Scoliosis

Scoliosis
A condition that involves complex lateral and rotational curvature of the spine. The spine is curved and sometimes twisted most common type of spinal deformity It is seen from behind (the back)

Classification
The deformity could be: 1)Postural - correctable 2)Structural - fixed

1)Postural scoliosis
The deformity is secondary or compensatory to some condition outside the spine Disappear with changes in posture (on flexion) No bony abnormality
Condition that lead to postural scoliosis are:
o Short leg (when pt sit cancelling leg asymmetry- curve disappear) o Pelvic tilt due to contracture of the hip o Local muscle spasm associated with prolapsed lumbar disc

2)Structural scoliosis
Accompanied by bony abnormality or vertebral rotation Deformity is fixed do not disappear with changes in posture Secondary curves develop to counterbalance the primary deformity Structural curve becomes more obvious on flexion

Types of structural scoliosis

Idiopathic scoliosis (more common) 1. Infantile <3yrs 2. Juvenile 4-9 yrs 3. Adolescent >10yrs (most common) Scoliosis due to known causes 1. Osteopathic: is due to Congenital vertebral anomalies 2. Neuropathic: due to asymmetrical muscle weakness (e.g. in cerebral palsy and Poliomyelitis) 3. Myopathic: in muscular dystrophies 4. Neurofibromatosis

Adolescent idiopathic scoliosis

Usually present before puberty Progress until skeletal growth ceases Cause is unknown Lateral curvature can occur in the thoracic or lumber spine. The vertebra that makes up the curve are rotated around the vertebral axis i.e. bodies point to the convexity (laterally) and the spinous processes to the concavity of the curve (medially) In thoracic curves ribs on the convex side make a hump

 Pt usually present between the age of 10 to 15. F>M Deformity is the only symptom Severity depends on which part of the spine involved. Higher curves are noticed earlier. more prominent on flexion unlike postural curves The shoulder is elevated on the side of convexity and the hip sticks out on the side of concavity Thoracic scoliosis the breasts are asymmetrical and the rib angles protrude

X-ray: Should include full length view of the spine The angle of curvature (cobbs angle) is measured Xray of the pelvis may show Rissers sign (iliac apophysis has ossified and fused)- sign of skeletal maturity, progression is minimal afterwards

Treatment The aim is to prevent the curve becoming severe and correcting the existing deformities. The younger the child and the higher the curve the worse the prognosis A period of preliminary observation may be needed before deciding between conservative and operative treatment At 4-monthly intervals the patient is examined, photographed and X-rayed so that the curves can be measured and checked for progression Conservative treatment Vs. Operative treatment

Conservative treatment Barcing: For progressive curves between 20 and 40 degrees For well balanced double curves With younger children until they reach adolescence (iliac apophysis ossified and fused) Prevent recurrence after spinal fusion Milwaukee brace, more recently Boston brace

Milwaukee brace

Boston brace

Operative treatment Curves that progress more than 40 degrees 50% correction is regarded satisfactory

Kyphosis
The term kyphosis is used to describe both the normal gentle rounding of the dorsal spine and the abnormal excessive dorsal curvature deformity.

Types of kyphosis
Postural kyphosis
It is common (round back or drooping shoulders) and may be associated with other postural defects such as flatfeet

Structural kyphosis
Is fixed and associated with changes in the shape of the vertebrae. It may occur in osteoporosis of the spine ankylosing spondylitis scheuermanns disease (adolescent kyphosis)

Kyphos (or Gibbus)

Is a Sharp posterior angulation due to localized collapse or wedging of one or more vertebrae. This may be a result from: congenital defect fracture spinal tuberculosis

Kyphos (or Gibbus)

Scheuermanns disease (adolescent kyphosis)

This is a developmental disorder of the growing spine in which there is irregular ossification and possibly some fragmentation of the vertebral body epiphyses The result is irregularity of mature vertebral endplates and could be associated with small central herniations of disc material into the vertebral body (schmorls nodules) Later on when muscle activity increases kyphosis is exaggerated

Scheuermanns disease (adolescent kyphosis)

2 types: Thoracic scheuermanns disease Thoracolumbar scheuermanns disease Thoracic scheuermanns disease: More common than the other Usually appear in mid-thoracic vertebrae M>F Teenager, round shouldered, backache, fatigue, kyphosis which do not improve with change in posture Treatment: conservative (brace for 18m) or operative

 Lateral radiograph of thoracic spine shows endplate irregularity and vertebral wedging characteristic of Scheuermann's disease

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