Deviations in normal spinal contours comprise a group of disorders termed spinal deformities of which idiopathic scoliosis is the most common. Spinal deformities are clinically important because they may produce pain, difficulty with sitting or ambulating, neurologic compromise, unacceptable cosmesis and in advanced cases cardiopulmonary compromise. Each type of spinal deformity is associated with its own clinical presentation, symptoms and natural history for progression.
For comparison, the normal spine is straight in the frontal plane, whereas in the sagittal plane it is composed of three curves: a cervical lordosis, a thoracic kyphosis and a lumbar lordosis.
Although scoliosis has been defined as lateral curvature of the spine, it is associated with vertebral rotation, which produces the cosmetically unacceptable rub hump. Idiopathic Scoliosis is classified according to the age at onset: infantile, juvenile and adolescent. Scoliosis seen after skeletal maturity is termed adult scoliosis. Progression of idiopathic curves correlates with the magnitude of the curve, the age of presentation and the patient’s menarchal status. Non-idiopathic causes of scoliosis must be determined because of their less predictable, and generally higher risk for progression (e.g. congenital, neurofibromatosis and neuromuscular).
Symptoms and Signs of Scoliosis:
Examination of the patient with spinal deformity should include determination of the patient’s overall frontal and sagittal alignment with particular attention to the relationship of the occiput with the sacrum. When the occiput is not centered over the sacrum, the patient is described as decompensated. Asymmetry of the shoulders and the pelvis may be present with high thoracic and lumbar curves, respectively. The skin should be carefully inspected for signs of café-au-lait spots (neurofibromatosis) or hair patches (spinal dysraphism). The forward bend test detects the rib hump, which correlates with curve magnitude and vertebral rotation. Bowel and bladder history and a complete neurological examination are mandatory for all patients.
Significant pain or neurological symptoms are uncommon with adolescent idiopathic scoliosis. These findings warrant further investigation to rule out tumor, infection, disc herniation, or other non-idiopathic causes of spinal deformity.
Scoliosis patients referred for evaluation of spinal deformities should obtain standing AP and lateral radiographs including the entire spine (36″x14″ film). If treatment is contemplated, bending films in the direction of each curve convexity will help to determine curve flexibility. Curves are measured according to the Cobb Method. The vertebrae, which are maximally tilted into the concavity of the curve, are the end vertebrae. Perpendiculars from their endplates are drawn and the angle between them determines the curve magnitude. Curves should be measured from the same vertebrae during each examination for serial comparison.
Patients presenting with neurological signs or symptoms, left thoracic curves or rapid progression should obtain magnetic resonance scans to rule out intraspinal pathology.
Treatment of Adolescent Idiopathic Scoliosis
Scoliosis Observation: Skeletally immature patients presenting curves less than 20 degrees or for those presenting with curves less than 40 degrees at skeletal maturity should be observed. Adolescent patients should be followed with radiographs at 4-6 month intervals until skeletal maturity.
Curves greater than 20 degrees or progression of greater than 5 degrees should be referred for treatment to a surgeon experienced in the management of patients with spinal deformity.
Bracing for Scoliosis: child in braceGrowing children with curves measuring 20-40 degrees or documented progression are candidates for brace treatment. Patients with curve apices below T8 can be fitted with polypropylene underarm type braces. Higher curves can only be controlled with a cervico-thoracic-lumbar orthosis (Milwaukee Brace). The goal of bracing is to halt progression. Long-term curve correction is rarely achieved with brace treatment.
The daily duration of brace wear is necessary to halt progression is controversial. Although historically braces have been worn for 23-24 hours per day, recent studies have indicated that limited daily brace wear may be equally effective. Generally, patients should be braced until skeletal maturity and then should be gradually weaned. For bracing instructions, click here.
Surgical Treatment for Scoliosis:
The prevalence of patients with curves greater than 20 degrees is 0.13 to 0.30 percent with few of them requiring surgery. Progressive curves, those 40 degrees or greater, and those resistant or non amenable to brace treatment are indicated for surgery. Newer surgical techniques are designed to both correct the frontal curve and decrease vertebral rotation whole providing secure fixation so that post-operative brace wear is often not needed. Instrumentation is accompanied by surgical fusion with bone grafting. Anterior fusion and instrumentation has been developed for certain lumbar curves. The length of the fusion depends on the type of curve treated. The preservation of lumbar motion segments below the fusion has been shown to correlated with a decreased incidence of low back pain in the adult patient.
We have the largest Spinal Deformity practice in the West. This is in large part due to our super-specialization in Scoliosis and Complex Scoliosis Revision surgery. We have a specialized spine team consisting of pain management, orthopedic surgeons, vascular surgeons, OR techs and nurses who exclusively work spine surgical procedures, and a designated anesthesiologist.
If you would like more information please call (310) 423-9983 to schedule an appointment with Dr. Pashman. Or email us at eSpine1@aol.com