Scoliosis

Question 1

Kyphosis

Answer 1

Normal curvature of T spine

Anterior concavity

Question 2

Scoliosis

Answer 2

Abnormal curve, primarily in coronal plane
Pathological or functional lateral curvature of spine
Lateral deviation in normally straight vertical spine

Most common is a double major curve - thoracolumbar
Pelvic imbalance

Single lumbar curves are NOT common

Question 3

Naming the Curve

Answer 3

Named for side of convexity
Sidebends and rotates opposite
Primarily in coronal plane (SB)

Question 4

Idiopathic Scoliosis

Answer 4

Most common presentation

Infantile: 0 - 3 yo
Juvenile: 4 - 9 yo
Adolescent: 10 yo or greater

Question 5

Infantile Idiopathic Scoliosis

Answer 5

Male > Female
Convexity to the left
Curve usually thoracolumbar
Only 15% are progressive
85% resolve spontaneously
If curve > 35 degrees refer to ortho

Question 6

Juvenile Idiopathic Scoliosis

Answer 6

Curves appear around age 6-9 yo
Most progress steadily
Occasionally quiescent then become progressive
Refer if Cobb angle > 20 degrees
Treatment: casting, bracing, surgery, OMT, exercise

Question 7

Adolescent Idiopathic Scoliosis

Answer 7

Most common presentation
80-85% of cases
Incidence almost equal between males and females
Progression to surgery- more common in females
Deformity increases with growth spurt

Curve types

• most common = double major: right thoracic and left lumbar
• 2nd = right thoracic
• 3rd = single thoracolumbar
• 4th = double thoracic
• 5th = isolated left lumbar (rare)

Question 8

Congenital Scoliosis

Answer 8

Failure of formation

• wedge vertebrae (partial unilateral)
• hemivertebrae (compete unilateral): partial segmentation; non-segmented

Failure of segmentation

• unilateral unsegmented bar
• bilateral (bloc vertebrae)

Approximately 25% will not progress
Approximately 50% will progress - will need surgery
Approximately 25% will progress slightly but will not need surgery

Question 9

Congential Scoliosis - Related Anomalies

Answer 9

Urinary Tract = 20%

• similar embryologic origin
• 6% life threatening

Cardiac = 10-15%

Spinal Dysraphism = up to 20%

• failure of spine to close properly along midline
• may also lead to club feet, pes planus, lower extremity asymmetry

Question 10

Neuromuscular Scoliosis

Answer 10

Cerebral Palsy

• trauma pre/postnatal
• upper motor neuron disease

Polio
- lower motor neuron disease

Duchenne’s muscular dystrophy
- chemical imbalance in structure of muscles

Question 11

Syndromic Scoliosis

Answer 11

Marfan's
Ehlers Danlos
Neurofibromastosis
- scoliosis if frequent
- combined kyphoscoliosis also common
- may have dural ectasia: widening of dural sac impairs spinal tissue; look for cafe au lait spots or neurofibromas

Question 12

Acquired Scoliosis

Answer 12

Structural short leg syndrome
Psoas syndrome
Poor posture
Healed leg fracture
Post hip prosthesis surgery
Splinting from pain

Question 13

Etiologies Theories

Answer 13

Multi factorial
Genetic loci
- Chrom 8, 9, 17, 19
Growth hormone secretion
Connective tissue structure
Vestibular function - axial posture

Question 14

Office Screen

Answer 14

Level of hips
Arm length
Bulge on back
Lean to side
Prominence of scapula

Body will try to keep eyes level:

• shoulder height difference
• posterior scapula
• crease at waist

Question 15

Evaluation and Landmarks

Answer 15

Posture
Shoulder height
Arm length
Scapula - superior and inferior borders
Iliac crests
Leg length

Adams Forward Bend Test

• indicates rotational component
• asymmetry noted on the side of the convexity
• rid prominence

Question 16

Cobb Angle

Answer 16

Select most cephalad vertebra that has the most curvature
Select more caudal vertebra that has the most curvature
Draw right angles to both these lines
Where they cross = Cobb’s Angle

Gold standard (10 degrees defines scoliosis)

Question 17

Indications for Referral to Ortho

Answer 17

Cobb angle > 20 degrees

Progression of Cobb angle > 5 degrees

Question 18

Treatment for Idiopathic Scoliosis

Answer 18

0 - 10 degrees, asymptomatic, skeletally immature patient

• OMT
• observation with follow up every 4-6 months

10 - 20 degrees, asymptomatic, skeletally immature patient

• OMT
• clinical exam and x-rays 4-6 months until mature skeletally

> 20 degrees, skeletally immature

• ortho referral
• OMT

0 - 30 degrees, skeletally mature

• OTM
• follow clinically

Goal - prevent progression to 50 degrees
- cause problems structurally. With cardiopulmonary function, back pain, etc.

Question 19

Bracing

Answer 19

Goal = halt progression
Curve usually 20-45 degrees
Not often effective for large curves
Not always effective even if done properly
Need to wear >16 hrs/day x 4 yrs

Question 20

Milwaukee Brace

Answer 20

23 hrs/day
20-40 degree curve
Used in growing patients
Necessary to exercise muscles supported by brace

Question 21

Boston Brace

Answer 21

Works on deformities such as lordosis and rotation as well as scoliosis
Apex of curve must be below T10
TLSO = Thoracic, Lumbar, Sacral Orthotic

Question 22

Charlestown Nighttime Brace

Answer 22

Worn only at night
Side bends child into curve
Studies have shown that it’s as affective as 23 hr braces
Allows child to participate in activities without a brace

Question 23

OMT and Scoliosis

Answer 23

Goal: restore mobility to MS system where possible
Comprehensive evaluation
Patient education important to success

Maintain flexibility and thus function
Encourage better compensation
Reduce/avoid side effects

Question 24

Surgical Procedures

Answer 24

Posterior Spinal Fusion (PSF)
- segmental implants

Harrington Rods

• large scar
• sometimes bone grafting used to help use segments
• new technology now doing through scopes to minimize scaring

Stapling convexity side of vertebra to prevent progression

Question 25

Lordosis

Answer 25

Normal curvature of C and L spine

Anterior convexity