Scoliosis

HOD:PROF.DR.K.PRAKASAM
M.S.Ortho,D.Ortho,DSC (HON)
MODERATOR:DR.A.E.MANOHARAN
PRESENTOR:DR.THOUSEEF.A.MAJEED
 INTRODUCTION
• “Scoliosis” - Greek word meaning “crooked.”
• It is a lateral curvature of the spine in upright
position.
• The Scoliosis Research Society has defined scoliosis
as a lateral curvature of the spine greater than 10
degrees as measured using the Cobb method on a
standing radiograph.
• Triplanar deformity of lordosis,
rotation & lateral wedging of
vertebrae.

• It produces body disfigurement.

• When deformity is extreme it

compresses viscera and reduces
life expectancy of the patient.
 Incidence of Scoliosis
• Develops between ages 8 to 15
(growth spurt)
• 7 times more prevalent in females
• 80% of scoliosis origin unknown
 Spinal Biomechanics

“Normal” alignment
• Spinous processes all line up in a
straight line over the sacrum

Scoliosis is a combination of

• Angular displacement

• Lateral displacement
Lateral displacement • Angular displacement
 Classification

• I. Non structural Scoliosis (Postural)

• II. Transient Structural Scoliosis

• III. Structural Scoliosis

 I. Non structural Scoliosis
• Postural Scoliosis
• Compensatory Scoliosis

II. Transient Structural Scoliosis

• Sciatic Scoliosis

• Hysterical Scoliosis

• Inflamatory Scoliosis
 III. Structural Scoliosis
• Idiopathic Scoliosis
 Old Classification
 Infantile Onset < 3 yrs Age

 Juvenile Onset 3-10 yrs Age

 Adolescent Onset > 10 yrs Age

 New Classification
– Early onset Onset < 8 yrs Age

– Late onset Onset > 8 yrs Age

• NEUROMUSCULAR DISORDER ASSOCIATED SCOLIOSIS

NEUROPATHIC MYOPATHIC
oPoliomyelitus oMuscular dystrophy

oCerebral palsy oUnilateral Amelia

oSyringomyelia oFriedreich’s ataxia

• TRAUMATIC SCOLIOSIS

o Vertebral eg: Fractures, irradiation Surgery

o Extra vertebral eg: Burns

 OTHER CAUSES OF SCOLIOSIS
• Neurofibramatosis
• Marfan’s syndrome
• Moroquio’s disease
• Arthrogryposis multiplex congenita
• Rheumatoid arthritis
• Stills disease
• Scheuermann’s disease
• Osteogenesis imperfecta
• Scoliosis assosiated with spinal tumours.
 Physiological Effects of Scoliosis

• Mid-back pain
• lower back pain,
• neck pain, headaches,
• premature disc and joint degeneration
• Decreased pulmonary function
 Descriptive terms
• The side towards which the convexity of the curve is
directed is designated as Right or Left.
• The involved location of the curve is described as
1. Cervial
2. Cervico thoracic
3. Thoracic
4. Thoracolumbar &
5. Lumbar
• Simple curve-Single spinal
deviation

• Compound curve-Displacements
in Right & Left direction

• Primary curve- Curve that

develops first

• Secondary or Compensatory
curve-Develops as a balancing
response to the primary curve
• Non structural curve- Curve
is flexible and corrects by bending
towards convex side

• Structural curve- Curve is not

corrected on bending on convex side
( vertebral and para-vertebral bodies
and soft tissues are deformation
developed)
• Major curve-Significant structural
changes take place (the one of greatest
degrees)

• Minor curve-Secondary or compensatory

curve in the opposite direction above and
below the major curve.

• Usually functional and nonstructural

• Double major curve: Two
balancing curve of equal
structural change and magnitude.

• Thoracic curve is major and the

lumbar curve is structural.

• Because the main thoracic curve

is always larger than the
thoracolumbar/lumbar curve.
– Function of curves
• Strength

• Flexibility
 KING CLASSIFICATION

• Most commonly used classification

• Describes 5 specific types of thoracic curves

based upon coronal radiographs

• Recommended specific fusion levels depending

upon the curve type.
 King classification

Type I - lumbar dominant (10%) - S-

shaped curve, Both thoracic and
lumbar curves cross midline, Lumbar
curve larger or more rigid
 King classification

Type II - thoracic dominant

(33%) - S-shaped curve, Both
thoracic and lumbar curves
cross midline, Thoracic curve
larger or more rigid
 King classification

Type III - thoracic (33%) -

Thoracic curve, Lumbar curve
does not cross midline
 King classification

Type IV - long thoracic

(10%) - Long thoracic
curve, L5 over sacrum,
L4 tilted into curve
 King classification

Type V - double thoracic (10%) -

Double thoracic curve, T1 tilted
into upper curve, Upper curve
structural
 INFANTILE IDIOPATHIC SCOLIOSIS
• Younger than age of 3 years
• Boys > girls,
• Primarily thoracic and convex to the
left.
• One hip is prominent but no ribs to
accentuate deformity
• Associated with Mental deficiency,
Congenital dislocation of hip,
Congenital heart defects
• Self-limiting

• Spontaneously resolve (70% to 90%)

• Progressive -
– Compensatory or secondary curves develop,

– > 37 degrees by Cobb Method

 JUVENILE IDIOPATHIC SCOLIOSIS

• Uncommon

• Between the ages of 4 and 10 years

• Right Thoracic curves

• 12% - 21% of idiopathic

• Prognosis is worse

• Surgical correction may be necessary before puberty

 ADOLESCENT IDIOPATHIC SCOLIOSIS

• Commonest type
• Age 10- 16 yrs
• Primary thoracic curve usually convex to right
• Lumbar curves to the left
• Intermediate (thoracolumbar) & combined (double
primary) curves also occur
• Curves under 20 degree either spontaneously or remain
unchanged
 ADOLESCENT IDIOPATHIC SCOLIOSIS
Proposed etiological factors,

(1) genetic factors,

(2) neurological disorders,

(3) hormonal and metabolic dysfunction,

(4) skeletal growth,

(5) biomechanical factors, and

(6) environmental and lifestyle factors.

 ADOLESCENT IDIOPATHIC SCOLIOSIS
• Once starts to progress, it goes
on throughout growth period

• Reliable predictors of
progression

1) Very young age

2) Marked curvature

3) Incomplete Risser sign at

presentation
 Problems in adult life

(1)Back pain,

(2) Pulmonary dysfunction,

(3) Psychosocial effects,

(4) Mortality
 THORACOLUMBAR
• Slightly more in females

• More common in right

• Features midway between

adolescent thoracic & lumbar
 LUMBAR SCOLIOSIS
• Common in females

• 80% convex to left

• One hip prominent

• Not noticed early

• Backache in adult life

 COMBINED SCOLIOSIS
• 2 primary curves, one in each
direction

• Radiologically severe

• Clinically less noticable

• Because always well balanced

 Structural scoliosis
• Non correctable deformity of affected spinal
segment.
• Vertebral rotation is an essential component.
• Spinous process swing round towards the
concavity of the curve.
• Transverse processes on the convexity rotates
posteriorly.
• In thoracic region the rib on the
convex side stand out predominantly
& produces rib hump.

• Initially deformity is corrected.

• When deformity is fully established

the deformity is liable to increase
through out the growth period.
 Types of structural scoliosis
• Idiopathic scoliosis (no obvious cause).
• Congenital or Osteopathic.(bony abnormality).
• Neuropathic
(Associated with muscle
• Myopathic dystrophies)
Congenital or Osteopathic
- Due to defect in segmentation or
defect in the formation including
- Hemivertebra
- Block vertebra
- Wedged vertebra

- Curves progress rapidly during

pre- adolescent growth period
CONGENITAL SCOLIOSIS
 B.PARALYTIC SCOLIOSIS
• Curve is long, convex towards the side with weaker
muscles ( spinal, abdominal or intercostal) & at first
mobile

• Loss of stability & balance which makes sitting

difficult in severe cases

• Loss of sensibility causes pressure ulceration

 CLINICAL FEATURES

• Deformity is usually the presenting symptom

• Pain is rare complaint
• Rib hump or abnormal para spinal muscular
prominence indicates spinal rotation
• Rib hump leads to asymmetry of trunk
called angle trunk rotation (ATR) .
 CLINICAL EVALUATION
• Trunk should be exposed
completely & examined in front ,
back & side
Trunk alignment
• Symmetry of shoulder girdles
• Scapula & ribcage observed for
asymmetry
• Spinous process palpated to
determine their alignment
 CLINICAL EVALUATION
• Plumb line - On posterior aspect, line drawn
from occiput should normally align with
gluteal cleft
 SCOLIOMETRY
•The patient bends over, arms
dangling and palms pressed
together, until a curve is
observed in the back.
•The Scoliometer is placed on the
back and measures the apex (the
highest point) of the upper back
curve.

Bunnell Scoliometer
 ADAM’S FORWARD BEND TEST

• Patient is asked to lean forward with feet together and bend 90

degrees at the waist.
• The examiner can easily view the angle & any asymmetry of the
trunk or any abnormal spinal curvatures.
 RADIOLOGY
• To determine the severity of the curve
• X-ray Antero Posterior, Lateral & Oblique view of
spine

• Right & left bending view – determine the degree

of flexibility of spine & to see how much curve can
be passively corrected
X Ray Standing AP film of whole spine on one film.
Lateral flexion AP radiographs

• provide information on the upper

and lower limits of a fixed curve

• Mobility of the motion segments, as

an aid to fusion levels.
Radiographs are assessed for
• Spinal column contour
• Congenital or developmental abnormalities,
• Degenerative
• Neoplastic abnormalities
 CURVE MEASUREMENTS
• COBBS METHOD
• RIB ANGLE OF MEHTA
• SCOLIOTIC INDEX
• RISSER-FERGUSON METHOD
• End-vertebrae -
maximum rotated
vertebra (most tilted
vertebrae )

• Apical vertebra-Vertebra
at the centre of the curve.
 LIPPMAN-COBB METHOD
• Line drawn at end plate of
upper end vertebra

• Another line at lower border

of lower end vertebra

• Perpenidular lines are drawn

from above two lines

• Angle formed between them

measured
Double curve

• One vertebra is upper end

vertebra for lower curve and
lower end vertebra for upper
curve (transitional vertebra).

Only one line drawn on this

vertebra.
 RIB ANGLE OF MEHTA
The difference between the
angle formed by a vertical line
through the centre of the
apical vertebral body on an AP
film and the rib on the convex
side and the same angle on the
concave side.
More than 200 or overlap of the head of the
rib over the vertebra are associated with a
high likelihood of progression.
 SCOLIOTIC INDEX
•Each vertebra (a–g) is considered an
integral part of the curve.
•A vertical spinal line (xy) is first
drawn whose endpoints are the
centres of the upper and lower end-
vertebrae of the curve.
•Lines are then drawn from the centre of
each vertebral body perpendicular to the
vertical spinal line (aa', bb', … gg').
•The values yielded by these lines
represent the linear deviation of each
vertebra
•Sum of vertebral body lines, divided by
the length of the vertical line (xy) gives
the scoliotic index
 RISSER-FERGUSON METHOD

•First line originating at the centre of

the upper end-vertebra
•Second line from the center of the
lower end-vertebra.
•Angle formed by the intersection of
two lines at the centre of the apical
vertebra gives the degree of curvature
 DEGREE OF ROTATION

• Rotation – reflects the degree of structural change

& resistance to correction of the scoliotic curve

• 2 methods are used.

• Moe pedicle method

• Cobb spinous-process method.

 Displacement of Pedicles
• When the vertebra rotates, one pedicle moves
toward the midline
• It is the relationship to midline that determines the
degree of rotation
• Other pedicle moves towards the lateral border of
vertebral body
 Moe pedicle method

• Divides the vertebra into six equal parts.

• Normally, the pedicles appear in the outer parts
 COBB SPINOUS-PROCESS METHOD

• Vertebra is divided into six equal parts.

• Normally, the spinous process appears at the center.
• Its migration to certain points toward the convexity of the
curve marks the degree of rotation.
 DETERMINING MATURATION

• Secondary sex characteristics

• Bone age

• Excursion of iliac apophysis (Risser's staging)

• Ossification of the vertebral ring apophysis.

Ossification of the vertebral ring apophysis
 Excursion of iliac apophysis

• Ossification of iliac crest starts laterally & proceeds

medially toward sacrum.

• Maturation complete, when it reaches Sacroiliac junction

 Risser's staging
Based on iliac crest
apophysis ossification
• Type I – ossification of
lateral 25%
• Type II – lateral 50%
• Type III – lateral 75%
• Type IV – lateral 100%
• Type V – fusion of Ilium
CT scans are used to provide
improved definition of
abnormalities of vertebral
size, shape or number
 Magnetic resonance
imaging - to evaluate the
spinal cord and spinal
nerves.

Myelography
 Other Studies
Pulmonary function
testing for patients with:
Curves greater than 60
degrees
Respiratory complaints
Scoliosis resulting from
a neuromuscular cause
TREATMENT
Aims of treatment

1) To prevent progression of the deformity

2) To correct an existing deformity

 Nonoperative treatment

• Observation

• Orthotics – braces

• Traction and Casting

 TREATMENT

Non operative

• Exercises maintain muscle tone but no effect

on the curve

• If curve between 20* & 30* is progressing,

bracing done
 Orthotics
• Hibbs and Risser – Turnbuckle cast

• Milwaukee brace ( CTLSO )– 1946

• Thoracolumbosacral othosis (TLSO’s) – 1960s

 Milwaukee brace
• Pelvic girdle

• Uprights – one anterior

and two posterior.

• Cervical ring with throat

mold and occipital piece

• Lateral pad – pressure on

apical vertebra
Thoracolumbosacral othosis (TLSO’s)
 Contra indictions for orthosis

• Curve > 40 °

• Extreme thoracic kyphosis

• Mature adolescent ; Risser grade 4 or 5, girls 2

yrs post menarchal

• High thoracic or cervicothoracic curves

 Stretching
• Daily application of longitudinal & lateral traction
forces mobilize the spine gradually

• Patient in lying position, head end attached with 10

pounds weight pulls proximally

• Pelvic girdle & traction straps with 20 to 30 pounds

weight pull distally
Halo traction device

• Spinal skeletal traction &

fixation device

• Halo traction device attached

to skull & is connected to a
plaster body cast by a steel
frame
 SURGERY

Criteria :-

1.Curve more then 40degree

2.Progressive increase in scoliosis
3.Failure to conservative treatment
4.Cardiopulmonary complications.
Methods :
1.Herrignton rod :- only fusion of spine
vertrebra , no correction of the deformity.
2.Double rod method : - on every single level
of vertebra of spine is fixed with screws.
3.Vertebral fusion :- fusion of vertebra where
scoliosis develop.
 Harrington system

• A rod is applied posteriorly along

the concave side of the curve

• Movable hooks attached to rod

which are engaged in upper &
lowermost vertebra to distract the
curve
• If curve is flexible, it will passively correct &
bone grafts are applied to obtain fusion

Disadvantage

• Does not correct the rotational deformity at the

apex of the curve

• Rib prominence remains unchanged

 ROD & SUBLAMINAR WIRING
(LUQUE)
• Modification of Harrington system
• Wires are passed under vertebral lamina at multiple
levels & fixed to rod on the concave side of the
curve
• Bending the rod & arranging the mechanism so that
wires pull backwards than side wards
• Rotational deformity is improved
 COTREL-DUBOUSSET SYSTEM
• Posterior rod system with multiple hooks placed at
various levels to produce either distraction or
compression

• With double rods, one can distract on concave &

compress on convex side

• Rotational deformity corrected.

 ANTERIOR INSTRUMENTATION (DWYER,
ZIELKE)
• Rigid curves & thora-columbar curves associated
with lumbar lordosis corrected from front.

• Removing the discs throughout the curve & then

applying a compression device in the convex of the
curve

• Bone grafts are added to achieve fusion

 INFANTILE IDIOPATHIC SCOLIOSIS

• Treated by applying serial elongation- derotation –

flexion(EDF) plaster casts

• Can be applied till 4yrs

• If deformity deteriorates, surgical correction done

• Anterior disc excision with use of rod to aid

correction
 CONGENITAL OR OSTEOPATHIC
Non operative treatment

• Milwaukee brace from age 1 or 2yrs until 9 or 10yrs when

surgery is done

• Previously, Risser localizer cast was used in children

from 1 to 4yrs

Indications

• progressive curve, moderately flexible

• Non progressive, somewhat flexible but unacceptable

 PARALYTIC SCOLIOSIS

• Conservative---- fitting a suitable sitting

support.

• Surgery---- stabilisation of entire paralysed

segment by combined anterior & posterior
fusion.
 CEREBRAL PALSY SCOLIOSIS

• Most often thoracolumbar curve

• Pelvic obliquity & hip contracture present

INDICATIONS

• Progressive curve of any degree

• Normal mortality
TREATMENT

• For severe lumbar & thoracolumbar curves anterior

fusion with dwyer instrumentation then after 2
weeks posterior fusion with harrington rods.
 NEUROFIBROMATOSIS SCOLIOSIS
• Constitutes about 1%
• Associated with skin lesions , multiple neurofibroma
& bony dystrophy affecting vertebra & ribs
• Curve is short & sharp
• Mild cases – conservative
• Severe cases – combined anterior & posterior
fusion.
 SUMMARY

• Curves <20’ needs observation.

• Curves more than 20 treatment.
• Curves between 20 to 40 degree can be treated
by bracing
• Curves > 40 degree needs surgical correction
& fusion.