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Approach to a case of Scoliosis

Approach to a case of 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

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Approach to a case of Scoliosis

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  1. Approach to a case of Scoliosis

  2. 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

  3. Upto 10 degrees is normal. • Can be seen as C- curve or S-curve. • S- curve is usually compensatory.

  4. 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.

  5. Anatomy • All bony elements are altered • Vertebra are wedge shaped • Rib vertebral angle altered • Pedicles rotated • Discs are wedged as well

  6. Types of Scoliosis • Congenital • Neuromuscular • Cerebral palsy • Syndrome related • Marfan’s syndrome • Idiopathic • 80% are this

  7. Etiological Theories • Genetic • Tissue deficiencies • Growth abnormalities • Central nervous system alteration

  8. Genetic • 11% incidence in first relatives of patients • Normal incidence < 3% • Monozygote twins more common • No gene identified to date

  9. Tissue Deficiencies • Marfan’s syndrome deficient fibrillin • Osteopenia noted in girls • Elevated calmodulin • Involved in contractile properties thru actin & myosin • Elevated in platelets • No consistent findings to date

  10. Growth Abnormality • Asymmetrical vertebral growth • Hueter-Volkman effect is suppression of growth on concave side • Hypokyphosis during growth spurt • No increased incidence with growth hormone • No initiating factor identified

  11. Central Nervous System • Different size cerebral cortices • Altered equilibrium • Primary or secondary • Deficient melatonin • Chicken model • Inconclusive in humans

  12. 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 • Primary vs secondary • Structural vs non-structural

  13. Classification • Infantile: 0-3 years old (.5%) • Juvenile: 4-11 years old (10.5%) • Adolescent: 10-17 years old (89%) • Adult: >18 years old

  14. History • Family history • Affected sibling 7 times more frequent • Affected parent 3 times more frequent • Recent growth history • Sexual maturity • Pain • ‘Fatigue pain’ • Post diagnostic pain • ‘Severe pain’

  15. Physical Exam • Iliac crest height • Leg length discrepancy • Shoulder height • Arm trunk space • Scapular position • Trunk shift • Inspection of skin • Café au lait spots

  16. Physical Examination: Features suggestive of polio, neurofibromatosis, Von Reclinghausen syndrome, Down’s, Marfan’s, Hurler’s syndrome, neural tube defects and osteogenesisimperfecta. 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.

  17. Tests of flexibility of spine: Adam’s forward bending test. Pushing the curve from convex side and noting the correction. Lifting the patient up from head. Lateral bending.

  18. Forward Bend TestAdam’s sign

  19. Neurologic Exam • Observe gait • Hop test • Heel and toe walk • Reflexes

  20. 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.

  21. 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.

  22. 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

  23. 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.

  24. Rotation • Spinous process rotates into concavity • Pedicle position

  25. Skeletal Maturity • Triradiate cartilage fusion • Risser sign

  26. MRI • Neurologic deficit • Infantile and juvenile curves • Spinal cord abnormality in younger children • Infantile idiopathic scoliosis 50% • Juvenile 20%

  27. 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.

  28. 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

  29. 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.

  30. 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.

  31. 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

  32. Infantile Treatment • 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

  33. Juvenile Treatment • Younger onset likely to progress • >30 degree curve almost always progress • Some adolescent curves are missed juvenile

  34. Adolescent Treatment • Most curves <10 degrees • Boys = girls for these curves • Usually don’t progress • More sever curves (>30 degrees) • 8 girls : 1 boy • Predicting who will progress

  35. Risk for Progression • Younger onset • Skeletal age • 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 • Apex above T12 • Degree at presentation • 20-29 degrees 68% risk for progression • 30-59 degrees 90% risk for progression

  36. Natural History • If curve <30 degrees at maturity • No adult consequences • Unlikely to ever progress • Curves >45 degrees may progress a degree/year • Mortality not increased unless curve >90 degree • Right heart failure • Decreased pulmonary function

  37. Treatment : 10 degrees curve or less 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.

  38. 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.

  39. Shoe Lifts: • Used for leg length discrepancies. • Worn in regular shoes. • Places opposing pressure on scoliosis curvatures. • Must be worn during every scoliosis radiograph.

  40. Treatment: 25 to 35 degree curve Day and night brace worn 20+ hours/day. Shoe lifts may also be needed. Stretches and exercises to loosen muscles and to relieve pain if present.

  41. 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.

  42. Left untreated: If progressing, can worsen upto 70 degrees + curve. Places pressure on vital organs. Can cause cardio-respiratory problems. Can eventually become untreatable.

  43. Non-Operative Treatment • <25 degrees monitor every 4-12 months • 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

  44. Braces : • 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.

  45. Bracing • Duration and time in brace • 23 hours per day • Wear until skeletally mature • Types • Milwaukee • Underarm orthosis • Electrical stimulation

  46. Braces

  47. 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

  48. 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

  49. Treatment Algorithm

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