1. A JOURNAL REVIEW ON SCOLIOSIS

3. • Scoliosis (from Greek: skoliōsis meaning from skolios,
"crooked")[1] is a medical condition in which a person's spine is
curved from side to side
• Lateral curvature of the spine >10º accompanied by vertebral
rotation.
[1]. Online Etymology Dictionary. Douglas Harper, Historian.
Accessed 27 December 2008. Dictionary.com
Scoliosis is defined as a lateral curvature of the spine with torsion
of the spine and chest as well as a disturbance of the sagittal
profile [2].
Classification and Terminology.
In Moe's Textbook of Scoliosis and Other Spinal Deformities 3rd edition.
Philadelphia Saunders; Winter RB 2002:39-43.

4. Types:
STRUCTURAL SCOLIOSIS
Idiopathic Neuromuscular Congenital Degenerative Traumatic
Infantile Neuropathic Failure of formation Fractures
0-3years Wedge vertebra Surgical
UMN
Juvenile LMN Hemivertebra Postlaminectomy
3-10years Postthoracoplasty
Dysautonomia
Failure of segmentation
Adolescent
> 10years Myopathic
Arthrogryposis
Muscular dystrophy
Congenital hypotonia
Myotonia dystrophica

5. Others
Neurofibromatosis
Following empyema
Extraspinal contractures
Following burns
Infections of bone
Rickets
Metabolic disorders
Osteogenesis imperfecta
Marfan’s Syndrome
Mesenchymal disorders
Ehlers-Danlos Syndrome

6. NON-STRUCTURAL SCOLIOSIS
Postural scoliosis
Hysterical scoliosis
Inflammatory
Leg length discrepancy
Contractures around the Hip

7. Classification by anatomic area:
• Cervical curve: apex between C1 and C6
• Cervico-thoracic curve: apex at C7 to T1
• Thoracic curve: apex between T2 to T11
• Thoraco-lumbar curve: apex between T12 and L1
• Lumbar curve: apex between L2 and L4
• Lumbosacral curve: apex between L5 to S1
Terminology Committee. Scoliosis Research Society:
A glossary of scoliosis terms. Spine 1:57- 58, 1976

8. Etiology:
• GENETIC FACTORS: Harrington studied women with a scoliotic
curve that exceeded 15° and found a 27 percent prevalence of
scoliosis among their daughters.[1]
• EFFECTS OF CONNECTIVE TISSUE: Changes in the distribution of
collagen in patients with IS differ from those of seen in subjects
without IS, but these changes are not consistent among those
with IS.[2] Elastic fiber abnormalities in the spinal ligaments
have also been reported in a substantial number of patients
with IS compared with those of individuals without IS.[3]
[1]. Harrington PR. The etiology of IS. Clin Orthop 1977;126:17-25.
[2]. Echenne B, Barneon G, Pages M, et al.
Skin elastic fiber pathology and IS. J Pediatr Orthop 1988;8:522-528.
[3]. Hadley-Miller N, Mims B, Milewicz DM. The potential role of the elastic
fiber system in adolescent IS. J Bone Joint Surg [Am] 1994;76:1193-1206.

9. SKELETAL MUSCLE ABNORMALITIES:
•The differences between type I (slow-twitch) and type II
(fast-twitch) muscle fibers in those with IS have been
studied.
•
•Decreased type II fibers in the paraspinous and gluteus
medius muscles have been reported.
Sahgal V, Shah A, Flanagan, N, et al.
Morphologic and morphometric studies of muscle in IS.
Acta orthopaedica Scandinavica, 1983;54:242-251.
Spencer GS, Eccles MJ.
Spinal muscle in scoliosis. Part 2. The proportion and size of type 1 and
type 2 skeletal muscle fibres measured using a computer-controlled
microscope.
Journal of Neurological Science 1976;30:143-154.

10. Another article reported a normal distribution of Type I
and type II fibers on the convexity of the curve, but a
lower frequency of Type I fibers on the concavity.
Bylund P, Jansson E, Dahlberg E, et al.
Muscle fiber types in thoracic erector spinae muscles. Fiber types in idiopathic
and other forms of scoliosis.
Clinical Orthopaedics 1987;214:222-228.
Another article showed a decrease in the number
and size of type II fibers, with no preference for
the convex or concave side.
Slager UT, Hsu JD.
Morphometry and pathology of the paraspinous muscles in IS.
Developmental Medicine & Child Neurology. 1986;28:749-756.

11. Another study found similar results of decrease in
the number and size of type II fibers from distant
muscle sites (deltoid, trapezius, gluteus, and
quadriceps)
Yarom R, Robin GC, Gorodetsky R.
X-ray fluorescence analysis of muscles in scoliosis.
Spine 1978;3:142-145.
CONCLUSION: A myopathic process may
play a significant role in the etiology of IS.

12. THE ROLE OF GROWTH AND DEVELOPMENT
An imbalance of growth that appears to exist
between the anterior and posterior structures of the
spine has been hypothesized as a contributing factor
to the etiology of IS.
It is suggested the anterior structures grow more
rapidly than the posterior ones, in effect forcing the
spine to rotate to the side upon forward bending.

13. Dickson RA, Lawton JO, Archer IA, et al.
The pathogenesis of IS. Biplanar spinal asymmetry.
Journal of Bone & Joint Surgery, 1984;66:8-15.
• 70 patients with thoracic curves taken
• Average Cobb angle was 39° with an average kyphosis of 20°,
as measured by a simple standing lateral radiographs.
• However, a"true" lateral of the apical vertebrae of the
thoracic curve could be viewed, by taking into account the
vertebral rotation associated with the curve, average lordosis
of 3° was noted.
• the apical one or two vertebrae were distinctly wedged,
anterior height greater than the posterior height
• Thus, Dickson et al. argued the coronal plane curvature as
seen in IS is entirely secondary to the sagittal plane imbalance
of growth.

14. Diagnosis:
• Diagnosis is made by physical examination
• Extent is often underestimated until
radiographs are visualized.
• Degree of spinal deformity is the most
important risk factor for respiratory failure,
and the effects of kyphosis and scoliosis are
additive.

15. Scoliosis Screening

16. Scoliosis Screening Recommendations
• American Academy of Orthopedic Surgeons
- Screen girls at ages 11 and 13
- Screen boys once at age 13 or 14
• American Academy of Pediatrics
- Screen at 10, 12, 14 and 16 years

17. Cobb Angle:
• The Cobb angle, named after the American orthopedic
surgeon John Robert Cobb (1903-1967)
• Originally used to measure coronal plane deformity on
antero-posterior plain radiographs in the classification
of scoliosis.
• Cobb angle is defined as the angle formed between a
line drawn parallel to the superior endplate of
one vertebra above the fracture and a line drawn
parallel to the inferior endplate of the vertebra one level
below the fracture.

19. • The Cobb angle is the preferred method of
measuring scoliosis and post-
traumatic kyphosis in a recent meta-
analysis of traumatic spine fracture
classifications.
Keynan O, Fisher CG, Vaccaro A, Fehlings MG, Oner FC, Dietz J, Kwon
B, Rampersaud R, Bono C, France J, Dvorak M.
Radiographic measurement parameters in thoracolumbar fractures: a
systematic review and consensus statement of the spine trauma study group.
Spine. 2006 Mar 1;31(5):E156-65.

20. ‘All of the Cobb angle prognostic assumptions are
based off a single study by Lonstein and Carlson in
1984, which has never been repeated or re-
produced to this very day’, according to Stitzel.
Dr Stitzel Lititz, Pennsylvania, United States
Is Cobb angle an obstacle to the future progress in scoliosis
treatment?
Source: www.fixscoliosis.com, Non surgical scoliosis treatment
program.

21. Adam’s Forward Bend Test
• The child bends forward dangling the arms,
with the feet together and knees straight.
• Examiner may observe an imbalanced rib
cage, with one side being higher than the
other, or other
deformities.

23. The Tanner Stages
• Tanner has proposed a scale, now uniformly
accepted, to describe the onset and
progression of pubertal changes
• rated on a 5 point scale

24. Pubic hair development in
females
Stage I (Preadolescent) - Vellos hair develops over the pubes in a manner not
greater than that over the anterior wall. There is no sexual hair.
Stage II - Sparse, long, pigmented, downy hair, which is straight or only
slightly curled, appears. These hairs are seen mainly along the labia. This
stage is difficult to quantitate on black and white photographs,
particularly when pictures are of fair-haired subjects.
Stage III - Considerably darker, coarser, and curlier sexual hair appears. The
hair has now spread sparsely over the junction of the pubes.
Stage IV - The hair distribution is adult in type but decreased in total
quantity. There is no spread to the medial surface of the thighs.
Stage V - Hair is adult in quantity and type and appears to have an inverse
triangle of the classically feminine type. There is spread to the medial
surface of the thighs but not above the base of the inverse triangle.

25. Male pubic hair development
Stage I (Preadolescent) - Vellos hair appears over the pubes with a degree of
development similar to that over the abdominal wall. There is no
androgen-sensitive pubic hair.
Stage II - There is sparse development of long pigmented downy hair, which
is only slightly curled or straight. The hair is seen chiefly at the base of
penis. This stage may be difficult to evaluate on a photograph, especially if
the subject has fair hair.
Stage III - The pubic hair is considerably darker, coarser, and curlier. The
distribution is now spread over the junction of the pubes, and at this point
that hair may be recognized easily on black and white photographs.
Stage IV - The hair distribution is now adult in type but still is considerably
less that seen in adults. There is no spread to the medial surface of the
thighs.
Stage V - Hair distribution is adult in quantity and type and is described in the
inverse triangle. There can be spread to the medial surface of the thighs.

26. Tanner stages for breast development
Stage I (Preadolescent) - Only the papilla is elevated above the level
of the chest wall.
Stage II - (Breast Budding) - Elevation of the breasts and papillae may
occur as small mounds along with some increased diameter of the
areolae.
Stage III - The breasts and areolae continue to enlarge, although they
show no separation of contour.
Stage IV - The areolae and papillae elevate above the level of the
breasts and form secondary mounds with further development of
the overall breast tissue.
Stage V - Mature female breasts have developed. The papillae may
extend slightly above the contour of the breasts as the result of
the recession of the aerolae.

27. Male genitalia development
Stage I (Preadolescent)- The testes, scrotal sac, and penis have a size and
proportion similar to those seen in early childhood.
Stage II - There is enlargement of the scrotum and testes and a change in the
texture of the scrotal skin. The scrotal skin may also be reddened, a
finding not obvious when viewed on a black and white photograph.
Stage III - Further growth of the penis has occurred, initially in length,
although with some increase in circumference. There also is increased
growth of the testes and scrotum.
Stage IV - The penis is significantly enlarged in length and circumference,
with further development of the glans penis. The testes and scrotum
continue to enlarge, and there is distinct darkening of the scrotal skin.
This is difficult to evaluate on a black-and-white photograph.
Stage V - The genitalia are adult with regard to size and shape.

28. Walter Reed Visual Assessment Scale

29. Sonia Pineda, Juan Bago, Carmen Gilperez and Jose M
Climent.
Validity of the Walter Reed Visual Assessment Scale
to measure subjective perception of spine deformity
in patients with idiopathic scoliosis.
BioMed Central Published: 08 November 2006
Scoliosis 2006, 1:18 doi:10.1186/1748-7161-1-18

30. Modified SRS Outcome Scale:
The SRS Outcomes Instrument is simple and internally
consistent.
Much sophisticated than SF-36
Asher, Marc A. MD; Min Lai, Sue PhD; Burton, Douglas C. MD
Further Development and Validation of the Scoliosis Research
Society (SRS) Outcomes Instrument
Spine: 15 September 2000 - Volume 25 - Issue 18 - pp 2381-2386

31. • The SRS-22 is a disease-specific instrument
• capacity to demonstrate change in health status more
effectively than the SF-12 and in more domains than the
Oswestry
• Test/retest reliability was excellent.
Bridwell, Keith H. MD; Cats-Baril, William PhD; Harrast, John; Berven, Sigurd
MD; Glassman, Steven MD; Farcy, Jean-Pierre MD; Horton, William C. MD;
Lenke, Lawrence G. MD; Baldus, Christine RN; Radake, Terri RN
The Validity of the SRS-22 Instrument in an Adult Spinal Deformity
Population Compared With the Oswestry and SF-12: A Study of Response
Distribution, Concurrent Validity, Internal Consistency, and Reliability
Spine: 15 February 2005 - Volume 30 - Issue 4 - pp 455-461

32. Trunk Appearance Perception Scale
(TAPS)
• valid instrument for evaluating the perception patients
have of their trunk deformity
• shows excellent distribution of scores, internal
consistency, and test-retest reliability, and has good
capacity to differentiate the severity of the disease.
Juan Bago, Judith Sanchez-Raya, Francisco Javier Sanchez Perez-
Grueso, Jose Maria Climent
The Trunk Appearance Perception Scale (TAPS): a new tool to
evaluate subjective impression of trunk deformity in patients with
idiopathic scoliosis.
Scoliosis 2010, 5:6

33. Prognosis:
• Mild disease has a good prognosis and requires supportive care
only.
• Adolescents- both surgery and brace treatment improve lung
function.
• Adults- surgery is of questionable benefit and carries a
significant complication rate.
• Medical therapy can include pulmonary rehabilitation,
supplemental oxygen as needed, and managing ventilatory
failure.

34. TREATMENT :

35. Idiopathic Scoliosis:
• Infantile scoliosis:
– Curve may disappear by itself with increasing age
– Well-applied body cast, under anesthesia,
regularly reapplied until maximum correction
– Milwaukee brace full time (23hrs a day) preferable
to TLSO- circumferential nature, can reduce
pulmonary functions by creating a tubular thorax
– Surgical correction
• Instrumentation without fusion
• Fusion of curve

36. Juvenile idiopathic scoliosis:
• Milwaukee brace- worn full time for 18-24
months
• With reduction in curve, time of wearing the
brace reduced from 20 hours to 6 hours
everyday.
• Surgery:
– Instrumentation without fusion
– Definite fusion(anterior and posterior approaches)

37. Adolescent idiopathic scoliosis:
• School screening
• Curves under 45 degrees: exercises, bracing,
electrical stimulation, manipulations,
biofeedback.
• Curves over 45-50 degrees: surgical intervention.
Moe’s Textbook of Scoliosis and other Spinal Deformities, 3rd Edn,
Pub: WB Saunders Company

38. Curves under 45 degrees:
Orthosis:
• Most common- Boston brace (TLSO)
74% success rate at halting curve
progression (while worn)
Circumferential nature
Can reduce pulmonary functions by
creating a tubular thorax

39. • Milwaukee brace

40. SpineCor Brace
• Is the first and only truly dynamic brace, which
provides a progressive correction of Idiopathic
Scoliosis from 15º Cobb angle and above.
• Preserves normal body movement and growth
and allows normal activities of daily living.
Carol C. Hasler, Stephanie Wietlisbach, Philippe Buchler.
Objective compliance of adolescent girls with idiopathic
scoliosis in a dynamic SpineCor brace.
Journal of Child Orthopaedics (2010) 4:211–218
The current study showed that the compliance of patients in
a dynamic SpineCor is as limited as in a conventional brace.

41. • First section  Second section
– the pelvic base (1),  the bolero (4) and
– the crotch bands (2)  the corrective elastic bands (5).
– and the thigh bands (3).

42. Chêneau Brace
• The objectives of the Chêneau brace are to obtain a
three-dimensional correction of the scoliotic
deformity, with emphasis not only on the coronal
and transverse planes, but also on the sagittal plane.

43. THORACIC SECTION LUMBAR SECTION
PELVIC SECTION TRANSVERSAL DEFORMITIES

44. •79 patients (58 girls and 21 boys) with progressive
idiopathic scoliosis, with initial Cobb angle between
20 and 45 degrees.
•Treated with Chêneau brace and physiotherapy
•Conservative treatment with Chêneau orthosis and
physiotherapy was effective in halting scoliosis
progression in 48.1% of patients.
Katarzyna Zaborowska-Sapeta, Ireneusz M Kowalski, Tomasz Kotwicki,
Halina Protasiewicz-Fałdowska, Wojciech Kiebzk4
Effectiveness of Chêneau brace treatment for idiopathic scoliosis:
prospective study in 79 patients followed to skeletal maturity
Scoliosis 2011, 6:2

45. Curves beyond 40-50 degrees
Surgical Approaches:
Basic Exposure: posterior approach
• Facet Joint Arthrodesis
• Instrumentation:
– HARRINGTON instrumentation- with fusion or without
fusion
– HARRINGTON instrumentation with Luque wiring
– WISCONSIN procedure
– LUQUE system

46. • Two great advantages in using Harrington’s
instruments. Firstly, a powerful corrective
force can be applied without pressure on the
skin ; and secondly, the time that the patient
has to remain in hospital is considerably
reduced.
C. R. BERKIN, HULL, ENGLAND
HARRINGTON’S INSTRUMENTATION AS A SALVAGE PROCEDURE FOR
PSEUDARTHROSES IN SPINE FUSIONS FOR SCOLIOSIS
Journal of Bone and Joint Surgery VOL. 50 B, NO. 3, AUGUST 1968

47. • Patients with segmentation failures should be
treated surgically as early as possible,
according to the rate of deformity formation
and certainly before pubertal growth spurt to
try to avoid cor pulmonale.
Angelos Kaspiris, Theodoros B Grivas, Hans-Rudolf Weiss and Deborah
Turnbull
Surgical and conservative treatment of patients with congenital scoliosis:
a search for long-term results.
Scoliosis 2011, 6:12

48. • 92.9% of the patients are active in professional life or
household
• 82.1% are actively engaged in sports activities
• the cosmetic appearance was rated in 87.7%
• the average correction of the scoliotic deformity in the frontal
plain was 50.6%.
CONCLUSION:
The operative technique according to Harrington provides
satisfactory results in idiopathic scoliosis after 20–30 year
follow–up.
D. Grob, M.D.,M. Rasmus, M.D., Thomas Egloff, M.D.
Idiopathic Scoliosis Treated with Harrington Instrumentation - A
Long-Term Follow-Up.

49. • Wisconsin segmental spinal instrumentation safely achieves
the objectives of partial correction, arthrodesis, and early
return to function.
• Complications of the procedure included two wound
infections (one superficial, one deep), one rod displacement,
and two wire breakages. No pseudarthroses or neurologic
complications were identified in this series.
Jeng CL, Sponseller PD, Tolo VT
Outcome of Wisconsin instrumentation in idiopathic
scoliosis. Minimum 5-year follow-up.
Spine (Phila Pa 1976). 1993 Sep 15;18(12):1584-90

50. • In all groups, the use of derotational instrumentation
increased correction (37% Wisconsin vs. 24.5% Harrington-
Luque) and decreased loss of correction (5% Harrington-
Luque vs. 28% Wisconsin).
• Rates of neurological complications were similar in all groups;
no persistent deficits were note
• Anterior release with halo traction and posterior fusion is the
optimal treatment of severe scoliosis.
Potaczek T, Jasiewicz B, Tesiorowski M, Zarzycki D, Szcześniak A
Treatment of idiopathic scoliosis exceeding 100 degrees - comparison of
different surgical techniques.
Orthopedic & Traumatology Rehabilitation. 2009 Nov-Dec;11(6):485-94.

51. Exercises:
Exercises to be done while wearing the brace
Pelvic tilts:
Spine extension in prone-lying

52. Push-ups
Sit-ups
Hamstrings stretch

53. Exercises to be done out of the brace:
Back strengthening
Back stretch Bicycle
Side stretch Abs strengthening

54. • Bilateral paraspinals do not act symmetrically during isokinetic exercises,
the muscles of the convexity having stronger contraction.
• Isokinetic exercises better than isometric exercises in treating scoliosis,
because Isokinetic exercise may trigger more motor units to act together
than isometric exercise.
• EMG activities of the thoracic muscle were significantly higher on the
nondominant(concave) side than on the dominant (convex) side. This
phenomenon suggests that compensated muscle activity may be needed
for larger curve scoliosis when doing resistance exercise.
• Recommendation: more midback protection for large curves scoliosis
when they are doing resistance exercises.
Yi-Ta Tsai, MD; Chau-Peng Leong, MD; Yu-Chi Huang, MD; Shih-Hua Kuo, MD; Ho-
Cheng Wang1, MD; Hsiang-Chun Yeh, BS; Yiu-Chung Lau, MD
The Electromyographic Responses of Paraspinal Muscles during Isokinetic
Exercise in Adolescents with Idiopathic Scoliosis with A Cobb’s Angle Less than
50 Degrees
Chang Gung Medical Journal 2010;33:540-50

55. • The subject improved in most measures, especially with pain,
combined thoracic and lumbar rotation and posture.
• Pain levels improved significantly, as did qualityof-life
measures (SRS-22) and pulmonary function(UCSD SOB)
(UCSD SOB): San Diego Shortness of Breath questionnaire
(SRS-22) : The Scoliosis Research Society-22 questionnaire
• The subject completed three pre-tests and post-tests before
and after completing 6 weeks of MFR treatment consisting of
two sessions each week for 60 min.
• Conclusion: significant improvement of the self-reported
questionnaires.
Aaron LeBauer, Robert Brtalik, Katherine Stowe.
The effect of myofascial release (MFR) on an adult with idiopathic scoliosis.
Journal of Bodywork and Movement Therapies (2008) 12, 356–363

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