Scoliosis and Kyphosis

Donald S. Corenman, M.D., D.C.

Biomechanics• Bipedal locomotion ability from sagittal and

coronal balance• Minimal expenditure of energy for locomotion• Upper limbs are now free for other complex tasks• Pathological contours cause malfunction,

increased energy usage, abnormal loading and therefore, premature wear

• Visceral deterioration and neurological compromise may occur

Normal Alignment

• Coronal balance- no more than 10º of lateral curvature

• Thoracic kyphosis- 20-40º (elderly can increase 5º

• Lumbar lordosis- 40-60º

Classification of Scoliosis- 1• Structural

– Idiopathic (Infantile 0-3) (juvenile 3-10) (Adolescent >10)

– Neuromuscular (UMN: CP, Spinocerebellar, Syringo, cord tumor and trauma) (LMN: Polio, trauma, myelomengiocele, dysautonomia)

– Myopathic (arthrogryposis, dystrophies, etc)– Congenital– Trauma, tumors etc

Classification of Scoliosis- 2

• Nonstructural Scoliosis– Postural– Hysterical– Nerve root irritation (antalgic)– Inflammatory (appendicitis)– Leg length discrepency– Hip contracture

Classification of Kyphosis• Postural• Scheuermanns• Congenital• Neuromuscular• Traumatic• Iatrogenic• Postirradiation• Metabolic (includes osteoporotic)• Dysplasias, tumors, inflammatory

(ankylosing spondylitis)

Glossary of Terms• Cobb Measurement- measurement of lines

perpendicular to transverse axis• Café au lait spots• Fractional Curve- correcting curve to horizontal• Gibbus- sharp angulated kyphus• Nonstructural curve- curve that corrects or

overcorrects on sidebending• Pelvic obliquity- deviation of the pelvis from

horizontal- cause can be above or below

Patient Evaluation- 1• How was deformity first noted?

• Any increase in the deformity?

• Any previous treatment? Brace? Compliance? Surgery?

• Pain? (In children and adolescents, deformity is not accompanied by pain)

• Neurologic symptoms?

Patient Evaluation- 2

• General health, developmental milestones (including health of the mother ;drugs, perinatal problems)

• Family History• Maturity (girls- pubic hair at rapid growth, boys-

before rapid growth) Menarche indicates decreased growth and occurs 2 years later. Axillary hair decreasing growth velocity

Physical Examination- 1• Patient must be examined front and back• Height and weight• Cornea (clouding in mucopolysaccharidosis),

Palate (high in Marfans), Ear (congenital anomolies), neck (webbing in Turners)

• Observe back- asymmetries in shoulders, scapulae, waist, obvious deformity?, Balance of thoracic spine over pelvis (C7 plumb to gluteal cleft)

Spinal Dysraphysm

Physical Examination-2• ROM of the spine in all planes- look for flexibility

of the curve• Where is pain present?• View patient from the side for sagittal contours (+

or – sagittal deformity and hypo/hyperlordosis)• Adams position- asymmetry measured with a

scoliometer- sharp or gentile contours (tight hamstrings- spondylo)

• Inspect skin- hair patches, dimples, nevi, chest for pectus carniatum/ excavatum

Physical Examination- 3• Maturity assessed- breast development (Tanner

scale), pubic and axillary hair• Joint flexibility• Lower extremity deformity or contraction• Neurological examination (superficial abdominal

reflex only abnormal finding in syringomyelia that mimics idiopathic scolio)

• Leg length • Mental Status

Scoliometer• Measures asymmetrical truncal rotation (ATR)• ATR of 5º should be referred after second

screening• ATR of 8º should be immediately referred

Incidence and Natural History• Schands and Eisenberg- chest minifilms on TB

screens- >10º: 1.9%, >20º: 0.5%• Duhaime et all; 1.1%• Lonstein; 1.1%• Nilsonne and Lundgren; Decreased work

capacity, 76% women unmarried, 47% disabled• Nachemson; mortality 2X normal, 25% disabled• Collis and Ponseti; not as bad as above

Incidence and Natural History- 2• Treatment depends upon amount of growth

remaining and size of the curve

• Lonstein; Curves between 20-29º and Risser 0-1 will progress 68% of time,

• Carman: Cobb measurement intraobserver error of 31% for 5º and 4% for 10º

• Curves >45º in immature will need surgery

Risser Sign

Alternative Treatments

• Electrical muscle stimulation- proven ineffective• Traction and antigravity- proven ineffective for

definitive treatment• Chiropractic- proven ineffective• Medication- proven ineffective• Exercise therapy- normally used in conjunction

with brace but by itself is ineffective

Adolescent Idiopathic Scoliosis Brace Treatment

• Single left thoracic curve is suspicious• Treat curves using orthosis 30-40º immediately or

20-29º with proven progression (>5º)• Curve must be cosmetically acceptable• Cannot use brace in thoracic lordosis• Curves less than 20º may not progress• Patient must be skeletally immature (Risser 0-2,

postmenarchaeal less than 1 year)

Adolescent Idiopathic Scoliosis Brace Treatment- 2

• Brace is worn full time but for PE, bathing and sports (20-22 hours/ day)

• Brace should correct curve 50% while on

• Brace should flatten lumbar lordosis

Orthotics• Goals: initially improve deformity and prevent

curve progression, allow social and physical development

• CTLSO (Milwaukee brace)- gold standard for scoliosis and hyperkyphosis

• Curves below T7 can use TLSO- above need Milwaukee

• Complications- increased intragastric pressure/ reflux, psychological

End of Orthosis Treatment• Wean from brace at end of growth (no height

increase, Risser 4, 12-18 mo post menarche• Standing PA X Ray 4 hours out of brace and

compare to last in-brace film• If no significant change, out of brace 4 hours daily• Protocol repeated every 4 months until child is

only sleeping in the brace (last 6-12 months of Rx)• Take radiograph at 1 full week out of brace

Juvenile Kyphosis• Normal 20-45º (greater than 50- excessive)

• Kyphosis in thoracolumbar junction or lumbar spine is abnormal

• Scheuermann’s- mechanical factors, familial occurrences, Thickened ALL

• Males = females

• Onset 10-12 years of age

Sagittal profile of Scheuermanns

Scheuermann’s• Most patients who present, present with

deformity

• Pain in 20-60% (increased with thoracolumbar forms)

• Can predispose patient to spondylolysis

• PE notes more rigid thoracic curve with a supple lumbar curve

Scheuermann’s Radiographic Findings

• Vertebral wedging (Sorenson- 5º in 3 consecutive vertebra)

• Schmorls nodes

• Irregular endplates

• Mild scoliosis (10-20) with or without rotation seen in 20-30% of patients

Postural Roundback vs. Scheurermann’s

• Postural roundback- curve only 40-60º

• Unassociated with muscle contraction

• Supple, easily correctable

• No vertebral irregularities (normally don’t show until 10-12 years- could be early Scheuermann’s)

Thank You