Scoliosis Evaluation and Decision
Making for the Pediatrician
John F. Sarwark, MD
Children’s Memorial Hospital
Head, Orthopedic Surgery
Northwestern University’s Feinberg School of Medicine,
Professor of Orthopedic Surgery
Cynthia R. LaBella, MD
Children’s Memorial Hospital
Medical director, Institute for Sports Medicine
Northwestern University's Feinberg School of Medicine
Instructor of Clinical Pediatrics
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Scoliosis: Overview
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Definition
Etiologies
Making the diagnosis
When to refer
Natural history/prognosis
Treatment
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Scoliosis is strictly defined
• Cobb angle measurement on Xray:
• Lateral curvature > 10°
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Scoliosis: Etiologies
• Two categories
• Structural
• Non-structural
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Non-structural etiologies
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Leg length discrepancy
Inflammation
Neurogenic / disc pathology
Hysterical
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Structural etiologies
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Idiopathic (most common)
Congenital
Neuromuscular (e.g. cerebral palsy)
Miscellaneous (lengthy list)
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Miscellaneous scoliosis: examples
• Associated with other conditions
• Osteoid osteoma
• Metabolic
• Rickets
• Osteogenesis Imperfecta
• Infection (late sequela)
• Limb deficiency syndromes
• Burn scar (truncal)
• Congenital heart disease
• Chest wall asymmetries
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Morquio-Brailsford Syndrome
• Mucopolysaccharidosis
• Spine normal at birth
• Kyphoscoliosis develops with
growth
• Usually also present:
• Odontoid hypoplasia
• Short stature
• Aortic valve abnormalities
• Hearing loss
• Corneal opacities
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Neurofibromatosis
• Spine involvement
is common
• Often exhibit bony
dyplasia
• Curves tend to be
sharp and
progressive
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Osteoid Osteoma
Night pain
Limited spinal mobility
Tenderness
Xray may reveal classic
features
• Bone scan often
diagnostic
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Marfan Syndrome
Scoliosis develops in most cases
Often have double and triple curves
Curves start earlier
Curves are more progressive, resistant,
and rigid
• Brace management less effective
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Normal Spinal Alignment
• Anteroposterior view……0° curvature
• Sagittal (lateral) view
• Thoracic kyphosis……….20-40° (varies)
• Lumbar lordosis…………40-60° (varies)
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Idiopathic Scoliosis
• Idiopathic scoliosis
with onset after age
10 is most common
and classic form
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Idiopathic Scoliosis: Incidence
• 2% referred after screen
• 0.3% require treatment
• Female:male – 7:1 (at >30°)
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Idiopathic Scoliosis: Incidence
• Incidence of scoliosis in
relation to curve magnitude
• Most scoliosis is low
magnitude
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Scoliosis: Diagnosis
The physical examination is the first line of
detection
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Scoliosis: Clinical Examination
• Inspection
• Shoulder height asymmetry
• Scapular prominence
• Waist line asymmetry
• Flank crease
• Pelvic asymmetry
• Adams Forward Bend Test
• Sine qua non for scoliosis
evaluation
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The Screening Exam
• Adam’s Forward Bend Test
• Prominence is accurately measured using
scoliometer
• Scoliometer measures the angle of trunk rotation
(ATR)
• Misleading traps
• Pelvis level? (LLD?)
• Back pain
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Scoliometer measures ATR
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Angle of trunk rotation (ATR)
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ATR Correlates With Cobb Angle
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Location of Curve
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When to Refer
• Refer when:
• ATR >5-7 degrees or
• Cobb angle >20 degrees
• False negative (“missed”) – 0.1%
• False positive (over-referred) – 5%
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Scoliosis: Natural history
• Effects of growth
and puberty
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Natural History of Curve Progression
in Idiopathic Scoliosis
• Curves < 30° are stable
• Curves > 50° tend to progress
• Avg. rate = 1°/year
• Factors in curve progression
• Vertebral rotation
• Translatory shifts
Weinstein
• Curve severity
JBJS 65A:447,
1983
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Natural History
Curve progression is
defined as increase
of 5 or more degrees
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Risk Factors for Progression
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Magnitude of curve at presentation
Curve location
Level of maturation
Risser grade
• Extent of iliac crest ossification on AP Xray
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Long Term Sequelae
• Cosmetic deformity
• Psychosocial effects
• No increased back pain in general – except
for T-L curves as adults
• If curve is >80°
• Cor Pulmonale
• If curve is >100°
• Cardiopulmonary death (rare)
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Physical Deformity
• Coronal plane curve –
“Cobb angle”
• Sagittal plane –
Hypokyphosis !
• Rotational deformity rib
effect
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Psychosocial effects
• Scoliosis has been shown to increase risk of
• Suicidal thought
• Worry
• Concern over body image
• Support groups and counseling may be
appropriate
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Non-Prognostic Factors
• Factors that do not predict curve
progression
• Family history
• Thoracic kyphosis
• Lumbar lordosis
• Lumbosacral anomalies
• Trunk balance
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Impact of Early Presentation
and Diagnosis
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Earlier detection
Smaller curves are easier to treat
Conservative treatment more likely
Surgery needed less often
If surgery is needed:
• Less complex
• Earlier intervention may have greater
impact on prognosis
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Scoliosis treatment
• Treatment options are based on natural
history and curve severity
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Scoliosis Treatment Summary
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Thank you
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