SCOLIOSIS

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Scoliosis
- lateral curvature of the spine with
vertebral rotation
- more common among females
- more frequently seen in
adolescence
- usually involves the thoracic &
lumbar region
sidedness is defined by the side of
convexity of the curve
Can be Single or Compound
single has one sided spinal
deviation
compound has both right and
left spinal deviations

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 Description of Curves
1. Primary curve
First curve (of several curves) to appear
structural curve, with wedging, angulation, rotation, and an abnormal position
Maybe the greatest curve
2. Secondary curve (compensatory)
nonstructural curve that develops in response to the primary structural curve
Develop above or below major curve in an attempt to maintain (N) body alignment
a. Compensated curve
another curve of same magnitude formed in the opposite direction to fully compensate for the
deformity
straighten significantly on side bending
function is to produce spinal balance
b. Decompensated curve
is a compensatory curve that does not fully correct the deformity
c. overcompensated curve
- compensatory curve that is more than the primary curve
3. Major curve
Largest curve w/ greatest angulation
often accompanied by a minor curve
4. Minor Curve
Smaller of the several curves
5. Double major curve
Two structural curves of equal severity & significance (i.e. the compensatory curve is as large as the
major curve)
Usually seen in structural scoliosis
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 Types of Curves
1. Structural (non-functional)
- irreversible curvature w/ fixed rotation of
vertebrae
- The curve cannot be corrected by
positioning the patient
- curve doesn't go away when the person
changes position

Causes:
1. neuromuscular (CP, SCI, PMD, polio)
2. osteopathic (hemivertebra,
osteolamacia, fractures, rickets)
3. Idiopathic
- depending upon the age of onset
a. infantile (1st 3 yrs. Of life)
b. juvenile ( 4-14 y/o)
c. adolescent (10-16 y/o)

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 Types of Curves
2. Postural (non-structural/ functional/ positional)
deformity is not fixed
not accompanied by rotational or asymmetric changes in individual structures of the spine
pathologic changes are outside the spine
reversible & can be corrected by positioning & muscle contraction
i.e. the curve will be corrected with lateral bending toward the convex side

Causes:
1. LLD
- actual difference in bony length
- hip dislocation
- asymmetric leg
- congenital
2. habitual or asymmetric posture
3. muscle guarding or spasm
- from a painful stimuli in the neck or back (ex. sprain, HNP)

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 Comparison
STRUCTURAL NON-
STRUCTURAL

Curve Fixed Flexible

Intrinsic changes in spine Present Absent

& supporting structures
Lateral Bending Asymmetric Symmetric

Involved vertebrae Fixed in rotation Not fixed

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 Etiology
1. Nonstructural scoliosis Structural scoliosis
postural scoliosis trauma (osteopathic)
compensatory scoliosis Fractures (causing wedging of the spine )
irradiation (for tumor arresting vertebral
2. Transient structural scoliosis growth plate )
sciatic scoliosis Surgery
hysterical scoliosis> Burns or rib resection
inflammatory scoliosis Infections
Pyogenic osteomyelitis
3. Structural scoliosis Tuberculosis
Idiopathic (70 - 80 % of all cases) Brucellosis
Congenital Tumors
due to an insult to the zygote or embryo Osteoid osteoma
during early development Osteoblastoma
neuromuscular Meningiomas
poliomyelitis Neurofibromas
cerebral palsy Astrocytomas
syringomyelia Ependymomas
muscular dystrophy Metastasis
amyotonia congenita 4. Miscellaneous causes
Friedreich's ataxia Congenital heart disease
neurofibromatosis Coarctation of the aortaFailure of segmentation
mesenchymal disorders Failure
ofCyanotic
formation
heart disease
Marfan's syndrome Congenital torticollis
Morquio's syndrome Ocular torticollis
rheumatoid arthritis (Stills dse) Spondylolisthesis
osteogenesis imperfecta Malignant hyperpyrexia
certain dwarves Familial dysautonomia
Metabolic bone disease
Endocrine bone disease 7
 Sites of Curve
Cervical
Apex from C1-C6
Cervicothoracic
Apex from C7or T1- T4 or T5
Thoracic
Apex between T2-T12
Right thoracic curves are most common
Can develop rapidly
Cardiopulmonary compromise will ensue
when curves reach 60 degree
Thoracolumbar
Apex at T12 or L1
Lumbar
Apex between L1 & L4
Most (65%) are left lumbar curves
not deforming but can lead to disabling
back pain in later life and during
pregnancy
Lumbosacral
Apex at L5 or below

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 Shapes of Curve:
Long C-curve
Thoracolumbar
Often uncompensated
Higher shoulder on convex
side
High pelvis of concave side
Maybe due to long term
asymmetric positioning
S-curve
Common in idiopathic
scoliosis
Involves a major and
compensatory curve

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 Severity of Curves
1. Mild
- < 20
2. Moderate
- 20-40
- associated with early
structural changes in the
vertebrae & rib cage
3. Severe
- >40
- curves 40-50 are
associated with pain &
DJD of the spine
- curves 60-70 are
associated with
significance
cardiopulmonary changes
& decreased life
expectancy

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 Epidemiology
often first detected around 11 y/o
usually develops during the years when the
bones are growing the fastest
from ages 9 to 14 years
occurs more often in people with cerebral
palsy, polio, muscular dystrophy or spina
bifida
mild form
girls = boys
Moderate or severe scoliosis
girls > boys
Up to 10 in 100 young people will develop
at least a mild case of scoliosis
Only a few of these mild cases will become
moderate or severe

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Apical vertebra (apex)
- vertebra with the greatest distance from
the
midline
- vertebra that is displaced and rotated most
- Its endplates are least tilted

End vertebra
the most superior and inferior
vertebrae in the curve
maximal tilting of the endplates
toward the concavity of the curve
They are laterally wedged, longer in
the convex side and compressed on
the concave side

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 Measurements of curve
1. Cobb method
- Horizontal lines are then drawn at the
superior border of the vertebra with the
greatest angulation above, and at the
inferior border of the inferior end
vertebrae
- The angle formed by the intersection of
the perpendicular lines to these two
horizontal lines is the Cobb angle
- Has high inter-rater reliability

2. Risser-Ferguson
- Straight lines are drawn from the center of
the end vertebra (superiorly & inferiorly)
to the center of the apical vertebra
- The angle between these lines is used to
assess the severity of the deformity
- not frequently used

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 ROTATIONAL ASSESSMENT
Rotation is an inherent structural change in
scoliosis & it correlates with the degree of
resistance to corrective therapy
1. Displacement of Pedicles
On A-P view, one pedicle rotates toward the
midline and the other rotates to the lateral
border of the vertebra
2. 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)
Pedicle Method (Nash & Moe)
- measurement of rotational deformity of the
vertebra
- estimate the degree of rotation of the vertebra at
the apex of the curve by looking at the relation of
the pedicles to midline
- the rotation is quantified on the basis of where
the pedicle is located
- (N) the pedicles are situated in the outer
segments.
- On frontal images, the vertebra is divided into 6
segments

(+) pedicle slightly toward midline

(++) pedicle 2/3 toward midline
(+++) pedicle at midline
(++++) pedicle moves beyond midline
Note: rotation is toward the concave side.
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 Clinical Features of Idiopathic Scoliosis

Infantile Juvenile Adolescent

Incidence Least common Most common

Onset/Diagnosis Less than 3 years 410 years Greater than 11

years
Ratio Males > females Males = females Males= however,
females worsen 810
times more
frequently
Curve Pattern Left Right thoracic or Right thoracic; Right
thoracolumbar double curve thoracic/Left lumbar

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 Diagnosis
Physical assessment
X-ray
Use to measure the degree of curve
may help to differentiate structural from nonstructural curves
A further goal of the radiographic examination is to determine the physiological
or skeletal maturity of the patient

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 SPECIAL TESTS
Lateral bending test
Assess flexibility of the curve, if the
curve corrects or reverses
The patient is ask to laterally bend
towards convex side
Forward bending test
Patient is ask to bend forward at
angle at the hips, knees fully extended
& arms dangling on the side
Plumbline
Used to assess if the curve is
compensated or uncompensated
If the plumbline deviates to one side=
uncompensated curve & the side of
major curve
McKenzie side glide

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 Signs & Symptoms
back pain
LOM/Tightness trunk & hip movements
LLD
Postural deviations
Rib hump
Note:
Young girls with scoliosis would often complain of unequal breasts
This is due to recess of the chest wall on the convex side of the
curve

Complications:
Arthritis
respiratory infections
heart problems

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 Pathologic changes
in the vertebral bodies and IVD

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 Impairments
CONCAVE SIDE
-structures are compressed or shortened
-Disc space & vertebral canal is narrower
-IVD are compressed & may bulge to opposite
side
- ALL is thickened
- Spinous process (in the area of the major curve)
turned towards this side
-(+) anterior prominence of thorax
-vertebra may become wedged on the concave
side in severe cases
-The lamina and pedicles are shorter
- Decreased flexibility
CONVEX SIDE
-structures may remain (N) or become
lengthened
-Disc space & vertebral canal is wider
- Nucleus pulposus migrates
- ALL is thinned
- Vertebral body turns toward this side
- (+) rib hump (posteriorly)
- Decreased in thoracic volume
- Higher shoulder & prominent scapula
-Muscle fatigue & ligamentous strain
- Stretch & weak musculature
- Nerve root irritation
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 Sources of pain:
1. nerve root irritation on the side of
concavity
2. potential muscle imbalance
3. decreased flexibility on the concave
side
4. stretch & weak ms. on convex side
5. if one hip is adducted, decreased
flexibility
6. the abductors are stretched & weak
- on the contralateral extremity,
opposite will occur

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 Physiological changes
Decrease in lung vital capacity
due to a compressed intrathoracic cavity on the
convex side
With left scoliosis, the heart is displaced
downward
in conjunction with intrapulmonary obstruction
this can result in right cardiac hypertrophy

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 Prognostic Indicators
In general, the following rules apply:
1. Thoracic curves
causes more deformity and disability
2.The earlier the age of onset, the greater the deformity and disability later in life

Other poor prognostic indicator

1. Family history (genetic inheritance)
2. Curves of more than 40 degrees
3. poor muscle tone
4. women near menopause with osteoporosis

Prognostic signs of x-ray for active progression of scoliosis:

osteopenia of the vertebra near the apex of the curve
narrowed intervertebral disc space
wedging of the apical vertebra

Note: Adults with curves less than 30 degrees usually do not progress

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 Treatment
1. Bracing
the only accepted conservative treatment for idiopathic
scoliosis
For curves greater than 25
primary role of a brace for idiopathic scoliosis is to arrest
curve progression and yield a post bracing curve that is of
a magnitude that will not progress as an adult
must reduce the curves and maintain curve reduction (>
50%) throughout the duration of wear
History:
Paul Aegina tried bandaging as a form of bracing in the 7th
century
1914: first fusion performed by Russell Hibbs
1946: Milwaukee brace was designed by Blount and Schmidt
2. Exercise
3. Surgery
For curves >40 degrees which show signs of steady
progression
should be done as a last resort for people who were
unsuccessfully treated in an orthosis or when the curve
was not detected early enough to treat with an orthosis

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 Nonoperative Treatment
Milwaukee brace
was first used to replace plaster casts after
spinal fusion surgery
Was later used for the nonoperative
management of scoliosis and kyphosis
still the only orthosis that is best to treat
curves higher in the spine (apex T-8 and up)
and for the treatment of kyphosis which
usually is in the mid and upper thoracic spine
TLSO orthoses
newer, shorter orthoses used to treat curves
lower in the spine
standard for present day treatment of
scoliosis because of the ability to completely
conceal the brace with clothing
Boston, Miami, Wilmington, Yamimoto,
Rosenberg orthoses

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Boston Brace Wilmington Jacket Rosenberger Orthosis

Milwaukee Brace

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 Surgical Management
Indications:
Adolescents with curve more than 45 degrees.
Relentless curve progression
Major curve progression in spite of bracing
Inability to wean the patient from the brace
Significant thoracic and lumbar pain
Progressive loss of pulmonary function.
Emotional or psychological inability to accept the brace.
Severe cosmetic changes in the shoulder and trunk.
Goals:
To achieve solid fusion
To stabilize the curve with a compensated trunk both in the frontal
and sagittal planes
To correct the curves (though this is not as important)

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 Surgical Approaches
1. Segmental spinal instrumentation
posterior approach
More preferred approach
Increases internal stabilization of the spine
Intersegmental wires can be secured through the spinous processes
(Drummon/Keene technique) or through the lamina of each vertebrae
(Luque technique)
The combination of rods and wires provides rigid fusion and is very
effective in treating collapsing type scoliosis, especially in neuromuscular
scoliosis
a. single rod
can be used to fix the upper and lower end of curves with a
Disadvantages:
prolonged immobilization
use of braces
suboptimal results
b. Two Harrington or Luque rods
can be used to accomplish segmental stabilization at each level of
spine using sublaminar wires
c. Use of the Cotrel-Dubousset system with multiple hooks with rods
may improve 3D results anterior spinal
segmental spinal instrumentation
d. Use of pedicular screws instrumentation
increases fixation, reduces the number of levels fused, and reduces
the number of junctional problems above and below the fused
vertebra

2. Anterior spinal instrumentation

anterior approach
used where posterior spinal elements are absent (ex. Myelomeningocele)
can be used with thoracotomy or thoracoscopy in which single or double
rods with screws are attached to each vertebral body
Has better results than those of other methods
use to treat the rib bump at same time

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 screw fixations

fixation by using pedicle

Harringtonrods with wires, screws, screw in a vertebral
hooks, and screws body

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patient with thoracic scoliosis, convex to the right, bridged by a
Harrington rod and bone graft along the concave side of the spine 30
 Post op care
Post op bracing is not necessary with the new technique of
internal fixation
However, a low profile brace is recommended for several
months to protect patients against accidents
Most patients can return to school or work within 2-3
weeks
Strenuous exercises are not recommended for the first few
months
Light sports such as tennis can be resumed at 3-4 months
At one year when fusion has mature, all forms of exercises
can be resumed, though patient should avoid heavy contact
sports

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END

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 If surgery is required, it's best to do it while the patient is
young. Younger patients heal more rapidly and easily than
adults, and generally have better cosmetic results from the
surgery than someone older with an advanced curve who
already has a severe deformity.
To help people with severe curves, the entire area of the
curve must be stiffened. This is done to prevent a more severe
curve from developing as the patient grows older.
During surgery, rods and hooks (Figure 13) are inserted into
the spine to hold the spine in a corrected position while the
individual segments of spine fuse together. Afterward, the
spine is permanently straightened. (The rods can be removed
later if the patient desires, but this is usually unnecessary,
unless they break or cause pain).

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 Surgical Techniques:
Fusion can be done through the anterior or posterior approach. The posterior
approach is preferred. In cases like myelomeningocele..
The posterior approach was first performed in 1911. The techniques have changed
somewhat with the introduction of spinal instrumentation in the past 40 years. But
in general, the principles are as followed:
The outer cortex of the laminae and spinous processes are removed so that raw
cancerous bone is exposed.
Posterior facet joints are destroyed.
Great quantity of iliac autografts are laid on the prepared bed.
The fusion extends one vertebrae above the superior end vertebrae and two below the
inferior end vertebrae.
A combination of Harrington instrumentation and are used to decrease rotation and
increase internal stabilization of the spine.
Intersegmental wires can be secured through the spinous processes (Drummon/Keene
technique) or through the lamina of each vertebrae (Luque technique). The combination
of rods and wires provides rigid fusion and is very effective in treating collapsing type
scoliosis, especially in neuromuscular scoliosis

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 Following surgery, almost all patients
can return to school or work two to
three weeks after leaving the
hospital. In the past, people were
placed in plaster of Paris body casts
for six months to a year (Figure 14),
but this technique is rarely used
anymore. Instead, we use
postoperative orthoses which can be
removed for showering or sleep.
Strenuous exercise, lifting or
bending is not recommended for 3-6
months, though walking is highly
recommended.

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 X-Rayed. Ask to see
your X-Rays

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 Prior to surgery, a set of lateral bending
films are often taken to assess the rigidity or
flexibility of the curves. In the illustration
below, the thoracic curve is the major curve
and the lumbar curve is simply a
compensatory curvature. This is shown by
the lateral bending films.
bending films
. As mentioned above, once skeletal
maturity has been reached, curvature below
30 degrees do not progress. Therefore, one
may at this time consider discontinuing
followup examinations in this population,
and scoliosis screening in the general
population of children.

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 Treatment Options
Observation: This option is appropriate when the curve is mild (less than 20 degrees) or if
the child is near skeletal maturity. However, the doctor will want to recheck the curve on a
regular basis to see that it is not progressively getting worse. You may be asked to return
every 3 to 6 months for re-examination. Most cases of scoliosis referred through school
screening will fall into this category.
Bracing: The goal of bracing is to prevent curves from getting worse. Bracing can be effective
if the child is still growing and has a spinal curvature between 25 and 45 degrees. There are
several types of braces, most being underarm. Your orthopaedist will recommend a brace
and tell you how long it should be worn each day. Wearing a brace does not affect
participation in sporting activities. Time out of brace is allowed for these activities.
Treatment Options: Surgical
Surgery: If the curve is more than 45 degrees and the child is still growing, the doctor may
recommend surgery. If growth is finished, surgery may still be recommended for curves that
exceed 50-55 degrees. Before the operation, your child may be asked to donate blood (which
will be used during the surgery as needed). The surgery requires a bone graft from the hip,
ribs or a bone bank. A series of rods, hooks, screws or wires are used to straighten the spine.
Following surgery, patients are walking without a brace by the second or third day, are
discharged from the hospital within a week and can rapidly resume their daily activities. A
return to some sports is possible in 6 to 9 months.

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