1. “Idiopathic Scoliosis”
Dr. Donald W. Kucharzyk
Clinical Assistant Professor
University of Chicago
Children’s Hospital

2. “Idiopathic Scoliosis”
Defines a common and potentially severe musculoskeletal disorder
The term scoliosis is derived from the Greek word meaning “crooked” as first used by Galen in 131 A.D.
References are made to scoliosis since ancient times as seen in ‘Corpus Hippocraticum’

3. “Idiopathic Scoliosis”
“Etiology”
Remains unknown
Several studies have attempted to look into this and various factors have been postulated: genetic, tissue deficiencies, vertebral growth abnormalities, and central nervous system theories

4. “Idiopathic Scoliosis”
“Genetic Factors”
Risenborough found a 11.1% incidence of scoliosis in first born relatives of patients with idiopathic scoliosis
Twins show a concordance of scoliosis with an incidence of 92% monozygotic and 63% dizygotic

5. “Idiopathic Scoliosis”
“Genetic Factors”
Despite this confirming evidence of a genetic etiology, the gene and gene products responsible for the development of idiopathic scoliosis remains still unknown

6. “Idiopathic Scoliosis”
“Tissue Deficiencies”
Primary pathology centered in the structural tissues of the spine
Fibrous Dysplasia results in dysplastic, mis-shapened vertebrae
Muscle disorders such as Duchene’s lead to a collapsing scoliosis

7. “Idiopathic Scoliosis”
“Tissue Deficiencies”
Soft tissue collagen disorders such as Marfan’s have a clear association with scoliosis (defect in fibrillin)
Osteopenia has been associated with idiopathic scoliosis…bone mineral density lower in girls aged 12 to 14 than a matched control with scoliosis: mechanism unknown

8. “Idiopathic Scoliosis”
“Vertebral Growth Abnormality”
Milner and Dickson postulated a differential growth rates between the right and left sides of the spine
Results in abnormal biomechanical loading of the spine: Heuter-Volkmann effect

9. “Idiopathic Scoliosis”
“Vertebral Growth Abnormality”
Dickson postulated a discrepancy between growths of the anterior and posterior spinal columns
Irregularities in the sagittal shape of the spine during rapid adolescent growth may contribute to development of scoliosis
Scoliotic patients are taller and thinner

10. “Idiopathic Scoliosis”
“Central Nervous System”
Goldberg noted greater asymmetry of the cerebral cortices
Abnormalities in equilibrium and vestibular functions have been noted in scoliosis patients
Melatonin and the pineal gland has been postulated

11. “Idiopathic Scoliosis”
“Central Nervous System”
Malchida et al, Hilibrand et al, and Bagnall et al have all looked at melatonin levels in blood and urine
Paraspinal muscle histology revealed denervation changes, also sarcolemma changes were seen at the myotendinous junction supporting a neuropathic cause

12. “Idiopathic Scoliosis”
“Natural History”
Understanding this is essential to determining when treatment is necessary
Few natural history studies examine curve progression in the untreated skeletally immature population

13. “Idiopathic Scoliosis”
“Natural History”
Curves under 20 degree’s are are low risk for progression
Certain factors due influence the natural history: sex, remaining growth, curve magnitude, and curve pattern

14. “Idiopathic Scoliosis”
“Natural History”
Sex: females progress the most
Remaining Growth: Risser sign, Menarchal status, and Peak Height Velocity
Curve Magnitude: ‘Lonstein et al”
Curve Pattern: Double curves and thoracic curves likely to progress followed by thoracolumbar and lumbar

15. “Idiopathic Scoliosis”
“Classification”
Curve Location:
cervical apex C2-C6
Cervicothoracic apex C7-T1
Thoracic apex T2-T12
Thoraocolumbar apex T12-L1
Lumbar apex L2-L4

16. “Idiopathic Scoliosis”
“Classification”
Age at Onset:
Infantile: age birth to 3 years
Juvenile: age 4 to 10 years
Adolescent: age 11 to 17 years
Adult: age 18 years up

17. “Idiopathic Scoliosis”
“Prevalence”
0.5 to 3 per 100 (curves over 10 degrees)
1.5 to 3 per 1000 (curves over 30 degrees)
Based upon age types: 0.5% infantile, 10.5% juvenile, and 89% adolescent

18. “Idiopathic Scoliosis”
“Prevalence”
When a sibling or parent has scoliosis: seven fold increase(sibling) and three fold increase(parent) compared to general population

19. “Idiopathic Scoliosis”
“Clinical Features”
Pain: not a common complaint.
Discomfort can be a common feature but not severe pain.
‘Ramirez et al’ noted mild back discomfort and fatigue in 23%
If severe pain: must question etiology of the idiopathic curve

20. “Idiopathic Scoliosis”
“Clinical Examination”
Evaluation of trunk shape, trunk balance, neurologic system, limb length, skin markings and any skeletal abnormalities
Adams forward bend test
Radiologic Assessment: standing PA and lateral

21. “Idiopathic Scoliosis”
“Interpretation of Scoliosis Film”
Soft tissue abnormalities
Congenital bony abnormalities
Pedicle appearance and width
Curve assessment (Cobb Method)
Vertebral rotation (Nash and Moe)
Skeletal Maturity

22. “Idiopathic Scoliosis”
“Curve Pattern Classification”
King-Moe Classification:
King I: Rt T Lt L lumbar larger
King II: Rt T Lt L thoracic larger
King III: Rt Thoracic
King IV: Long Thoracolumbar
King V: Double thoracic

23. “Idiopathic Scoliosis”
“Curve Pattern Classification”
Lenke Classification: more comprehensive and considers both frontal and sagittal plane deformity
Currently being evaluated for practicality and usefulness
‘Spine Volume 26 Number 21
Nov. 1, 2001’

24. “Idiopathic Scoliosis”
“General Treatment Concepts”
OBSERVATION
No treatment needed if curve magnitude under 25 degrees
Repeat evaluation in 3 to 4 months
If 7 to 10 degree change then considered progression and treatment needed

25. “Idiopathic Scoliosis”
“General Treatment Concepts”
BRACE TREATMENT
Nachemson 1995: effectiveness of bracing versus observation…bracing better
Types of braces available: Milwaukee, TLSO(Boston), Charleston Bending Brace, SpineCor
Brace wear duration

26. “Idiopathic Scoliosis”
“Types of Braces”
Milwaukee and Boston: data supports good results with either
Charleston Bending Brace: variable results; “Price et al” 79% success “Katz et al” Boston vs Charleston and Boston better “Howard et al” compared all three with Boston/TLSO better of the three

27. “Idiopathic Scoliosis”
“Types of Braces”
Griffet et al: “SpineCor system”
worn as an undergarment
allows normal spine movement while applying a dynamic corrective force
limitation: progressive curves under
30 degrees
initial data is promising

28. “Idiopathic Scoliosis”
BRACE TREATMENT
Brace treatment is effective
Does change the Natural History
Full-time use better than part-time
“Rowe et al: 23 hrs better”
Indications: progressive curves over 25 degrees; initial curve presentation of between 30 and 40 degrees

29. “Idiopathic Scoliosis”
BRACE TREATMENT
In brace radiographs are important and obtained in 2 to 4 weeks
40 to 50% correction for Boston
70 to 90% correction for Charleston
Insufficient in-brace correction leads to unsatisfactory outcomes

30. “Idiopathic Scoliosis”
SURGICAL CORRECTION
GOALS
Reduce the magnitude of the curve
Obtain fusion to prevent progression
Create a well-balanced spine

31. “Idiopathic Scoliosis”
SURGICAL CORRECTION
INDICATIONS
Curves over 45 degrees
Trunk deformity(rotation)
Trunk balance
Progressive curves despite bracing

32. “Idiopathic Scoliosis”
SURGICAL CORRECTION
INSTRUMENTATION
Harrington
Luque
Cotrel-Dubousset
TRSH
Isola
Colorado II

33. “Idiopathic Scoliosis”
SURGICAL CORRECTION
MECHANISM OF CORRECTION
Frontal plane realignment through translation
Distraction increases thoracic kyphosis and reduces the scoliosis
Compression corrects the scoliosis and restores maintains lumbar lordosis

34. “Idiopathic Scoliosis”
SURGICAL CORRECTION
“Newer Techniques”
Pedicular screws: Suk et al reported better frontal plane correction and improved de-rotation
Hammill et al reported that screws reduced end vertebra tilt better than with hooks

35. “Idiopathic Scoliosis”
SURGICAL CORRECTION
“ANTERIOR APPROACH”
Used to mobilize a large curve in conjunction with posterior fusion
Limits the number of segments to be fused in thoracolumbar/thoracic curves
Allows anterior instrumentation
Eliminates crankshaft phenomenon

36. “Idiopathic Scoliosis”
SURGICAL CORRECTION
“ANTERIOR APPROACH”
Dwyer and Schafer were the first
Kaneda et al: positive results
Betz et al: re-established kyphosis
Picetti and Crawford et al: endoscopic release and instrumentation resulted in less pain, improved muscle function and smaller incisions

37. “Idiopathic Scoliosis”
OUTCOME OF SURGICAL
INTERVENTION
Harrington: 48% coronal improvement
CD: 61% coronal and sagittal plane improvement
Anterior correction: 58% improvement

38. “Idiopathic Scoliosis”
GENERAL GUIDELINES FOR
TREATMENT OF SCOLIOSIS
Under 20 degree’s: observe
20 to 30 degree’s: observe with frequent follow-up; progression then brace
30 to 45 degree’s: brace unless Risser 4/5 then observe
45 plus degree’s: instrumentation

39. “Idiopathic Scoliosis”
THANK YOU