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Spinal Disorders- LeFebvre > B3. Scoliosis > Flashcards

B3. Scoliosis Flashcards

1
Q

What is scoliosis?

A

Spinal deviations caused by buckling/distortions into all planes. Deviations may be:

  • lordosis
  • rotation/torsion
  • lateral
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2
Q

What is the most common scoliosis curve and what is the second most common?

A

Thoracic is most common followed by lumbar

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3
Q

What is the etiology of scoliosis?

A

Unknown although there are theories that have a common thread: sensory info is aberrant or misinterpreted at spinal cord level or in cortical centers which leads to inappropriate proprioceptive output.

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4
Q

What is the difference between functional and structural/anatomical scoliosis?

A

Functional scoliosis is compensatory, postural or transient while structural/anatomical scoliosis not

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5
Q

What are some causes of compensatory functional scoliosis?

A
  • LLI
  • pelvic subluxation with unleveling
  • anatomical asymmetry or anomaly
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6
Q

If scoliosis curve improves with sitting, what does this tell you?

A

There is a functional scoliosis that is likely due to LLI instead of pelvic unleveling

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7
Q

What are some postural causes of functional scoliosis?

A
  • muscular imbalance

- handedness

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8
Q

What are some transient cause of functional scoliosis?

A
  • antalgic
  • inflammatory
  • traumatic
  • psychogenic
  • radiculopathy
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9
Q

What is the cause of structural scoliosis?

A
  • 80 % are idiopathic
  • congenital
  • Scheuermann’s
  • mesenchymal disorder
  • neurofibromatosis
  • neuromuscular disorder (neuro or myopathic)
  • metabolic disorder (RIckets, osteogenesis imperfecta)
  • vertebral neoplasm (osteoid osteoma)
  • acquired/traumatic
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10
Q

Who gets scoliosis?

A
  • girls 10-12

- boys 11-16

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11
Q

Is pain a common complaint with structural scoliosis?

A

No, only about 25% have pain and it is usually mild.

Severe pain requires a search for disease process

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12
Q

What are some disease processes that could cause structural scoliosis?

A
  • spinal infection
  • spinal tumor (osteoid osteoma)
  • chiari type 1 with syrinx
  • tethered spinal cord
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13
Q

What 5 strategies would be used on exam for evaluating scoliosis?

A
  • observe for associated findings (club foot, cafe au lait spots, etc)
  • perform postural assessment
  • Adam’s test
  • leg length check
  • neurological screen
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14
Q

Weakness or spasticity, abnormal sensation and/or abnormal reflexes on neuro exam of patient with scoliosis may indicate:

A

Tethered cord syndrome or syringomyelia

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15
Q

What is a positive Adam’s test?

A

Patient stands and then bends over. A fixed rotational prominence on the convex side of a scoliosis curve (razorback spine) would be a positive Adam’s test. This should be repeated sitting and prone. If the prominence improves with sitting or prone, the scoliosis is functional

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16
Q

With a positive Adam’s test, a scoliometer is then used to measure the prominence. What scoliometer reading would suggest scoliosis?

A

> /= 7 degrees

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17
Q

What should be done if the scoliometer reading is >/= 7 degrees?

A

Order radiograph

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18
Q

What should be done if the scoliometer reading is < 7 degrees?

A

Follow up in 6-12 months

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19
Q

What kind of radiographs should be obtained when screening for scoliosis?

A

Full spine and recumbent and lateral bend into convexity

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20
Q

What are you looking for on radiographs when screening for scoliosis?

A
  • congenital findings such as hemivertebrae
  • location of curve
  • pelvic unleveling
  • Cobb angel
  • bone age with Risser sign
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21
Q

Direction of a scoliosis curve is defined based on:

A

the direction of the convexity

I.e. left curve has apex on left

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22
Q

What curve is more common, right or left?

A

> 90% are convexity right

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23
Q

How do you measure a Cobb angle?

A
  • determine primary/major curve
  • draw line across top of superior vertebral segment in primary curve
  • draw line across bottom of inferior vertebral segment in primary curve
  • draw perpendicular and intersections lines from each of the vertebral lines
  • the angle the perpendicular line intersect to form is the Cobb angle
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24
Q

What is the minimum angulation of a Cobb angel to define scoliosis?

A

10 degrees

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25
Q

Why does the time of day radiographs are taken matter when evaluating for scoliosis?

A

IVD swelling in the AM vs PM can cause an average difference of 5 degrees (sometimes 10-20 degrees)

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26
Q

What Risser numbers are considered immature?

A

1-2

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27
Q

What Risser numbers are considered mature?

A

3-5

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28
Q

What is a Risser number?

A

A number indicating the percent ossification of iliac epiphysis and therefore skeletal maturity. Smaller Risser number = more epiphyseal plate present and therefore more skeletal immaturity

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29
Q

What are some risk factors from history for scoliosis curve progression?

A
  • female with early onset (50% risk of progression if onset is before menarche while <20% risk of progression is onset is after menarche)
  • family history
  • maternal age >30
30
Q

What are some radiographic risk factors for scoliosis curve progression?

A
  • greater curve at detection
  • skeletal immaturity (Risser<2)
  • right thoracic major curve
  • double major curve
  • marked rotation (>30%)
  • L5 high in pelvis/interiliac crest line above 4th lumbar disc space
  • associated thoracic hyperkyphosis
31
Q

Patient presents with scoliosis and pain that is worse at night and relieved by NSAIDs. What is you primary diagnosis?

A

Osteoid osteoma

32
Q

What are some examples of myopathic neuromuscular diseases that could cause structural scoliosis?

A

Muscular dystrophy

Amyotonia congenita

33
Q

What are some examples of neuropathic causes of structural scoliosis?

A
  • LMNL (polio)
  • UMNL (tumor, cerebral palsy)
  • syringomyelia
  • cord trauma
34
Q

What is the primary indication that the cause of structural scoliosis may be neuropathic?

A

Left thoracic primary curve

These are less common and always considered pathologic

35
Q

What is another name for neurofibromatosis?

A

Von Recklinghausen’s disease

36
Q

What are some examples of mesenchymal disorders that could cause structural scoliosis?

A
  • Marfan’s syndrome
  • Ehlers-Danlos
  • dwarfism
  • RA
37
Q

Congenital structural scoliosis can have other associated symptoms. What are they?

A
  • GU abnormality (20%)

- heart defects (15%)

38
Q

What are indications for MRI in scoliosis?

A
  • severe or progressive curve
  • left thoracic curve
  • young patient (under 11)
  • no family history
  • neuro abnormalities
  • concerning radiographic findings
  • painful scoliosis, unresponsive to treatment
39
Q

Idiopathic structural scoliosis can further be categorized by age of onset. What are these classifications?

A
  • infantile (<3 years)
  • juvenile (3-10 years)
  • adolescent (10 to skeletal maturity)
40
Q

In idiopathic scoliosis, what direction do the spinous processes rotate into?

A

Into the concavity because the vertebral bodies rotate into the convexity

41
Q

What is AIS?

A

Adolescent Idiopathic scoliosis, the most common type of scoliosis

42
Q

Who gets AIS?

A
  • 2% of the population
  • those with genetic predisposition
  • female>male 6:1
43
Q

What is the recommended screening for scoliosis?

A
  • twice for girls ages 10-12

- once for boys ages 13-14

44
Q

What is the overall treatment goal for chiropractic management of scoliosis?

A

Keep scoliosis < 50 degrees by skeletal maturity

45
Q

What are the 4 considerations when making treatment decisions for scoliosis?

A
  • Cobb’s angle
  • Risers’ measure
  • severity of symptoms (neuro)
  • speed of progression
46
Q

What are the 4 scoliosis treatment objectives?

A
  • improve strength and flexibility based on curves
  • improve motor control
  • normalize mechanics
  • assign respiratory exercises
47
Q

One treatment goal for scoliosis is to improve strength and flexibility based on curves. Which side should be strengthened and which side should be stretched?

A

Strengthen convex side and stretch concave side

48
Q

What are some strategies to improve motor control in the treatment of scoliosis?

A
  • balance, coordination, proprioceptive work on balance board
  • oculo-vestibular therapy to improve integration
49
Q

What are some strategies to normalize mechanics in the treatment of scoliosis?

A
  • improve segmental joint dysfunction
  • normalize weight bearing
  • correct forward head carriage
  • treat upper cross syndrome
50
Q

Why is it important to incorporate respiratory exercises in the treatment of scoliosis?

A

Because 60% of curves >60 degrees have decreased vital capacity. Tailored exercises can increase chest expansion and therefore vital capacity

51
Q

What should the follow up be for abnormal spinal curves that are under 10 degrees?

A

Every 6 months until skeletal maturity

52
Q

What should the follow up be for abnormal spinal curves that are 11-20 degrees?

A

Every 3-6 months with neuro/orthopedic evaluation and radiographs each visit

53
Q

What classifies as a significant progression in scoliosis?

A

5-6 degrees on 3-6 month follow up.

NOTE: would require referral for brace therapy if significant progression is noted on consecutive exams.

54
Q

What should the follow up be for abnormal spinal curves that are 21-30 degrees?

A

Every 3-6 months with neuro/orthopedic evaluation and radiographs each time.
Refer fro brace at 25-30 degree and Risser grade 2 or less or if there is rapid progression

55
Q

What should the follow up be for abnormal spinal curves that are 31-40 degrees?

A

Every 3-6 months with neuro/orthopedic evaluation and radiographs each time.

Will refer for bracing and co-treatment with orthopedist

56
Q

What should the follow up be for abnormal spinal curves that are 41-50 degrees?

A

Every 3-6 months with neuro/orthopedic evaluation and radiographs.

Will need to refer for bracing and co-treatment with orthopedist.

Possibly surgical

57
Q

When should a AIS case be referred for surgical consult?

A

Cobb angle > 45° with Risser = 2 or Cobb > 50

even if mature (Risser >/= 3)

58
Q

What role does chiropractic treatment play in an AIS case with a curve > 50 degrees?

A

Because surgery is often indicated in this scenario, chiropractic can facilitate the success of the surgery and/or relieve symptoms and improve function of patient who elects to not have surgery. Respiratory breathing may be difficult and training can be done for this

59
Q

What are some possible chiropractic treatments that would be offered to AIS patients?

A
  • flexion-distraction with spine in corrected position
  • manipulation
  • proprioception rehab
  • Stretching
  • lift therapy
  • exercise therapy
  • electrospinal muscle stimulation
60
Q

On what side of a scoliosis curve should muscles be strengthened?

A

Convex

61
Q

On what side of a scoliosis curve should muscles be stretched?

A

Concave

62
Q

How often should heel lift therapy for scoliosis be re-evaluated?

A

Every 6 weeks

63
Q

Which muscles would you treat for a pelvis unleveling in a scoliosis case that is due to an elevated ilium?

A

Strengthen: contralateral QL and adductors, ipsilateral gluteus medius

Stretch: ipsilateral QL and adductors, contralateral gluteus medius

64
Q

What is the goal of electrospinal muscle stimulation for scoliosis?

A

upper motor neuron and proprioception re-education to establish balance of function between concave muscles and convex muscles

65
Q

What kind of fibers are largely in the concave muscles of a scoliosis curve?

A

A fibers

66
Q

What kind of fibers are largely in the convex muscles of a scoliosis curve?

A

B fibers (“slow twitch”)

67
Q

Bracing for 23 hours/day as treatment for idiopathic scoliosis had what success rate in one study?

A

93%

68
Q

What is the Boston brace?

A

Most common brace used. Low profile and no chin support and therefore has better patient acceptance. It is worn 16-22 hours/day

69
Q

What is the Milwaukee brace?

A

2nd most common brace. Has pelvic attachments, chin support and adjustable height. Worn 23 hours/day

70
Q

What is the goal of bracing in scoliosis?

A

Stop the progression of scoliosis. Does not address improve cosmetics

71
Q

What is the surgical treatment for scoliosis?

A

Harrington rods with spinal fusion

72
Q

Approximately what percentage of post-surgical AIS patients return to normal physical and athletic activities within 3 months?

A

1/3

Spinal Disorders- LeFebvre (25 decks)

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