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Aka: Idiopathic Scoliosis, Adolescent Scoliosis Advertisement I. A. B. Epidemiology Prevalence: 2% of adolescent population Age 1. Girls: After 9-10 years old 2. Boys: After 11-12 years old C. Gender 1. Boys and girls affected equally 2. Girls are much more likely to significantly progress II. A. B. Causes Idiopathic scoliosis (85%) Congenital Causes 1. Failed vertebral development (e.g. Hemivertebra) 2. Developmental failure of vertebrae to segment C. Neuromuscular disorders 1. Neurofibromatosis 2. Syringomyelia 3. Diastematomyelia (congenital spinal cord splitting) 4. Cerebral Palsy 5. Muscular Dystrophy 6. Myelomeningocele 7. Spinal muscular atrophy 8. Friedreich ataxia 9. Tethered cord
Scapular prominence 3. B. Connective Tissue Disease 1. Risk in first degree relatives: 11% II. Homocystinuria II. Spinal cord or vertebral tumor 3. Idiopathic scoliosis is inherited 1.Syrinx D. Pathophysiology Lateral curvature of the spine 1. Asymmetric Pelvis 2. II. History Age of onset. Vertebral infection E. Miscellaneous Causes 1. B. A. A. progression and prior management Back pain or stiffness symptoms Signs Scoliosis screening should begin at age 6 years Right thoracic and left lumbar curvature is the norm Landmarks 1. Shoulder height 2.10. Concordance in monozygotic twins: 73% 3. A. Marfan Syndrome 2. C. Ehlers-Danlos Syndrome 3. Autosomal dominant inheritance (variable penetrance) 2. Flank crease . Rotation of vertebrae about vertical axis B.
Gait G. Determine growth spurt 1. Forward Bending Test 2. See Scoliosis Examination 1. Neurologic Exam 2. Marfan's Syndrome stigmata II. A. Functional exam 1. Left thoracic curve (possible spinal cord lesion) 2. See Scoliosis XRay (Cobb Angle) 2.4. Measure Sitting Height (Truncal Height) q3 months 3. Leg Length Discrepancy D. Spine CT or MRI for atypical scoliosis . Images a. Obtain Risser Grading (Iliac XRay) F. Assessment Tools 2. Adam's Test E. Neurofibromatosis stigmata 3. Red Flags 1. Pelvic symmetry 5. Radiology Thoracic Spine XRay (may require full spine) 1. Scoliometer (measures trunk rotation) 3. B.
Course: Curves at skeletal maturity Curves <20 degrees: Resolve spontaneously 50% of cases Curves <30 degrees: Progress minimally Curve 40-50 degrees: 10-15 degree lifetime progression Curve >50 degrees: Progresses 1-2 degrees per year Course: Curves before skeletal maturity Spinal Curvature 20-29 degrees Risser Grade 0 to 1: 68% probability of progression Risser Grade 2 to 4: 23% probability of progression II. C. F. B. A. C. Differential Diagnosis Nonstructural Scoliosis Leg Length Discrepancy Local inflammation B. E. B. A. D. Progression risk factors Females Higher apex vertebral level Thoracic or thoracolumbar curve (70% progression) Double major curves (70% progression) Young children at beginning of growth curve Larger curves progress more severely . A.Left thoracic curve Onset of scoliosis before age 8 years Rapid curve progression >1 degree per month Neurologic deficit or pain II. D. A. II. Structural Scoliosis See Causes above II.
II. ii. A. b. Angle of trunk rotation exceeds 7 degrees Observation protocol (curves <10 to 15 degrees) Observe for progression until stable or maturity Examine every 3-4 months Indications to Repeat Thoracic XRay every 6 months a. It is subdivided into 3 categories: 1)Infantile Scoliosis: Birth to 3 years old 2)Juvenile Scoliosis: 3 . Angle exceeds 20 degrees Scoliometer a. Bracing is controversial and noncompliance is high Bracing options Thoracolumbar-Sacral Orthosis (TLSO) Cervicothoracolumbar-Sacral Orthosis (CTLSO) Cobb Angle greater than 45 to 50 degrees a. Management Treatment based on progression risk See Progression risk factors above B. B. bone grafting) Idiopathic Scoliosis: This is the most common type of scoliosis. i.10 years old 3)Adolescent Scoliosis: 10 years old to skeletal maturity . B. Curve increasing Child has growth spurt Management Strategies Cobb Angle greater than 20 degrees a. and constitutes 80% of the cases of scoliosis. b. Surgery (rod placement. There is no known cause of idiopathic scoliosis. Orthopedic referral indications Cobb Angle a.
It is often due to failures of formation or segmentation of the spine. Her rib prominence is most obvious when bending forward. . scapula (shoulder blade). It is the most common type. The term "idiopathic" means that the cause of this disorder is not known (in most cases). Right. Top of page Classification • Scoliosis can occur at any age. Neuromuscular Scoliosis: In this type of scoliosis. or hip appears higher than the other. Understanding the spine can help you better understand scoliosis. scoliosis can occur in several people within a family. People with congenital scoliosis will develop lateral spinal curves in infancy. ○ Adolescent idiopathic scoliosis occurs after the age of 10 years. Description • • • Scoliosis is a sideways curvature of the spine that makes the spine look more like an "S" or "C" than a straight "I". When it does. Middle. Learn more about spine anatomy at Spine Basics Left. the exact cause is not known (idiopathic).5% to 3. Top of page In most cases of scoliosis. Degenerative Scoliosis: Degenerative scoliosis occurs in adults and is due to degeneration of the spine that occurs with aging.2% to 0.3% of the population ○ • Cause • Small spinal curves occur with similar frequency in boys and girls. Clinical photograph of an adolescent girl with right thoracic idiopathic scoliosis. X-ray clearly demonstrates right thoracic scoliosis.5% of the population Curves exceeding 30° occcur in 0. Scoliosis can cause the bones of the spine to turn (rotate) so that one shoulder.Congenital Scoliosis: This is a rare type of scoliosis. Courtesy of Texas Scottish Rite Hospital for Children Top of page Statistics • Frequency of scoliosis: ○ ○ Scoliosis curves measuring at least 10° occur in 1. there is probably a genetic component to its cause. a lateral curvature of the spine occurs due to muscular weakness or neurological disorders.3% to 0.0% of the population Curves exceeding 20° occur in 0. However. but girls are more likely to have a progressively larger scoliotic curve that will require treatment.
Your doctor will measure the degree of the curve.○ Infantile scoliosis occurs in children less than 3 years old. This is called the "Adam's forward bend test. Tests Many schools regularly conduct scoliosis screenings of students." He or she will also check for any limb-length discrepancies. the doctor will want to recheck the curve on a regular basis to see that it is not progressively getting worse. or other potential causes. Cosmetic concerns are significant to many patients. which in some patients can lead to diminished lung capacity and the development of restrictive lung disease. the child's age. However. You may be asked to return every 3 to 6 months for re-examination. Your child may receive a referral for scoliosis to a doctor based on the results of a school screening. . Top of page Nonsurgical Treatment Observation This option is appropriate when the curve is mild (less than 20°) or if the child is near skeletal maturity. neurological dysfunction. Most instances of scoliosis identified by school screening will fall into this category. There are several types of braces. This x-ray of a patient's scoliosis measures 82° in the upper curve. which will show any deformities (see the image above). most being the underarm type. Bracing The goal of bracing is to prevent scoliotic curves from getting worse. or unknown reasons (idiopathic). and 75° in the lower curve. These screenings usually occur during the middle school years. various syndromes. Progressive deterioration of the scoliotic curve can occur. Bracing can be effective if the child is still growing and has a spinal curvature between 25° and 45°. The concern over the cosmetic appearance of the back often is the primary concern of the patient and parents. Top of page Investigations. curves exceeding 50° can lead to problems in the long term. The incidence of back pain among patients with scoliosis is similar to that of the general population. Top of page Examination. as shown in the accompanying x-ray. It is not common ○ Top of page Symptoms • Scoliosis does not usually cause any pain. Top of page Treatment . Scoliosis is confirmed with an x-ray of the spine. abnormal neurological findings. or respiratory problems. Juvenile scoliosis occurs in children between the ages of 3 and 10 years. Signs • The doctor will ask your child to bend forward.Indications • The type of treatment required depends on the kind and degree of the curve. neurologic disorders. and the number of remaining growth years until the child reaches skeletal maturity. Courtesy of Texas Scottish Rite Hospital for Children Top of page Natural History If left untreated. It may result from abnormally shaped vertebrae at birth (congenital).
Juvenile idiopathic scoliosis . patients are usually walking by the second day without the need for a brace. A return to most sporting activities is possible in 6 to 9 months after surgery. Bone graft from the bone bank. Wearing a brace does not affect participation in sporting activities. or from the patient's hip region. Scoliosis: Types list The list of types of Scoliosis mentioned in various sources includes: • Types of scoliosis based on age: ○ ○ ○ • Adolescent idiopathic scoliosis .most common type. and can rapidly resume their daily activities. Courtesy of Texas Scottish Rite Hospital for Children Your orthopaedist will recommend a brace and tell you how long it should be worn each day.occurs ages 3-10 Types of scoliosis based on the cause of scoliosis: . is discouraged. However. Top of page Surgical Treatment If the curve is more than 45° and the child is still growing. participation in contact sports. the doctor may recommend surgery. such as football or rugby. your child may be asked to donate blood (which will be used during the surgery. hooks. and/or wires is used to straighten the spine (Figure C). Courtesy of Texas Scottish Rite Hospital for Children Following surgery. Time out of the brace is allowed for these activities.when aged under 3. surgery may still be recommended for scoliotic curves that exceed 50° to 55°. Procedure Before surgery. is also used to help the operated portion of the spine heal solid. but with the implant used to correct the scoliosis. over 10 years old. This is an x-ray of the same patient shown in the x-ray above. If the patient has reached skeletal maturity. The spine fusion should not interfere with girls' future pregnancies or deliveries.This underarm brace is intended to prevent a scoliotic curve from worsening to the point of needing surgery. if needed). the main research focus in idiopathic scoliosis is investigation into genetic factors as a cause of scoliosis. Top of page Research At present. An implant made up of rods. screws. are discharged from the hospital within 1 week. Long-Term Outcome Following Surgery Patients usually don't experience much pain once they have recovered from surgery. Infantile idiopathic scoliosis . due to permanent limitation of some spine movement following surgery.
(Source: excerpt from Questions and Answers about Scoliosis in Children and Adolescents: NIAMS) Questions and Answers about Scoliosis in Children and Adolescents: NIAMS (Excerpt) Causes of curves are classified as either nonstructural or structural.a temporary condition caused by some underlying condition. or muscular dystrophy). Types of scoliosis based on the apex of the spinal curvature: ○ ○ Thoracic curve scoliosis Lumbar curve scoliosis Thoracolumbar curve scoliosis ○ Types discussion: Questions and Answers about Scoliosis in Children and Adolescents: NIAMS (Excerpt) Adolescent idiopathic scoliosis (scoliosis of unknown cause) is the most common type and occurs after the age of 10. changing curve. Structural scoliosis can be caused by neuromuscular diseases (such as cerebral palsy. brother. injury. Since scoliosis can run in families. such as Marfan's syndrome. Idiopathic scoliosis can also occur in children younger than 10 years of age.○ ○ • Nonstructural (functional) scoliosis . certain infections. poliomyelitis. This is a temporary. Early onset or infantile idiopathic scoliosis occurs in children less than 3 years old. or sister with idiopathic scoliosisshould be checked regularly for scoliosis by the family physician. Structural scoliosis . • Structural scoliosis--A fixed curve that doctors treat case by case. but is very rare.a fixed curve not always caused by an underlying condition. • Nonstructural (functional) scoliosis--A structurally normal spine that appears curved. Girls are more likely than boys to have this type of scoliosis. muscle spasms. In other cases. It is caused by an underlying condition such as a difference in leg length. in which one side of a vertebra fails to form normally before birth). Doctors treat this type of scoliosis by correcting the underlying problem. tumors (such as those caused by neurofibromatosis. a child who has a parent. Sometimes structural scoliosis is one part of a syndrome or disease. an inherited connective tissue disorder. it occurs by itself. Juvenile idiopathic scoliosis occurs in children between the ages of 3 and 10. birth defects (such as hemivertebra. a birth defect sometimes . It is more common in Europe than in the United States. or inflammatory conditions such as appendicitis.
the more likely it will progress (depending on the amount of growth remaining). or unknown factors (idiopathic scoliosis). shape. connective tissue disorders.or C-shaped. Pattern--Curves frequently follow patterns that have been studied in previous patients (see "Curve Patterns" diagram). the location of the apex is the "location" of the curve. pattern. rheumatic diseases. A thoracolumbar curve has its apex where the thoracic and lumbar vertebrae join (see "Normal Spine" diagram ). • • Shape--The curve usually is S. doctors find the apex of the curve (the vertebra within the curve that is the most off-center). A thoracic curve has its apex in the thoracic area (the part of the spine to which the ribs attach). A lumbar curve has its apex in the lower back. • Location--To identify a curve's location. metabolic diseases. (Source: excerpt from Questions and Answers about Scoliosis in Children and Adolescents: NIAMS) Questions and Answers about Scoliosis in Children and Adolescents: NIAMS (Excerpt) Doctors group curves of the spine by their location.associated with benign tumors on the spinal column). The larger the curve is. and cause. They use this information to decide how best to treat the scoliosis. Symptoms of Scoliosis The list of signs and symptoms mentioned in various sources for Scoliosis includes the 7 symptoms listed below: • • • • • • • Spinal curvature Sideways curvature of the spine Sideways body posture One shoulder raised higher than the other Clothes not hanging properly Local muscular aches Local ligament pain Tests and diagnosis discussion for Scoliosis: The doctor takes the following steps to evaluate a patient for scoliosis: .
pelvis. can suggest that the scoliosis is caused by a birth defect. The x ray should be done with the patient standing with his or her back to the x-ray machine. Certain changes in the skin. The doctor checks if the patient's shoulders are level.mild conditions may require no treatment other than monitoring for worsening. for example. • Physical examination--The doctor looks at the patient's back. or other disorders that can be associated with scoliosis. trauma. The view is of the entire spine on one long (36-inch) film. • • • Watchful waiting . and skin. Treatment of any underlying cause of scoliosis Bracing ○ Spinal cast Spinal brace Milwaukee brace Thoracolumbosacral orthosis (TLSO) ○ ○ ○ • • Surgery Other treatments that have not been successful ○ Chiropractic manipulation . legs. Occasionally. whether the head is centered. He or she finds the vertebrae at the beginning and end of the curve and measures the angle of the curve (see "Curve Patterns" diagram ). and whether opposite sides of the body look level. the doctor will refer the patient to an orthopaedic spine specialist (a doctor who has experience treating people with scoliosis). Curves that are greater than 20 degrees require treatment. chest. feet. Treatment List for Scoliosis The list of treatments mentioned in various sources forScoliosis includes the following list. doctors ask for more tests to see if there are other problems. such as so-called café au lait (coffee-with-milk-colored) spots. Always seek professional medical advice about any treatment or change in treatment plans.• Medical history--The doctor talks to the patient and the patient's parent or parents and reviews the patient's records to look for medical problems that might be causing the spine to curve. • Curve measurement--The doctor measures the curve on the x-ray image. If there is a significant asymmetry (difference between opposite sides of the body). • X-ray evaluation--Patients with significant spinal curves. or signs of involvement of the central nervous system (brain and spinal cord) such as bowel and bladder control problems need to have an x ray. The doctor also examines the back muscles while the patient is bending forward to see if one side of the rib cage is higher than the other. birth defects. unusual back pain.
○ • Supportive treatments to cope with the spinal curvature: ○ Built-up shoe .if one leg is longer than the other .○ ○ Electrical stimulation Nutritional supplementation Exercise .not successful in correcting scoliosis but desirable to maintain mobility.
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