Scoliosis

Scoliosis is a three-dimensional deformity of the spine characterized by lateral curvature >10° in the coronal plane, accompanied by vertebral rotation.

Key Points

• Prevalence: 2-3% of adolescents
• Female:Male ratio = 7:1 for curves requiring treatment
• 80% are idiopathic
• Screening typically done during school years
• Growth potential is crucial for progression risk

1. By Age of Onset

• Infantile (0-3 years):
  • Resolving type (spontaneous resolution)
  • Progressive type (requires treatment)
  • Often associated with other conditions
• Juvenile (4-10 years):
  • Higher risk of progression
  • Requires close monitoring
• Adolescent (>10 years):
  • Most common type (80%)
  • Progressive during growth spurts
• Adult (after skeletal maturity):
  • De novo scoliosis
  • Progression of adolescent curves

2. By Etiology

• Idiopathic (80%):
  • No identifiable cause
  • Genetic predisposition likely
• Congenital:
  • Formation defects (hemivertebrae)
  • Segmentation defects (bars)
  • Mixed defects
• Neuromuscular:
  • Upper motor neuron:
    • Cerebral palsy
    • Syringomyelia
    • Spinal cord injury
  • Lower motor neuron:
    • Poliomyelitis
    • Spinal muscular atrophy
  • Myopathic:
    • Duchenne muscular dystrophy
    • Arthrogryposis
• Syndromic:
  • Marfan syndrome
  • Ehlers-Danlos syndrome
  • Neurofibromatosis

3. By Curve Pattern

• Single curves:
  • Thoracic (most common)
  • Thoracolumbar
  • Lumbar
• Double curves:
  • Double thoracic
  • Thoracic and lumbar
• Triple curves

Signs and Symptoms

• Physical findings:
  • Shoulder asymmetry
  • Scapular prominence
  • Trunk shift
  • Rib hump (on forward bend)
  • Waistline asymmetry
  • Leg length discrepancy
• Symptoms:
  • Usually asymptomatic in adolescents
  • Back pain (more common in adults)
  • Respiratory symptoms (severe curves)
  • Psychological impact

Physical Examination

• Adams forward bend test
• Scoliometer measurement
• Neurological examination
• Skin examination (café-au-lait spots)
• Assessment of flexibility
• Evaluation of skeletal maturity

Imaging Studies

• Radiographs:
  • Standing PA and lateral spine
  • Side-bending films
  • Cobb angle measurement
  • Nash-Moe rotation grading
  • Risser sign assessment
• Advanced imaging:
  • MRI indications:
    • Early onset scoliosis
    • Rapid progression
    • Atypical curves
    • Neurological findings
  • CT scan:
    • Congenital anomalies
    • Surgical planning

Treatment Options

• Observation:
  • Curves <20°
  • Regular follow-up
• Bracing:
  • Indications:
    • Curves 25-45°
    • Skeletal immaturity
    • Progressive curves
  • Types:
    • TLSO (Boston brace)
    • Charleston bending brace
    • Milwaukee brace
    • Providence brace
• Surgical Treatment:
  • Indications:
    • Curves >45-50°
    • Progressive curves
    • Failed conservative treatment
  • Techniques:
    • Posterior spinal fusion
    • Anterior spinal fusion
    • Combined approaches
    • Growth-friendly techniques for EOS

Early Onset Scoliosis (EOS)

• Special management principles:
  • Serial casting
  • Growth-friendly implants
  • Regular lengthening procedures
• Types of growing systems:
  • Traditional growing rods
  • MAGEC rods
  • VEPTR
  • Shilla growth guidance

Adult Scoliosis

• De novo vs. Progressive AIS
• Focus on:
  • Pain management
  • Curve progression
  • Sagittal balance
  • Neurological symptoms

Conservative Treatment

• Brace-related:
  • Skin problems
  • Psychological impact
  • Compliance issues

Surgical Complications

• Early:
  • Neurological injury
  • Infection
  • Blood loss
• Late:
  • Pseudarthrosis
  • Adjacent segment disease
  • Implant failure
  • Proximal junctional kyphosis

Natural History Complications

• Progression risk factors:
  • Skeletal immaturity
  • Curve magnitude
  • Curve pattern
• Long-term effects:
  • Chronic pain
  • Respiratory compromise
  • Psychological impact
  • Decreased quality of life