Definition explanation Classification and management

1. Scoliosis
DR ASAD ALI
ORTHOPAEDIC SURGEON
MAYO HOSPITAL LAHORE

2. Definition
Scoliosis-Greek word meaning “crooked”.
 It is defined as lateral deviation of the normal vertical
line of the spine, which when measured on the
radiographs, is greater than 10 degree, with
associated rotation of vertebrae.
 It is three dimensional deformity of spine-sagittal,
frontal and coronal.

3. Incidence and Etiology
 2 percent of children effect at same stage of their life.
 Girls are effected more than boys.
 Multifactorial in etiology, 80 percent idiopathic.
 Mostly patients have positive family history -11
percent risk in first degree relative.
 Related to hormonal, brainstem and proprioception
disorder.

4. Clinical Features
 Deformity is usually the Presenting Complaint
 Pain
 Rib hump due to asymmtry of trunk rotation (ATR
 Headache
 Neck pain
 Lower back pain
 Shoulder Elevation

5. Signs
 Raised scapula
 Waist line deformity
 Trunk shift
 LLD
 Cavovarus deformity
 Hips assymetry

6. Classification
 Structural: Radiographic Cobb angle greater than 25 degree
on ipsilateral bending radiographic views.
 Further classified into infantile, Juvenile, congenital and
adolescent(Age group), traumatic,Neuromuscular and
degenerative
 Non structural: Compensatory and postural i. e
 Postural scoliosis, hysterical scoliosis, contracture around hip
joint etc

7. Lenke classification
 Six curve types
 3 lumbar
 3 thoracic sagittal
 Helps to determine fusion levels during surgery
 Structural curves:
Largest curve, fails to bend to less than 25 degree
 Lumbar Modifier:
Based on position of CSVL in relation to apical vertebra of thorocolumbar
curve

8.  Type A:
CSWL is between the pedicles of the apical vertebra
 Type B:
CSWL touches between the concave pedicle and lateral
body
 Type C:
CSWL falls outside of apical vertebral body

10. Congenital Scoliosis
 It is progressive three dimensional deformity of the spine, caused by
congenital anomalies of the vertebrae, results in imbalance in
longitudinal growth.
 Developmental defect during 5th-8th week of gestation.
 High incidence of associated anomalies
 Intraspinal-20 to 40 percent, syringomyelia, thetered cord
 Cardaic-12 to26 percent,
 Genitourinary-20 percent, renal agensis, ectopic kidney
 3 basic types of defects-failure of segmentation, failure of formation
and mixed
 VACTERL association(vertebral defects,Anal atresia, Cardaic
anomalies, Tracheo-esophageal fistula, renal defects,limb defect

12. Neuromuscular Scoliosis
 Second most common form
 Associated with disorders of nerves and muscular system
 Neuropathic:
Lower motor neuron (Polio)
UMN(cerebral palsy)
 Myopathetic
progressive (muscular dystrophy)
Static(Amyotonia congenita)
others(Friedreich’s ataxia)

13. Idiopathic Scoliosis
 Most common tyoe
 No etiological factor
 Divided into three categories on the basis of chronological
age.
 Infantile:birth to 3 years
 Juvenile:3 years to 10 years
 Adolescent:10 years to 18 years

14. Infantile Scoliosis
 Male predominant
 Left sided thoracic curve patterm is present.
 Plegiocephaly often present.
 Congeintal defects may also be present.
 2 types - resolving, progressing; depends upon RVAD”position of medial
rib relative to apical vertebra.
 Phase 1:no overlap
RVAD less than 20 percent:80 percent chance of no progression
RVAD greater than 20 percent:80 percent chance of progression(Mehta
classification)
 Phase 2: rib overlap present with high risk of curve progression
 MRI is needed for evaluation of neural axis abnormalities.

16. Juvenile Scoliosis
 Most common in females
 Right thoracic curve most common
 High risk of progression, 95 percent in one study
 Least likely resoonds to bracing
 MRI needed for evaluation
 Rate of spinal cord deformity is 25 percent

17. Adolescent Scoliosis
 Most common scoliosis in children
 Female predominant
 Right sided thoracic curve
 Not associated with pain

18. Management

19. History
 Age of patient
 Duration
 Antenatal history
 Birth history
 Vaccination history
 Complete neurological history
 Family history

20. Examination
 Skin Inspection i. e tuft of hairs, local defect, curvature ,
symmetry of shoulder and iliac crest, foot shape
 Height measurement
 Assessmentvof pubertal development
 Neurlogical examination
 Gait

21. Assessment of Scoliosis
 Four parameters are evaluated
 Curvature
 Rotation
 Flexibility
 Skeletal maturuty

22. Scoliometry
 A scoliometer is placed on the
highest point on the upper back
curve and apex is measured

23. Plumb line
 On posterior aspect, a line drawn from
occiput and should allign with gluteal
cleft.

31. Imaging
 Standing full length PA radiograph, lateral radiograph, right
and left bending films, push prone radiograph
 Stagnara view:eliminate rotational component of cuve
 Radiographic, parameters to assess maturity, hand and
wrist(tanner white house) , development of iliac crest
apophysis(Risers sign), triradiate cartilage
 CT scan
 PFTs
 Echo
 MRI

45. Treatment

46. Infantile Scoliosis
 Resolving curves:
Observation e serial physical examination and
radiographic monitoring
Sleeping in prone position is recommended
 Progressive Curves:
Treated e serial casting followed by orthotic treatment

47. Treatment Options
 Serial casting plus bracing plus later fusion
 pre-oprative traction plus later fusion
 Growing rod or vertical expandable prosthesis titanium rib
(VEPTR)
 Best results obtained with in casting started before 20 months
and 60 degreee curve.
 Cast cahnges after every 2-4 months

51. Juvenile idiopathic Scoliosis
 Orthotic treatment is indicated if curves is witn in 25 to 30
degree.
 Surgical treatment is considered when curve magnitude
exceeds 50 degree.

54. Adolescent idiopathic scoliosis
 Depends on likelihood of cuve progression
 Obesrvation:skeletal immature patients with curve less than 20-25 degree
 Skeletally mature patuents with curve less than 45 degree
 Bracing:slow curve progression in skeletal immature patients(Risser 0-2)bracing doesn’t
reverse the curve.
 Indication:
 Curve of more than 25 degree or progression of 20 degree with documentation
progression
 Types:
 Milwaukee brace
 Throcolumbosacral brace
 Brace should wear 18 hours per day in risser 0
 It is dose dependant effective when wear more than 12 hours in a day

66. Thank you