1. IDIOPATHIC SCOLIOSIS
DR MUHAMMAD ADNAN
PGMO ORTHO 1

2. SCOLIOSIS
 ”Scoliosis is defined as a lateral deviation of the
normal vertical line of the spine.
 The lateral curvature of the spine also is
associated with rotation of the vertebrae.
 This produces a three-dimensional deformity of the
spine that occurs in the sagittal, frontal, and coronal
planes.
 Idiopathic scoliosis is most common type,the exact
etiology of which is unknown.

3. CLASSIFICATION OF IDIOPATHIC SCOLIOSIS
 Infantile scoliosis
• From birth to 3 years of age;
 juvenile idiopathic scoliosis,
• between the ages of 4 and 10
years;
 adolescent Idiopathic scoliosis
• between 10 years of age and
skeletal maturity.

4. INFANTILE IDIOPATHIC SCOLIOSIS
 Infantile idiopathic scoliosis is a structural, lateral
curvature of the spine occurring in patients younger
than age 3 years.
 more frequent in boys than in girls, and were
primarily thoracic and convex to the left.
 Associated findings are mental
deficiency,congenital hip
dislocation,plagiocephaly,congenital heart defects.

5. INFANTILE SCOLIOSIS

6. PROGRESSION OF INFANTILE IDIOPATHIC
CURVE
 Most curves in infantile idiopathic scoliosis are
selflimiting and spontaneously resolve (70% to
90%); however,
 some curves may be progressive, usually
increasing rapidly, are often difficult to manage, and
may result in significant deformity and pulmonary
impairment.
 Risk of curve progression <6 mo: low and>1 yr:
high
 rate of curve progression:Gradual progression: 2 to
3 degrees/yr
 Malignant progression: 10 degrees/yr

7. RIB VERTEBRAL ANGLE AND RVAD
 Mehta developed a method to differentiate resolving from
progressive curves in infantile idiopathic scoliosis based on
measurement of the rib-vertebral angle (RVA).
 She evaluated the relationship of the convex rib head and
vertebral body of the apical vertebra by drawing one line
perpendicular to the apical vertebral endplate and another
from the midneck to the midhead of the corresponding rib; the
angle formed by the intersection of these lines is the RVA .
 . The RVA difference (RVAD) is the difference between the
values of the RVAs on the concave and convex sides of the
curve.
 Mehta reported that 83% of the curves resolved if the RVAD
measured less than 20 degrees and that
 84% of the curves progressed if the RVAD was greater than
20 degrees.

8. RVA
Construction of rib-vertebral angle (RVA).

9. RVAD

10. MRI
 An increased incidence of neural axis abnormalities
(Chiari malformation, syrinx, low-lying conus, and
brainstem tumor) has been noted on MRI in
patients with infantile idiopathic scoliosis (21.7%).
 MRI evaluation is now recommended for infantile
scoliosis for curves measuring more than 20
degrees. These patients usually require sedation
for MRI.

11. TREATMENT
 Because of the favorable natural history in 70% to
90% of patients with infantile idiopathic scoliosis,
active treatment often is not required.
 If the initial curve is less than 25 degrees and the
RVAD is less than 20 radiographic follow-up every
6 months is recommended.
 Most resolving curves correct by 3 years of age;
however, follow-up should continue even after
resolution because scoliosis may recur in
adolescence.

12. CASTING
 Once the diagnosis of a progressive curve is made
based on either a progressive Cobb angle or a
RVAD of more than 20 degrees, or a double curve
treatment is recommended.
 In a very young child, serial casting with general
anesthesia may be required until the child is large
enough for a satisfactory orthosis.
 The interval between cast changes is determined
by the rate of the child’s growth, but a cast change
usually is required every 2 to 3 months.

13. A, Position on table with traction applied
to halter and pelvis. B, Example of correction maneuver for
derotation of left thoracic curve. C, Underarm cast with
windows.

14. ORTHOSIS
 An orthotist can make a satisfactory
thoracolumbosacral orthosis (TLSO) or
cervicothoracolumbosacral orthosis (CTLSO) for
curves that are not too large.
 Brace wear is continued full time until the curve
stability has been maintained for at least 2 years. At
that point, brace wear can be gradually reduced.
 McMaster reported control of the curves in 22
children with infantile scoliosis with an average
brace time of more than 6 years

15. TLSO BRACE

16. OPERATIVE TREATMENT
 If a curve is severe or increases despite the use of
an orthosis or casting, surgical stabilization is
needed.
 Ideally, surgery should not only stop progression of
the curve but also allow continued growth of the
thorax and development of the pulmonary tree.
 Growing rods may be used to control curve
progression and still allow for growth of the spine
 VEPTR vertical expandable prosthetic titanium rib
instrumentation has been reported as another
alternative to correct the curve and allow for
continued growth of the spine

17.  When surgical fusion is necessary, a relatively short
anterior and posterior arthrodesis should be
considered, including only the structural or primary
curve. Combined anterior and posterior arthrodesis
is necessary to prevent the “crankshaft”
phenomenon.
 Because of the deleterious effect on the developing
thoracic cage and lung function, fusionless
instrumentation techniques are preferred.
SURGICAL FUSION

19. JUVENILE IDIOPATHIC SCOLIOSIS
 Juvenile idiopathic scoliosis appears between the
ages of 4 and 10 years.
 Multiple patterns can occur, but the convexity of
the thoracic curve usually is to the right.
 Juvenile idiopathicscoliosis comprises 12% to 21%
of idiopathic scoliosis cases.
 The female-to-male ratio is 1 : 1 in children
between 3 and 6 years of age.
 The natural history of juvenile idiopathic scoliosis is
usually slow to moderate progression until the
pubertal growth spurt.

20. TREATMENT
 juvenile idiopathic scoliosis is treated according to
guidelines similar to those for adolescent idiopathic
scoliosis.
 For curves of less than 20 degrees, observation is
indicated, with examination and standing
posteroanterior radiographs every 4 to 6 months.
Evidence of progression on the radiographs as
indicated by a change of at least 5 to 7 degrees
warrants brace treatment. If the curve is not
progressing, observation is continued until skeletal
maturity.

21. ORTHOTIC TREATMENT
 Milwaukee brace, a TLSO is used for thoracic curves
with the apex at T8 or below.
 Initially, the brace is worn full time (22 of 24 hours). If
the curve improves after at least 1 year of full-time
bracing, the hours per day of brace wear can be
decreased gradually to a nighttime-only bracing
program, which is much more tolerable, especially when
the child reaches puberty.
 However, the patient is carefully observed for any sign
of curve progression during this weaning process.
 If curve progression is noted, a full-time bracing program
is resumed.

22. EVALUATION OF BRACE TREATMENT
OF JUVENILE IDIOPATHIC SCOLIOSIS
BY THE RIB-VERTEBRAL ANGLE
DIFFERENCE (RVAD)
 If the RVAD values progress above 10 degrees
during brace wear, progression can be expected.
 ■ If the RVAD values decline as treatment
continues, parttime brace wear should be
adequate.
 ■ Those patients with curves with RVAD values
near or below 0 degrees at the time of diagnosis
generally will require only a short period of full-time
brace wear before part-time brace wear is begun.

23. SURGICAL TREATMENT
 If orthotic treatment fails, operative management of the
curve should be considered.
 Important considerations in the operative treatment of
patients with juvenile idiopathic scoliosis are the
expected loss of spinal height and the limited chest wall
growth and lung development after spinal fusion.
 Another important consideration is the crankshaft
phenomenon.
 With a solid posterior fusion, continued anterior growth
of the vertebral bodies causes the vertebral body and
discs to bulge laterally toward the convexity and to pivot
on the posterior fusion, causing loss of correction,
increase in vertebral rotation, and recurrence of the rib
hump.

24. Crankshaft phenomenon. A, Spine with
scoliosis.
B, Despite solid posterior fusion,
continued anterior growth
causes increase in deformity.
A B

25. Fifty-seven-degree
curve (A) was corrected to 39 degrees
with posterior fusion and instrumentation
(B). C, Three years after
surgery, deformity has recurred because
of crankshaft phenomenon.

26. SURGERY OPTIONS
 If the child is younger than 8 years and small, the
ideal treatment is a growing rod system without
fusion or growth modulation techniques.
 If the child is 9 or 10 years of age or large, growing
rods or growth modulation may still be used but
instrumentation and fusion may be appropriate.
This should be a combined anterior and posterior
spinal fusion to avoid the crankshaft phenomenon.

27. GROWING ROD INSTRUMENTATION
 Growing rod instrumentation is a technique of
posterior instrumentation that is sequentially
lengthened to allow longitudinal growth while still
attempting to control progressive spinal deformity.
 Moe et al. described the use of a subcutaneous
Harrington rod without fusion, followed by a full-time
external orthosis, in certain flexible curves in
growing children. The authors noted an average
length gain in the instrumented area of 3.8 cm that
ultimately required fusion.
 Complications,most frequently hook dislocation and
rod breakage, occurred in 50% of patients.

28. Technique of dual-rod instrumentation. A,
Anteroposterior
view. B, Lateral view showing construct
contoured
to maintain sagittal alignment. Extended
tandem connectors
are placed in thoracolumbar spine to
minimize profile.

29. Growing rod.

30. A, Model of thoracic chamber. Correct placement of rib anchors
(white arrows) lateral to tips of transverse processes
(black arrows). B, Dissection of soft tissue anterior to rib.

31. Postoperative posteroanterior and lateral
radiographs after dual growing
rods with proximal rib anchors (white
arrows). Black arrows indicate connectors
and cross-link.

32. Guided growth and physeal stapling.

33. ADOLESCENT IDIOPATHIC SCOLIOSIS
 present when the spinal deformity is recognized
after the child is 10 years of age but before skeletal
maturity.
 Most idiopathic curves are lordotic or hypokyphotic
in the thoracic region.
 most common type of idiopathic scoliosis
 Risk of curve progression is 23%
 Rate of curve progression is : 1 to 2 degrees/month
during puberty
 Curve resolution is rare

34. ETIOLOGY
There are many proposed etiological factors, but
these can be divided into six general categories: (1)
genetic factors,
(2) neurological disorders,
(3) hormonal and metabolic dysfunction,
(4) skeletal growth,
(5) biomechanical factors, and
(6) environmental and lifestyle

35. FACTORS RELATED TO PROGRESSION OF
ADOLESCENT IDIOPATHIC SCOLIOSIS
 ■ Girls > boys
 ■ Premenarchal
 ■ Risser sign of 0
 ■ Double curves > single curves
 ■ Thoracic curves > lumbar curves
 ■ More severe curve

36. EFFECTS OF CURVE PROGRESSION
 The effect of progressive curves on adults with
untreated scoliosis has been studied by several
investigators. Five major considerations in the
natural history of untreated adolescent idiopathic
scoliosis in adults are
 (1) back pain,
 (2) pulmonary function,
 (3) psychosocial effects,
 (4) mortality, and
 (5) curve progression.

37. PATIENT EVALUATION
A. History
B. Physical examination
 Serial measurement of height
 Any dimpling, hair patches, or skin abnormalities, such
as hemangiomas or café au lait spots.
 Asymmetry of the shoulder, scapula, ribs, and
waistline should be noted by drawing plumb line.
 Adam forward bending test
 Limb lengths should be measured because a
discrepancy may cause a pelvic tilt and a
compensatory scoliosis.

38. SIGNS OF SCOLIOSIS

39. ADAMS TEST

40. NEUROLOGICAL EXAMINATION
 A thorough neurological examination should be
done to determine if an intraspinal neoplasm or a
neurological disorder is the cause of scoliosis.
 Particular attention should be given to the
abdominal reflexes, because often they are the only
neurological abnormality found with some
intraspinal disorders.

41. RADIOGRAPHIC EVALUATION
 Posteroanterior and lateral radiographs of the
spine, including the iliac crest distally and most of
the cervical spine proximally, should be made with
the patient standing.
 Assessment of the flexibility of a scoliotic curve
pattern is important when the patient is being
evaluated for surgery or bracing. This can be
assessed by right and left bending films, traction
films, fulcrum bending films, or push prone
radiographs.

42. STAGNARA VIEW
 Stagnara described a
radiographic technique to
eliminate this rotational
component of the curve. In
this technique, an oblique
radiograph is made with the
cassette parallel to the
medial aspect of the
rotational rib prominence and
the x-raybeam positioned at
right angles to the cassette.
 A film made at 90 degrees to
this provides the true lateral
view, allowing a much more
accurate measurement of the
curve size and better
evaluation of vertebral
anatomy
Diagram of Stagnara
derotation view.

43. Radiographs at four points during rotational cycle of articulated scoliotic
spine show changes in Cobb angle with
rotation. On anteroposterior view, apparent Cobb angle of 87 degrees
(A) and true Cobb angle of 128 degrees (B). On lateral view,
apparent kyphosis of 61 degrees (C) and true apical lordosis of 14
degrees (D).

44. A, Standard posteroanterior radiograph of large scoliosis. B,
Stagnara view showing better detail of curve, size, and
vertebral anatomy.

45. ASSESMENT OF SKELETAL MATURITY
1. The Risser sign
 is a measurement based on the
ossification of the iliac apophysis,
which is divided into four quadrants.
.
The Risser sign may not be as
useful for predicting curve
progression because grade 1 has
been found to begin after the
period of rapid adolescent growth or
peak height velocity.

46. RISSER SIGN

47. PHV
 PHV is calculated from serial height measurements
and is expressed as centimeters of growth per year.
 Average values of PHV are 8 cm per year in girls
and 9.5 cm per year in boys.
 Little et al., in a study of 120 girls with scoliosis,
found that PHV reliably predicted cessation of
growth (3.6 years after PHV in 90%) and likelihood
of curve progression.

48. MEASUREMENT OF CURVES
Cobb method:
:
 (1) locating the superior end vertebra,
 (2) locating the inferior end vertebra, and
 (3) drawing intersecting perpendicular lines from
the superior surface of the superior end vertebra
and from the inferior surface of the inferior end
vertebra. The angle of deviation of these
perpendicular lines from a straight line is the angle
of the curve.
 If the endplates are obscured, the pedicles can be
used instead.

49. COBB ANGLE
D5
75°

51. VERTEBRAL ROTATION
1. Nash and Moe:
 if the pedicles are equidistant from the sides of the
vertebral bodies, no vertebral rotation is present (0
rotation).
 The grades progress to grade IV rotation, in which
the pedicle is past the center of the vertebral body

53. SAGITAL BALANCE
 Overall spinal sagittal balance is determined by a
plumb line dropped from the dens.
 This plumb line usually falls anterior to the thoracic
spine, posterior to the lumbar spine, and through
the posterior superior corner of S1 .
 On the standing long lateral films generally used in
spinal deformity evaluation, the dens is not easily
seen. The plumb line therefore usually is dropped
from the middle of the C7 vertebral body. This
plumb line is called the sagittal vertebral axis.

54. 7 sagittal plumb line is useful measurement
of
sagittal balance. Plumb line dropped from
middle of C7 vertebral
body falls close to posterior superior corner
of S1 vertebral body.

56. NON OPERATIVE TREATMENT
A. Observation:
 Some degree of scoliosis is frequent in the general
population,but few individuals have curves that
require treatment. Unfortunately, no method is
reliable for accurately predicting at the initial
evaluation which curves will progress; thus,
observation is the primary treatment of all curves.
 A radiograph of the spine currently is the only
definitive documentation of curve size and curve
progression

57. SKELETALLY IMMATURE PTS
 In general, young patients with mild curves of less
than 20 degrees can be examined every 6 to 12
months.
 A curve of more than 20 degrees in a patient who
has not reached skeletal maturity will need more
frequent examination, usually every 4 to 6 months,
with standing posteroanterior radiographs.
 If progression of the curve (an increase of 5
degrees during 6 months) beyond 25 degrees is
noted, orthotic treatment may be considered.

58. SKELETALLY MATURE PTS
 Skeletally mature patients with curves of less than
20 degrees generally do not require further
evaluation
 Curves of 30 to 40 degrees in skeletally mature
patients generally do not require treatment, but
because studies indicate a potential for progression
in adult life, these patients should be observed with
yearly standing posteroanterior radiographs for 2 to
3 years after skeletal maturity and then every 5
years throughout life.

59. ORTHOTIC TREATMENT
 The optimal inclusion criteria consist of
 age 10 years or older ,
 Risser grades 0 to 2,
 primary curve angles of 25 to 40 degrees, no prior
treatment, and,
 if female, either premenarchal or less than 1 year
postmenarchal.

60.  The orthoses were
originally intended to
be worn 23 hours a
day, but concern about
compliance has led to
parttime bracing
regimens. Most part-
time bracing protocols
call for approximately
16 hours or less of
brace wear each day.

61. INDICATIONS FOR OPERATIVE
TREATMENT OF IDIOPATHIC SCOLIOSIS
 Increasing curve in growing child
■ Severe deformity (>50 degrees) with asymmetry of
trunk in adolescent
■ Pain uncontrolled by nonoperative treatment
■ Thoracic lordosis
■ Significant cosmetic deformity

62. SURGICAL GOALS
The goals of surgery for spinal deformity are
 to correct or to improve the deformity,
 to maintain sagittal balance,
 to preserve or to improve pulmonary function,
 to minimize morbidity or pain, to maximize
postoperative function, and
 to improve or at least not to harm the function of
the lumbar spine.

63. POSTERIOR SURGERIES
 Posterior fusion
 Posterior spinal instrumentation
 Multiple hook segmental instrumentation
 Pedicle fixation

64. A and B, Hybrid fixation of Lenke 1A
(King III)
curve with pedicle screws at lower end of
construct.

65. COMPLICATION OF POSTERIOR SURGERIES
 Early
 NEUROLOGICAL INJURY
 ATELECTASIS
 PNEUMOTHORAX
 DURAL TEAR
 WRONG LEVELS
 Urinary complication
 Vision loss
 Late
 Psudoarthrosis
 Crankshaft phenomenon
 Superior mesenteric artery syndrome
 Late infection

66. ANTERORIOR SURGERIES
 Anterior spinal fusion
ASF if younger than 11 yr
with open triradiate
cartilage

67. Flexible 43-degree thoracic curve. B, Correction on bending
film. C, Correction of fractional curve on bending film.
D and E, After anterior fusion with Texas Scottish Rite
Hospital (TSRH) instrumentation.