Scoliosis

How are curves of 10-15 degrees treated?

Curves of 10-15 degrees are treated by 6-12 month follow-up with clinical evaluation and possible x-ray.

How are curves of 15-20 degrees treated?

Curves of 15-20 degrees need serial AP radiographic follow-up every 3-4 months for larger curves and every 6-8 months for small curves or for patients near the end of growth.

How are curves greater than 20 degrees treated?

Curves of 20 degrees or greater need referral to an orthopaedist for continuous monitoring and management.

What is adolescent scoliosis?

Idiopathic adolescent scoliosis is the most common cause (80%) of spinal deformity. The right thoracic curve is the most common pattern.

How does idiopathic scoliosis present clinically?

Idiopathic scoliosis is a painless disorder 70% of the time. A patient with pain requires a careful evaluation. Any patient presenting with a left-sided curve has a high incidence of intraspinal pathology (syrinx or tumor). Evaluation of the spine with magnetic resonance imaging (MRI) is indicated in these cases.

How is scoliosis diagnosed?

Radiographs standing PA and lateral. Cobb angle > 10° defined as scoliosis - intra-interobserver error of 3-5°. MRI - to rule out intraspinal anomalies. Should be performed if atypical curve pattern, rapid progression, neurologic symptoms of pain, reflex abnormalities, etc.

What dictates treatment for scoliosis?

Treatment is based on degree of curvature.

How is congenital scoliosis treated?

Treatment of congenital scoliosis hinges on early diagnosis and identification of progressive curves. Orthotic treatment is not helpful in congenital scoliosis. Early spinal surgery should be performed once progression has been documented. This can help prevent major deformities. Patients with large curves that cause thoracic insufficiency should undergo surgery immediately.

How are curves 20-40 degrees treated?

Moderate curves (20 to 40°) are treated conservatively (eg, physical therapy and bracing) to prevent further deformity.

What is congenital scoliosis?

Abnormalities of the vertebral formation during the first trimester may lead to structural deformities of the spine that are evident at birth or early childhood. Congenital scoliosis can be classified as follows: -Partial or complete failure of vertebral formation (wedge vertebra or hemivertebra) -Partial or complete failure of segmentation (unsegmented bars) -Mixed

How are curves greater than 40 degrees treated?

Surgery if > 40°.

What is compensatory scoliosis?

Adolescents with a leg-length discrepancy may have a positive screening examination for scoliosis. Before correction of the pelvic obliquity, the spine curves in the same direction as the obliquity. However, with identification and correction of any pelvic obliquity, the curvature should resolve, and treatment should be directed at the leg-length discrepancy. Thus it is important to distinguish between a structural and compensatory spinal deformity.

What is scoliosis?

Alterations in normal spinal alignment that occur in the anteroposterior plane are termed scoliosis.

What is the Adam's test?

At routine screening, a patient is asked to flex forward and the scapula height is observed (known as Adam's test) if scoliosis is present, asymmetry in scapular height is noted.

Which thoracic curvature is an indication for treatment with bracing in an adolescent with scoliosis? A. Less than 20 degrees B. 20 to 40 degrees C. 40 to 60 degrees D. 40 degrees with lumbar curvature of 30 degrees E. Greater than 70 degrees

B. 20 to 40 degrees Scoliosis is defined by lateral curvature of the spine with rotation of vertebrae and is typically located in thethoracic or lumbar spine in the right or left directions. Idiopathic scoliosis most commonly presents as a right thoracic curve in females from 8 to 10 years of age. Scoliosis is typically asymptomatic unless curvatures are so severe that there is pulmonary dysfunction or there is an underlying disorder (bone or spinal tumor) that is causing the scoliosis. X-rays need to be taken of the entire spine to help determine the degree of curvature. Treatment modalities are based on the degree of curvature: 20 degrees or less does not normally require treatment; 20 to 40 degrees is an indication for bracing in an immature child; and 40 degrees and greater is resistant to bracing and requires surgical fixation with spinal fusion, which is best done at special centers. A greater than 70-degree curvature is associated with poor respiratory function in adulthood.

Which of the following statements about scoliosis is true? A. The most common form is congenital B. The patient has a normal Adam's test C. Patients with abnormalities > 5 degrees should be referred to an orthopaedist D. Most curvature is to the right in the thoracic spine, causing the right shoulder to be higher than the left E. Syringomyelia is not associated with scoliosis

D. Most curvature is to the right in the thoracic spine, causing the right shoulder to be higher than the left Scoliosis is defined as the presence of a lateral spinal curvature of 11 degrees or more. Its prevalence during adolescence is estimated to be between 2% and 3%. Curvatures > 100 degrees can contribute to restrictive pulmonary disease; however, deviations of this magnitude are extremely rare. Scoliosis is classified as idiopathic (80% of cases), congenital (5%), neuromuscular (10%), or miscellaneous (5%). Severe scoliosis is more common in female patients. Idiopathic scoliosis is an inherited autosomal-dominant condition that occurs with variable penetrance. Most patients are asymptomatic; however, they may report backaches. The child should be examined with his or her back facing the examiner. The patient is asked to flex forward, and the scapula height is observed (known as the Adam's test). If scoliosis is present, asymmetry in scapular height is noted. In most cases, the right shoulder is higher than the left because of a convex curve of the spine to the right in the thoracic area and to the left in the lumbar area. Hip height and symmetry may also be affected. Radiographs should only be considered when a patient has a curve that might require treatment or could progress to a stage requiring treatment (usually 40 to 100 degrees). Radiographs should include posteroanterior and lateral views of the spine with the patient standing. Magnetic resonance imaging should be obtained in patients with an onset of scoliosis before 8 years of age, rapid curve progression of more than 1 degree/ month, an unusual curve pattern such as left thoracic curve, neurologic deficit, or pain. Treatment depends on the degree of curvature. The primary goal of treating adolescent idiopathic scoliosis is preventing progression of the curve magnitude. Curves < 10 to 15 degrees require no active treatment and can be monitored unless the patient's bones are very immature and progression is likely. Moderate curves between 25 and 45 degrees in patients lacking skeletal maturity used to be treated with bracing, but this treatment has never been proven to prevent curve progression. Poor compliance with wearing a brace obviates any potential usefulness of the therapy. Much controversy surrounds brace indications, and trends since the mid-1980s have moved toward no bracing or bracing only the more significant curves (20 to 50 degrees). In more severe cases, braces (e.g., Milwaukee brace) or surgery may be indicated. Painful scoliosis may indicate underlying neurologic problems, such as syringomyelia or spinal cord lesion, and is less likely to be idiopathic.

What are the types of idiopathic scoliosis?

Idiopathic scoliosis can be classified in three categories: infantile (birth to 3 years), juvenile (4-10 years) and adolescent (>11 years).

What is the epidemiology of idiopathic scoliosis?

Idiopathic scoliosis is the most common form of scoliosis. It occurs in healthy, neurologically normal children. Approximately 20% of patients have a positive family history. The incidence is slightly higher in girls than boys, and the condition is more likely to progress and require treatment in females. There is some evidence that progressive scoliosis may have a genetic component as well.

What is juvenile scoliosis?

Juvenile scoliosis is uncommon but may be underrepresented because many patients do not seek treatment until they are adolescents. In any patient younger than 11 years of age, there is a greater likelihood that scoliosis is not idiopathic. The prevalence of an intraspinal abnormality in a child with congenital scoliosis is approximately 40%.

What complications are associated with congenital scoliosis?

More than 60% of patients have other associated abnormalities, such as VACTERL association (vertebral defects, imperforate anus, cardiac anomalies, tracheoesophageal fistula, renal anomalies, limb abnormalities such as radial agenesis) or Klippel-Feil syndrome. Renal anomalies occur in 20% of children with congenital scoliosis, with renal agenesis being the most common; 6% of children have a silent, obstructive uropathy suggested the need for evaluation with ultrasonography. Congenital heart disease occurs in about 12% of patients. Spinal dysraphism (tethered cord, intradural lipoma, syringomyelia, diplomyelia, and diastematomyelia) occurs in approximately 20% of children with congenital scoliosis. These disorders are frequently associated with cutaneous lesions on the back and abnormalities of the legs and feet (e.g. cavus foot, neurological changes, calf atrophy). MRI is indicated in evaluation of spinal dysraphism.

What is the peak age for scoliosis?

Most commonly begins at 8-10 years of age.

What is the prognosis of neuromuscular scoliosis?

Once scoliosis begins, progression is usually continuous. The magnitude of the deformity depends on the severity and pattern of weakness, whether the underlying disease process is progressive, and the amount of remaining musculoskeletal growth. Nonambulatory patients have a higher incidence of spinal deformity than ambulatory patients. In nonambulatory patients, the curves tend to be long and sweeping, produce pelvic obliquity, involve the cervical spine, and also produce restrictive lung disease. If the child cannot stand, then a supine or seated anteroposterior radiograph of the entire spine, rather than a standing posteroanterior view, is indicated.

What is neuromuscular scoliosis?

Progressive spinal deformity is a common and potentially serious problem associated with many neuromuscular disorders, such as cerebral palsy, Duchenne muscular dystrophy, spinal muscular atrophy, and spina bifida. Spinal alignment must be part of the routine examination for a patient with neuromuscular disease.

What health maintenance test should be performed on patients with scoliosis?

Pulmonary function tests to determine whether the scoliosis is affecting breathing. Will demonstrate a restrictive airway pattern.

What is a Cobb angle?

Scoliosis is defined as a lateral spinal curvature with a Cobb angle of 10° or more.

How is neuromuscular scoliosis treated?

The goal of treatment is to prevent progression and loss of function. Nonambulatory patients are more comfortable and independent when they can sit in a wheelchair without external support. Progressive curves can impair sitting balance, which affects quality of life. Orthotic treatment is usually ineffective in neuromuscular scoliosis. Surgical treatment may be necessary with frequent fusion to the pelvis.

What is the prognosis of congenital scoliosis?

The risk of spinal deformity progression in congenital scoliosis is variable and depends on the growth potential of the malformed vertebrae. A unilateral unsegmented bar typically progresses, but a block vertebra has little growth potential. About 75% of patients with congenital scoliosis will show some progression that continues until skeletal growth is complete, and about 50% will require some type of treatment. Progression can be expected during periods of rapid growth (before 2 years and after 10 years).

How is idiopathic scoliosis treated?

Treatment of idiopathic scoliosis is based on the skeletal maturity of the patient, the size of the curve, and whether the spinal curvature is progressive or nonprogressive. Initial treatment for scoliosis is likely observation and repeat radiographs to assess for progression. No treatment is indicated for nonprogressive deformities. The risk factors for curve progression include gender, curve location, and curve magnitude. Girls are five times more likely to progress than boys. Younger patients are more likely to present than older patients. Typically, curves under 25 degrees are observed. Progressive curves between 20 degrees and 50 degrees in a skeletally immature patient are treated with bracing. A radiograph in the orthotic is important to evaluate correction. Curves greater than 50 degrees usually require surgical intervention.