SCOLIOSIS

Scoliosis is a disorder that causes an abnormal curve of the spine, or backbone. The spine has
normal curves when looking from the side, but it should appear straight when looking from the
front. Kyphosis is a curve seen from the side in which the spine is bent forward. Lordosis is a curve
seen from the side in which the spine is bent backward. People with scoliosis develop additional
curves to either side, and the bones of the spine twist on each other like a corkscrew.

CAUSES:
Functional: In this type of scoliosis, the spine is normal, but an abnormal curve develops because of
a problem somewhere else in the body. This could be caused by one leg being shorter than the
other or by muscle spasms in the back.

Neuromuscular: In this type of scoliosis, there is a problem when the bones of the spine are
formed. Either the bones of the spine fail to form completely, or they fail to separate from each
other. This type of scoliosis develops in people with other disorders including birth defects,
muscular dystrophy, cerebral palsy, or Marfan's disease. If the curve is present at birth, it is called
congenital. This type of scoliosis is often much more severe and needs more aggressive treatment
than other forms of scoliosis.

Degenerative: Unlike the other forms of scoliosis that are found in children and teens, degenerative
scoliosis occurs in older adults. It is caused by changes in the spine due to arthritis. Weakening of
the normal ligaments and other soft tissues of the spine combined with abnormal bone spurs can
lead to an abnormal curvature of the spine.

Others: There are other potential causes of scoliosis, including spine tumors such as osteoid
osteoma. This is a benign tumor that can occur in the spine and cause pain. The pain causes people
to lean to the opposite side to reduce he amount of pressure applied to the tumor. This can lead to a
spinal deformity.

CLASSIFICATION:
1. Infantile: Occurs between birth and 3 years of age. Usually noticed in the first year of life.
More common in boys particularly from England. Left thoracic curve occurs more common,
and often resolves spontaneously. Few patients will have progressive curves which can be
quite severe requiring early bracing and even surgery.
2. Juvenile: Occurs between 4-10 years of age. Incidence is equal for boys and girls. Most
curves are right thoracic. Curves are progressive in nature and need close follow up.
3. Adolescent: Usually diagnosed at the age of 10. Most curves are right thoracic and
thoracolumbar. Curves have a strong tendency to progress during adolescent growth spurt.
Extremely active, athletic teenage girls with delayed menses are most of risk for curve
progression.
ASSESSMENT:
1. IMAGING ASSESSMENT:

 A single standing P-A film taken from occiput to sacrum is adequate. Radiographic imaging
may not be needed in children with very mild curves detected on routine school screening
examination. These children can be followed by physical examination with scoliometer. If
there is a significant change over the previous 6 months or if there is a severe rib rotation,
Xray is then warranted.
 In general, young patients with mild scoliosis can be safely seen in follow up and Xray done
every 6-9 months. For faster progressive curves, Xray every 3 months is recommended. In
adolescents, a progression of 1 degree/month is normal, where as a significant progression
is 3-5 degree/month.
 Spot lateral view is useful to assess for spondylolisthesis and spondylosis which can occur
in 30-35% of children with Scheuermann's disease (occurs in 5% of idiopathic scoliosis
which is the same as that of the general population).

2. CURVE MEASUREMENT:

a. Cobb method: This method relies on the accuracy of identifying the vertebra at the upper
and lower end of the curve. These end vertebrae are those with maximal tilt toward the
concave side. Horizontal lines are then drawn at the superior border of the superior end
vertebrae and at the inferior border of the inferior end vertebrae. Perpendicular lines to
these two horizontal lines will intersect.
b. Risser-Ferguson method: Straight lines are drawn from the middle of the end vertebra to the
middle of the vertebrae at the apex of the curve. This method is not frequently used.

3. ROTATION ASSESSMENT: Rotation is an inherent structural change in scoliosis. It

correlates with the degree of resistance to corrective therapy. Rotation can be recorded in
two ways:

a. Displacement of Pedicles: On A-P view, one pedicle rotates toward the midline and the other
rotates to the lateral border of the vertebra.
b. Displacement of Spinous Processes: (+) rotation is a displacement of one width of the spinous
process from the midline, and so forth. This method is not accurate since the spinous
processes are often deformed (bent toward the concave side).

4. SKELETAL MATURITY: Scoliotic progression slows significantly at full maturity. It is

therefore essential to know when skeletal growth is complete to plan for therapy, follow up
frequency, and cessation of therapy. In general, girls mature at about 16 ½ years old, and
boys about age of 18. Reviewing the radiographs can reasonably predict skeletal maturity:

a. Left hand and wrist films for comparison with Greulich and Pyle atlas.
b. Excursion of the iliac crest described by Risser. Ossification of the crest starts laterally and
meets with the SI junction as well as fuses with the ilium at full maturity.
c. Growth plate of the vertebra form a solid union at full maturation. At 6-8 years of age in
girls (7-9 years old in boys), a calcific ring develops at the superior and inferior aspect of the
vertebra. This ring gradually fuses with the vertebral body at the age of 14-15. Complete
fusion occurs at age 21-25.
MANAGEMENT:
1. Bracing

Although a definite inconvenience, bracing is sometimes necessary, and may prevent the need for
surgery. A recent study has shown that bracing is effective in stopping the progression of the curve
in about 80 per cent of patients, until the age of 16. A variable degree of relapse of the curve does
occur after the cessation of bracing, usually at the age of 15 - 16. However, those children who have
been braced generally still have curves within the acceptable range, which should not carry any
particular disadvantage into adulthood.

2. Physiotherapy

Surface electrical stimulation has now been discredited as a treatment, and studies have shown that
the children treated in this way do no better than those left untreated. Treatment such as
manipulation has no place in the management of the mechanical defect in scoliosis, although
manipulation and physical therapies can help any low back pain that occurs in association with a
scoliosis. In the majority of functional scolioses, Physiotherapists can give advice regarding:

 Posture;
 Strengthening of muscles and correction of muscle imbalance;
 Strapping;
 Ergonomics;
 Exercise.

Exercises can be prescribed, but they will probably not effect the progression of a curve. If a brace is
required, an exercise programme will also be prescribed, but if not required, instruction regarding
review of the scoliosis and exercises will be provided.

3. Surgery

In the rare cases where the scoliosis reaches the point of no return, surgery may be required. In
thoracic scoliosis it entails the insertion of metal rods - called Cotrel-Dubousset Instrumentation -
along the spine. These rods act as braces to straighten the spine and prevent further deterioration
of the scoliosis. These rods are usually left in the spine throughout life. These operations are
performed by Orthopaedic Surgeons, who are specialised in the area of Paediatric Orthopaedics.
This type of surgery does not require the patient to wear a plaster jacket after the operation. The
stay in hospital is about 7 to 9 days, and return to school is about 1 month. Life after surgery
returns to near normal by about 9 months, except that body contact sports are not permitted.
Lumbar scoliosis is treated with other operations including fusion, and the underarm brace is
required for up to 6 months after surgery.
Adam’s Forward Bend Test
The screening test used most often in schools and in the offices of pediatricians and primary care
physicians is called the Adams forward bend test.
The child bends forward dangling the arms, with the feet together and knees straight. The curve
of structural scoliosis is more apparent when bending over. In a child with scoliosis, the
examiner may observe an imbalanced rib cage, with one side being higher than the other, or
other deformities.
The forward bend test is a test used most often in schools and doctor's offices to screen for
scoliosis. During the test, the child bends forward with the feet together and knees straight while
dangling the arms. Any imbalances in the rib cage or other deformities along the back could be a
sign of scoliosis.
Halo Traction.

Halo traction is a way of keeping your head and neck still while you get better after an accident or
operation to your neck bones.  This will usually always be used in adults with broken necks if
surgery is not performed immediately post injury.  If surgery goes ahead and is successful post
injury then there's usually no further need for halo traction.  If surgery is ruled out then the halo
traction will be used for up to two months on bed rest and then a further month to three months
attached to a specially made vest so the head is kept perfectly still whilst sitting.
The halo traction equipment is made up of three pieces:
 a ring around your head and then or
 a special vest
 Weights attached to the halo at head end of bed over a pulley system
 a set of four rods and two blocks.
Halo traction is attached to the head by titanium screws which are screwed into the skull
bone.  The screws have to be tightened periodically to ensure the halo is fitting correctly. 
The halo traction vest when required will be made just for the individual. 
Conservative Scoliosis Treatment

The primary aim of scoliosis management is to stop curvature progression. Improvement

of pulmonary function (vital capacity) and treatment of pain are also of major importance.
The first of three modes of conservative scoliosis management is based on physical
therapy, including Méthode Lyonaise , Side-Shift , Dobosiewicz, Schroth and others.
Although discussed from contrasting viewpoints in the international literature, there is
some evidence for the effectiveness of scoliosis treatment by physical therapy alone.

Non-Surgical Treatment

Adolescents with a spinal curvature of less than 20 degrees usually do not require extensive
treatment. They do, however, need periodic check-ups and X-rays to make sure the curve does
not get worse.

If the spinal curve is 25 to 40 degrees and the child is still growing, a 24-hour brace is often
worn. Bracing is an attempt to prevent further progression of the curve, but it will not reverse or
cure scoliosis.

Surgical Treatment

Those who have spinal curves greater than 40 to 50 degrees are often considered for scoliosis
surgery. While surgery will not perfectly straighten the spine, the goal is to make sure the curve
does not get worse. During scoliosis surgery, the vertebrae are fused together so the spine cannot
bend. This is called a spinal fusion. The process is similar to what occurs when a broken bone
heals.

Surgery begins with an incision in the middle of the back. The muscles are then moved to the
side to expose the spine, and the joints between the vertebrae are removed to loosen them up.
Metal implants (usually rods, screws, hooks or wires) are put in to hold the spine in place while
the vertebrae gradually fuse. The procedure usually takes four to six hours, but varies from
patient to patient.

The implants are left in the body, even after the bones have fused, to avoid additional surgery.
Diagnosis

Uneven ribs and shoulder imbalance may be the first noticeable signs of scoliosis. The
diagnosis of scoliosis is based upon X-ray of the spine.

If a person with scoliosis is suspected of having an underlying disease, other tests may be
necessary. Symptoms of possible underlying diseases include:

 Significant pain
 Colored markings
 A hairy patch on the skin
 A deformity of the foot

Certain types of scoliosis also are associated with other diseases, such as kidney disease. In
addition to having an X-ray, other tests may be done to check for signs of underlying
diseases, such as an ultrasound to look for kidney disease and a magnetic resonance
imaging (MRI) scan to look for an abnormality of the nervous system.

Adam’s Forward Bend Test

The screening test used most often in schools and in the offices of pediatricians and primary care
physicians is called the Adams forward bend test.
The child bends forward dangling the arms, with the feet together and knees straight. The curve
of structural scoliosis is more apparent when bending over. In a child with scoliosis, the
examiner may observe an imbalanced rib cage, with one side being higher than the other, or
other deformities.
The forward bend test is a test used most often in schools and doctor's offices to screen for
scoliosis. During the test, the child bends forward with the feet together and knees straight while
dangling the arms. Any imbalances in the rib cage or other deformities along the back could be a
sign of scoliosis.