Scoliosis

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Scoliosis

• Andrea Chymiy
• Swedish Family Medicine
• September 24, 2002

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Scoliosis

• What is it?
• How do we screen for it?
• When to refer?
• How is it treated?

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What is scoliosis?

• 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

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Secondary causes for scoliosisInherited
connective tissue disorders

• - Ehlers Danlos syndrome
• - Marfan syndrome
• - Homocystinuria

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Secondary causes for scoliosisNeurologic
disorders

• Tethered cord syndrome
• Syringomyelia
• Spinal tumor
• Neurofibromatosis
• Muscular dystrophy

• Cerebral palsy
• Polio
• Friedeichs ataxia
• Familial dysautonomia
• Werdnig-Hoffman disease

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Secondary causes for scoliosisMusculoskeletal
disorders

• Leg length discrepancy
• Developmental hip dysplasia
• Osteogenesis imperfecta
• Klippel-Feil syndrome

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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)

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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

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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

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Natural history of scoliosis

• Assessing growth potential using Risser grading
• - Measures progress of bony fusion of iliac
• apophysis
• - Ranges from zero (no ossification) to 5
  (complete
• bony fusion of the apophysis)
• - The lower the grade, the higher the potential
  for
• progression

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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.
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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)

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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

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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

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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.

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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
• Uneven waist
• Changes in look or texture of skin overlying the
  spine (dimples, hairy patches, color changes)
• Leaning of entire body to one side

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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.

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Red flags on PE

• Left-sided thoracic curvature
• Pain
• Significant stiffness
• Abnormal neurologic findings
• Stigmata of other clinical syndromes associated
  with curvature

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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.

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Referral Guidelines Treatment

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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

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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)

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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

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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)

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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)

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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.
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Question 1
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Answer 1
The answer is D monitor the patient's condition.
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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?
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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.

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Answer 2

• According to AAP the answer is B screen at 10,
  12, 14
• 16 years
• 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.

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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.

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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.
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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

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Conclusions

• 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