Scoliosis Flashcards
Scoliosis
Refers to deformity of the spine involving the lateral curvature and vertebral rotation
3 Classifications of Scoliosis based on Etiology
- Non Structural
- Transient Structural
- Structural Scoliosis
Non-Structural
Flexible reversible (minor) curvature with minimal rotation
Curve will spontaneously correct with side bending towards the convexity of curve or when patient is supine
Examples:
Compensatory curves caused by LLD
Habitual poor posture or those curves above or below major curves
Transient Structural Scoliosis
Reversible type of curvature which appears structural but will spontaneously correct when the underlying cause has been corrected
Example curves caused by pain or muscle spasm from sciatica, inflammation, or trauma
Structural Scoliosis
Irreversible (major) curvature with marked rotation
Does not correct with side bending or removal of gravity
3 types
- Idiopathic
- Congenital
- Neuromuscular
Idiopathic structural scoliosis
Unknown specific cause with probable genetic origins. Accounts for approximately 80% of all braced scoliosis.
Congenital structural scoliosis
Skeletal deformities such as hemi vertebra or failed segmentation (not braced)
Neuromuscular structural scoliosis
Neuropathic forms such as cerebral palsy or polio, myopathic forms such as DMD (usually accommodated, braced to allow for improved sitting position in chair)
Classes of Idiopathic Scoliosis
Infantile (10 years, chance of occurrence 2 years post menarche is minimal)
Infantile IS
<2 years Rare Affects M=F Left thoracic most common Some resolve spontaneously Rib vertebral angle less than 20 degrees is predictive of resolution Treated with serial cast or brace
Junvenile IS
<10 years
Mild precursor to AIS
Associated with Arnold Chiari Malformation (15% of cases)
Brace if curvature is greater than 20 degrees
Adolescent IS
> 10 years, chance of occurrence 2 years post menarche is minimal
80% female
Often seems like it occurred overnight
Usually brace between 20-45 degrees
Beyond 45 degrees, bracing ineffective, surgery is indicated
Common Idiopathic Curvatures
Curve patterns fall in to 4 distinct patterns
- Thoracic
- Thoracolumbar
- Lumbar Curve
- Double Major Curve
Thoracic Curvature
Major structural curve
Usually to the right, with minor compensatory curves occurring above and below
Apex above T10
Thoracolumbar
Longer structural curve
Either left or right with minor compensatory curves above or below
Apex between T10-L2
Lumbar Curve
Major structural curve, usually to the left
Thoracic compensatory curve remains flexible
Apex L2 or lower
Double Major Curve
Major Lumbar Curve, usually left
Major thoracic curve usually right
Usually well compensated and balanced
Initial Manifestations of Scoliosis
Ribs on convex side of the curavture are pushed posterior and begin to separate
Ribs on concave side of the curve are pushed anterior and are compressed together
Secondary Changes
Disc Spaces become narrower and wedging of the vertebra toward the concave side
The pedicles and lamina become shorter and thinner on the concave side
The spinal canal narrows toward the concave side
Vertebral body distortion toward convex side
Once secondary pathologic changes set in
Curve and rotation will become more rigid and harder to correct
Secondary changes will turn minor non structural compensatory curve into a structural one
Tendency for increase in lumbar lordosis, thoracic kyphosis associated with scoliotic deformities
Most favourable indications for orthotic treatment includes
Curves in children with at least 1, preferably 2 years of growth remaining
Curves between 25-40 degrees with apex of T8 or lower with 50% flexiblity
Goal of the orthosis
To prevent or slow the progression of the curve until skeletal maturity is reached
Skeletal Maturity Males/Females
Males finish around the age of 18
Girls finish growing around the age of 16, 2 years post menarche
Schedule of wear
General research has shown that most effective orthotic treatment is with compliance of 23 hours a day of brace wearing
Minimum 18 hours, it is best to stress longer rather than shorter number of hours as patient compliance can be an issue
Physiotherapy
Plays active role in scoliosis treatment, increase flexibility of hip flexors, hamstrings, and para spinal muscles and maintain core strength
Improve effectiveness of the brace
Indications for Milwaukee
T7 apex or higher
active correction
Indications for Charleston
Night brace
Best for single curves
Antigravity
Bending brace
Boston
T8 or lower
Custom Molded
T8 or lower
Cheneau
Primarily done in Europe, starting in USA
Highly aggressive
Providence
Night Brace
Treatment Theories (2)
- Solid Pelvic Base
2. Outrigger or extensions form base for pressure application
Solid Pelvic Base
a) Prefabricated pelvic module
b) Symmetrical
c) Partial reduction of lordosis (usually 15 degrees is what is included)
Theory behind the reduction of lordosis is to unlock the facet joints to allow for greater back flexibility
Outrigger or extensions form base for pressure application
a) use of force couples where ever possible
b) relief of areas or voids created opposite the corrective force
c) trimlines established according to x ray
d) lumbar corrective pressure applied by pad over the musculature directly lateral to transverse processes
e) length of lumbar pad from distal base of curve to apex or “null point” of lumbar curve
f) thoracic corrective pressure applied to ribs, transferring force to vertebrae
g) length of thoracic pad from distal base of curve to rib attaching to vertebra at the apex of null point of the thoracic curve
h) physiotherapy- stretching and strengthening exercises
Weening off period
Usually 6 month weening period
Once curve has been shown not to be progressing and patient has riser sign of 5
Surface Anatomy, Important Landmarks
Spine of Scapula/Superior Angle Inferior angle of Scapula PSIS ASIS Waist roll Pubic bone Xyphoid Process Umbilicus Greater Trochanter
Orientate X ray
Heart (left side)
Stomach Bubble (left side)
X- ray marker
Examinate X ray
Type of Curvature Direction of Curvature Range of curve Magnitude of the angle (Cobb angle) Apex of the curve Rotation (pedicles) Presence of pelvic obliquity Riser sign Head compensation
Risser Classification
Classification of Illiac Epiphysis to evaluate skeletal maturity
Ossification progresses from direction of ASIS to PSIS
Based on % of excursion
Risser sign indicates change of curve progression
Rotation - Nash Moe Technique
Measures pedicle rotation by dividing vertebral body into segments
Segment into which the pedicle is located quantifies the rotation
Uses symmetry of pedicels as point of reference, migration of pedicles toward the concavity of the curve determines degree of rotation
Why Treat Scoliosis
Cosmesis
- mild 20-30 degree do not experience pain
- body image
Decreased Pulmonary Function
- 20-30 degrees, lung capacity is decreased to 75-80% of normal
Pain as an adult
- mild curvatures do not experience more back pain than normal population
- however >40 degrees may experience pain
- also tend to be a progressive curve, 1 degree/year increase
Orthotic Management
is only non operative method to alter natural history of progressive scoliosis
ONLY BRACE UNTIL SKELETAL MATURITY
~14 in girls
~ 17 in boys
Indications and Goals for Bracing
Infantile - usually self correcting
Juvenile and Adolescent
- 20 decision to brace is made
- 25 to 40-45 degrees
- skeletal immaturity
- Risser 0, 1, 2
Goals
Stop Progression
Prevention of Surgery
Delay of Surgery- earlier you fuse vertebrae, more likely you will lose height
Patient History
Age
Height and Weight
Presence of family history
Menarche- indicator of skeletal maturity
Progression in the curvature
Visual Assessment - Back
Head- shifted to left or right
Shoulders - level
Scapula - height, winging
Ribs - one side more posterior than other
Waist roll- one side more prevalent
One arm hangs closer
Pelvic obliquity
Knees, legs, ankles, foot position
Visual Assessment - Front
Check shoulders
Breast Asymmetry
ASIS position - one lower than the other, more anterior
Lateral pelvic tilt
Sagittal
Kyphosis
Lordosis
Pelvic Tilt
Adam’s Forward Bend Test
Forward bend with hands clapped together
No knee bend
Sighting down the spine
DO NOT say “touch your toes”, maybe a presence of asymmetrical hamstring tightness
Thoracic region: Rib hump
- on the convex side
Lumbar region: Prominence of paraspinal muscles
X-Ray Evaluation (9 points)
- Type of Curvature
- Direction fo Curvature
- Range
- Apex
- Degree
- Rotation
- Bony Age (Risser or wrist)
- (De)Compensation
- Pelvic Obliquity
X-Ray Orientation (4)
Viewed from POSTERIOR to ANTERIOR
4 Identifiers
Location of the heart - situated on the left
Stomach bubble on the left
Liver located on the right
Marker on the X ray
Brace selection based on
Location of apex of the curvature
Type of curvature
Patient Compliance
SpineCor
Uses dynamic forces to cause body to work in conjunction
Simulate continual physiotherapy
Correction movement to become neuromuscularly indicated
Worn 20 h a day
Mild to moderate curvatures
