1. Scoliosis

2. Scoliosis What is it? How do we screen for it? When to refer?
How is it treated?

4. What is scoliosis?
Lateral curvature of the spine >10º accompanied by vertebral rotation
Idiopathic scoliosis - Multigene dominant condition with variable phenotypic expression & no clear cause
Multiple causes exist for secondary scoliosis

5. Secondary causes for scoliosis: Inherited connective tissue disorders
- Ehler’s Danlos syndrome
- Marfan syndrome
- Homocystinuria

6. Secondary causes for scoliosis: Neurologic disorders
Tethered cord syndrome
Syringomyelia
Spinal tumor
Neurofibromatosis
Muscular dystrophy
Cerebral palsy
Polio
Friedeich’s ataxia
Familial dysautonomia
Werdnig-Hoffman disease

7. Secondary causes for scoliosis: Musculoskeletal disorders
Leg length discrepancy
Developmental hip dysplasia
Osteogenesis imperfecta
Klippel-Feil syndrome

8. Characteristics of idiopathic scoliosis:
Present in 2 - 4% of kids aged 10 – 16 years
Ratio of girls to boys with small curves (<10º) is equal, but for curves >30º the ratio is 10:1
Scoliosis tends to progress more often in girls (so girls with scoliosis are more likely to require treatment)

9. Natural history of scoliosis
Of adolescents diagnosed with scoliosis, only 10% have curve progression requiring medical intervention
Three main determinants of curve progression are:
(1) Patient gender
(2) Future growth potential
(3) Curve magnitude at time of diagnosis

10. Natural history of scoliosis
Assessing future growth potential using Tanner staging:
Tanner stages 2-3 (just after onset of pubertal growth) are the stages of maximal scoliosis progression

11. Natural history of scoliosis
Assessing growth potential using Risser grading:
- Measures progress of bony fusion of iliac
apophysis
- Ranges from zero (no ossification) to 5 (complete
bony fusion of the apophysis)
- The lower the grade, the higher the potential for
progression

12. Risk of Curve Progression
Curve (degree)
Growth potential (Risser grade)
Risk *
10 to 19
Limited (2 to 4)
Low
High (0 to 1)
Moderate
20 to 29
Low/mod
High
>29
Very high .
*—Low risk = 5 to 15 percent; moderate risk = 15 to 40 percent; high risk = 40 to 70 percent; very high risk = 70 to 90 percent.

13. Natural history of scoliosis
Back pain not significantly higher in pts with scoliosis
Curves in untreated adolescents with curves < 30 º at time of bony maturity are unlikely to progress
Curves >50 º at maturity progress 1º per year
Up to 19% of females with curves >40 º have significant psychological illness
Life-threatening effects on pulmonary function do not occur until curve is >100 º (ie: Cor pulmonale)

14. Scoliosis Screening
In years past, widespread school-based screening led to many unnecessary referrals of adolescents with minimal curvatures
U.S. Preventive Services Task Force notes “insufficient evidence” to recommend for or against routine screening of asymptomatic adolescents for idiopathic scoliosis

15. Scoliosis Screening Recommendations
American Academy of Orthopedic Surgeons
- Screen girls at ages 11 and 13
- Screen boys once at age 13 or 14
American Academy of Pediatrics
- Screen at 10, 12, 14 and 16 years

16. Adam’s forward bend test
For this test, the patient is asked to lean forward with his or her feet together and bend 90 degrees at the waist. The examiner can then easily view from this angle any asymmetry of the trunk or any abnormal spinal curvatures.

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

18. Scoliometer
An inclinometer (Scoliometer) measures distortions of the torso.
The patient bends over, arms dangling and palms pressed together, until a curve can be observed in the upper back (thoracic area).
The Scoliometer is placed on the back and measures the apex (the highest point) of the upper back curve.
The patient continues bending until the curve can be seen in the lower back (lumbar area). The apex of this curve is also measured.

19. Red flags on PE: Left-sided thoracic curvature Pain
Significant stiffness
Abnormal neurologic findings
Stigmata of other clinical syndromes associated with curvature

20. Measure spinal curvature using Cobb method:
Choose the most tilted verterbrae 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 is the Cobb angle.

21. Referral Guidelines & Treatment
Curve (degrees)
Risser grade
X-ray/refer
Treatment
10 to 19
0 to 1
Every 6 months/no
Observe
2 to 4
20 to 29
Every 6 months/yes
Brace after 25 degrees
Observe or brace *
29 to 40
Refer
Brace
>40
0 to 4
Surgery †

22. Brace Treatment for Scoliosis
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

23. Brace Treatment for Scoliosis
Of patients with 20 º - 29 º curves, only 40% of those wearing braces ultimately required surgery, compared to 68% of those not wearing back braces
Length of wearing time correlates with outcome (At least 16 hrs per day leads to best chance of preventing curve progression)

24. Surgical Treatment for Scoliosis
Curves in growing children greater than 40 º require a spinal fusion (Risser grade 0 to 1 in girls and Risser 2 or 3 in boys)
Skeletally mature patients can be observed until their curves reach 50 º
Posterior spinal fusion is best choice for thoracic curves
Anterior spinal fusion is best treatment for thoracolumbar and lumbar curves

25. Surgical Treatment for Scoliosis
Spinal surgery with instrumentation
significantly corrects deformity &
usually stops curve progression
Surgery is accompanied by spinal
cord monitoring using somato-
sensory & motor-evoked potentials
(risk of neurologic injury is 1/7000)

26. Post-Op Treatment & Long Term Consequences of Spinal Fusion
If segmental instrumentation used, no post-op cast or brace required
Post-fusion back pain does occur and is more common in distal spinal fusions
Usually out of hospital in 4-5 days & back at school in 2 wks
OK to participate in athletics after 9 – 12 months
(should avoid contact sports)

27. Case #1
MP is a 16-year-old male who presents to your office for his annual health assessment and sports physical.
During the course of his examination, you note a mild convexity in the thoracic region of his spine with forward flexion at the hips.
Based on your clinical examination, you estimate a lateral spinal curvature of about 5 degrees.
You note these findings to the patient and then to his mother.

28. Question 1 Which one of the following procedures should be1.
Which one of the following procedures should be implemented next?    A.
Recommend a back-strengthening program. B.
Refuse to permit participation in contact sports. C.
Order a radiograph of the back to quantify the curvature (e.g., Cobb angle). D.
Monitor the patient's condition. E.
Refer for orthopedic consultation. 1.
Which one of the following procedures should be implemented next?    A.
Recommend a back-strengthening program. B.
Refuse to permit participation in contact sports. C.
Order a radiograph of the back to quantify the curvature (e.g., Cobb angle). D.
Monitor the patient's condition. E.
Refer for orthopedic consultation.
Question 1 1.
Which one of the following procedures should be
implemented next?
A. Recommend back-strengthening exercises.
B. Refuse to permit participation in contact sports.
Order a radiograph of the back to quantify the
curvature (e.g., Cobb angle).
D. Monitor the patient's condition.
E. Refer for orthopedic consultation.

29. Answer 1
The answer is D: monitor the patient's condition.

30. Question 2 Because you have recently agreed to serve as school
physician in the district where your office is located, you
wonder what scoliosis screening programs are in place and
who has been examining these school children for scoliosis.
Which one of the following procedures should you implement?

31. Question 2 (cont.)
Arrange scoliosis screening for all students between 10 and 16 years of age.
B. Arrange scoliosis screening for all students 10, 12 , 14 and 16 years of age.
C. Contact the school nurse and review skills for scoliosis screening procedures.
Visually inspect for severe curves only when the back is examined for other reasons.
Screen girls for scoliosis at 11 and 13 years of age and boys at 13 and 15 years of age.

32. Answer 2 According to AAP the answer is B: screen at 10, 12, 14 &
16 years
According to U.S. Prev Services Task Force, the answer is D:
visually inspect for severe curves only when the back is
examined for other reasons.

33. Question 3
Which of the following statement(s) about treatment for adolescent
scoliosis is/are correct?
Exercise therapy has been shown to be an effective treatment for preventing progression of scoliosis.
B. Spinal surgery for scoliosis is not supported by studies showing improvements in clinical outcomes, such as decreased back pain and increased functional status.
C. Lateral electrical surface stimulation for eight hours nightly can limit progression of spinal curvature
D. Back bracing (e.g., orthoses) reduces symptoms of low back pain.

34. Answer 3
The answer is B: Although surgery for scoliosis is generally not recommended without marked curvature, well-conducted outcomes studies with patients who have had surgery have not been completed. Symptoms of back pain do not appear to correlate with magnitude of surgical correction.

35. Conclusions
Screening for scoliosis remains controversial & has led to many unnecessary referrals
Adolescent scoliosis can be followed by family docs if the curve has a low risk of progression & underlying causes have been excluded
Curves demonstrating significant progression with continued growth remaining or those at high risk of progression should be referred for orthopedic evaluation
Always refer when red flags are present on PE or X-ray

36. Conclusions
90% of kids with scoliosis will not require medical intervention
Girls are much more likely than boys to need intervention for scoliosis
Bracing can slow progression of many curves and significantly decrease need for surgery
Spinal fusion surgery is recommended for curves greater than 45 – 50 degrees

37. Torticollis

38. What is it? Also known as Wryneck
Head and chin are tilted at opposite angles, causing head to twist
Asymmetrical Appearance
Effected muscle:sternocleidomastoid

40. What is it? Can exist before or at birth
Congenital Muscular Torticollis
Can occur during childhood up through adult age
Acquired/Noncongenital Muscular Torticollis
Both cause asymmetrical appearance and function in the neck and head of those afflicted

42. Prevalence Less than .4% of newborns
Torticollis does not prefer one side of head or the other
In CMT, ratio of boys to girls is 3:2
Increased head size in male babies

43. Prevalence
In adults, noncongenital muscular torticollis has an average onset of 40 years old
Females twice as likely afflicted than males
Usually equal distribution between right and left side of body afflicted
Slightly more right torticollis in older female populations

44. Causes? Not well understood
Almost 80 entities have been reported to cause torticollis
Common causes:
Developmental disorders affecting sternocleidomastoid muscle
Imbalance in function of cervical muscles
Other abnormalities in skull/cervical area

45. Other Causes Genetic defect
Infants position during pregnancy or delivery
Tumors in head or neck
Arthritis of neck
Pseudotumors in infants
Certain medications
Genes
More likely to be afflicted if family member had torticollis or similar disorder

46. Symptoms Adults and Children:
Abnormal contraction of the neck
Limited range of motion
Stiff neck muscles
Possible swelling and pain
Can often be mistaken for more serious condition
See medical professional immediately

47. Symptoms
Infants:
Tilting of chin
Small mass (pseudotumor) in neck
Small neck spasms
Diagnosed before 1 month old = shorter physical therapy

48. Prognosis Most helpful diagnosis is made early Not life threatening
May self correct itself
May be chronic and reoccurring
Any complications may result from compressed nerve roots

49. Treatments Stretching and lengthening affected neck muscles
Applying heat, massage, analgesics
Can be combined with TENS
Transcutaneous Electrical Nerve Stimulation
Medical treatment—Bacolfen or Botox
Injection every three months

50. Treatments Surgery in severe cases
Patients whose pathology does not resolve after 12 months of physical therapy or who develops facial asymmetry
Risk of injury to spinal nerves

51. Preventive Measures Nearly impossible to prevent
Become familiar with symptoms
Seek medical attention
Other serious conditions may be confused for Torticollis and are not treated correctly

52. 
Any Questions?