Adolescent Idiopathic Scoliosis

December, 11st 2020

Spine team : MX SI
Supervisor : DR.dr. Karya Triko Biakto, SpOT (K), MARS
 Background
• History : In the fifth century BC, Hippocrates
described scoliosis for the first time, and
designed a distraction apparatus for
correction of the deformity
the mid-sixteenth century :
Ambroise Paré first described
congenital scoliosis and
recommended new external
breastplates to be made every
3 months or so
 Definition

idiopathic
scoliosis Adolescen
Adolescent
(individuals (a spinal deformity t
characterized by
between the ages of
10 to 18 ) lateral bending and Idiopathic
fixed rotation of the Scoliosis
spine in the absence of
any known cause)
 Epidemiology

• Prevalence is 3% in the general population

(most common)
• A female predominance is noted
• Few adolescent patients (0.3%) develop
curves requiring treatment
Pathogenesis
• Lerique et.al, electromyographic
asymmetry in the paraspinal muscles
Muscular Theories • Calmodulin regulates
• Platelets

Neurological • damage to this segmental blood

supply produced a neuromuscular
Theories type of deformity
• syrinx

Connective-tissue collagen structure

Abnormalities (Marfan or Ehlers–Danlos
syndrome )

• chromosome 19 as a possible
candidate for a genetic source of the
Genetic Theories disorder
• higher incidence of idiopathic
scoliosis within families compared
with the general population (30%)
 Prsentation
• Typically the child with scoliosis will not have any
complaints related to the condition
• The most common presenting statement is, “I was told
that I have scoliosis.”
• up to 35% of patients may complain of some degree of
back pain.
• back pain, or neurological symptoms including
radicular pain, muscle weakness, sensory changes,
and bowel or bladder incontinence extremely unusual
• Full details of the degree (pain score), location,
radiation, and exacerbating and relieving factors
for a patient’s pain should be reviewed.
• medial subscapular pain over the rib hump
• muscular flank pain from a truncal shift and
asymmetric muscle contraction
• assess the menarchal status of female
• date of initial observation of a truncal asymmetry,
the perceived degree of progression
• The patient’s medical and surgical history
• associated conditions include congenital
muscular torticollis, Klippel–Feil syndrome,
Scheuermann’s kyphosis, Marfan disease,
spondylolysis, spondylolisthesis,
spondyloepiphyseal dysplasia, spinal cord or
musculoskeletal tumors, and inflammatory
conditions
• A family history of scoliosis
Physical Examination
This 8-year-old child presented with a severely deformed rib cage and a hairy patch in the mid apical region. Her left leg
was smaller than her right leg and she had a mild cavus deformity. The hairy patch was associated with a
diastematomyelia. The radiographic triad is that of a widened interpedicular space on the apical vertebra, narrowed
disc
space, and presence of a bony spike. (A) Frontal view showing significant truncal imbalance. (B)A posterior view shows
the hairy patch in the middle of the child’s major spinal curve. (C)Close-up view of the hairy patch
• other important findings on physical exam 
leg length inequality
waist asymmetry and pelvic tilt
foot deformities (cavovarus)
asymmetric abdominal reflexes
 Imaging
• standing posteroanterior (PA) and lateral
views(14 x 36 in). lower cervical spine and
shoulders, entire thoracolumbar spine,
• An erect sitting position
• supine radiographs
• Serial radiograph
• oblique views,
• Computed Tomography:
in cases of severely
rotated curves and
congenital curves and
evaluation of pedicle
diameter, less radiation
• MRI : very helpful in
the diagnosis of neural
axis pathology in
children with scoliosis
 IMAGING

• End Vertebra : The top and bottom vertebrae that tilt maximally into
concavity of the curve, they are typically least rotated, least horizontally
displaced vertebra within a curve.
• Curve magnitude (Cobb method) : The angle formed by the intersection of
the two line that are drawn across the superior end plate of the upper end
vertebra and the inferior end plate of the lower end vertebra.
 IMAGING
• Balance Assessment
 The C7 plumbline (C7PL) is a
line dropped vertically from
the center of the C7
vertebral body. This line
should normally pass
through the center of S1
 A vertical line is constructed
from the midpoint of the C7
vertebra through the pelvis
on upright lateral image.
Here it intersects S2.
 Thoracic lordosis of 2
degrees represents a severe
form of hypokyphosis.
VERTEBRAL ROTATION POSITION (NASH-MOE
CLASSIFICATION)
• VERTEBRAL ROTATION POSITION (NASH-MOE
CLASSIFICATION)
 KING MOE CLASSIFICATION

• Type I - lumbar dominant (10%) - S-shaped

curve, Both thoracic and lumbar curves cross
midline, Lumbar curve larger or more rigid King-Moe (the simple thing’s)
• Type II - thoracic dominant (33%) - S-shaped
curve, Both thoracic and lumbar curves cross • Type 1: “S” Lumbar >
midline, Thoracic curve larger or more rigid thoracic.
• Type III - thoracic (33%) - Thoracic curve, Lumbar
curve does not cross midline • Type 2: “S” Thoracic >
• Type IV - long thoracic (10%) - Long thoracic
curve, L5 over sacrum, L4 tilted into curve
Lumbar curve.
• Type V - double thoracic (10%) - Double thoracic • Type 3: Single thoracic w/o
curve, T1 tilted into upper curve, Upper curve
structural
structural Lumbar.
•
 Assessment of Skeletal
Maturity

Risser’s Sign describes the ossification of the illiac Fig. 5.18 The Sanders classification system of skeletal maturity.
epiphysis Stage 1: Juvenile slow [G/P F 8–9 M 12.5]. Stage 2:
Preadolescent slow (Tanner 2) [G/P F 10 M 13 ]. Stage 3:
• Grade 0 : absent Adolescent rapid-early (Tanner 2–3, Risser grade 0, TRC open),
• Grade 1 : (0-25%) Peak height velocity [G/P F 11–12 M 13.5–14 ]. Stage 4:
• Grade 2 : (26-50%) Adolescent rapid-late (Tanner 3, Risser
grade 0, TRC open) [G/P F 13 M 15 ]. Stage 5: Adolescent
• Grade 3 : (51-75%) steadyearly (Risser grade 0, TRC closed) [G/P F 13.5 M 15.5 ].
• Grade 4 : (76-100%) Stage 6: Adolescent steady-late (Risser grade 0) [G/P F 14 M 16
• Grade 5 : fusion of epiphysis of illiac ]. Stage 7: Early mature [G/P F 15 M 17 ].
 MANAGEMENT (three Os)
Aim of Treatment :
to prevent a mild deformity from becoming
severe, to correct an existing deformity that
is unacceptable to the patient
– Observation
• Cobb angle less then 20
• Mature Skeletal Cobb angle less than 30
• Followed up at 4- to 12 months interval
 ORTHOSIS
Indication :
 Risser 0-1 with the curve 20-29
 Risser 2 with the curve 20-29 with
progressiveness (observe per 3
months)
 30-40 curve on immature skeletal (on
risser sign <1)
 ORTHOSIS
• Milwauwkee (CTLSO) for
apex above T7. Boston
(TLSO) : apex at T7 or below.
• Charleston brace (bending
brace)
• goal is to stop progression,
not to correct deformity
Protocol:
Must wear 23 hours until 2 yrs
after menarche or risser 4 and
wean off in year
 BOSTON BRACE
• Underarm orthoses - Thoracolumbar spinal orthosis (TLSO)
[Boston]- If apex of curve below T8 - Made from
thermoplastic material, from cast of patient in corrected
position. Worn and weared as for Milwaukee brace.
 OPERATION
• The main goal of surgery : to achieve correction of
deformity including rotation, a fusion of the
structural deformity of the spine, which will
prevent further progression
• Indications of surgery
– Progressive curves >40-45◦ in growing children.
– Failure of bracing.
– Progressive curves beyond 50o in adults.
Types of surgery
– Posterior spinal instrumentation and posterior fusion
– Anterior spinal instrumentation and anterior fusion
– Anterior spinal fusion combined with posterior spinal
instrumentation and fusion
– Extremely large stiff curves (e.g. .100° depending on curve flexibility and
location)
– To address coexistent rigid sagittal plane deformities (e.g. excessive
thoracic lordosis, hyperkyphosis)
– To prevent the crankshaft phenomenon in the situation of a patient
younger than age 10 who has open triradiate cartilages, especially if
surgery is performed prior to peak height velocity.
– Revision procedures following unsuccessful prior scoliosis surgery
 COMPLICATION
• SMA syndrome (superior mesenteric artery
syndrome)
– presents with symptoms of bowel obstruction 
• Neurologic injury
• Flat back syndrome
• Crankshaft phenomenon
• Pseudoarthrosis (1-2%)
• Hardware failure 
• Infection (1-2%)
CASE
 AUTOANAMNESIS
Chief Complain: Crooked spine
• Complaints have been felt since the last 3 years the patient began to notice a
crooked spine, accidentally there was a feeling of prop in his back when he
leaned against the wall and the patient's mother felt the high position of the
school skirt was next to it.
• The patient began to feel easily tired and had difficulty breathing and could
walk some distance since the last 1 year. The patient has no other complaints.
• No tumor history, no family history of similar diseases. No history of pain, no
history of chest palpitations, history of menarche when patient 14 Yo, no
history of surgery.
• The patient can still move as usual at this time, there is no weakness in the
limbs.
 LOCAL STATUS
Vertebra region
Look : Deformity (+) Gibbus (-), Wound (-), swelling (-),
hematoma (-)
Feel : Tenderness (-)

Special test
Adam Forward bending test (+)
PRE OP
PRE OP
• (SAE13PE.45) What is the minimum hours per
day of wear that has been correlated with the
effectiveness of bracing on curve progression
in idiopathic scoliosis?
1. Prescribed brace wear 23 hours/day
2. Prescribed brace wear 16 hours/day
3. Actual brace wear more than 12 hours/day
4. Actual brace wear 6 hours/day
 2
The efficacy of brace treatment for patients with adolescent
idiopathic scoliosis is controversial because its effectiveness
remains unproven. One of the challenges is patient noncompliance
with prescribed bracing regimens. A recent study investigated
curve progression based on actual brace wear using a temperature
sensor to accurately assess brace wear. The total hours of brace
wear correlated with lack of curve progression with a dose-
response effect noted. Curves did not progress in 82% of patients
who actually wore the brace more than 12 hours per day. For those
who wore the brace for fewer than 7 hours per day, curves
progressed in 69%. Prescribed bracing regimens (eg, 16 hours/day
or 23 hours/day) had no effect on actual brace wear or curve
progression.
• (SAE07PE.98) A 12-year-old girl who is Risser stage 3 has had intermittent
mild midback pain for the past 4 weeks. The pain is worse after
prolonged sitting and after carrying a heavy backpack at school. She
occasionally takes acetaminophen, but the pain does not limit sport
activities. Examination reveals a mild right rib prominence during
forward bending. Neurologic examination is normal. Radiographs show a
20-degree right thoracic scoliosis with no congenital anomalies or lytic
lesions. Management should consist of  ?
• 1. back muscle stretching and reduced weight in the backpack.
• 2. consultation with a pain management specialist.
• 3. MRI of the thoracic spine.
• 4. a technetium Tc 99m bone scan.
• 5. a thoracolumbosacral orthosis.
 1
• Mild scoliosis is not a painful condition, but it usually presents
during adolescence. Intermittent back pain is reported by 25% to
30% of adolescents whether or not scoliosis is present. Such pain is
often attributed to muscle strain from tight muscles, poor posture,
or heavy school backpacks. The clinician must distinguish typical
pain (mild, intermittent, nonlimiting) from atypical pain. The latter
requires more careful examination and imaging studies (bone scan
or MRI) to determine the source of pain. The patient’s age and
right thoracic curve pattern are typical for idiopathic scoliosis;
therefore, imaging of the neuroaxis is not necessary to look for
cord syrinx, tethering, or tumor. Brace treatment is not required for
this small curve unless future progression is demonstrated.
THANK YOU