARNING OUTCOMES
Describe epidemiology, aetiology and pathoanatomy of scoliosis.
Describe the clinical features of scoliosis.
Select relevant investigations to confirm the diagnosis according to
the age of presentation and to monitor the progress of disease.
Plan the management according to the state of disease and age of
the patient.
Develop regular follow up plan and management.
Discuss the complications of scoliosis and prevention by screening.

 Scoliosis is an apparent lateral

(sideways) curvature of the spine.
Two broad types of deformity are :

Postural
scoliosi
s

Structur
al
scoliosi
s

POSTURAL SCOLIOSIS
Deformity is secondary or compensatory to some
condition outside the spine ; short leg, or pelvic tilt due to
contracture of the hip.

When patient sits (therefore cancelling leg asymmetry)

the curve disappears.

Local muscle spasm a/w prolapsed lumbar disc may

cause a skew back; although sometimes called sciatic
scoliosis

STRUCTURAL SCOLIOSIS
In structural scoliosis there is a non-correctable
deformity of the affected spinal segment, an
essential component of which is vertebral rotation.
The spinous processes swing round towards the
concavity of the curve and the transverse processes
on the convexity rotate posteriorly.
In the thoracic region the ribs on the convex side
stand out prominently, producing the rib hump,
which is a characteristic part of the overall deformity.

 The initial deformity is probably correctable, but

once it exceeds a certain point of mechanical
stability the spine buckles and rotates into a fixed
deformity that does not disappear with changes in
posture.
Secondary (compensatory) curves nearly always
develop to counterbalance the primary deformity;
they are usually less marked and more easily
correctable, but with time they, too, become fixed.
Once fully established, the deformity is liable to
increase throughout the growth period.
With very severe curves, chest deformity is marked
and cardiopulmonary function is usually affected

TYPES
Idiopathic
scoliosis

Osteopathic
(Congenital)
Scoliosis

Neuropathic
and
myopathic
scoliosis

Scolios and
neurofibroma
tosis

CLINICAL FEATURES

DEFORMITY

PAIN

Obvious skew back or

rib hump in
thoracolumbar curves

Rare complaint

Balanced curves
sometimes pass
unnoticed until an adult
presents with backache

Possibility of a neural
tumour and the need
for MRI
Scoliosis with pain
suggests a spinal
tumour until proven
otherwise

FAMILY HISTORY
ABNORMALITY DURING
PREGNANCY OR
CHILDBIRTH
EARLY DEVELOPMENTAL
MILESTONE

Trunk
Skin
Spin
e

Completely exposed, examine from front, back and side

Skin pigmentation
Congenital anomalies : sacral dimples or hair tufts

May be obviously deviated from the midline

May become apparent only when the patient bends forward
(Adams test)
Level and direction of the major curve convexity are noted

Hip &
Scapula

Breast &
Shoulder

Ribs

Pelvis sticks out on the concave side

Scapula on the convex side

May be asymmetrical

With thoracic scoliosis, rotation causes the

rib angles to protude, producing an
asymmetrical rib hump on the convex
side of the curve

Neurologic
al
examinati
on

Leg legth

Any abnormality suggesting a spinal cord

lesion calls for CT/MRI

Length is measured
If one side is short, pelvis is levelled by
standing the patient on wooden blocks and
re-examined the spine

Search for the possible cause

General Assessment of cardiopulmonary function
examinati
(reduced in severe curves)
on

Balanced
deformities : the
occiput is over the
midline

Unbalanced (or
decompensated)
curves : the occiput is
not over the midline

Determined by
dropping a plumbline
from the prominent
spinous process of C7
and noting whether it
falls along the gluteal
cleft

 Diagnostic feature of fixed scoliosis is that

forward bending makes the curve more
obvious.
Spinal mobility should be assessed and
effect of lateral bending on the curve noted.
Side-on posture should also be observed.
There may appear to be excessive kyphosis
or lordosis

INVESTIGATIONS
CT & MRI : to
define a
Skeletal
vertebral
Plain x-rays
maturity
abnormality or
Rissers sign
cord
compression
Pulmonary
Biochemical
function
and
test : in severe
neurological
chest
investigation
deformity
s

PLAIN X-RAYS
Full-length posteroanterior (PA)
and lateral x-rays of the spine and
iliac crests must be taken with the
patient erect.
The degree of curvature is measured by drawing
lines on the x-ray at the upper border of the
uppermost vertebra and the lower border of
the lowermost vertebra of the curve; the
angle subtended by these lines is the angle of
curvature (Cobbs angle)

SKELETAL MATURITY RISSERS

SIGN
Iliac apophyses start ossifying shortly after
puberty ; ossification extends medially and,
once the iliac crests are completely
ossified, further progression of the
scoliosis is minimal (Rissers sign)
This stage of development usually coincides with
fusion of the vertebral ring apophyses.
Skeletal age also may be estimated from x-rays
of the wrist and hand

IDIOPATHIC SCOLIOSIS

LateEarlyonset
onset
(Adolesce
(Juvenile)
nt)
Earlyonset
(Infantile)

LATE-ONSET (ADOLESCENT)
IDIOPATHIC SCOLIOSIS
Aged 10 or over
This is the commonest type, occuring in 90% of
cases
Mostly occur in girls
Primary thoracic curves are convex to the right,
lumbar curves to the left; intermediate
(thoracolumbar) and combined (double primary)
curves also occur.

 Most curves less than 20 degrees either resolve

spontaneously or remain unchanged.
Once curve starts to progress, it usually goes on
doing so throughout the remaining growth
period.
Reliable predictors of progression are :
Very young age
Marked curvature
Incomplete Rissers sign at presentation

TREATMENT
Aims of treatment :
To prevent a mild deformity become
severe
To correct existing deformity that is
unacceptable to the patient

Nonoperative
treatment

Operative
treatment

NON-OPERATIVE
TREATMENT
Exercis
es

No effect on the curve

Maintain muscle tone and inspire confidence in
favourable outcome

Treatment of progressive scoliotic curves

between 20 and 30 degrees

Bracin
g

Milwaukee brace to reduce the lumbar

lordosis and encourage active stretching and
straightening of thoracic spine
Boston brace snug fitting underarm brace
that provide lumbar or low thoracolumbar
support

OPERATIVE TREATMENT
Surgery is indicated :
Curves of more than 30 degrees that are cosmetically
unacceptable, esp in pre-pubertal children who are
liable to develop marked progression during growth
spurt
Milder deformity that is deteriorating rapidly.

Objectives are :
To halt progression of deformity
To straighten the curve (including the rotational
component)
To arthrodese the entire primary curve by bone grafting

OPERATIVE TREATMENT

Harrington
system

Rod and
sublaminar
wiring (Luquel)

Anterior
instrumentatio
n (Dwyer,
Zielke, Kaneda)

CotrelDubousset
system

Rib hump
-costoplasty

OPERATIVE TREATMENT
Harringto
n system

Rod was applied posteriorly along the concave side of the curve;
attached to the rod were moveable hooks that were enggaged in the
uppermost and lowermost vertebrae to distract the curve.
Does not correct the rotational deformity at the apex of the curve thus
rib prominence remains virtually unchanged.

This is a modification of the Harrington system.

Rod and
sublamin
ar wiring
(Luque)

Wires are passed under the vertebral laminae at multiple levels and are
fixed to the rod on the concave side of the curve, thus providing a more
controlled and secure fixation.
Rotational component of the deformity can be substantially improved.
Increased risk of neurological damaged due to sublaminar wires
dangerously close to the dura

Cotrel
Dubousset
system

This mechanism combines a pedicle screw box foundation at the

caudal end of the deformity, with multiple hooks which can be
placed a various levels to produce either distraction or
compression.
Can correct the rotational deformity
Sufficiently rigid to make postoperative bracing unnecessary

Rigid curves and thoracolumbar curves a/w lumbar lordosis

can be corrected by approaching the spine from the front,
removing the discs throughout the curve and then applying a
compression device along the convex side of the curve.

Anterior
instrumentati
on (Dwyer;
Provides strong fixation with fewer vertebral segments having
Zielke;
to be fused
Kaneda)
Overal shortening of deformed section lessens risk of cord
injury due to spinal distraction

WARNING!
Whatever method is used, spinal cord function should be
monitored during the operation.
Ideally this is done by measuring somatosensory and motor
evoked potentials during spinal correction.
If these facilities are not available, the wake-up test is used:
anaesthesia is reduced to bring the patient to a semi-awake
state and he or she is then instructed to move their feet.
If there are signs of cord compromise, the
instrumentation is relaxed or removed and reapplied
with a lesser degree of correction. Patients have no memory
of the wake-up procedure.

COMPLICATIONS OF
SURGERY

Neurological compromise
Spinal decompensation
Pseudoarthrosis
Implant failure

EARLY-ONSET (JUVENILE)
IDIOPATHIC SCOLIOSIS
Presenting in children aged 49, this type is
uncommon.
The characteristics of this group are similar
to those of the adolescent group, but the
prognosis is worse and surgical correction
may be necessary before puberty.
However, if the child is very young, a brace
may hold the curve stationary until the age
of 10 years, when fusion is more likely to
succeed.

EARLY-ONSET (INFANTILE)
IDIOPATHIC SCOLIOSIS
Children aged 3 or under, is rare in North America and is
becoming uncommon elsewhere
Boys predominate
Most curves are thoracic with convexity to the left.
Although 90% of infantile curves resolve spontaneously,
progressive curves can become very severe; those in which the
rib-vertebra angle at the apex of the curve differs on the two
sides by more than 20 degrees are likely to deteriorate
Because this also influences the development of the lungs, there
is a high incidence of cardiopulmonary dysfunction.

 Curves assessed as being potentially progressive should be

treated by applying serial elongationderotation- flexion (EDF)
plaster casts under general anaesthesia, until the deformity
resolves or until the child is big enough to manage in a brace.
From about the age of 4 years onwards curve progression slows
down or ceases and the child may not need further treatment.
If the deformity continues to deteriorate, surgical correction may
be required.
This takes the form of anterior disc excision and fusion to control
the apex of the curve, combined with posterior fusion to prevent
posterior overgrowth

OSTEOPATHIC (CONGENITAL)
SCOLIOSIS
Commonest bony cause is some type of vertebral
anomaly
Hemivertebra
Wedged vertebra (failure of formation)
Fused vertebrae sometimes combined with absent or
fused ribs (failure of segmentation)

Overlying tissues often shows angiomas, naevi,

excess hair, dimples or a pad of fat.
Spina bifida may be associate and visceral anomalies
are common esp heart and kidneys.

 These children require painstaking clinical

investigation and imaging
in order to discover any other congenital anomalies;
to assess the risk of spinal cord damage.

Treatment :
Treatment is more difficult and specialized than that of
idiopathic infantile scoliosis
These children should be treated in special units: the
approach is to undertake staged resection of the
curve apex, followed by instrumentation and spinal
fusion.
If multiple segments of the spine are involved, surgery may
be too hazardous and should probably be withheld.

NEUROPATHIC AND MYOPATHIC

SCOLIOSIS
Neuromuscular conditions associated with scoliosis include
poliomyelitis, cerebral palsy, syringomyelia, Friedreichs ataxia
and the rarer lower motor neuron disorders and muscle dystrophies; the
curve may take some years to develop.
The typical paralytic curve is long, convex towards the side with
weaker muscles (spinal, abdominal or intercostal), and at first is mobile.
In severe cases the greatest problem is loss of stability and balance,
which may make even sitting difficult or impossible.
Additional problems are generalized muscle weakness and (in some
cases) loss of sensibility with the attendant risk of pressure ulceration.
X-ray with traction applied shows the extent to which the deformity is
correctable.

 Treatment depends upon the degree of

functional disability :
Mild curves may require no treatment
at all.
Moderate curves with spinal stability
are managed as for idiopathic scoliosis.
Severe curves, associated with pelvic
obliquity and loss of sitting balance,
can often be managed by fitting a
suitable sitting support.
If this does not suffice, operative
treatment may be indicated. This
involves stabilization of the entire
paralyzed segment by combined
anterior and posterior instrumentation
and fusion.

Typical post-poliomyelitis paralytic

scoliosis shown characterised by a
long C-shaped curve.

SCOLIOSIS AND
NEUROFIBROMATOSIS
About one third of patients with neurofibromatosis develop spinal
deformity, the severity of which varies from very mild (and not
requiring any form of treatment) to the most marked manifestations
accompanied by skin lesions, multiple neurofibromata and bony
dystrophy affecting the vertebrae and ribs.
The scoliotic curve is typically short and sharp. Other clues to the
diagnosis lie in the appearance of the skin lesions and any associated
skeletal abnormalities.
Mild cases are treated as for idiopathic scoliosis.
More severe deformities will usually need combined anterior and
posterior instrumentation and fusion. As with other forms of skeletal
neurofibromatosis, graft dissolution and pseudarthrosis are not
uncommon.

This patient has a short structural curve

plus multiple skin lesions features
suggesting neurofibromatosis

THANK YOU!

SEMINAR MARK SHEET

Topic

No
1

Seminar
Paediatric Orthopaedic Problem (part III)
Scoliosis
Contents
Full
marks
Introduction
1

Marks
awarded
1

Content:
1. Applied anatomy
2. Epidemiology
3. Pathophysiology
4. Clinical features
5. Specific clinical tests
6. Differential diagnosis
7. Investigation
8. Principle of management
9. Rehabilitation
10. Complications

Arrangement of presentation

Literature Review/ References

Presentation skill

Total

10