Scoliosis (Long Case) – Mr.

Kamarul

Aim:

1. Identify Scoliosis
2. Differentiate between Postural Scoliosis and True Scoliosis
3. Direction of Curve
4. Fast growing/ Slow growing?

Clerking:

Chief Complaint: Accidental finding of back deformity by parents.

Age group: Adolescent (9 – 18 y/o) or in between the age of menarche and the age of stop growing.

Sex: Female

Analysis of Chief Complaint:

 Growth Rate: determine Fast growing or Slow growing?

- 1 year before & 1 year after menarche, growth rate is maximum.

Example:

- A 12 y/o patient with menarche at 9 y/o (slow growing)

- A 10 y/o patient with menarche at 9 y/o (fast growing)
- A 12 y/o patient with menarche at 11 y/o (fast growing)
- A 12 y/o patient with menarche at 9 y/o (slow growing)

Aim of knowing growth rate:

- Faster growth rate, more progressive is the curve.

- Slower growth rate, less progressive is the curve.

Others add on history:

- Low back pain

- Seek treatment?
- What treatment received?

No need includes history of Trauma and history of Infection because not relevant.

Physical Examination:

Inspection

1. Gait/ Walk: usually no abnormal gait, only tilted shoulder level in severe cases
- See the shoulder level
- Shoulder level not same (severe type of scoliosis or structural type of scoliosis)
 2. Squat and stand
- To determine the motor power
3. Heel walking/ tip toe walking
- All spine case can perform heel & tip toe walking except CSM

Specific inspection at the back

Position: sitting position
(1 to 4: Same like inspection in Low Back Pain)
1. Sinus discharge
2. Tuff of hair
3. Swelling: Gibbus (TB)
4. Cafe au lait spot (neurofibromatosis one of the causes of scoliosis in pediatric)
5. Shoulder level (Deformity)
- If shoulder level become same after sitting (Postural Scoliosis)
- In case of True Scoliosis/ Structural Scoliosis/ Severe type of Scoliosis, no matter
standing or sitting, shoulder drop will be always there.

General Inspection (head to toe)

Look for Sign of Marfan Syndrome (Hyperlaxity Syndrome)

 Eye: Light Reflex (see the position of lens)

Position of Lens:
- If lens at superior, Marfan Syndrome
- If lens at center, Homocystinuria : Known as hyperlaxity syndrome, 3 common
Cause of scoliosos
- If lens at inferior, Ehler’s Danlos Syndrome
 Mouth: High Arch Palate (Marfan syndrome)
 Chest: pectus excavatum, barrel shape, depression at center of chest. Harrisons sulcus
 Abdomen: organomegaly
 Knee: Genu recuvatum
 Foot: Flat Foot (foot arch in the medial aspect disappear): pes planus
  Hyperextension of elbow
 Measure the arm span, then the height of patient and make a ratio between arm span and
height should be 1:1 but for scoliosis will be more than 1.

Palpation: Thoracic, Thoracolumbar, lumbar (Left and Right)

a. Superficial palpation
- Temperature: use dorsum of hand and finger feel for 9 regions
- Soft Tissue: use palm and finger palpate for 6 regions (paravertebral muscle), feel for
muscle spasm and muscle tenderness

b. Deep palpation: To see the direction of curvature (Convexity and concavity)

- Palpate down from C7 spinous process using thumb, ask for any tenderness. Palpate one
by one until you reach L5.
- Aim for deep palpation in scoliosis case is to determine the direction of curve
(convex curve or concave curve)
- After palpate, marked it with pen. Mark for each vertebrae palpated.

Note that:
- PID case: determine level of tenderness
- Scoliosis case: delineate the side of curvature

Movement:

1. Bend forward
2. Extension
3. Lateral flexion: if right lateral flexion is restricted then the convexity is on the right

If convex curve on right side, degree of lateral flexion in left side is more than degree of lateral
flexion on the right side because there is a limitation on direction of lateral flexion toward the right
side (convex curve side)

Special Test: Winddavis criteria, abdominal reflexes

1. Adam Forward Bending Test

- Stand behind patient
- Ask patient to bend forward (90 deg, knee extend, trunk extended)
- Patient must touch the floor with the palms.
- See the back of patient at horizontal eye level to observed for thoracic hump.
- If thoracic hump higher on the right side mean the convexity is on the right side.
- If thoracic hump higher on the left side mean the convexity is on the left side.
- 90 % will have hump on the right side. If left side hump then must do MRI.
Scoliometer Test (will be provided)

- Scoliometer is a type of protractor used to measure the vertebral rotation and rib humping
that is seen in scoliosis with the forward-bending test.
- Put Scoliometer at the hump, scoliometer will be tilted and bubble inside will move
away from center (0 degree)
- If the bubble move < 20 degree = Postural Scoliosis
- If the bubble move > 20 degree = Structural Scoliosis/ True Scoliosis

2. Plum Line test

- Plum line test is to test the alignment of the body.
- Method: hold the plum line at C7 spinous process, then hang or dangle the plum.
- In normal person, plum line will be aligned with gluteal cleft.
- In scoliosis patient, plum line will be shifted toward one side = True Scoliosis/ non
compensated/ severe
- If the plum line still aligned with gluteal cleft = Postural Scoliosis/ compensated/ mild

Prove for True Scoliosis

1. Curve seen on inspection & palpated on sitting position.
2. Hump on Adam forward bending test + Scoliometer test > 20°
3. Plum line test not aligned with gluteal cleft or shifted away from gluteal cleft.
 3. Tanner Staging
- Aim: determine fast growing & slow growing.
- Inspect: Breast & Pubic Hair
- How to do Tanner Staging based on Breast Finding?
Inspect from lateral
- How to do Tanner Staging based on Pubic Hair?
Inspect from anterior

The principle of Tanner Staging is the smaller the Stage, the faster the growth rate, more
progressive is the curve (vice versa). Treatment is based on growth rate. Choose either breast or
pubic hair.

Tanner Staging for Breast (simplify version): inspect from side. Mosly is female patient so can
inspect the breast. If male patient inspect pubic hair.
Stage 1 & 2
 Does not see anything in breast: no soft tissue swelling, flat
 Growth rate Fast
Stage 2: Areola only can be seen, no nipple, no soft tissue
Stage 3
 Nipple protruding, no soft tissue
 Growth rate Medium
Stage 4, 5
 Nipple protruding
 Whole breast tissue swelling
 Growth rate Slow down
Stage 5: well formed breast

Tanner Staging for Pubic Hair (simplify version): from front

Stage 1
 no pubic hair
 growth rate fast
Stage 2
 pubic hair spare. Within the border. Away from the border
 colour is brown
Stage 3
 pubic hair not yet reach border
 colour is darker
 hair is slightly curved
Stage 4
 pubic hair is at the border
Stage 5
 pubic hair at thigh
 growth rate slow down

Arm Span Ratio

Normally = 1: 1
 Marfan Syndrome = 1.2: 1

Beighton 9-Point scoring system for Joint Hypermobility

 Dorsiflex the 5th metacarpophalangeal joint to > 90°
 Oppose the thumb to volar aspect of the ipsilateral forearm
 Hyperextended elbows to > 10°
 Hyperextended knee to > 10°
 Place hands flat on the floor with knees fully extended

4. Wind- Davis Criteria: hyperlaxity

1. extend the wrist

2. Flex wrist, push thumb against forearm

3. Abduct

4. Stand, inspect from side, henu recivatum

5. dorsiflex ankle, touch dorsum of foot to shin of tibia

Score of 4 or more is considered a sign of generalized joint hypermobility.

Simplify:
1 test positive = normal
2 tests positive = Marfanoid
> 3 tests positive = Marfan’s Syndrome
5. Abdominal reflexes.

Divide the abdomen into 4 regions. Scratch (back of tendon hammer) each quadrant. Look at the
umbilicus for any movement. Umbilicus must move towards the quadrant you are scratching.
Normal people wont have this reflex. If patient has this reflex then must do MRI.

Respiratory Examination (NO NEED)

Examination of Respiratory System is not required if Curve is < 60°

Respiratory Problems only occurs when the curve is > 60°
Investigation:

1. Full Blood Count

2. X-ray Spine
a. Thoracolumbar spine X-ray (AP & Lateral view in standing position)
How to choose which vertebrae to measure cobb angle?
- Choose the most tilted superior vertebrae and most tilted inferior vertebrae and draw
and straight line until both the line intersects and form a cobb angle.
How to determine which vertebrae is most tilted one?
- Choose the intervertebral which have equal space for both outer and inner aspect of
intervertebral disc/ inner aspect of intervertebral space is wider than outer aspect.
- The concave side and the convex side the intervertebral space must be equal on both
side. Up vertebrae: draw a line above it, for the lower vertebrae, draw a line below the
vertebrae.

b. Pelvic X-ray for Risser Staging: AP view

The Risser sign is an indirect measure of skeletal maturity, whereby the degree of ossification of the
iliac apophysis by x-ray evaluation is used to judge overall skeletal development. Mineralization of the
iliac apophyses begins at the anterolateral crest and progresses medially towards the spine.

Risser’s Sign is use to determine fast growing or slow growing

The principle for Risser’s sign is same like Tanner Staging,

Lowers the stage the fast the growth rate, the higher the stage the slower the growth rate.

The ilium: can divide into 4 from lateral to medial. If can see all the lones then its riser 4. Got 5
stages.
3 ways to determine fast growing and slow growing?
1. History of menarche
2. Tanner Staging
3. Risser Sign
Ultrasound and CT scan no need.

c. MRI
No need to do MRI scan EXCEPT,
1. If curvature toward the left side
2. Present of neurological deficit: presence of abdominal reflex
(lower limb numbness and lower limb weakness)

Treatment: depends on cobb’s angle and tanner staging.

Observation: every 6 months do an Xray: cobb’s angle: < 20 deg

Thoracolumbar spinal orthosis: Cobb’s angle 20-45 deg

Surgery: cobb’s angle is more than 45 deg.

Management for Slow Growing

Observation Brace Surgery

- Cobb angle < 20° - Cobb angle 20° to 45° - > 45°
- follow up every 6 months &
measure cobb angles Thoracolumbar Spinal Postural Instrumentation +
Orthosis Joint Fusion
The above management only applied, provided that Tanner Stage ≥ 3 or Risser’s Stage ≥ 3
(High Stage, Slow growing, Curve less progressive)

Management for Fast Growing

Management different if the Tanner Stage < 3 or Risser’s Stage < 3
(Low Stage, Fast growing, Curve more progressive)
If Low Stage, Management = Jump one step higher than usual management.
Example 1: Cobb angle < 20°, Tanner Stage 1: Brace (Usual management is Observation but now the
management jump one step higher because it is low stage, fast growing and curve will be more
progressive)
Example 2: Cobb angle 25°, Risser Stage 2: Surgery (Usual management is Brace but now the
management jump one step higher because it is low stage, fast growing and curve will be more
progressive)

*If cobb’s angle is more than 45 deg then ignore the tanner staging and the riser, its for sure surgery.

Surgery: Posterior instrumentation.

Other questions:
Criteria to off the brace
1. Age
2. Tanner Staging, Risser Sign (High Stage, Slow Growing, Curve less progressive)
3. Cobb angle remain consistently same during follow up

However, even if age > 18 years old (stop growing), High Tanner Staging & Risser Staging BUT
Cobb angle increase 5° during subsequent follow up. Should not off the brace.

Principle of Management also same for Scoliosis in Marfan Syndrome.