Adolescent Idiopathic

SCOLIOSIS

I Ketut Suyasa

General Surgeon, Orthopaedic Surgeon, Spine Consultant

Denpasar, 20 Oktober 2018
 SCOLIOSIS
 Classic Definition :
Abnormal lateral curvature of
the spine of 10° or more.

 SCOLIOSIS :
Complex 3 Dimensional
Deformity of the spine:
 Lateral curve in coronal plane
 Kyphotic deformity in sagittal
plane
 Rotation in axial plane.
PREVALENCE
• The most common >300 CURVE: 1-3/1000,
form is idiopathic M:F=1:8
scoliosis

• Usually becomes
evident in the early
adolescent years in
approximately 3 CURVE
percent of children PROGRESSION IN
under age 16 BACK PAIN HIGHER ADULTHOOD
RATE THAN •RARE IF < 30O
• Has a genetic CONTROLS •COMMON IF
•>50-750 THORACIC
tendency (although •>30-400 LUMBAR 1
the specifics of the /YEAR
genetic influence
have not been
completely
determined)
ETIOLOGY

Neuromuscular Congenital Curves resulting Idiopathic curves

curves curves from a specific • Infantile (birth-3 years)
• Neuropathic disorders • Failure of formation disorder 1% : Boys, left thoracic
(CP, spinocerebellar (Hemivertebra) >>>
• Systemic Disorders
dysfunction, • Failure of • Juvenile (3-10 years)
• Infections 15% : Girls, Right
Poliomyelitis) segmentation
• Tumors thoracic >
• Myopathic disorders (Unsegmented
(DMP, arthrogryposis) vertebra) • Trauma • Adolescent (10-17
• Combined (Worst) years) 85% : Girls >>>>
Classification of Scoliosis
Congenital scoliosis

Idiopathic scoliosis

Neuromuscular scoliosis

Postural scoliosis

Syndromic scoliosis.
 Effect of Scoliosis

Initial effect: Breathing

Arthritis
Back pain restriction

Gait
Changes
ADOLESCENT IDIOPHATIC SCOLIOSIS
 Incidence of Scoliosis

Develops between ages 8 to 15

(growth spurt)

7 times more prevalent in

females

80% of scoliosis origin unknown

1 Ahn et al, New Hampshire Spine Institute. The etiology of adolescent

idiopathic scoliosis. Am J Orthop 2002 Jul;31 (7):387-95
HISTORY
Growth History

Development of milestone

Medical History (ex. history of severe back pain; prior surgery)

Presence of neurologic symptoms

Family History

Neurologic history (ex. patient’s difficulties with grasping, writing,

walking, and climbing stairs)
Physical examination

General condition

Any possibilities of • E.g. : café au lait,

manifestation of other
cause syndromes

Neurological
condition
Leg length
discrepancy
Cor pulmonale
status
Physical examination
SIGNS
 One shoulder blade may appear
prominent
 Uneven waist
 One hip is higher than the other
 Clothing does not fit properly
(uneven hemline or one pant leg
is longer than the other)
 Body appears to lean to one side
Physical Examination
Deformity Evaluation
 Inspection from posterior,
side and anterior
 Standing in Straight and
flexed  Look at trunk and
spine flexibility
 Look for Asymmetry : Neck,
Shoulder, Ribs, waist, hips
 Trunk Balance : Plumb Line
 Body Arm Distance
 Find any joint laxity
Physical Examination
SPECIAL TEST
 Adam’s Test (Forward Bending)
 Scoliometer  measure angle of trunk rotation (ATR) using
an inclinometer
Physical Examination
Limb length inequality

Can contributes to apparent scoliosis

Assessed by placing hands to midlateral iliac

crests to asses pelvic tilt due to inequality

Any inequality should be measured by placing

blocks under the short leg
Neurologic examination

Things should be evaluated :

• Patient’s balance
• Sensation
• Motor strength

Balanced tested by watching the patients gait.

Check also deep tendon reflexes in upper and lower

extremities

Pathologic reflexes  intraspinal disorders (syringomyelia)

IMAGING
Standing PA / Stagnara view

Lateral: Sagital deformity

Bends films
Side bending, fulcrum bending

MRI :
• Age < 10, left thoracic, neurological findings
Radiographic Studies
Assessed:
 End vertebra
 Apical
 Curve Pattern
 Curve magnitude
 Risser sign
 Structural curve
 Nonstructural curve
Angle measurement
 Cobb’s Angle
- Choose the most tilted vertebrae
above & below apex of the curve.
- Angle b/t intersecting lines drawn
perpendicular to the top of the
superior vertebrae and bottom of
the inferior vertebrae or lines from
the pedicle.
Risser sign :
 0 : absent
 1 : 0-25 %
 2 : 25 – 50 %
 3 : 51 – 75 %
 4 : 76 – 100%
(correlate with the end of
spinal growth)
 5 : fusion of epiphysis to the ileum
(correlate with the end of height
increase)
Lenke Classification
 More Comprehensive
 To select level should be fused

This Scoliosis was classified according to:

- Curve type
- Lumbar spine modifier
- Sagittal thoracic modifier
Step by Step For Lenke
Classification

Identify Apex
Vertebra
•Proximal Thoracic Identify
Identify End Identify Identify
: Th2-Th6 Structural /
Vertebra •Main Thoracic : Central Sacral Thoracic
non structural
Upper and Th6-Th12 vertebral Line Sagital Line
 Side
Lower •Thoracolumbar : (CVSL) (Th5-Th12)
Th12-L1 Bending X-Ray
•Lumbar : L1-L4
Curve Type
Lumbar Spine Modifier
 A : Central Sacral Vertical
Line between pedicle
 B : Central Sacral Vertical
Line touches apical
bodies
 C : Central Sacral Vertical
Line completely medial
Thoracic Sagital Profile
 - : Hypokifosis < 10o
 N : Normal 10 – 40o
 + : Hyperkifosis > 40o
Scoliosis severity
Depends on the degree of the curvature and whether
it threatens vital organs, specifically the lungs and
heart :

Mild Scoliosis (less than 20 degrees)

Moderate Scoliosis (25 - 40 degrees)

Severe Scoliosis (more than 40-70 degrees)

Very Severe Scoliosis (more than 70 degrees)

Treatment
Goal :

• To prevent progression
• Correction Balance
• Maintain respiratory function
• Reduce pain
• Preserve neurologic status
• Cosmetic

Consequence of untreated

• Mortality rate
• Pulmonary and cardiac function
• Back pain
Treatment
Treatment options (3 “O”)
• Observation & re-evaluate
• Orthoses
• Operation

Consideration for curve treatment:

• Age of patient & growth potential remaining
• Curve pattern & magnitude
• Curve progression rate (5-10⁰ within 6
month/less)
• Cosmetic appearance
Referral Guidelines & Treatment
Curve
Risser grade X-ray/refer Treatment
(degrees)
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 25

degrees

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 †
Reamy BV, Slakey JB. Adolescent idiopathic scoliosis: review and current concepts; Am Fam Physician. 2001;64(1):116.

John P. Horne, MD; Robert Flannery, MD; and Saif Usman, MD; Am Fam Physician. 2014 Feb 1;89(3):193-198.
Non Operative :

• No treatment for non progressive infantile type

• Children with curves of 20-40 and with 2 years or
more
• Observation :
• < 25 o Immature
• < 50o Mature
• Rontgen 3 months after first visit, then 6 months for <
20o & 4 – 6 months for > 20o
• Significant change :
• progression > 10o for curve < 20o
• progression > 5o for curve > 20o
Exercise
Orthosis
Curve 30 – 40o

Milwaukee (CTLSO) for apex above T8

Boston (TLSO) up to T8 apex

Must be wear 23 hours until 2 years after
menarch / risser 4 and wear off in year,
follow up every 6 months and radiographs
every 12 months
Brace Treatment
Most common is Boston brace
(aka Thoraco-lumbar-sacral
orthosis)

Braces have 74% success rate at

halting curve progression (while
worn)

Bracing does not correct scoliosis,

but may prevent serious
progression

Usually worn until patient reaches

Risser grade 4 or 5
 Anterior upright

Milwaukee
Dua Occipital Pad

Brace
Cervical Ring

(CTLSO) Torax Mold

Posterior Upright

Molded Pelvic Section

Boston Brace (TLSO)
• Best for apex curve at the middle
of spine and single curve (Apex at
level T6 – L3)

Thoraco-lumbar
Thoracic
Lumbar
Hyphokhyposis
DYNAMIC BRACE
CASTING

Serial casting was first

described more than 50
years ago.

In older and/ or syndromic

patients, casting was
found
• to reduce the curve size,
• improve chest and body shape,
and
• delay surgery.
 Casting technique.
The patient is positioned on the table, with traction applied
to the head halter and pelvis
The anterior window
relieves cast pressure on
the chest and abdomen
while preventing
rotation of the lower ribs
Operative treatment
Indications

•Progressive Curve > 40 – 45 o in

growing Children
•Failure of bracing
•Progressive Curve beyond 50 o
in adult
Surgical Considerations

Bigger surgery = more complications

Anterior posterior spinal fusion associated with longer

operative times, more EBL, more transfusion, more
pulmonary complications than anterior or posterior fusion
alone

Rule of 6
• if operative time is longer than 6h, or if more than 6 levels
fused, complication risk is higher

Erickson MA and Baulesh DM. Curr Opin Pediatr 2011.

The Goals
Maintaining sagittal
balance
Correct or improve the
deformity
Prevent progression of
curve
Spine and pelvic balance is
more important than curve

GOALS Prevent respiratory

compromise

Prevent back pain

Cosmetic
Methods of Surgical treatment
Anterior Spinal Posterior Spinal
Fusion (ASF) Fusion (PSF)
• Single Rod • Hooks
• Double Rod • Hooks and
pedicle
screws
• All pedicle
screws
 POSTERIOR FUSION
Depend on the classification of scoliosis

Upper level
•Upper hook should be higher if kyphosis is present
to correct sagittal deformity

•Upper thoracic curve should be fused if the curves

is structural, T1 is out of balance and the left
shoulder is high

Distal extent fusion

• Include Harrington stable zone : two perpendicular
lines from the sacral pedicles

• Include neutral vertebrae: are nonrotated vertebrae

• The distal vertebra is the stable vertebra, determine

by the center sacral line

• Avoid fusion beyond the L4 vertebrae to preserve

distal motion segments. The distal vertebra should
be neutral, stable and horizontal to the sacrum after
instrumentation
Scoliosis Screening Recommendations

American • Screen girls at ages 11

Academy of and 13
Orthopedic • Screen boys once at
Surgeons age 13 or 14

• Screen at 10, 12, 14 and

American 16 years
Academy of
Pediatrics
Screening hints:

Uneven
waist
Rib cages
Appearance
are at
of a raised,
different
prominent hip
Head is not heights
centered Changes in look or
directly texture of skin
above the overlying the spine
Shoulders are (dimples, hairy
different heights pelvis
patches, color
– one shoulder changes)
blade is more
prominent than
the other Leaning of
entire
body to
one side
Red flags

Left-sided thoracic curvature

Pain

Significant stiffness

Abnormal neurologic findings

Stigmata of other clinical syndromes

associated with curvature
CONCLUSION
Complex 3 Dimensional Deformity of the spine

Caused by neuromuscular, congenital, various specific disorder, and

Idiopathic

Appropriate identification were needed to obtain precise diagnosis and

degree of severity

Treatment options depend on degree of severity to prevent progression,

correction balance, maintain respiratory function, reduce pain, preserve
neurologic status and cosmetic

Screening was performed for early diagnosis and preventing progression