SCOLIOSIS

• A general spinal deformity characterized by

lateral curvatures and vertebral rotation.
• It may be associated with a fixed structural
curve or reducible functional curve.
• Correlation with discomfort is unclear, but low
back pain is usually the initial symptom.
• It is related to curve severity and usually
begins at the convexity.
 PATHOLOGY
The Scoliosis Research Society
(SRS) has defined a medically significant frontal plane curve
(scoliosis) as any curve which is greater or equal to 10 degrees,
with or without a rotatory component (3). The definition of
a pathological sagittal plane curve is less settled. The spine is
“balanced” in the sagittal plane along a plumb line dropped
from the center of C7 to the sacral promontory (4). This balance
can be influenced by the position of the head and neck,
as well as the pelvis and lower limbs. This dynamic balance
may help explain some of the outstanding controversy about
pathological sagittal curves.
normal range of thoracic kyphosis to be 20 to 40 degrees,
others
(1) give the range as 30 to 50 degrees. Fon et al. (6) have
shown that kyphosis increases about 4 to 5 degrees over
childhood
to the end of adolescence. Kyphosis is also known to
increase with aging. The SRS has agreed that normal thoracic
kyphosis ranges from 20 to 50 degrees. The range of normal
for lumbar lordosis is even wider. Jackson and McManus (7)
found the mean lordosis to be 59 degrees. Vaz et al. (8) found
a mean lumbar lordosis of 46.5 degrees, with a range from 26
to 76 degrees. The SRS has agreed (4) that normal lumbar
lordosis can range from 31 to 79 degrees, depending on
measurement
technique
 Clinical features
• Right thoracic curve Most common; the apex can
typically be seen at T7 or T8.
• Double major curve Right thoracic with a left
lumbar curve; little cosmetic deformity.
• Lumbar curve Left lumbar curves are greater than
right lumbar curves.
• Thoracolumbar curve Less cosmetic deformity
than thoracic curve, may have rib and flank
distortion.
• Left thoracic curve Rare; may be associated with
spinal cord abnormalities.
 IMAGING
• X-rays help establish diagnosis and prognosis.
–– Follow-up x-rays will depend on skeletal maturity, patient age, and degree
of
curvature.
–– Younger patients with rapidly progressing curves warrant earlier x-ray
follow-up.
• Rotation (Figure 4–176)
–– Pedicle portion estimates the amount of vertebral rotation on the PA view.
–– Grading: 0 (no rotation) to 4 (complete pedicle rotation out of view).
• Curve: Cobb angle (Figure 4–177)
–– An angle formed by the perpendicular lines drawn from the endplates of
the most tilted
proximal and distal vertebrae to measure the scoliotic curve.
 ETIOLOGY
Idiopathic Most common
• Infantile Birth to 3 years: associated with congenital defects
• Juvenile 4 years to 10 years; high risk of curve progression
• Adolescent Most common; 10 years to maturity; high risk
of progression
Congenital May be due to an early embryologic
developmental defect
• Open Caused by myelomeningocele
• Closed May be associated with neurologic deficits
Associated with a wedged vertebra, hemivertebra,
congenital bar, or block vertebrae
Neuromuscular
Certain neuromuscular disorders may have a rapid curve
progression with associated pulmonary and spinal cord
complications
TABLE 34.1 Types of Scoliosis and Typical Ages
of OnsetPathophysiological Typeof Scoliosis Typical
Age of Onset
• Idiopathic Infancy to adolescence
• Neuromuscular Childhood to adolescence
• Bone or ligamentous dysfunction Childhood
• Traumatic/posttraumatic All ages
• Infectious or neoplastic All ages
• Degenerative Middle age to seniors
 Treatment
Degree of angulation
• Observation <20°
• Bracing 20° to 40°
• Surgery >40° (>35° for neuromuscular diseases)
Conservative
• –– Rehabilitation program
• –– Bracing
■■ Prevents worsening of the curvature but does not correct scoliosis.
■■ Worn 23 hours a day until spinal growth is completed.
■■ Weaning off can begin when radiographs display signs of maturity, and curves are
stable.
■■ Patients should be evaluated at 2- to 3-year intervals
Tipe :
Milwaukee brace High thoracic curves (apex at T8)
Low profile TLSO Lower thoracic, thoracolumbar, and lumbar curves (apex below T8)
• Surgical
–– Spinal procedures are indicated for scoliosis
with:
■■ Relentless progression.
■■ >40° curvature in the skeletally immature,
>50° in the skeletally mature, <35° in
Neuromuscular diseases, or progressive loss of
pulmonary function.
 ANAMNESA
The first clue to the etiology of the deformity will be
the age of onset. If the scoliosis presents at or soon
after birth, it is more likely to be associated with a
congenital bony deformity or inherited disease
involving the neuromuscular system. If the scoliosis
begins in late childhood or adolescence, it is likely
to be idiopathic. Spinal deformity that begins in
young adulthood is most likely due to trauma or
infection; in middle age or later, it is likely to be
associated with degenerative disk or joint disease
and/or osteoporosis.
It is also important to determine if the onset of the curve
is associated with any acute problem such as trauma or infection.
The degree of curvature and how fast the size of the curve
increases also offer insights into etiology. An underlying
neuromuscular or ligamentous condition may promote quicker
progression. Children within their adolescent growth spurt
may have greater progression due to the rate of overall growth.
Progression in an older adult may be an indicator of poor bone
health.
Although pain is associated with spinal deformity in adults, it
is uncommon in children
and adolescents (13) and obligates the physiatrist to search
for underlying pathologies including neoplasm or infection.
Similar to other pain-evoking conditions, details about the
quality, intensity, and temporal and spatial parameters of the
pain will help distinguish among bony, soft-tissue–based, and
neuromuscular-based pain. Cardiopulmonary dysfunction
is the most serious morbidity of spinal deformity. Therefore,
questions about fatigability, shortness of breath, palpitations,
and decrease in endurance must be included in the history.
Any suggestion of cardiopulmonary dysfunction should lead
to a more rapid and aggressive workup.
It is important to inquire about the symptoms of central
nervous system dysfunction. Problems with loss of balance or
falls may indicate a coordination problem such as is seen in
cerebellar syndromes. Complaints of muscle spasms may indicate
spasticity. Conversely, complaints of weakness or sensory
loss may indicate peripheral nervous and/or muscle pathology.
Reports of frequent joint sprains may indicate the presence of
a condition associated with ligamentous laxity. In children and
adolescents, it is important to obtain a history of developmental
milestones. Indication of delay in any of the developmental
spheres—social/behavioral, communication and cognition,
fine motor, gross motor—may provide clues to the presence
of an underlying syndrome.
Since spinal deformity may be initiated or
exacerbated by conditions affecting other areas
of the body, the physiatrist should ask about
conditions that may affect the lower limbs, such
as a history of hip dislocation or leg length
discrepancy, and even conditions associated
with asymmetry of the upper limbs and head.
 Physchiatric clinical examination
• assessment of pain, strength, endurance, sensation,
balance (in sitting and standing), coordination, range of
motion,reflexes,mobility, and dressing skills. Leg length
discrepancy should be assessed,
• The surface anatomy should be viewed in both prone
and side lying. If the patient can sit, then the spine
must be seen in sitting. If he or she can stand, even
with support, then the spine must be viewed in
standing. If there is concern about leg length
discrepancy and/or pelvic asymmetry, the spine should
also be viewed in standing with leveling blocks under
the foot on the “short” side and the depth
• the examiner should look at the shapeof the
rib cage for prominence or humping (Adam’s
forward bending test

negative positif