Orthopedics

Scoliosis

Background

Scoliosis is defined as a curvature of the spine greater than 10 degrees in the AP plane and is often accompanied by rotation. It is more common and likely to progress in girls. 

Etiology

  1. Idiopathic accounts for the majority of cases, and it is further subdivided by age (infantile 0-3 years old, Juvenile 4 to 10 years old, and Adolescent 11-18 years old). Likely a small genetic contribution.
  2. Associated with connective tissue disorders such as Marfans, homocystinuria, and Ehlers-Danlos. 
  3. Underlying neuromuscular disorder, intraspinal lesions, or leg length discrepancy

Clinical Assessment

  1. History
    Note: questions are centered upon determining an etiology and risk of progression
    1. Family history of scoliosis
    2. Presence of back pain- idiopathic usually asymptomatic
    3. Shortness of breath or difficulty breathing
    4. Neurologic or limb changes- development of limp, joint or limb pain 
    5. Bladder and bowel habit changes- associated with spinal cord abnormalities
    6. Weakness
    7. History of secondary sexual traits development. Menarche? 
    8. Renal or cardiac defects- some associated with scoliosis
    9. Ataxia
  2. Physical Examination - should detect curvature and rule out underlying causes such as leg length discrepancy, neurologic abnormalities, and hip pathology
    1. Height and weight
    2. Examine spine for tenderness
    3. Measure lower extremities to rule out leg length discrepancy
    4. Observe gait
    5. Sexual maturity assessment
    6. Check skin for lesions associated with neurofibromatosis, hair patches along the spine
    7. Check feet for signs of high arch 
    8. Thorough neurologic exam including strength assessment
  3. Scoliosis Examination:
    1. Inspection: Observation of patient from back and front looking for asymmetry of the shoulders, scapulas, iliac crest, angle between the arms and body, breast height.
    2. Adams forward bend test: demonstrates the rotational component of scoliosis. Sensitivity and specificity depends on skill of examiner
      1. Observe patient from the back while he or she bends forward at the waist until the spine becomes parallel to the horizontal plane, with feet together, knees straight ahead, and arms hanging free
      2. If  scoliosis present, a thoracic (rib) or lumbar (loin) prominence on one side will be evident
    3. Scoliometer: A version of a carpenter's level that measures the angle of trunk rotation.
      1. It helps determine which patients need radiographs 

Scoliometer.jpg
https://commons.wikimedia.org/wiki/File:Scoliometer.jpg

Radiograph Evaluation

  • required to confirm the diagnosis of scoliosis
  • determine the type (congenital, neuromuscular, idiopathic)
  • determine severity
  • evaluate skeletal maturity (to determine the risk for progression)
  • Standing PA and lateral of the spine. Before ordering other tests, should consult with orthopedic surgeon to avoid unnecessary radiation and expense.
  • Asymmetric height discrepancies should be corrected when getting radiograph

Risk for Progression: Impossible to predict which complete accuracy which curves will progress

  1. Sex: 3-10 times more likely in females
  2. Curve magnitude: Cobb angle 20-29° more likely to increase by ≥5° than Cobb angle 5-19°
  3. Curve pattern: Double and thoracic curves are 3x more likely to progress
  4. Maturity: assessment depends on several markers (Risser sign, chronological age, menarchal status)

Complications

  1. Pulmonary compromise- restrictive lung disease uncommon with curves less than 100 degrees.
  2. Pregnancy usually not affected
  3. Not associated with pain. This is the reason that scoliosis may go undiagnosed.
    1. Progression after maturity
    2. 30 degrees little progression
    3. 30-50 degrees- may progress 10-15 degrees during lifetime
    4. 50 degrees- may progress 1 degree per year

Treatment

Must treat underlying etiology if present; otherwise, idiopathic cases are treated as stated below

  1. Physical therapy and exercises have no role in treatment.
  2. 20 degrees- careful follow-up at q6-8 month intervals. If progression ≥5° at followup, treatment indicated
  3. 30-40 degrees & skeletal immaturity OR ≥5° progression at followup interval- consider bracing. Efficacy is questionable in correcting curvature and preventing progression. Wearing a brace continuously is associated with self esteem issues, compliance problems, physical activity limitations, sleep disturbances, and being hot.
  4. 40 degrees consider surgery 

Controversies in Scoliosis Detection and Management

  1. Effectiveness of large school based screening programs? Does earlier detection improve outcomes?
    1. Proponents suggest that earlier detection permits conservative therapy (ie bracing)
    2. Opponents suggest scoliosis lacks characteristics needed for good screening (ie high prevalence, a test with high sensitivity, ability to alter natural course, cost effective)
  2. Effectiveness of braces
  3. Effectiveness and when to operate.

The role of the pediatrician is to detect significant curvature of the spine, rule out any underlying disorder that is related to the scoliosis, and refer the patient to the appropriate subspecialist. With minor deformities, it is appropriate for the pediatrician to observe the patient and follow at frequent intervals. It is important that when making a referral, that the specialist is familiar with scoliosis is pediatric patients. It is also important that the pediatrician doesn't unnecessarily alarm the family and child.

References

  1. Scherl, Susan A. Clinical features; evaluations; and diagnosis of adolescent idiopathic scoliosis. UpToDate Inc. Last updated 10/4/2011. Accessed 4/1/12. Http://www.uptodate.com
  2. Scherl, Susan A. Treatment and prognosis of adolescent idiopathic scoliosis. UpToDate Inc. Last updated 10/13/2010. Accessed 4/1/12. Http://www.uptodate.com
  3. Ascher, Marc A, and Burton, Douglas C. Adolescent idiopathic scoliosis: natural history and long term treatment effects. Scoliosis. 2006. 1(2).
  4. SOSORT guideline committee. Indications for conservative management of scoliosis (guidelines). Scoliosis 2006. 1(5).
  5. DiGuiseppi, Carolyn, and Woolfe, Steven. The Family Physician's Role in Adolescent Idiopathic Scoliosis. An Editorial . American Family Physician Volume 53 # 7 pages 2268-2272.
  6. Chin K. et al. A guide to early detection of scoliosis Contemporary Pediatrics September 2001
  7. Reamy B. Adolescent Idiopathic Scoliosis: Review and Current ConceptsAmerican Family Physician. July 1, 2001
  8. King and Sarwark.  A Look at Scoliosis  The Child's Doctor Spring 2002
  9. AAP. Screening for Idiopatic Scoliosis in Adolescents.  Journal of Bone and Joint Surgery Jan 2008
  10. Hresko, HT.  Idiopathic Scoliosis in Adolescents,  NEJM Idiopathic Scoliosis in Adolescentsebruary 28, 2013