Scoliosis Dr. Khodor Hassan Haidar Philosophy Doctorate (PhD) “Nutrition and Health”, Italian Doctorate Degree in General Medicine and Surgery. University of Florence. Diploma of Specialization in Orthopedics, University of Florence. Master in Shoulder’s Pathologies “Diagnostic and Treatment”. University of Bologna and Rimini. Master degree in Bones Metabolic Diseases. University of Florence.

Normal Spinal Curvature There are 4 natural curves in the vertebral column

Linear Spinal Curvatures KyphosisLordosis Spine curves backward in the chest area “Roundback” Spine curves forward at the waist “Swayback”

Scoliosis Sideways curvature of the spine Spine turns on its axis like a corkscrew Normal spine has a “l” appearance Scoliosis produces an “S” or “C” appearance

History of spinal traction and bracing Hippocrates first described the signs and synmptoms of scoliosis 2400 years ago and noted that curvature of the spine occured aven in individuals who were apparently in good health. Hippocrates also described the use of spinal traction (in Egypt). Galen ( AD) first used the terms scoliosis, kyphosis and lordosis; he also used traction in the treatment of this deformity. Sayre first applied a cast (1874). Hibbs and Risser developed and used turnbuckle casts (1920). Hippocrates. The genuine works of Hippocrates. NY: WM Wood, 1849

10 Scoliosis Mythology  Scoliosis can be caused by carrying heavy book bags, poor posture or sleeping on a bad mattress  Sports favoring one side can cause scoliosis  Lower back pain in adolescents is an indicator for scoliosis  Scoliosis always progresses and requires some form of treatment  Scoliosis is similar to osteoporosis in it’s destruction of the bone  Scoliosis is usually painful  Minor leg inequality will lead to scoliosis

11 Scoliosis Facts Race, ethnic background & socioeconomics do not appear to be factors Tends to occur in families Usually painless and without symptoms Child is generally unaware of curvature Untreated scoliosis of greater than 30 degrees can lead to back pain in adults 60 % of curvatures in rapidly growing prepubertal children will progress Increased risk for osteoporosis & gall bladder problems later in life Poor nutrition may play a role

What is scoliosis? Lateral curvature of the spine >10º accompanied by vertebral rotation Idiopathic scoliosis - Multigene dominant condition with variable phenotypic expression & no clear cause Multiple causes exist for secondary scoliosis

Scoliosis The Scoliosis Research Society (SRS) definition of scoliosis is a lateral curvature of the spine greater than 10° as measured by the Cobb method on a standing x-ray of the thoraco-lumbar spine 2% to 4% of children between 10 and 16 years of age have measurable but small curves In patients with curves around 10°, the ratio of girls to boys is equal The ratio of girls to boys increases to more than 5 : 1 in populations with curves greater than 20°

International Journal of Epidemiology Vol 13 N° , 1984 Adolescent Idiopathic Scoliosis: Epidemiology and Treatment Outcome in a Large Cohort of Children Six Years after Screening YVONNE ROBITAILLE, CECILIA VILLAVICENCIO-PEREDA and JEAN GURR A prospective study was carried out in a cohort of 6873 children The prevalence of AIS of 6° or more at time of diagnosis was 8.1% The female to male ratio for curves of 6° or more was 1.07:1 with an increase to 6:1 for curves greater than 21°. SCOLIOSIS: Epidemiology

American Journal of Public Health, Vol. 75, Issue , 1985 Age- and sex-specific prevalence of scoliosis and the value of school screening programs. T Morais, M Bernier and F Turcotte children of a community in the province of Quebec. The prevalence of the condition among school children aged 8 to 15 years was 42.0 per 1,000 in the screened population, 51.9 per 1,000 among girls, and 32.0 per 1,000 among boys. SCOLIOSIS Epidemiology

A Population-Based Study of School Scoliosis Screening B. P. Yawn, R. A. Yawn, D. Hodge et al JAMA. 1999;282: children screened Incidence of diagnosed scoliosis was: -1.8% (95% confidence interval [CI], 1.2%-2.3%) for curves of more than 10° -1.0% (95% CI, 0.6%-1.5%) for curves of at least 20° -0.4% (95% CI, 0.1%-0.6%) for curves of 40° or more -0.4% (0.5% of girls and 0.3% of boys) were treated for scoliosis SCOLIOSIS: Epidemiology

17 Causes for Scoliosis Congenital Problem with the formation of vertebrae or fused ribs during prenatal development Present at birth Neuromuscular, Connective Tissue & Chromosomal Abnormalities Caused by a neurological disorder of CNS or muscular weakness Cerebral palsy, Muscular dystrophy, Spina bifida, Paralysis Marfan’s Syndrome Down’s syndrome Idiopathic Structural spinal curvature with no established cause Appears in a previously straight spine 80-85% of cases

Classification of Scoliosis Idiopathic Congenital Syndromes Compensatory Neuromuscular

Classification Idiopathic Infantile: birth - 3 yrs (rare) Juvenile: 3 – 10 yrs Adolescent: > 10yrs (most common) Congenital - 20% have congenital GU malformations;10-15% have congenital heart disease; high association with spinal dysraphism Failure of formation Wedge vertebrae, hemivertebrae Failure of segmentation Unilateral bar, bilateral bar Mixed

Classification Syndromes Neurofibromatosis Marfan syndrome Compensatory Leg-length discrepancy

Secondary causes for scoliosis Inherited connective tissue disorders: Ehler’s Danlos syndrome Marfan syndrome Down syndrome

Secondary causes for scoliosis: Neurologic disorders Neurophatic Cerebral palsy Polio Friedeich’s ataxia Syringomyelia Spinal tumor Neurofibromatosis Myophatic Muscular dystrophy Arthrogryposis Congenital hypotonia

Secondary causes for scoliosis: Musculoskeletal disorders »Leg length discrepancy »Developmental hip dysplasia »Osteogenesis imperfecta »Klippel-Feil syndrome

Spinal level of curve Cervical scoliosis (apex between C1-C6) Cervicothoracic curve (apex C7-C8-T1) Thoracic curve (apex T2-T11) Thoracolumbar curve (apex T12-L1) Lumbar curve (apex L2-L3-L4) Lumbosacral curve (apex L5-S1)

25 1. Right thoracic 90% of thoracic curvatures are to the right 2. Right thorocolumbar 3. Left lumbar 4. Double major-S curve Most Common Forms

Characteristics of idiopathic scoliosis: Present in 2 - 4% of kids aged 10 – 16 years Ratio of girls to boys with small curves ( 30º the ratio is 10:1 Scoliosis tends to progress more often in girls

Natural history of scoliosis 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

Curve progression Four factors are known to increase the risk for curve progression:  A younger age at diagnosis, the occurence of the initial curve before tho onset of mestruation  An increase in the magnitude of the curve  The presence of a double curve pattern  The most important predictors for curve progression identified to date include curve pattern, age, menarche status and a positive Risser sign.

Natural history of scoliosis 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

Risk of Curve Progression Curve (degree)Growth potential (Risser grade)Risk * 10 to 19Limited (2 to 4)Low 10 to 19High (0 to 1)Moderate 20 to 29Limited (2 to 4)Low/mod 20 to 29High (0 to 1)High >29Limited (2 to 4)High >29High (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.

Natural history of scoliosis Back pain not significantly higher in pts with scoliosis Curves in adolescents less than 30 º at skeletal maturity tend not to progress. The thoracic curves between 50° and 75º progress the most rapidly, 1% 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)

Scoliosis

Scoliosis Screening School-based screening Target population American Academy of Orthopedic Surgeons - Screen girls at ages 11 and 13 - Screen boys once at age 13 or 14

34 Girls Vs Boys  Primary age of onset years During the last major growth spurt of adolescence  Time of greatest risk: Girls: 6 months before & after onset of menstruation Boys: Time when their voices deepen risk

Clinical examination 1.Postural assement 2.Flexibility of spinal deformity 3.Range of motion of trunk and lower extrimities 4.Strength assement of trunk and lower extremities 5.Neurological assement 6.Skin/soft tissue assement

Physical Exam Iliac crest height –Leg length discrepancy Shoulder height Arm trunk space Scapular position Trunk shift Inspection of skin –Café au lait spots Patient standing in a relaxed posture

37 6 Step Screening Process 1. Front standing position 2. Back standing position 3. Back bending away from you 4. Side bending position 5. Front bending toward you 6. Side bends American Red Cross of Northeast Tennessee

38 Step 1 Front View Shoulders should be level and at the same height Distance between arm and torso equal on both sides Crest of hips level on horizontal plane Head straight and centered Abnormal Normal

39 Step 2 Back Standing View Shoulders should be level and the same height Distance between arm and torso equal on both sides Crest of hips level on horizontal plane Head straight and centered Scapula level on both sides

40 Adam’s Bending Test The patient is asked to lean forward with his or her feet together and bend 90 degrees at the waist:  Feet slightly apart  Palms together  Arms outstretched with straight elbows  Head out  Bend forward at waist  Place hands between legs at knee level

41 Step 3 Back Bending Away ADAMS test Look For: Rib prominence Lumbar Prominence (abnormal spinal curvatures) Differences in height of hip crests

42 Step 4 Side View Look for exaggerated rounding of the back Kyphosis

43 Step 5 Bending Front View Shoulders level? Is one side of torso more rounded than the other? Look for lumbar prominence

44 Step 6 Side Bends Ask the student to bend at The waist to each side Look for S curvatures

45 Degrees of Curvature Scoliosis is a lateral deviation of the normal vertical line of the spine which, when measured by an X-ray, is greater than 10 degrees. MILD MODERATE SEVERE

47 Diagnosis Physician Physical Exam Scoliometer measurements X Ray MRI American Red Cross of Northeast Tennessee

Scoliometer  It is a tool that measures the degree of rotational deformity, when it is placed at the position of maximal prominence  The Scoliometer is placed on the back and measures the apex (the highest point) of the upper back curve An inclinometer (Scoliometer) measures distortions of the spinal curve.

Forward Bend Test Adam’s sign Assesses the rotation deformity

Measure spinal curvature using Cobb method: - Choose the most tilted verterbrae above & below apex of the curve:  locate the superior end vertebra  locate the inferior end vertebra  draw 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.

Rotation (Nash and Moe) Spinous process rotates into concavity Pedicle position

Skeletal Maturity Gruelich & Pyle atlas Triradiate cartilage fusion Risser sign

Treat or Not to Treat

Referral Guidelines & Treatment Curve (degrees)Risser gradeX-ray/referTreatment 10 to 190 to 1Every 6 months/noObserve 10 to 192 to 4Every 6 months/noObserve 20 to 290 to 1Every 6 months/yes Brace after 25 degrees 20 to 292 to 4Every 6 months/yes Observe or brace 29 to 400 to 1ReferBrace 29 to 402 to 4ReferBrace >400 to 4ReferSurgery †

55 Scoliosis Treatment Observation: Minor curvatures (>20 degrees) Skeleton is close to maturity Exercises may help with surrounding muscular strength Brace: Around torso and hips Helps hold spine in place while it grows Can be removed for sports Surgery: Major curvatures (<45 degrees) Rapid deterioration/progression Generally spinal fusion

Natural History If curve <30 degrees at maturity –No adult consequences –Unlikely to ever progress Curves >45 degrees may progress a degree/year Mortality not increased unless curve >90 degree –Right heart failure –Decreased pulmonary function

Non-Operative Treatment <25 degrees monitor every 4-12 months –Depends on skeletal maturity >25 degrees monitor every 3-6 months >30 degrees in skeletally immature brace Curve change by 10 degrees brace Curve >40-45 degrees surgery

Therapeutic EXERCISE in scoliosis Exercise to address muscle function and flexibility of trunk and pelvis Posterior pelvic tilts, in multiple functional positions Abdominal exercises for upper, lower and oblique muscle groups Anterior chest wall stretches Spinal stabilizzation and stretching into the curve convexity Esercise to address the lumbopelvic relationship and lower extrimity musculature Hip flexor stretches and strengthening Hamstring streches and strengthening Iliotibial/tensor fascia lata stretches and strengthening Erector spinae stretches and strengthening ROM Respiratory exercises Postural self-correction exercises Use of the mirror for visul feedback helps An imporatant role with brace

Goal of exercise programs for individuals with scoliosis Develop or enhance the patient’s awareness of hip or posture Enhance the respiratory function and chest mobility Improve trunk muscle strength and function Improve or prevent the futher loss of mobility of the spine and lower extremities Augment the function of the orthosis through active exercise while in the brace Enhance the body biomechanical mechanism to perform better the activities of daily living while wearning the orthosis

Bracing Duration and time in brace –23 hours per day –Wear until skeletal matures Types –Milwaukee –Underarm orthosis –Charleston night time bending brace

Braces

Brace 1.Reduce gross spinal motion to some degree 2.Stabilize individual motion segments 3.Apply closed chain force systems 4.To protect surgical constructs

Brace efficacy Success of spinal orthotic treatment depends on a person’s ability to properly wear the orthosis enough hours daily to facilitate optimal outcome.

Problems with Braces Argued efficacy Narrow treatment window to initiate Poor compliance Must have good orthotist –Curves corrected by 20 degrees in brace do better

Spinal orthotic treatment  The mechanical stiffness and applied force systems of the orthosis may be considered magnitude of treatment, while wearning time might be considered dosage of treatment.  It is over time the treatment effectiveness for prevention, correction and stabilizzation of deforming curves that are secondary to idiopathic, neuromuscolar and congenital scoliosis; traumatic and pathological fractures and postinfectious instabilities and tumors. It has been demostrated both clinically and in the literature.

Orthotic The primary goal of orthotic intervetion in idiopathic scoliosis is prevention or minimization of further progression for individuals with skeletal immaturity throughout the entire growth period until skeletal maturity The correction depends on the positioning of the pad, the direction of the applied force, and the duration that these forces are applied.

Spinal orthosis for scoliosis Milwaukee Brace it is a cercicothoracolumbosacral orthosis (CTLSO), was initially employed as a post-operative modality. The brace consists of a pelvic section, wich helps to reduce lumbar lordosis and an attached “superstructure” (3 metal uprights attached to the neck ring with chin and occipital support) It is prescribed to be worn 23 hours a day.

Boston brace 1970 To be worn full time More globality accepted Thoraco-lumbar-sacral orthosis Spinal orthosis for scoliosis

 Evolutive scoliosis, but still flexible  Double primary curves  Thoracolumbar and lumbar curves with caudal deformities at T7 (<30°-35°)  Kyfosis superior of T6 Spinal orthosis for scoliosis

Brace and exercise Prevention of secondary functional and cardiopolmonary impairments related to inactivity imposed by long-term orthotic wear.

Surgery Failed bracing Curves >45 degrees Unbalanced curves >40 degrees Surgery is fusion with instrumentation

Surgical Treatment for Scoliosis Curves in growing children greater than 40 º require a spinal fusion (Risser grade 0 to 1 in girls and Risser 2 or 3 in boys) Skeletally mature patients can be observed until their curves reach 50 º Posterior spinal fusion is best choice for thoracic curves Anterior spinal fusion is best treatment for thoracolumbar and lumbar curves

Surgical Treatment for Scoliosis Spinal surgery with instrumentation significantly corrects deformity & usually stops curve progression Surgery is accompanied by spinal cord monitoring using somato- sensory & motor-evoked potentials (risk of neurologic injury is 1/7000 )

Post-Op Treatment & Long Term Consequences of Spinal Fusion If segmental instrumentation used, no post-op cast or brace required in generally Post-fusion back pain does occur and is more common in distal spinal fusions OK to participate in athletics after 9 – 12 months (should avoid contact sports)

Treatment Algorithm

Conclusions The scoliosis may have been due in part to loosening of the joints, delay in puberty onset (which can lead to weakened bones), and stresses on the growing spine. There have been other reports of a higher risk for scoliosis in young athletes who engage in vigorous sports that put an uneven load on spine. These include figure skating, dance, tennis, skiing, javelin throwing, and other sports. It should be strongly noted that in most cases the scoliosis is minor, and everyday sports do not lead to scoliosis. Exercise has many benefits for people both young and old and may even help patients with scoliosis.

Natural history of scoliosis Assessing future growth potential using Tanner staging: Tanner stages 2-3 (just after onset of pubertal growth) are the stages of maximal scoliosis progression

Red flags on PE: Left-sided thoracic curvature Pain Significant stiffness Abnormal neurologic findings Stigmata of other clinical syndromes associated with curvature

Modeling exercises in brace. A - The patient is in a relaxed position. B - The patient moves away from sternal upright to do a maximum thoracic kyphotization movement. C - The patient is in a relaxed position. D - The patient moves away from abdominal upright to maximally exert a pressure on the lumbar pressure pad

Brace treatment must almost always achieve a very good aesthetic body shaping. Elisa started her treatment pre-menarchial at Risser 1, with 58 and 59 degrees curve and refusing to be operated on. At the end of treatment she reached a very good aesthetic while reducing the curves. She has already had some experiences in the fashion world.

Fig. 3. The Sforzesco brace, whose study lead to the development of the SPoRT concept of scoliosis correction.

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