• Straight Spine

-has 0° curve

• Curvature of the Spine

-has a curve that is
between 0° and 10°

• Scoliosis of the Spine

-has a curve that is
greater than 10°
 What is scoliosis?

 An abnormal lateral curve

to the vertebral column
greater than 10°
 It is most common in the
thoracic and lumbar
regions of the spine and
can involve one or both of
these regions
 Many different forms of
scoliosis
Epidemiologi
 Symptoms of Scoliosis
One shoulder may appear
The body may tilt to one side higher

One side of the rib

cage may appear
higher

Waist may appear One leg may appear

uneven or hips elevated shorter than the other
 What causes scoliosis?

Kongenital

Degeneratif
SCOLIOSIS
Neuromuscular

Idiopatik
Idiopathic Scoliosis

Infantile-Onset Juvenile-Onset Adolescent-Onset

Idiopathic Idiopathic Idiopathic
Scoliosis: Scoliosis: Scoliosis:
Age 0 – 3 Age 4 – 9 Age 10 – 18
 Adolescent Idiopathic Scoliosis (AIS)
• Side-to-side curve • Curve gets larger
• Greater than 10° during rapid growth
• Twisting of the spinal • Otherwise, patients
column are healthy
• Spine resembles a • No known cause
“C” • 30% have some
or “S” family history
• Patients are between • Genetic connection
10 and 18 years
Diagnose
 AIS Testing

X-ray

This test involves the student bending

forward with arms stretched
downward toward the floor and knees
straight. This angle most clearly shows
any asymmetry in the spine and/or
trunk. Often preformed in school
starting in the fifth grade.
• Scoliosis is defined by the region of the
spine where the curve or curves
develop (upper thoracic spine, thoracic
spine, or lumbar spine).
• Scoliosis may be present in one or
more sections producing single,
double, or triple curves. The direction
of the curve may be to the right or left.
 The size of the curve is
measured on an x-ray in degrees
and calculated as an angle. This is
called the Cobb Angle or Cobb
Measurement.
In the presence of an unusual curve pattern (ex:
left thoracic curve) or other symptoms, additional
testing may be recommended. An MRI (magnetic
resonance image) checks the spinal cord for
problems.

• Indications for MRI

– Atypical, specific pain
– Neuro abnormality (Abnormal reflexes,
Ataxia, weakness, Progressive foot
deformity (cavus feet))
– Left thoracic curve
– Rapidly progressive curve
– Males
• Routinely recommended, but minimal
data to support
• The Risser Sign is used to evaluate
skeletal maturity. When the skeleton
is fully mature, a “cap” of growth
cartilage covers the topof the pelvic
bone (iliac wing) and solidifies. This
growth cartilage turns to bone and
becomes visible on x-ray.
• This process occurs during puberty.
An x-ray of the hand and wrist will show
the growth plates of the individual bones
in the hand. These growth plates remain
open during growth and have a pattern of
closure with skeletal maturity that is
actually more reliable than the Risser
Sign.
This can be helpful in determining how
much skeletal growth remains.
 Treatment

11-25o 25-40o >40-50o

Skeletal maturity?* Skeletal maturity?

yes no yes no
Consider surgical
treatment
F/u every 4-6 mos Follow up every
Follow up as until skeletal Consider bracing
3-5 years
needed maturity + *skeletal maturity = Risser 3
exam/x-ray or greater
 What is Bracing?

The typical scoliosis brace (also called an

orthosis or TLSO: thoracolumbo- sacral
orthosis) is made of contoured plastic that
fits snugly around the torso and hips. It
applies “directed” pressure to the curve(s).

The biomechanical principles of bracing

are founded on evidence that “directed”
pressure reduces the curve(s) and moves
the spine into better alignment while the
brace is worn.
 Treatment - Bracing

• Types
– Full-time bracing
• Boston
• Milwaukee (if apex higher than T7)
– Night-time bending brace
• Charleston
• Providence
– Others
• Spine-Cor
Treatment - Bracing

• TLSO (Boston-type)
– Worn as much as possible
• Can take off for sports, sleepovers
etc
– Want at least 50% correction in
brace
 Treatment - Bracing

• Milwaukee brace
– For refractory curves
– Apex >T7
– Not really tolerated in our
patient population
 Treatment - Bracing
• Night-time bending braces:
– Overcorrects the curve
– Only worn at night
– Probably not as efficacious
• Price et al1 - 66% success, only 17%
requiring surgery
• Randomized study - Charleston vs Boston
brace2
– 41% vs 61% success (<5 degrees
progression)
– 31% vs 19% required surgery

1. Price CT et al JPO 1997;17:703-707

2. Katz DE Spine 1997;22:1302-12.
 Treatment - Bracing
• SpineCor
– Well advertised
– Soft straps, so more easily worn under
clothers/during physical activity
– Originators report only 40% progressed,
only 23% needed surgery1
• Other authors have found no better
results with SpineCor2

1. Christine C et al. Stud Health Technol Inform 2008;135:341-55.

2. Wong MS et al Spine 2008;33:1360-5.
 Treatment - Surgery
 Best for:
– Girls1
• Boys only 38% compliant with brace wear
• 30 degree curve 50% chance of surgery
– Lower BMI2
• BMI >25 --> 2.5x risk of failure, double
surgical rate
– More flexible curves
– Younger patients
• Many studies
• Higher rate of progression by natural 1. Karol LA Spine 2001;26:2001-5.
history 2. O’Neill PJ et al. JBJS Am 2005;87:1069-74.
 Treatment - Surgery
• Indications for surgery:
– Thoracic curve >40-45 degrees in
skeletally immature patient
– Thoracic curve >50 degrees in skeletally
mature patient
– Lumbar numbers: usually around >40
degrees
– Double curves more well tolerated
• Goals of surgery:
– Achieve solid fusion SAFELY!
– (improve cosmesis, body image)
Treatment - surgery

Implant
 Posterior Spinal Fusion with Instrumentation.

There are two general surgical approaches to

the spine: posterior and anterior.

The most common approach is through the

back and is known as a Posterior Spinal
Fusion with Instrumentation.

With this procedure, an incision is made

along the spine, screws and/or hooks are
then attached to the vertebrae, and rods are
then attached to the screws or hooks. These
screws and hooks act as anchor points to
secure the rods.
 Anterior Spinal Fusion with Instrumentation.

An Anterior Spinal Fusion with

Instrumentation is done through an incision
either on the flank or chest and is an option
when there is a single curve to be treated.

One or two screws are placed from the side

through the front (anterior) part of each
vertebra that is going to be fused. Rods are
then attached to the screws lengthwise along
the spine.
Thoracoscopic Anterior Spinal Fusion with
Instrumentation

Some curve patterns may be best

treated with a Combined Anterior and
Posterior Approach.
The combined approaches are reserved
for very young patients and those with
more rigid curves.

A Thoracoscopic Anterior Spinal Fusion

with Instrumentation is done through
four or five small incisions on the chest.