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How to do a clinical and radiological workup?
SCOLIOSIS
Dr Kshitij Chaudhary
MS, DNB, Fellowship in Spine Surgery (USA).
C...
Scoliosis is NOT a diagnosis
Skeletal
Maturity
Natural History
Decision
Etiology
History
Examination
Imaging
Specialist Referrals
Clinical markers
Skel...
Growth and Maturity
12 yr old girls
14 yr old boys
Maturity Markers
• Menarche
• Secondary Sexual Characters
Breast
Pubic and axillary hair
Genitals
Voice change
Facial hair...
Tanner 2
0.5 cm /month Standing height
Risser 4
No change in serial height
Closure of triradiate
cartilage
Menarche
Axilla...
Tanner 2
Breast budding
Appearance of Pubic Hair
(Girls)
Appearance of Pubic Hair
(Boys)
History
Deformity
Pain
Neurologic symptoms
Cardiopulmonary issues
Functional / psychological issues
Deformity
Cosmesis / Psychological Concerns
Deformity
• When was it first noticed?
• How was it first noted?
• Is it progressive?
• What treatment has been taken so f...
Pain
Idiopathic Scoliosis does not cause pain
Neurologic Symptoms
Especially when angular kyphosis
Gait problems
Loss of balance
Cardiopulmonary Problems
History
• Birth History
Issues in pregnancy?
Health of mother? Diabetic? Antenatal care appropriate?
Previous pregnancies ...
History
• Family History
Parents and their families (AIS, NM, NF)
Siblings
Examine family if in room - Adam’s test
History
• Past medical or surgical history
Hearing / visual problems
Cleft lip/ palate
Tracheo-esophageal fistula, Anorect...
Physical Examination
Spine
Head to Toe
Neurological
Equipment
Look
Gait
Posture
Spinal Alignment
Skin
Sexual maturity
Feel
Tenderness
Step-offs
Paraspinal muscles
Move
Range of Motion
...
Posture
• Head centered over pelvis
• Ear, shoulder, GT, Ankle
• Hips and knees extended
• Pelvis is horizontal
• Shoulder...
Posture
Spinal Alignment
• Location (apex)
• Side (Right or left) - convexity
• Largest curve (Major curve)
• Symmetry
• Shoulder
...
Physical Examination
• Back
• Front
• Side
• Supine
• Prone
• Sitting
• Walking
Shoulder level
Deformity (Apex, side, extent)
Rib prominence
Asymmetric flank crease
Pelvic level
Head Decompensation
Trun...
Shoulder level
Deformity (Apex, side, extent)
Rib prominence
Asymmetric flank crease
Pelvic level
Head Decompensation
Trun...
Shoulder level
Deformity (Apex, side, extent)
Rib prominence
Asymmetric flank crease
Pelvic level
Head Decompensation
Trun...
Trunk Decompensation
Head Decompensation
Adam’s Forward Bending
Adam’s Forward Bending
Adam’s Forward Bending
Rib Prominence
Sharp Smooth
Adam’s Forward Bending
Lumbar Prominence
Head tilt
Neck line
Chest asymmetry
Rib impingement
Pelvis ASIS
Secondary sexual characters
Skin
Frontal view
Ear, Shoulder, GT, MM
Thoracic Kyphosis
Lumbar Lordosis
Hip/knee flexion
Side View
Breast development
LLD
Neurological Exam
Supine
Spine is unloaded - see how it corrects
Flexibility tests
Hyperextension
Push Prone
Tender points palpated
Prone
Flexibility
Aided Bending
Flexibility
Traction
Flexibility
Push Prone Test
Head to Toe
Head to Toe
Physical Examination
Head to Toe Exam
Head to Toe
Head to Toe
Head to Toe
Hyper flexibility
Beighton Score
14+6y old girl who is 18 months postmenarchal
with right sided thoracic scoliosis,
probably adolescent onset idiopathic,
w...
Thank You
Scoliosis examination
Scoliosis examination
Scoliosis examination
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Scoliosis examination Slide 1 Scoliosis examination Slide 2 Scoliosis examination Slide 3 Scoliosis examination Slide 4 Scoliosis examination Slide 5 Scoliosis examination Slide 6 Scoliosis examination Slide 7 Scoliosis examination Slide 8 Scoliosis examination Slide 9 Scoliosis examination Slide 10 Scoliosis examination Slide 11 Scoliosis examination Slide 12 Scoliosis examination Slide 13 Scoliosis examination Slide 14 Scoliosis examination Slide 15 Scoliosis examination Slide 16 Scoliosis examination Slide 17 Scoliosis examination Slide 18 Scoliosis examination Slide 19 Scoliosis examination Slide 20 Scoliosis examination Slide 21 Scoliosis examination Slide 22 Scoliosis examination Slide 23 Scoliosis examination Slide 24 Scoliosis examination Slide 25 Scoliosis examination Slide 26 Scoliosis examination Slide 27 Scoliosis examination Slide 28 Scoliosis examination Slide 29 Scoliosis examination Slide 30 Scoliosis examination Slide 31 Scoliosis examination Slide 32 Scoliosis examination Slide 33 Scoliosis examination Slide 34 Scoliosis examination Slide 35 Scoliosis examination Slide 36 Scoliosis examination Slide 37 Scoliosis examination Slide 38 Scoliosis examination Slide 39 Scoliosis examination Slide 40 Scoliosis examination Slide 41 Scoliosis examination Slide 42 Scoliosis examination Slide 43 Scoliosis examination Slide 44 Scoliosis examination Slide 45 Scoliosis examination Slide 46 Scoliosis examination Slide 47 Scoliosis examination Slide 48 Scoliosis examination Slide 49 Scoliosis examination Slide 50 Scoliosis examination Slide 51
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Scoliosis examination

Examination of a scoliosis patient. Presented at Bombay Orthopaedic Society's Postgraduate preparatory course for the MS Orthopaedic Exams

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Scoliosis examination

  1. 1. How to do a clinical and radiological workup? SCOLIOSIS Dr Kshitij Chaudhary MS, DNB, Fellowship in Spine Surgery (USA). Consultant Spine Surgeon Sir HN Reliance Foundation Hospital Mumbai
  2. 2. Scoliosis is NOT a diagnosis
  3. 3. Skeletal Maturity Natural History Decision Etiology History Examination Imaging Specialist Referrals Clinical markers Skeletal markers Do nothing Observe Brace Surgery Severity of curve
  4. 4. Growth and Maturity
  5. 5. 12 yr old girls 14 yr old boys
  6. 6. Maturity Markers • Menarche • Secondary Sexual Characters Breast Pubic and axillary hair Genitals Voice change Facial hair • Radiographic signs Risser’s sign Triradiate Cartilage • Serial Height measurements (PHV)
  7. 7. Tanner 2 0.5 cm /month Standing height Risser 4 No change in serial height Closure of triradiate cartilage Menarche Axillary hair Risser 1
  8. 8. Tanner 2 Breast budding Appearance of Pubic Hair (Girls) Appearance of Pubic Hair (Boys)
  9. 9. History Deformity Pain Neurologic symptoms Cardiopulmonary issues Functional / psychological issues
  10. 10. Deformity Cosmesis / Psychological Concerns
  11. 11. Deformity • When was it first noticed? • How was it first noted? • Is it progressive? • What treatment has been taken so far? How long? Details about old records / X-rays Bracing? Prior procedures
  12. 12. Pain Idiopathic Scoliosis does not cause pain
  13. 13. Neurologic Symptoms Especially when angular kyphosis Gait problems Loss of balance
  14. 14. Cardiopulmonary Problems
  15. 15. History • Birth History Issues in pregnancy? Health of mother? Diabetic? Antenatal care appropriate? Previous pregnancies ending in miscarriages? Issues during perinatal and postnatal period Term delivery? C-section or vaginal ICU / ventilatory care • Developmental History Motor milestones Learning disabilities Grade in School? Keeping up with peers Menarche (record in yr+mo)
  16. 16. History • Family History Parents and their families (AIS, NM, NF) Siblings Examine family if in room - Adam’s test
  17. 17. History • Past medical or surgical history Hearing / visual problems Cleft lip/ palate Tracheo-esophageal fistula, Anorectal problems Cardiac murmurs / anomalies Genitourinary disorders Respiratory disorders Neurological disorders
  18. 18. Physical Examination Spine Head to Toe Neurological
  19. 19. Equipment
  20. 20. Look Gait Posture Spinal Alignment Skin Sexual maturity Feel Tenderness Step-offs Paraspinal muscles Move Range of Motion Flexibility Measure Height Weight
  21. 21. Posture • Head centered over pelvis • Ear, shoulder, GT, Ankle • Hips and knees extended • Pelvis is horizontal • Shoulder are level • Neck is neutral
  22. 22. Posture
  23. 23. Spinal Alignment • Location (apex) • Side (Right or left) - convexity • Largest curve (Major curve) • Symmetry • Shoulder • Ribs prominence / Lumbar prominence • Waist asymmetry • Pelvic obliquity - LLD, Hip exam • Decompensation - Head/Trunk • Flexibility
  24. 24. Physical Examination • Back • Front • Side • Supine • Prone • Sitting • Walking
  25. 25. Shoulder level Deformity (Apex, side, extent) Rib prominence Asymmetric flank crease Pelvic level Head Decompensation Trunk Decompensation Palpate tender points ROM Skin Back
  26. 26. Shoulder level Deformity (Apex, side, extent) Rib prominence Asymmetric flank crease Pelvic level Head Decompensation Trunk Decompensation Palpate tender points ROM Skin Back
  27. 27. Shoulder level Deformity (Apex, side, extent) Rib prominence Asymmetric flank crease Pelvic level Head Decompensation Trunk Decompensation Palpate tender points ROM Skin Back
  28. 28. Trunk Decompensation Head Decompensation
  29. 29. Adam’s Forward Bending
  30. 30. Adam’s Forward Bending
  31. 31. Adam’s Forward Bending Rib Prominence Sharp Smooth
  32. 32. Adam’s Forward Bending Lumbar Prominence
  33. 33. Head tilt Neck line Chest asymmetry Rib impingement Pelvis ASIS Secondary sexual characters Skin Frontal view
  34. 34. Ear, Shoulder, GT, MM Thoracic Kyphosis Lumbar Lordosis Hip/knee flexion Side View
  35. 35. Breast development LLD Neurological Exam Supine
  36. 36. Spine is unloaded - see how it corrects Flexibility tests Hyperextension Push Prone Tender points palpated Prone
  37. 37. Flexibility Aided Bending
  38. 38. Flexibility Traction
  39. 39. Flexibility Push Prone Test
  40. 40. Head to Toe
  41. 41. Head to Toe
  42. 42. Physical Examination Head to Toe Exam
  43. 43. Head to Toe
  44. 44. Head to Toe
  45. 45. Head to Toe
  46. 46. Hyper flexibility Beighton Score
  47. 47. 14+6y old girl who is 18 months postmenarchal with right sided thoracic scoliosis, probably adolescent onset idiopathic, with trunk decompensation but without head decompensation, partially flexible normal neurology Clinical Diagnosis Keep it simple Curve (side, location) Probably etiology Decompensation Flexibility Sexual maturity Neurology
  48. 48. Thank You
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Examination of a scoliosis patient. Presented at Bombay Orthopaedic Society's Postgraduate preparatory course for the MS Orthopaedic Exams

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