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Adolescent idiopathic scoliosis diwakar

This document discusses scoliosis, including its definition, classification, evaluation, treatment, and complications. Scoliosis is a lateral curvature of the spine with rotation of the vertebrae. It is classified based on age and cause. Evaluation involves physical exam, x-rays, and curve measurement. Treatment options include observation, bracing, and surgery depending on the curve severity and progression. Potential surgical complications include neurologic injury, blood loss, and implant-related issues.

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 The word “scoliosis” is derived from the Greek word meaning “crooked.” Scoliosis is defined as a lateral deviation of the normal vertical line of the spine. The lateral curvature of the spine also is associated with rotation of the vertebrae. This produces a three- dimensional deformity of the spine that occurs in the sagittal, frontal, and coronal planes.  The Scoliosis Research Society recommends that idiopathic scoliosis is classified according to the age of the patient. Infantile scoliosis occurs from birth to 3 years of age; juvenile idiopathic scoliosis between the ages of 4 and 10 years; and adolescent idiopathic scoliosis between 10 years of age and skeletal maturity.
 Idiopathic scoliosis is the most common type seen, but the exact etiology of this type of scoliosis is not known. Congenital scoliosis is caused by a failure in vertebral formation or segmentation of the involved vertebrae.
 Adolescent idiopathic scoliosis is present when the spinal deformity is recognized after the child is 10 years of age but before skeletal maturity.  The characteristics of adolescent idiopathic scoliosis include a three-dimensional deformity of the spine with lateral curvature plus rotation of the vertebral bodies. Most idiopathic curves are lordotic or hypokyphotic in the thoracic region, and this may represent an important factor in the etiology of idiopathic scoliosis.
ETIOLOGY  The exact cause of idiopathic scoliosis remains unknown.  There are many proposed etiological factors (1) genetic factors (2) neurological disorders (3) hormonal and metabolic dysfunction (4) skeletal growth (5) biomechanical factors (6) environmental and life style factors.
 Idiopathic scoliotic curves of more than 10 degrees are estimated to occur in 2% to 3% of children younger than 16 years of age.
PATIENT EVALUATION  The initial evaluation of the patient should include  Thorough history.  Complete physical and neurological examinations. Radiographs of the spine. After the general physical examination , the spine should be examined carefully and the characteristics of the deformity should be recorded.
 Serial measurement of height will detect when peak height velocity is occurring associated with an increase in progression of the curve. The height of the patient while standing and while sitting should be measured and recorded; these measurements are compared with later ones to determine changes in the patient’s total height and whether any change is caused by growth of the lower extremities or by an increase or a decrease in the height of the trunk.
 On inspection of the spine, the examiner should look for any dimpling, hair patches, or skin abnormalities, such as hemangiomas or café au lait spots. Asymmetry of the shoulder, scapula, ribs, and waistline should be noted.
 The best clinical test for evaluating spinal curvature is the Adams forward bending test.  The scoliometer may be used in conjunction with the Adams forward bending test to evaluate truncal rotation. An angle less than 7 degrees is considered within the limits of normal. Limb lengths should be measured because a discrepancy may cause a pelvic tilt and a compensatory scoliosis.
Adam’s forward bending test
 Structural vs. non-structural curves: Defined based on curve magnitude on side-bending AP radiographs Curves are considered to be structural curves if they are more than 25 degree on PA radiograph and do not bend to < than 25 degree on side bending radiograph. Non-structural: < 25°
RADIOGRAPHIC EVALUATION  Postero-anterior and lateral radiographs of the spine, including the iliac crest distally and most of the cervical spine proximally, should be made with the patient standing.  The patient’s shoulders are flexed forward, the elbows are fully flexed, and the fists should rest on the clavicles.
 scoliosos 2
Vertebral Rotation  Vertebral rotation may be assessed on radiographs through asymmetry of pedicles and/or shift of spinous processes: 1. Nash-Moe method
MEASUREMENT OF CURVES  The Cobb method of measurement recommended by the Terminology Committee of the Scoliosis Research Society consists of three steps: (1) locating the superior end vertebra, (2) locating the inferior end vertebra, and (3) drawing intersecting perpendicular lines from the superior surface of the superior end vertebra and from the inferior surface of the inferior end vertebra.  The angle of deviation of these perpendicular lines from a straight line is the angle of the curve. If the endplates are obscured, the pedicles can be used instead. The end vertebra of the curve is the one that tilts the most into the concavity of the curve being measured.
CURVE PATTERNS  PONSETI AND FRIEDMAN CLASSIFICATION 1)Single major lumbar curve. The lumbar curve has its apex between the L1-2 disc and L4. These curves produce an asymmetry of the waistline with prominence of the contralateral hip that parents often assume is caused by a short leg on the side of the curve.
 2) Single major thoracolumbar curve. The thoracolumbar curve apex is at T12 or L1. This curve tends to produce more trunk imbalance than other curves. This decompensation from the midline often produces a severe cosmetic deformity.
 3). Combined thoracic and lumbar curves (double major curves). Symmetrical double major curves generally cause less visible deformities because the curves are nearly the same degree in size and the trunk usually is well balanced.
 4). Single major thoracic curve. This curve pattern generally is a convex right pattern. Because of the thoracic location of the curve, rotation of the involved vertebrae may be obvious. The curve produces prominence of the ribs on the convex side, depression of the ribs on the concave side, and elevation of one shoulder, resulting in an unsightly deformity.
LENKE CLASSIFICATION  Measurements are obtained from standard posteroanterior, lateral, and right and left bending radiographs.  The three steps in this classification system are (1) identification of the primary curve, (2) assignment of the lumbar modifier, and (3) assignment of the thoracic sagittal modifier.  Curves are considered to be structural curves if they are more than 25 degrees on posteroanterior radiographs and do not bend to less than 25 degrees on side-bending radiographs.
 The second step is to determine the lumbar spine modifier. This is determined by drawing a vertical line upward from the center of the sacrum (center sacral vertical line [CSVL]).  The lumbar spine modifier is then determined by the relationship of the CSVL to the concave pedicle of the apical lumbar vertebra and can be assigned into A, B, or C.  The third step is to determine the thoracic sagittal modifier. The sagittal modifier is hypokyphotic (<10 degrees), normal (10 to 40 degrees), or hyperkyphotic (>40 degrees). 
 Forty-two discrete curve classifications can be identified by this three-step process. Recommendations for fusion levels can be made based on these curve types. The recommendation is that the major and structural minor curves be included in the instrumentation and fusion and the nonstructural curves excluded.
NON OPERATIVE TREATMENT  Various methods have been used to treat adolescent idiopathic scoliosis over the years, including physical therapy, manipulation, and electrical stimulation, but there is no scientific evidence supporting their effectiveness. The two most widely accepted non operative techniques for idiopathic scoliosis are observation and bracing.
 OBSERVATION Young patients with mild curves of less than 20 degrees can be examined every 6 to 12 months. Adolescents with larger degrees of curvature should be examined every 4 to 6 months. Skeletally mature patients with curves of less than 20 degrees generally do not require further evaluation. A curve of more than 20 degrees in a patient who has not reached skeletal maturity will need more frequent examination, usually every 4 to 6 months, with standing postero anterior radiographs.
 If progression of the curve (an increase of 5 degrees during 6 months) beyond 25 degrees is noted, orthotic treatment may be considered. For curves of 30 to 40 degrees in a skeletally immature patient, orthotic treatment is recommended at the initial evaluation. Curves of 30 to 40 degrees in skeletally mature patients generally do not require treatment, but because studies indicate a potential for progression in adult life, these patients should be observed with yearly standing posteroanterior radiographs for 2 to 3 years after skeletal maturity and then every 5 years throughout life.
 ORTHOTIC TREATMENT The goal of brace treatment is to limit further progression of the scoliotic curve and avoid surgery. Correction may occur while in the brace, but the curve will generally settle to its pretreatment degree of curvature once the brace is discontinued. Brace correction of spinal curves is thought to occur through molding of the spine, trunk, and rib cage during growth, specifically through transverse loading of the spine through the use of corrective pads.
 A brace for a flexible curve of 20 to 30 degrees in a growing child with documented progression of 5 degrees or more. Curves in the 30- to 40-degree range in growing children are treated at initial evaluation. Although surgery usually is indicated for curves in the 40- to 50-degree range in growing children, orthotic treatment may be considered for some curves, such as a cosmetically acceptable double major curve of 40 to 45 degrees. Orthotic treatment is not used in patients with curves of more than 50 degrees.
Wearing Schedule  The correction achieved by a brace is thought to be caused by the constant corrective molding of the trunk and spine during growth.  Full-time (23 hours per day) brace wear was first advised by Blount and continues to be recommended by many who prescribe scoliosis braces.  Certain centers began to treat patients for only 16 hours per day, allowing the child to go to school without the brace
Brace Efficacy  The effectiveness of bracing for idiopathic scoliosis has been presumed for many years, yet controlled treatment trials with and without bracing have not been completed until recently .  An initial curve between 20 and 29 degrees and at high risk for progression, the brace was found to be effective compared to natural history data pertaining to the untreated state
Boston Brace
Milwaukee brace
Charleston sleeping brace
OPERATIVE TREATMENT  SURGICAL GOALS The goals of surgery for spinal deformity are to correct or to improve the deformity, to maintain sagittal balance, to preserve or to improve pulmonary function, to minimize morbidity or pain, to maximize postoperative function, and to improve or at least not to harm the function of the lumbar spine. To accomplish these goals in patients with idiopathic scoliosis, surgical techniques may include anterior, posterior, or combined anterior and posterior procedures.
Harrington distraction rod is seen on the left, combined with a smaller threaded compression rod on the right. B: Distraction into the lumbar spine associated with this system unfortunately often leads to a reduction in lumbar lordosis, creating a flat- back deformity.
COMPLICATIONS  The complications of scoliosis surgery can be serious, although over the last 20 years these procedures have become much safer due to advances in anesthesia, blood loss management, instrumentation systems, and neurologic monitoring.  Neurologic Injury A result of direct trauma (contusion) to the cord; excessive traction to the neural elements caused by corrective instrumentation; and vascular insufficiency to the cord.
Spinal Cord Monitoring  Continuous electrical spinal cord monitoring has become almost standard in surgical correction of spine deformity. Monitoring of both sensory and motor pathways is possible; however, from a technical standpoint, sensory monitoring is simpler and more widely accepted. Somatosensory evoked potentials (SSEPs) are obtained by stimulating distally (legs) and measuring the response proximally (brain), and have been very reliable in detecting changes in spinal cord function, giving the surgeon relatively rapid feedback about any effect that the deformity correction procedure may be having on neurologic function.
Blood Loss  Scoliosis surgery may be associated with blood loss requiring transfusion.  Preoperative autologous donation may be the most reliable way to avoid exposure to allogenic blood products, although this is not possible in all patients
Implant Related Complications  Complications related to the implants may present early or late in the postoperative period. Despite greatly improved implant systems, there is still a potential for early failure of the bone and hardware interface by either implant dislodgment or bony fracture.
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