A Posterior View of a Normal Spine Peer Reviewed
Paediatr Child Health. 2007 Nov; 12(9): 771–776.
Language: English | French
Scoliosis: Review of diagnosis and treatment
Joseph A Janicki
oneSection of Orthopaedics, Northwestern Academy, Children'southward Memorial Hospital, Chicago, Illinois, United states of america
Benjamin Alman
twoDivision of Orthopaedic Surgery, The Hospital for Ill Children, University of Toronto, Toronto, Ontario
Abstract
Scoliosis is a spinal deformity consisting of lateral curvature and rotation of the vertebrae. The causes of scoliosis vary and are classified broadly every bit congenital, neuromuscular, syndrome-related, idiopathic and spinal curvature due to secondary reasons. The bulk of scoliosis cases encountered by the full general practitioner volition be idiopathic. The natural history relates to the etiology and historic period at presentation, and usually dictates the treatment. However, it is the patient's history, concrete examination and radiographs that are critical in the initial evaluation of scoliosis, and in determining which patients demand additional considerations. Scoliosis with a principal diagnosis (nonidiopathic) must be recognized by the doc to identify the causes, which may require intervention. Patients with congenital scoliosis must be evaluated for cardiac and renal abnormalities. School screening for scoliosis is controversial and is falling out of favour. The treatment for idiopathic scoliosis is based on historic period, curve magnitude and risk of progression, and includes ascertainment, orthotic management and surgical correction with fusion. A child should be referred to a specialist if the bend is greater than x° in a patient younger than ten years of age, is greater than xx° in a patient 10 years of age or older, has atypical features or is associated with dorsum pain or neurological abnormalities.
Keywords: Back pain in scoliosis, Idiopathic scoliosis, Nonidiopathic scoliosis, Scoliosis screening
Résumé
La scoliose est une malformation rachidienne constituée d'une courbure latérale et d'une rotation des vertèbres. Les causes de la scoliose sont variables et se divisent généralement en grandes classes : origine congénitale, origine neuromusculaire, reliée à un syndrome, origine idiopathique et courbure rachidienne imputable à des raisons secondaires. La majorité des scolioses qu'observe l'omnipraticien sont d'origine idiopathique. L'évolution naturelle est reliée à 50'étiologie et à fifty'âge au moment de la consultation et, d'ordinaire, elle dicte le traitement. Cependant, l'histoire, l'examen physique et les radiographies du patient sont essentiels pour l'évaluation initiale de la scoliose et cascade déterminer quels patients ont besoin d'une évaluation plus poussée. Le médecin doit établir qu'une scoliose se rapporte à un diagnostic primaire (non idiopathique) afin de déceler les causes qui exigent peutêtre une intervention. Il faut évaluer les patients atteints d'une scoliose congénitale afin d'établir s'ils ont des anomalies cardiaques et rénales. Le dépistage de la scoliose en milieu scolaire est controversé et de moins en moins prôné. Le traitement de la scoliose idiopathique dépend de fifty'âge, de 50'importance de la courbure et du risque d'évolution, et il inclut l'observation, le port d'une orthèse et une correction chirurgicale avec fusion. Il faut aiguiller fifty'enfant de moins de dix ans vers un spécialiste lorsque la courbure est supérieure à x° et aiguiller celui de dix ans ou plus lorsque la courbure est supérieure à 20°, de même que lorsque les caractéristiques de la scoliose sont atypiques ou que la scoliose s'associe à des douleurs dorsales ou à des anomalies neurologiques.
Scoliosis is defined as a departure of the normal vertical line of the spine, consisting of a lateral curvature with rotation of the vertebrae within the curve. Typically, for scoliosis to be considered, there should exist at least 10° of spinal angulation on the posterior-inductive radiograph associated with vertebral rotation (1). The causes of scoliosis vary and are classified broadly as built, neuromuscular, syndrome-related, idiopathic and spinal curvature due to secondary reasons. Congenital scoliosis is due to a vertebral aberration causing the mechanical deviation of the normal spinal alignment. Scoliosis tin can be due to neurological conditions (eg, cerebral palsy or paralysis), muscular abnormalities (eg, Duchenne muscular dystrophy) or other syndromes (eg, Marfan syndrome and neurofibromatosis). Occasionally, pregnant lateral departure of the spine can occur with little or no rotation of the spine and without bony abnormalities. In these cases, the 'scoliosis' can be the result of pain, spinal cord abnormalities, tumours (both intraspinal and extraspinal) and infection. The majority of scoliosis cases encountered by the general practitioner will be without an obvious cause (idiopathic), and will be the principal focus of the present review. The natural history relates to the etiology and historic period at presentation, and usually dictates the treatment. However, information technology is the patient'southward history, physical exam and radiographs that are critical in the initial evaluation of scoliosis and in determining which patients need boosted evaluation and consideration.
PATIENT HISTORY
Much of the history and physical exam is focused on identifying nonidiopathic and often more ominous causes of scoliosis (Table 1). Young age at onset (younger than ten years of age), rapid bend progression and the presence of neurological symptoms are the most useful findings in identifying nonidiopathic scoliosis (1). Fortunately, most frontline physicians will merely run across idiopathic scoliosis during their careers. Perhaps the well-nigh of import task for the physician, however, is to identify underlying causes that may require intervention.
TABLE 1
Patient history components
| Age at onset |
| Evidence of maturation |
| Presence of dorsum pain |
| Neurological symptoms, including gait abnormalities, weakness or sensory |
| changes |
| Feelings virtually overall appearance and back shape |
| Family unit history |
Usually, patients nowadays spinal deformity or, more than likely, chest wall and back disproportion. Whether identified past the patient, their parents, or through school or md screening programs, posterior chest wall prominence is the most outward manifestation of spinal curvature. With more meaning scoliosis, adolescent girls sometimes detect a divergence in their chest sizes. Other body characteristics may include shoulder asymmetry and overall posture imbalance in the coronal airplane.
While not typically the presenting symptom, back pain is not unusual (2). Approximately ane-quarter of patients with boyish idiopathic scoliosis (AIS) present with dorsum pain (ii). Patients with idiopathic scoliosis will sometimes take back pain and, specifically, posterior chest wall hurting on the side of the rib prominence. Lower back hurting is common in the adolescent population with or without scoliosis. Back pain without injury that is astringent and unremitting is a cause of business concern and should be investigated with, at minimum, a consummate examination and radiographs because in that location may be a more specific diagnosis (2,3). Acute back pain associated with fever, for example, should be evaluated for spinal infections. Dorsum hurting isolated to one area, which is worse at night and significantly improved with nonsteroidal anti-inflammatory drugs, may be indicative of a spinal tumour such as an osteoid osteoma.
With any spinal condition, the wellness care provider must be on the watch for neurological problems. A complete neurological history should include inquiries of weakness, sensory changes, problems of balance, gait and coordination, too as bowel and bladder difficulties such as incontinence. Significant disturbances in these may suggest intraspinal pathology such as syringomyelia (central spinal string dilation), tethered cord or tumour (4,5).
The adventure of curve progression in idiopathic scoliosis and hence its treatment and prognosis is based on remaining spinal growth (6). The near reliable method of monitoring growth is simple height measurements. Therefore, the principal physician oft possesses this information from their annual examinations. Furthermore, it is important to look at other markers of growth and maturity, including signs of puberty, onset of menarche and breast evolution.
In that location is a genetic component to this condition with siblings (vii times more frequently) and children (iii times) of patients with scoliosis having a college incidence (vii). Adults with idiopathic scoliosis should know that their children should be carefully screened.
Finally, it is important to empathise the patient'south general thoughts nigh their advent. Because, as will be discussed, AIS is primarily a cosmetic deformity, handling is based on the desire to alter the shape of the dorsum or to prevent the deformity from worsening. The self-perception of a patient and whether they are happy with their appearance is important in the controlling process.
Physical Test
The scoliosis patient's physical examination should begin with the overall appearance, the peel and the neuromuscular system before the evaluation of the dorsum's shape (Tabular array 2). A height measurement is important to monitor skeletal growth and the run a risk of scoliotic curve progression. In addition, patients who are alpine with long fingers and an increased arm span to tiptop ratio should be assessed for other signs of Marfan syndrome (such as cardiac abnormalities). Patients with joint and skin hyperlaxity along with scoliosis may need to have further work up for a connective tissue condition such every bit Ehlers-Danlos syndrome. Loftier-arched or cavus feet may be associated with a neurological disorder such as Charcot-Marie-Molar disease or a spinal cord abnormality such as a tumour. Skin inspection that notes café-au-lait spots or axillary freckles suggests neurofibromatosis, while a hairy patch or skin dimpling in the back may identify a spinal dysraphism such as myelomeningocele. Assessment of pubertal evolution (Tanner staging) should exist included with the general appearance.
Table 2
Physical examination components
| Height measurement |
| Gait check |
| Pes shape |
| Peel inspection |
| Cess of pubertal evolution |
| Neurological examination, including motor, sensory and reflex tests (including abdominal) |
| Symmetry of shoulders and iliac crest |
| Frontward angle exam |
A complete neurological examination should evaluate residue, reflexes and motor testing in all muscle groups, and sensory testing of the lower extremities, back and chest. Rapid assessment of strength and rest can be made past observing gait, toe-walking, heel-walking, heel-to-toe walking along a straight line and hopping on one foot. Weakness of the lower extremities may be acquired by a spinal mass or a central nervous system trouble. Sensory changes to light touch along the back and spine may exist a subtle sign of an underlying spinal syrinx causing the scoliosis. Upper and lower extremity deep tendon reflexes should be included, too as the Babinski test. Abdominal reflexes obtained by stroking the 4 quadrants around the umbilicus in a supine patient (belly button moving toward the stroked side is normal) should exist completed. Abnormal examination may bespeak an intraspinal disorder such as syringomyelia.
When examining the back of a patient with suspected scoliosis, the evaluator should inspect the shoulders and hips for asymmetry. Pregnant leg length discrepancies, apace judged by feeling the pinnacle of the iliac crests or the level of the dimples fabricated by the posterior-superior iliac spines, can cause an oblique spinal accept-off from the pelvis, which results in spinal curvature. The classic screening examination for scoliosis, the forward angle test, is finally performed by having the patient bend forward at the waist with knees direct and palms together (Figure 1) (i,viii). The examiner should expect for any asymmetry in the contours of the back resulting from the rotational deformity of the spine (9). In classic thoracic scoliosis with the noon of the curve to the right, the patient's correct side is prominent. While this is most hands seen in the thoracic spine, it is important to wait in the lumbar region for prominence as well. The disability to perform this exam due to hurting in the back or hamstring tightness can suggest other pathology, including mechanical dorsum pain, disc herniation, spondylolysis or infection.
Photograph of a patient with idiopathic scoliosis upright (A) and forward bending test (B). Note the rotational asymmetry of the back
IMAGING EVALUATION
Once scoliosis is suspected, a continuing posterior-inductive radiograph should be obtained. These films are taken on a three-foot cassette if possible. Further evidently radiograph imaging is beyond a screening examination and should exist determined by the orthopaedic surgeon. Besides examining the curve itself, careful attention should be paid to the vertebral bodies on the radiographs. In that location should be ii pedicles at every level and there should exist rotation of the spine, with the apex of the curve having the most rotation. Remember, truthful scoliosis is not simply a deformity in the coronal plane but is also a rotational deformity. A scoliotic curve without rotation should be investigated for other causes, including bony tumours (osteoid osteoma), intraspinal pathology (syringomyelia and masses) and nervus root irritation.
If back pain is present, a lateral radiograph of the spine including the lumbosacral region should exist obtained to look for vertebral abnormalities associated with diagnoses such equally spondylolysis (an idiopathic fracture of the posterior elements of the vertebral body), spondylolisthesis (a slipping frontwards of one vertebral body on the adjacent ane), infection or bony destruction. Further imaging for patients with scoliosis and back hurting may include a bone browse or a magnetic resonance imaging (MRI) exam. These imaging modalities are beyond screening examinations and are usually obtained by the treating surgeons.
An MRI is not needed for most patients with AIS; although this is somewhat controversial. Some treating centres automatically request an MRI for any patient with scoliosis. However, an MRI is most likely to be useful for patients younger than x years of age at presentation (juvenile and infantile scoliosis) (10,11), those with left thoracic curves (xi) and those with an abnormality on neurological test.
TYPES OF SCOLIOSIS
Congenital scoliosis is due to skeletal abnormalities of the spine that are present at birth. These anomalies, which can include multiple levels, are the result of and broadly classified as a failure of formation or a failure of segmentation (or both) during vertebral development (Effigy 2). Because these spinal deformities are present in utero, they are often first identified on fetal ultrasound (12). Organ systems that develop at the aforementioned gestational time (fifth to 6th week) may also demonstrate abnormalities in upwards to sixty% of cases (13,xiv). Thus, it is important to place associated anomalies with a thorough evaluation of the neurological, cardiovascular and genitourinary system, including a adept neurological and cardiac physical examination, an abdominal ultrasound and an echocardiogram. Treatment is based on the age of the patient, progression of the curve, and the location and type of anomaly. The options for surgical treatment include in situ fusion and resection with correction of the deformity.
Congenital scoliosis – computed tomography depicting a hemivertebrae
Scoliosis can be associated with neurological conditions, muscular abnormalities and global syndromes. This long list of diagnoses would typically take other signs, symptoms and physical manifestations besides as scoliosis. Normally, these varying diagnoses are treated at 3rd intendance facilities with special expertise in the management of patients with circuitous multisystem problems. The caregiver who treats these patients should be familiar with the nonspinal manifestations of these atmospheric condition. Some examples can exist seen in Table iii.
Table 3
A partial listing of syndromes and neuromuscular atmospheric condition associated with scoliosis
| Cerebral palsy |
| Charcot-Marie-Tooth disease |
| Poliomyelitis |
| Spinal muscular atrophy |
| Arthrogryposis |
| Duchenne muscular dystrophy |
| Built hypotonia |
| Neurofibromatosis |
| Paralysis |
| Marfan syndrome |
| Ehlers-Danlos syndrome |
| Myelomeningocele |
| Osteogenesis imperfecta |
| Achondroplasia |
As noted higher up, a curve can be found in the coronal plane on radiographs with minimal or no rotation of the vertebral bodies (Figure 3). Often, at that place is pain associated, which contributes to the deformity. This is non a true scoliosis, and other causes of the deformity should exist investigated.
Spinal curvature without rotation – other diagnoses autonomously from idiopathic scoliosis must be considered
Idiopathic scoliosis is, in some ways, a diagnosis of exclusion. However, idiopathic scoliosis is by far the most mutual type of spinal deformity with a prevalence of one to three per 100 (curves of greater than 10°) in an equal proportion of boys and girls (15–xviii). Meanwhile, the prevalence of curves greater than xxx° is one to 3 per 1000 with a i:8 ratio of boys to girls (18–twenty). Patients are divided into age at which the scoliosis presents – infantile idiopathic scoliosis in patients nothing to three years of age (0.five% of idiopathic scoliosis), juvenile idiopathic scoliosis in patients four to ten years of historic period (10.v% of idiopathic scoliosis), and AIS in patients older than x years of age (89% of idiopathic scoliosis) (21).
Infantile curves may exist associated with neuroaxial abnormalities, plagiocephaly, hip dysplasia, congenital heart illness and mental retardation, and unremarkably (xc%) resolve spontaneously (7,22). Juvenile scoliosis, on the other hand, is oftentimes progressive and, due to the remaining growth, has the potential for astringent trunk deformity and eventual cardiac or pulmonary compromise. If left untreated, curves that reach xxx° are almost always progressive (23).
Patients with AIS typically present after ten years of historic period which corresponds with rapid adolescent growth (1). The historical nomenclature system is the King-Moe system, while the newer Lenke arrangement is currently used more than widely (24,25). Take a chance factors for progression include female gender, bend magnitude of greater than 50° at maturity, curve type and remaining growth. Curves progress most rapidly when the kid is growing rapidly – adolescent growth spurt (26). Clinically, this tin can exist estimated (with varying degrees of accuracy) by historic period (on average, girls grow until 14 years of historic period and boys until 16 years of age), the menarche condition (typically growth is most rapid in the six months before menarche and ceases, on average, ii years after menarche) and acme height velocity. Radiographically, markers for determining remaining growth include the closure of the triradiate cartilage, the ossification of the iliac crest apophysis (Risser sign) and diverse skeletal markers on the hand or elbow when compared with normal controls. Finally, curves greater than 30° (27) with an apex above T12 are more than probable to progress (28).
NATURAL HISTORY AND Treatment
Natural history studies of patients with idiopathic scoliosis later on skeletal maturity, establish that curves less than 30° do not progress, while most curves of greater than 50° proceed to progress. The progression is approximately 1° per twelvemonth (29,thirty). In patients with severe thoracic curves (greater than xc° to 100°), there is an increased run a risk of cor pulmonale and right heart failure. However, an increased mortality charge per unit has not been found in long-term studies (31,32) of patients with AIS. Pulmonary role can become limited with astringent scoliosis (greater than 90°) (31,33). Back pain is common in the normal population, making studies evaluating back hurting in scoliosis difficult. Some studies testify a slightly higher rate of back pain in patients with AIS (34). Scoliosis has also been found to be a risk cistron for psychosocial issues and wellness compromising behaviour (35). Even so, at that place have been no studies comparing treated and untreated patients with scoliosis to their rates of back pain and their self image.
School-based and dr. screening programs are controversial. In a population-based written report (36), school screening identified some of the children who went on to receive handling but referred many more who did non. The Scoliosis Inquiry Lodge (USA) recommends almanac screening of all children between 10 and 14 years of historic period (37). The American Academy of Pediatrics has recommended screening with the forrard bending exam at routine health supervision visits at 10, 12, 14 and 16 years of age (38). Meanwhile, the United states Preventive Services Task Force (39) and the Canadian Job Force on the Periodic Health Examination (forty) ended that there was insufficient evidence to recommend for or against routine screening of asymptomatic adolescents for idiopathic scoliosis. The US Preventive Services Chore Strength ended that the harms of screening adolescents for idiopathic scoliosis may exceed potential benefits (39). Most jurisdictions have abandoned routine screening.
The handling of scoliosis is based on the type of scoliosis, the magnitude of the bend, the number of years of growth remaining and the patient's opinion virtually the shape of their back. The treatment of patients with built-, neuromuscular- and syndrome-associated scoliosis, and those with idiopathic scoliosis younger than 10 years of age, presents a number of controversies. These patients should be treated at specialized facilities; their handling is beyond the telescopic of the present paper.
The treatment options for AIS include observation, bracing and surgery. While many other factors must be considered, the general goal is to proceed curves under l° at maturity. Typically, observation is recommended for young patients with curves of less than 25°. Orthotic direction is recommended for immature patients with progressing curves between 25° and 50° (41). There are a number of dissimilar braces (Milwaukee brace, Boston brace and the Charleston bending brace) available with varying published results. Compliance and wearing time also seems to have a role in the efficacy of bracing (42). Bracing, however, does not permanently improve or correct the curve merely tries to forbid it from worsening (43). While orthotic management is the standard of care for progressive scoliosis, the scientific ground is not conclusive (1). A prospective, randomized trial to await at the efficacy of bracing is currently underway.
Surgical correction of idiopathic scoliosis is considered for curves greater than 45° in immature patients and for curves greater than 50° in mature patients. The trunk deformity and residue is besides included in the conclusion-making process (Effigy 4A) (1). Every bit noted, the long-term consequences of an untreated patient with 55° of scoliosis at maturity are not definitive. Thus, the patient unremarkably should be unhappy with the shape of their back to undergo a significant and potentially dangerous surgical correction of scoliotic deformity less than 60°. Surgery is usually performed during boyhood, but newer techniques allow skilful correction to exist accomplished into early on adulthood. The goals for surgical handling are to forestall progression and to improve spinal alignment and balance. The hips and shoulders should be level, and the head over the sacrum while maintaining sagittal alignment. The spine is corrected with a combination of rods, hooks, screws and wires while being fused by bone graft – either from the patient, a cadaver or artificially (Figure 4B). Strategies include fusion with and without instrumentation from the anterior, the posterior or both depending on the curve type, historic period and surgeon preference. The techniques for the correction and fusion change quickly; long-term results have non been obtained for the newest techniques. However, with older technology, adept results have been found in a xx-year follow-up period (44).
A Typical adolescent idiopathic scoliosis requiring correction and fusion; B Fused spine with hook and spiral construct
Given these treatment guidelines, master care physicians should refer any kid with an singular curve of greater than 10° to a specialist, including patients younger than ten years of historic period, those with left thoracic curves, those with neurological abnormalities or those with pregnant pain. A child older than 10 years of age who has not reached skeletal maturity tin can exist referred at any fourth dimension, but definitely one time the curve reaches twenty° to 25°. Considering typical scoliosis rarely progresses faster than 1° per month, a referral within iii to 6 months is appropriate. Singular scoliosis should be seen inside one calendar month.
SUMMARY
Scoliosis is a deviation of the spine consisting of lateral curvature and rotation of the vertebrae. While scoliosis is associated with many diagnoses, the vast majority of patients encountered are idiopathic in nature. A thorough history and physical examination and radiographs should exist completed to identify nonidiopathic causes of the scoliosis. The handling for idiopathic scoliosis is based on age, bend magnitude and risk of progression, and includes observation, orthotic direction and surgical correction.
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