This document discusses scoliosis, including: 1) It defines scoliosis as a lateral deviation of the spine associated with vertebral rotation. 2) It lists factors to assess in a patient history and exam findings that can indicate scoliosis. 3) It describes different types of scoliosis like idiopathic, congenital, and neuromuscular and treatments depending on the patient's age and curve severity/risk of progression.

1. Dr. Ahmed Al Issa

2.  Scoliosis is defined as a lateral deviation of
the normal vertical line of the spine
associated with vertebra rotation.

3. ◦ Age, Sex,
◦ Perinatal Hx (Pregnancy, presentation, delivery
method, and apgars)
◦ Developmental Hx (growth ht/wt, milestones)
◦ Menerach
◦ Activities
◦ Pain
◦ Notice the deformity

4. ◦ Cardiac and pulmonary symptoms
◦ Bowel and bladder symptoms
◦ Past Medical History, Surgical history Medications
and Allergies
◦ Family history
◦ Hx of treatment

5.  Adams forward bending test
 Forward bending sitting test
◦ can eliminate leg length inequality as cause of scoliosis
 Leg length inequality
 Midline skin defects (hairy patches, dimples, nevi)
 Shoulder height differences
 Truncal shift
 Rib rotational deformity (rib prominence)
 Waist asymmetry and pelvic tilt
 Cafe-au-lait spots (neurofibromatosis)
 Foot deformities (cavovarus)
 Asymmetric abdominal reflexes

6.  Cobb angle
◦ End vertebra are the most superior and inferior
vertebra which are least displaced and rotated
and have the maximally tilted end plate.
 Spinal balance
◦ coronal balance is determined by alignment of C7
plumb line to central sacral vertical line
◦ sagittal balance is based on C7 plumb from
center of C7 to the posterior-superior corner of
S1

7. • Apical vertebrae
• The most laterally displaced, direction of displacment is
considered direction of curve
• Stable zone
• Between lines drawn vertically from lumbosacral facet
joints
• Stable vertebrae
 Most proximal vertebrae that is most closely bisected by
central sacral vertical line
◦ Neutral vertebrae
 Rotationally neutral (spinous process equal distance to
pedicles on AP xray)

8.  Idiopathic
◦ Infantile
◦ Juvenile
◦ Adolescent
 Congenital
 Neruomascular (Cerebral palsy)
 Syndromes related (Marfan syndrome)

9.  Age: < 3 years
 Left curve more common
 Boys > Girls
 Plagiocephaly, intellectual impariment, hernias,
DDH and heart diease.
 Nerual axis abnormalites (syrinx, brainstem tumor,
chiari malformation, tetherd cord)
 Self limiting (70% to 90%)

10.  Imaging
◦ Xray
 Cobb angle
 Rib Vertebrae Angle Difference (RVAD, Mehta angle)
 angle between the endplate and rib, compare both
sides (a measure of rotation)
 > 20 degrees linked to high rate of progression
 < 20 degrees associated with spontaneous recovery
 rib-vertebra overlap indicates progression

11.  Imaging
◦ MRI
 to rule out tether, cyst, or tumor, synrinx (20% incidence)

12.  Treatment
◦ Observation
 Cobb < 25 degrees
 RVAD < 20 degrees
◦ Casting and bracing
 Cobb < 35
 RVAD > 20 degrees

13.  Treatment
◦ Surgical
 Cobb > 35 to 40 degrees
 VEPTR & growing rods
 ASF & PSF (cant do PSF alone due to crankshaft phenomen)

14.  Age: 3 – 10
 Right thoracic curve
 Boys = girls ( later girls > boys )
 Neural axis abnormality
 High risk progression

15.  Imaging
◦ Xray
 Cobb angle
◦ MRI

16.  Treatment
◦ observation
 curves < 20°
 frequent radiographs to observe for curve progression
◦ bracing
 curves 20 - 50°
 designed to prevent curve progression, not correct the
curve
 contraindication to bracing is thoracic hypokyphosis
 16-23h/day until skeletal growth completed or surgery
indicated

17.  Treatment
◦ Surgical
 non-fusion procedures (growing rods, VEPTR)
 curves > 50° in small children with significant growth
remaining
 allows continued spinal growth over unfused segments
 definitive PSF +/- ASF performed when the child has
grown and is closer skeletal maturity

18.  Treatment
◦ Surgical
 anterior / posterior spinal fusion
 curves > 50° in younger patients
 required in order to prevent crankshaft phenomenon
 posterior spinal fusion
 curve > 50° in older patients near skeletal maturity
 remains gold standard for thoracic and double major
curves (most cases)
 anterior spinal fusion
 curve > 50°
 best for thoracolumbar and lumbar cases with a normal
sagittal profile

19.  Age: > 10 years till skeletal maturity
 Most common
 Right thoracic curve
 Girls > boys
 Three dimensional deformity of the spine
with lateral curvature plus rotation of the
vertebral bodies

20.  Causes
◦ Unknown
◦ Genetic factors
◦ Neurological disorders
◦ Hormonal and metabolic dysfunction
◦ Skeletal growth
◦ Biomechanical factors
◦ Environmental and lifestyle factors.

21.  Prognosis
◦ increased incidence of acute and chronic pain in
adults if left untreated
◦ curves > 90° are associated with cardiopulmonary
dysfunction, early death, pain, and decreased self
image

22.  Risk factors for progression (at presentation)
◦ Curve magnitude
◦ Remaining skeletal growth
◦ Curve type

23. • Curve magnitude
 before skeletal maturity
 > 25° before skeletal maturity will continue to progress
 after skeletal maturity
 > 50° thoracic curve will progress 1-2° / year
 > 40° lumbar curve will progress 1-2° / year

24. • Remaining skeletal growth
 Younger age
 < 12 years at presentation
 Tanner stage (< 3 for females)
 Risser Stage (0-1)
 Open triradiate cartilage
 Peak growth velocity
 is the best predictor of curve progression
 in females it occurs just before menarche and before Risser 1
(girls usually reach skeletal maturity 1.5 yrs after menarche)
 most closely correlates with the Tanner-Whitehouse III RUS
method of skeletal maturity determination
 if curve is >30° before peak height velocity there is a strong
likelihood of the need for surgery

25. • Curve type
 Thoracic more likely to progress than lumber
 Double curves more likely to progress than single
curves

26.  Treatment
◦ observation alone
 cobb angle < 25°
 obtain serial radiographs to monitor for progression
◦ bracing
 cobb angle from 25° to 45°
 only effective for flexible deformity in skeletally immature patient
(Risser 0, 1, 2)
 goal is to stop progression, not to correct deformity
◦ outcomes
 poor prognosis with brace treatment associated with poor in-
brace correction
 hypokyphosis (relative contraindication)
 male
 obese
 noncompliant (effectiveness is dose related)

27.  Treatment
◦ posterior spinal fusion
 cobb angle > 45°
 can be used for all types of idiopathic scoliosis
 remains gold standard for thoracic and double major
curves (most cases)
◦ anterior spinal fusion
 best for thoracolumbar and lumbar cases with a normal
sagittal profile
◦ anterior / posterior spinal fusion
 larges curves (> 75°) or stiff curves
 young age (Risser grade 0, girls <10 yrs, boys < 13 yrs)
 in order to prevent crankshaft phenomenon

28. Thank you