Scoliosis Scoliosis What is it? How do we screen for it? When to refer? How is it treated? What is scoliosis? Lateral curvature of the spine >10 accompanied by vertebral rotation Idiopathic scoliosis - Multigene
dominant condition with variable phenotypic expression & no clear cause Multiple causes exist for secondary scoliosis Secondary causes for scoliosis: Inherited connective tissue disorders - Ehlers Danlos syndrome - Marfan syndrome - Homocystinuria
Secondary causes for scoliosis: Neurologic disorders Tethered cord syndrome Syringomyelia Spinal tumor Neurofibromatosi s Muscular dystrophy Cerebral palsy
Polio Friedeichs ataxia Familial dysautonomia Werdnig-Hoffman disease Secondary causes for scoliosis: Musculoskeletal disorders Leg length discrepancy Developmental hip dysplasia
Osteogenesis imperfecta Klippel-Feil syndrome Characteristics of idiopathic scoliosis: Present in 2 - 4% of kids aged 10 16 years Ratio of girls to boys with small curves (<10) is equal, but for curves >30 the ratio is 10:1 Scoliosis tends to progress more often in girls (so girls with scoliosis
are more likely to require treatment) Natural history of scoliosis Of adolescents diagnosed with scoliosis, only 10% have curve progression requiring medical intervention Three main determinants of curve progression are: (1) Patient gender (2) Future growth potential (3) Curve magnitude at time of diagnosis
Natural history of scoliosis Assessing future growth potential using Tanner staging: Tanner stages 2-3 (just after onset of pubertal growth) are the stages of maximal scoliosis progression Natural history of scoliosis
Assessing growth potential using Risser grading: - Measures progress of bony fusion of iliac apophysis - Ranges from zero (no ossification) to 5 (complete bony fusion of the apophysis) - The lower the grade, the higher the potential for progression Risk of Curve Progression
Curve (degree) Growth potential (Risser grade) Risk 10 to 19 10 to 19 20 to 29 20 to 29 >29 >29
Limited (2 to 4) High (0 to 1) Limited (2 to 4) High (0 to 1) Limited (2 to 4) High (0 to 1) Low Moderate Low/mod High
High Very high . *Low risk = 5 to 15 percent; moderate risk = 15 to 40 percent; high risk = 40 to 70 percent; very high risk = 70 to 90 percent. Natural history of scoliosis Back pain not significantly higher in pts with scoliosis Curves in untreated adolescents with curves <
30 at time of bony maturity are unlikely to progress Curves >50 at maturity progress 1 per year Up to 19% of females with curves >40 have significant psychological illness Life-threatening effects on pulmonary function do not occur until curve is >100 (ie: Cor pulmonale) Scoliosis Screening In years past, widespread school-based screening led to many unnecessary
referrals of adolescents with minimal curvatures U.S. Preventive Services Task Force notes insufficient evidence to recommend for or against routine screening of asymptomatic adolescents for idiopathic scoliosis Scoliosis Screening Recommendations American Academy of Orthopedic Surgeons - Screen girls at ages 11 and 13
- Screen boys once at age 13 or 14 American Academy of Pediatrics - Screen at 10, 12, 14 and 16 years Adams forward bend test For this test, the patient is asked to lean forward with his or her feet together and bend 90 degrees at the waist. The examiner can then easily view from this angle any asymmetry of the trunk or any abnormal spinal curvatures.
Screening hints: Shoulders are different heights one shoulder blade is more prominent than the other Head is not centered directly above the pelvis Appearance of a raised, prominent hip Rib cages are at different heights Uneven waist Changes in look or texture of skin overlying the spine (dimples, hairy patches, color changes) Leaning of entire body to one side
Scoliometer The patient bends over, arms dangling and palmsmeasures distortions of th nclinometer (Scoliometer) pressed together, until a curve can be observed in the upper back (thoracic area). The Scoliometer is
placed on the back and measures the apex (the highest point) of the upper back curve. The patient continues bending until the curve can be seen in the lower back (lumbar area). The apex of this curve is also Red flags on PE: Left-sided thoracic curvature
Pain Significant stiffness Abnormal neurologic findings Stigmata of other clinical syndromes associated with curvature Measure spinal curvature using Cobb method: - Choose the most tilted
verterbrae above & below apex of the curve. - Angle b/t intersecting lines drawn perpendicular to the top of the superior vertebrae and bottom of the inferior vertebrae is the Cobb angle. Referral Guidelines & Treatment
Curve (degrees) Risser grade X-ray/refer Treatment 10 to 19 10 to 19 20 to 29
0 to 1 2 to 4 0 to 1 20 to 29 2 to 4 Observe Observe Brace after 25
degrees Observe or brace 29 to 40 29 to 40 >40 0 to 1 2 to 4 0 to 4 Every 6 months/no
Every 6 months/no Every 6 months/yes Every 6 months/yes Refer Refer Refer Brace Brace Surgery
Brace Treatment for Scoliosis Most common is Boston brace (aka Thoraco-lumbar-sacral orthosis) Braces have 74% success rate at halting curve progression (while worn) Bracing does not correct scoliosis, but may prevent serious progression Usually worn until patient
reaches Risser grade 4 or 5 Brace Treatment for Scoliosis Of patients with 20 - 29 curves, only 40% of those wearing braces ultimately required surgery, compared to 68% of those not wearing back braces Length of wearing time correlates with outcome (At least 16 hrs per day leads
to best chance of preventing curve progression) Surgical Treatment for Scoliosis Curves in growing children greater than 40 require a spinal fusion (Risser grade 0 to 1 in girls and Risser 2 or 3 in boys) Skeletally mature patients can be observed until their curves reach 50 Posterior spinal fusion is best choice for thoracic curves
Anterior spinal fusion is best treatment for thoracolumbar and lumbar curves Surgical Treatment for Scoliosis Spinal surgery with instrumentation significantly corrects deformity & usually stops curve progression Surgery is accompanied by spinal cord monitoring using somatosensory & motor-evoked potentials (risk of neurologic injury is 1/7000)
Post-Op Treatment & Long Term Consequences of Spinal Fusion If segmental instrumentation used, no post-op cast or brace required Post-fusion back pain does occur and is more common in distal spinal fusions Usually out of hospital in 4-5 days & back at school in 2 wks OK to participate in athletics after 9 12 months (should avoid contact sports)
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.
Question 1 Which one of the following procedure implemented next? A. Recommend back-strengthening e B. Refuse to permit participation in c C.Order a radiograph of the back to q curvature (e.g., Cobb angle). D. Monitor the patient's condition. E.Refer for orthopedic consultation.
Answer 1 The answer is D: monitor the patient' condition. Question 2 Because you have recently agreed to serve physician in the district where your office is wonder what scoliosis screening programs who has been examining these school child
Which one of the following procedures shou Question 2 (cont.) A. Arrange 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.
D. Visually inspect for severe curves only when the back is examined for other reasons. E. Screen girls for scoliosis at 11 and 13 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 Question 3 Which of the following statement(s) about treatm scoliosis is/are correct? A. Exercise 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 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. Conclusions Screening for scoliosis remains controversial & has led to many unnecessary referrals Adolescent scoliosis can be followed by family docs if the curve has a low risk of progression & underlying causes have been excluded Curves demonstrating significant progression with continued growth remaining or those at
high risk of progression should be referred for orthopedic evaluation Always refer when red flags are present on PE or X-ray Conclusions 90% of kids with scoliosis will not require medical intervention Girls are much more likely than boys to need intervention for scoliosis Bracing can slow progression of many curves and significantly decrease need
for surgery Spinal fusion surgery is recommended for curves greater than 45 50 degrees Torticollis What is it? Also known as Wryneck Head and chin are tilted at opposite angles, causing head to twist
Asymmetrical Appearance Effected muscle:sternocleidomastoid What is it? Can exist before or at birth Congenital Muscular Torticollis Can occur during childhood up through adult age
Acquired/Noncongenital Muscular Torticollis Both cause asymmetrical appearance and function in the neck and head of those afflicted Prevalence Less than .4% of newborns Torticollis does not prefer one side of head or the other
In CMT, ratio of boys to girls is 3:2 Increased head size in male babies Prevalence In adults, noncongenital muscular torticollis has an average onset of 40 years old Females twice as likely afflicted than males
Usually equal distribution between right and left side of body afflicted Slightly more right torticollis in older female populations Causes? Not well understood Almost 80 entities have been reported to cause torticollis Common causes: Developmental disorders affecting
sternocleidomastoid muscle Imbalance in function of cervical muscles Other abnormalities in skull/cervical area Other Causes Genetic defect Infants position during pregnancy or delivery Tumors in head or neck Arthritis of neck
Pseudotumors in infants Certain medications Genes More likely to be afflicted if family member had torticollis or similar disorder Symptoms Adults and Children: Abnormal contraction of the neck
Limited range of motion Stiff neck muscles Possible swelling and pain Can often be mistaken for more serious condition See medical professional immediately Symptoms
Infants: Tilting of chin Small mass (pseudotumor) in neck Small neck spasms Diagnosed before 1 month old = shorter physical therapy Prognosis
Most helpful diagnosis is made early Not life threatening May self correct itself May be chronic and reoccurring Any complications may result from compressed nerve roots Treatments Stretching and lengthening affected neck muscles Applying heat, massage, analgesics Can
be combined with TENS Transcutaneous Electrical Nerve Stimulation Medical treatmentBacolfen or Botox Injection every three months
Treatments Surgery in severe cases Patients whose pathology does not resolve after 12 months of physical therapy or who develops facial asymmetry Risk of injury to spinal nerves Preventive Measures Nearly impossible to prevent Become familiar with symptoms
Seek medical attention Other serious conditions may be confused for Torticollis and are not treated correctly Any Questions?
