Scoliosis

Question 1

What is Scoliosis?

Answer 1

A complicated deformity, characterised by both lateral curvature and vertebral rotation.
As the disease progresses:
- the vertebrae and spinous processes of the major curve rotate toward the concavity of the curve
- ribs follow the rotation of the vertebrae
Concave side of the curve:
- ribs close together
- the anterior ribs pushed anteriorly.
Convex side:
- ribs widely separated
- the posterior ribs pushed posteriorly, causing the characteristic rib hump seen in thoracic scoliosis.

A significant lateral deviation (more than 10° ) of the spine with vertebral rotation within the curve
Remember: True scoliosis is not only a deformity in the coronal plane, but it is also a rotational deformity.

Scoliosis curves most common in thoracic spine
Diagnosed in childhood or early adolescence with the primary age of onset being 10-15 years old
A Cobb angle of <10°:
- asymptomatic
- does not progress
Treatment:
- smaller curves do not require treatment
- larger curves require a brace or surgery to restore normal posture

Question 2

What is Dextroscoliosis?

Answer 2

Curve convex to right

Question 3

What is Levoscoliosis?

Answer 3

Curve convex to left

Question 4

What is Kyphoscoliosis?

Answer 4

Scoliosiswith component of kyphosis

Question 5

What is S-Curve Scoliosis?

Answer 5

3 adjacent curves (1 to right, 1 to left and 1 at lumbosacral junction)

Question 6

What is Primary curve (Aka major curve or structural curve) ?

Answer 6

The most pronounced curve where the main structural abnormality is present

Question 7

What is Secondary curve (Aka minor curve or non-structural curve)?

Answer 7

Less pronounced compensatory curves that develop above and/or below the primary curve to maintain balance

Question 8

What is the Apex?

Answer 8

The vertebral body or disc space demonstrating the greatest rotation and/or furthest deviation from the expected centre of the vertebral column. The endplates of the apical vertebra are often horizontal or near horizontal.

Question 9

What is the end vertebrae?

Answer 9

The vertebrae most tilted towards each other and present on either side of the apex. They form the basis of the Cobb angle.

Question 10

What is neutral vertebrae?

Answer 10

Present on either side of the apex with no rotation (axial plane). In some cases, they are like end vertebrae but never closer to the apex than the end vertebrae.

Question 11

What is stable vertebra?

Answer 11

The first vertebra below the lowest curve, roughly bisected by the central sacral vertical line

Question 12

What type of curve is a primary curve?

Answer 12

first to develop
At the time of diagnosis, it is not always possible to differentiate primary curves from secondary curves.
structural
largest curve
not correctable with ipsilateral bending
vertebral morphologic changes (E.G wedging)
May progress
Usually > 25 degrees

Question 13

What type of curve is a secondary curve?

Answer 13

develop to balance the head and trunk over the pelvis, in the frontal and the sagittal plane.
At the time of diagnosis, it is not always possible to differentiate primary curves from secondary curves.
compensatory curve
smaller curve
non structural
correctable with ipsilateral bending
doesn’t usually progress
usually <25 degrees

Question 14

What type of curve is a structural curve?

Answer 14

Do Not correct with side-be

Question 15

What type of curve is a non-structural curve?

Answer 15

can be secondary curves - postural, secondary to short leg or muscle spasm.

Question 16

What is cobb angle?

Answer 16

measured between the superior endplate of the proximal end vertebra and the inferior endplate of the distal end vertebra
most consistent despite inter-examiner variability
Two lines are drawn on a PA spinal radiograph
one extending from the top of the most tilted upper vertebra and the other from the bottom of the most tilted lower vertebra.
The angle formed by these lines is the Cobb angle.

Question 17

What is risser-ferguson method?

Answer 17

First line originating at the centre of the upper end-vertebra
Second line from the centre of the lower end-vertebra
Angle formed by the intersection of two lines at the centre of the apical vertebra gives the DEGREE OF CURVATURE

Question 18

tell me about cobbs vs risser-ferguson

Answer 18

Risser’s method - only used on congenital curves
Cobb’s method - preferred method
Cobb’s is more consistent inter- and intra-examiner reliability of measurement.
Cobb’s gives higher measurement (5-10° or 25%)
Regardless of which method is used it is essential that the same vertebral levels are used on subsequent examinations for follow-up
Radiograph must be produced with patient in same position as initial study

(So need standardized positioning protocol)

Question 19

What is pedicle rotation?

Answer 19

After measuring the angle of curvature, estimate the degree of rotation of the vertebra at the apex of the curve by looking at the relation of the pedicles to midline.

GRADE 0: No pedicle rotation.
GRADE 1: Pedicle visible between the lat. edge of the VB & midline.
GRADE 2: Pedicle of the convexity visible just lateral to the center line.
GRADE 3: Pedicle of the convexity overlaps the center line.
GRADE 4: Pedicle is rotated past center line.

Question 20

What is the Skeletal Maturity: Iliac Apophysis (Risser’s sign)?

Answer 20

Determine the physiological or skeletal maturity of the patient to treat patients effectively as Skeletal maturity and chronological age do not necessarily match.
The iliac crests provide a convenient index of skeletal maturity.
Appears 16 M, 14 F
Grows progressively toward PSS - Lat-med
Grades 1-4 within 1yr (capping)
Grade 5 or fusion takes 2-3yrs after capping
When the iliac crest apophyses meet the sacroiliac junction and firmly seal to the ilium, maturation is nearly complete.
once skeletal maturity has been reached, curvature below 30 degrees do not progress

Question 21

What is the skeletal maturity - Left Hand & Wrist – Greulisch &Pyle ?

Answer 21

A single AP view of the left hand and wrist to estimate skeletal maturity
Patients under 20 yoa
Important in planning treatment regime

Question 22

What is the vertebral maturity: Vertebral Ring Apophysis?

Answer 22

Look for evidence of maturation in the VBs at the endplates.
When the plates blend in with the VB to form a solid union, maturation is complete.

Question 23

What are the different types of scoliosis?

Answer 23

Structural (Non-functional):
- Idiopathic
- Congenital
- Degenerative
- Neuromuscular
- Post-traumatic
2. Non-structural (Functional)
- postural scoliosis
- compensatory scoliosis
- due to muscle spasm (secondary to lumbar or thoracic injuries) or leg length discrepancy(causing a lateral shift in the spine)
3. Transient structural scoliosis
- sciatic scoliosis
- hysterical scoliosis
- inflammatory scoliosis

Question 24

tell me about Structural Scoliosis : Idiopathic Scoliosis

Answer 24

Unknown cause
most common type of scoliosis
usually diagnosed during puberty
Equal prevalence in boys and girls though curves greater than 30° that require treatment is more prevalent in girls than boys (ratio 1:8)
Does not require surgical intervention
Further divided into:
infantile idiopathic scoliosis – 0 – 3 years of age
juvenile idiopathic scoliosis – 4 – 10 years of age
Adolescent idiopathic scoliosis – >10 years of age

Question 25

Tell me more about infantile idiopathic scoliosis?

Answer 25

Presents as a left thoracic curve in 90% of cases The male/female ratio is 3:2

Question 26

Tell me more about juvenile idiopathic scoliosis?

Answer 26

The male/female ratio is 1:2 to 1:4 Boys are more affected between 3 and 6 years of age (1:1) Girls are more affected between 6 and 10 years of age (1:8) The number of right and left curves is equal in the younger group (<6 years at presentation) Right curves predominate in the older group (80%).

Question 27

What is adolescent idiopathic scoliosis?

Answer 27

A structural lateral curvature of the spine between 10 and 18 yoa - m/c a thoracic curve with right-sided convexity, with or without a compensatory lumbar curve with left-sided convexity. The diagnosis is confirmed when a 10° lateral curvature is present on a frontal upright radiograph.  MR imaging - for the evaluation of an unusual pattern of curvature, associated with neuropathy or a curve with an early onset, unusually rapid progression, and neurologic deterioration at follow-up Curvatures <50° - same incidence of back pain and mortality as in the general population  Curvatures >50° - greater prevalence of back pain. Thoracic curvatures >100° - affect lung function and increased mortality rate compared with the general population Treatment - varied and includes observation, bracing, and surgery.  - Bracing - limited effectiveness - for curves between 25° and 40° (skeletally immature patients) - successfully prevent curve progression in 75% population

Question 28

tell me about congenital scoliosis

Answer 28

Most frequent congenital spinal deformity present at birth which can first be identified on foetal ultrasound Further divided into: Incomplete or failure of formation of vertebrae (Hemivertebra) Failure of separation/segmentation of vertebrae (Block vertebra) Combination of both above/Mixed congenital syndromes (Klippel-Feil, caudal regression etc) Treatment based on: - patient age - progression of curve - location & type of anomaly

Question 29

what is incomplete formation of vertebrae?

Answer 29

Hemivertebra – where part of one (or more) vertebra may not form completely at birth - produces a sharp angle in the spine

Question 30

What is a failure of separation of vertebrae?

Answer 30

Where the spine fails to separates into vertebral segments resulting in partial fusion (joining two or more vertebrae together)

Question 31

What is Combination of Bars and Hemivertebrae?

Answer 31

Combination of 1 and 2 above occurring together causing growth problems and requiring surgery at an early age to stop the increased curvature of the spine

Question 32

What is Degenerative Scoliosis (AKA Adult Scoliosis)?

Answer 32

Affects adults (>50 years of age) M/c in the lumbar spine but other curve patterns may occur Often associated with hypolordosis and coronal plane decompensation  Asymmetric degenerative change of the discs or facet joints leading to asymmetric biomechanical forces that result in additional asymmetric disc space collapse and eventual lateral listhesis and segmental rotator listhesis between lumbar segments A common cause of back pain and disability - associated with foraminal, lateral root compression or claudication due to central, foraminal, or subarticular spinal stenosis Further divided into: 1. Type 1 - primarily degenerative. - caused most frequently by a disc or facet joint arthritis 2. Type 2 - progression of adolescent scoliosis in adulthood 3. Type 3 - secondary scoliosis mostly caused by osteoporosis Surgical treatment - primarily neural decompression and correction of truncal balance

Question 33

What are the 3 types of Degenerative Scoliosis (AKA Adult Scoliosis)?

Answer 33

Type 1 - primarily degenerative. - caused most frequently by a disc or facet joint arthritis 2. Type 2 - progression of adolescent scoliosis in adulthood 3. Type 3 - secondary scoliosis mostly caused by osteoporosis

Question 34

What is Neuromuscular Scoliosis?

Answer 34

Secondary to neurological or muscular diseases e.g., cerebral palsy, spinal cord trauma, muscular dystrophy, spinal muscular atrophy and spina bifida. Generally, progresses more rapidly than idiopathic scoliosis often requires surgical treatment Spinal curvature without rotation – other diagnoses apart from idiopathic scoliosis must be considered

Question 35

What is post-traumatic scoliosis?

Answer 35

Vertebral Fracture Radiation Surgical Micro-trauma (Spondylolisthesis) Degenerative Extraspinal contractures (post-burns)

Question 36

What is Non-Structural Scoliosis?

Answer 36

Generally non-progressive Milder curves and usually a minor curve Less rotational component No structural alterations Correction on lateral bending Due to: Postural Hysterical Antalgic – Disc herniations / Nerve root irritation Inflammatory - Inflammatory bowel disease, appendicitis LLD (leg-length deficiency) – extraspinal cause Hip contractures

Question 37

When diagnosing scoliosis, what is the patient history components to consider?

Answer 37

Age of onset Evidence of maturation Presence of back pain Neurological symptoms, including abnormalities, weakness or sensory changes Feelings about overall appearance and back shape Family history

Question 38

When diagnosing scoliosis, what is the physical examination components to consider?

Answer 38

Height measurement Gait check Foot shape Neurological examination including motor, sensory and reflex testing (including abdomen) Skin inspection Assessment of pubertal development Symmetry of shoulders and iliac crest Forward bending test

Question 39

What are signs of scoliosis?

Answer 39

Uneven shoulders Head not cantered directly above the pelvis One or both hips raised or unusually high Rib cages at different heights Uneven waist The appearance or texture of the skin overlying the spine changes (dimples, hairy patches, colour abnormalities) The entire body leaning to one side

Question 40

What are the symptoms of scoliosis?

Answer 40

Back pain or stiffness Diminishing pulmonary function (e.g., difficulty breathing) Pain and numbness in legs

Question 41

What are the four basic spinal parameters evaluated in scoliosis?

Answer 41

Curvature rotation flexibility skeletal maturation

Question 42

All radiographic scoliosis imaging should be reported according to the scoliosis reporting template with all the individual components described . What are the Locally agreed standards?

Answer 42

Indicate number of curves Identify each apical vertebra and whether right or left side curved Quantify the Cobb angle for each curve Comment on rotation Comment on shoulder asymmetry Assess skeletal maturity (Risser staging) Comment on presence of vertebral abnormality Save key image with Cobb angle(s) Any recommendations for further imaging

Question 43

How do you take the cobb angle?

Answer 43

Choose the most tilted vertebrae, toward the concavity, above and below the apex of the curve (i.e., the  of the curve) The angle between intersecting lines drawn perpendicular to the superior endplate of the superior-end vertebra to the inferior endplate of the inferior-end vertebra = the Cobb angle. When reporting the angle, REMEMBER to mention that the Cobb method is being used and STATE the end vertebrae used for the measurement. Once chosen, the same levels should be used to measure curvature on follow-up radiographs. NOTE: If endplates are difficult to visualize, the borders of the pedicles may be used.

Question 44

What does a cobb angle of 0-10 degrees indicate?

Answer 44

Spinal curve

Question 45

What does a cobb angle of 10-20 degrees indicate?

Answer 45

Mild scoliosis

Question 46

What does a cobb angle of 20-40 degrees indicate?

Answer 46

Moderate scoliosis

Question 47

What does a cobb angle of >40 degrees indicate?

Answer 47

Severe scoliosis

Question 48

What is the risser-ferguson method?

Answer 48

In this method of scoliotic curvature is determined by the angle formed by the intersection of two lines at the centre of the apical vertebra The first originating at the centre of the upper end vertebra and the other at the centre of the lower end vertebra

Question 49

What is the skeletal maturation?

Answer 49

Iliac apophyses appear first at ASIS Ossification travels medially to the PSIS Boys – 16 yoa; Girls – 14 yoa LIMITATION: far less reliable in boys as ossification starts at a later age than girls. THEREFORE, in boys, growth not considered complete until grade 5 ossification is achieved. The crest is divided into four equal parts: - Grade 1 – 4 = EXCURSION - excursion of the ossified apophysis takes approximately 1 year - Grade 4 = complete excursion of the ossified apophysis of the iliac crest = completion of spinal growth and cessation of curve progression in girls - Grade 5 = FUSION - fusion of the ossification centre to the iliac crest takes another 2 years

Question 50

What is sagittal balance?

Answer 50

Describes the relationship of the head relative to the pelvis in the sagittal plane. Measured on a standing lateral view by dropping a plumb line from the centre of the C7 vertebral body vertically downward and assessing the distance of this line from the posterior aspect of the S1 vertebral body Restoration of sagittal balance improves the success rate of scoliosis surgery RESULTS: 1. Neutral sagittal balance (Healthy patients) - Plumb line intersects the sacral landmark 2. Positive sagittal balance - Plumb line >2 cm anterior to the posterior aspect of the S1 vertebral body - Patients present with back pain (likely to be fatigue pain due to truncal muscles, hips, knees, and thighs under continual strain to keep head in line with the shoulders and hips and over the feet) - “flat-back” deformity due to loss of normal lumbar lordosis and resultant forward-tilting posture (e.g., flexed hips and knees to maintain an erect posture) 3. Negative sagittal balance - Plumb line is 2 cm posterior to the sacral landmark

Question 51

What is coronal balance?

Answer 51

Coronal balance is measured on an upright anteroposterior view. A plumb line is dropped vertically from the centre of the C7 vertebral body. This usually intersects with the central sacral vertical line. Positive and negative coronal balance are present when this plumb is line is greater than 2 cm to the right and left, respectively. The restoration of coronal balance reduces several cosmetic deformities including having one shoulder higher than the other.

Question 52

What are the treatment options for scoliosis?

Answer 52

The treatment options for scoliosis: Conservative: Curve measuring <20°: - Observe / Active monitoring - monitor regularly with imaging to check curve progression - Information class Curve measuring <20° - 40°: - Orthoses e.g., brace - Physiotherapy 2. Surgical: Curve measuring >40°: - Surgery + postoperative rehabilitation.

Question 53

What are the causes of structural scoliosis?

Answer 53

Idiopathic (70%) - infantile, juvenile and adolescent Congenital (10%) - Failure in vertebral formation, failure in vertebral segmentation or combination of the two Trauma Extra spinal contractures Bone infection Lung disease: previous h/o empynema, fibrosis or pneumonectomy Neurofibromatosis Rheumatoid disease

Question 54

What are the causes of non-structural scoliosis?

Answer 54

Postural Nerve root irritation - herniation of nucleus pulposus / tumours related to leg length discrepancy related to contractures of the hip

Question 55

An increase in the Cobb angle by 5° or more per year indicates progression of scoliosis. True or false?

Answer 55

True

Question 56

What is Hueter-Volkmann law?

Answer 56

scoliosis is initiated by vertebral rotation in the axial plane, producing asymmetric forces of compression and traction on the convex and concave sides of spinal curvature.

Question 57

The identification of the curve apex, end vertebrae, neutral vertebrae, and stable vertebrae is important when interpreting the radiographic features of scoliosis. True or false?

Answer 57

True

Question 58

minor curves may begin as non-structural curves and progress to structural curves. True or false

Answer 58

True

Question 59

What is the most common type of scoliosis?

Answer 59

Idiopathic scoliosis

Question 60

What are the progressive forms of scoliosis?

Answer 60

Juvenile (4-10)- idiopathic Congenital

Question 61

What are the non generally progressive forms of scoliosis?

Answer 61

Infantile (0-3) and adolescent (11-18) - idiopathic

Question 62

What is the risser index?

Answer 62

Risser index: - describes skeletal maturity as the extent of excursion of the ossification centre of the iliac crest - grade 0 (no ossification centre) - grade 1 (ossification centre at the outer fourth of the iliac crest)

Question 63

What imaging can be used to detect underlying causes of scoliosis?

Answer 63

Both MR imaging and CT can be recommended for the detection of underlying causes of scoliosis

Question 64

What is structural scoliosis?

Answer 64

Often accompanied by vertebral axial rotation Will not completely correct and does not reduce to less than 25° on bending views.  If the structural curve is straightened, the non-structural curve will correct spontaneously.

Question 65

What is non-structural scoliosis?

Answer 65

Curves maintain truncal balance, e.g., a lumbar levoscoliosis may be present to compensate for the major thoracic dextroscoliosis and keep the head above the pelvis. a lumbar levoscoliosis will straighten when the patient bends to the left. Over time, it may become structural because of shortening of ligaments, muscle atrophy, and osseous changes that occur with the spine in a prolonged position.