B3. Scoliosis Flashcards
What is scoliosis?
Spinal deviations caused by buckling/distortions into all planes. Deviations may be:
- lordosis
- rotation/torsion
- lateral
What is the most common scoliosis curve and what is the second most common?
Thoracic is most common followed by lumbar
What is the etiology of scoliosis?
Unknown although there are theories that have a common thread: sensory info is aberrant or misinterpreted at spinal cord level or in cortical centers which leads to inappropriate proprioceptive output.
What is the difference between functional and structural/anatomical scoliosis?
Functional scoliosis is compensatory, postural or transient while structural/anatomical scoliosis not
What are some causes of compensatory functional scoliosis?
- LLI
- pelvic subluxation with unleveling
- anatomical asymmetry or anomaly
If scoliosis curve improves with sitting, what does this tell you?
There is a functional scoliosis that is likely due to LLI instead of pelvic unleveling
What are some postural causes of functional scoliosis?
- muscular imbalance
- handedness
What are some transient cause of functional scoliosis?
- antalgic
- inflammatory
- traumatic
- psychogenic
- radiculopathy
What is the cause of structural scoliosis?
- 80 % are idiopathic
- congenital
- Scheuermann’s
- mesenchymal disorder
- neurofibromatosis
- neuromuscular disorder (neuro or myopathic)
- metabolic disorder (RIckets, osteogenesis imperfecta)
- vertebral neoplasm (osteoid osteoma)
- acquired/traumatic
Who gets scoliosis?
- girls 10-12
- boys 11-16
Is pain a common complaint with structural scoliosis?
No, only about 25% have pain and it is usually mild.
Severe pain requires a search for disease process
What are some disease processes that could cause structural scoliosis?
- spinal infection
- spinal tumor (osteoid osteoma)
- chiari type 1 with syrinx
- tethered spinal cord
What 5 strategies would be used on exam for evaluating scoliosis?
- observe for associated findings (club foot, cafe au lait spots, etc)
- perform postural assessment
- Adam’s test
- leg length check
- neurological screen
Weakness or spasticity, abnormal sensation and/or abnormal reflexes on neuro exam of patient with scoliosis may indicate:
Tethered cord syndrome or syringomyelia
What is a positive Adam’s test?
Patient stands and then bends over. A fixed rotational prominence on the convex side of a scoliosis curve (razorback spine) would be a positive Adam’s test. This should be repeated sitting and prone. If the prominence improves with sitting or prone, the scoliosis is functional
With a positive Adam’s test, a scoliometer is then used to measure the prominence. What scoliometer reading would suggest scoliosis?
> /= 7 degrees
What should be done if the scoliometer reading is >/= 7 degrees?
Order radiograph
What should be done if the scoliometer reading is < 7 degrees?
Follow up in 6-12 months
What kind of radiographs should be obtained when screening for scoliosis?
Full spine and recumbent and lateral bend into convexity
What are you looking for on radiographs when screening for scoliosis?
- congenital findings such as hemivertebrae
- location of curve
- pelvic unleveling
- Cobb angel
- bone age with Risser sign
Direction of a scoliosis curve is defined based on:
the direction of the convexity
I.e. left curve has apex on left
What curve is more common, right or left?
> 90% are convexity right
How do you measure a Cobb angle?
- determine primary/major curve
- draw line across top of superior vertebral segment in primary curve
- draw line across bottom of inferior vertebral segment in primary curve
- draw perpendicular and intersections lines from each of the vertebral lines
- the angle the perpendicular line intersect to form is the Cobb angle
What is the minimum angulation of a Cobb angel to define scoliosis?
10 degrees
Why does the time of day radiographs are taken matter when evaluating for scoliosis?
IVD swelling in the AM vs PM can cause an average difference of 5 degrees (sometimes 10-20 degrees)
What Risser numbers are considered immature?
1-2
What Risser numbers are considered mature?
3-5
What is a Risser number?
A number indicating the percent ossification of iliac epiphysis and therefore skeletal maturity. Smaller Risser number = more epiphyseal plate present and therefore more skeletal immaturity
What are some risk factors from history for scoliosis curve progression?
- female with early onset (50% risk of progression if onset is before menarche while <20% risk of progression is onset is after menarche)
- family history
- maternal age >30
What are some radiographic risk factors for scoliosis curve progression?
- greater curve at detection
- skeletal immaturity (Risser<2)
- right thoracic major curve
- double major curve
- marked rotation (>30%)
- L5 high in pelvis/interiliac crest line above 4th lumbar disc space
- associated thoracic hyperkyphosis
Patient presents with scoliosis and pain that is worse at night and relieved by NSAIDs. What is you primary diagnosis?
Osteoid osteoma
What are some examples of myopathic neuromuscular diseases that could cause structural scoliosis?
Muscular dystrophy
Amyotonia congenita
What are some examples of neuropathic causes of structural scoliosis?
- LMNL (polio)
- UMNL (tumor, cerebral palsy)
- syringomyelia
- cord trauma
What is the primary indication that the cause of structural scoliosis may be neuropathic?
Left thoracic primary curve
These are less common and always considered pathologic
What is another name for neurofibromatosis?
Von Recklinghausen’s disease
What are some examples of mesenchymal disorders that could cause structural scoliosis?
- Marfan’s syndrome
- Ehlers-Danlos
- dwarfism
- RA
Congenital structural scoliosis can have other associated symptoms. What are they?
- GU abnormality (20%)
- heart defects (15%)
What are indications for MRI in scoliosis?
- severe or progressive curve
- left thoracic curve
- young patient (under 11)
- no family history
- neuro abnormalities
- concerning radiographic findings
- painful scoliosis, unresponsive to treatment
Idiopathic structural scoliosis can further be categorized by age of onset. What are these classifications?
- infantile (<3 years)
- juvenile (3-10 years)
- adolescent (10 to skeletal maturity)
In idiopathic scoliosis, what direction do the spinous processes rotate into?
Into the concavity because the vertebral bodies rotate into the convexity
What is AIS?
Adolescent Idiopathic scoliosis, the most common type of scoliosis
Who gets AIS?
- 2% of the population
- those with genetic predisposition
- female>male 6:1
What is the recommended screening for scoliosis?
- twice for girls ages 10-12
- once for boys ages 13-14
What is the overall treatment goal for chiropractic management of scoliosis?
Keep scoliosis < 50 degrees by skeletal maturity
What are the 4 considerations when making treatment decisions for scoliosis?
- Cobb’s angle
- Risers’ measure
- severity of symptoms (neuro)
- speed of progression
What are the 4 scoliosis treatment objectives?
- improve strength and flexibility based on curves
- improve motor control
- normalize mechanics
- assign respiratory exercises
One treatment goal for scoliosis is to improve strength and flexibility based on curves. Which side should be strengthened and which side should be stretched?
Strengthen convex side and stretch concave side
What are some strategies to improve motor control in the treatment of scoliosis?
- balance, coordination, proprioceptive work on balance board
- oculo-vestibular therapy to improve integration
What are some strategies to normalize mechanics in the treatment of scoliosis?
- improve segmental joint dysfunction
- normalize weight bearing
- correct forward head carriage
- treat upper cross syndrome
Why is it important to incorporate respiratory exercises in the treatment of scoliosis?
Because 60% of curves >60 degrees have decreased vital capacity. Tailored exercises can increase chest expansion and therefore vital capacity
What should the follow up be for abnormal spinal curves that are under 10 degrees?
Every 6 months until skeletal maturity
What should the follow up be for abnormal spinal curves that are 11-20 degrees?
Every 3-6 months with neuro/orthopedic evaluation and radiographs each visit
What classifies as a significant progression in scoliosis?
5-6 degrees on 3-6 month follow up.
NOTE: would require referral for brace therapy if significant progression is noted on consecutive exams.
What should the follow up be for abnormal spinal curves that are 21-30 degrees?
Every 3-6 months with neuro/orthopedic evaluation and radiographs each time.
Refer fro brace at 25-30 degree and Risser grade 2 or less or if there is rapid progression
What should the follow up be for abnormal spinal curves that are 31-40 degrees?
Every 3-6 months with neuro/orthopedic evaluation and radiographs each time.
Will refer for bracing and co-treatment with orthopedist
What should the follow up be for abnormal spinal curves that are 41-50 degrees?
Every 3-6 months with neuro/orthopedic evaluation and radiographs.
Will need to refer for bracing and co-treatment with orthopedist.
Possibly surgical
When should a AIS case be referred for surgical consult?
Cobb angle > 45° with Risser = 2 or Cobb > 50
even if mature (Risser >/= 3)
What role does chiropractic treatment play in an AIS case with a curve > 50 degrees?
Because surgery is often indicated in this scenario, chiropractic can facilitate the success of the surgery and/or relieve symptoms and improve function of patient who elects to not have surgery. Respiratory breathing may be difficult and training can be done for this
What are some possible chiropractic treatments that would be offered to AIS patients?
- flexion-distraction with spine in corrected position
- manipulation
- proprioception rehab
- Stretching
- lift therapy
- exercise therapy
- electrospinal muscle stimulation
On what side of a scoliosis curve should muscles be strengthened?
Convex
On what side of a scoliosis curve should muscles be stretched?
Concave
How often should heel lift therapy for scoliosis be re-evaluated?
Every 6 weeks
Which muscles would you treat for a pelvis unleveling in a scoliosis case that is due to an elevated ilium?
Strengthen: contralateral QL and adductors, ipsilateral gluteus medius
Stretch: ipsilateral QL and adductors, contralateral gluteus medius
What is the goal of electrospinal muscle stimulation for scoliosis?
upper motor neuron and proprioception re-education to establish balance of function between concave muscles and convex muscles
What kind of fibers are largely in the concave muscles of a scoliosis curve?
A fibers
What kind of fibers are largely in the convex muscles of a scoliosis curve?
B fibers (“slow twitch”)
Bracing for 23 hours/day as treatment for idiopathic scoliosis had what success rate in one study?
93%
What is the Boston brace?
Most common brace used. Low profile and no chin support and therefore has better patient acceptance. It is worn 16-22 hours/day
What is the Milwaukee brace?
2nd most common brace. Has pelvic attachments, chin support and adjustable height. Worn 23 hours/day
What is the goal of bracing in scoliosis?
Stop the progression of scoliosis. Does not address improve cosmetics
What is the surgical treatment for scoliosis?
Harrington rods with spinal fusion
Approximately what percentage of post-surgical AIS patients return to normal physical and athletic activities within 3 months?
1/3
