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Scoliosis

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Other Names

  • Adolescent Idiopathic Scoliosis (AIS)
  • Juvenile Scoliosis
  • Infantile Scoliosis
  • Degenerative Scoliosis

Background

  • This page refers to all forms of scoliosis, including pediatric and adult forms
  • Definition: spinal deformity of the normal vertical line of the spine
    • Consists of a lateral curvature with rotation of vertebrae within the curve
    • Typically requires at least 10° spinal angulation on the posterior-anterior radiograph

History

Epidemiology

  • Prevalence in adults ranges from 2% to 32%[1]
  • The prevalence of degenerative scoliosis ranges from 6% to 68%[2]
  • Idiopathic
    • Most common, prevalence of 1-3 per 100 person-years[3]

Pathophysiology

  • Congenital
    • Vertebral abnormality causing the mechanical deviation of the normal spinal alignment
    • Failure of formation or a failure of segmentation (or both) during vertebral development
    • Often co-occuring with other congenital abnormalities
  • Neuromuscular
    • Neurological conditions: cerebral palsy, paralysis
    • Muscular abnormalities: Duchenne muscular dystrophy
  • Syndrome-related
    • e.g. Marfan syndrome, neurofibromatosis
  • Idiopathic
    • Majority of cases, diagnosis of exclusion
    • After skeletal maturity, found that curves less than 30° do not progress, while most curves of greater than 50° continue to progress
    • Progression is estimated to be 1° per year
  • Adolescent Idiopathic Scoliosis (AIS)
    • Present after 10 years of age which corresponds with rapid adolescent growth[4]
    • Risk factors for progression: female gender, curve magnitude of greater than 50° at maturity, curve type and remaining growth
  • Degenerative
    • Refers to progressive degeneration of structural spinal elements
    • asymmetric degeneration of intervertebral disc, facet joints at different levels leading to asymmetric loading of the spinal segment
  • Due to secondary reasons
    • Widely varied including pain, spinal cord pathology, neoplasm, infection

Risk Factors

  • Genetic[5]
    • 7 fold more likely if sibling has
    • 3 fold more likely if parent has
  • Osteoporosis

Differential Diagnosis


Clinical Features

  • General: Physical Exam Back
  • Red flags for non-idiopathic causes[6]
    • Age at onset
    • Evidence of maturation
    • Presence of back pain
    • Neurological symptoms, including gait abnormalities, weakness or sensory changes
    • Feelings about overall appearance and back shape
    • Family history
  • History
    • Patients report spinal deformity, chest wall or back asymmetry
    • Deformities may be identified by parents, school, physician screening
    • Women may notice difference in breast size
    • Back pain is not unusual, but not typically a presenting symptom in kids[7]
    • Adults present with back pain 90% of the time
    • Must screen for neuro symptoms: weakness, sensory changes, problems of balance, gait and coordination, bowel and bladder dysfunction
  • Physical Exam
    • Pediatrics: height, puberty development
    • Proper gait evaluation
    • Symmetry of shoulders, iliac crest, leg length
    • Thorough neurological exam
  • Special Tests

Evaluation

Radiographs

  • Standard Long Spine Radiographs
    • Evaluate curve in the coronal plane
    • Rotational deformity (absence of rotational deformity is a red flag)
  • Cobb Angle
    • Measured by marking perpendicular lines to the end plates of the most angulated vertebrae involved in the curve

MRI


Classification

Lenke Classification of AIS

  • 1. Label primary curve at Type 1-6
  • 2. Assign lumbar modifier (A,B,C)
  • 3. Assign sagittal modifier (-,N,+)

Aebi Classification of Adult Scoliosis

  • Type 1: Primary degenerative or "de novo" scoliosis [8]
    • Often due to disc and/or facet joint arthritis, affecting those structures asymmetrically
    • predominantly back pain symptoms, often accompanied either by signs of spinal stenosis
  • Type 2: Idiopathic adolescent scoliosis of the thoracic and/or lumbar spine
    • Progresses in adult life, usually combined with secondary degeneration and/or imbalance.
  • Type 3: Secondary adult curves
    • (a) Secondary curve in idiopathic, neuromuscular and congenital scoliosis, or asymmetrical anomalies at the lumbosacral junction;
    • (b) Metabolic bone disease combined with asymmetric arthritic disease and/or vertebral fractures.

Management

Screening

  • School based screening is controversial
  • Scoliosis Research Society (USA) recommends annual screening of all children between 10 and 14 years of age[9]
  • American Academy of Pediatrics has recommended screening with the forward bending test at routine health supervision visits at 10, 12, 14 and 16 years of age[10]
  • US Preventive Services Task Force, Canadian Task Force on the Periodic Health Examination: insufficient evidence to recommend for or against routine screening of asymptomatic adolescents for idiopathic scoliosis[11][12]
  • Concern about routine screening is identifying asymptomatic cases who are subsequently referred for sub-specialty care unnecessarily

Prognosis

Nonoperative

Operative

  • Consideration/ Indications:
    • Curves greater than 45° in immature patients
    • Curves greater than 50° in mature patients
  • Goals
    • Prevent progression
    • Improve spinal alignment and balance
  • Technique
    • Anterior fusion
    • Posterior fusion

Rehab and Return to Play

Rehabilitation

Return to Play


Complications

  • Back pain
  • Cor Pulmonale
  • Right Heart Failure
  • Diminished pulmonary function
  • Psychosocial issues

See Also


References


  1. Aebi M. The adult scoliosis. Eur Spine J 2005; 14(10):925–48.
  2. Anasetti F, Galbusera F, Aziz HN, Bellini CM, Addis A, Villa T. et. al,. Spine stability after implantation of an interspinous device: an in vitro and finite element biomechanical study. J Neurosurg Spine 2010;13(5):568–75.
  3. Kane WJ, Moe JH. A scoliosis-prevalence survey in Minnesota. Clin Orthop Relat Res. 1970;69:216–8.
  4. Morrissy RT, Weinstein SL. Lovell and Winter’s Pediatric Orthopaedics. Philadelphia: Lippincott Williams & Wilkins; 2006. pp. 693–762
  5. Wynn-Davies R. Familial (idiopathic) scoliosis. A family survey. J Bone Joint Surg Br. 1968;50:24–30.
  6. Joseph A Janicki, MD, Benjamin Alman, MD FRCSC, Scoliosis: Review of diagnosis and treatment, Paediatrics & Child Health, Volume 12, Issue 9, November 2007, Pages 771–776
  7. Ramirez N, Johnston CE, Browne RH. The prevalence of back pain in children who have idiopathic scoliosis. J Bone Joint Surg Am. 1997;79:364–8
  8. Aebi M. The adult scoliosis. Eur Spine J. 2005;14(10):925‐948. doi:10.1007/s00586-005-1053-9
  9. Scoliosis Research Society. Park Ridge: Scoliosis Research Society; 1986. A handbook for patients.
  10. American Academy of Pediatrics. Elk Grove Village: American Academy of Pediatrics; 1988. Guidelines for health supervision II.
  11. US Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd edn. Washington DC: Office of Disease Prevention and Health Promotion; 1996.
  12. Canadian Task Force on Periodic Health Examination. Canadian guide to clinical preventive care. Ottawa: Canada Communication Group; 1994. pp. 346–54.
  13. Willers U, Normelli H, Aaro S, Svensson O, Hedlund R. Long-term results of Boston brace treatment on vertebral rotation in idiopathic scoliosis. Spine. 1993;18:432–5.
Created by:
John Kiel on 17 June 2019 16:43:44
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Last edited:
23 November 2020 15:41:42
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