Approach to a case of
Scoliosis
Scoliosis
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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
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Lumbar lordosis normally = 50-60
degrees
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Range 10-50 degrees
Range 35-80 degrees
Spinal rotation causes posterior
prominence
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Upto 10 degrees is
normal.
Can be seen as Ccurve or S-curve.
S- curve is usually
compensatory.
Demographics :
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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
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Discs are wedged as well
Types of Scoliosis

Congenital
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Neuromuscular
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Syndrome related
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Cerebral palsy
Marfan’s syndrome
Idiopathic
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80% are this
Etiological Theories
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Genetic
Tissue deficiencies
Growth abnormalities
Central nervous system alteration
Genetic
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11% incidence in first relatives of patients
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Normal incidence < 3%
Monozygote twins more common
No gene identified to date
Tissue Deficiencies
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Marfan’s syndrome deficient fibrillin
Osteopenia noted in girls
Elevated calmodulin
Involved in contractile properties thru actin &
myosin
 Elevated in platelets
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No consistent findings to date
Growth Abnormality
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Asymmetrical vertebral growth
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Hueter-Volkman effect is suppression of growth on
concave side
Hypokyphosis during growth spurt
No increased incidence with growth hormone
No initiating factor identified
Central Nervous System
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Different size cerebral cortices
Altered equilibrium
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Primary or secondary
Deficient melatonin
Chicken model
 Inconclusive in humans
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Terminology

Named by apex
Cervical if between C2-C6
 Cervicothoracic if between C7-T1
 Thoracic if between T2-T11
 Thoracolumbar if between T12-L1
 Lumbar if between L2 and below
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Primary vs secondary
Structural vs non-structural
Classification
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Infantile:
Juvenile:
Adolescent:
Adult:
0-3 years old (.5%)
4-11 years old (10.5%)
10-17 years old (89%)
>18 years old
History
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Family history
Affected sibling 7 times more frequent
 Affected parent 3 times more frequent
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Recent growth history
Sexual maturity
Pain
‘Fatigue pain’
 Post diagnostic pain
 ‘Severe pain’
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Physical Exam
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Iliac crest height
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Leg length discrepancy
Shoulder height
Arm trunk space
Scapular position
Trunk shift
Inspection of skin
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Café au lait spots
Physical Examination:
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Features suggestive of polio, neurofibromatosis,
Von Reclinghausen syndrome, Down’s,
Marfan’s, Hurler’s syndrome, neural tube defects
and osteogenesis imperfecta.
Forward protrusion of chest wall on affected
side.
Increased flank creases on opposite side.
Higher ASIS and PSIS on concave side.
Spinous process turned into concave side.
Tests of flexibility of spine:

Adam’s forward bending test.
Pushing the curve from convex side and noting
the correction.
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Lifting the patient up from head.
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Lateral bending.
Forward Bend Test
Adam’s sign
Neurologic Exam
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Observe gait
Hop test
Heel and toe walk
Reflexes
Early Detection:
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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:
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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
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Plain x-rays
Need standing 36 inch cassette
 Posterior to anterior
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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
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Spinous process rotates into concavity
Pedicle position
Skeletal Maturity
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Triradiate cartilage fusion
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Risser sign
MRI
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Neurologic deficit
Infantile and juvenile curves
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Spinal cord abnormality in younger children
Infantile idiopathic scoliosis 50%
 Juvenile 20%
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Who needs an MRI:
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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
patient’s 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.
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.
Medical complications:
At 100 degrees or greater: increased potential
for life threatening effects on pulmonary
function.
Psychologic illness: seen in up to 19% of
females with curves great than 40 degrees as
adults.
Treatment principles:
Orthotic braces - 74% success rate at halting
progression
Must be worn 20 hours a day, but most pts are
not compliant.
Braces do not correct scoliosis.
Surgical therapy is definitive, but indicated
only for those at 40 degrees or above
Infantile Treatment
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Must prove idiopathic
90% are left thoracic
3 female : 2 male
90% resolve spontaneously
Predict progression by RVAD
< 20 degrees 83% resolve
 >20 degrees 84% progress
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Juvenile Treatment
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Younger onset likely to progress
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>30 degree curve almost always progress
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Some adolescent curves are missed juvenile
Adolescent Treatment
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Most curves <10 degrees
Boys = girls for these curves
 Usually don’t progress
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More sever curves (>30 degrees)
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8 girls : 1 boy
Predicting who will progress
Risk for Progression
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Younger onset
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Skeletal age
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Risser 0-1 at presentation 60-70% progress
Risser 3 only 10% risk
Menses starts after growth spurt
Female more likely than male
Curve pattern
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Apex above T12
Degree at presentation
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20-29 degrees 68% risk for progression
30-59 degrees 90% risk for progression
Natural History
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If curve <30 degrees at maturity
No adult consequences
 Unlikely to ever progress
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Curves >45 degrees may progress a degree/year
Mortality not increased unless curve >90 degree
Right heart failure
 Decreased pulmonary function
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Treatment : 10 degrees curve or
less
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This curve is considered normal.
No action is taken.
Follow up appointments are prescribed to
monitor the patient.
Usually done every 3-6 months, but at the
physician discretion.
Treatment:10 to 25 degree curve
Sometimes no treatment needed, if no
progression.
 Begins with simple orthotics(very effective)
 daytime/nighttime braces.
 Shoe lifts for leg length discrepancies.
 Stretches, exercises.
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Shoe Lifts:
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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
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Day and night brace worn 20+ hours/day.
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Shoe lifts may also be needed.
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Stretches and exercises to loosen muscles and to
relieve pain if present.
Treatment: 45 degree + curve
Almost always treated with surgery.
 Vertebrae are fused using Bone grafts.
 Hardware(metal splints)
 Still require braces to be worn in post op period.
 Causes growth to stop.
 Can cause nerve damage, infection and other
problems.
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Left untreated:
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If progressing, can worsen upto 70 degrees +
curve.
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Places pressure on vital organs.
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Can cause cardio-respiratory problems.
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Can eventually become untreatable.
Non-Operative Treatment
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<25 degrees monitor every 4-12 months
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Depends on skeletal maturity
>25 degrees monitor every 3-6 months
>30 degrees in skeletally immature brace
Curve change by 10 degrees brace
Curve >40-45 degrees surgery
Braces :
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Made of polypropylene.
Contoured to size and shape
of body.
Curved to oppose specific
points of scoliosis curvature.
Flexible and comfortable.
Worn under clothing.
Nighttime/daytime use.
Must be worn faithfully.
Bracing
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Duration and time in brace
23 hours per day
 Wear until skeletally mature
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Types
Milwaukee
 Underarm orthosis
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Electrical stimulation
Braces
Successful Bracing
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Prevent curve progression
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Randomized study
Braced 74% did not progress
 Not braced 34% did not progress
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Electrical stimulation
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33% did not progress
Charleston brace still controversial
Problems with Braces
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Argued efficacy
Narrow treatment window to initiate
Poor compliance
Must have good orthotist
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Curves corrected by 20 degrees in brace do better
Treatment Algorithm
Surgery
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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.
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After 8 years- anterior and posterior spinal
fusion.
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After 11 years- posterior spinal fusion.
Surgical Options:
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Adolescent scoliosis:
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Posterior spinal fusion with instrumentation.
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Anterior spinal fusion if younger than 11 years
and with open triradiate cartilage.
THANK YOU
…