DISORDERS OF SPINE

(SCOLIOSIS)

Dr. I Gusti Lanang N. A Artha Wiguna, Sp.OT (K)

Historical Perspective
(ANCIENT GREEK)

• Hippocrates (5th century BC) : 1st time

described scoliosis, recommended
treatment using Hippocratic ladder,
board, and scamnum

Hippocratic
Hippocratic Hippocratic
scamnum
ladder board
Historical Perspective (cont..)
(ANCIENT GREEK)

• Galen (131 – 201 AD) : coining the terms

scoliosis, kyphosis, and lordosis. Use
chest binders and jackets to control
spinal curves
Historical Perspective (cont..)

• Nicholas Andry (1741) : introduced the

word “orthopaedia” (straight child)
Historical Perspective (cont..)

• John Cobb (1948) : introduced a method

to measuring scoliosis curve magnitude
• Walter Blount & Albert Schmidt (1946) :
popularized Milwaukee brace
 Definition

• Spinal deformity characterized by

lateral bending and fixed rotation of the
spine in the absence of any known
cause.
• The criteria Cobb > 100.
• 4 types :
• Infantile (0-3 yr)
• Juvenile (3-10 yr)
• Adolescent (>10 – 19)
• Adult (>19).

Asher, M. A. and Burton, D. C. (2006) ‘Adolescent idiopathic scoliosis: Natural history and long term
treatment effects’, Scoliosis, 1(1), pp. 1–10. doi: 10.1186/1748-7161-1-2.
Etiology

• Unknown à ongoing research.

• Factors.
• Genetic Factors à incidence families.
• CNS.
• Collagen, muscle, platelet defects.
• Growth and hormonal factors à melatonin.
• Biomechanical factors.
 Anatomy

• Human à erect, physiologic

curvature cervical lordosis, thoracic
kyphosis, lumbar lordosis.

• Coronal planeà straight.

• Scoliosis à curvature coronal plane.

Sagittal plane, most cases
hypokyphotic.
Prevalence and Natural history

• Risk factors for progression:

• Sex.
• Female > Male
• Menses help determine the growth spurt. Within 12 mo
after menses
• Skeletal growth .
• Risser 1 or less, prog à 60 – 70%.
• Risser 3 reduce to 10%
• Curve location.
• Apex T12 or above > progress than isolated Lumbar curve.
• Curve magnitude.
• Greater curve à more progress.
• 80% of cases of scoliosis the
cause is largely unknown.
• 90% presentation will show
a right-sided thoracic
curve.

Choudhry, M. N., Ahmad, Z. and Verma, R. (2016) ‘The Open Orthopaedics Journal Adolescent Idiopathic
Scoliosis’, The Open Orthopaedics Journal, 10(16), pp. 143–154. doi: 10.2174/1874325001610010143.
 Epidemiology

Prevalence of AIS in
Indonesia:
• 9-16 years old
• 2.93% children at
school age
• M:F – 1:4.7

Komang-Agung IS, Dwi-Purnomo SB and Susilowati A (2017) Prevalence rate of adolescent idiopathic scoliosis: Results of school-
based screening in surabaya, Indonesia. Malaysian Orthopaedic Journal 11(3): 17–22. DOI: 10.5704/MOJ.1711.011.
 Congenital Scoliosis

Idiophatic Scoliosis:

• Infantile
• Juvenile
Classification • Adolescent (most)

Neuromuscular
Scoliosis

Others

Choudhry, M. N., Ahmad, Z. and Verma, R. (2016) ‘The Open Orthopaedics Journal Adolescent Idiopathic
Scoliosis’, The Open Orthopaedics Journal, 10(16), pp. 143–154. doi: 10.2174/1874325001610010143.
 Natural History

Development
Age Birth History
of milestone

Physiologic
Family History Maturity (e.g Absence Pain
menarche)

Neurologic
history

Choudhry, M. N., Ahmad, Z. and Verma, R. (2016) ‘The Open Orthopaedics Journal Adolescent Idiopathic
Scoliosis’, The Open Orthopaedics Journal, 10(16), pp. 143–154. doi: 10.2174/1874325001610010143.
 PRESENTATION

• Asymmetry:
• Shoulders
• Waist
• Rib cage.
• Noticed by the patient,
a family member, the
primary care physician
or a school nurse

Altaf, F. et al. (2013) ‘Adolescent idiopathic scoliosis’, BMJ (Online), 346(7906), pp. 1–7. doi:
10.1136/bmj.f2508.
 Height Measurement

Gait Check

Foot Shape

Skin Inspection
Physical
Examination Assessment of Pubertal
Development

Neurological examination

Symmetry of shoulders and iliac

crest

Forward bending test

 Warning Sign

• Uneven shoulders and/or

shoulder blades
• Uneven hips and waist
• Appearance of leaning
• Head is not centered over
the body
Special Test

• Adam’s Test (Forward Bending)

 Special Test

• Scoliometer à measure angle of trunk

rotation (ATR) using an inclinometer

Coelho, D. M., Bonagamba, G. H. and Oliveira, A. S. (2013) ‘Scoliometer measurements of patients with idiopathic scoliosis’,
Brazilian Journal of Physical Therapy, 17(2), pp. 179–184. doi: 10.1590/S1413-35552012005000081.
 - Patient’s balance
Things should - Sensation
be evaluated : - Motor strength

Balanced tested by
watching the patients
gait.
Neurologic
Examination
Check also deep tendon
reflexes in upper and
lower extremities

Pathologic reflexes à
intraspinal disorders
(syringomyelia)
IMAGING
IMAGING

Full Length
Standing AP and Pelvic X-Ray
Lateral View

MRI :
Bends films
• Age<10, left
Side bending, thoracic,
fulcrum bending neurological findings
Pelvic X-Ray

Lateral View
AP View
Bending
 Lenke
Classification

This Scoliosis was classified

according to:
• - Curve type
• - Lumbar spine modifier
• - Sagittal thoracic modifier

https://surgeryreference.aofoundation.org/spine/deformities/adolescent-idiopathic-scoliosis/further-reading/lenke-
classification
Assign Type 1-6 based on chart
Risser sign :
• 0 : absent
• 1 : 0-25 %
• 2 : 25 – 50 %
• 3 : 51 – 75 %
• 4 : 76 – 100%
(correlate with the end of
spinal growth)
• 5 : fusion of epiphysis to the ileum
(correlate with the end of height
increase)
Mild Scoliosis (less than 20 degrees)

Moderate Scoliosis (25 - 40 degrees)

Severe Scoliosis (more than 40-70 degrees)

Very Severe Scoliosis (more than 70 degrees)

Scoliosis Severity
Treatment

Goal :
• To prevent progression
• Correction Balance
• Maintain respiratory function
• Reduce pain
• Preserve neurologic status
• Cosmetic

Consequence of untreated
• Mortality rate
• Pulmonary and cardiac function
• Back pain
 Observation

TREATMENT Bracing

Surgical
Treatment
 Observation

• When the curvature is less than 25

degrees, patient can be observed on a 6
to 12 monthly basis with clinical and
radiological follow up.
• Exercise

Hawary, R. El et al. (2019) ‘Brace treatment in adolescent idiopathic scoliosis: risk factors for failure—a literature review’,
Spine Journal. Elsevier Inc., 19(12), pp. 1917–1925. doi: 10.1016/j.spinee.2019.07.008.
 Bracing

• Curves between 25º-45º below

the level of T8 in general →
curve progression.
• Milwaukee brace, Boston brace
and Charleston brace.
• Must be wear 23 hours until 2
years after menarch / risser 4
and wear off in year, follow up
every 6 months and
radiographs every 12 months.

Hawary, R. El et al. (2019) ‘Brace treatment in adolescent idiopathic scoliosis: risk factors for failure—a literature review’,
Spine Journal. Elsevier Inc., 19(12), pp. 1917–1925. doi: 10.1016/j.spinee.2019.07.008.
 The Goals Surgical Treatment

Maintaining sagittal balance

Correct or improve the deformity

Prevent progression of curve

Spine and pelvic balance is more important than curve

Prevent respiratory compromise

Prevent back pain

Cosmetic
Operative treatment

Indications

• Progressive Curve > 40 – 45 o in

growing Children
• Failure of bracing
• Progressive Curve beyond 50 o in
adult
 Surgical Treatment

vAnterior only (Open or Thoracoscopic)

vCombined Anterior/Posterior
vPosterior Only

Choudhry, M. N., Ahmad, Z. and Verma, R. (2016) ‘The Open Orthopaedics Journal Adolescent Idiopathic
Scoliosis’, The Open Orthopaedics Journal, 10(16), pp. 143–154. doi: 10.2174/1874325001610010143.
 CASE PRESENTATION 1

• Female, 24 yo
• Complained of bent back
since 2 years ago
• Intermittent back pain
since 1 months ago
• No pain and tingling
• Normal urination and
defecation
 Objective

Thoracolumbar Region: Shoulder tilt (R): 0,5 cm

L: Shoulder tilt + rib hump + pelvic tilt - Plumb line: 0 cm
F: tenderness (-) sensory normal,
Rib hump (R): 1 cm
hipoestesia (-)
M: Forward flexion 0-90˚ Body arm distance: 3 cm (L)/2
cm (R)
extension 0-35°
left lateral bending 0-30° Pelvic tilt (L) : 0 cm
right lateral bending 0-40˚ Scoliometer degree : 3°
Scoliosis Series

Assessment:
Adolescent Idiopathic Scoliosis Lenke Type 1A (-) Risser Grade V
Therapy: Immobilization with Brace
CASE PRESENTATION 2

• Female, 19 yo
• Complained of bent back
since 4 years ago
• Easily felt tired when
stands or sits for a long
time for the last 1 year
• Normal urination and
defecation
 Objective

Thoracolumbar Region Shoulder tilt : 2 cm

L : Café au lait (-), scar (-), deformity Plumb line : 2 cm
(+) scoliosis with right angulation of the Rib hump: 4 cm
upper spine, and left angulation on the Body arm distance 1 cm (left) 3
lower spine, rib hump (+) on right side, cm (right)
step off (-) Pelvic tilt : 2 cm
gibbus or sinus (-) Body Height : 162 cm
F : Tenderness (-), hypoesthesia (-) BB : 42 kg
Scoliometer degree : 19°
Forward flexion 0-90°
Extension 0-20°
Left Lateral Bending 0-40°
Right Lateral Bending 0-50°
Scoliosis Series

Assessment: Adolescent Idiopathic Scoliosis Lenke 1B (+)

Scoliosis Surgery (Deformity
Correction): Durante Op
Scoliosis Surgery: Post-op
 CASE PRESENTATION 4

• Female, 12 yo
• Crooked back since 1 years
ago
• Easily felt tired when
stands for a long time
• Pain radiating to left foot,
no tingling
• Normal urination and
defecation
 Objective

Thoracolumbar Region Shoulder tilt : 2 cm

L: Deformity + Rib Hump + Scapular Plumb line: 0 cm
Rib hump (R): 2 cm
tilt to right, Pelvic Tilt -
Body arm distance: 0 cm/2 cm
Pelvic tilt : 0 cm
F: tenderness -, sensory normal Scoliometer degree : 26°

M: Forward flexion 0-90˚ Body Weight 42 kg

Height 153 cm
Extension 0-15°
Left lateral bending 0-35°
Right lateral bending 0-20˚
Scoliosis Series

Adolescent Idiopathic Scoliosis Lenke 3B (-)

1st Stage: Anterior Release
1st Stage: Anterior Release
Traction
2nd Stage: Correction Deformity
2nd Stage: Correction Deformity
Scoliosis Surgery: Pre and Post-op
Conclusion

• Idiopathic scoliosis is one of the most

frequent presentations of spinal
deformity.
• This condition results in higher incidence
of back pain and discontent with body
image.
• Curves ≥50° in thoracic region and ≥30°
degrees in lumbar region progress at a
rate of 0.5 to 1 degree per year into
adulthood.
• Curves ≥ 60° can lead to pulmonary
functional deficit.
Thank You