Scoliosis (long case)

Aims:
1. Make diagnosis of scoliosis
2. To know how fast patient growing (the faster the growth rate, the more
progressive the curve)
3. True or postural type of scoliosis
4. To know direction of curve (R/L)

Chief complain: Accidental finding of abnormal curvature of back/ discrepancy of

level of shoulder

Analysis of chief complain:

1. To know how fast is the growth rate of patient by age and also age of
menarche.
a. Age: younger the age, faster the growth rate
b. Age of menarche: growth rate is peak within 2years after menarche
 Eg: patient 16years old, menarche at 14years old= peak growth rate
 patient 10years old, not yet menarche, so we ask family
member(mother/sister) when is their menarche, if their menarche is at 12years
old(within 2 years)= peak growth rate
 patient 18years old, menarche at 11years old= slow growth rate
2. Any low back pain (usually no pain in scoliosis so no need ask DD of pain)
3. Any lower limb weakness/ numbness (neurological deficit)

Examination:
Sequence: Inspection, Palpation, Movement, Special test
Exposure: From head to toe except private part (all spine case do same sequence
such as PID, Spondylosis,Cervical Spondylotic myelopathy)

1. Observe patient gait with shoe off

 Shoulder level tilted due to scoliosis, no any abnormal gait such as short limb
gait or antalgic gait

2. Then ask patient squat and stand

 To see the motor power or strength of lower limb (power is at least 4 or 5 if
patient can squat and stand because can against gravity)

3. Ask patient to do heel walking and tip toe walking

 Every spine case can do heel and tip toe walking except Cervical Spondylotic
Myelopathy(do Romberg test if got CSM)
Inspection
 Do local inspection of back first then general inspection
a. Local inspection: Ask patient to sit at side of bed and inspect the back for
 Any shoulder level discrepancy
 Curvature still there anot
 If discrepancy disappear/ equal after sit= postural scoliosis
 If curvature less/ become straight = postural scoliosis
 If discrepancy or curvature still exist= true scoliosis
 Also inspect for: deformity, swelling, sinus discharge, tuft of hair, cafe au lait
spot(neurofibromatosis one of the cause of scoliosis in paeds)
b. General inspection:
 Eye: Do light reflex by torch to see position of lens
 If superiorly dislocated= Marfan syndrome
 If inferiorly dislocated= homocystinuria
 If centrally dislocated= Ehlers Danlos Syndrome
 Hyperlaxity syndrome include Marfan syndrome, Ehlers Danlos Syndrome and
Homocystinuria which lead to scoliosis= muscle surrounding the back must be
strong to let the back straight, in hyperlaxity syndrome, one side of muscle is
weak.
 Mouth: Check palate to look for high arch palate (Marfan Syndrome)
 Chest: See the shape of chest and also subcostal rib
 Barrel shape chest with pectus excavatum(central depression)= Marfan
Syndrome
 Prominent subcostal rib(harrison sulcus)= Marfan syndrome
 Abdomen: Organomegaly in Marfan syndrome(protruding organ thru
abdominal wall)
 Knee: Inspect from lateral to see any hyperextension of knee(in Marfan
Syndrome & other Hyperlaxity Syndrome)
 Foot: Flat foot(pes planus)(no medial arch) in Marfan Syndrome
 Upper limb: ask patient to abduct to see any hyperextension of elbow and also
measure arm span ratio
 Arm span ratio= measure arm span and height (normally 1:1, in Marfan
syndrome 1:1.2/1:1.4)

Palpation
 Superficial and deep palpation
 Superficial palpation:
 6 region= divide into thoracic, thoracolumbar and lumbar, and R and L for each.
a. Feel temperature at 6region of the back with back of hand
 No raise in temperature
b. Palpate paravertebral muscle at 6 region
 Hold and squeeze
 No muscle spasm in Scoliosis (muscle spasm in PID, Spondylosis which complain
of lower back pain)
 Deep palpation:
 To know the direction of curve/convexity
 Use both thumb together and hook it then press along the spinous process from
C7 to L5 spinous process
 In PID and Spondylosis, palpate using same method but purpose is to know the
level of tenderness.

Movement
 We stand at side of patient, then we do first and ask patient follow
1. Forward flexion: no problem in scoliosis but pain in PID
2. Extension: No problem in scoliosis
3. Lateral flexion:
 if limited right lateral flexion, left side okay= convexity in right side
 If limited left lateral flexion, right side okay= convexity in left side

Special test
 Check convexity by deep palpation,lateral flexion and adam forward bending
test
 How to know is thoracic or lumbar= palpate down subcostal rib to back=
thoracolumbar, if above= thoracic, if below= lumbar

1. Adam forward bending test

 We stay behind the patient and ask patient to bend forward
 Patient hand must be able to touch their big toe(usually children so can do)
 Ask patient maintain this position and we inspect from the back(eye must be
parallel to the back)
 We look for thoracic hump and tell where is the place of convexity(to the R/L)
 If the thoracic hump is on the right(80% on right)= convexity on right
 If the thoracic hump is on the left= convexity on left
 If convexity or hump on left side need to do MRI even no neurological deficit.
2. Scoliometer
 Put the scoliometer on the hump
 The scoliometer will tilt and can see the bubble move
 Check the reading, if >20degree= true type scoliosis, if <20degree= postural type
scoliosis

3. Plumb line test

 To look for R or L truncal shift
 Ask patient to stand
 Then we hang weight at C7 spinous process and let the weight dangle or hang
 Normally will hang at middle(gluteal cleft).
 If not at middle= true type scoliosis (severe type)
 If at middle= postural type or true type but compensated
 Measure how far from gluteal cleft

4. Tanner staging(90% scoliosis in female so focus on tanner staging of female)

 To know patient young or old can by asking age and also by Tanner Staging
 Breast and pubic hair (choose 1)
 Lower staging,higher growth rate
 Higher staging, lower growth rate
a. Breast:
 nipple,areola and soft tissue
 Inspect from side of patient
 5 Stage:
I. Nothing or flat, no soft tissue swelling, no nipple, no budding (very young and
growth rate very fast)
II. Budding(protruding of areola), no nipple, no soft tissue swelling
III. Nipple can be seen
IV. Soft tissue swelling but not much/well formed
V. Well formed
 Example: Stage 3 patient older than stage 1, so stage 1 patient has faster growth
rate
b. Pubic hair:
 Triangular in shape in female
 Inspect from from front of patient
 5 stage:
I. No pubic hair (very young, growth rate very fast)
II. Light colour, sparse amount(minimal), away from border but within flexion
crease
III. Dark colour, curly, away from border, within flexion crease
IV. Pubic hair encroach the border/ at flexion crease
V. Hair at thigh
5. Wynne Davies Criteria (Kamarul use this)
 To rule out hyperlaxity syndrome
a. With elbow extend or straight, ask patient to extend wrist(推东西的姿势), push
finger and make it parallel with forearm
 Become parallel to forearm in hyperlaxity syndrome
b. Flex wrist, then push thumb to touch forearm
c. Abduct elbow 90degree to see any hyperextension of elbow
d. See the knee from side for any hyperextension of knee
e. Ask patient to sit, dorsiflex the ankle and push foot to shin of tibia
 >3 out of 5= hyperlaxity syndrome
 <3 out of 5= marfanoid

Most commonly use for hyperlaxity syndrome= Beighten Score

6. Abdominal reflex(will happen in deep sleep only)
 Divide abdomen into 4 quadrant around umbilicus
 Scratch each quadrant with back of tendon hammer
 Look for any reflex of umbilicus
 Normally no reflex
 If reflex present need to do MRI

Investigation

1. Laboratory
 FBC
 No ESR & CRP
 No Tumor Marker
 No Nerve Conduction study

2. Radiological
I. X-ray
a. Thoracolumbar AP & Standing
 To measure cobb’s angle: >45degree= surgery. <45degree= conservative
treatment
b. Pelvic
 To measure Risser sign(similar to Tanner staging)
 Lower staging, higher growth rate
II. No CT
III. No Ultrasound
IV. MRI when indicated: can see tethering of spinal cord (in left thoracic hump) bcs
when vertebra grow, spinal cord grow too but in this, vertebra grow but spinal
cord stunted (not growing) so got tethering or tersangkut.
 Back pain
 Neurological deficit
 Left thoracic curvature
 Left hump
 Positive abdominal reflex

How to measure cobb’s angle?

 Locate apex vertebra(apex of curvature)
 Locate superior vertebra by looking at intravetebral disc space (choose space
that is parallel), then choose the superior border of superior vertebra
 Locate inferior vertebra by looking at intravertebral disc space (choose space
that is parallel), then choose inferior border of inferior vertebra.
 Then from the superior and inferior border draw a line until intersect
 Then draw a perpendicular line on both line until intersect

Risser Sign
 The iliac wing is divide into 4 section from lateral to medial
 The Risser sign is an indirect measure of skeletal maturity, whereby the degree
of ossification of the iliac apophysis (whitish area which not attach to ileum) by
x-ray evaluation. Mineralization of the iliac apophyses begins at the
anterolateral crest and progresses medially towards the spine
 Cannot see Risser 5 anymore because already fuse
 Lower the stage, faster the growth rate
Treatment
I. Observation
 Cobb’s angle 0-20degree
 Ask patient come back every 6months and repeat thoracolumbar X-ray and
measure cobb’s angle

II. Brace
 Cobb’s angle 20-45degree
 Thoracolumbar spinal orthosis
 Lumbar corset for PID and spondylosis

III. Surgery
 Cobb’s angle >45degree
 Posterior instrumentation and fusion (screw at each vertebra and connect with
rod to straighten the spine, but when patient grow the rod will curve too so
need to fuse the vertebra)

 All above treatment applicable only when patient at slow growth

rate (Tanner staging or Risser 4 or 5)
 If Tanner/Risser 1 or 2, need to jump to next step of usual
treatment
 Example: Cobb angle = 18degree, brace instead of observation
 Example: Age 11, menarche at 10, Tanner and Risser 2 (fast growing),
cobb angle 37degree= surgery instead of brace