scoliosis 2
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ontinuity linic
Scoliosis
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Objectives
Know the etiology and natural history of
scoliosis
Describe how and when to examine for
scoliosis
Know how to determine the magnitude
and pattern of spinal curvature
Be familiar with treatment options
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Epidemiology
Scoliosis is a lateral curvature of
the spine greater than 10 degrees.Idiopathic vs. Secondary
Idiopathic is the most common type.
Secondary causes include connectivetissue, neurologic, and musculoskeletal
disorders.
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Classification
Idiopathic Scoliosis - defined by the
age of onsetInfantile - birth to 3 years
Juvenile - 3 to puberty
Adolescent - after pubertyAdolescent Idiopathic Scoliosis is
the most common type.
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Etiology: AIS
No direct cause has yet been
isolated.
Leading theory: Multigenedominant condition with variable
phenotypic expression
Studies of twins have shown
greater risk in monozygotic than
dizygotic, and the rate of curve
progression was nearly identical
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Prevalence: AIS
Scoliosis is present in 2 to 4% of
children between 10 and 16 years
of age.Girls tend to have more severe
curves.
F:M ratio 1:1 in those with smallcurves (10 degrees)
F:M ratio increases to 10:1 in those
with curves greater than 30 degrees
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Diagnosis
Need to exclude secondary causes.
History:
family history
presence of pain and neurologic changes
bowel and bladder dysfunction
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Physical Exam
Complete neurologic examTanner staging - curve progression
occurs most rapidly during stage 2 or 3
Adams forward bend test
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Adams Bend TestPt bends forward,spine horizontal to thefloor, while holdingpalms together, armsextended.
Examine from sideand behind thepatient.
Look for a rib hump
Rib hump is ahallmark of a scolioticcurve greater than 10degrees.
Make sure pelvis is not dipping on
one side AND leg length is symmetric
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Imaging
Imaging is ordered for any patientwith a lateral thoracic or lumbar spine
curvature > 10 degrees. It should be
considered in all patients with
cervical curvature!
A single standing PA plain film of the
spine is needed.
The degree of the curve is measured
by the Cobb method.
90% of curves are to the right!
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Red Flagsneed MRI
A thoracic curve to the left
painful scoliosis
abnormal neurologic findingsuntoward stiffness
deviation to one side during the bend
testsudden rapid progression in
previously stable curve
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The Cobb method
Choose the mosttilted vertabrae
above and below
the apex of the
curve.Draw a line
perpendicular to that
vertabrae.
The angle createdbetween these
intersecting lines is
the Cobb angle.
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When do you observe vs.
treat or refer?
What is the likelihood the curve willprogress?
What degree of curvature leads to
medical complications?
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Will the curve progress?
Three factors involved in progression
patients gender
future growth potential
curve magnitude at time of diagnosis
Females are 10 times more likely to
have progression than males.
The greater the growth potential and
larger the curve = more likely to
progress
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How to determine growth potential?
Tanner staging - pts in
stage 2 and 3 more
likely to progress
Risser grade
based on ossification of
iliac apophysisgraded from 0 (no
ossification) to 5
(complete bony fusion)
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The magic # is... 30
Data from multiplestudies has yieldedthe Risk of CurveProgression table.
The table assists inpredicting progressionand hence guidingtreatment.
What is the risk for an11 yo girl with a 25degree curve and
Risser grade 1?
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Curve Progression
Curves 30 to 50 degrees progress
an average of 10 to 15 degrees
over a lifetime.
Curves > 50 at maturity progress
steadily at a rate of 1 degree per
year.Curves less than 30 at bone
maturity are unlikely to progress.
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Medical Complications
At 100 degrees or greater: increased
potential for life threatening effects onpulmonary function
Psychologic illness: seen in up to 19%
of females with curves great than 40degrees as adults.
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Does Screening help?
AAOS recommends screening girls at
ages 11 and 13; boys once at 13 or 14.
AAP recommends at 10, 12, 14, and 16.
But in fact... in 1996 the US Preventative
Task Force found insufficient evidence
for or against screening in asymptomaticpts. This was updated again in June
2004 with the same conclusion.
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Treatment
Orthotic braces - 74% success rate
at halting progression
Must be worn 20 hours a day, butmost pts are not compliant.
Braces do not correct scoliosis.
Surgical therapy is definitive, butindicated only for those at 40
degrees or above
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Conclusion
Adolescent Idiopathic Scoliosis is the
most common type.
Overall, females more prone and tendto have more severe curves (to the
right!).
Screening is of limited value.There are extensive research based
guidelines for predicting curve
progression and treatment
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