Scoliosis

Scoliosis

What is it?
How do we screen for it?
When to refer?
How is it treated?
 What is scoliosis?

Lateral curvature of the spine >10

accompanied by vertebral rotation
Idiopathic scoliosis - Multigene
dominant condition with variable
phenotypic expression & no clear cause
Multiple causes exist for secondary
scoliosis
 Secondary causes for scoliosis:
Inherited connective tissue disorders

- Ehlers Danlos syndrome

- Marfan syndrome
- Homocystinuria
 Secondary causes for scoliosis:
Neurologic disorders

Tethered cord Cerebral palsy

syndrome Polio
Syringomyelia Friedeichs ataxia
Spinal tumor Familial
Neurofibromatosi dysautonomia
s Werdnig-Hoffman
Muscular disease
dystrophy
Secondary causes for scoliosis:
Musculoskeletal disorders

Leg length discrepancy

Developmental hip
dysplasia
Osteogenesis
imperfecta
Klippel-Feil syndrome
Characteristics of idiopathic scoliosis:

Present in 2 - 4% of kids aged 10 16

years
Ratio of girls to boys with small curves
(<10) is equal, but for curves >30 the
ratio is 10:1
Scoliosis tends to progress more often
in girls (so girls with scoliosis are more
likely to require treatment)
 Natural history of scoliosis
Of adolescents diagnosed with
scoliosis, only 10% have curve
progression requiring medical
intervention
Three main determinants of curve
progression are:
(1) Patient gender
(2) Future growth potential
(3) Curve magnitude at time of
 Natural history of scoliosis
Assessing future
growth potential
using Tanner
staging:

Tanner stages 2-3

(just after onset of
pubertal growth) are
the stages of
maximal scoliosis
progression
 Natural history of scoliosis
Assessing growth potential using
Risser grading:
- Measures progress of bony fusion of
iliac
apophysis
- Ranges from zero (no ossification) to 5
(complete
bony fusion of the apophysis)
- The lower the grade, the higher the
 Risk of Curve Progression
Curve (degree) Growth potential (Risser grade) Risk *
10 to 19 Limited (2 to 4) Low
10 to 19 High (0 to 1) Moderate
20 to 29 Limited (2 to 4) Low/mod
20 to 29 High (0 to 1) High
>29 Limited (2 to 4) High
>29 High (0 to 1) Very high
.

*Low risk = 5 to 15 percent; moderate risk = 15 to 40 percent; high

risk = 40 to 70 percent; very high risk = 70 to 90 percent.
 Natural history of scoliosis

Back pain not significantly higher in pts

with scoliosis
Curves in untreated adolescents with
curves < 30 at time of bony maturity
are unlikely to progress
Curves >50 at maturity progress 1 per
year
Up to 19% of females with curves >40
have significant psychological illness
Life-threatening effects on pulmonary
 Scoliosis Screening
In years past, widespread school-based
screening led to many unnecessary
referrals of adolescents with minimal
curvatures
U.S. Preventive Services Task Force
notes insufficient evidence to
recommend for or against routine
screening of asymptomatic adolescents
for idiopathic scoliosis
Scoliosis Screening Recommendations

American Academy of Orthopedic

Surgeons
- Screen girls at ages 11 and 13
- Screen boys once at age 13 or 14
American Academy of Pediatrics
- Screen at 10, 12, 14 and 16 years
 Adams forward bend test

For this test, the patient is asked to lean

forward with his or her feet together and bend
90 degrees at the waist. The examiner can
then easily view from this angle any
asymmetry of the trunk or any abnormal
spinal curvatures.
 Screening hints:
Shoulders are different heights one
shoulder blade is more prominent than the
other
Head is not centered directly above the pelvis
Appearance of a raised, prominent hip
Rib cages are at different heights
Uneven waist
Changes in look or texture of skin overlying
the spine (dimples, hairy patches, color
changes)
Leaning of entire body to one side
 Scoliometer
Anpatient
The inclinometer (Scoliometer)
bends over, arms measures distortions
dangling and palms pressed
together, until a curve can be
observed in the upper back
(thoracic area).
The Scoliometer is placed on
the back and measures the
apex (the highest point) of the
upper back curve.
The patient continues
bending until the curve can be
seen in the lower back
(lumbar area). The apex of
this curve is also measured.
 Red flags on PE:

Left-sided thoracic curvature

Pain
Significant stiffness
Abnormal neurologic findings
Stigmata of other clinical syndromes
associated with curvature
Measure spinal curvature using Cobb
method:
- Choose the most tilted
verterbrae above & below
apex of the curve.
- Angle b/t intersecting
lines drawn perpendicular
to the top of the
superior vertebrae and
bottom of the inferior
vertebrae is the Cobb
angle.
 Referral Guidelines & Treatment
Curve
(degrees) Risser grade X-ray/refer Treatment
10 to 19 0 to 1 Every 6 months/no Observe
10 to 19 2 to 4 Every 6 months/no Observe
20 to 29 0 to 1 Every 6 Brace after 25
months/yes degrees
20 to 29 2 to 4 Every 6 Observe or brace *
months/yes
29 to 40 0 to 1 Refer Brace
29 to 40 2 to 4 Refer Brace
>40 0 to 4 Refer Surgery
 Brace Treatment for Scoliosis
Most common is Boston
brace (aka Thoraco-lumbar-
sacral orthosis)
Braces have 74% success
rate at halting curve
progression (while worn)
Bracing does not correct
scoliosis, but may prevent
serious progression
Usually worn until patient
reaches Risser grade 4 or 5
 Brace Treatment for Scoliosis
Of patients with 20 - 29
curves, only 40% of
those wearing braces
ultimately required
surgery, compared to
68% of those not wearing
back braces
Length of wearing time
correlates with outcome
(At least 16 hrs per day
leads to best chance of
preventing curve
 Surgical Treatment for Scoliosis
Curves in growing children greater than 40
require a spinal fusion (Risser grade 0 to 1 in
girls and Risser 2 or 3 in boys)
Skeletally mature patients can be observed
until their curves reach 50
Posterior spinal fusion is best choice for
thoracic curves
Anterior spinal fusion is best treatment for
thoracolumbar and lumbar curves
 Surgical Treatment for Scoliosis

Spinal surgery with instrumentation

significantly corrects deformity &
usually stops curve progression
Surgery is accompanied by spinal
cord monitoring using somato-
sensory & motor-evoked potentials
(risk of neurologic injury is 1/7000)
Post-Op Treatment & Long Term
Consequences of Spinal Fusion
If segmental instrumentation used, no post-op
cast or brace required
Post-fusion back pain does occur and is more
common in distal spinal fusions
Usually out of hospital in 4-5 days & back at
school in 2 wks
OK to participate in athletics after 9 12
months
(should avoid contact sports)
 Case #1
MP is a 16-year-old male who presents to your office for
his annual health assessment and sports physical.
During the course of his examination, you note a mild
convexity in the thoracic region of his spine with forward
flexion at the hips.
Based on your clinical examination, you estimate a
lateral spinal curvature of about 5 degrees.
You note these findings to the patient and then to his
mother.
 Question 1
Which one of the following procedures sho
implemented next?
A. Recommend back-strengthening exerc
B.Refuse to permit participation in contact
C.Order a radiograph of the back to quanti
curvature (e.g., Cobb angle).
D. Monitor the patient's condition.
E.Refer for orthopedic consultation.
 Answer 1

The answer is D: monitor the patient's

condition.
 Question 2

Because you have recently agreed to serve as sc

physician in the district where your office is locate
wonder what scoliosis screening programs are in
who has been examining these school children fo
Which one of the following procedures should yo
 Question 2 (cont.)
A. Arrange scoliosis screening for all students
between 10 and 16 years of age.
B. Arrange scoliosis screening for all students 10,
12 , 14 and 16 years of age.
C. Contact the school nurse and review skills for
scoliosis screening procedures.
D. Visually inspect for severe curves only when
the back is examined for other reasons.
E. Screen girls for scoliosis at 11 and 13 years of
age and boys at 13 and 15 years of age.
 Answer 2

According to AAP the answer is B: screen at

10, 12, 14 &
16 years

According to U.S. Prev Services Task Force,

the answer is D:
visually inspect for severe curves only when
the back is
 Question 3
Which of the following statement(s) about treatment for a
scoliosis is/are correct?
A. Exercise therapy has been shown to be an effective
treatment for preventing progression of scoliosis.
B. Spinal surgery for scoliosis is not supported by
studies showing improvements in clinical outcomes,
such as decreased back pain and increased
functional status.
C. Lateral electrical surface stimulation for eight hours
nightly can limit progression of spinal curvature
D. Back bracing (e.g., orthoses) reduces symptoms of
low back pain.
 Answer 3

The answer is B: Although surgery for scoliosis is

generally not recommended without marked
curvature, well-conducted outcomes studies with
patients who have had surgery have not been
completed. Symptoms of back pain do not appear
to correlate with magnitude of surgical correction.
 Conclusions
Screening for scoliosis remains
controversial & has led to many
unnecessary referrals
Adolescent scoliosis can be followed by
family docs if the curve has a low risk of
progression & underlying causes have
been excluded
Curves demonstrating significant
progression with continued growth
remaining or those at high risk of
 Conclusions
90% of kids with scoliosis will not
require medical intervention
Girls are much more likely than boys to
need intervention for scoliosis
Bracing can slow progression of many
curves and significantly decrease need
for surgery
Spinal fusion surgery is recommended
for curves greater than 45 50 degrees
Torticollis
 What is it?

Also known as Wryneck

Head and chin are tilted at opposite

angles, causing head to twist

Asymmetrical Appearance

Effected muscle:sternocleidomastoid
 What is it?
Can exist before or at birth
Congenital Muscular Torticollis

Can occur during childhood up through adult

age
Acquired/Noncongenital Muscular Torticollis

Both cause asymmetrical appearance and function in the

neck and head of those afflicted
 Prevalence
Less than .4% of newborns

Torticollis does not prefer one side of

head or the other

In CMT, ratio of boys to girls is 3:2

Increased head size in male babies
 Prevalence
In adults, noncongenital muscular torticollis
has an average onset of 40 years old
Females twice as likely afflicted than males

Usually equal distribution between right and

left side of body afflicted
Slightly more right torticollis in older female populations
 Causes?
Not well understood
Almost 80 entities have been reported to
cause torticollis

Common causes:
Developmental disorders affecting
sternocleidomastoid muscle
Imbalance in function of cervical muscles
Other abnormalities in skull/cervical area
 Other Causes
Genetic defect
Infants position during pregnancy or delivery
Tumors in head or neck
Arthritis of neck
Pseudotumors in infants
Certain medications
Genes
More likely to be afflicted if family member had
torticollis or similar disorder
 Symptoms
Adults and Children:
Abnormal contraction of the neck
Limited range of motion
Stiff neck muscles
Possible swelling and pain

Can often be mistaken for more serious

condition
See medical professional immediately
 Symptoms

Infants:
Tilting of chin
Small mass (pseudotumor)
in neck
Small neck spasms

Diagnosed before 1
month old = shorter
physical therapy
 Prognosis
Most helpful diagnosis is made early
Not life threatening
May self correct itself
May be chronic and reoccurring
Any complications may result from
compressed nerve roots
 Treatments
Stretching and lengthening affected
neck muscles
Applying heat, massage, analgesics
Can be combined with TENS
Transcutaneous Electrical Nerve Stimulation
Medical treatmentBacolfen or Botox
Injection every three months
 Treatments
Surgery in severe cases
Patients whose pathology does not resolve
after 12 months of physical therapy or who
develops facial asymmetry
Risk of injury to spinal nerves
Preventive Measures
Nearly impossible to prevent
Become familiar with symptoms
Seek medical attention
Other serious conditions may be confused
for Torticollis and are not treated correctly
Any Questions?