This PowerPoint presentation covers idiopathic scoliosis, including its classification, presentation, imaging, and treatment options. It discusses the different types of scoliosis based on age of onset, curve location, and curve progression. Imaging techniques like X-rays are used to measure curve magnitude and progression over time. Treatment depends on factors like curve size, skeletal maturity, and remaining growth. Options include observation, bracing, and surgery to prevent curve progression as the patient grows.

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Idiopathic Scoliosis
By Dr. Yousef Khoja

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Out-line
• Introduction.
• Etiology.
• Classification.
• Presentation.
• Imaging.
• Treatment.
• Complication.
• Qs

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Introduction
• Greek word = crooked spine
• 3-D problem:
• Coronal plane deformity: lateral deviation >10°
(by Cobb method)
• Sagittal plane deformity: hypokyphosis or
flattening of the normal curve
• Axial plane deformity: rotation of the vertebrae
• Without an identifiable cause.

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Etiology
• Unknown, hormonal, brainstem, or
proprioception disorder.
• Recent studies hormonal factors (melatonin)
may play a significant role in the cause.
• +ve family history, Autosomal dominant but
variable expression.
• need to rule out other causes
• Congenital
• Secondary causes: inflammatory, tumor-
Osteoid osteoma, NF, leg length discrepancy
(LLD)
• Neurologic causes: tethered cord, syrinx
• Connective tissue abnormalities: Marfan's,
Ehlers-Danlos, and homocystinuria

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Classification
• 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.
• Prognostic significance:
• 90% of those diagnosed between 3-10 yrs
old progress and 70% require surgery.

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Classification
• Curve location
• Cervical (C2 through C6)
• Cervicothoracic (C7-T1)
• Thoracic (T2-T11/12 disk)
• Thoracolumbar (T12-L1)
• Lumbar (L1-2 disk through L4)
• The deformity is described as right or left
based on the direction of the apical
convexity.
• Right thoracic curves are the most common,
followed by double major (right thoracic and left
lumbar), left lumbar, and right lumbar curves

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Presentation
• History:
• Most patients will be unaware of their
scoliosis even when curves exceed 30
• Rule Out Other Causes
• Med/surg history: Neuromuscular disease
• Family hx
• LBP:
• Bowel or bladder dysfunction: neurogenic
causes such as tethered cord,
myelomeningocele, Arnold Chiari
• Other neurological complaints: leg pain,
numbness, tingling

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Presentation
• Examination:
• AAOS/SRS recommendations
• Girls: Screen twice at 10 and 12 yrs,
grades 5 and 7
• Boys: Screen once at 13 or 14 yrs, grades
8 or 9
• Adams forward-bending test
• Scoliometer: Refer if >7°
• Correlates with a Cobb angle of 20°
• Skeletally immature children with
curves greater than 20º or fully mature
adolescents with curves greater than
40º should be considered for referral to
a surgeon

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bend forward at the waist with knees straight and arms
together and hanging toward the floor, and the back parallel
to the floor. Examiner looks along the axis of the spine for
rotatory asymmetry of the trunk. A difference of 8 mm in
height between sides is considered abnormal

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Presentation
• Examination:
• leg length discrepancy
• midline skin defects
• shoulder height differences
• rib rotational deformity (rib hump)
• waist asymmetry and pelvic tilt
• cafe-au-lait spots in cases of
neurofibromatosis
• foot deformities (cavovarus indicates
neural axis abnormalities)
• asymmetric abdominal reflexes
• if present consider MRI to rule out
syringomyelia

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Imaging
• PA and lateral standing films of entire
spine
• change over time
• Measure the same vertebrae at each
visit, to determine change
• Also look at whether the worst levels
have changed and measure change in
worst curve

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Imaging
• Coronal View (PA)
• Cobb angle
• Central sacral vertebral line (CSVL).
• Apical vertebral translation (AVT).
• Neutral vertebrae (NV).
• Stable Vertebrae (SV).
• Pelvic obliquity.

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Imaging
• Coronal View (PA)
• Cobb angle :
• Angle between lines drawn on endplates of
the end vertebrae, > 10 as scoliosis
• Intraobserver variability: +/- 3-6°

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Imaging
• Coronal View (PA)
• Central sacral vertebral line (CSVL)
• line drawn straight up from middle of
sacrum

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Imaging
• Coronal View (PA)
• Apical vertebral translation (AVT)
• how much the apex of the curve has
translated from the CSVL.

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Imaging
• Coronal View (PA)
• Neutral vertebrae (NV)
• no rotation (pedicles appear symmetric)

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Imaging
• Coronal View (PA)
• Stable Vertebrae (SV)
• inferior vertebrae most closely bisected by
CSVL and in between Harrington’s stable
lines

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Imaging
• Coronal View (PA)
• Pelvic obliquity.

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Imaging
• Coronal View (PA)

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Imaging
• Sagittal Plane
• Normal curve in pediatric population
• Cervical lordosis: 40 +/- 10
• Thoracic kyphosis: 44° +/- 11 (T4-T12)
• Lumbar lordosis: 48° +/- 12 (L1-L5)
• Scoliosis
• Thoracic hypokyphosis
• Thoracic kyphosis in scoliosis can change
by curve type (higher average in lumbar
curves), but overall average is 23° +/-12

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Imaging
• Rotational Deformity
• The larger the prominence on Adams forward
bend test, the more rotational deformity
• if there isn’t any rotation, it’s probably not
idiopathic

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Imaging
• Structural vs. nonstructural curves:
• Select proper fusion levels;
• larger curve usually structural curve;
• less flexible curve usually structural curve;
• structural curves displaced away from the
midline on the convex side where as non
structural curves e displaced away from the
midline on the concave side;
• non structural curves usually do not show
significant malrotation;

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Imaging
• MRI:
• rule out intraspinal anomalies (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)
• asymmetric abdominal reflexes

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Treatment
• Differ according to type of IS:
• observation, bracing, and surgery.

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Adolescent IS
• 10:1 female to male ratio for curves > 30
degrees.
• Right thoracic curve most common
• Classification:
• King-Moe: original classification of curves
• Lenke: most commonly used now, need PA
bending films and lateral to classify
• Lenke 1 - single thoracic
• Lenke 2 - double thoracic Lenke 3 - double
major with thoracic
• Lenke 4 - triple major
• Lenke 5 - thoracolumbar/lumbar curve
• Lenke 6 - double major with lumbar > thoracic

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Adolescent IS
• Predicting Progression:
• Sex: females
• Curve type:
• larger curves vs. smaller curves,
• Thoracic and double primary curves vs.
single lumbar or thoracolumbar curves.
• Curve rotation: the more rotation, the more
likely it is to progress
• Remaining growth at presentation: scoliosis
worsens with growth,
• Peak Height Velocity (PHV): the time
during which a child grows the most in
height generally occurs before Risser
grade 1.
• Curve is less likely to progress significantly
if past PHV

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Adolescent IS
• Predicting Progression:
• Physiologic age
• Based on menarche & Risser status
• Pre-menarchal/Risser 0 and >20°-68%
• Risser 2-4 and >20° -23% (15)
• 2/3 of curves > 50° at maturity will progress
at 1°/yr and cause pain and deformity
• decreased pulm function if >70°

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Ossification of the iliac apophysis starts at the anterior
superior iliac spine and progresses posteromedially. The
iliac crest is divided into quadrants, and the stage of
maturity is designated as the number of ossified quadrants.

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Adolescent IS
• Treatment:
• Based on skeletal maturity of patient,
magnitude of deformity, and curve progression
• Observation
• Immature < 20°-every 3-6 mos (more
frequently around PHV)
• Mature < 60° (if well-balanced, no
progression or complaints)
• Brace
• Immature 20°-30° if progress > 5°-10°
• Immature 30°-45°
• Surgery
• Immature > 45°
• Mature > 60°

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Adolescent IS
• Treatment:
• bracing
• only effective in flexible deformity in
skeletally immature patient
• can prevent curve progression but cannot
correct
• brace types
• curves with apex above T7
• Milwaukee brace (extends to neck) for
apex above T7 (Compliance worse)
• apex at T8 or below
• TLSO
• Boston-style brace (under arm)
• Charleston Bending brace is a curved
night brace

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Milwaukee brace

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TLSO

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Boston-style brace

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Charleston Bending brace

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Adolescent IS
• Treatment:
• Surgery:
• somatosensory-evoked potentials is gold
standard
• Fusion level selection
• Harrington: one level above and two
levels below the end vertebrae if these
levels fall wilthin the stable zone
• Moe: fusion to the neutral vertebrae
• Cochran: increase incidence of low
back pain with fusion to L5, and to a
lesser extent L4. avoid fusion to L4 & L5
• it is almost never required to fuse to the
pelvis in idiopathic scoliosis

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Adolescent IS
• Treatment:
• Surgery:
• When? Not too early, because of
• Growth of spinal height 5 cm/yr until
puberty and then up to 8 cm/yr during
PHV
• Crankshaft phenomenon: If the spine
is fused posteriorly too early, the
anterior spine continues to grow and
causes increased torsion and curvature
of the spine. This is less likely with
pedicle screws because they stabilize 3
columns of the spine

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Adolescent IS
• Treatment:
• Surgery:
• ASF with instrumentation
• for thoracolumbar and lumbar cases
• advantage is better correction while
saving lumbar fusion levels
• decrease pulmonary function with
thoracotomy
• PSF with instrumentation
• remains gold standard for thoracic and
double major curves (most cases)
• ASF/PSF with instrumentation
• curve > 75 degrees
• young age (Risser grade 0, girls <10
yrs, boys < 13 yrs)

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Juvenile IS
• Right-sided thoracic curves most common
• Progression in up to 90%
• Spinal fusion likely required if bracing doesn’t halt
curve
• High incidence of cord abnormalities (18-20%)
syringomyelia or Arnold-Chiari syndrome … need
MRI.
• presentation and treatment similar to adolescent IS.
• Fusion should be delayed until the onset of the
adolescent growth spurt if possible (unless curve
magnitude is > 50 degrees).
• Non-fusion procedures
• growing rods
• VEPTR

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Infantile IS
• Growth velocity of the T1-L5 segment is fastest in
the first 5 years of life, with the height of the thoracic
spine doubling between birth and skeletal maturity.
• Most with L-sided thoracic curves
• Plagiocephaly is common association
• Recommend MRI if curve >20° on presentation

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Infantile IS
• Mehta’s Radiographic Measurements to Predict
Curve Progression:
• Phase 1: rib head on each side of the apical
vertebra does not overlap the vertebral body →
measure RVAD
• Phase 2: rib head overlaps vertebral body on
convex side of curve → progression of curve is
certain and no need to measure RVAD
• Rib-Vertebral Angle Difference (RVAD)- line drawn
perpendicular to end-plate of apical vertebrae and
along center of rib. Calculate RVAD by subtracting
the angle formed by the 2 lines on the convex side
from the concave side
• < 20° → 83% resolve
• > 20°→ 84% progress

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Infantile IS
• Treatment:
• Nonoperative
• observation alone
• Cobb < 25 degrees
• RVAD < 20 degrees
• 90% will resolve spontaneously
• casting and bracing
• Cobb < 35
• RVAD > 20 degrees

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Infantile IS
• Treatment:
• Operative
• surgical deformity correction (growing rod
construct vs ASF&PSF)
• Cobb > 35 to 40 degrees
• techniques
• VEPTR & growing rods
• ASF& PSF

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Complications
• Crankshaft phenomenon
• Short-term postoperative complications.
• superior mesenteric artery syndrome:
• extrinsic compression of the third part of
the duodenum from the superior
mesenteric artery and aorta
• Symptom similar to small bowel
obstruction
• generally respond to NG suction and IV
fluids
• Neurologic injury occurs in up to 0.7% of
patients as a result of compressive, tensile,
or vascular phenomenon

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Complications
• Infections occur in up to 5% of patients.
• Early infection (<6 months after surgery)
• Chronic deep infections of spinal
implants
• P. Acnes most common organism for
delayed infection
• Implant failure and pseudarthrosis
• most common at the L3-L4 level
• low back pain
• early fatigability and back pain
• treat with revision surgery with posterior
closing wedge osteotomies

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Complications
• Vision Loss
• Prevalence of blindness ~ 0.2%.
• Not seen in <10 yr old
• Ischemic optic neuropathy
• prolonged procedures (> 6 hr), have
substantial blood loss (>1000 ml), or both.
• No association with controlled hypotension.
• No apparent transfusion threshold that is
preventative
• Heads should be level or higher than the heart.
• No direct pressure on the eyes. However cases
have been reported where head was supported
by pins.
Anesthesiology - 01-JUN-2006; 104(6): 1319-28
Practice Advisory for Perioperative Visual Loss Associated with Spine Surgery: A Report by
the American Society of Anesthesiologists Task Force on Perioperative Blindness

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Q1
• A 12-year-old female presents with a left
thoracic rib prominence. Physical exam
shows absent abdominal reflexes in the
upper and lower quadrants on the left side.
Radiographs show a 24 degree left thoracic
curve.

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Q1
• What is the next step in management?
1. observation with repeat radiographs in
6 months
2. bracing with a thoraco-lumbar-sacral
orthosis
3. magnetic resonance imaging (MRI)
4. posterior spinal fusion with
instrumentation
5. anterior and posterior spinal fusion with
instrumentation

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Q2
• In the treatment of thoracolumbar idiopathic
scoliosis using an anterior single rod
technique with interbody cages, which of
the following variables has been associated
with pseudoarthrosis:
1. Thoracic curve coronal correction of > 40%
2. Thoracolumbar/lumbar curve coronal correction
> 50%
3. Smaller adolescents (<50 kg)
4. Failure to maintain lumbar lordosis of > 45
degrees
5. Thoracic hyperkyphosis (>40 degrees )

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Q3
• A 14-year-old girl has adolescent idiopathic
scoliosis. Her parents would like to know
what kind of problems she will have
compared to her peers who do not have
scoliosis. You should inform them that she
will have:
1. difficulty with pregnancy in the future.
2. decreased pulmonary function regardless of
the severity of scoliosis.
3. limitations in athletic participation.
4. more acute or chronic back pain.
5. increased risk of developing cancer.

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Q4
• When compared to normal controls, adults
with untreated idiopathic scoliosis have a
higher rate of?
1. acute and chronic back pain
2. premature death
3. disability
4. clinical depression
5. limitation in activities of daily living

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Case #1
MP is a 16-year-old male who presents to your office for
his annual health assessment and sports physical.
During the course of his examination, you note a mild
convexity in the thoracic region of his spine with forward
flexion at the hips.
Based on your clinical examination, you estimate a
lateral spinal curvature of about 5 degrees.
You note these findings to the patient and then to his
mother.

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Question 1
1.
Which one of the following p
Recommend back-strength
Refuse to permit participatio
Order a radiograph of the b
curvature
Monitor the pa
Refer for ortho

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Answer 1
The answer is D: monitor the patien
conditio

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Question 2
Because you have recen
physician in the district wh
wonder what scoliosis screeni
who has been examining these
Which one of the following proc

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Question 2 (cont.)
.AArrange scoliosis screening for all students
between 10 and 16 years of age.
B.Arrange scoliosis screening for all students
10, 12 , 14 and 16 years of age.
C.Contact the school nurse and review skills for
scoliosis screening procedures.
.DVisually inspect for severe curves only when
the back is examined for other reasons.
.EScreen girls for scoliosis at 11 and 13 years of
age and boys at 13 and 15 years of age.

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Answer 2
•According to AAP the answer is B: screen at
10, 12, 14 &
16 years
•According to U.S. Prev Services Task Force,
the answer is D:
visually inspect for severe curves only when
the back is

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Question 3
Which of the following statement(
.AExercise therapy has been shown to be an effective
treatment for preventing progression of scoliosis.
B.Spinal surgery for scoliosis is not supported by
studies showing improvements in clinical outcomes,
such as decreased back pain and increased
functional status.
C.Lateral electrical surface stimulation for eight hours
nightly can limit progression of spinal curvature
D.Back bracing (e.g., orthoses) reduces symptoms of
low back pain.

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Answer 3
The answer is B: Although surgery for scoliosis is
generally not recommended without marked
curvature, well-conducted outcomes studies with
patients who have had surgery have not been
completed. Symptoms of back pain do not appear
to correlate with magnitude of surgical correction.