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ScoliosisScoliosis is a lateral curvature of the spine with vertebral rotation. It can be caused by congenital, developmental or degenerative problems, but most cases actually have no known cause, and it is also known as idiopathic scoliosis. Pathophysiology
1. produces a rib prominence. 2. as the spine begins to curve, the vertebral column rotates around its long axis and causes ribs in the thoracic region to become prominent on the convex side.
Causes of Idiopathic Scoliosis:
Symptoms and diagnosis of idiopathic scoliosisMost typically, symptoms may include one or several of the following:
Adam’s forward bend test is used to determine whether or not they may have scoliosis. It involves the student bending forward with arms stretched downward towards the floor and knees straight. This angle most clearly shows any asymmetry in the spine and/or trunk of the adolescent’s body.
Because a curvature is usually in the thoracic or thoracolumbar spine, if a rib hump or asymmetry of the lumbar spine is found, or if the shoulders are different heights, it is possible that the patient has scoliosis. If this is the case, follow up with a physician for a clinical evaluation and an x-ray is the next step. The clinical evaluation with the physician will usually include a physical exam, during the physician will also test to make sure that there are no neurological deficits. The radiographic assessment of the scoliosis patient begins with erect anteroposterior and lateral views of the entire spine. ManagementThere are essentially three treatment options for adolescents with scoliosis: Observation, bracing and surgeryObservationThe curvature is measured on X-rays by what is known as the Cobb method, and this form of measurement is accurate to within 3 to 5 degrees.Curves that are less than 10 degrees are not considered to even represent scoliosis but rather spinal asymmetry.
Treatment for patients with progressing curves, or curves over 30 degrees in a skeletally immature patient, is usually centered on use of a back brace. Back bracesBracing is designed to stop the progression of the spinal curve, but it does not reduce the amount of angulation already present. The majority of curve progression happens during a child’s growth phase, and once the growth has ended, there is little likelihood of progression of a curve. Therefore, bracing is continued until the child is skeletally mature and has completed the growing phase.The only curves that tend to continue to progress after skeletal maturity are those that are greater than 50 degrees in angulation, so the treatment objective is to try to get the child into adulthood with less than a 50 degree curvature. There are two types of commonly used scoliosis brace. They are thoracolumbosacral orthosis(TLSO) and Charleston bending brace. TLSO is a custom moulded back brace that applies three-point pressure to the curvature to prevent its progression whereas Charleston bending back brace applies more pressure and bends the child against the curve. It is worn only at night while the child is asleep. Bracing used to stop the progression for the curvatures in the growing child. (not used in children who are already skeletally mature or almost mature). If a child with a curve of greater than 30 degrees and is almost mature, his curvature will be treated with observation as there is little growth left and bracing will not do much good. SurgerySurgery is only recommended for patients with curves greater than 40-45 degrees and is continuing to progress. However, for most patients with curves that are greater than 50 degrees. The main objective of scoliosis surgery is to fuse the spine so that the curve will not continue to progress into adulthood.If curve is allowed to progress to 70-90 degrees à very disfiguring deformity will result in cardiopulmonary compromise due to the curve in the spine rotating around the chest and closes down the space available for the lung and heart. There are two approaches to scoliosis surgery-posterior and anterior approach. Posterior approach-patients with severe deformity and those with rigid curvature:
Removing the disc, allows for better reduction of spine and better fusion. This is important if patient is a young child and has a lot of growth left. Anterior approach-for curves at thorocolumbar junction T12-L1. Requires an open incision and removal of a rib usually on the left side as the diaphragm which can be released from the chest wall and spine; with excellent exposure in obtaining thoracic and lumbar spinal vertebral bodies. Disc is removed and thus loosens up the spine. Screws can be placed in the vertebral bodies and reduction of the curvature obtained and held with a rod. Then bone is added to the disc space to allow the spine to fuse together. Advantage of anterior approach Allows better reduction of the curve and a more favorable cosmetic result. Saving some of the motion for the lumbar back curves because if the fusion goes below the L3 there is higher risk of later back pain and arthritis. Saving lumbar motion segment helps prevent loading all the stress on just a few motion segments. Disadvantage Can be done for thoracolumbar curves and most scoliosis curves are in the thoracic spine Potential risk and complications :
Postop care
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These types of curves are extremely unlikely to progress and generally do not need any treatment. If the child is very young and physically immature, then the progress of the curve can be followed during the child’s regular check up with her pediatrician. If the curve is noticed to progress beyond 20 degrees, then the child should be referred to an orthopedic surgeon for continued treatment. Curves that are between 20-30 degrees in a growing child can be observed at 4 to 6 months intervals. Any progression that is less than 5 degrees is not considered significant. If the curve progresses more than 5 degrees, then the curve will need treatment. Any curve over 30 degrees in a skeletally immature patient (child who is still growing) will need treatment.