Scoliosis Idiopathic Scoliosis In Adolescents NEJM Feb 28, 2013: 368:9 Brown Bag #1

Scoliosis Definition: 10 degrees or greater lateral curvature of the spine (Cobb Angle, XR) Etiology Congenital (vertebral anomaly) Neuromuscular (Brain – spastic quadriplegia; Cord – syringomelia, Periph– SMA, MD, NF Connective Tissue Disorder (Marfan, Ehlers Danlos) Idiopathic – any age possible, FH (10% in 1st degree relative - no specific gene)

PREVALENCE of IDIOPATHIC SCOLIOSIS Of 2000 adolescents screened with shoulder, hip, forward bend testing Asymmetry is exceedingly common, > 98% had asymmetric posture Diagnosis requiring treatment is not ~4% screened positive for scoliosis (n = 80) ~2% had idiopathic scoliosis (> 10 degree curvature on XR) (n = 40) 0.4% required treatment (n = 8)

The Dangerous Curve - CONSEQUENCES Disfigurement #1 concern Rarely pain in adolescents or adults – Proceed with separate evaluation for BACK PAIN Only affects lung volumes if > 70 degrees

Scoliosis Treatment Most do not need treatment Goal to prevent progression Limited data on PT other modalities Cast for children < 3 years old if significant curve Bracing for children > 3 yo with curves 25-45º Observational data supports bracing Ongoing RCT BrAIST: bracing vs. watchful waiting Spinal fusion if > 45º with immature skeleton or progression after maturity

Screening guidelines USPTF – no screening as screening has not demonstrated improved outcomes AAP/ AAOS / SRS / POSNA – visual inspection at set ages Girls 5th grade (age 10-11) & 7th grade (13-14) Boys in 8th grade (13-14)

Scoliosis Evaluation Physical exam Asymmetry Assessment shoulder and scapula, rib prominence on forward bend (Adams Test)- usually left lumbar, right thoracic waist and trunk Scoliometer Measurement <7º is associated with a 95% probability of curve < 30 degrees on XR RULE OUT OTHER POTENTIAL ETIOLOGIES Skin: café au lait spots, axillary freckles, subcutaneous fibromas Neurologic exam and midline spinal deformities Musculoskeletal – joint laxity, spider digits, leg length discrepancy

Scoliosis Imaging X-RAY MRI SCOLIOSIS FILMS with Cobb Angle: C7 to iliac crest PA standing and lateral Bone age if serial heights not available (to predict skeletal maturity) MRI <10 years of age True kyphosis Clinically significant pain Abnormal neurologic exam or midline neurocutaneous defects *Left thoracic curve is less common, but not sufficient condition for MRI

SUMMARY of Proposed Algorithm for IDOPATHIC SCOLIOSIS Physical exam / screen at set ages* XR if scoliometer > 7º Then use XRAY results to determine f/u and referral needs Other considerations MRI if neurologic concerns or < 10 yo / Neurosurgery consult Cardiology and Genetics consults if c/f Connective Tissues Problem Separate back pain evaluation if child has significant back pain

Summary of Proposed Algorithm Refer immediately > 30 degrees at any age 25-29 degrees and early puberty 20-24 degrees before puberty Increase in 5 degrees on XR at any interval Follow-up 3 months 15-24 degrees and early puberty Follow-up 6 months 15-29 degrees and late puberty Follow-up in 1 year < 14 degrees but not yet done with puberty Follow-up in 5 years Post puberty and Cobb angle 20-29 degrees Do not monitor Normal exam, scoliometer < 7 Scoliosis < 19 degrees and done with puberty

The “Dangerous Curve” by Numbers 7º on scoliometer = GET INITIAL X-RAY 10º Cobb Angle on XR = DIAGNOSIS < 14º on XR = F/U IN 1 YEAR if still growing, otherwise stop 15-29º = F/U and REFERRAL GUIDELINES BASED ON PUBERTY STAGE & CHANGE 30º at end of puberty = UNLIKELY TO PROGRESS, get f/u film in 5 years >50º at end of puberty may progress 1º/year >70º affects lung volumes >100º symptomatic restrictive lung disease