Idiophatic Scoliosis in

Adolescents
By:
Dea Karima Purbohadi
Case
A 12-year-old girl presents with her parents after a positive school screening
for scoliosis. Physical Examination reveals shoulder and torso asymmetry
with trunk imbalance (shift from the midline). Neurologic and skin
examinations are normal. How Should the patient be evaluated and treated?
The Clinical Problem
What is Scoliosis?

The most common deformity of spine

Define as a lateral curvature of the spine that is 10 degrees or

greater on a radiographic image while the patient in standing
position
 Prevalence of Idiopathic
Scoliosis
Curves 10 or less, 3-5
out of 1,000 people

Curves less than 20 is

equal in males and
females

Overall, 2% of females
and 0.5% of males are
affected by scoliosis
 Types of Scoliosis
Idiopathic (80%)
-Infantile 2mo-3yr
- Juvenile 3yr-10yr
- Adolescent >10yr

Congenital

Neuromuscular
Classification of idiophatic scoliosis

Based on the age:

Infantile (in children from birth up to 3 years of age)

juvenile (in children 3 to 10 years of age)

Adolescent (in children older than 10 years of age),or adult.

 Classification of idiophatic scoliosis
1. Ponseti Classification

The initial attempt in classification of idiopathic scoliosis was made

by Ponseti and Friedman3 in 1950, and divided cases into single-
curve, double-curve, and triple-curve patterns.

2. King's Classification
It is useful for communication and helps in prognosticating the
disease. It also provides some guidance about treatment strategy.
 Classification of idiophatic scoliosis
3. Lenke's Classification

It is composed of three components: curve type (Type 1 to 6), a

lumbar spine modifier (A, B or C) and a sagittal thoracic modifier (,
N or +). The six curve types have specific characteristics on coronal
and sagittal radiographs that differentiate structural and non-
structural curves in the proximal thoracic, main thoracic, thoraco-
lumbar and lumbar regions.
 Symptoms of Scoliosis
One shoulder may
The body may tilt to appear higher
one side
One side of
the rib cage
may appear
higher

Waist may appear One leg may appear

uneven or hips shorter than the
elevated other
Key Clinical Points
The diagnosis of scoliosis is suspected on the basis of physical examination and is confirmed by
radiography, performed while the patient is in a standing position, that reveals spinal curvature of
10 degrees or greater.

Idiopathic scoliosis is present in 2% of adolescents.

Most adolescents with nonprogressive idiopathic scoliosis can be seen by a primary care
physician and do not require active treatment

Surgical treatment is recommended in patients with an immature skeleton who have progressive
scoliosis greater than 45 degrees.
Evaluation
The physical examination is fundamental in the diagnosis of
scoliosis and elimination of underlying conditions that may
cause spinal deformity.

Classic findings of scoliosis on examination are shoulder

and scapular asymmetry, rib prominence on forward flexion
on the Adams test. and asymmetry of the waist and trunk.
Axial rotation of the trunk on the Adams test can be
quantified with an inclinometer;
Adams 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.
Evaluation
Spinal radiography remains the standard of imaging for the evaluation
of scoliosis. More than 90% of patients with idiopathic scoliosis will
have a convex curvature that is right thoracic or left lumbar scoliosis.

Magnetic resonance imaging (MRI) is useful in the evaluation of an

abnormality of the neural axis, but it is not routinely required.

Indications for MRI in patients with idiopathic scoliosis are onset before
10 years of age, kyphotic apex of the scoliosis, clinically significant
pain, a neurologic abnormality, neurofibromatosis, or midline
cutaneous anomalies (which are known to occur with neural-tube
defects).
 Referral Guidelines & Treatment

Curve (degrees) Risser grade X-ray/refer Treatment

10 to 19 0 to 1 Every 6 months/no Observe

10 to 19 2 to 4 Every 6 months/no Observe

20 to 29 0 to 1 Every 6 months/yes Brace after 25 degrees

20 to 29 2 to 4 Every 6 months/yes Observe or brace *

29 to 40 0 to 1 Refer Brace
29 to 40 2 to 4 Refer Brace

>40 0 to 4 Refer Surgery

Evaluation
Assessment of skeletal maturity is critical in predicting the
risk of progression of scoliosis. The growth velocity, as
assessed by means of serial height measurements,
correlates with the likelihood of progression of scoliosis.

In girls, peak growth velocity occurs in the year before

menarche. If serial height data are not available, skeletal
maturity is assessed by means of radiography to estimate
bone age.
 Skeletal age is more important
than Chronological age:
May vary months or yearsvery
Most Accurate important for prognosis

A left view of the wrist is obtained to determine skeletal age.

(Left wrist view comparison with standard atlas of Greulich and Pyle)
Algorithm for the diagnosis and management
 AIS
Treatment
Observatio
n

Bracing

Surgery
 Observation

Consider patients age

(girls grow rapidly until age 14, boys until age 16)

Consider status of females 1st menstrual period

(growth slows down)

Consider x-ray of the spine and pelvis

(shows skeletal maturity on a scale of 0 to 5)
Observation
 Bracing

Used with curves between 25 and 40

during the growth phase

Designed to each patients shape

Prevents curve progression

Worn under clothes

Worn all day or just at night

Worn until growth of the spine has stopped

 Surgery Treatment
with Spinal Fusion
Harrington Method Contrel-Dubousset
Instrument
Fusion with one rod hooked Fusion with a combination of
to the spine two rods, screws, hooks, and
wires
Obsolete flatback
Modern
Increase wear and tear
Low rate of failure
Early onset of arthritis 5-7 Day hospital stay
Degeneration of discs 3-4 Weeks out of school
Muscle stiffness 6 Month recovery time
Reliance of painkillers For more information go to
Further surgery required Scoliosis Research Society
Disability (SRS)
Thank you!