Dibyendunarayan BidSenior Lecturer

Sarvajanik College of Physiotherapy, Surat

Scoliosis is defined as a lateral curvature of the spine combined with a rotational component, due to various etiologies. : -Scoliosis Research Society (SRS).

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Nonstructural scoliosis

postural scoliosis compensatory scoliosis

•Transient structural scoliosis

sciatic scoliosis hysterical scoliosis inflammatory scoliosis

•Structural scoliosis •idiopathic (70 - 80 % of all cases) •congenital •neuromuscular

poliomyelitis cerebral palsy syringomyelia muscular dystrophy amyotonia congenita Friedreich's ataxia

•neurofibromatosis

•mesenchymal disorders Marfan's syndrome Morquio's syndrome rheumatoid arthritis osteogenesis imperfecta certain dwarves

•trauma fractures irradiation surgery

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Congenital result of an abnormality of

the development of the vertebrae

Neuromuscular caused by cerebral palsy,

spina bifida, muscular dystrophies, spinal cord injuries

Poor posture Unequal leg length Idiopathic scoliosis

cause unknown most common form (80%)

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- Ehler’s Danlos syndrome

- Marfan syndrome- Homocystinuria

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Tethered cord syndrome

Syringomyelia Spinal tumor Neurofibromatos

is Muscular

dystrophy

Cerebral palsy Polio Friedeich’s

ataxia Familial

dysautonomia Werdnig-

Hoffman disease

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Leg length discrepancy

Developmental hip dysplasia

Osteogenesis imperfecta

Klippel-Feil syndrome

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Of adolescents diagnosed with scoliosis, only 10% have curve progression requiring medical intervention

Three main determinants of curve progression are:(1) Patient gender(2) Future growth potential(3) Curve magnitude at time of diagnosis

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Assessing future growth potential using Tanner staging:

Tanner stages 2-3 (just after onset of pubertal growth) are the stages of maximal scoliosis progression

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Assessing growth potential using Risser grading:

- Measures progress of bony fusion of iliac apophysis- Ranges from zero (no ossification) to 5

(complete bony fusion of the apophysis)- The lower the grade, the higher the potential

for progression

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Risk of Curve Progression

Curve (degree) Growth potential (Risser grade) Risk *

10 to 19 Limited (2 to 4) Low

10 to 19 High (0 to 1) Moderate

20 to 29 Limited (2 to 4) Low/mod

20 to 29 High (0 to 1) High

>29 Limited (2 to 4) High

>29 High (0 to 1) Very high

.

*—Low risk = 5 to 15 percent; moderate risk = 15 to 40 percent; high risk = 40 to 70 percent; very high risk = 70 to 90 percent.

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Curve (degrees) Risser grade X-ray/refer Treatment

10 to 19 0 to 1 Every 6 months/no Observe

10 to 19 2 to 4 Every 6 months/no Observe

20 to 29 0 to 1 Every 6 months/yes Brace after 25 degrees

20 to 29 2 to 4 Every 6 months/yes Observe or brace *

29 to 40 0 to 1 Refer Brace

29 to 40 2 to 4 Refer Brace

>40 0 to 4 Refer Surgery †

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Back pain not significantly higher in pts with scoliosis

Curves in untreated adolescents with curves < 30 º at time of bony maturity are unlikely to progress

Curves >50 º at maturity progress 1º per year

Up to 19% of females with curves >40 º have significant psychological illness

Life-threatening effects on pulmonary function do not occur until curve is >100 º (ie: Cor pulmonale)

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•Idiopathic scoliosis is the most common type of spinal deformity.

• Its onset can be rather insidious, its progression relentless, and its end results deadly.

•Proper recognition and treatment of idiopathic scoliosis help to optimize patient outcomes.

•Once the disease is recognized, effective ways exist to treat it.

Some Examples…

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Comparison of spinal alignment between unaffectedteenager and a teenager with right

idopathic scoliosis.

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It is, at times, grossly oversimplified as mere lateral deviation of the spine, when in reality, it is a complex 3-dimensional deformity (Asher, 1999).

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In fact, some have used the term rotoscoliosis to help emphasize this very point.

Two-dimensional imaging systems (plain radiographs) remain somewhat limiting, and scoliosis is commonly defined as greater than 10° of lateral deviation of the spine from its central axis.

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J.I.P. James is credited with classifying idiopathic scoliosis according to the age of the patient at the time of diagnosis (James, 1954).

Using his classification system, children diagnosed when they are: younger than 3 years ►infantile idiopathic scoliosis. aged 3-10 years ► juvenile idiopathic scoliosis,

and older than 10 years ► adolescent idiopathic

scoliosis.

These age distinctions, though seemingly arbitrary, have prognostic significance.

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Scoliosis is almost always discussed in terms of its prevalence (i.e., the total number of existing cases within a defined population at risk).

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Stirling and his coauthors studied almost 16,000 patients aged 6-14 years in England and found the point prevalence of idiopathic scoliosis (Cobb angle >10°) to be 0.5% (76 of 15,799 patients) (Stirling, 1996).

The prevalence of scoliosis was highest (1.2%) in patients aged 12-14 years (Stirling, 1996).

Data such as these indicate that the focus of screening efforts should be on children in this age group. (12-14 years)

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SCHOOL SCREENING

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The precise etiology of idiopathic scoliosis remains unknown, but several intriguing research avenues exist.

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The vast majority of patients initially present due to perceived deformity. This may be patient or family perception of asymmetry about the shoulders, waist, or rib cage.

A primary care physician or school-screening nurse may perceive similar findings.

Adams forward-bending test (in conjunction with the use of a scoliometer) has been found to be an effective screening tool.

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A. With student standing (grid), observe for: a) high shoulder, b) curved spine, c) uneven shoulder blades, d) uneven hips or waist creases, and

e) unequal distance from arm to side of body

B. Adams forward bend testScoliometer measurement (thoracic,

thoracolumbar, lumbar)-Angle of trunk rotation (ATR) > 7 degree – referral)

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Bending position (Adam’s test). Student should stand erect with feet together, knees fully extended, and the palms of both hands touching each other as the student bends forward until the back is horizontal. Asymmetry of the thoracic or lumbar spine may be detected by using a scoliometer to measure the angle of trunk rotation (ATR) at the thoracic, thoracolumbar, and lumbar areas of the spine

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For this test, the patient is asked to lean forward with his or her feet together and bend 90 degrees at the waist. The examiner can then easily view from this angle any asymmetry of the trunk or any abnormal spinal curvatures.

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•The patient bends over, arms dangling and palms pressed together, until a curve can be observed in the upper back (thoracic area).

•The Scoliometer is placed on the back and measures the apex (the highest point) of the upper back curve.

•The patient continues bending until the curve can be seen in the lower back (lumbar area). The apex of this curve is also measured.

An inclinometer (Scoliometer) measures distortions of the torso.

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Traditionally, scoliosis has been described as a nonpainful condition, and aggressive workup has been recommended for patients in whom this rule is violated (Hensinger, 1995).

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Physical ExamA. Trunk symmetry (Adams Forward Bend Test)B. Shoulder heightC. Hip, pelvis, breast prominenceD. Leg lengthE. SkinF. ROMG. Neurological exam – upper/lower limbs,

abnormal reflexes

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Physical examination should include a baseline assessment of posture and body contour. Shoulder unleveling and protruding scapulae are common. In the most common curve pattern (right thoracic), the right shoulder is consistently rotated forward and the medial border of the right scapula protrudes posteriorly.

Assessment of lower (and often upper) extremity reflexes should be performed. Abdominal reflex patterns should also be assessed. The presence or absence of hamstring tightness should be investigated, and screening should be performed for ataxia and/or poor balance or proprioception (i.e., Romberg test).

Measuring leg length will prove valuable, as a significant percentage of patients with scoliosis have several centimeters of limb-length discrepancy.

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“tip-offs” to scoliosis: Uneven shoulders Prominent

shoulder blade (s)

Uneven waist Elevated hips Leaning to one

side

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- Choose the most tilted vertebrae above & below apex of the curve.

- Angle b/t intersecting lines drawn perpendicular to the top of the superior vertebrae and bottom of the inferior vertebrae is the Cobb’s angle.

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•PATIENT EVALUATION

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HISTORY PHYSICAL EXAM IMAGING LAB TEST DIAGNOSTIC

PROCEDURES TIME LINE

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SCHOOL SCREENING

OF SCOLIOSIS

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FORWARD BENDING TEST

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RIB HUMP

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NEED ORTHO EVALUATION

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HISTORY OF PAIN NEUROLOGICAL

SYMPTOMS FAMILY HISTORY GROWTH SPURT MENARCHE

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REAR VIEW

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PLUMB LINE

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HAND SUSPENSION

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TRACTION XRAY

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FRONT VIEW

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INEQUALITY

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SLR

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THOMAS TEST

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LIGAMENT LAXITY

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SKELETAL MATURITY RISSER SIGN VERTEBRAL RING APOPHYSIS FUSION WRIST X-RAY

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ILIAC APOPHYSIS 0 – ABSENT 1- 25% 2- 50% 3- 75% 4- FULL EXCURSION 5- FUSED

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The main treatment options for idiopathic scoliosis may be summarized as "the 3 O's": (1) observation, (2) orthosis, and (3) operative intervention.

When to choose each of these treatments is a complicated matter.

The risk of curve progression varies based on the idiopathic scoliosis group in which a patient belongs (i.e., infantile, juvenile, adolescent).

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Although defined by a seemingly arbitrary age limit (<3 year at the time of diagnosis), infantile idiopathic scoliosis demonstrates marked differences that distinguish it from the other 2 categories of idiopathic scoliosis.

Infantile idiopathic scoliosis is the only type of idiopathic scoliosis whose most common curve pattern is left thoracic. Infantile idiopathic scoliosis is the only type of scoliosis that is

more common in boys. with any significant reputation for spontaneous resolution.

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Prediction of curve progression in infantile idiopathic scoliosis has been tied to assessment of the rib vertebral angle difference (RVAD) originally described by Mehta in 1972 (Mehta, 1972).

This measurement is carried out at the apical vertebra of the curve. In instances in which the curves resolved spontaneously, the RVAD was less than 20° in about 80% of cases, and in those instances in which the curves were progressive, the RVAD exceeded 20° in about 80% of cases (Mehta, 1972).

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Nonoperative treatment of progressive infantile idiopathic scoliosis predominates and may involve the use of conventional thoracolumbosacral orthosis (TLSO)–type braces, Milwaukee-type braces, and even intermittent Risser casting.

Some have questioned the value of bracing in infantile idiopathic scoliosis and have stated, "a curve that resolves in a brace would probably have resolved without treatment" (Herring, 2002).

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An underarm thoracolumbosacral orthosis (TLSO).

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Modified Boston Model underarm brace used for most patients with idiopathic scoliosis

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If surgical treatment becomes necessary, anterior release and fusion followed by posterior spinal fusion with instrumentation is considered to be the functional treatment.

Every effort should be made to delay such surgical intervention as long as possible to optimize spinal growth, but relentless curve progression should not be accepted or tolerated while awaiting some arbitrary chronologic age.

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Curves less than 25° with an RVAD less than 20° are preferentially observed and monitored with spinal radiographs at regular intervals.

Curves exceeding these parameters are typically braced, with some consideration given to the value of intermittent Risser casting.

Surgery is considered for curves not adequately controlled with nonoperative measures.

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It is more common in females, and its most common curve pattern is a right thoracic curve (Robinson, 1996).

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Observation for curves less than 25° with follow-up radiographs at regular intervals

Bracing for curves that range from 25-40° and at least consideration of bracing (based on curve flexibility) for curves from 40-50°

Bracing for smaller curves that demonstrate rapid progression to the 20-25° range

Surgical intervention for inflexible curves that exceed 40° or virtually any curve that exceeds 50°.

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Most common is Boston brace (aka Thoraco-lumbar-sacral orthosis)

Braces have 74% success rate at halting curve progression (while worn)

Bracing does not correct scoliosis, but may prevent serious progression

Usually worn until patient reaches Risser grade 4 or 5

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Of patients with 20 º - 29 º curves, only 40% of those wearing braces ultimately required surgery, compared to 68% of those not wearing back braces

Length of wearing time correlates with outcome (At least 16 hrs per day leads to best chance of preventing curve progression)

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Bracing and casting may be used outside the above-mentioned parameters in an effort to help control a large curve in a young child for whom the surgeon is attempting to optimize spinal growth.

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Adolescent idiopathic scoliosis is the most common type.

Progressive curvature may be predicted by a combination of physiologic and skeletal maturity factors and curve magnitude.

Small curves in more mature patients have a substantially lower risk of progression (about 2%) than larger curves in more immature patients, in whom the risk is much higher (risk may approach or exceed 70%).

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Treatment recommendations for adolescent idiopathic scoliosis are driven almost totally by curve magnitude (the only caveat being that brace treatment is thought to be effective only in patients who are still growing).

It is thus somewhat ironic to note that stated recommendations urge observation for curves less than 30°, bracing of curves that reach the 30-40° range, and consideration of surgery for curves that exceed 40°.

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This amounts to a 10° window between observation and major spinal surgery. It is even more ironic to note that 10° is a commonly discussed margin of error for measuring such scoliotic curves.

Additional patient factors may also influence some orthopedic surgeons to brace patients with curves measuring less than 30° or in excess of 40°. For instance, a rapidly progressive curve in a 12-year-old child that suddenly goes from 16-26° may easily prompt bracing.

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When it comes to surgical considerations, patients with adolescent idiopathic scoliosis may be functionally subdivided into those patients in whom significant anterior spinal growth is a concern and those in whom it is not. This amounts to a quantification of risk of development of the complication known as crankshaft phenomenon (Dubousset, 1989).

This can have a major impact on the surgical treatment plan in that a child at significant risk for crankshaft phenomenon will require an anterior spinal fusion procedure.

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Few, if any, absolute contraindications exist regarding scoliosis care, just as few, if any, absolute indications for intervention exist.

Accepted contraindications for bracing include skeletal maturity and excessive curve magnitude.

Thoracic lordosis and certain curve patterns such as double thoracic curves also have been offered as at least relative contraindications to bracing.

The main contraindication to posterior scoliosis surgery would be medical instability and inability to survive surgery.

Anterior scoliosis surgery would also be contraindicated in these patients, as well as in those with a precarious pulmonary status.

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Preoperative assessment of hemoglobin and hematocrit levels.

Autologous blood predonation

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Bending radiographs, including those over a fulcrum (Cheung, 1997).

Klepps and Lenke et al found that thoracic fulcrum bending radiographs worked best for them when dealing with isolated main thoracic curves (Klepps, 2001).

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MRI has been indicated in patients with idiopathic scoliosis with unusual complaints such as: severe unexplained headaches and when clinical findings such as ataxia or cavus feet are present.

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Pulmonary function studies have been used rather extensively in the evaluation of patients with idiopathic scoliosis.

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Medical therapy: Nonoperative management consists of either mere

observation or orthosis use. Observation is watchful waiting with appropriate intermittent radiographs to check for the presence or absence of curve progression.

Orthosis use for scoliosis is discussed extensively below.

No other treatments, including electrical muscle stimulation, physical therapy, spinal manipulation, and nutritional therapies, have been shown to be effective for managing the spinal deformity associated with idiopathic scoliosis.

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The first widely used scoliosis brace with proven effectiveness was the Milwaukee brace.

This brace was developed by Walter Blount and Albert Schmitt in 1946 (Moe, 1970).

The brace was originally designed to be used as part of the surgical treatment of scoliosis and only later evolved into a stand-alone nonoperative treatment.

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Milwaukee brace was effective in preventing significant curve progression in patients with 20-39° curves (Lonstein, 1994).

These same authors recommended that adolescents with a curve of 25° and a Risser sign of 0 be braced immediately and not wait for evidence of curve progression (Lonstein, 1994).

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Rowe and his colleagues performed a meta-analysis aimed at evaluating the efficacy of nonoperative treatments for idiopathic scoliosis (Rowe, 1997). They calculated the weighted mean proportion of success for 3 nonoperative treatments: observation, electrical stimulation, and bracing.

They were able to successfully combine data on 1910 patients from 20 different studies for purposes of meta-analysis. Their main results are as follows (treatment, success rate):

Treatment Success Rate Observation, 49% Electrical stimulation, 39% Bracing 8 hours per day, 60% Bracing 16 hours per day, 62% Bracing 23 hours per day, 93%

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The psychological stress associated with scoliosis has been documented (Payne, 1997), and this does not improve compliance with brace wear.

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Compliance with prescribed brace wear regimens has been shown to be poor.

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Questions have also been raised regarding the consistency of strap tension in TLSO bracing (Aubin, 1999).

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In part due to the aforementioned psychological and brace wear compliance issues, new approaches to bracing are being developed.

One such approach is that developed by Dr. Christine Coillard and Dr. Charles Rivard of the St. Justine Hospital in Montreal, Canada. Their dynamic bracing approach is referred to as the SpineCor Brace or as the St. Justine Brace.

It involves elastic straps that are anchored on a pelvic corset, and, based on curve morphology, these straps are tensioned to exert corrective forces. The brace is a radical departure from traditional plastic and metal orthoses. Early results with the St. Justine Brace are rather encouraging, with success rates comparable to those of traditional bracing.

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Surgical therapy:

Even in the setting of adequate correction and solid fusion, up to 38% of patients still have occasional back pain (Lenke, 1998).

The primary goal of scoliosis surgery is to achieve a solid bony fusion.

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Modern instrumentation systems have been shown to allow for adequate curve correction but with little or no ability to diminish associated rib humps (Lenke, 1992).

Despite claims of certain instrumentation systems to derotate the spine, little actual derotation has been documented.

Derotation of the instrumented curve also has been shown to possibly occur at the expense of creation of new rotation in uninstrumented portions of the spine (Rajasekaran, 1994).

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Previously, much attention has been paid to the ability of certain spinal instrumentation systems (e.g., Cotrel-Dubousset to derotate the spine during scoliosis correction).

Jarvis and Greene showed that use of the Wisconsin segmental spinal instrumentation (a system traditionally thought to not be associated with significant spinal derotation) was associated with spinal derotation equal to or greater than Cotrel-Dubousset–type systems (Jarvis, 1996). dnbid 105

Posterior correction and instrumentation Anterior correction and instrumentation Anterior release / fusion, plus posterior

instrumentation Posterior release/fusion, plus anterior

instrumentation Combined anterior and posterior

instrumentation and fusion

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Preoperative evaluation focuses on specifics of curve location, magnitude, and flexibility.

These parameters are used in conjunction with patient maturity factors to determine optimal treatment choices.

The goal is always to fuse as little of the spine as possible while adequately treating existing major curvature.

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When the primary problem is a thoracic curve (with adequate flexibility) without any significant associated lumbar curvature - the most common surgical approach has not changed since the days of Paul Harrington: posterior spinal fusion with instrumentation.

Surgeons may choose from a diverse array of anchors to secure large diameter rods (usually in the 0.25-in range) to the spine.

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These anchors include sublaminar hooks, pedicle hooks, transverse process hooks, sublaminar wires (aka Luque wires), spinous process wires (aka Drummond wires), and pedicle screws.

In recent years some surgeons have also advocated anterior spinal fusion and instrumentation for such isolated thoracic curves. These have included both open (thoracotomy) and limited incision (thoracoscopic) techniques.

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When the primary problem is a large stiff thoracic curve (usually not bending less than 50°), a different surgical tactic is usually undertaken in which an anterior release (usually including discectomy and bone grafting) is performed prior to posterior spinal fusion and instrumentation.

Anterior spinal fusion and instrumentation has also been advocated in this situation, provided the patient is not the unusual one with excessive kyphosis associated with their large thoracic curve.

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Large curve patterns that include both thoracic and lumbar deformity continue to challenge scoliosis surgeons.

If adequate flexibility and balancing of the lumbar spine is possible - then selective fusion of the thoracic curve is possible.

When this is not the case, extensive fusion (at times down to the fourth lumbar segment) may become necessary.

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The Scoliosis Research Society has a rather specific definition of thoracolumbar scoliosis: a curve whose apex lies at the body of T-12, L-1 or the T12-L1 interspace.

These curves are most commonly left-sided curves and they present one of the most common scenarios in which anterior spinal fusion and instrumentation is utilized.

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Pulmonary function testing is commonly used in the preoperative evaluation of patients with idiopathic scoliosis.

Such testing may influence the surgeon's enthusiasm for related procedures such as costoplasty (thoracoplasty). Pulmonary function testing may also uncover previously unrecognized tobacco use or undiagnosed (subclinical) pulmonary disease.

Predonation of several units of donor-directed blood is considered standard for most patients.

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Hoppenfeld has described an ankle clonus test for intraoperative assessment of the integrity of the spinal cord during scoliosis surgery.

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Postoperative patient management involves close monitoring, which often occurs initially in an intensive care unit setting.

Patients have monitoring devices, such as arterial lines, and closed suction devices, such as chest tubes, that also require special nursing attention.

The use of certain special spine-specific hospital beds, such as the Stryker frame, may also aid in patient care and comfort (change from supine to prone position) during the initial postoperative period.

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The use of postoperative bracing varies from surgeon to surgeon.

The roots of scoliosis surgery involved immobilization in a body cast. Following the development of initial instrumentation systems (eg, Harrington instrumentation), external immobilization was still used routinely. With the advent of large-rod multiple-hook constructs, such as the Cotrel-Dubousset system and its direct decendents, bracing has been de-emphasized a bit.

Today, it is almost as likely that a patient will not receive a postoperative brace as receive one, whereas previously, bracing was much more widespread.

In certain specific circumstances, postoperative bracing is still almost always used, such as anterior thoracic or thoracolumbar instrumentation procedures or surprisingly weak bone stock. dnbid 116

When a brace is used, it is typically to be worn full-time for at least 6 weeks, followed by a period in which the brace may be off for bathing with subsequent progressive weaning.

As a rule of thumb, patients may also miss up to 6 weeks of school (if their procedure is done at such time of the year), and up to 6 months may be required before they resume most of their normal activities.

Vigorous sports may be restricted for at least a year, in some instances permanently (based on risk versus benefit discussions between patients, families, and their surgeons). dnbid 117

At an average of 21 years following posterior spinal fusion with Harrington instrumentation (performed by Paul Harrington himself), about 21% of patients experienced significant interscapular pain (Dickson, 1990).

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Complications are of great concern to parents, patients, and surgeons.

Thankfully, complications are rare with modern scoliosis surgery, despite the magnitude of these spinal deformity procedures.

Several important intraoperative, early postoperative, and late postoperative complications are discussed here.

McKie and Herzenberg described coagulopathy as a complication of intraoperative blood salvage during scoliosis surgery (McKie, 1997).

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The importance of appropriate intraoperative spinal cord monitoring during scoliosis surgery is hardly debatable.

Somatosensory and motor evoked potentials are commonly used to monitor spinal cord function.

Some concern exists regarding postoperative activity level and the possible hazards of trauma.

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Delayed infections following posterior spinal fusion with Texas Scottish Rite Hospital instrumentation has been reported.

Much has been written regarding a particular complication called crankshaft phenomenon. It may occur following posterior spinal fusion of idiopathic scoliosis in patients who have significant anterior spinal growth remaining.

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Significant concern exists regarding the inferior (caudad) extent of a patient's spinal fusion and its potential relationship with future low back pain (Kostuik, 1990).

Pseudoarthrosis is a complication that represents a basic failure of the central intention of scoliosis surgery: bone fusion.

Luckily, pseudarthrosis is very rare in modern scoliosis surgery. This is in small part due to excellent stable internal fixation (scoliosis instrumentation systems) and in large part due to proper attention to fusion technique.

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Clinical outcomes following treatment of idiopathic scoliosis are strongly linked to curve magnitude.

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THANK YOU

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