Lecteurer of Rheumatology, Physical Medicine& Rehabilitation SCOLIOSIS Dr. Eman Baraka Lecteurer of Rheumatology, Physical Medicine& Rehabilitation BenhaUniversity

Normal Spinal Curves Each section of the spine has a natural curve. Viewed from the side: 1.The cervical and lumbar spines have lordotic, or slight concave curves. 2.The thoracic spine has a kyphotic, or gentle convex curve.

The normal thoracolumbar spine is relatively straight in the sagittal plane and has a double curve in the coronal plane. As shown below, the thoracic spine in convex posteriorly (kyphosis) and the lumbar spine is convex anteriorly (lordosis). Normally there should be no lateral curvature of the spine

Scoliosis – lateral (side-to-side) curve of the spine. Scoliosis is a complicated deformity that involved lateral curvature of the spine greater than 10o accompanied by vertebral rotation, excluding mobile scoliosis.

1-Lateral deviation of the spine

2. Longitudinal rotation of the vertebrae - SIMPTOMS 2. Longitudinal rotation of the vertebrae (torsion: procesus spinosus rotates toward the concavity, while the body of the vertebrae rotates toward the convexity). The body of the vertebrae are wedged on the side of the concavity. The spine changes its shape and way of functioning.

- SIMPTOMS When the vertebrae rotates, the ribs also rotates, therefore we find a rib hump.

- SIMPTOMS 4. The intercostal space is reduced on the concav side (ribs are getting closer). 5. The intervertebral space is narrower on the concav side, and wider on the convex side.

6. The vertebral canal is narrower on the convex side. - SIMPTOMS 6. The vertebral canal is narrower on the convex side.

- SIMPTOMS 7. Constriction of the vertebrae (the wedge of the vertebrae is situated on the concav side; the bigger wedge is located in the apex of the deformation).

The apical vertebra – in a curve, the vertebra most deviated laterally from the vertical axis that passes through the patient's sacrum, i.e. from the central sacral line

Structural - usually combined with a rotation of the vertebrae. Non structural – scoliotic poor posture

Structural scoliosis Classification of scoliosis Nonstructural scoliosis postural scoliosis resolves when the child is recumbent compensatory scoliosis caused by leg-length discrepancy; there is no fixed rotation of the vertebrae Transient non structural scoliosis sciatic scoliosis hysterical scoliosis inflammatory scoliosis Structural scoliosis idiopathic (70 - 80 % of all cases) congenital neuromuscular

TYPES OF structural SCOLIOSIS IDIOPATHIC – the cause is unknown. NEUROMUSCULAR – is due to loss of control of the nerves or muscles that support the spine. The most common causes of this type of scoliosis are cerebral palsy and muscular dystrophy. DEGENERATIVE – may be caused by breaking down of the discs that separate the vertebrae or by arthritis in the joints that link them. CONGENITAL – due to abnormal formation of the bones of the spine and is often associated with other organ defects.

It can be subclassified into Idiopathic scoliosis accounts for about 80 % of all cases of the disorder, and has a strong female predilection (7:1). It can be subclassified into INFANTILE – Curvature appears before age three 2-JUVENILE – Curvature appears between ages three and ten. 3-ADOLESCENT– Curvature usually appears between ages of ten and 13, near the beginning of puberty. 4-ADULT - Curvature begins after physical maturation is completed.

Infantile Idiopathic Scoliosis of 20 month-old boy Young boy with juvenile idiopathic scoliosis

Adolescent Idiopathic Scoliosis (AIS) Definition:(10x10( Adolescent Idiopathic Scoliosis (AIS) is a deformity that involved lateral curvature of the spine greater than 10o accompanied by vertebral rotation and occurs in children aged 10 years to maturity. AIS may start at puberty or during an adolescent growth spurt. 5 % of adolescents will be found to have some form of scoliosis. The incidence of AIS of females to males is about 9:1 3% of these girls usually develop more severely progressive curves than males that require treatment.

Assessment of the scoliotic child

(I) CLINICAL HISTORY of AIS The following is a list of questions that may ask to cover causes and important risk factors: 1. The of age 2. The family history 3. History suggesting any underlying medical conditions to exclude individuals who have 2ry scoliosis. This will help us to determine the number of years that remain before the child reaches skeletal maturity. The curve mainly continue to progress throughout adulthood.

(A) Symptoms of scoliosis Deformity is the first symptoms: Pain Many patients are asymptomatic while others complain of muscle aches in the lower back after sitting or standing a long time ا a. The pain is mechanical in nature mainly at night and is probably caused by disc and/or facet joint degeneration. The pain becomes worse the longer they are ambulatory and the symptoms are rapidly relieved upon lying down b. In sometimes, the pain is radicular in nature; due to nerve root compression. (B) Neurological complain

(II) The clinical examination of AIS This clinical assessment provides the physician with a “baseline” from which future curve progression can be measured & determines the strategies of ttt. Complete general & neurological examinations: During the physical and neurological examinations the physician has to evaluate the patient’s health and general fitness. . Cardiopulmonary assessment: Checking for medical complications and testing of functions of the heart and lungs Neurological examination: To exclude other neurological causes of scoliosis

.Physical assessment for the back: Physical assessment for the back in 3 positions: standing, lying & suspending. Back exam : Inspection, palpation & ROM 2. Physical assessment for the extremities: 3. Physical assessment for the chest 4. Assessment for the gait 5. Special diagnostic tests. Plumb line Adam’s forward bending test Scoliometer

Lowered shoulder blade Inequality of the Lorent`s triangle EXAMINATION Lowered shoulder Lowered shoulder blade Curvature of the spine Inequality of the Lorent`s triangle Lowered pelvis

Standing posture shows an elevated Rt shoulder and scapular asymmetry

Forward bend demonstrates the large right rib hump Forward bend demonstrates the large right rib hump. Forward bend test brings out the rib prominence and is a vital part of the clinical examination. The rib hump that is often noticeable in scoliosis is due to rotation of the rib cage.

AIS leads to lateral curvature of the spine, a twisting (rotation) of the spinal column and rib hump.

The scoliosis is determined according to the convex side. RIGHT SCOLIOSIS LEFT SCOLIOSIS

Scoliosis may develop: In the whole spine (total scoliosis) Only in one part of the spine (partial scoliosis)

Scoliosis may be: Simplex Duplex Triplex – with the primary and compensatory curves

Cervical Cervicotoracal Toracal Toracolumbar Lumbar Lumbosacral

Scoliometer It is quite accurate in identifying the degree of trunk rotation done by a physician, school nurse & Parents. Children with reading of 5 or more have a curve measuring less than 20.

Imaging evaluation 1.The radiological assessment The radiographic assessment of the scoliosis patient begins with erect anteroposterior and lateral views of the entire spine (occiput to sacrum). In addition, the examination should include a lateral view of the lumbar spine to look for the presence of spondylolysis or spondylolisthesis (prevalence in the general population is about 5 %). The scoliotic curve is then measured from the AP view

Components of the curve Apical vertebra: It is the vertebra at the summit of the curve. End vertebrae: Are the last vertebrae of the curve. Neural vertebra: It is the vertebra at the junction of two primary curves and it is part of both curves; it is both the lowest vertebra in the upper curve and the highest in the lower curve. The shape of the spinal curves are usually S or C-shaped.

The scoliotic curve is named according 1.To side of the convex side. (Right or left scoliosis). 2- to the location of the apex of the curve, as shown below.

Cobb’s method To use the Cobb metho d, one must first decide which vertebrae are the end-vertebrae of the curve. These end- vertebrae are the vertebrae at the upper and lower limits of the curve which tilt most severely toward the concavity of the curve. Once these vertebrae have been selected, one then draws a line along the upper endplate of the upper body and along the lower endplate of the lower body as shown below.

X-ray 53° Rt thoracic curve

Determination of the severity of rotation Mild scoliosis: curves between 0-69 Severe scoliosis: curves between 70-99 Very severe scoliosis: curves 100 or over. 2. Assessment of functional state of the back If the spine is compensated or uncompensated. An uncompensated spine as in Paralytic, congenital scoliosis & AIS

(1) The primary curve (structural, fixed): It is identified by persistence of lateral curvature with fixed rotation on forward bending. This curving may be progress until epiphysial closure is completed & the end of skeletal maturity. (2) The secondary curves =Compensatory curves: 2nd curves develop to counter balance 1ry They may be early mobile, by progression of the condition, they may become fixed.

The aim of the presence of the 2nd curves: To maintain & develop a balance of the body by keeping the head of the patient in vertical level with the horizontal level of ocular vision i.e. to maintain the alignment of the body with the center of gravity.

lateral bending films are often taken to assess the rigidity or flexibility of the curves

3. The method of Nash and Moe 2. The Harrington factor This method is used to measure the severity of spine curvature & to follow progression. The angle of the curvature is divided by the number of the vertebrae forming the curve and the resultant is the Harrington factor. A value 5 or more is a significant of severe deformity. 3. The method of Nash and Moe This technique is used to measure vertebral rotation related to rotation of the vertebral pedicle & by dividing the vertebral body into 4 segments. Grades 1 and 2: The convex pedicle is visible on AP view. Grades 3 and 4: The convex pedicle has twisted out of view.

3-The presence of any vertebral or rib anomalies should be reported 2-Estimate the degree of rotation of the vertebra at the apex of the curve by looking at the relation of the pedicles to midline. 3-The presence of any vertebral or rib anomalies should be reported

X-ray 53° Rt thoracic curve

Laboratory tests are normal in-patients with AIS 2. MRI MRI scan of the spine can be requested to rule out an intracanal spinal lesion that can result in scoliosis. If there are any neurological deficits that would indicate impingement of the spinal cord (e.g. hyperactive reflexes) Laboratory investigations Laboratory tests are normal in-patients with AIS Prognosis of AIS 1. The curve pattern. 2. Age of recognition 3. Skeletal age 4. Status of ossification pattern of the iliac apophysis and the vertebral ring 5. Stage development of the physical characteristics of puberty

Coronal images Scoliotic deformity

Risser Sign The Risser Sign looks at the iliac crest growth plate, a fan-shaped part of the pelvis that fuses with the pelvis at maturity. When the ossification of the iliac apophysis is complete also the vertebral ring apophysis is closed---- skeletal maturation. Vertebral growth usually ceases at bone age of 16 years in girls and 18 years in boys. At skeletal maturity, Progression may stop in a curve is less than 45 Progression continue in a curve is greater than 50 So, the treatment objective is to try to get the child into adulthood with less than 50 curvature. The girls skeletal maturity rarely continues more than 18 months after the menarche.

Risser's sign

Risser grade: Each grade from 1-4 corresponds with a 25% increment of iliac crest ossification. A low grade indicates that the skeleton still has considerable growth. A Risser grade 5 corresponds to skeletal maturity. The lower the Risser grade at the time of curve detection, the greater the risk of progression

determination of vertebral maturity One can also look for evidence of maturation in the vertebral bodies themselves at the endplates, as shown below When the plates blend in with the vertebral bodies to form a solid union, maturation is complete.

Surgical interventions Physical training: Therapeutic exercises for scoliosis & complications Back braces Treatment Patient & family education -Principles of anatomy of the spine, body mechanics & posture. Nature of the disease Applications of orthosis Modified life style Surgical interventions

Prevent more complications. Change the child's life style. Management of scoliosis Three treatment options for AIS: Follow up (observation) &Alternative treatment Orthosis & Physical programs Scoliosis surgery. Main aims of treatment . Maintaining balanced spine and preventing more deformity until skeletal maturity. Prevent more complications. Change the child's life style.

Observation Observation is generally for patients whose curves are less than 25-30º who are still growing, or for curves less than 45º in patients who have completed their growth. Scoliosis surgeons often wish to observe the scoliosis every few years after patients complete their growth to make sure it does not progress into adulthood. Alternative Treatment Alternative treatments to prevent curve progression or prevent further curve progression such as chiropractic medicine, physical therapy, yoga, etc. have not demonstrated any scientific value in the treatment of scoliosis. However, these and other methods can be utilized if they provide some physical benefit to the patient such as core strengthening, symptom relief, etc. These should not, however, be utilized to formally treat the curvature in hopes of improving the scoliosis.

Most curves can be treated nonoperatively if they are detected before they become too severe. However, 60 % of curvatures in rapidly growing prepubertal children will progress. Therefore, scoliosis screening should be done. This screening is probably not necessary until the fifth grade. Beyond that point, boys and girls should be examined every 6 - 9 months. Generally, curvatures less than 30 degrees will not progress after the child is skeletally mature. Once this has been established, scoliosis screening and monitoring can usually be stopped. However, with greater curvatures, the curvature may progress at about 1 degree per year in adults. In this population, monitoring should be continued.

2. To relief the pain by reduction of axial loading. The indications of back Orthosis: All preadolescent children when the curve measures 25-40 degrees in a skeletally immature patient. Since the majority of curve progression happens during a child's growth phase, bracing treatment is continued until the end of growth to keep the correct the spinal alignment. 2. To relief the pain by reduction of axial loading. Contraindication of back orthosis: 1. Growing children + the curve is 45-50 2. Child with already skeletally mature + the curve 50 or more.

Biomechanics of orthosis : Back Orthosis Biomechanics of orthosis : Orthosis does not reduce the amount of angulation already present but it is designed to stop the progression of the spinal curve. Orthosis can successfully prevent curve progression in the majority of patients(80%). Orthosis applies three-point pressure to the curvature to prevent its progression: end point control, transverse loading & curve correction. So, the back orthosis is a kinetic, not a static brace in treatment of AIS.

(I) High profile orthosis Types of back Orthosis (I) High profile orthosis Cervico – thoracolumbo - sacral orthosis (CTLSO): Milwaukee orthosis: It is the ideal brace for AIS. (II) Low profile orthosis Thoracolumbo -sacral orthosis (TLSO): Boston orthosis. Charleston bending orthosis. (III) Recently computer aided design (CAD) using the (Insignia technique) It is 3 dimensional image of body parts transmitted to the computer for more accuracy of the measurements.

Milwakee Brace

Milwakee brace

Boston Brace

Boston Brace (low profile brace)

Boston Brace

What is the protocol for wearing the orthosis. 1 What is the protocol for wearing the orthosis? 1. Full time protocol: 23 hours a day. It can be taken off to swim or to play sports as Boston & Milwaukee. Most patients start wearing the orthosis at nighttime and then gradually extend the time into the day. 2. Part time protocol: It is worn only at night while the child is asleep as Charleston 3. After 4 -5 weeks: the patient will return to the scoliotic clinic for an x-ray in the orthosis and a follow-up examination to ensure that the brace is correcting the curve effectively. 4. The child is skeletally mature and finished growing.

Boston Brace in X-ray

Response of curves to bracing 1. Most curves substantially improved: Most curves will appear substantially improved (80%) while the brace is worn; however, the great majority will return to the original pre-treatment magnitude shortly after brace discontinuance. 2.Some spinal curves will continue to progress. Unfortunately, even with appropriate bracing, some spinal curves will continue to progress. Many times it is very difficult to predict which curves will continue to progress and need surgery later, especially if the child is young and skeletally immature..

Disadvantages of back bracing Braces can be uncomfortable, unattractive, hot, and can make a child self-conscious even though well disguised under clothing. It is recommended that a cotton T-shirt be worn underneath the brace so that the brace does not have direct contact with the skin. Also it is important during removing of the orthosis to check the skin for any signs of breakdown Children may loose weight from the brace, due to increased pressure on the abdominal area.

Surgical Management Surgical treatment is recommended for patients whose curves are greater than 45o while still growing, or are continuing to progress greater than 45o when growth stopped. The goal of surgical treatment is two-fold: first, to prevent curve progression and secondly to obtain some curve correction Surgical management of scoliosis is generally intended to prevent future consequences of progressive deformity.

development of progressive pain pulmonary or cardiac compromise Although most adolescents have little impairment or symptoms related to their deformity, future consequences include the possible: development of progressive pain pulmonary or cardiac compromise progressive deformity and unacceptable appearance neurological deterioration

Surgical treatment today utilizes metal implants that are attached to the spine, and then connected to a single rod or two rods. Implants are used to correct the spine and hold the spine in the corrected position until the instrumented segments fuse as one bone. The surgery can be performed from the back of the spine (posterior approach) through a straight incision along the midline of the back or through the front of the spine (anterior approach)

Although there are advantages and disadvantages to both approaches, the posterior approach is utilized most often in the treatment of AIS and can be utilized for all curve types. The anterior approach is an option when a single thoracic curve or a single lumbar curve is being treated. Following surgical treatment, no external bracing or casts are used. The hospital stay is generally between 3 and 6 days. The patient can perform regular daily activities and generally returns to school in 3-4 weeks. Depending on the activities of the patient, full participation is allowed between 3 and 6 months after surgery. Most children will not need pain medications 10-14 days after surgery.

Thank You

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