Scoliosis

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Scoliosis

• Baylor College of Medicine
• Med-Peds Continuity Clinic
• Anoop Agrawal, M.D.

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Epidemiology

• Scoliosis is a lateral curvature of the spine
  greater than 10 degrees.
• Idiopathic vs. Secondary
• Idiopathic is the most common type.
• Secondary causes include connective tissue,
  neurologic, and musculoskeletal disorders.

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Classification

• Idiopathic Scoliosis - defined by the age of
  onset
• Infantile - birth to 3 years
• Juvenile - 3 to puberty
• Adolescent - after puberty
• Adolescent Idiopathic Scoliosis is the most
  common type.

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Etiology AIS

• No direct cause has yet been isolated.
• Leading theory Multigene dominant condition with
  variable phenotypic expression
• Studies of twins have shown greater risk in
  monozygotic than dizygotic, and the rate of curve
  progression was nearly identical

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Prevalence AIS

• Scoliosis is present in 2 to 4 of children
  between 10 and 16 years of age.
• Girls tend to have more severe curves.
• FM ratio 11 in those with small curves (10
  degrees)
• FM ratio increases to 101 in those with curves
  greater than 30 degrees

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Diagnosis

• Need to exclude secondary causes.
• History
• family history
• presence of pain and neurologic changes
• bowel and bladder dysfunction

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Physical Exam

• Complete neurologic exam
• Tanner staging - curve progression occurs most
  rapidly during stage 2 or 3
• Adams forward bend test

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Adams Bend Test

• Pt bends forward, spine horizontal to the floor,
  while holding palms together, arms extended.
• Examine from side and behind the patient.
• Look for a rib hump
• Rib hump is a hallmark of a scoliotic curve
  greater than 10 degrees.

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Imaging

• Imaging is ordered for any patient with
  abnormalities on physical exam.
• A single standing PA plain film of the spine is
  needed.
• The degree of the curve is measured by the Cobb
  method.
• 90 of curves are to the right!

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Red Flags, i.e. need MRI

• A thoracic curve to the left
• painful scoliosis
• abnormal neurologic findings
• untoward stiffness
• deviation to one side during the bend test
• sudden rapid progression in previously stable
  curve

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The Cobb method

• Choose the most tilted vertabrae above and below
  the apex of the curve.
• Draw a line perpendicular to that vertabrae.
• The angle created between these intersecting
  lines is the Cobb angle.

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When do you observe vs. treat or refer?

• What is the likelihood the curve will progress?
• What degree of curvature leads to medical
  complications?

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Will the curve progress?

• Three factors involved in progression
• patients 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

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How to determine growth potential?

• Tanner staging - pts in stage 2 and 3 more
  likely to progress
• Risser grade
• based on ossification of iliac apophysis
• graded from 0 (no ossification) to 5 (complete
  bony fusion)

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The magic is... 30

• Data from multiple studies has yielded the Risk
  of Curve Progression table.
• The table assists in predicting progression and
  hence guiding treatment.
• What is the risk for an 11 yo girl with a 25
  degree curve and Risser grade 1?

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Curve Progression

• Curves 30 to 50 degrees progress an average of 10
  to 15 degrees over a lifetime.
• Curves gt 50 at maturity progress steadily at a
  rate of 1 degree per year.
• Curves less than 30 at bone maturity are unlikely
  to progress.

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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.

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Does Screening help?

• AAOS recommends screening girls at ages 11 and
  13 boys once at 13 or 14.
• AAP recommends at 10, 12, 14, and 16.
• But in fact... in 1996 the US Preventative Task
  Force found insufficient evidence for or against
  screening in asymptomatic pts. This was updated
  again in June 2004 with the same conclusion.

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Treatment

• 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

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Conclusion

• Adolescent Idiopathic Scoliosis is the most
  common type.
• Overall, females more prone and tend to have more
  severe curves (to the right!).
• Screening is of limited value.
• There are extensive research based guidelines for
  predicting curve progression and treatment

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Questions?