CASE REPORT

SCOLIOSIS

Febriyani R
C11110291
ADVISOR
Dr. SHANDY PUTRA
Dr. HERBERT YURIANTO
SUPERVISOR
Dr. KARYA TRIKO BIAKTO Sp.OT (K) Spine

DIBAWAKAN DALAM RANGKA TUGAS KEPANITERAAN KLINIK

BAGIAN ORTOPEDI DAN TRAUMATOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN
MAKASSAR
2015
Name : Miss. NN
Age : 24 years old
Sex : Female
Occupation : Student
Date of admission : 07-12-2015
Registration No : 673009
Chief complaints : Bending of the backbones
History of illness :
- Firstly realized the abnormality since 9 years ago (2006, 15 y.o)
without any pain and other problems. Patients also feel right
shoulder higher than the left shoulder.
- Patient got the treatment at RS NTB (2012) and advised to use
bracing but she refused.
- Since the last 3 months, patient feels pain in his back , especially
during vigorous activities and disappear after taking rest.
- Patient was then referred to the Poli RSWS.
- Urinating and defecating is normal.
- History of prolonged cough (-).
- No history of trauma .
- History of puberity at 12 years old
- No family history of same disease.
BP : 120/70 mmHg
HR : 78 x/minute
RR : 20 x/minute
T : 36.7 C
NRS :0
 Inspection :

Asymmetric shoulder, higher on right shoulder.

Asymmetric right and left chest. Prominence on the
right scapula , Swelling (-), hiperemis (-) Hematoma(-),
Gibbus (-)

Palpation:

Tenderness (-)
Department of Orthopaedic and Traumatology, Faculty of Medicine, Hasanuddin University
 L: Deformity (+), elevation of shoulder (+) scapula

prominent (+) right side, asymmetry arm to body (+),

curve to the right side,

F : Tenderness (-), Processus spinosus line bent to right

direction in thoracal region

Department of Orthopaedic and Traumatology, Faculty of Medicine, Hasanuddin University

 L : Hip protrusion on left hip.

F : Tissue Masses (-), swelling (-)

M : Active and passive movement of the hip joint is

normal

Department of Orthopaedic and Traumatology, Faculty of Medicine, Hasanuddin University

5 5
5 5
5 0
5
5 5
5 5

5 5
5 5
5 5
5 5
5 5

No
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2 Any anal sensation
2 2 2 2 Y
0 Absent
2 2 2 2 1 Impaired
2 2 2 2 2 Normal
2 2 2 2 NT Not testable
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
REFLEX
Physiologic reflex Pathologic Reflex

R L R L
Biceps (+) (+) Babinski (-) (-)
Triceps (+) (+) Chadock (-) (-)
Achilles (+) (+) Openheim (-) (-)
Patellar (+) (+) Clonus (-) (-)
 WBC 14,5[10x3/ul]
RBC 4,67 [10x3/ul]
HGB 12,2 [g/dl]
HCT 38 [%]
PLT 184 [10x3/ul]
CT 700
BT 200
HbsAg Non Reactive
BTA (-)
 Thoracolumbar X- PA / Lateral view
Ray

Identification of primary
curve
1. Apex = most rotated, least tilted,
2. Apex Th VIII main thoracic )
3. Apex Th X thoracolumbar / lumbar )
Cobbs angle measurement
1. Identify vertebrae at both ends of the
curve ( end vertebrae ). End
vertebrae the vertebrae most tilted,
Th V and Th X least rotation
2. With use of a goniometer ; construct
lines along the superior endplate

3. Determine angle .

curvartura scoliosis thoracal

dextroconvex with lippman Cobb 45 0
Thoraolumbar X-Ray AP
Lumbosakral
Thoracolumbar X-Ray
AP Lumbosakral
1. erect thorakolumbal
250
Thoracolumbar X-Ray
AP view Bending

1. Right bending main

thoracic = 45
2. Righ bending
thoracolumbal/lumbal :
450
3. Main thoracic = structural
(major = largest cobb
measurement)
Thoracolumbar X-Ray
AP view Bending

1. Left bending main thoracic = 60

2. Left bending thoracolumbar /
lumbar = 0
3. Thoracolumbar / lumbar =
structural
Thoracolumbar X-Ray
AP Lumbosakral

1. Apex lumbar curve = L.

III
2. CSVL ( central sacral
vertical line ) =
between the pedicies
Thoracolumbar X-Ray
AP Lumbosakral
1. Thoracic sagittal
profile = 30
2. Normal thoracic
sagittal profile
Pelvis AP
Summary
A woman 24 years old came to the hospital with chief complain Bending
of the vertebra. Firstly realized the abnormality since 9 years ago(2006,
15.y.o) without any pain and other problems. Patients also feel right
shoulder higher than the left shoulder. Patient got the treatment at RS
NTB (2012) and advised to use bracing but she refused. Since the last 3
months, patient feels pain in his back , especially during vigorous
activities and disappear after taking rest.Defecation and urination are
normal. No history of prolonged cough, no history of trauma, no family
history of same disease.
On physical examination, from inspection seen the alignment of vertebra
bending. The motoric and sensoric funtion normal.
On radiological examination therere two of curvartura scoliosis which is
thoracal dextroconvex with lippman Cobb 440 .
Diagnosis

Adult Idiopathic Scoliosis Lenke Classification 1A-N

Non operative
Analgesic
Operation (scolisis corection)
 What is Scoliosis?
Scoliosis is the Spinal deformity characterized by
lateral bending and fixed rotation of the spine.
Cobb angle > 10

Scoliosis is a 3-dimintional problem

Involves a curvature in the sagittal,

frontal, and transverse plane.

Rothman-Simeone, THE SPINE , Sixth Edition.

 Nerve
Genetic
disorder

Endocrine
gland Herediter
disorder

Habits or bad
Physical posture
abnormalities Etiology during
childhood

Reamy Brian. Adolescent Idiopathic Scoliosis : Review and Current Concepts. Volume 64. July 2001
 Scoliosis postural

Muscle spasm and

NON STRUCTURAL pain

Different in leg
length discrepancy

CLASSIFICATION
Idiopathic - juvenile
-infantile
-adolescent

Osteopathic
STRUCTURAL osteogenesis
imperfecta

Neuropathic spina
bifida,
neurofibromatosis
Clinical Manifestation
Back pain

Leg length discrepancy

An abnormal gait

Uneven hips

Clothes no longer fit correctly

One shoulder higher than the other

Shortness of breath

Susan M. Anderson. Spinal Curves and Scoliosis, Radiologic Technology Vol 79 No. 1, September 2007.
Physical Findings

Susan M. Anderson. Spinal Curves and Scoliosis, Radiologic Technology Vol 79 No. 1, September 2007.
Curve Patterns:
Classification:

1. Congenital 1 to 5 %.

2. Idiopathic 80%.

3. Neuromuscular and Others 10% .

Rothman-Simeone, THE SPINE , Sixth Edition.

 Classification:
1) Congenital:

Failure of formation.
Failure of segmentation.

Rothman-Simeone, THE SPINE , Sixth

Edition.
 Classification:

2) Neuromuscular :
Myopathic
Arthrogryposis.
Muscular Dystrophy.

Neuropathic
UML.
LML.

Others:
Trauma.
Tumors.
 Classification:
3) Idiopathic:

Infantile (birth to 2 years +

11 months)
Juvenile (3 years to 9 years
+ 11 months)
Adolescent (10 years to 17
years + 11 months)
Adult (> 18 years)

Rothman-Simeone, THE SPINE , Sixth Edition.

Classification:
Adolescent :
Most common type (80-90%) .

Typically right sided thoracic curve, left

lumbar if 2nd curve .

Family history in 30%.

Females: more severe forms, Males: 25%

incidence intrathecal abnormalities.

Future growth potential.

Progressive.
Physical Assessment
 Radiological Assessment

Cobbs Method :

Universal standard for measuring the degree of a lateral

curvature by evaluating the AP radiographic projection of the
spine .

It is by identifying the vertebrae at both ends of the curve end

vertebrae.
Rothman-Simeone, THE SPINE , Sixth Edition.
Radiological Assessment

Rothman-Simeone, THE SPINE , Sixth Edition.

Cobbs Angle

Susan M. Anderson. Spinal Curves and Scoliosis, Radiologic Technology Vol 79 No. 1, September 2007.
 Radiological Assessment
Risser Sign : An x-ray to provide information about
skeletal maturation. The Risser Sign looks at the iliac crest
growth plate, a fan-shaped part of the pelvis. The crest
fuses with the pelvis at maturity.

Nash-Moe : This method is used to determine the

degree of rotation of the scoliotic spinal column. In the x-
ray image, the positions of the pedicles in relation to the
vertebral body are assessed in terms of 4 different
degrees of rotation.
RISSER SIGN
Rissers Sign describes the
ossification of the illiac
epiphysis
Grade 0 : absent
Grade 1 : (0-25%)
Grade 2 : (26-50%)
Grade 3 : (51-75%)
Grade 4 : (76-100%)
Grade 5 : fusion of
epiphysis of illiac
Radiological Assessment
 LENKE CLASSIFICATION
Step 1: Identification of primary curve (Type 1-6)
1.Measure regional curves
1. proximal thoracic (PT)
2. main thoracic (MT)
3. thoracolumbar/lumbar (TL/L)
2.Identify major curve (biggest curve)
1. always either MT (Type 1-4) or .MT/L (Type 4*,5,6)
3.Determine if minor curve is structural or not
1. definition of structural
2. > 25 in coronal plane on standing AP and do not bend out to < 25 on
bending films
3. OR > 20 in sagital plane
4.Assign Type 1-6 based on chart below
LENKE CLASSIFICATION
Step 2: Assignment of Lumbar modifiers (A,B,C)

Identify apical lumbar vertebrae (ALV)

is the inferior lumbar body that falls outside of the curve
Draw centeral sacral vertical line (CSVL) and see where it sits in relationship to
pedicles of ALV
Assign modifer
A if CSVL passes between pedicles of apical lumbar vertebrae (ALV)
CSVL falls between pedicles of the lumbar spine up to stable vertebra
B modifier if CSVL touches pedicle of apical lumbar vertebrae (ALV)
C modifier if CSVL does not touch apical lumbar vertebrae (ALV)
apex of lumbar curve falls completely off the midline depicting a
curve with complete apical translation off the CSVL
LENKE CLASSIFICATION
Step 3: Assignment of Sagittal thoracic modifier (-, N, +)

Measure sagital Cobb from T5 to T12

Assign modifier
hypokyphotic (-) if < 10
normal if 10-40
hyperkyphotic (+) if >40
Treatment
General objective:
Stop progression
Maintain / restore sagittal & coronal balance
Preserve function of lower lumbar motion
segments
Correct spinal deformity
Allow futher growth of spine (infantile & juvenile
age)
Fundamental treatment options: observation,
bracing & casting, and surgery.

Boos N, Aebi M. Spinal Disorders: Fundamentals of Diagnosis and Treatment: Springer; 2008
Weinstein SL. Lovell and Winter's Pediatric Orthopaedics: Wolters Kluwer Health; 2011
Herkowitz HN, Garfin SR, Eismont FJ, Bell GR, Balderston RA. Rothman-Simeone The Spine: Expert Consult: Elsevier Health Sciences; 2011
References:
Scoliosis Spine Associates : http://www.scoliosisassociates.com/
Morphopedics : http://morphopedics.wikidot.com/spinal-scoliosis
Screening for AIS By Richard B. Goldbloom .
The Genetic Basis of Adolescent Idiopathic Scoliosis By Christopher R. Good, M.D.
Manchester Physio : http://www.manchesterphysio.co.uk/
The Schroth Method : http://www.schrothmethod.com/about/scoliosis-exercises
ScolioCare : http://www.scolicare.com.au/treatments
Scoliosis Systems : http://www.scoliosissystems.com/Scoliosis-Treatment/
International Encyclopedia of Rehabilitation- Scoliosis Rehabilitation :
http://cirrie.buffalo.edu/encyclopedia/en/article/49/
Dr. Enas F Yossef, Dammam Uniersity, PT Dept. : Spinal Deformities Lecture.
Hana Kim, MD, Hak Sun Kim, MD, Eun Su Moon, MD, Scoliosis Imaging: What Radiologists Should Know-
Radiographics Journal, November-December 2010 , doi: 10.1148/rg.307105061
Hans-Rudolf Weiss MD, Scoliosis Short-Term Rehabilitation (SSTR) A Pilot Investigation -The Internet Journal
of Rehabilitation. 2010 Volume 1 Number 1. DOI: 10.5580/e71
Dariusz Czaprowski , Tomasz Kotwicki : Physical capacity of girls with mild and moderate idiopathic
scoliosis: influence of the size, length and number of curvatures- European Spine Jornal, (2012) 21:10991105
Tsuyoshi Sato, Toru Hirano: Back pain in adolescents with idiopathic scoliosis: epidemiological study for 43,630
pupils in Niigata City, Japan- European Spine Jornal,2011 February; 20(2): 274279.
Mir Sadat-Ali, Abdallah Al-Othman : Does scoliosis causes low bone mass? A comparative study
between siblings, European Spine Jornal 2008 July; 17(7): 944947.
C Fusco, F Zaina: Physical exercises in the treatment of adolescent idiopathic scoliosis: An updated systematic
review- Physiotherapy Theory and Practice, 27(1):80114, 2011
Thank You
 Righ Left

ALL 91 91

TLL 95 95
Physical Assessment
Range of motion : To measure the patients
ability to perform flexion, extension,
bending, and rotation movements.

Muscle Power : To test the muscle strength

of the flexion/extension and lateral
movements in both sides of the trunk, upper
& lower extremities.

Neurological assessment : In addition to

testing reflexes, examine if the patients
symptoms include pain, numbness, tingling,
extremity weakness or sensation, muscle
tone, and bowel/bladder changes.
To determine the appropriate vertebral
levels to be included in an arthrodesis
(on the basis of radiographs made in the
coronal and sagittal planes)
Scoliosis Assessment
 Physical Assessment
Physical assessment : looking for asymmetry of the
trunk such as uneven shoulders or hips, humpback, or
listing to one side and gait.

Cardiopulmonary Testing : To test the function of the

heart and lungs Cardiopulmonary Exercise Testing,
Spirometer.

Palpation : to feel the abnormalities, tenderness if

present.

Leg length discrepancy .

Adams Forward Bending Test : The patient bends

forward at the waist, with arms extended forward. The
physician looks for asymmetry thoracic prominence
(such as a shoulder blade), or a lumbar prominence.
Rothman-Simeone, THE SPINE , Sixth Edition.
Bracing & Casting
Usually started when the patient is skeletally
immature (Risser 2) and presents with a 25o-
40o curve, & without thoracic lordosis.
Curves with apex above T6 would likely require
the use of a Milwaukee, curves with apices at T7
or below and above L2 do well in a Boston
brace. Charleston bending brace for child;
which typically worn at night.

Boos N, Aebi M. Spinal Disorders: Fundamentals of Diagnosis and Treatment: Springer; 2008
Weinstein SL. Lovell and Winter's Pediatric Orthopaedics: Wolters Kluwer Health; 2011
Herkowitz HN, Garfin SR, Eismont FJ, Bell GR, Balderston RA. Rothman-Simeone The Spine: Expert Consult: Elsevier Health Sciences; 2011
 Orthotic Management :

1) Thoraco-Lumbo-Sacral-Orthosis
(TLSO):

Boston Brace/ underarm brace.

ThermoPlastic-molded form.

23 hrs/day.

Apex of the scoliosis must be below level 8

thoracic vertebra.
 Orthotic Management :

2) Cervico-Thoraco-Lumbo-Sacral-
Orthosis :

Milwaukee brace.

Includes a neck ring held in place by

vertical bars attached to the body of the
brace.

23 hrs/day.
 Orthotic Management :

3) Charleston Bending Brace :

Night-time brace.

Molded to the patient while he/she is

bent to the side, and thus applies more
pressure and bends the child against the
curve.

The apex of the curve needs to be below

the level of the shoulder blade for the
Charleston brace to be effective.
 Physiotherapy :

Aims of Physiotherapy intervention in scoliosis

management :

To Improve the spinal curve in non-progressive

nature Postural .

To halt the progression of the idiopathic scoliosis.

To reduce the co-morbidities pain, reduced

mobility and functions , cardiopulmonary
complications.

Enhance better functional levels and lifestyle.

 Physiotherapy :
Physiotherapy management includes :

Postural Correction awareness and

training.

Cardiopulmonary exercises.

Spinal mobility exercises AROM,

Aerobic to maintain maximum
possible trunk flexibility.

Stretching exercises for the tight

muscles.
 Physiotherapy :
Physiotherapy management includes :

Strengthening exercises for the weak

muscles.

Physical Agents for pain relief and

muscle spasm.

Alternatives include :
Massage.
Traction.
Spinal Mobilization.
 Surgical Treatment
Age of Onset

Infant (0-2 yrs) Juvenile (3-9 yrs) Adolescent (10-17 yrs)

General Loss of spinal height, chest wall growth, & Arrest of curve progression,
Consideration lung restriction deformity correction, & solid spinal
fusion
Age > 6 yrs if possible (lungs maturation)

Cobb Angle Progressive curve >45-60o despite former Progressive curve >40o in
orthotic treatment skeletally immature
Curve >45-60o in skeletally
mature
Technique
Growing Rod Young children -
Anterior & Older children (8-10 yrs) + risk of Skeletally immature patients + risk
Posterior Fusion crankshaft phenomenon of crankshaft phenomenon
Anterior Release Severe rigid deformity
& Posterior
-
Fusion
Anterior or Depends on curve type
Posterior Fusion
-Boos N, Aebi M. Spinal Disorders: Fundamentals of Diagnosis and Treatment: Springer; 2008
Curve (degrees) Risser grade X-ray/refer Treatment

10 to 19 0 to 1 Every 6 months/no Observe

10 to 19 2 to 4 Every 6 months/no Observe

20 to 29 0 to 1 Every 6 months/yes Brace after 250

20 to 29 2 to 4 Every 6 months/yes Observe or brace*

29 to 40 0 to 1 Refer Brace

29 to 40 2 to 4 Refer Brace

>40 0 to 4 Refer Surgery**

*If the patient is Risser grade 4, probably only observation is warranted.

**If the patient is Risser grade 4, surgery can be delayed.

(K. ALLEN GREINER, M.D., M.P.H., University of Kansas Medical Center,

Kansas City, Kansas American Academy of Family Physicians)
 Posterior approach Anterior Approach
(fusion) (fusion)

ical Treatment
Boos N, Aebi M. Spinal Disorders: Fundamentals of Diagnosis and Treatment: Springer; 2008