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adolescent idiopathic scoliosis Flashcards

1
Q

what is scoliosis

A
  • 3D deformity
  • frontal/coronal plane: cobb angle > 10 degrees
  • transverse plane: angle of trunk rotation > 5 degrees, produces posterior prominence
  • sagittal plane: altered contour - hypokyphosis, thoracic kyphosis usually 30-35 degrees (range 10-50), lumbar lordosis typically 50-60 (range 35-80)
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2
Q

what percentage of children meet diagnostic criteria for scoliosis

A

2-3%

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3
Q

anatomy of scoliosis

A

all bony elements are altered
* vertebra are wedge shaped
* rib vertebral angle altered
* pedicles rotated
discs are wedged as well

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4
Q

types of scoliosis

A
  • congenital scoliosis
  • neuromuscular scoliosis and syndrome related scoliosis
  • early onset scoliosis (idiopathic)
  • adolescent idiopathic scoliosis

adolescent idiopathic scoliosis (most common)

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5
Q

congenital scoliosis

A

due to bony abnormalities
* can be identified by ultrasound en utero
* often diagnosed in infant or toddler years, sometimes not until later
failure of formation
* hemivertebrae or fused vertebrae
failure of segmentation
* block vertebra, bar, bar with hemivertebrae

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6
Q

neuromuscular scoliosis

A
  • caused by disorders of the brain, spinal cord, and muscular system
  • imbalance of trunk/spine muscles, poor muscle control, spasticity
  • thoracic and lumbar spine and pelvic obliquity
  • more severe and progressive, particilarly in patients who are non-ambulatory
  • curves usually not associated with pain
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7
Q

neuromuscular scoliosis: associated diagnoses and incidence

A

cerebral palsy
* 2 limb involvement - 25%
* 4 limb involvement - 80%
spinal muscule atrophy (SMA) - 67%
chiari malformation, syrinx
spinal cord injury < 10 years - 100%
myopathic disorders
* duchenne muscular dystrophy - 90%
* spina bifida
connective tissue disorders
* marfan syndrome
* elhers danlos
genetic conditions
* friedreich ataxia (spinocerebellar degernation) - 80%
* neurofibromatosis

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8
Q

early onset scoliosis (idiopathic)

A

diagnosed before age 10, and not due to congenital or neuromscular etiologies
infantile scoliosis (0-3)
* 1% of all patients with idiopathic scoliosis
* boys 60%, girls 40%
* 90% resolve without treatment
juvenile scoliosis (4-10)
* 10-15% of all patients with idiopathic scoliosis

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9
Q

early onset scoliosis (idiopathic) - assessing risk of progression

A

Cobb angle (curve < 35 degrees, 90% resolve without treatment)
angle of rotation
rib-vertebral angle difference (RVAD) at apical vertebra
* < 20 degrees - 83% resolve
* > 20 degrees - 84% progress

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10
Q

adolescent idiopathic scoliosis (AIS)

A
  • identified during pre/pubertal growth spurt (age 10-18)
  • 80-90% of scoliosis is AIS
  • 1.5% of all teens
  • tall, slim, active teens
  • curves 10-30 degrees (1.4 girls : 1 boy)
  • curves over 30 degrees (10 girls : 1 boy)
  • most patients only need periodic x-rays and orthopedic follow ups
  • intermittent back pain?
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11
Q

adult scoliosis

A
  • adolescent scoliosis is typically painfree, but can be painful in adulthood
  • progression and aesthetics can be an issue
  • adult neuromuscular scoliosis (PD, MS)
  • post traumatic - screen for red flags on systems review
  • DDS degenerative de-novo scoliosis
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12
Q

theories of AIS etiology

exact etiology of AIS is unknown

A

genetic factors
hormones and metabolic dysfunction
biomechanical factors

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13
Q

AIS etiology theory - genetic factors

A
  • genetic basis for risk factors, but mode of inheritance not determined and many other factors influence progression
  • 20% change of developing scoliosis if present in a family member
  • women with curves > 15 degrees - 27% incidence of scoliosis in their daughters
  • identical twins 73%
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14
Q

AIS etiology theory - hormones and metabolic dysfunction

A
  • hypoestrogen
  • leptin-hypothalamic-sympathetic nervous system (LHS concept)
  • low nocturnal melatonin
  • platelet calmodulin higher in patients with a progressive curve than in patients with stable curves or no curve
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15
Q

AIS etiology theory - biomechanical factors

A
  • geometric and mechanical torsion: hueter volkmann law of compressive and distractive forces -> relative anterior spinal overgrowth and hypokyphosis
  • muscular imbalance: many studies have documented an abnormal distribution of slow-twitch and fast-twitch muscle fibers in paravertebral muscles (multifidi predominently type I [slow] in convexity of curve)
  • postural control: somatosensory dysfunction has been shown to influence dynamic balance control, but needs to be studied further for causality of AIS
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16
Q

classification of curves

scoliosis

A
  • spinal asymmetry > 10 degrees
  • mild 10-25 degrees
  • moderate 25-50 degrees
  • severe > 50 degrees
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17
Q

curve patterns and terminology

scoliosis

A

defined by direction of convexity of curve
* dextro - right
* levo - left
defined llcation of curve’s apex in spine
* cerivcal C2-C6
* cervicothoracic C7-T1
* thoracic T2-T11
* thoracolumbar T12-L1
* lumbar L2 and below
primary vs secondary
structural vs nonstructural/compensatory

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18
Q

curve patterns

scoliosis

A
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19
Q

history impacts prognosis of scoliosis

A

family history
* affected sibling 7x more frequent
* affected parent 3x more frequient
recent growth spurt
pubertal status
* pre or post menarche
* sexual maturity
pain
* fatigue pain
* post diagnostic pain
* severe pain

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20
Q

Cobb angle

scoliosis diagnosis

A
  • drawn lines parallel to upper border of upper vertebral body and lower border of lowest vertebra of the curve
  • draw perpendiculars from lines to cross - the angle between is angle of curve
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21
Q

pedicle rotation - nash and moe

scoliosis diagnosis

A
  • spinous process rotates into concavity
  • shadow of pedicle compared to midline
  • graded 0-4
22
Q

triradiate cartilage

skeletal maturity - scoliosis

A
  • in acetabulum
  • fuses just before menarche in girls
23
Q

risser

skeletal maturity - scoliosis

A
  • radiologic measurement based on ossification of iliac apophysis
  • 0: no ossification center
  • 1: 25%
  • 2: 25-50%
  • 3: 50-75%
  • 4: 100%
  • 5: complete ossification and fusion of iliac crest apophysis
24
Q

risk of curve progression in AIS

A

progression factor = [cobb angle - (3 x Risser)]/chronological age
younger onset
* pubertal growth spurt is time of greatest risk of curve progression
* female more likely than male
curve pattern
* apex above T12
* degrees at presentation
* 20-29 degrees - 68% risk for progression
* 30-59 degrees - 90% risk for progression

25
prognosis for curve progression after skeletal maturity (done growing) | natural history
* 0-30 degrees: minimal risk of progression * 30-50 degrees: it depends * > 50 degrees: very likely to progress, up 1 degree per year lumbar curves > 30 degrees progress about 0.5 degrees per year
26
adults with untreated AIS | natural history
no increased rate of mortality or impact to other systems unless curve > 90 degrees * right heart failure * decreased pulmonary function respiratory failure if curve > 110 degrees increased risk of SOB, especially if thoracic curve > 80 degrees chronic back pain * common * not related to size or located of curve * usually does not interfere with ability to work
27
static standing exam | scoliosis posture and momvent analysis
* multiple views (A-P, lateral, stand, sit) * iliac crest height (LLD) * shoulder height * arm-trunk space/waist angle * scapular position * trunk shift/trunk imbalance
28
dynamic exam | scoliosis posture and movement analysis
* forward bend rib prominence/bump (formerly hump) * side bend, extension, rotation * squat, single leg balance, single leg squat * is curve flexible or rigid? does it unwind with motion?
29
adams test | PT exam
adams forward bend test * left to right asymmetry of rib cage * spinous processes not in line * + loss of normal arc of flexion | diagnostic accuracy for thoracic curve: Sn .92, Sp .60
30
scoliometer | PT exam
* type of inclinometer that objectively measures angle of trunk rotation * if > 5 degrees asymmetry noted, refer for x-ray * placed vertically during adams test, center the notch over spinous processes * measure thoracic and lumbar
31
neurologic exam
* observe gait * heel and toe walk * upper and lower quarter screen * myotomal testing * reflexes * sensation
32
palpation and manual assessment - scoliosis
look for aymmetries in soft tissue contours and bony landmarks leg length (stand and supine) muscle length * pectroals, hamstrings, hip flexors, gastrocs muscle strength * core/trunk, deep neck flexors, mid/lower trapezius, hips spine mobility/accessory motion testing * cervical, thoracic, lumbar * rib mobility and respiration
33
physical therapy intervention | overview scoliosis
* patient education * posture awareness (neutral, symmetry, equal WB) * breathing * flexibility * strength * joint mobility in adjacent areas * restrain movement * ICF based interventions if early onset, consider symmetry of gross motor skills
34
AIS management and treatment
predict risk of progression * curve magnitude * skeletal maturity SOSORT guidelines or treatment algorithms most people only need periodic ortho follow ups and x-rays
35
SOSORT
36
management of scoliosis - growth sparing
* casting * bracing * halo traction * magnetic growing rods * vertebral body tethering * physical therapy * goal: avoid or delay spine fusion (trunk height, lung development) * success depends on the etiology of the deformity and patient compliance
37
management of scoliosis - growth arresting
* spine fusion * goal: stabilization of severe or progressive deformities * if fused too young, will not have sufficient thoacic height to support adult lung capacity -> restrictive lung disease
38
casting | scoliosis
* early onset or congenital scoliosis * aim to slow or prevent progression * compliance vs brace - can't be taken off
39
braces | scoliosis
* aim to halt or minimize curve progression * must be worn as recommended - 18-23 hours/day until skeletally mature * compliance can be an issue, heat sensor in brace can track how long it's worn * best for: girls (boys only 38% compliant), more flexible curves, younger patients types of braces: boston (3D), rigo-cheneau, providence, night time, scoli, spine cor
40
boston brace | scoliosis
41
halo traction | scoliosis
* large, stiff curves * early onset or congenital scoliosis * used before or between bracing/casts, or before surgery * halo ring with 4-12 pins * pulley system attached to walker or wheelchair * add 2 pounds/day until almost lifting out of chair * 4-8 weeks, 8-12 hours/day when awake * stand or walk 4 hours/day * breathe easier, spend less energy, less pain, eat more, gain weight
42
magnetic growing rods | scoliosis
* early onset, congenital or neuromuscular scoliosis * after age 3 or 4 due to rod size * primary thoracic curve * surgical rod placement, single or dual * adjusted with external device in physician office every 2-6 months * achieves up to 1.5-2 mm/month or 6 mm/year of growth * improvement in Cobb angle and pulmonary function
43
magnetic growing rods example | scoliosis
44
vertebral body tethering (VBT) | scoliosis
* candidates have specific curve magnitudes and open growth plates * screws in affected vertebrae on convex side * flexible tether on convex side, preserves mobility/flexibility * gradual curve correction as patient grows
45
spine fusion indications | scoliosis
* curves > 45 degrees * unbalanced curves > 40 degrees * no long-term prospectives controlled studies to support surgery for AIS over natural history goals: * prevents curve progression * permanent correction * improves aesthetics of back spare lumbar spine when possible
46
spine fusion AIS | scoliosis
* 2-3 days in hospital * no precations once incision healed * return to sports/activities as tolerated * return to contact sports later, depending on level of lumbar fusion * return to school 2-3 weeks * expensive to health care system
47
PT - mobilization | scoliosis
* to increase flexibility, manily at apex of curve * passive and active techniques * myofascial, connective tissue, neural tissue * mobilzation of ribs, thoracic spine, lumbar spine, diaphragm
48
PT - breathing work | scoliosis
* soda can model - integration of CP function, breathing mechanics, and postural control in scoliosis, corrective breathing work can: * increase rib mobility * increase strength of diaphragm and intercostals * increase CV endurance * increase vital capacity * increase breathing function
49
physiotherapeutic scoliosis specific exercises (PSSE) - schroth | scoliosis
indications * adolescent idiopathic scoliosis * cobb angle 10-50 degrees * considerations: progression, risser, best in rapid growth phase, minimum age 10-11 for girls/boys * able to perform SSE at home 30 min, 5 days a week * equipment and exercise space at home
50
goals of schroth therapy | scoliosis
* learn curve characteristics and how to achieve best possible 3D posture correction * improve cardio-respiratory dysfunction * improve mobility and postural stability * reduce pain * reduce or decelerate the incidence of curve progression and improve aesthetics (when used with brace) * helps avoid loss of correction after brace wear completed * improve comfort and compliance of brace wear
51
schroth exercises basic principles | scoliosis
* neutral, centered pelvis * axial elongation * sagittal corrections * derotation with breathing * stabilzation * mobilization * exercises are prescribed on specific curve patterns identified in exam/eval center pelvis, restack, grow tall elongation: long hang, semi hang, bow, prone on knees or stool, sit and reach supine sid lying standing and dynamic exercises

MSK IV (8 decks)

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