1. Dr Lalit Sharma Spine Surgeon Narayana Multispeciality Hospital Jaipur
Scoliosis - Basics
Dr Lalit Sharma
Spine Surgeon
Narayana Multispeciality Hospital
Jaipur

2. What is scoliosis
Demographics & Etiology
Clinical Evaluation
Radiological Evaluation
Treatment

3. Scoliosis
“Abnormal lateral curvature of spine” Deformity in the coronal plane

4. 3 Dimensional Deformity
Coronal Plane
Sagittal Plane
Axial Plane

5. 3 Dimentional Deformity

6. Demographics Occurs in 1-3% of population below the age of 16 years.
0.1% have a curve greater than 40 degrees.
Girls are more affected than boys.
Those with a curve of more than 30 degrees are generally girls, outnumbering boys by 10:1.

7. Types of Scoliosis Congenital Neuromuscular Syndromic Idiopathic –
Cerebral palsy / PPRP
Syndromic
Marfan’s syndrome
Neurofibromatosis
Idiopathic –
80% - Most common
Degenerative

8. Idiopathic - Classification
Infantile: 0-3 years old (.5%)
Juvenile: years old (10.5%)
Adolescent: years old (89%)
Early Onset : 5 years or less
Late Onset: more than 5 years

9. Anatomy All bony elements are altered Discs are wedged as well
Vertebra are wedge shaped
Poorly Developed Concave side
Pedicles rotated
Discs are wedged as well

10. Etiological Theories Genetic Tissue deficiencies Growth abnormalities
Central nervous system alteration

11. Genetic Strongly Familial 11% incidence in first relatives of patients
Normal incidence < 3%
Monozygote twins more common
Gene identified – Chromosome 3p26. LBX1, DSCAM gene

12. Tissue Deficiencies Marfan’s syndrome deficient fibrillin
Osteopenia noted in girls
Elevated calmodulin
Involved in contractile properties thru actin & myosin
Elevated in platelets
No consistent findings to date

13. Growth Abnormality Asymmetrical vertebral growth
Hueter-Volkman effect is suppression of growth on concave side
Hypokyphosis during growth spurt
No increased incidence with growth hormone
No initiating factor identified

14. Central Nervous System
Different size cerebral cortices
Associated Syrinx, Low lying cord, Arnold Chiari Malformation –Functional Spinal Cord Tethering
Deficient melatonin
Chicken model
Inconclusive in humans

15. History First noted and progression Family history
Affected sibling 7 times more frequent
Affected parent 3 times more frequent
Recent growth history
Sexual maturity
Pain
‘Fatigue pain’
Post diagnostic pain
‘Severe pain’

16. Physical Exam Iliac crest height Shoulder height Arm trunk space
Leg length discrepancy
Shoulder height
Arm trunk space
Scapular position
Trunk shift
Neuro exam /Muscle charting
Generalized Features – Marfan’s
Inspection of skin
Café au lait spots
Hair patch

17. Physical Examination:
Features suggestive of polio, neurofibromatosis, Von Reclinghausen syndrome, Down’s, Marfan’s, Hurler’s syndrome, neural tube defects and osteogenesis imperfecta.
Forward protrusion of chest wall on affected side.
Increased flank creases on opposite side.
Higher ASIS and PSIS on concave side.
Spinous process turned into concave side.

18. Forward Bend Test Adam’s sign

19. Radiological Evaluation
PA & Lateral Whole Spine Standing Films
Posterior to anterior
Decrease thyroid and breast exposure 3-7 fold
AP – Whole spine right and left bending films – lying down
Traction X-rays
Fulcrum Bend X-rays

20. Scoliosis – Analyzing Curve
Structural and Non Structural
Primary Curve and Secondary Curve
End vertebra
Apex
Cobb’s Angle
Stable zone
Rotation

21. Structural Curve – Position Independent Fixed deformity
Structural changes

22. Primary Curve Structural Lateral Curvature with Rotation
Recognized Clinically
Measured Radiographically
End Vertebra
Most tilted vertebra
Last to show rotation of Spinous process
Pedicle width equal on each side
Neutral Disc / Neutral Vertebra

23. Compensatory Curves Above and below the primary curve
In opposite direction to primary curve
No fixed clinical rotation
“Righting Reflex”

24. Measurement of Scoliosis Cobb’s Angle

25. Rotation Spinous process rotates into concavity
Nash & Moe method - Pedicle position

26. Stable Zone / Stable Vertebra

27. Nomenclature Cervical – C1 to C6-7 Disc Cervicothoracic – C7 to T1
Thoracic – T1-2 Disc to T11-12 Disc
Thoracolumbar – T12 to L1
Lumbar – L1-2 Disc to L4-5 Disc
Lumbosacral –L5 and below

28. T5 T9
Compansatory
Curve
760 L1

29. Skeletal Maturity History and Physical Exam
Triradiate cartilage fusion
Risser sign

30. King’s Classification
Double curve, both curve cross the midline, • Lumbar curve larger , stiffer than the thoracic curve
Double curve, both cross the midline • Thoracic curve larger, stiffer than the lumbar curves.
Long thoracic curve in which L5 is centered over sacrum but L4 tilts into long thoracic curve
Thoracic curve and T1 tilts to upper curve
Thoracic curve crosses midline and lumbar curve does not cross midline

31. Lenke Classification

32. MRI Neurologic deficit Infantile and juvenile curves
Spinal cord abnormality in younger children
Infantile idiopathic scoliosis 50%
Juvenile 20%

33. Who needs an MRI: A thoracic curve to the left. Painful scoliosis.
Abnormal neurological findings.
Untoward stiffness.
Deviation to one side during the bend test.
Sudden rapid progression of a previously stable curve.

34. Treatment

35. Natural History - Curve Progression
Curves 30 to 50 degrees progress an average of 10 to 15 degrees over a lifetime.
Curves > 50 at maturity progress steadily at a rate of 1 degree per year.
Curves less than 30 at bone maturity are unlikely to progress.

36. Medical complications:
At 90 degrees or greater: increased potential for life threatening effects on pulmonary function.
Psychologic illness: seen in up to 19% of females with curves great than 40 degrees as adults.

37. Natural History
Close relationship b/w increase in height & curve progression
Infantile rapid stage
Juvenile slow stage
Adolescent rapid stage
Mature – slow stage

38. Will the curve progress?
Three factors involved in progression
Patient’s gender –
Females are 10 times more likely to have progression than males.
Future growth potential –
Skeletal Maturity – Radiological / clinical
Curve magnitude at time of diagnosis
The greater the growth potential and larger the curve = more likely to progress

39. Treatment
Observation
Bracing
Surgery

40. Treatment RISSER CURVE Action 0 - 1 0 - 20 degrees 20 - 40 degrees
Observe
Brace
2 - 3
degrees
30 – 40 degrees
0 - 3
0 - 4
40 – 50 degrees
50 degrees and higher
Gray
Surgery

41. Bracing Orthotic braces - 74% success rate at halting progression
Must be worn hours a day, but most pts are not compliant.
Braces do not correct scoliosis.

42. Braces

43. Bracing - Contraindications
Curves >450
Patient with noticeable Trunk shift
Skeletally mature adolescents – Riser 4-5, 2 yrs post menarchal
Curve apex above T6
Excessive Thoracic Hypokyphosis < 200

44. Scoliosis - Surgery Fusion – gold standard
Creating a well balanced spine – both Sagittal and Coronal plane
Instrumentation – to maintain acceptable alignment
Non-fusion options - developmental

45. Surgery Anterior Release Anterior Instrumenation
Posterior Instrumentation
Osteotomies -
Ponte’s
VCR
Growth rods

46. Tests of flexibility of spine:
Adam’s forward bending test.
Pushing the curve from convex side and noting
the correction.
Lifting the patient up from head.
X-rays - Lateral bending / Fulcrum bend /Traction X-Rays

50. Early Onset Scoliosis Preserve as much growth potential as possible
Lung development
Thoracic insufficiency syndrome

51. Infantile Treatment Must prove idiopathic 90% are left thoracic
3 female : 2 male
90% resolve spontaneously
Predict progression by RVAD
< 20 degrees 83% resolve
>20 degrees 84% progress

52. Congenital Scoliosis Vertebral malformation Rib Anomalies
Failure of formation
Failure of segmentation
Mixed
Rib Anomalies
Spinal cord anomalies
Urogenital / Cardiac

53. Growing Rod Technique

57. Conclusion Scoliosis is common – most are lordoscoliosis
Treatment depends on remaining growth potential, curve magniitude, and sex
Goal of treatment is to have a curve of < at Skeletal Maturity
Bracing
Surgery

58. Thank You Dr. Lalit Sharma lalitspine@gmail.com
Consultant Spine Surgeon
Narayana Hrudayalaya Hospital
Jaipur