A Case

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 Melissa
• 11 year-old girl

UMMC, KL
 Melissa
• 11 year-old girl
• Presented with history of back deformity with
abnormal shoulder level for 6 months
• Initially noticed by her swimming teacher

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 Scoliosis

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 Treatments
• Consulted many doctors

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 Treatments
• Consulted many doctors

Doctor A said 25 degrees – observe

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 Treatments
• Consulted many doctors

Doctor A said 25 degrees – observe

Doctor B said 40 degrees – wear brace

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 Treatments
• Consulted many doctors

Doctor A said 25 degrees – observe

Doctor B said 40 degrees – wear brace

Doctor C - Surgery

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 Treatments
• Consulted many doctors

Doctor A said 25 degrees – observe

Doctor B said 40 degrees – wear brace

Doctor C - Surgery

Doctor D - Don’t do surgery 50/50

 Treatments

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 Treatments

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 18 months later

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UMMC, KL
UMMC, KL
Diagnosis and Management of
Adolescent Idiopathic Scoliosis

Kwan Mun-Keong
Spine Unit
Department of Orthopaedic Surgery,
Faculty of Medicine,
University of Malaya,

UMMC, KL
 Overview
• What is Scoliosis and its causes?
• How common is Scoliosis?
• When you should suspect scoliosis?
• How to assess objectively?
• What are the management options?
– Bracing
– Surgery
• Future
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 Overview
• What is Scoliosis and its causes?
• How common is Scoliosis?
• When you should suspect scoliosis?
• How to assess objectively?
• What are the management options?
– Bracing
– Surgery
• Future
UMMC, KL
 What is Scoliosis?
• Deformity of spine
• Spine curves from side to
side, forming a “C” or “S”
shape

• Cobb angle of more than

10° (SRS definition)

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 What is Scoliosis?
• Deformity of spine
• Spine curves from side to
side, forming a “C” or “S”
shape

• Cobb angle of more than

10° (SRS definition)

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Rotational Deformity
 What is the cause?

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 What is the cause?

> 90% of cases

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 Genetics

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 Genetics

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 Genetics

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 Genetics

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 What is the cause?

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 What is the cause?

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 Congenital Scoliosis

A progressive 3 -dimensional
deformity of the spine due to
congenital anomalies of the
vertebrae that result in an
imbalance of the longitudinal
growth of the spine.
 Congenital Scoliosis

Developmental defect in the

formation during the 4th-6th
weeks of development
 Overview
• What is Scoliosis and its causes?
• How common is Scoliosis?
• When you should suspect scoliosis?
• How to assess objectively?
• What are the management options?
– Bracing
– Surgery
• Future
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 Epidemiology

• Prevalence : 2.0%
• Prevalence ( Curve > 200) : 0.2%

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 Epidemiology

• Prevalence : 2.0%
• Prevalence ( Curve > 200) : 0.2%
2 in 1000

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 Epidemiology

• Female: Male = 9:1 (≥ 20˚)

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 Epidemiology

• Female: Male = 9:1 (≥ 20˚)

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 Overview
• What is Scoliosis and its causes?
• How common is Scoliosis?
• When you should suspect scoliosis?
• How to assess objectively?
• What are the management options?
– Bracing
– Surgery
• Future
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 Plump Line
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 Adam Forward Bending Test

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 Adam Forward Bending Test

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Cobb angle = Measurement x 3
 Does Scoliosis Hurt?

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 Does Scoliosis Hurt?

No

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 Older untreated scoliosis
cases

Muscle Strain

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11/19/10
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UMMC, KL
UMMC, KL
UMMC, KL
 Overview
• What is Scoliosis and its causes?
• How common is Scoliosis?
• When you should suspect scoliosis?
• How to assess objectively?
• What are the management options?
– Bracing
– Surgery
• Future
UMMC, KL
 Diagnosis
• AP view of whole spine
standing taken from a
distance 2m using a 14
x 36 in cassette.

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 Diagnosis
• AP view of whole spine
standing taken from a
distance 2m using a 14
x 36 in cassette.

UMMC, KL
 Diagnosis
• AP view of whole spine
standing taken from a
distance 2m using a 14
x 36 in cassette.

UMMC, KL
 Diagnosis
• AP view of whole spine
standing taken from a
distance 2m using a 14
x 36 in cassette.

UMMC, KL
 Diagnosis
• AP view of whole spine
standing taken from a
distance 2m using a 14
x 36 in cassette.

UMMC, KL
 Diagnosis
• AP view of whole spine
standing taken from a
distance 2m using a 14
x 36 in cassette.

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Cobb Angle

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Cobb Angle

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Cobb Angle

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Cobb Angle

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 Overview
• What is Scoliosis and its causes?
• How common is Scoliosis?
• When you should suspect scoliosis?
• How to assess objectively?
• What are the management options?
– Bracing
– Surgery
• Future
UMMC, KL
 Management
• Maturity – assessment of how much is the
remaining growth.
• Curve severity – based on Cobb measurement.

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 Management
• Maturity – assessment of how much is the
remaining growth.
• Curve severity – based on Cobb measurement.

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 Maturity

Risser Sign
 Management
• Maturity – assessment of how much is the
remaining growth.
• Curve severity – based on Cobb
measurement.

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 Management

Cobb Angle (X°) Mode of Treatment

10 – 20 ° Observation
 Observation
• To observe the progression of the curve
• 4 – 6th monthly

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 Management

Cobb Angle (X°) Mode of Treatment

10 – 20 ° Observation

20 – 45 ° Brace
 Bracing
• Help to hold the curve and prevent it from
progressing

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 TLSO/ Boston Brace

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 Management

Cobb Angle (X°) Mode of Treatment

10 – 20 ° Observation

20 – 45 ° Brace

> 45 ° Surgery
 Surgical Intervention
Cobb angle > 45 degrees
Truncal imbalance

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 Reasons for Surgery
• To prevent worsening the curve
• To improve the magnitude of the curve
• To improve the lungs function
• To improve the abdominal space
• Cosmetic i.e. taller, balanced shoulder, trunk and
neck, less prominent thoracic/ lumbar humb

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 Reasons for Surgery
• To prevent worsening the curve
• To improve the magnitude of the curve
• To improve the lungs function
• To improve the abdominal space
• Cosmetic i.e. taller, balanced shoulder, trunk and
neck, less prominent thoracic/ lumbar humb

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 Before Maturity

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Dec 2007 May 2008 Dec 2008
Dec 2007 May 2008 Dec 2008
Dec 2007 May 2008 Dec 2008
Dec 2007 May 2008 Dec 2008
 After Maturity (> 18 year-old)

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18 year-old

32 year-old
 Reasons for Surgery
• To prevent worsening the curve
• To improve the magnitude of the curve
• To improve the lungs function
• To improve the abdominal space
• Cosmetic i.e. taller, balanced shoulder, trunk and
neck, less prominent thoracic/ lumbar humb

UMMC, KL
 Reasons for Surgery
• To prevent worsening the curve
• To improve the magnitude of the curve
• To improve the lungs function
• To improve the abdominal space
• Cosmetic i.e. taller, balanced shoulder, trunk and
neck, less prominent thoracic/ lumbar humb

UMMC, KL
 Reasons for Surgery
• To prevent worsening the curve
• To improve the magnitude of the curve
• To improve the lungs function
• To improve the abdominal space
• Cosmetic i.e. taller, balanced shoulder, trunk and
neck, less prominent thoracic/ lumbar humb

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Pre OP Post OP
Pre OP Post OP
Pre OP Post OP
 Reasons for Surgery
• To prevent worsening the curve
• To improve the magnitude of the curve
• To improve the lungs function
• To improve the abdominal space
• Cosmetic i.e. taller, balanced shoulder, trunk and
neck, less prominent thoracic/ lumbar humb

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Lumbar Curve
 Management

Cobb Angle (X°) Mode of Treatment

10 – 20 ° Observation

20 – 45 ° Brace

> 45 ° Surgery

> 70 ° Complicated Surgery

 Severe Deformity

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 Severe Deformity

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 Lungs

Kidney

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How do we perform the Surgery?

Posterior Instrumented Spinal

Fusion using Pedicle Screws
System.

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Old Technique
Old Technique
 What are Pedicle Screws?

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CONCLUSIONS: Pedicle screws insertion in AIS has a
total perforation rate of 20.3% (410/2020) with a
'critical perforations' rate of 2.2% (44/2020). The rate of
symptomatic screw perforation leading to radicular
symptoms was 0.1%. There was no spinal cord, aortic,
esophageal or lung injuries caused by malpositioned
screws in this study.
CONCLUSIONS: Pedicle screws insertion in AIS has a
total perforation rate of 20.3% (410/2020) with a
'critical perforations' rate of 2.2% (44/2020). The rate of
symptomatic screw perforation leading to radicular
symptoms was 0.1%. There was no spinal cord, aortic,
esophageal or lung injuries caused by malpositioned
screws in this study.
CONCLUSIONS: Pedicle screws insertion in AIS has a
total perforation rate of 20.3% (410/2020) with a
'critical perforations' rate of 2.2% (44/2020). The rate of
symptomatic screw perforation leading to radicular
symptoms was 0.1%. There was no spinal cord, aortic,
esophageal or lung injuries caused by malpositioned
screws in this study.
 Technique
• Global Rotation
• Translation
• Direct Vertebral / Segmental Derotation
• Centilever
 Rose PS, Lenke GL.
Othop Clinics of North America 2007

UIV
• Upper Thoracic (Lenke 2 and 4) – T2
• Mid Thoracic (Lenke 1, 3 and 6) – T3 (T2 left
shoulder high or T4 right shoulder high).
• Lumbar (Lenke 5) - Upper End Vertebra
 Rose PS, Lenke GL.
Othop Clinics of North America 2007

LIV
• 1st vertebra touched by the center sacral
vertical line (CSVL).
What is the risks of the surgery?

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 Risk of Surgery

Scoliosis Research Society Report 2006

 Risk of Surgery

< 1.0%

Scoliosis Research Society Report 2006

 How long is the surgery?

Usually 3-4 hours

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When will I be able to get up and
walk for the first time after
surgery?

Usually 24 hours

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How many days stay in hospital?

3 -4 days

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How long before the patient can go
back to school?

3 -4 weeks

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How soon patient is enabled to
return to normal activities after
surgery?

3 – 4 months

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 Overview
• What is Scoliosis and its causes?
• How common is Scoliosis?
• When you should suspect scoliosis?
• How to assess objectively?
• What are the management options?
– Bracing
– Surgery
• Future
UMMC, KL
 Future
• Scoliscore
 Future
• Scoliscore
• Tethering System

Lenke LG JBJS 2011

 Future
• Scoliscore
• Tethering System
 Future
• Scoliscore
• Tethering System
 Future
• Scoliscore
• Tethering System
 Future
• Scoliscore
• Tethering System
 Future
• Scoliscore
• Tethering System
4 year post op
 Future
• Scoliscore
• Tethering System
• Minimally Invasive
Spinal Surgery

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 Take Home Message
• Consult the doctor early – to confirm the
diagnosis and assess the severity.

• Once diagnosis made – start bracing.

• If the curve is > 45 deg - surgery before

the curve deteriorates.
Don’t Wait
Thank You

UMMC, KL