Lateral curvature of the spine 10º accompanied by vertebral rotation
Idiopathic scoliosis - Multigene dominant condition with variable phenotypic expression no clear cause
Multiple causes exist for secondary scoliosis
5 Secondary causes for scoliosisInherited connective tissue disorders
- Ehlers Danlos syndrome
- Marfan syndrome
6 Secondary causes for scoliosisNeurologic disorders
Tethered cord syndrome
7 Secondary causes for scoliosisMusculoskeletal disorders
Leg length discrepancy
Developmental hip dysplasia
8 Characteristics of idiopathic scoliosis
Present in 2 - 4 of kids aged 10 16 years
Ratio of girls to boys with small curves (is equal but for curves 30º the ratio is 101
Scoliosis tends to progress more often in girls (so girls with scoliosis are more likely to require treatment)
9 Natural history of scoliosis
Of adolescents diagnosed with scoliosis only 10 have curve progression requiring medical intervention
Three main determinants of curve progression are
(1) Patient gender
(2) Future growth potential
(3) Curve magnitude at time of diagnosis
10 Natural history of scoliosis
Assessing future growth potential using Tanner staging
Tanner stages 2-3 (just after onset of pubertal growth) are the stages of maximal scoliosis progression
11 Natural history of scoliosis
Assessing growth potential using Risser grading
- Measures progress of bony fusion of iliac
- Ranges from zero (no ossification) to 5 (complete
bony fusion of the apophysis)
- The lower the grade the higher the potential for
12 Risk of Curve Progression
Low risk 5 to 15 percent moderate risk 15 to 40 percent high risk 40 to 70 percent very high risk 70 to 90 percent. 13 Natural history of scoliosis
Back pain not significantly higher in pts with scoliosis
Curves in untreated adolescents with curves º at time of bony maturity are unlikely to progress
Curves 50 º at maturity progress 1º per year
Up to 19 of females with curves 40 º have significant psychological illness
Life-threatening effects on pulmonary function do not occur until curve is 100 º (ie Cor pulmonale)
14 Scoliosis Screening
In years past widespread school-based screening led to many unnecessary referrals of adolescents with minimal curvatures
U.S. Preventive Services Task Force notes insufficient evidence to recommend for or against routine screening of asymptomatic adolescents for idiopathic scoliosis
15 Scoliosis Screening Recommendations
American Academy of Orthopedic Surgeons
- Screen girls at ages 11 and 13
- Screen boys once at age 13 or 14
American Academy of Pediatrics
- Screen at 10 12 14 and 16 years
16 Adams forward bend test
For this test the patient is asked to lean forward with his or her feet together and bend 90 degrees at the waist. The examiner can then easily view from this angle any asymmetry of the trunk or any abnormal spinal curvatures.
17 Screening hints
Shoulders are different heights one shoulder blade is more prominent than the other
Head is not centered directly above the pelvis
Appearance of a raised prominent hip
Rib cages are at different heights
Changes in look or texture of skin overlying the spine (dimples hairy patches color changes)
Leaning of entire body to one side
18 Scoliometer An inclinometer (Scoliometer) measures distortions of the torso.
The patient bends over arms dangling and palms pressed together until a curve can be observed in the upper back (thoracic area).
The Scoliometer is placed on the back and measures the apex (the highest point) of the upper back curve.
The patient continues bending until the curve can be seen in the lower back (lumbar area). The apex of this curve is also measured.
19 Red flags on PE
Left-sided thoracic curvature
Abnormal neurologic findings
Stigmata of other clinical syndromes associated with curvature
20 Measure spinal curvature using Cobb method
Choose the most tilted verterbrae above below apex of the curve.
- Angle b/t intersecting lines drawn perpendicular to the top of the
superior vertebrae and bottom of the inferior vertebrae is the Cobb angle.
21 Referral Guidelines Treatment
22 Brace Treatment for Scoliosis
Most common is Boston brace (aka Thoraco-lumbar-sacral orthosis)
Braces have 74 success rate at halting curve progression (while worn)
Bracing does not correct scoliosis but may prevent serious progression
Usually worn until patient reaches Risser grade 4 or 5
23 Brace Treatment for Scoliosis
Of patients with 20 º - 29 º curves only 40 of those wearing braces ultimately required surgery compared to 68 of those not wearing back braces
Length of wearing time correlates with outcome (At least 16 hrs per day leads to best chance of preventing curve progression)
24 Surgical Treatment for Scoliosis
Curves in growing children greater than 40 º require a spinal fusion (Risser grade 0 to 1 in girls and Risser 2 or 3 in boys)
Skeletally mature patients can be observed until their curves reach 50 º
Posterior spinal fusion is best choice for thoracic curves
Anterior spinal fusion is best treatment for thoracolumbar and lumbar curves
25 Surgical Treatment for Scoliosis
Spinal surgery with instrumentation
significantly corrects deformity
usually stops curve progression
Surgery is accompanied by spinal
cord monitoring using somato-
sensory motor-evoked potentials
(risk of neurologic injury is 1/7000)
26 Post-Op Treatment Long Term Consequences of Spinal Fusion
If segmental instrumentation used no post-op cast or brace required
Post-fusion back pain does occur and is more common in distal spinal fusions
Usually out of hospital in 4-5 days back at school in 2 wks
OK to participate in athletics after 9 12 months
(should avoid contact sports)
27 Case 1 MP is a 16-year-old male who presents to your office for his annual health assessment and sports physical. During the course of his examination you note a mild convexity in the thoracic region of his spine with forward flexion at the hips. Based on your clinical examination you estimate a lateral spinal curvature of about 5 degrees. You note these findings to the patient and then to his mother. 28 Question 1 29 Answer 1 The answer is D monitor the patients condition. 30 Question 2 Because you have recently agreed to serve as school physician in the district where your office is located you wonder what scoliosis screening programs are in place and who has been examining these school children for scoliosis. Which one of the following procedures should you implement 31 Question 2 (cont.)
Arrange scoliosis screening for all students between 10 and 16 years of age.
B. Arrange scoliosis screening for all students 10 12 14 and 16 years of age.
C. Contact the school nurse and review skills for scoliosis screening procedures.
Visually inspect for severe curves only when the back is examined for other reasons.
Screen girls for scoliosis at 11 and 13 years of age and boys at 13 and 15 years of age.
32 Answer 2
According to AAP the answer is B screen at 10 12 14
According to U.S. Prev Services Task Force the answer is D
visually inspect for severe curves only when the back is
examined for other reasons.
33 Question 3 Which of the following statement(s) about treatment for adolescent scoliosis is/are correct
Exercise therapy has been shown to be an effective treatment for preventing progression of scoliosis.
B. Spinal surgery for scoliosis is not supported by studies showing improvements in clinical outcomes such as decreased back pain and increased functional status.
C. Lateral electrical surface stimulation for eight hours nightly can limit progression of spinal curvature
D. Back bracing (e.g. orthoses) reduces symptoms of low back pain.
34 Answer 3 The answer is B Although surgery for scoliosis is generally not recommended without marked curvature well-conducted outcomes studies with patients who have had surgery have not been completed. Symptoms of back pain do not appear to correlate with magnitude of surgical correction. 35 Conclusions
Screening for scoliosis remains controversial has led to many unnecessary referrals
Adolescent scoliosis can be followed by family docs if the curve has a low risk of progression underlying causes have been excluded
Curves demonstrating significant progression with continued growth remaining or those at high risk of progression should be referred for orthopedic evaluation
Always refer when red flags are present on PE or X-ray
90 of kids with scoliosis will not require medical intervention
Girls are much more likely than boys to need intervention for scoliosis
Bracing can slow progression of many curves and significantly decrease need for surgery
Spinal fusion surgery is recommended for curves greater than 45 50 degrees
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