Non-Structural Scoliosis

Question 0

What happens with sacral base unleveling?

Answer 0

Curve compensates for the pelvic tilt. Most curves measure less than 15 degrees, even if the unleveling is severe. This compensatory curve is a frequent cause of low back pain.

Question 1

What is a common cause of non-structural scoliosis?

Answer 1

Sacral base unleveling

Question 2

What are the categories of etiologies for sacral base unleveling?

Answer 2

Anatomic
Congenital anomalies
Lower extremity deformities
Pelvic somatic dysfunction

Question 3

What are the anatomic etiologies of sacral base unleveling?

Answer 3

Short leg & short hemi-pelvis

Question 4

What are the congenital anomaly etiologies of sacral base unleveling?

Answer 4

Sacral & L5 anomalies

Question 5

What are the lower extremity deformity etiologies of sacral base unleveling?

Answer 5

Unilateral pes planus, knee deformities, hip deformities

Question 6

What are the pelvic somatic dysfunction etiologies of sacral base unleveling?

Answer 6

Superior & inferior innominate shear, anterior & posterior rotation of innominate

Question 7

What defines a short leg?

Answer 7

If the only deformity present is a leg length inequality, then a person can have up to 1/2” short leg life-long, without symptoms. However, in the presence of other problems in the back or pelvis, discrepancies as small as 1/8” can cause the back to become symptomatic.

Question 8

What are known consequences of a leg length inequality greater than 1/2”?

Answer 8

Arch collapse - long leg side
Osteoarthritis - hip on long leg side
Trochanteric bursitis - long leg side
Premature spinal osteoarthritis 
Piriformis syndrome - long leg 
Ovarian cyst - short leg side
Infertility/chronic fetal wastage

Question 9

When diagnosing non-structural scoliosis, where should you look for asymmetry?

Answer 9

Popliteal creases
Greater trochanters
Gluteal folds
Iliac crests 
PSIS

Question 10

When assessing the mid-gravity line and Adam test, what should you see?

Answer 10

Mid-gravity line - all the spinous processes should be mid-line
Adam test - curves should straighten

Question 11

How can you determine leg length?

Answer 11

Measure between fixed bony landmarks
X-Ray: scanogram in growing child or adolescent - look at epiphysis
X-Ray: erect AP & lateral lumbar spine & pelvis

Question 12

How do you measure the anatomic leg length?

Answer 12

Measure distance from ASIS to medial malleolus

Question 13

How do you measure the functional leg length?

Answer 13

Measure distance from midline point (umbilicus or xiphoid process) to medial malleolus

Question 14

What is the goal of treatment for non-structural scoliosis?

Answer 14

Straighten the spine, usually by leveling the sacral base. All other concerns are secondary.

Question 15

What is treatment if epiphyses are still open in children?

Answer 15

Repetitive compression stimulate bone growth
Have patient jump rope or hop around on short leg only
If inequality is severe - can surgically staple epiphyses closed in the long leg to allow short leg to catch up

Question 16

How are plates and screws used to halt epiphyseal growth?

Answer 16

Take them out when legs are more even so longer leg can continue to grow alongside shorter leg.

Question 17

What is the management of children with leg length inequality and scoliosis?

Answer 17

Typically children are reevaluated annually, unless they are in a growth spurt. During rapid growth, the child is reevaluated for every inch of increase in height (can be measured by parents at home).

Question 18

If bone growth is completed, what treatment can be used?

Answer 18

Heel lift treatment - want to minimize the scoliosis. Must be tailored to the individual. In some patients, an entire lift can be placed at a time. In others, lift may need to be applied in increments as small as 1/16” over months or years to allow body to adapt to the lift.

Question 19

What is the Heilig formula?

Answer 19

Formula gives the amount of the initial heel lift and the amount of subsequent incremental increases.
Lift = (sacral base declination)/(duration) + (compensation)

Question 20

How is duration calculated for the Heilig formula?

Answer 20

D = 1 (0-10 years)
D = 2 (10-30 years)
D = 3 (over 30 years)

Question 21

How is compensation calculated for the Heilig formula?

Answer 21

C = 0 (little or no rotation)
C = 1 (rotation)
C = 2 (early spondylosis)
C = 3 (late spondylosis)
C = 4 (vertebral wedging)

Question 22

How is sacral base declination measured?

Answer 22

By extending a line horizontally across the sacral base to lines projected vertically through the apex of each hip joint. Vertical height difference between the sides is the sacral base declination.

Question 23

What is the Lloyd/Eimerbrink classification?

Answer 23

Classification system for patterns of pelvic disproportion: lower line represents femoral heads, upper line represents sacral base plane.
I - parallel unleveling
Ia - disproportion same side; femoral head unleveling greater
Ib - disproportion same side; sacral base unleveling greater
II - no sacral tilt; femoral head unleveling
III - “primary sacral tilt”; sacral base unleveling only

Question 24

Which Lloyd/Eimerbrink classification indicates no scoliosis? Why?

Answer 24

II - no sacral base issues, so no scoliosis (and thus no need for heel lifts)

Question 25

When does the shoe get built upon a platform for heel lift therapy?

Answer 25

When the heel lift are over 1” in height.

Question 26

How are platform shoes fixed so that they don’t affect the gait pattern of the wearer too much?

Answer 26

A rocker is added to the bottom of the shoe.