This document discusses idiopathic scoliosis, which is defined as a spinal deformity characterized by lateral bending and fixed rotation of the spine without a known cause. It is divided into subgroups based on age of onset, including infantile, juvenile, and adolescent idiopathic scoliosis. Treatment options include observation for mild curves, bracing to prevent progression of moderate curves, and surgery to correct severe or progressive curves. Surgical techniques have advanced from Harrington instrumentation to segmental fixation with hooks and more recently pedicle screws, allowing for improved three-dimensional correction while fusion fewer vertebrae.

1. IDIOPATHIC
SCOLIOSIS

2. • Scoliosis is an apparent lateral (sideways) curvature
of the spine.
• ‘Apparent’ because, although lateral curvature does
occur  actually a triplanar deformity with lateral,
anteroposterior and rotational components (Dickson
et al., 1984).

3. General classification
• Postural scoliosis
– the deformity is secondary or compensatory to some
condition outside the spine, such as a short leg, or pelvic
tilt due to contracture of the hip.
• Structural scoliosis
– Structural scoliosis there is a non-correctable deformity of
the affected spinal segment,

6. Etiology
• Congenital scoliosis
• Idiopathic scoliosis
• Neuromuscular scoliosis

7. IDIOPATHIC SCOLIOSIS

8. • Idiopathic scoliosis is the most common type of
scoliosis.
• defined as a spinal deformity characterized by
lateral bending and fixed rotation of the spine in
the absence of any known cause
• In general, the younger the age at diagnosis, the
more likely the deformity will progress and
require treatment.

9. A lateral deviation and rotation deformity of the spine
without an identifiable cause.
Divided in to 3 sub groups based on the age onset :
1.Infantile idiopathic scoliosis ( birth to 3 years old )
2.Juvenile idiopathic scoliosis ( 4 to 10 years old )
3.Adolescent idiopathic scoliosis ( after 10 years old )
 the most common

10. infantile idiopathic scoliosis
• Common in Europe but rare in the United States (1%
of cases in United States)
• Male predominance
• Left thoracic curve pattern is most common
(vs. adolescent idiopathic scoliosis, in which right-sided thoracic curves are typical)
• Association with plagiocephaly, developmental delay,
congenital heart disease, and developmental hip
dysplasia

11. • Two types have been identified: a resolving
type (85%) and a progressive type (15%)
• distinguished by analyzing the rib-vertebral
angle difference (RVAD) and rib phase
Progressive type
– RVAD convex – concaf  >20°
– Rib phase 2

13. Treatment for
infantile idiopathic scoliosis
• Resolving curves
– observed with serial physical examinations and radiographic
monitoring.
– Sleeping in the prone position is recommended
• Progressive curves are treated with serial casting followed by
orthotic treatment with a Milwaukee brace
• Surgery : posterior spinal instrumentation without fusion or
the vertically expandable prosthetic titanium rib (VEPTR).

15. • Posterior spinal instrumentation and fusion are not
recommended due to:
– restriction of thoracic cage and lung development,
– the risk of crankshaft phenomenon
(persistent anterior spinal growth in the presence of a posterior fusion, leading
to recurrent and increasing spinal deformity).
• In extreme cases, a combined anterior and posterior
fusion procedure is an option but will limit
development of the thorax, lungs, and normal trunk
height.

16. juvenile idiopathic scoliosis
• Less common than adolescent idiopathic scoliosis (12%–16% of all
patients with idiopathic scoliosis)
• Increasing female predominance is noted with increasing age
(female-to-male ratio is 1:1 from 4–6 years and increases to 8–10:1
from 6–10 years)
• Most common curve patterns are right thoracic
• Approximately 70% of curves progress and require some forms of
treatment (bracing or surgery)
• Magnetic resonance imaging (MRI) of the entire spine (also in
infantile idiopathic scoliosis) because spinal deformity may be the
only clue to the presence of a coexistent neural axis abnormality

17. Treatment of
juvenile idiopathic scoliosis
• Orthotic treatment is initiated for curves in the 25° to 50° range.
• Surgical treatment is considered when curve magnitude exceeds 50°
• Surgical decision making is complex
(the effect of treatment on remaining growth and potential for development of
crankshaft if a single-stage posterior fusion procedure is performed)
• Combined anterior and posterior fusion with posterior instrumentation is
an option for older patients
• Innovative growth modulation techniques such as convex disc stapling are
under investigation and may offer an option for fusionless correction of
scoliosis in the future.

18. adolescent idiopathic scoliosis
• The most common type of scoliosis in children
(prevalence is 3% in the general population)
• A female predominance is noted
• Thoracic curve patterns are generally convex to the
right (atypical curve patterns are an indication for MRI)
• Idiopathic scoliosis in adolescence is not typically
associated with severe pain

19. Patient’s Evaluation
Patient history:
Includes menstrual history, birth and developmental history,
and family history of scoliosis
PHYSICAL EXAMINATION
•Height and weight assessment
•Observation (look for shoulder, thorax, or waist asymmetry)
 plumb line
•Adams forward bend test.
•Use a scoliometer to quantitate asymmetry
•Neurologic assessment.
•Upper and lower extremity assessment (include gait and leg
length evaluation)

20. RADIOGRAPHIC ASSESSMENT
• A standing posteroanterior (PA) long cassette radiograph is the
initial view obtained
• Lateral radiographs
• Side-bending radiographs (vulcrum bending x ray)
• Pelvis x ray

21. What to assessed in PA radiograph ???
• curve location,
• curve direction,
• curve magnitude,
• end vertebra,
• apical vertebra, and
• Risser sign

22. • Curve location. The curve location is defined by its apex
Curve Apex
–Cervicothoracic C7 or T1
–Thoracic Between T2 and T11–T12 disc
–Thoracolumbar T12 or L1
–Lumbar Between L1–L2 disc and L4
–Lumbosacral L5 or S1
• Curve direction. Curve direction is determined by the side
of the convexity.
• Curve magnitude. The Cobb-Lippman technique is used to
determine curve magnitude.
Perpendicular lines are drawn in relation to reference lines along the superior
endplate of the upper end vertebra and along the inferior endplate of the lower
end vertebra. The angle created by the intersection of the two perpendicular lines
is termed the Cobb angle and defines the magnitude of the curve.

23. • End vertebra. The top
and bottom vertebra that
tilt maximally into the
concavity of the curve are
termed the end vertebra.
They are typically the
least rotated and least
horizontally displaced
vertebra within the curve
• Apical vertebra. The
apical vertebra is the
central vertebra within a
curve. It is typically the
least tilted, most
rotated, and most
horizontally displaced
vertebra within a curve
Risser
stage 4 correlates with the end of spinal growth in females, and Risser stage 5 correlates with
the end of spinal growth in males

24. Nash-moe system

25. Side bending x ray
• Side-bending radiographs are used to assess the flexibility of
curves that comprise a spinal deformity
• Patient present with a combination of fixed and flexible spinal
deformities.
• Curves that correct completely when the patient bends toward the
convexity of the curve are termed nonstructural curves.
• Nonstructural curves permit the shoulders and pelvis to remain
level to the ground and permit the head to remain centered in the
midline above the pelvis.
• For this reason, nonstructural curves are also referred to as
compensatory curves.

27. King-Moe classification
• thoracic curve patterns in idiopathic scoliosis distinguishes
five curve types as a guide to surgical treatment
• The King classification does not address lumbar curves,
thoracolumbar curves, or triple major curves.
• It does not evaluate sagittal plane alignment.

28. Type 1: S-shaped curve in which both the thoracic and lumbar curves cross the midline. Both
curves are structural, and the lumbar curve may be larger or less flexible than the thoracic curve
Type 2: S-shaped curve in which the thoracic curve is larger or less flexible than the lumbar
curve (also called a “false” double major curve)
Type 3: Single thoracic curve without a structural lumbar curve
Type 4: Long thoracic curve in which L5 is centered over the sacrum and L4 is tilted into the
thoracic curve
Type 5: Double thoracic curve with T1 tilted into the convexity of the upper curve

29. Lenke Classification
• Lenke and colleagues developed a comprehensive,
practical two-dimensional classification system in
2001.
• The Lenke curve classification includes not only
thoracic curves, but also thoracolumbar/lumbar
curve patterns.
• Additionally, this classification allows the surgeon to
assess curves in coronal and sagittal planes

30. Lenke classification
• Based on assessment of PA, lateral, and side-bending
radiographs.
• Six curve types are identified
• basic steps in curve classification include:
– Determine curve type:
• Measure all curves. Identify the major curve. Determine whether the
minor curves arestructural or nonstructural (see Fig. 39-4)
– Determine the lumbar spine modifier:
• The six main curve types are subclassified as A, B, or C on relationship
ofthe center sacral vertical line (CSVL) to the lumbar spine
– Determine the thoracic sagittal modifier:
• “-”, “N”, or “1” is determined on, the T5 to T12 sagittal Cobb angleThis
triad of radiographic information (curve type 1 lumbar modifier 1 sagittal
modifier) is required to determine the curve classification (e.g. 1B1).

32. Treatment
• Objectives :
– To prevent progression
– To correct deformity
• Based on :
– Skeletal maturity : Risser stage
– Curve magnitude : Cobb’s angle
– Curve progression : observation

33. treatment options
• The three O’s
• observation, orthoses, and operation

34. observation
• The purpose of observation for adolescent
idiopathic scoliosis is to identify and
document curve progression and
• Curves less than 20° are observed

35. risk factors for curve progression
• Future growth potential of the patient (assessed by a variety of
factors, including age at presentation, Risser stage, Tanner stage,
menarche, peak height velocity, triradiate physeal closure, skeletal
age as determined by hand radiographs)
• Curve magnitude at the time of diagnosis
• Curve pattern (double curves progress more frequently than single
curves)
• Female sex (curves in females are more likely to progress than
curves in males)
• Genetic risk score (ScoliScore Prognostic Test, Axial Biotech)

36. Risk of progression
• less than 30° at maturity are least likely to progress.
• Curves 30° to 50° degrees are likely to progress an
average of 10° to 15° over the course of a normal
lifetime.
• Curves measuring 50° to 75° at maturity progress
steadily at a rate of approximately 1° per year.
• Lumbar and thoracolumbar curves are more likely to
progress than thoracic curves because they lack the
inherent stability provided by the rib cage.

37. Orthosis (Bracing)
• spinal orthosis is used to prevent curve progression and
generally does not lead to permanent curve improvement.
• successful brace treatment is the initial correction achieved
by 50% or more upon initiation of bracing
• Risser stage 0 to 1 and premenarchal with curves 20° to 29°
are candidates for immediate bracing
• Risser stage 2 patient with a curve of 20° to 29°, progression
of 5° should be documented before bracing is initiated
- Recent study :
- 25% of cases in bracing continue to progress

38. Contraindication of
brace treatment
• Skeletally mature patients
• Curves greater than 40°
• Thoracic lordosis (bracing potentiates
cardiopulmonary restriction)
• Patients unable to cope emotionally with treatment

39. Type of Brace
• CTLSO (Milwaukee brace). Used less commonly due to
its cosmetic appearance. However, for curves with an
apex above T8, it remains most efficacious
• TLSO (e.g. Boston brace). These lower-profile orthoses
are better accepted by patients and are indicated for
curves with an apex at T8 or below
• Bending brace (e.g. Charleston brace). This type of
brace holds the patient is an acutely bent position in a
direction opposite to the curve apex. It is worn only
during sleep. It has been advocated as an alternative
to full-time bracing regimens
• Flexible brace (e.g. SpineCor brace)

41. Prognosis
• Factors :
– Curve magnitude : more angulation & rotation,
progress more (>20°)
– Age : younger, progress more (<12yo)
– Risser’s score : score 0-1, progress more
– Curve length : shorter curves, progress more
– Location : higher curves, progress more
– Flexibility : stiffer curves, progress more

42. Operative / Surgery
• Objective :
• obtain a solid fusion and to have the top and the
bottom of the fusion balanced within the stable
zone
• Indication for surgery :
– <30° failed conservative treatment
– 30° - 45°, with progression
– >30° with cosmetically unaccepted in skeletal
maturity
– Balanced, double curves, if >60° and progressing
– Adult with backpain

43. • With hook constructs, it has been recommended that the
distal level be the “stable” vertebra, the one that is
intersected or bisected by the center sacral line
• the appropriate level to fix proximally is determined by the
sagittal plane as well. In the sagittal plane, the top and the
bottom of the fusion should be transitional, in an area of
relative lordosis
• Established teaching was that posterior fusion should stop
two levels above and one level below the transitional
segments
• Those levels can at times be shortened if fixation is
achieved at every level with hooks or pedicle screws and if
the “saving of levels” is compatible with the sagittal plane

44. Operative / Surgery
• Goals :
– Halting progression
– Achieve correction
– Achieve spinal balance
• Objectives :
– Reduce rotational deformity & lateral deviation
– Athrodese the primary curve

45. Operative / Surgery
Types :
• Posterior approach
• Anterior approach
• Combined posterior & anterior approach
• Video-assisted Thoracoscopic Surgery (VATS)

46. Posterior Approach
• 1960’s : Harrington system
• 1970’s : Segmental fixation
– Moe fusion technique
– Luque method
• 1980’s : Cotrel-Dubousset (CD) instrumentation
– Stronger fixation ⇒ no post-operative bracing
– Better correction in 3 dimensions (derotation)

47. Posterior Approach
• 1990’s : Pedicle screws
– Reduce the number of fusion levels ⇒ reduce the number
of junctional problems
– The Moss Miami Instrumentation System
Subroto Sapardan
– PSSW ( Pedicle Screw Sublaminary Wiring)
– University of Indonesia (UI) System

48. Harrington Instrumentation

49. LUQUE
LUQUE GALVESTON
HARRINGTON
LUQUE
WISCONSIN

50. Cotrel-Dubousset (CD) instrumentation

51. Anterior Approach
• Dwyer / Zielke :
– Disc excision followed by compression across the
disc
– The use of a solid rod & screw system
– The use of two solid rods
– Thoracoplasty : to reduce the size of the rib hump

52. DWYER
INSTRUMENTATION
ZIELKE INSTRUMENTATION

53. Video-Assisted Thoracoscopic Surgery
(VATS)
• Minimally invasive surgery
• Smaller incisions to insert a screw at each
level and a single rod

54. Video-Assisted Thoracoscopic Surgery (VATS)
Discectomy
Intervertebral Disc Removal
Endplate Removal
C-Arm Fluoroscopic View of
Vertebral Screw Insertion

55. ECIF (External Correction Internal Fixation)
FOR SCOLIOSIS

56. THANK YOU