Scoliosis

Budio Satya Sinuraya

173307020099
 Scoliosis
– Derived from Greek for
“crooked”

cervical, thoracic, lumbar, pathological

conditions that form a vertical column
with a vertebral center in the midline

– Clinical sign, not an outright

diagnosis
• Four main categories
– Congenital
– Degenerative
– Neuromuscular/syndromic
– Idiopathic
Definition

 Spinal deformity in the

form of vertebrae
deviation laterally, not
primary disease, but
secondary to certain
diseases Side curvature
of the spine which can
damage the vertebrae)
 Normal curvature
Cervical Lordosis
(anterior, 200-
400) Thoracic
kyposis (back,
200-400) Lumbar
lordosis (anterior,
400-600) Sacral
kyphosis (sacral)
Etiology
 Numerous theories, none proven
 Answer is there…
– Male: female ratio1
• 1:1 for minor curves
• 1:8 for treatable curves
– Family history
• 27% prevalence of scoliotic curves >15 degrees in
daughters of scoliotic mothers2
– Curve type
• Majority right thoracic (about 98%)
– Left thoracic is red flag for possible intraspinal abnormality
1. Bunnell WP Spine 1986;11:773-6.

2. Harrington PR Clin Orthop 1977;126:17-25.

 Curve description The direction of
scoliosis Major / primary curves
Compensatory curves Major double
curve Apex curve The location of the
curve Cervical, thoracal, lumbar
 Curve shape
Degree of scoliosis

 The degree of scoliosis depends on the

size of the angle and the amount of
rotation Classification of the degree of
scoliosis: Mild scoliosis: curve <200
Medium scoliosis: curve 200-500
Severe scoliosis: curve> 500
Classification

 Infantil: 0-3 years old

 Juvenil: 4-9 years
 Adolesen: 10 years - growth stops
Diagnosis

 History Physical examination Screening:

Forward bending test, Adam’s test
Viewed from the front and back
,Neurological examination, Scoliometer
 Supporting investigation X-ray & MRI
Anamnesis

 Age, gender
 Family history
 Abnormalities during pregnancy or
childbirth
 Complaints of pain
 Advanced deformity
 General health history
Physical examination
 Forward bending test (Adam’s test)
Viewed from behind
 Shoulder asymmetry
 Strapula protrusion Bending of the spine
 Protrusion of the rib hump on the convex side
 Waist lines or hip height are not the same
 There is a deviation of the head and neck against
the crevices of the buttocks curve
 Pelvic obliquity
 Both legs are judged to be the same length
Seen from the front
 Asymmetrical shoulders and breasts
 In the convex part, visible breasts more
prominent
Neurological examination
 Reflex examination, sensation, motorik
 Scoliometer u / measure the angle of
the curvature
Screening
 Somewhat controversial
– AAOS, SRS, POSNA and AAP
currently recommend1:
• Females screened twice at ages 10
and 12
• Males screened once, at age 13 or
14
– British Orthopaedic Association and
British Scoliosis Society advise
against screening
– United States Preventive Services
Task Force (USPSTF) in 2004
recommended against screening
• AAOS, SRS, POSNA, AAP
responded with 2008 information
statement1
1. Richards BS and Vitale MG JBJS
Am 2008;90:195-8.
Screening - controversy
 In summary:
– Screening is fairly
reliable to detect curves
(though not terribly
accurate)
– Early detection could
result in improved health
outcomes (by potentially
avoiding surgery)
– Brace therapy is likely
effective in altering
natural history for many
patients (but not all)
 Most organizations
continue to recommend
screening
Evaluation
 History
– Reason for presentation (in patient or parent’s
own words
– Pain
• Red flag warnings: positive finger test, night pain, non-
activity related pain
– Age
– Family history
– Pubertal status
– Rate of progression
– Any neurologic complaints
• Radicular symptoms
• Bowl/bladder incontinence
Evaluation
 Back pain and AIS
– 23% have pain at presentation1
• Only 9% of these had
underlying pathological
condition
– 9% have pain during course of
observation1
– Significant association if1:
• > 15 years
• Risser 2 or more
• Post-menarchal status
• History of injury
– Painful left thoracic curve or
abnormal neuro exam more
likely to have neuro-axis
problem
1. Ramirez et al JBJS Am 1997;79:364-8.
Evaluation - radiographs

Cobb Angle -
inter/intra observer
error 5o
Evaluation
 Indications for MRI
– Atypical, specific pain
– Neuro abnormality
• Abnormal reflexes
• Ataxia
• weakness
• Progressive foot deformity
(cavus feet)
– Left thoracic curve
– Rapidly progressive curve
– ?males
• Routinely recommended, but
minimal data to support1
1. Nakahara D et al Spine 2010 (epub ahead
of print)
Evaluation
 Classification systems
– King-Moe
– Lenke
Evaluation
 Classification
systems
– King-Moe
– Lenke
Treatment

 A lot of information on
the internet
 Three main
treatments:
– Observation
– Bracing
• Daytime
• Nighttime
• Spine-Cor
– Surgery
 Treatment
11-25o 25-45o >40-50o

Skeletal maturity?* Skeletal maturity?

yes no yes no
Consider
surgical
F/u q5 yrs Consider intervention
F/u every 4-
F/u as 6 mos until to assess bracing, f/u q
needed skeletal progression 4-6 mos *skeletal maturity =
maturity Risser 3 or greater
 Natural History

From Lonstein JE and Carlson JM JBJS

Am 1984;66:1061-71.
Treatment - bracing
 Types
– Full-time bracing
• Boston
• Milwaukee (if apex
higher than T7)
– Night-time bending
brace
• Charleston
• Providence
– Others
• Spine-Cor
Treatment - bracing

 TLSO (Boston-type)
– Worn as much as
possible
• Can take off for
sports, sleepovers etc
– Want at least 50%
correction in brace
Treatment - bracing

 Milwaukee brace
– For refractory curves
– Apex >T7
– Not really tolerated in
our patient
population
Treatment - bracing
 Night-time bending
braces:
– Overcorrects the curve
– Only worn at night
– Probably not as efficacious
• Price et al1 - 66%
success, only 17%
requiring surgery
• Randomized study -
Charleston vs Boston
brace2
– 41% vs 61% success
(<5 degrees
progression)
– 31% vs 19% required
surgery 1. Price CT et al JPO 1997;17:703-707
2. Katz DE Spine 1997;22:1302-12.
 Treatment - bracing
 SpineCor
– Well advertised
– Soft straps, so more
easily worn under
clothers/during physical
activity
– Originators report only
40% progressed, only
23% needed surgery1
• Other authors have
found no better results
with SpineCor2

1. Christine C et al. Stud Health Technol Inform

2008;135:341-55.
2. Wong MS et al Spine 2008;33:1360-5.
 Treatment - bracing
 Brace efficacy -
– Data all over the place, both for and against
– Meta-analysis by Rowe et al1
• 1910 patients in 22 studies on non-operative treatments
– Weighted mean proportion of success
» 0.93 for bracing
» 0.49 for observation
» 0.39 for electrical stimulation
– Prospective international study2
• Boston brace in girls with 25-35 degree curves
– 74% success vs 34% with observation alone
– Prospective study of Boston brace with heat sensor (compliance)
• >12 hours/day: 82% success
• <7 hours/day: 31% success
• Patients who went on to surgery: 24% compliance
• Patients who did not progress to surgery: 42% compliance
Treatment - bracing
 Best for:
– Girls1
• Boys only 38% compliant with
brace wear
• 30 degree curve 50% chance of
surgery
– Lower BMI2
• BMI >85th %ile --> 2.5x risk of
failure, double surgical rate
– More flexible curves
– Younger patients
• Many studies
• Higher rate of progression by
natural history

1. Karol LA Spine 2001;26:2001-5.

2. O’Neill PJ et al. JBJS Am 2005;87:1069-74.
Treatment - bracing
 Summary:
– Probably alters natural history
in some but not all
• Especially if patient young, thin,
and compliant
• Curve can definitely still
progress
– Only tool we have to prevent
progression
– Success = prevent progression
• Never corrects the curve!
– Prospective, blinded,
randomized controlled study
needed
• BRAiST underway
• Enrollment has been difficult
Treatment - surgery
 Indications for surgery:
– Thoracic curve >40-45
degrees in skeletally immature
patient
– Thoracic curve >50 degrees in
skeletally mature patient
– Lumbar numbers: usually
around >40 degrees
– Double curves more well
tolerated
 Goals of surgery:
– Achieve solid fusion SAFELY!
– (improve cosmesis, body
image)
Treatment - surgery
Treatment - surgery
 No long-term, prospective controlled
studies to support hypothesis that
surgery for AIS is superior to natural
history
– Reliably prevents progression
– Achieves permanent correction
– Improves appearance
 Not a small undertaking
– 4-7 day hospital stay
– 6 months out of contact sports
– Complications:1
• Infection 0-6%
• Pseudarthrosis 2-7%
• Reoperation rate 5-7%
• Possibility of permanent neurologic
injury
– Expensive to health care system
1. Westrick ER and Ward T JPO 2011;31:S61-8.
Treatment - surgery

 A brief history of correction:

– All methods at core the same:
• Expose the spine (facet joints)
• Get correction
– Coronal plane (Cobb angle)
– Axial plane (rotation)
– Sagittal plane (maintain normal
kyphosis/lordosis relationship)
• Wait for the fusion
Treatment - history of surgery
 (Brief) history of
correction
– 1958, Moe
• Risser cast, bed rest,
no instrumentation
• Ave correction 43%
Treatment - history of surgery
 (Brief) history of
correction
– 1958, Moe
• Risser cast, bed rest, no
instrumentation
• Ave correction 43%
– 1964, Moe
• Harrington rods, Risser
cast
• Ave correction 55% -->
41%
Treatment - history of surgery
 (Brief) history of correction
– 1958, Moe
• Risser cast, bed rest, no
instrumentation
• Ave correction 43%
– 1964, Moe
• Harrington rods, Risser cast
• Ave correction 55% --> 41%
– 1992, Lenke
• CDI - Cotrel Dubousset
instrumentation
• Ave correction 48%
Treatment - history of surgery
 (Brief) history of
correction
– 2004, Luk et al
• Comparative studies of 4
different systems (CD
Horizon, Moss-Miami, TSRH,
Isola)
• Ave correction: 63% for CD
Horizon, Moss-Miami vs 58%
for TSRH, Isola
• Equal when matched against
bending films
Treatment - history of surgery
 (Brief) history of correction
– 2004, Luk et al
• Comparative studies of 4 different
systems (CD Horizon, Moss-Miami,
TSRH, Isola)
• Ave correction: 63% for CD Horizon,
Moss-Miami vs 58% for TSRH, Isola
• Equal when matched against bending
films
– 2005, Suk
• Introduction of pedicle screw
• Ave correction 62%
– Other pedicle screw correction rate: 62-
76%
Treatment - current techniques

 Approach:
– Posterior vs
– Anterior
• Open vs
• Thoracoscopic
– Combined approach
• For very big, stiff curves
• Younger patients
– To prevent crankshaft
Treatment - current techniques

 Standard posterior approach

– Positioning
• Prone
• neuromonitoring
– Approach
• Posterior exposure
• Careful at most cephalad and caudal ends to
avoid unnecessary exposure
• +/- Use of C-arm
Treatment - current techniques

 Preparing the spine

for fusion
– Facetectomies
 “loosening up the
spine”
– Ponte osteotomies
– Allow for better Cobb
correction and
kyphosis creation
Treatment - current techniques
 Screw placement
– Free-hand
– With C-arm
– With O-arm
– Definitely dealer’s choice
 Correction
– In 3 planes
• Coronal (straight rods)
• Axial (derotation)
• Sagital (rod contour)
Treatment - current technique
 Screw types
– Monoaxial
– Uniplanar
– Polyaxial
 Ways to reduce the
screws to the rods
– Reduction screws
– Reduction tools
• Each company has
their specific types
Treatment - current techniques
 Preparation for fusion
– Facetectomies
– Decortication
• Various techniques
– Addition of bone graft
• Autograft (iliac crest)
• Allograft
– Many options!
 Closure!
– +/- drain
– +/- brace
Treatment - current techniques

 “MIS” scoliosis
surgery
– Applying some adult
techniques to
pediatric scoli
– At cephalad levels
mostly
– ? Fusion rates?
Overview

 Definition
 Etiology
 Prevalence/Natural History
 Screening/Evaluation
 Treatment
– Non-operative
– Operative
 On the Horizon…
On the Horizon
 Scoli score = developed by Axial Biotech/Jim
Ogilvie and crew
– Saliva test
– Predictive of progression
– For Caucasian girls, age 9-13, with curves between
10 and 25 degrees
• Likelihood will progress to surgical curve
– Based on 53 genetic markers
– Log scale from 0 to 200
– Very high and very low scores helpful, middle
score unclear
– Not widely used or accepted
– Expensive
– May be more helpful in research
• Ie are curves with high scores those that progress
despite a brace?
On the Horizon
 “Fusionless”
techniques:
– Compressing
anterior overgrowth
• Vertebral stapling
• Spinal tethering
– Newton et al
» Encouraging
results in
animal model
» Human trials
just starting
Summary
 AIS
– 3-dimensional deformity
– Defined as 10 degrees of curve on PA xray
– Exact cause unknown; watch for red flags
– Screening controversial but still recommended by
most
• Girls at 10 and 12 years (younger better)
• Boys at 13 or 14 years
– > 7 degrees on Adams forward bend, consider
xray vs referral to orthopaedist
– Treatment
• Based on age and size of curve
• Includes observation, bracing, and surgery
Thank you