Paediatric Idiopathic Scoliosis Flashcards
adolescent idiopathic scoliosis juvenile idiopathic scoliosis infantile idiopathic scoliosis
Define adolesent idiopathic scoliosis?
- scoliosis in children >10 years old
- most common type of scoliosis
What is the epidemiology of adolscent idopathic scoliosis?
- Incidence of 3% for curves 10-20o
- Incidence of 0.3% for curves >30%
-
10:1 Female vs male for curves >30o
- 1:1 M:F for small curves
- right thoracic curves most common
- left curves rare- need MRI to rule out cyst/syrinx
Describe the pathophysiology of adolescent idopathic scoliosis?
- Unknown
- potential causes
- Multifactorial
- hormonal- melatonin
- Brain stem
- proprioception disorder
- platelet
- calmodulin
- most have positive FHX
What is the prognosis of adolscent idopathic scoliosis?
- Natural hx
- increased incidence of acute and chronic pain in adults if left untreated
- Curves >90o assoc with cardiopulmonary dysfunction, early death, pain and decreased self image
What are the risk factors for curve progression?
-
Curve Magnitude
-
before skeletal maturity
- >250 will continue to progress
-
after skeletal maturity
- >50o thoracic will progress 1-2o pa
- >40o lumbar will porgress 1-2o pa
-
before skeletal maturity
-
Curve Type
- Thoracic more likely to progress than lumbar
- double curves more likely to progress than single curves
-
Remaining skeletal growth
- Younger age <12yrs
- Tanner stage <3 females
- Risser stage <3 females
- open triradiate cartilage
-
peak growth velocity
- best predictor of curve progression
- in females just before menarche & before Reisser 1 ( girls reach Sk maturity 1.5yrs post menarchy)
- if curve is 30o B4 peak growth velocity strong likelihood of surgery
What is Risser Stage used for and can you describe it?
- Used to identify Maturity of skeleton
- V is fused
- 1 is apophysis at anterior edge

How is adolscent idopathic scoliosis identifed?
- School screening on adams forward bending test
- 7o abnormal = 20o coronal plane curve
- axial plane deformity indicates stuctural curve- see pic
- forward bending sitting test can eliminiate leg length inequality as cause of scoliosis

What other important signs are seen on examination in a pt with adolscent idopathic scoliosis?
- Leg length inequality
-
midline skin defects- hairy patches, dimles, nevi
- signs of spinal dysraphism
- shoulder height difference
- truncal shift
- rib rotational deformity- rib prominence
- waist asymmetry and pelvic tilt
- cafe-au-lait spots
-
foot deformities
- cavovarus-? neural axis deformity =MRI
-
Asymmetric abdominal reflexes
- preform MRI

What is seen on xrays with a pt of adolscent idopathic scoliosis?
- Standing PA and lateral
-
Cobb angle
- >100 = scoliosis
-
Spinal Balance
- plump line C7-post -superior corner S1
-
Cobb angle

When are MRI indicated in adolscent idopathic scoliosis?
- left sided curves
- rapid progression
- excessive kyphosis
- neurological symptoms
- assymetrical abdominal reflexes
- foot deformities
idea to rule out intraspinal anomalies
What is the tx of adolscent idopathic scoliosis?
Non operative
-
Obervation alone
- if cobb angle <25o
- serial xrays review progression
-
Bracing
- Cobb angle 25-45o
- in immature Pt Reisser 0-2
-
goal to stop progression not correct deformity__
- poor prognosis
- male, obesity, hypokyphosis, noncompliant
Surgery
-
Posterior spinal fusion
- Cobb >45o
- gold standard for thoracic/ double curves
-
Anterior spinal fusion
- best for thoracolumbar/ lumbar cases with normal sagittal profile
-
Anterior/Posterior spinal fusion
- large curve >75o & stiff
- young age risser 0
- prevent crankshaft phenomenon
Describe the technique of bracing in adolscent idopathic scoliosis?
- recommended for 16-23 hours a day until skeletal mature or surgical innervention necessary
- Brace types
- Curves above T7
- milwaukee brace- Cervicothoracolumbosacral orthosis-CTLSO
-
Apex at T7 or below
- Thoracolumbosacral orthosis TLSO
- boston brace
- Curves above T7

What is the techique of surgery
-
Posterior spinal fusion
- aims
- to include enough levels to maintain sagittal and coronal balance whilst being minimal as safely possible
- typical fusion prox end of vertebra to one/two levels cephalad to stable vertebra
-
Harrington technique
- 1 level above to 2 levels below the end vertebra
-
L5 level- cochran found increaed incidence of low back pain with fusion to L5, and lesser extent L4
- try to avoid fusion L4/5
- pelvis almost never fused in idiopathic scoliosis
- aims
What is monitored in adolescent idiopathic scoliosis surgery?
-
Somatosensory -evoked potentials SSEPs
- allow identication of injuries from positioninf
- most common reversible intraop neurological injury
-
Motor-evoked potential - MEPs
- provide intraop warning of impeding spinal cord dysfunction
What happens if neurological injury occurs in theatre whilst monitoring SSEPs/ MEPs?
- Lessen reverse correction
- check HB and transfuse
- elevate BP
- administer Stagnaras wake up test
- waking the patient during the surgery and asking them to move their feet.
- remove instrumentation if spine stable
Complications of spinal surgery on adolescent idiopathic scoliosis?
-
Neurological injury
- 1:1000
- Pseudoarthrosis
-
Infection 1%
- late pain
- incision often looks clean
- Propionibacterium acnes - most common organism for delayed infection
-
Flat back syndrome
- early fatigability & pain due to loss of lumbar lordosis
-
Crankshaft phenomenon
- rotational deformity of spine ctreated by continued anterior spinal growth in setting of post fusion
- avoid by preforming anterior discectomy + fusion with post fusion in young pt
-
SMA syndrome- superior mesenteric artery syndrome
- pc bowel obstruction
- tx with NG tube and iv fluids
-
Hardware failure
- late rod breakage
What is juvenile idiopathic scoliosis?
- scoliosis in children <10 years
What is the epidemiology of juvenile idiopathic scoliosis?
- Greater in females than males
- mainly appear right sided thoracic curves
What are the associated conditions of juvenile idiopathic scoliosis?
- high incidence of neural axis abnormalities = 18-25%
-
Syringomyelia
- cyst/tubular cavity within spinal cord
-
Arnold-Chiari syndrome
- cerebellar tonsil are elongated. Protrude thru thr opening of base of the skull and blocking CSF flow
- Tethered cord
- Dysraphism
- spinal cord tumours
-
Syringomyelia

How do they present with juvenile idiopathic scoliosis?
- School screening
- ADAMS forward bending test
- abnormal 7o= 20o coronal plane curve
- cafe au lait spots
- leg length discrepancy
- shoulder height difference
- truncal shift
- rib rotational
- waist asymmetry
- foot deformity- cavovarus
- asymmetrical abdo reflexes
What is seen on imaging of juvenile idiopathic scoliosis?
- Xrays PA & lateral upright
- Cobb angle >100
- MRI those who <10 years with curve >20o
What is the tx of juvenile idiopathic scoliosis?
Non operative
-
Observational
- curves <20o
- freq radiographs- see curve progression
-
Bracing
- curves 20-50o
- prevent curve progression, no correct deformity
- CI thoracic hypokyphosis
- 16-23 hrs until skeletal mature
Surgery
-
Non fusion proceedure- growing rods
- Curves >50o in small children- alot growth left
- allow continued spinal growth
- Definitive PSF +ASF when child grown
-
Anterior/posterior fusion
- Curves >50o in younger pts
- to prevent crankshaft phenomenon
-
Posterior Spinal fusion
- curve >50o in older pt skeletal mature
- gold standard doublecurves/ thoracic curves
-
Anterior spinal fusion
- curve >50 degrees with thoracolumbar/thoracic cases w normal sagittal profile
Define infantile idiopathic scoliosis?
- Scoilosis that presents prior to age 3
What is the epidemiology of infantile idiopathic scoliosis?
- 4% of idiopathic scoliosis cases
- more common in MALES
- autosomal dominance w variable penetrance
- location
- usually LEFT THORACIC
- Risk factors
- most resolve spontaneously
- apical vertebra rib overlap places curve at high risk of progression

What is infantile idiopathic scoliosis associated with ?
- Plagiocephaly- skull flattening
- Congenital defects
- Neural axis abnormalities
- 22% pt with curves >20o
- 80% of these will need neurosurgery
- Cardiopulmonary involvement
- pulmonary function affected curves >60o
- Symptomatic when curve >90o
What do you look for on exam of a pt with infantile idiopathic scoliosis?
- Skin
- cafe- au- lait- NF1/2
- patches of hair, dimpling, naevi- spinal dysraphism
- Cranial
- plagiocephaly
- Motor
- milestones
- lower extremity - cavovarus
- abdo reflexes- syrinx
What investigations are useful in infantile idiopathic scoliosis?
- Cobb angle
- evaluate phase of rib position- medial rib position w repsepct to apical vertebra
-
phase 1
- no rib overlap
-
Phase 2
- rib overlap with apical vertebra
- high risk of curve progression
- Rib Vertebrae angle difference - RVAD/Mehta angle
- >20 linked to high rate of pregression
- <20 assoc with sponataneous recovery
-
phase 1

What is the tx of infantile idiopathic scoliosis?
Non operative
-
Observe alone
- Cobb angle <30o
- RVAD <20o ( rib vertebrae angle difference)
- 90% resolve spontaneously
-
Serial Mehta casting (derotatonal )or thoracolumbosacral orthosis TLSO
- Cobb angle 25-30
- Phase 2 rib vertebra relationship
Operative
- Growing rod construct ( dual rod or VEPTR)
-
cobb angle >50-60 degrees
- allow growth of spine up to 5cm
- anchors proximal and distally
- serial lengthening
