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PassPMR - 07 Musculoskeletal Medicine > 1b - Scoliosis > Flashcards

1b - Scoliosis Flashcards

1
Q

When to say this patient has scoliosis? Define scoliosis 🔑🔑

A

💡 The Scoliosis Research Society (SRS) has defined a medically significant frontal plane curve (scoliosis) as any curve which is greater or equal to 10 degrees, with or without a rotatory component.

Spinal deformity characterized by

  1. Lateral curvatures >10 degrees in PA film
    • Cobb angle: angle formed by the perpendicular lines drawn from the endplates of the most tilted proximal and distal vertebrae to measure the scoliotic curve
  2. Vertebral rotation
    • Grading: 0 (no rotation) to 4 (complete pedicle rotation out of view)

Why not CT or MRI?

  • Neither CT nor MRI is able to assess the impact of gravity on a curve, since both studies are done in a supine position.

Important Notes

  • Correlation with discomfort is unclear, but low back pain is usually the initial symptom.
  • It is related to curve severity and usually begins at the convexity

Cuccurollo 4th Edition Chapter 4 MSK pg302

DeLisa 5th Edition Chapter 34 Scoliosis

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2
Q

Scoliosis in PA Xray. 🔑🔑 Dr. Jamal

List 4 measurements used in PA film

List 4 methods to measure vertebral rotation

A

PA VIEW

  • Cobb angle
  • Coronal balance
    • Positive balance: the plumb line passes to the right of the midline, by >2 cm
    • Neutral balance: the plumb line passes within 2 cm of the midline
    • Negative balance: the plumb line passes to the left of the midline, by >2 cm
  • Pelvic tilt

LATERAL ERECT VIEW

  • Sagittal balance
    • To identify spondylolisthesis, the degree of kyphosis/lordosis

LATERAL FLEXION/BENDING VIEW

  • Assesses the range of motion of the spine

https://radiopaedia.org/articles/scoliosis

https://radiopaedia.org/cases/scoliosis-important-lines-and-angles

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3
Q

Pattern of scoliosis.

A
  1. ThoRacic curve
    1. Right thoracic curve: Most common, aspex at T7 or T8
    2. Left thoracic curve: Associated with spinal cord abnormalities
  2. Lumbar curveL: Left lumbar curves are greater than right lumbar curves
  3. Double major curve: Right thoracic with a Left lumbar curve
  4. ThoRacolumbar curve: Rib and flank distortion

Cuccurollo 4th Edition Chapter 4 MSK pg303

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4
Q

List 4 Causes of Non-Structural / Functional Scoliosis & Prognosis. 🔑🔑

A

CAUSES

Spine

  1. Herniated disk (unilateral)
  2. Spondylolisthesis
  3. Trauma
  4. Paraspinal strain
  5. Postural

Hip & Pelvis

  1. Arthritis
  2. Pelvic Obliquity
  3. Hip disease
  4. Muscle spasm

Legs

  1. Leg-length discrepancy

PROGNOSIS

  • Resolves with correction of underlying cause
  • No significant vertebral body rotation
  • Scoliosis is reversible.

Cuccurollo 4th Edition Chapter 4 MSK

Cuccurollo 4th Edition Chapter 10 Peds pg750

Michael A. Alexander Pediatric Rehabilitation - 5th Edition Chapter 10 Ortho & MSK

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5
Q

List 3 Types of Idiopathic Scoliosis 🔑🔑

Incidence - Onset - Associations - Rule Out

A

Cuccurollo 4th Edition Chapter 10 Peds MSK

Michael A. Alexander Pediatric Rehabilitation - 5th Edition Chapter 10 Ortho & MSK

DeLisa 5th Edition Chapter 34 Scoliosis

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6
Q

List 8 Neuromuscular Causes of Scoliosis. 🔑🔑

A

UMN LESION

  1. Brain: Cerebral palsy
  2. Spine: Syringomyelia, Spina bifida, Spinal cord trauma or tumor, Friedreich’s Ataxia (Spinocerebellar + Lateral Corticospinal + Dorsal Column)

LMN LESION (MND & AHC)

  1. MND: Poliomyelitis, SMA, ALS
  2. Peripheral Nerve: Charcot-Marie-Tooth

MYOPATHIC

  1. Muscular dystrophy (Duchenne, Limb-girdle, Facioscapulohumeral)

Delisa 5th Edition Chapter 34 Scoliosis pg894 Table 34.3

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7
Q

Neuromuscular Conditions with Scoliosis

What is the most important risk factor for scoliosis progressing? 🔑🔑

Prognosis & Treatment of NMSK Scoliosis 🔑

A

NEUROMUSCULAR SCOLIOSIS

💡 Scoliosis is uncommon in children who are able to walk

Causes

  1. Brain: Cerebral Palsy
  2. Spinal Cord : Spina bifida, Spinal cord injury
  3. Anterior Horn Cell: Spinal muscular atrophy (SMA)
  4. Myopathy: Duchenne muscular dystrophy

Risk Factors

  1. Non-Ambulation
    • CP Spastic Quadriplegic who is unable to stand or walk
    • Spina Bifida with thoracolumbar lesion who is unable to stand or walk
    • Duchenne muscular dystrophy (DMD) once become full-time wheelchair

Prognosis → Progressive Weakness & Deformity

  • Aggressive progression
  • Less responsive to bracing
  • Progress after maturity
  • Associated pulmonary, cardiac and spinal cord complications
  • Risk for contractures, hip dislocations, sensory abnormalities, and pressure ulcers.

Bracing

  • Neurologic, pulmonary, cardiac, or gastrointestinal comorbidities impact the child’s ability to wear spinal orthosis
  • Often, a softer foam orthosis, rather than one of rigid orthoplast, will be more tolerable to the patient and have less adverse impact on pulmonary function.
  • Orthosis may improve trunk control, sitting, and head position, and serve a functional purpose.

Cuccurollo 4th Edition Chapter 4 MSK pg303

Cuccurollo 4th Edition Chapter 10 Peds pg749-750

Michael A. Alexander Pediatric Rehabilitation - 5th Edition Chapter 10 Ortho & MSK

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8
Q

Patient with myelomeningocele, rapid progression of scoliosis. List 2 causes. 🔑🔑 EXAM

A

MRIs should be obtained

  1. Tethered cord
  2. Worsening hydrocephalus, or hydromyelia
  3. Spinal cord syrinx
  4. Spinal fracture
  5. Intraspinal tumors

Michael A. Alexander Pediatric Rehabilitation - 5th Edition Chapter 10 Ortho & MSK

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9
Q

Why Duchenne muscular dystrophy are at higher risk of scoliosis progression?

How do you manage scoliosis in DMD? 🔑 🔑

A

Scoliosis in DMD

  • Due to muscular dystrophy and weakness

Progression

  • Rate of 8 degrees per year before maturity
  • Rate of 1.5 degrees per year even after maturity

Treatment

  1. STEROID: The use of oral steroids slow the decline in muscle strength and delays nonambulatory status
  2. SURGERY:
    • As early as curves of 20 to 30 degrees
    • To be done with a forced vital capacity [FVC] > 35% to maximize pulmonary status
    • Early surgical intervention shows higher benefits & better outcome
    • Improve seating and respiratory function early on.

Michael A. Alexander Pediatric Rehabilitation - 5th Edition Chapter 10 Ortho & MSK

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10
Q

Patient with Duchenne muscular dystrophy with curve >50 degrees planned for surgical fixation.

List 4 Factors negatively affecting the post-op outcomes. 🔑

A
  1. Limited respiratory reserve (FVC < 35%)
  2. Reduced bone quality
  3. More rigid curve
  4. Advancing age
  5. Impaired skin integrity

Michael A. Alexander Pediatric Rehabilitation - 5th Edition Chapter 10 Ortho & MSK

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11
Q

Rule of bracing in neuromuscular scoliosis. 🔑🔑

A

💡 Softer foam orthosis, rather than one of rigid orthoplast, will be more tolerable to the patient and have less adverse impact on pulmonary function.

  1. Improve trunk control
  2. Improve sitting
  3. Improve head position
  4. Serve a functional purpose

Michael A. Alexander Pediatric Rehabilitation - 5th Edition Chapter 10 Ortho & MSK

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12
Q

List subtypes of Congenital Scoliosis 🔑

Most important screening test. 🔑🔑 Dr. Haitham

Prognosis & Treatment 🔑

A

CLOSED CONGENITAL SCOLIOSIS

  1. Failure of formation → can present as torticollis
    • Wedged vertebra : partial unilateral failure of formation
    • Hemivertebra : complete unilateral failure of formation
  2. Failure of segmentation
    • Block vertebrae : bilateral failure of segmentation
    • Congenital bar : unilateral failure of segmentation

OPEN CONGENITAL SCOLIOSIS

  • Conditions: Myelomeningocele, Meningocele
  • Progressive tendency
  • Required early surgery before spinal rigidity or secondary pulmonary deficiencies occur

ASSOCIATIONS

  • Cardiac, renal, and gastrointestinal systems share the same origin “mesoderm cells”
  • Abnormalities of the trachea, esophagus, renal tract, gastrointestinal tract, lungs, heart, radius, ear, lip, and palate often accompany congenital scoliosis.

SCREEN FOR

  • Congenital urinary abnormality: unilateral renal agenesis.

TREATMENT = NMSK Scoliosis

  • Orthoses are ineffective
  • Maintaining cardiovascular health and endurance
  • Surgical intervention at an early age, before spinal rigidity or secondary pulmonary deficiencies occur

Cuccurollo 4th Edition Chapter 4 MSK pg302

Cuccurollo 4th Edition Chapter 10 Peds pg749

Michael A. Alexander Pediatric Rehabilitation - 5th Edition Chapter 10 Ortho & MSK

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13
Q

List 3 Causes of Acquired Scoliosis

A
  1. Degenerative scoliosis (Senile)
  2. Degenerative Posttraumatic (fracture)
  3. Overuse (repetitive microtrauma)

Cuccurollo 4th Edition Chapter 10 Peds pg750

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14
Q

List 2 Connective Tissue Disease Causing Scoliosis

A
  1. Ehlers–Danlos
  2. Chondrodysplasia
  3. Marfan’s

Cuccurollo 4th Edition Chapter 10 Peds pg750

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15
Q

Red flags for Scoliosis 🔑🔑

A
  1. SCI: Muscle weakness, Bowel, and bladder changes
  2. TUMOR: Unintentional weight loss, Pain
  3. WORSEN: Rapid curve progression (Syrinx or tethered cord)
  4. FRACTURE: Recent trauma

Michael A. Alexander Pediatric Rehabilitation - 5th Edition Chapter 10 Ortho & MSK

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16
Q

What are the 2 major growth spurt? 🔑🔑

A
  1. FIRST < 3 years
  2. SECOND during puberty (Girls at Tanner stage 2, Boys at Tanner stage 3)

Michael A. Alexander Pediatric Rehabilitation - 5th Edition Chapter 10 Ortho & MSK

17
Q

Examination of Scoliosis 🔑🔑 Dr. Jamal OSCE

A

STATIC INSPECTION

  • Skeletal Curvature
    1. Pectus carinatum or excavatum.
    2. Asymmetry shoulder girdle acromioclavicular joint
    3. Asymmetry at the waist triangle as the arms hang down
    4. Asymmetry of the scapula
    5. Abnormal spine curve C or S shape and convex side
    6. Pelvic obliquity iliac crests or PSIS
  • Foot deformities (Myopathic or Neuromuscular)
  • Skin (Neuromuscular)
    1. Café au lait spots
    2. Hairy patches
    3. Skin dimples
    4. Webbed neck
    5. Low hairline

DYNAMIC INSPECTION & MEASURES

  • Range of motion
    1. Joint contractures or deformities
    2. Tendon contractures
  • Standing Measures
    1. Plump line (Line from the C7 spinous → gluteal cleft)
    2. Leg length discrepancy
    3. Trunk to leg height
    4. Trunk height
    5. Height arm span (Marfan)
    6. Beighton Score (Hypermobility/Ehler Danlos Syndrome)
    7. Chest expansion
    8. Side flexion : hand to floor distance
  • Bending Measures
    1. Adam forward bending test: convex side
    2. Scioliometer > 6-7 degrees associated with ≥ 20 degree
    3. Palms to floor distance

FUNCTIONAL INSPECTION → MYOPATHIC

  1. Balance: Romberg & Tandem Walk
  2. Squat (proximal strength, pelvic girdle)
  3. Walk on heels (peritibial muscles) and toes (quadriceps)

NEUROLOGY → NEUROMUSCULAR +/- SCI

  1. Sensation
  2. Tone
  3. Motor power
  4. Reflexes
  5. UMN Signs

RESPIRATORY

  1. Pulmonary Function Test
    • Thoracic scoliotic curve > 50 degrees → Compromises pulmonary function
    • Restrictive lung disease → Decrease in total vital capacity

Cuccurollo 4th Edition Chapter 10 Peds pg750-751

Michael A. Alexander Pediatric Rehabilitation - 5th Edition Chapter 10 Ortho & MSK

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5422115/

18
Q

Managment for Scoliosis 🔑🔑 Dr. Jamal OSCE

A

EDUCATION

  • Goal is to prevent progression
  • Patient exercises are done in an outpatient setting
  • Follow up x-ray PA every 6-12 months or if scoliosis worsen at anytime

PROTECTION = BRACING

Goal

  • Prevents worsening of the curvature but does not correct scoliosis
  • Increase spine stability and functional status of the patient

Use

  • Worn 23 hours a day until spinal growth is completed

Type

  • Milwaukee CTLSO: High thoracic curves (apex at T8)
  • Boston TLSO: Lower thoracic, thoracolumbar, and lumbar curves (apex below T8)

Wean Off

  • Skeletal maturity: Risser stage 4 in girls or stage 5 in boys
  • Age: 2 years postmenarche
  • Curve: after 50 degrees

PHYSIOTHERAPY

  • Stretching and ROM exercise to prevent contracture
  • Abdomen and truck control
  • Scoliosis-specific exercises (SSEs): Shroth, SEAS, FITS
  • Gait training
  • Abdominal and gluteal strengthening exercises

OCCUPATIONAL THERAPY → CP, Spina Bifida, DMD

  • Transfer activities
  • Seating balance
  • Improve trunk posture and alignment
  • Seating and WC assessment

CARDIORESPIRATORY REHAB → DMD

  • Maintaining cardiovascular health and endurance
  • Respiratory rehab (breathing - cough - clearance)
  • Aspiration prevention (Dysphagia)
  • Restrictive lung disease

SURGICAL INTERVENSION

  1. Progression
    • Relentless progression
  2. Curve
    • < 35 degrees in neuromuscular diseases
    • > 40 degrees in the skeletally immature
    • > 50 degrees in the skeletally mature
    • > 60 degrees in CP (pulmonary compromise: mild 70 degrees, severe 100 degrees)
  3. Complications
    • Progressive loss of pulmonary function.
  4. Skeletal maturity
    • Skeletal Maturity (Risser Stage 4)
    • 2 years post menarche

Cuccurollo 4th Edition Chapter 4 MSK pg304

Cuccurollo 4th Edition Chapter 10 Peds pg751

Michael A. Alexander Pediatric Rehabilitation - 5th Edition Chapter 10 Ortho & MSK

DeLisa 4th Edition Chapter 34 Scoliosis

19
Q

List 2 Indicators of hip dysplasia in examination. 🔑🔑

A
  1. Excessive lordosis or kyphosis
  2. Leg-length discrepancy
  3. Limited hip or hamstring ROM

Michael A. Alexander Pediatric Rehabilitation - 5th Edition Chapter 10 Ortho & MSK

20
Q

Two indications for bracing 🔑🔑

A
  1. Curves reach 20 degrees
  2. 5 to 10 degrees of progression have been noted over a 6-month period.

Michael A. Alexander Pediatric Rehabilitation - 5th Edition Chapter 10 Ortho & MSK

21
Q

How long should patient wear braces for scoliosis? 🔑🔑

A

WEAR

Braces should be worn 18 to 24 hours a day until skeletal maturity is reached.

WEAN

Boys: Risser stage 5

Girls: Risser stage 4 or 2 years postmenarche

22
Q

List 4 Skin lesions in Scoliosis & their indications 🔑🔑

A

Spina bifida occulta, or neurofibromatosis.

  1. Café au lait spots
  2. Hairy patches
  3. Skin dimples
  4. Webbed neck
  5. Low hairline

Michael A. Alexander Pediatric Rehabilitation - 5th Edition Chapter 10 Ortho & MSK

23
Q

Scoliosis of 30° angle for 16yo female, would you brace her? 🔑🔑

What are the causes of poor results? 🔑🔑

A

INDICATIONS = SKELETAL IMMATURITY

  1. Skeletal immature patient (Risser 0, 1, 2)
  2. 5 to 10 degrees of progression have been noted over a 6-month period.
  3. Curve More than >20-25 degrees

CONTRAINDICATION = SKELETAL MATURITY

  1. Skeletal mature patient (Risser 4)
  2. Girls with 2 years postmenarchal
  3. Height change <1cm over 2 visits 6 months apart

Poor prognosis with brace treatment associated with

  1. Male
  2. Obese
  3. Noncompliant (effectiveness is dose related)
  4. Poor in-brace correction
24
Q

List 5 risk factors for scoliosis progression in cerebral palsy. 🔑🔑

A
  1. Younger age.
  2. Quadriparesis.
  3. Poor sitting balance.
  4. Curve > 40 degrees.
  5. Increased spasticity.
  6. Pelvic obliquity.

Ref: Alexander and matthews pg 175.

25
Q

Indicators for risk progression 🔑🔑

A

Cuccurollo 4th Edition Chapter 4 MSK

Cuccurollo 4th Edition Chapter 10 Peds

Michael A. Alexander Pediatric Rehabilitation - 5th Edition Chapter 10 Ortho & MSK

26
Q

Marfan’s syndrome:

(a) list 6 MSK features.
(b) List 2 cardiac features. 🔑🔑
(c) list one ophthalmologic feature. 🔑
(d) what are the most likely to suffer sudden death from? 🔑🔑

A

MSK FEATURES:

  1. FACE:
    • High palate with dental crowding
    • Others: dolichocephaly, malar hypoplasia, enophthalmos, retrognathia, down-slanting palpebral fissures
  2. CHEST:
    • Pectus carinatum or excavatum
  3. ARMS:
    • Increased arm span to height ratio > 1.05
    • Long fingers and thumb - arachnodactyly
    • Reduced elbow extension (<170 degrees).
  4. SPINE:
    • Scoliosis >20 degrees or spondylolisthesis.
  5. TORSO & LEGS:
    • Reduced upper-body-to-lower body ratio <0.86
    • Protrusio acetabuli
    • Pes planus
  6. JOINT
    • Joint hypermobility.

CARDIAC FEATURES:

  1. Dilation of ascending aorta (+/- aortic regurgitation).
  2. Dissection of ascending aorta.

EYE

  1. Ectopia lentis – luxation of lens (60% of marfans).

MORTALITY

  • Dilated aortic root → dissection
  • Mitral regurgitation/prolapse
  • Dysrhythmisas.

Ref: Circulation.2008;117:2802-2813; European Journal of Human Genetics (2007) 15,724–733; Cañadas, V. et al. Nat. Rev. Cardiol. 7, 256–265 (2010); THEJOURNAL OF BONE& JOINT SURGERY· JBJS.ORG VOLUME88-A · NUMBER3 · MARCH2006..

27
Q

What is the criteria for Beighton score for hypermobility?

A

BEIGHTON CRITERIA: 5+/9.

  1. dorsiflex D5 MCP ≥ 90 degrees (2)
  2. thumb to volar forearm (2)
  3. elbow hyperextension ≥ 10 degrees (2)
  4. knee hyperextension ≥ 10 degrees (2)
  5. hands flat on floor without bending knees (1)

Ref: Best Practice & Research Clinical Rheumatology Vol. 17, No. 6, pp. 989 – 1004, 2003.

PassPMR - 07 Musculoskeletal Medicine (8 decks)

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