Adolescent Idiopathic Scoliosis

Adolescent idiopathic scoliosis is

characterized by a lateral bending and
twisting of the spine. It is the most common
spinal deformity affecting adolescents 10 to
16 years of age. Children with scoliosis are
frequently referred to the patients primary
care physician by way of scoliosis screening
programs, school nurses, and concerned
parents. Although scoliosis is most common
in adolescents, the general principles of the
evaluation and diagnosis of scoliosis in
adolescents may be easily applied to
younger children.
Causes
The development of changes in the
alignment of the spine in adolescents has
been the focus of numerous studies. Multiple
causes for this condition have been
considered. The role of genetics in idiopathic
scoliosis has received the most attention and
twin studies show that identical twins have a
higher incidence than non-identical twins for
developing scoliosis. In addition, there is
another family member with scoliosis in
approximately 30% of children who present
with a scoliotic curve. Studies to identify the
specific gene that causes scoliosis are
underway. Research has also evaluated the
possible effects of hormones and the
adolescent growth spurt on changes in spinal
alignment. To date, a link between
adolescent scoliosis and the effects of hormones, such as growth-stimulating
hormone, has not been established. Abnormalities in connective tissue which affect
the structure and function of the spine, the muscles of the back and platelets have
been found in patients with scoliosis. However, it is unknown whether these
abnormalities is a cause or an effect of the abnormal spinal curvature. Finally, the
equilibrium system of the adolescent which controls balance and helps us to be
aware of the position of our bodies in space has been considered a possible factor
in idiopathic scoliosis. Additional research is ongoing.
PATIENT EVALUATION
History and Physical Examination
Adolescents may present for evaluation of
a spinal deformity in a wide variety of ways.
They may have had an abnormality noted during
a scoliosis screening examination in school, or
they or their parents may become concerned
about shoulder asymmetry, excessive round
back deformity, upper back pain (especially
associated with the use of book bags), waist
asymmetry, uneven pelvis, or rib deformity.
Once these concerns have been brought to the
attention of the pediatrician, family physician or
orthopedic surgeon a thorough history and
physical are necessary to differentiate idiopathic
scoliosis from scoliosis caused by trauma,
infection, tumor or spinal cord abnormality. It is important to note whether the child
or adolescent has experienced back pain. If pain is present, it is important to clarify
its character, duration, severity, and whether medications have been taken in an
attempt to relieve pain. Idiopathic scoliosis, in and of itself, is seldom a source of
pain. Complaints of bowel or bladder incontinence, difficulty ascending or
descending stairs, or pain radiating below the knee suggest neurological
involvement and are atypical in idiopathic scoliosis.
The physical examination for scoliosis emphasizes a comprehensive
evaluation from the adolescents head to his or her toes. Muscle strength, range of
motion and sensation of both arms and both legs are tested. Hamstring tightness,
sometimes seen as a limitation of forward bending with the knees fully extended,
should be noted. Reflexes at the knee and ankle and sometimes the abdomen are
also important parts of the physical examination. The feet should be examined for
any obvious asymmetry, clawing of the toes, a rigid high arch, or abnormal calluses.
With the patient standing in front of the examiner, the spine should be viewed
from behind. Neck range of motion is evaluated. This range of motion should be
possible without significant involuntary muscle guarding or spasm. Examination of
the spine begins at the base of the neck and extends to the pelvis. The spinous
processes should be examined and palpated to evaluate alignment. Symmetry of
the neck outline should also be noted. The two shoulder blades should appear to
be at the same level on the back. Motion of the shoulder blades should be
assessed by having the patient raise both arms over his or her head and then lower
them. Asymmetry of the lower spine is assessed by the presence or absence of
muscle fullness on either side of the spine, asymmetry of the waist, or the
appearance of an uneven pelvis.
The Adam's forward bend test is considered a standard in the examination
for scoliosis. The patient bends forward until the trunk is horizontal to the floor, with
hands hanging freely and knees fully extended. While
standing behind the patient, the examiner can assess
asymmetry of the rib cage as well as the lower back.
This asymmetry is noted as fullness or as an elevation
of one side in comparison to the other.
The need for a reliable screening tool to be
used in school settings gave rise to the development
of the Scoliometer. This specially designed
protractor measures the angle of trunk rotation, and
has been a simple and effective tool for identifying
patients who might benefit from referral for a
secondary evaluation and/or treatment of their
scoliosis. The Scoliometer is placed over the spine
and the angle formed while the Scoliometer is in
contact with the back is measured. An angle of 7 or
greater is an indication for further evaluation.
Typically, a measurement of 7 on the scoliometer
correlates with a 20 scoliotic curve on x-ray. The
patient is considered to need further evaluation and a
spinal x-ray if there is (1) an obvious deformity on the Adam's forward bend test, (2)
a Scoliometer measurement of 7 or greater, (3) a markedly uneven pelvis, or (4)
asymmetry of the shoulder blade or neck not due to poor posture.
X-Rays
The gold standard for evaluation of the child with a
potential spinal deformity is an x-ray of the entire spine on
a single film. The total radiation exposure is generally
considered minimal. The proper measurement of a
scolioic curve defines the angle formed by the least
number of vertebrae that produce the maximum degree of
angulation or curvature of the spine. The correct selection
of the upper and lower end vertebrae is critical to an
accurate measurement. By definition, the term scoliosis is
used only for curves that measure in excess of 10 by this
technique. Accurate measurement of the initial curve is
paramount to follow progression and to determine a
treatment regimen for the patient.
Skeletal maturity is an important factor in scoliosis because progression will slow or
end (unless scoliosis is severe) when vertebral growth is finished. The
disappearance of the growth plates in the upper end of the thigh bone and the hip
socket and the appearance of a growth plate at the top of the pelvis are important
indicators of skeletal maturity. The growth plate at the top of the pelvis helps to
define the Risser sign. The Risser sign
appears near the end of the adolescent
growth spurt and is seen as a white line
across the top of the pelvis on the
scoliosis x-ray. The appearance of the
Risser sign is divided into five stages. A
Risser 1 is when the line extends 25% of
the distance across the pelvis, Risser 2 is
halfway across, Risser 3 is 75% of the
way, and Risser 4 is all the way across.
The separation between this line and the
rest of the pelvis eventually disappears and when this happens the child is
considered to be a Risser 5, indicating skeletal maturity. As mentioned previously,
the x-ray provides useful information beyond the degree of scoliosis. A thorough
inspection of the spine x-ray reveals the presence or absence of abnormal
vertebrae, the degree of vertebral body rotation, whether the childs head is
centered over the pelvis, and the pattern of the curve.
Ongoing Evaluation and Treatment
The probability of curve progression is the primary consideration when
deciding whether to refer a patient to a pediatric orthopedic surgeon. Several
factors influence curve progression prior to the
completion of skeletal growth. These include (1) a
rapid increase in the rate of spinal growth during
puberty; (2) menarchal status; (3) skeletal
immaturity based on Risser sign; (4) whether the
patient is male or female; and (5) curve pattern.
The most rapid spinal growth occurs from
ten to twelve years of age in girls and twelve to
fourteen years of age in boys. This increase in
growth velocity means that there is a greater risk
of significant curve progression at twelve years of
age than at fifteen years of age. The increase in
the Risser stage and closure of the growth plates
are indicators of completion of skeletal growth.
Potential curve progression is greatest at Risser 0
and Risser 1 stages; however, there is variability
between girls and boys in the correlation between
the Risser stages and risk of progression.
The curve pattern by x-ray is also important. The curve is described by the
total number of vertebrae included in the deformity, which direction the spine curves
(left or right), and, finally, the location of the curve. Thoracic curves (curves in the
upper part of the spine) most commonly have the apex to the right. A left thoracic
curve should raise suspicions for possible involvement of the spinal cord as well as
the vertebrae. In general, double curves progress more frequently than single
curves, and, of the single curve patterns, a thoracic curve has a higher likelihood of
progression than a lower (lumbar) curve.
TREATMENT
The pediatric orthopedic surgeon will take into account the patient's physical
examination, the x-ray appearance of the curve, and the degree of skeletal
maturation in determining a treatment plan. The choices include (1) reassurance,
(2) observation, (3) brace wear, and (4) surgery.
Reassurance
Reassurance regarding the condition is offered to patients in whom the
likelihood of progression is extremely low and the present curve is minimal. Most
pediatric orthopedists will counsel patients about the low probability of curve
progression if the curve is small and they have completed their growth spurt. In all
likelihood, follow-up will not be necessary.
Observation
For the patients who are considered
skeletally immature because they have open growth
plates, a Risser stage less than 2, or are
premenarchal, and for those who present with a
curve that measures between 20 and 25,
observation and follow-up are indicated. Follow-up
x-rays and examinations are necessary to document
the lack of significant progression until the
completion of skeletal growth. Evidence of
significant progression warrants consideration of
brace wear.
Brace Treatment
The indication for offering brace wear to an
adolescent is the presence of a curve between 25
and 45 and a high probability of progression. The
majority of brace wear now offered to patients is an
underarm thoracolumbosacral orthosis (TLSO). The
underarm brace is a custom-molded device
prepared in such a manner as to control curve progression through padding,
contouring, or both. The majority of brace wear offered in the United States fits
beneath the clothing and is worn for most of the day and night. However,
extracurricular activities are encouraged and may be participated in out of the
brace. The full-time underarm brace is preferred for management of most curves.
An alternative to the TLSO is the Charleston or
Providence bending brace. This brace is primarily for
single small lumbar curves and it is worn only at
night. When fitted properly it should bend the trunk
in the opposite direction, straightening out the
scoliotic curve.
Monitoring progression of the curve until skeletal
maturation is necessary with both the TLSO brace and
the Charleston brace.
With any bracing option, the goal is to prevent or
slow the rate of progression of the curve during the
rapid adolescent growth spurt. It is felt that the
effectiveness of the brace is directly related to the
amount of time spent in it. However, despite the best
efforts of some patients and their families sometimes
the curve can progress in the brace.
Physical therapy, exercise programs,
chiropractic manipulations, electrical stimulations, and
special diets have all been studied as alternative
treatments for scoliosis. To date, none of these have
been proven to prevent or slow curve progression.
Without brace With brace
Surgery
Spinal surgery is recommended for mature adolescents with large curves
that are likely to progress in adulthood. It is also recommended for growing
adolescents who have curves that are already 40 to 50 and have significant
potential for worsening with continued growth. The goal of surgery is to diminish the
scoliotic curve, then maintain the corrected position during the 6 months required for
complete healing. The use of instrumentation (metal rods, hooks, screws and
wires) has eliminated the need for a cast or brace after surgery in most cases.
There are few long-term limitations after successful fusion.
The vertebra to be fused are identified and then
screws or hooks are attached to the bones (A).
The first rod is shaped or rotated to provide safe
correction of the spinal curvature (B). A second
rod is added to help maintain the correction (C).
Bone graft is added over the
spinal instrumentation to
produce the spinal fusion
B C A
CONCLUSION
Adolescent idiopathic scoliosis is usually a benign condition that results in a
mild to moderate deformity associated with few limitations of function. The vast
majority of patients presenting for an evaluation will ultimately be diagnosed with a
curve that measures less than 15. In general, these patients will not require follow-
up with the specialist. Bracing will be offered to those adolescents who have curves
between 25 and 45 and who are considered skeletally immature. The skeletally
mature fifteen to seventeen year old with a curve between 25 and 40 should be
reassured that long term problems related to their scoliosis are unlikely.
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John T. Killian, MD 2009
Fifty degree scoliosis is reduced to ten degrees
with two rods and multiple screws