Scoliosis

Scoliosis

...... is defined as an appreciable lateral deviation in the normally straight vertical line of the spine.

-Panjabi & White

Scoliosis

• The term “Scoliosis” is usually credited to Hippocrates…He was the first to describe the disorder.

• It’s derivation is from the Greek word “Skolios”…which means twisted or crooked curvature

1st…Scoliosis

• Galen was the first to use the term (131-201) A.D.

• Hippocrates is credited with the first description of this disorder.

• Guerin was the first to do Surgery for Scoliosis in 1839

1st…Scoliosis

• Wilhelm Konrad Roentgen was the first to x-ray in 1895.

• Hibbs performed the first spinal fusion for Scoliosis in 1914. (Early 1900’s, T.B. was widespread…spinal fusion was developed and used to control spinal involvement).

Scoliosis Classification

•Non-structural•Structural

Scoliosis Classification

• In an attempt to classify cases of scoliosis according to cause, it becomes apparent that there is an overlap between structural and non- structural causes. A non-structural curve is described as a non-progressive scoliosis, possessing symmetrical side bending movements on clinical and radiographic examination. The curve is generally mild and is found in the lumbar and thoracolumbar regions.

– The major cause of these curves is the short leg, and is quite commonly found in practice.

Scoliosis Classification

• The Structural scoliosis deformity is characterized as being more likely to progress, having a fixed vertebral body rotation, and a prominence viewed in the thoracic or lumbar region. This prominence, referred to as a rib hump or lumbar prominence, persists through side bending, forward flexing, and radiographic examinations.

Non-structural Scoliosis(non-progressive)

•Postural•Mild…found in Lumbar and thoracolumbar regions.

•LLI…Major cause found in practice.•Sciatic •Inflammatory

Important!!!

• The importance of Non-structural Scoliosis lies in its ability to evolve into a structural deformity. Once the curve takes on structural manifestation, it is more likely to progress and have a poorer prognostic outlook for the patient.

– Prime example of this altered growth pattern is explained by the Heuter-Volkman Law: Suggests that altered end plates with pressure via the scoliosis, may retard normal vertebral body development resulting in body wedging.

Structural Scoliosis

•Idiopathic (85-90%)…Skeletally immature patients (boys <18 & girls < 16), the most common type of scoliosis is caused by unknown factors. Infantile: 0 - 3 years; Juvenile: 3 - 10 years; Adolescent: 10 to S.M. (B = 18 & G = 16)

•Congenital

•Neuromuscular

•Neurofibromatosis…a familial condition characterized by developmental changes in the nervous system, muscles, bones, and skin, and marked by the formation of neurofibromas over the entire body associated with areas of pigmentation.

Structural Scoliosis

•Traumatic•Metabolic

•Family Hx: –Determine genetic link and seek out siblings due to increased risk. Ruth Wynne - Davies reports siblings of scoliotic patients have a 40% greater chance/risk of developing spinal deformities as compared to the general population.

Structural Scoliosis

• As the magnitude of the curvature increases, the lateral deformity increases as well…and so does the accompanying rotation. The Rotation of the vertebral column promotes prominence of the rib heads and TVP’s.

• These findings are fundamental for early detection.

Complications of Scoliosis

• Cardiopulmonary disease

• Degenerative arthritis

• Curve progression

• Pain

• Radiation – induced abnormalities

• Psychological

How do we find it?

•School screenings…ABC’s (40 % of the curves detected on school screenings may be attributed to leg length inequality during adolescence).

•Rib Hump: ( >0.8 cm in T region)

•Lumbar Prominence: (> 0.5 cm in L region)

•Scoliometer (> 5° ATR)

•Radiographic assessments

School Screenings

• Torell et.al demonstrated success in performing school screening and effectively reducing the number of children who progress to a protocol indicating surgical stabilization. They targeted early detection and treatment of idiopathic scoliosis.

• 3 fold increase in number of patients treated for Scoliosis, the number requiring surgery declined!

School Screenings

• 3 methods: ABC’s of school screenings!

– A) Have the patient to flex forward while standing and to observe the horizon created by the thoracic and lumbar region…however, this method is extremely subjective and offers no quantitative findings.

School Screenings

– B) Utilize the same forward flexion; however, this time, the rib hump and lumbar prominence are measured with a ruler. A measurement of 5 to 8 mm is significant (5mm in lumbar region & 8 mm in the thoracic region).

• Spine 7 (6) : 556, 1982• Illustration on page 311: Low back pain by Cox.

• In addition to the rib hump and lumbar prominence, consider the height of the shoulder, the scapula, the iliac crest and the axillary gaps. The purpose of measuring for an increase in the Rib/Lumbar regions is to reduce the large number of insignificant and false positive curves.

School Screenings

– C) Use a Scoliometer…developed by William Bunnel. The Scoliometer is placed on the dorsal region of the forward bending patient in the T and L regions…at the apices of the curves. Minimal angle of trunk (ATR) is 5°. At 5° of ATR, you should refer the student for possible radiographic assessment. However, to avoid further radiation, use the Scoliometer to monitor progression.

– Lower than 5°…Observe and re-evaluate in 6 months (continue with Chiropractic care)

Radiographic assessment

Radiographic assessment

– Valuable Dx tool

– To help assist in etiology and Dx; curve magnitude; skeletal age; wedging; Rotation.

– P - A view is better…for reduction of radiation to visceral organs and breast tissue. Use rare earth screens to help minimize radiation in adolescent patient’s

A left view of the wrist is obtained to determine skeletal age.(Left wrist view comparison with standard atlas of Greulich and Pyle)

Most Accurate

Skeletal age is more importantthan Chronological age:

May vary months or years…veryimportant for prognosis

Risser Sign

– Use the A - P or P - A view to evaluate the Risser sign.

– A secondary ring apophysis (growth plate) develops over the top of each iliac crest. The apophysis will appear at the most lateral aspect of the crest near the A.S.I.S. and migrate medially toward the sacral ala. As the apophysis migrates, it is graded from 1 to 4 for females, and 1 to 5 for males.

Risser Sign

– It can be used as a prognostic indicator. A child with a low grade Risser sign (I.e., 1) and a scoliotic deformity of significant magnitude has a poorer prognosis than one who has a high grade Risser sign (I.e., 4) and equal curve magnitude.

– Low grade Risser…More growth potential and associated curve progression.

– High grade Risser…Less growth potential and less likely to demonstrate curve progression

Risser sign…4 for females, 5 for males.