Idiopathic scoliosis

1. Idiopathic Scoliosis
By
Dr. Ali Al-Shehri

2. Idiopathic Scoliosis
• Overview.
• Definition: A lateral deviation and rotation deformity of
the spine without an identifiable cause.
• prevalence of scoliosis:
• - 10 deg curve is considered to be the threshold for
scoliosis;
• - curves > 10 deg occur in 2.5/100; (1.9-3%)
• - curves > 20 deg occur in about 1/2500
• - increased prevalence in females for larger,
progressive curves.

3. Idiopathic Scoliosis
• Overview .
• genetics:
- women with a scoliotic curve greater
than 15 deg have a 27 % prevalence of
scoliosis among their daughters.
- 11 % of first-degree relatives are affected,
as are 2.4 and 1.4 percent of second and third-
degree relatives.

4. Idiopathic Scoliosis
• Overview
• Etiology:
The precise etiology of idiopathic scoliosis remains
unknown, but several intriguing research avenues exist.
The contractile proteins of platelets ,
and calmodulin
abnormal fibrillin metabolism It is fair to say that
Disorganized skeletal growth no final answer is
melatonin yet available.

5. Definitions
• End vertebra: the top and
bottom vertebra that tilted
maximally into the concavity
of the curve, least rotated,
least horizontally displaced
vertebra within the curve
• .
• Apical vertebra: the central
within the curve, the least
tilted, most rotated, most
horizontally displaced.
• Neutral vertebra: first non
rotated vertebra at the
caudal and cranial ends.
• Stable vertebra: the
vertebra bisected by the
CSVL.

6. Definitions
• Rib-vertebra angle-
difference (RVAD

7. Idiopathic Scoliosis
• Presentation
The vast majority of patients initially present
due to perceived deformity. This may be patient
or family perception of asymmetry about the
shoulders, waist, or rib cage.

8. Idiopathic Scoliosis
• How do you approach the
patient?

9. Idiopathic Scoliosis
• History:
-age 
Infantile < 3 , juvenile 3-10 adolecent >10
- deformity
-physiologic maturity  menarche
- presence or absence of pain
- family members

10. Idiopathic Scoliosis
• Physical examination
– Neurologic examination of the lower extremities
(sensory examination, motor examination, and
reflexes).
– examine skin for
cafe-au-lait spot( neurofibromatosis)
– Lower extremity evaluation should rule out cavovarus
feet (associated with neural axis abnormalities) and
document normal strength, gait, and coordination.

11. Idiopathic Scoliosis
Physical examination
– Hairy patches, dimples, nevi, or tumors over the
spine may be indicative of spinal dysraphism.
– Dimples outside the gluteal fold are generally
benign.
– Asymmetric abdominal reflexes are associated
with a syrinx and are an indication for MRI of the
spine.

12. Idiopathic Scoliosis
Physical examination:
-magnitude of curve and rib humb while
standing and leaning forward.
- asymmetrical shoulder levels.

13. • Physical examination:
– physiological age

14. Idiopathic Scoliosis
• Radiographic
evaluation
• PA and lateral upright
(weight-bearing) views
(36-inch cassette)
should be obtained.
• Bending or traction
films are useful for
surgical planning.

15. Idiopathic Scoliosis
• MRI of spine
• MRI R/O (tethered cord, syringomyelia,
dysraphism, and spinal cord tumor).
• Indications
– Atypical curve patterns (eg, left thoracic curve, short
angular curves, absence of apical thoracic lordosis,
absence of rotation and congenital scoliosis)
– Patients <10 years of age with a curve >20°
– Abnormal neurologic finding on examination,
abnormal pain, rapid progression of curve (>1°/mo)

16. Natural History
• Note that most patients will be unaware of
their scoliosis even when curves exceed 30
deg.
• Progression is related to size of curve, area of
spine involved, & physiologic age of child
• Thoracic curves >50° and lumbar curves
>40° have been shown to progress up to a
mean of 1°/year after skeletal maturity.

17. Natural History
• Red flag:
– Left side curve (juvenile adolescent)
– Abnormal neurological exam
– Abnormal skin finding
– Foot or other dformity

18. Classification
• 1- Age:
- Infantile (<3 years of age) represents 4% of IS
cases.
- Juvenile (3 to 10 years of age) represents
15% of IS cases.
- Adolescent (>10 years of age) represents
80% of IS cases. Prevalence: 2% to 3% for
curves 10° to 20°, 0.3% for curves >30°.

19. Classification
• Infantile IS
a. Male to female ratio is 1:1.
b. the most common curve location is the thoracic
spine; 75% of curves are left convex.
c. Risk of progression overall is 10%. Curves with
(RVAD) angle, >20°

20. Classification
• Juvenile IS
a. Incidence is higher in females than in males.
b. Right thoracic curves are most common.
c. Spontaneous resolution is uncommon.
d. Curves with RVAD >20° increase risk of
progression.
e. 95% of curves will progress.
f. Incidence of neural axis abnormalities is 20% to
25%; hence MRI is necessary.

21. Classification
• Adolescent IS
• a- female to male ratio is 1:1 for small curves but
increases to 10:1 for curves >30°.
• Risk of progression is related to curve size and
remaining skeletal growth, which is assessed by
Tanner stage, Risser grade, age of menarche, and
presence of open triradiate cartilages.

22. Classification
• Adolescent IS
• Girls at greatest risk for progression are premenarchal,
Risser grade 0, Tanner stage <3, and have open triradiate
cartilage.
• Peak height velocity (fastest growth) generally occurs
before Risser grade 1.
• Peak height velocity in adolescence is approximately 10
cm/year and occurs just before the onset of menses in
girls.
• If the curve is >30° at peak height velocity, the curve is
likely to require surgery.

23. Classification
• Surgical classification of adolescent idiopathic
scoliosis:
- King-Moe
- Lenke

24. Important definition
• Major curve: large cobb angle, and it is a
structural.
• minor curve: could be structural or non structural.
• Structural curve: inflexibility on side bending > 25
(in coronal plan). hyperkyphosis >20 of PT(T2-T5)
or TL/L (T10-L2) in sagittal plan.
• Non structural curve: compensatory curve.
• Stable zone: within parallel lines drawn vertically
up from the lumbosacral facet joint.

25. King-Moe

26. Lenke
• Consist of triad system:
1. Curve type (1 through 6).
2. Lumbar spine modifier (A, B, and C).
3. Sagittal thoracic modifier( _, N, and +).

27. Lenke classification
• The curve apex is
defined as follows for
localization purposes:
• Upper thoracic Th2 and
Th6
• Thoracic : Th6 and
intervertebral disc Th11/12
• Thoracolumbar : Th12
and L1
• Lumbar: intervertebral
disc L1/2 and L4

28. Lenke classification

29. Lenke
NS: non structural
S : structural
a : major curve

30. Type 1- MT
• Posterior thoracic
instrumentation and fusion
is the gold standard.

31. Type 2- DT
General role is fusion of
both curve.

32. Lenke
NS: non structural
S : structural
a : major curve

33. Type 3- DM
General role is posterior
treatment with segmental
instrumentation and fusion.

34. Type4-TM

35. Lenke
• Lumbar spine modifier:
• It is the relation of the lumbar apex to the CSVL.
1. A : CSVL fall between the pedicles.
2. B : CSVL touch the apex of the lumbar curve.
3. C : CSVL is medial to the apex of the lumbar curve

36. Lenke
• Sagittal thoracic modifier:
• Based on T5 to T10 sagittal alignment.
Thoracic sagittal profile
T5 – T12
<10Hypokyphotic_
10-40NormalN
>40hyperkyphotic+

38. Treatment
• Remember 3 Os:
• Observation non surgical
• Orthosis
• Operative treatment

39. Treatment
• Recommendations are based on the natural
history of scoliosis.
• Nonsurgical:
• 1-Infantile: Patients with RVAD >20°, phase
2 rib-vertebrae relationship, and Cobb angle
>30° are at high risk of progression , so it is
reasonable not to brace until a curve reaches
30°.

40. Treatment
• Bracing:
1- Bracing is usually started for juveniles with
curves >20° and adolescents >25°; smaller
curves are treated with observation.
2- Bracing is used for skeletally immature
patients (Risser 0, 1, or 2). Recommended for 16
to 23 h/day and continued until completion of
skeletal growth or curve progression to >45° (at
which point bracing is no longer considered
effective

41. • Bracing:
3- Thoracic hypokyphosis
is relative contraindication
for bracing.
4- An underarm brace, or
thoracolumbosacral orthosis
(TLSO), is most effective
when the curve apex is at T7
or below

42. Treatment
• Bracing:
• The efficacy of brace treatment is
controversial.

43. Treatment
• Surgical
• Indication 
 Infantile/juvenile—Cobb >50° to 60°.
 Adolescent—Thoracic curves >45° to
50°. Lumbar curves >45° or marked trunk
imbalance with curve >40° (relative)

44. Treatment
• Surgical
• Contraindications 
Patients with active infections
Poor skin at surgical site
 Inability to adhere to postoperative activity
limitation
Significant concomitant medical
comorbidities

45. Treatment
• Surgical
• Procedures
• Infantile/juvenile—Dual
growing rod constructs
can permit growth of
affected spine up to 5.0
cm over the
instrumented levels.

46. Treatment
• Procedures
• Adolescent 
- Both anterior and posterior fusions .
• - Anterior release addition to posterior fusion
for large (>70° to 80°), stiff (<50% flexibility
index) curves but may not be necessary with
newer generation spinal implants

47. Treatment
• Procedures
• in Risser 0 patients with
open triradiate cartilage
, anterior diskectomy
and fusion has been
recommended to avoid
the crankshaft
phenomenon

48. complications
• 1- short term post op
• ileus
• atelectasis
•  pneumonia
•  superior mesenteric artery syndrom
syndrome which refers to extrinsic
compression of the third part of the duodenum
from the superior mesenteric artery and aorta;

50. complications
2. Crankshaft
phenomenon
- progression of spine
deformity after a solid
posterior fusion due to
continued anterior spinal
growth
-

51. complications
• 3. infection :
up to 5%
early ( < 6month) : I&D , i.v Abx keep implant
chronic deep :I&D, i.v Abx remove implant

52. complications
• 4- Implant failur and pseudarthrosis -> 3%
• 5-Neurological inj.  0.7%
• Current recommendation intra OP spinal
cord monitoring of (SSEPs) and (MEPs)

53. complications
• (SSEPs) and (MEPs) suggest inj 
– Technical (electrodes- anesthesia)
– Real
»Revers or loosen the correction
»Raise BP
»Give blood
»Give steroid (30mg/Kg & 6.5mg/Kg)
» all failed remove instru.

54. complications
• 6- dicrease pulmonary function:
• Anterior fusion and posterior
thoracoplasty

55. Summery