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Scoliosis
Scoliosis
Abnormal lateral curvature of spine
in which there is deformity in the
coronal plane.
May alter sagittal plane as well
Thoracic kyphosis normally = 30-35
degrees
Range 10-50 degrees
Lumbar lordosis normally = 50-60
degrees
Range 35-80 degrees
Spinal rotation causes posterior
prominence
Upto 10 degrees is
normal.
Can be seen as C-
curve or S-curve.
S- curve is usually
compensatory.
Demographics :
Occurs in 2-3% of population below the age of
16 years.
0.1% have a curve greater than 40 degrees.
Girls are more affected than boys.
Those with a curve of more than 30 degrees are
generally girls, outnumbering boys by 10:1.
Generally progresses during the period of
growth spurts.
Adolescents are more routinely tested for this.
Anatomy
All bony elements are altered
Vertebra are wedge shaped
Rib vertebral angle altered
Pedicles rotated
Neuromuscular
Cerebral palsy
Syndrome related
Marfans syndrome
Idiopathic
80% are this
Etiological Theories
Genetic
Tissue deficiencies
Growth abnormalities
Central nervous system alteration
Genetic
11% incidence in first relatives of patients
Normal incidence < 3%
Monozygote twins more common
No gene identified to date
Tissue Deficiencies
Marfans syndrome deficient fibrillin
Osteopenia noted in girls
Elevated calmodulin
Involved in contractile properties thru actin &
myosin
Elevated in platelets
Primary vs secondary
Structural vs non-structural
Classification
Infantile: 0-3 years old (.5%)
Juvenile: 4-11 years old (10.5%)
Adolescent: 10-17 years old (89%)
Adult: >18 years old
History
Family history
Affected sibling 7 times more frequent
Affected parent 3 times more frequent
Lateral bending.
Forward Bend Test
Adams sign
Neurologic Exam
Observe gait
Hop test
Heel and toe walk
Reflexes
Early Detection:
Visual examination of
gait, posture, limb length
and lateral curvature of
spine.
A posterior view taken,
bent at 90 degrees at
hips.
Can also be detected
accidently when
radiographs are taken to
rule out other
pathologies.
Once scoliosis is suspected:
A scoliosis series is
ordered.
AP cervical, thoracic
and lumbar spine
Xrays collimated to
soft tissues needed.
Sometimes lateral
views may also be
necessary.
Imaging
Plain x-rays
Need standing 36 inch cassette
Posterior to anterior
Decrease thyroid and breast exposure 3-7 fold
Note rotation
Measure deformity by Cobb method
Skeletal maturity
Cobb Method
Choose the most
tilted vertebrae above
and below the apex of
the curve.
Draw a line
perpendicular to that
vertebrae.
The angle created
between these
intersecting lines is
the Cobb angle.
Rotation
Spinous process rotates into concavity
Pedicle position
Skeletal Maturity
Triradiate cartilage fusion
Risser sign
MRI
Neurologic deficit
Infantile and juvenile curves
Spinal cord abnormality in younger children
Infantile idiopathic scoliosis 50%
Juvenile 20%
Who needs an MRI:
A thoracic curve to the left.
Painful scoliosis.
Abnormal neurological findings.
Untoward stiffness.
Deviation to one side during the bend test.
Sudden rapid progression of a previously stable
curve.
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
Curve Progression
Curves 30 to 50 degrees progress an average
of 10 to 15 degrees over a lifetime.
daytime/nighttime braces.
Stretches, exercises.
Shoe Lifts:
Used for leg length
discrepancies.
Worn in regular
shoes.
Places opposing
pressure on scoliosis
curvatures.
Must be worn during
every scoliosis
radiograph.
Treatment: 25 to 35 degree curve
Day and night brace worn 20+ hours/day.
Bone grafts.
Hardware(metal splints)
Types
Milwaukee
Underarm orthosis
Electrical stimulation
Braces
Successful Bracing
Prevent curve progression
Randomized study
Braced 74% did not progress
Not braced 34% did not progress
Electrical stimulation
33% did not progress
Charleston brace still controversial
Problems with Braces
Argued efficacy
Narrow treatment window to initiate
Poor compliance
Must have good orthotist
Curves corrected by 20 degrees in brace do better
Treatment Algorithm
Surgery
Failed bracing
Curves >45 degrees
Unbalanced curves >40
degrees
Surgery is fusion with
instrumentation
Surgical Options:
Infantile and juvenile scoliosis:
<8 yrs- instrumentation without fusion.