Scoliosis

Question 1

You are seeing a 14-year-old girl who has been complaining of some back pain in the thoracic spine area in the last 2 weeks. She rates the pain 2- 3/10 and described the pain as an ‘annoying pain’ that is there most of the time. She does not get woken up from sleep by the pain. She is also a keen horse rider and her mother has noticed that she is not sitting properly in her saddle with her right shoulder always higher than the left.

Impression/DDx/Goals

Answer 1

Impression
Most likely adolescent idiopathic scoliosis (90% between 10-18 yrs) given pain, asymmetrical posture. I would like to rule out other causes of spinal deformity including syringomyelia (cyst in spinal column), and neuromuscular or congenital scoliosis.

Complications
- Risks of reduced respiratory function

DDx
- Malignancy (primary bone malignancy, mets)
- MSK pain (general)
- Spondylolisthesis/Spondylosis
- Trauma
- Fracture
- Connective tissue: ehlers danloss, marfans
- inflammatory arthropathies

Goals:
- identify underlying cause, rule out differentials
- comprehensively asses and institute appropriate patient management

Question 2

Scoliosis - History

Answer 2

History
- sx: pain history, motor/sensory deficits or changes, gait changes, asymmetry, posture changes, radiculopathy
- REDS: constitutional sx, night pain, neurological sx
- risk factors: age>10, family history, onset of pubertal growth spurt, puberty history (how far along - Tanner stage hx)
- PSHx, PMHx, FamHx
- Social (HEADSSS assessment)
- Paediatric history (ADING)

Question 3

Scoliosis - Examination

Answer 3

Examination
- general inspection: looking for shoulder +/- waist +/- thoracic wall/breast asymmetry, paraspinal prominences, skin changes
- Scoliometer measurement (>5%)
- MSK: spinal ROM, tenderness, leg length discrepancy, obvious deformity (L-sided is R flag is it rarer).
- Assessment of pubertal development:
o Tanner stages to assess stage of puberty
- Neurological examination (UL/LL)

Question 4

Scoliosis - Investigations

Answer 4

Investigations
- Scoliosis is predominantly a clinical diagnosis made on the basis of physical examination.

However, imaging studies can be utilised to further assess the extent of scoliosis, and are useful in planning of definitive management options
- Standing PA and lateral X-Rays of cervical, thoracic, lumbar, and sacral spine - looking for Cobb angle >10 degrees in <13 yrs, >20 degrees in 13-17yrs
- X-Ray of non-dominant hand for skeletal maturity assessment - growth velocity
- MRI (if for surgery)

Question 5

Scoliosis - Management

Answer 5

Management:
Supportive
- Regular review to monitor for progression
- Regular exercise: including core strengthening exercises
- Referral to paediatric orthopod for further assessment and advice on ongoing management plan
- Patient education given increased risk of degenerative changes
- Simple analgesia PRN

Definitive
- TLSO Bracing - prevents further scoliosis until musculoskeletal maturity at which point risk of progression is limited - must wear for 20-23 hours per day
o growth spurt is prior to menses, so if before menses then higher risk of progression
o if high growth potential and high Cobb angle, then this is indication for bracing
o Cobb angle greater than 40 degrees then go to surgery.
- Surgical spinal arthrodesis if severe and red flag sx; referral to paeds spinal ortho team
o growth modulation without fusion
o growth modulation with fusion