SCOLIOSIS Flashcards
PATHOLOGICAL CURVE
any curve which is greater or equal to 10 degrees, with or without a rotatory component
KYPHOSIS
normal range of thoracic kyphosis to be 20 to 50 degrees, increases with aging
sagittal curves with a posterior vertex (concave anteriorly)
LORDOSIS
normal lumbar lordosis can range from 31 to 79 degrees,
a sagittal curve with an anterior vertex (concave posteriorly
SPINAL COLUMNS
The anterior column is composed of the anterior longitudinal ligament and the anterior portion of the vertebral body.
The middle column is made up of the posterior wall of the vertebral body and the posterior longitudinal ligament.
The posterior column is formed by the posterior bony arch, which consists of the transverse processes, facets, laminae, and spinous processes.
SCOLIOSIS
Idiopathic - Infancy to adolescence
Neuromuscular - Childhood to adolescence
Bone or ligamentous dysfunction - Childhood
Traumatic/posttraumatic - All ages
Infectious or neoplastic - All ages
Degenerative Middle - age to seniors
HISTORY
AGE OF ONSET AT BIRTH – CONGENITAL ADOLESCENCE – GROWTH SPURT ONSET OF THE CURVE DEGREE OF CURVATURE AND PROGRESSION SYMPTOMS – FATIGUE, DYPSNEA, SHORTNESS OF BREATH, LOSS OF BALANCE, DEVELOPMENTAL MILESTONES
PHYSICAL EXAMINATION
General Examination – review of systems
Physiatric Clinical Examination
Surface Anatomy – observe spine while prone, side lying, sitting and standing
Palpation of the spinal curvatures
Truncal range of motion in all planes—forward flexion, rearward extension, R & L lateral flexion, and R & L lateral rotation
ADAM’S TEST - While the patient is flexing forward, the examiner should look at the shape of the rib cage for prominence or humping
Rib Cage Deformity
Pelvic symmetry - either at the brim of the pelvis at the iliac crests or at the posterior superior iliac spines, which is seen on the surface of the buttocks as the two sacral “dimples.”
Symmetry of the head and the appendicular skeleton
Upper Limb - from the acromioclavicular joint to the radial styloid.
Lower Limb - from the anterior superior iliac spine at the pelvis down to the medial malleolus
DIAGNOSIS
X-RAYS
SCOLIOTIC SERIES – cervical, thoracic, lumbar
The P-A film - should be taken with the arms at the side STANDING
to fully visualize the hips, pelvis, and proximal femurs
the Lateral film - should be done with the arms at 90 degrees of abduction to keep the upper limb from obscuring the spine
PELVIS AP
Assessing Vertebral Integrity
The spinal elements should be inspected for signs of hemivertebra, unsegmented bars, and/or bifid spinous processes
The ribs should be viewed to look for asymmetry or changes in the natural curve.
The pelvis should be examined for signs of asymmetry
The hip joint should be examined for signs of subluxation
FEMUR – asymmetry
CT and MRI – other modalities that may be used for scoliosis
X-RAY
COBB’s ANGLE – curve angle
first note the upper border, lower border, and vertex of the curve.
classified by the position of the vertex into thoracic, thoracolumbar (vertex at the thoracolumbar junction), or lumbar
ASSESSING ROTATION
the position of the pedicles provides the best sense of degree of rotation on a plain x-ray
If asymmetry is present, the pedicle that is more prominent will indicate rotation away from that side of the vertebra.
SYMPTOMS
Pain
40 – 90 % in adult scoliosis, and increase risk if diagnosed during childhood or adolescence
Kyphosis – Scheuermann’s disease – 20 – 60 % of symptoms
Abscess or disciitis
Epidural hematoma
Tumors
Congenital deformities – OI, achondroplasia,
Mobility
spine asymmetry is likely to exacerbate the difficulties with balance control
increased amounts of sagittal and lateral sway in standing, along with increased sway radius, leading to decreased stability in standing
increased losses of balance and falls as well as increased and asymmetric stress on lower limb joints
Cardiopulmonary Symptoms
Most critical, a compromise to the cardiovascular system
begins with restrictive lung disease resulting from deformity of the bellows mechanism formed by the rib cage, thoracic spine, and diaphragm – decrease in lung vital capacity
70 degrees - a mild decrease in vital capacity
90 to 100 degrees - the patient with have dyspnea on effort
curves greater than 100 degrees - alveolar hyperventilation, CO2 retention, pulmonary hypertension, and right-sided heart failure are seen
Emotional and Behavioral Health
Poor self esteem due to deformity
poorer body image and greater unhappiness,
increased participation in high-risk behaviors
greater incidence of depression
PATHOPHYSIOLOGY
Intrinsic
Bony Abnormalities – CONGENITAL and ACQUIRED
Supporting/Elastic Tissue – Ligaments and Discs
Neuromuscular – Weakness, Motor and Sensory
Extrinsic
Mechanical – Leg, Pelvis Assymetry, Above Pelvis
Neuromuscular – Weakness, Motor and Sensory
BONY DYSFUNCTION
Congenital
Some outright and some subtle may show when the child is sitting or standing
a failure of segmentation, a failure of formation, or a combination of both
Acquired
Trauma
Infectious Diseases – Pott’s Disease or TB osteomyelitis / Pyogenic – Strep. A
Tumors - osteoid osteoma, osteoblastoma, giant cell tumor, and aneurismal bone cyst
Degenerative – Osteoarthritis,
ELASTIC DYSFUNCTION
Congenital osteogenesis imperfecta, achondroplasia, Marfan syndrome (fibrillin) (laxity of joint) , and Ehlers Danlos syndrome.(collagen) (laxity of joints) Acquired Trauma Infection Neoplasm
NEUROMUSCULAR DYSFUNCTION
Congenital Charcot-Marie-Tooth Disease Riley-Day familial dysautonomia (an autosomal recessive disorder at chromosome 9q31-q33) Friedrich’s ataxia Spinal Muscular Atrophy Acquired Tumors - Neurofibromatosis
IDIOPATHC
Categorized by the AGE OF THE ONSET OF THE CURVE
INFANTILE – occurs at less than 3 years old
usually benign, with 80% to 85% resolving spontaneously
Curves of less than 25 degrees with a rib-vertebral angle difference of less than 20 degrees can be monitored with radiographs every 4 to 6 months until the curve resolves and then every 1 to 2 years until the child reaches skeletal maturity.
Larger curves are usually managed with a body cast and progressed to a molded orthotic once the child is older and the rate of growth slows.
SURGERY – if the curve progresses
JUVENILE
includes children over 3 years of age and less than the age when signs of physical maturity start to become apparent
half will only need orthotic intervention, while the other half will eventually need surgical fixation
monitoring every 4 to 6 months is considered acceptable for curves less than 25 degrees.
Curves beyond 20 to 25 degrees will require active intervention, beginning with orthotic management.
Adolescent
onset is after the initiation of puberty
the size of the curve at onset (which is positively correlated with progression) and the age and level of maturity of the patient (which is negatively correlated with progression.
Tanner scales (which use external signs of sexual maturity)
Risser’s sign (which is an indication of the degree of epiphyseal closure at the iliac crest)
formal bone age radiographs of the hands.
If the curve continues to progress to more than 40 degrees before the patient achieves skeletal maturity, planning for surgery should begin
PHYSIATRIC TREATMENT PLAN
Exercise cannot stop the progression of the curve - primarily to prevent secondary morbidities and to reduce the adverse influence of extraspinal processes (such as asymmetric limb joint contractures) on a progressive spinal deformity.
patients with idiopathic scoliosis (especially under orthotic management) run the risk of core muscle weakness - abdominal and gluteal strengthening exercises should be done to prevent deconditioning and atrophy.
range-of-motion exercise of the hip flexors should be done to prevent contracture
to restore range of motion and strength should begin as soon as pain has been controlled in order to return the person to his or her premorbid functional state
to improve trunk posture and alignment may prevent the development of pathological curvature – Degenerative scoliosis
PHYSICAL MODALITIES
Limited, secondary and supportive
Treat the symptomatic symptoms
Massage, electrical stimulation, traction, and/or spinal manipulation should also be considered only for symptomatic treatment
