adolescent idiopathic scoliosis Flashcards
what is scoliosis
- 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)
what percentage of children meet diagnostic criteria for scoliosis
2-3%
anatomy of scoliosis
all bony elements are altered
* vertebra are wedge shaped
* rib vertebral angle altered
* pedicles rotated
discs are wedged as well
types of scoliosis
- congenital scoliosis
- neuromuscular scoliosis and syndrome related scoliosis
- early onset scoliosis (idiopathic)
- adolescent idiopathic scoliosis
adolescent idiopathic scoliosis (most common)
congenital scoliosis
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
neuromuscular scoliosis
- 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
neuromuscular scoliosis: associated diagnoses and incidence
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
early onset scoliosis (idiopathic)
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
early onset scoliosis (idiopathic) - assessing risk of progression
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
adolescent idiopathic scoliosis (AIS)
- 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?
adult scoliosis
- 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
theories of AIS etiology
exact etiology of AIS is unknown
genetic factors
hormones and metabolic dysfunction
biomechanical factors
AIS etiology theory - genetic factors
- 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%
AIS etiology theory - hormones and metabolic dysfunction
- 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
AIS etiology theory - biomechanical factors
- 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
classification of curves
scoliosis
- spinal asymmetry > 10 degrees
- mild 10-25 degrees
- moderate 25-50 degrees
- severe > 50 degrees
curve patterns and terminology
scoliosis
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
curve patterns
scoliosis
history impacts prognosis of scoliosis
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
Cobb angle
scoliosis diagnosis
- 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
pedicle rotation - nash and moe
scoliosis diagnosis
- spinous process rotates into concavity
- shadow of pedicle compared to midline
- graded 0-4
triradiate cartilage
skeletal maturity - scoliosis
- in acetabulum
- fuses just before menarche in girls
risser
skeletal maturity - scoliosis
- 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
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
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
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
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
SOSORT
casting
scoliosis
- early onset or congenital scoliosis
- aim to slow or prevent progression
- compliance vs brace - can’t be taken off
boston brace
scoliosis
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
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
magnetic growing rods example
scoliosis
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
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
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
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
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
