SCOLIOSIS

1
SCOLIOSIS

• Maryellen Flaherty-Hewitt, MD
• Department of Pediatrics
• Hospital of Saint Raphael

2
Case Presentation

• An 11 year old girl comes to your office with her
  mother because the school nurse says she failed
  her scoliosis screening

3
Case Presentation (cont)

• What questions would you like answered about her
  history and review of systems?

4
Case Presentation (cont)

• On further history-taking, you find out that she
  has no significant past medical history and no
  surgeries.
• There is no family history of scoliosis
• She does not complain of back pain or stiffness,
  no tingling or pins and needles in her lower
  extremities or problems with bladder or bowel
• She has not had her period yet

5
Case Presentation (cont)

• On Physical Exam
• right scapula noted to be elevated
• scoliometer reading 9 degrees
• normal neurological exam
• Tanner 2
• What is your next step?

6
Case Presentation (cont)

• You decide to obtain a scoliosis series which
  reveals a thoracolumbar curvature with a Cobb
  angle measurement of 28 degrees.
• Thoughts on how to proceed from here?

7
Background

• Definition lateral curvature of the spine gt 10
  degrees by Cobb angle accompanied by vertebral
  rotation
• Idiopathic no clear underlying cause
• Secondary
• Connective tissue disorders Ehlers-Danlos,
  Marfan
• Neuro disorders tethered cord, CP, muscular
  dystrophy
• Musculoskeletal disorders DDH, OI, leg length
  discrepancy

8
Statistics

• Infantile onset before 3 yrs lt 1 all cases
• Juvenile 3-10 yrs 12-21 all cases
• Adolescent gt 10 yrs majority of cases
• Prevalence 2-4 of children 10-16 yrs
• ?? 11 for curves lt 10
• ?? 51 for curves 10-30
• ?? 101 for curves gt30

9
Progression

• Determinants of Progression
• Female risk of progression 10x male risk
• Future growth potential
• Curve magnitude at time of diagnosis

10
Growth Potential

• Tanner 2-3 time of maximum growth progression
• Risser Grade measurement of ossification of
  iliac apophysis
• 0 no ossification
• 1 lt 25
• 2 26-50
• 3 51-75
• 4 76-100
• 5 complete bony fusion of apophysis

11
Curve Magnitude

• Determined by measurement of the Cobb angle on a
  standing Xray of the spine.
• Cobb angle Angle of intersecting lines drawn
  through the curves superior and inferior
  vertebrae.

12
Screening

• AAOS
• Screen ? at 11 and 13 yrs
• Screen ? once between 13-14 yrs
• AAP
• Screen all at 10, 12, 14, 16 yrs

13
History Physical

• History
• Family h/o scoliosis
• Onset of menses
• Neuro changes
• Pain
• Physical Exam
• Tanner staging
• Neuro exam
• Adams forward bend test
• Scoliometer

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Red Flags

• Significant pain
• Stiffness
• Rapid progression
• Abnormal neuro exam

15
Diagnositic Testing

• Standing PA Xray for Cobb angle and Risser
  grading
• Consider MRI whenever there is a left-sided
  curve, pain, or abnormal neuro exam looking for
  spondylolisthesis, tumor or syringomyelia.

16
Referral
From Remy, BV Adolescent Idiopathic Scoliosis Am
Fam Phys 2001 64 111-116
17
Treatment

• Not proven helpful PT, chiropractors,
  biofeedback, electrical stimulation
• Bracing and Surgery helpful
• Immature pts curve 25 to 40 BRACE
• Immature pts curve gt 40 SURGERY
• Mature ptscurve gt50/progression SURGERY

18
Braces

• Milwaukee brace
• First brace used
• had neck ring
• recommended wearing time 23 hrs
• Boston brace
• under arm brace
• wearing time 16 hrs
• Charleston/ Providence braces
• part-time night braces
• only for lumbar small thoracolumbar curves
• need long-term studies

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Braces
Boston Brace
Charleston Brace
Milwaukee Brace
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Braces

• Purpose of bracing is to prevent further
  curvature.
• Milwaukee most successful has the most studies,
  but VERY poor compliance
• Recent studies have shown the Boston brace to be
  comparable, with better compliance with fewer
  hours recommended wear
• Braces to be used gt2 yrs post-menarche and until
  Risser 4 for girls Risser 5 for boys.

21
Surgery

• Generally reserved for skeletally mature patients
  with curves gt 50 or skeletally immature patients
  with curves gt 40
• Posterior spinal fusion thoracic curves
• Anterior spinal fusion thoracolumbar/ lumbar
  curves
• Post-op
• instrumentation avoids need for bracing/ casting
• back to school 2 weeks post -op
• athletics not recommended for 9-12 mos after
  spinal fusion- no contact sports

22
Back to Our Patient

• Given the degree of curvature and relative
  skeletal immaturity (although Risser grading was
  not given), she would require bracing and close
  follow-up by orthopedics.