Scoliosis

• Idiopathic scoliosis is most frequent, but we should not forget other types (neurological, infantile, juvenile, neuro-muscular…)

• Right thoracic curve most common

• generally family history of scoliosis

• Increased incidence of acute and chronic pain in adults if left untreated  

• curves > 90° are associated with cardiopulmonary dysfunction, early death, pain, and decreased self image

• curve magnitude

  • before skeletal maturity

    • > 25° before skeletal maturity will continue to progress

  • after skeletal maturity

    • > 50° thoracic curve will progress 1-2° / year

    • > 40° lumbar curve will progress 1-2° / year

Physical exam

• special tests

  • Adams forward bending test 

    • axial plane deformity indicates structural curve

  • forward bending sitting test

    • can eliminate leg length inequality as cause of scoliosis

• other important findings on physical exam 

  • leg length inequality

  • midline skin defects (hairy patches, dimples, nevi)

    • signs of spinal dysraphism

  • shoulder height differences

  • truncal shift

  • rib rotational deformity (rib prominence)

  • waist asymmetry and pelvic tilt

  • cafe-au-lait spots (neurofibromatosis)

  • patches of hair

  • foot deformities (cavovarus)

    • can suggest neural axis abnormalities and warrant a MRI

  • asymmetric abdominal reflexes

    • perform MRI to rule out syringomyelia

  • Pain : generally idiopathic scoliosis are not painful.

Imaging

• Xrays AP+ L: scoliosis is defined as Cobb’s angle > 10

  • R/O any vertebral deformity (in case of infantile’s scoliosis)

• MRI ( Not Routine)

  • should extend from posterior fossa to conus 

  • purpose is to rule out intraspinal anomalies

  • indications to obtain MRI

    • atypical curve pattern (left thoracic curve, short angular curve, apical kyphosis) 

    • rapid progression

    • excessive kyphosis

    • structural abnormalities

    • neurologic symptoms or pain

    • foot deformities

    • asymmetric abdominal reflexes

    • a syrinx is associated with abnormal abdominal reflexes and a curve without significant rotation

ANOMALIES : NOT FOUND IN IDIOPATHIC SCOLIOSIS

Treatment of iodiopathic scoliosis

• Observation

  • cobb angle < 25°.

  • Obtain serial radiographs to monitor for progression

• Bracing:

  • cobb angle from 25° to 45°

  • only effective for flexible deformity in skeletally immature patient (Risser 0, 1, 2)

  • goal is to stop progression, not to correct deformity

• Operative: posterior or/and anterior fusion

  • cobb angle > 45°

Imaging:

• anterior wedging across three consecutive vertebrae >5 degree 

  1. disc narrowing

  2. endplate irregularities

  3. Schmorl's nodes (herniation of disc into vertebral endplate)

  4. scoliosis  

  5. compensatory hyperlordosis

  6. spondylolysis on dedicated lumbar films if patient has low back pain

  7. determine sagittal balance by dropping C7 plumb line

• hyperextension lateral radiograph

  • supine lateral radiograph with patient lying in hyperextension over a bolster

  • can help differentiate from postural kyphosis

Scheuermann's Kyphosis

A rigid thoracic hyperkyphosis defined by > 45 degrees, caused by anterior wedging of  >5 degrees across three consecutive vertebrae, narrowed disc spaces. Differentiates from postural kyphosis by rigidity of curve (limited correction on extension xrays)

Thoracic Kyphosis is most frequent, but thoraco-lumbar or lumbar kyphosis exist too

Symtpoms: may complain of thoracic or lumbar pain, cosmetic concerns, tight hamstrings, iliopsoas, and anterior shoulder

Treatment

• stretching, observation, physical therapy if kyphosis < 60° and asymptomatic (mild symptoms)

• bracing with an extension-type orthosis (Jewitt type - with high chest pad): indicated if 60°-80° kyphosis and growth remaining

• Operative

Adult Spinal Deformity

• Deformity of the spine in either the coronal or sagittal plane

  • coronal plane imbalance 

    • defined as lateral deviation of the normal vertical line of the spine > 10 degrees

  • sagittal plane imbalance

    • defined as radiographic sagittal imbalance of >5cm

• Degenerative scoliosis occurs more commonly in the lumbar spine.

Symptoms

• Back pain

• neurogenic claudication: stenosis

• radicular leg pain and weakness, especially on the side of the concavity

Treatment

• Observation

• corrective surgery