This document discusses scoliosis, including its definition, classification, evaluation, treatment, and complications. Scoliosis is a lateral curvature of the spine with rotation of the vertebrae. It is classified based on age and cause. Evaluation involves physical exam, x-rays, and curve measurement. Treatment options include observation, bracing, and surgery depending on the curve severity and progression. Potential surgical complications include neurologic injury, blood loss, and implant-related issues.

1. Moderator: Dr. Chetan Presenter : Dr.Diwakar

2.  The word “scoliosis” is derived from the Greek word
meaning “crooked.” 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.
 The Scoliosis Research Society recommends that idiopathic
scoliosis is classified according to the age of the patient.
Infantile scoliosis occurs from birth to 3 years of age;
juvenile idiopathic scoliosis between the ages of 4 and 10
years; and adolescent idiopathic scoliosis between 10 years
of age and skeletal maturity.

3.  Idiopathic scoliosis is
the most common type
seen, but the exact
etiology of this type of
scoliosis is not known.
Congenital scoliosis is
caused by a failure in
vertebral formation or
segmentation of the
involved vertebrae.

4.  Adolescent idiopathic scoliosis is present when the
spinal deformity is recognized after the child is 10
years of age but before skeletal maturity.
 The characteristics of adolescent idiopathic scoliosis
include a three-dimensional deformity of the spine
with lateral curvature plus rotation of the vertebral
bodies. Most idiopathic curves are lordotic or
hypokyphotic in the thoracic region, and this may
represent an important factor in the etiology of
idiopathic scoliosis.

5. ETIOLOGY
 The exact cause of idiopathic scoliosis remains
unknown.
 There are many proposed etiological factors
(1) genetic factors
(2) neurological disorders
(3) hormonal and metabolic dysfunction
(4) skeletal growth
(5) biomechanical factors
(6) environmental and life style factors.

6.  Idiopathic scoliotic curves
of more than 10 degrees are
estimated to occur in 2% to
3% of children younger
than 16 years of age.

7. PATIENT EVALUATION
 The initial evaluation of the patient should include
 Thorough history.
 Complete physical and neurological examinations.
Radiographs of the spine.
After the general physical examination , the spine
should be examined carefully and the characteristics
of the deformity should be recorded.

8.  Serial measurement of height will detect when peak
height velocity is occurring associated with an increase
in progression of the curve. The height of the patient
while standing and while sitting should be measured
and recorded; these measurements are compared with
later ones to determine changes in the patient’s total
height and whether any change is caused by growth of
the lower extremities or by an increase or a decrease in
the height of the trunk.

9.  On inspection of the spine,
the examiner should look for
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.

10.  The best clinical test for evaluating spinal curvature is
the Adams forward bending test.
 The scoliometer may be used in conjunction with the
Adams forward bending test to evaluate truncal
rotation. An angle less than 7 degrees is considered
within the limits of normal. Limb lengths should be
measured because a discrepancy may cause a pelvic tilt
and a compensatory scoliosis.

11. Adam’s forward bending test

13.  Structural vs. non-structural curves:
Defined based on curve magnitude on side-bending
AP radiographs
Curves are considered to be structural curves if they are
more than 25 degree on PA radiograph and do not
bend to < than 25 degree on side bending radiograph.
Non-structural: < 25°

14. RADIOGRAPHIC EVALUATION
 Postero-anterior 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.
 The patient’s shoulders are flexed forward, the elbows
are fully flexed, and the fists should rest on the
clavicles.

15.  scoliosos 2

16. Vertebral Rotation
 Vertebral rotation may be
assessed on radiographs
through asymmetry of
pedicles and/or shift of
spinous processes:
1. Nash-Moe method

17. MEASUREMENT OF CURVES
 The Cobb method of measurement recommended by the
Terminology Committee of the Scoliosis Research Society
consists of three steps: (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. The end
vertebra of the curve is the one that tilts the most into the
concavity of the curve being measured.

19. CURVE PATTERNS
 PONSETI AND FRIEDMAN
CLASSIFICATION
1)Single major lumbar curve.
The lumbar curve has its apex between
the L1-2 disc and L4. These curves
produce an asymmetry of the waistline
with prominence of the contralateral hip
that parents often assume is caused by a
short leg on the side of the curve.

20.  2) Single major thoracolumbar curve.
The thoracolumbar curve apex is at T12 or L1. This
curve tends to produce more trunk imbalance than
other curves. This decompensation from the midline
often produces a severe cosmetic deformity.

21.  3). Combined thoracic and lumbar
curves (double major curves).
Symmetrical double major curves
generally cause less visible
deformities because the curves are
nearly the same degree in size and
the trunk usually is well balanced.

22.  4). Single major thoracic curve.
This curve pattern generally is a convex
right pattern. Because of the thoracic
location of the curve, rotation of the
involved vertebrae may be obvious. The
curve produces prominence of the ribs
on the convex side, depression of the ribs
on the concave side, and elevation of one
shoulder, resulting in an unsightly
deformity.

23. LENKE CLASSIFICATION
 Measurements are obtained from standard
posteroanterior, lateral, and right and left bending
radiographs.
 The three steps in this classification system are (1)
identification of the primary curve, (2) assignment of
the lumbar modifier, and (3) assignment of the
thoracic sagittal modifier.
 Curves are considered to be structural curves if they
are more than 25 degrees on posteroanterior
radiographs and do not bend to less than 25 degrees
on side-bending radiographs.

24.  The second step is to determine the lumbar spine modifier.
This is determined by drawing a vertical line upward from
the center of the sacrum (center sacral vertical line
[CSVL]).
 The lumbar spine modifier is then determined by the
relationship of the CSVL to the concave pedicle of the
apical lumbar vertebra and can be assigned into A, B, or C.
 The third step is to determine the thoracic sagittal
modifier. The sagittal modifier is hypokyphotic (<10
degrees), normal (10 to 40 degrees), or hyperkyphotic (>40
degrees).


25.  Forty-two discrete curve classifications can be
identified by this three-step process.
Recommendations for fusion levels can be made based
on these curve types. The recommendation is that the
major and structural minor curves be included in the
instrumentation and fusion and the nonstructural
curves excluded.

28. NON OPERATIVE TREATMENT
 Various methods have been used to treat adolescent
idiopathic scoliosis over the years, including physical
therapy, manipulation, and electrical stimulation, but
there is no scientific evidence supporting their
effectiveness. The two most widely accepted non
operative techniques for idiopathic scoliosis are
observation and bracing.

29.  OBSERVATION
Young patients with mild curves of less than 20
degrees can be examined every 6 to 12 months.
Adolescents with larger degrees of curvature should be
examined every 4 to 6 months. Skeletally mature
patients with curves of less than 20 degrees generally
do not require further evaluation. 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 postero anterior radiographs.

30.  If progression of the curve (an increase of 5 degrees
during 6 months) beyond 25 degrees is noted, orthotic
treatment may be considered. For curves of 30 to 40
degrees in a skeletally immature patient, orthotic
treatment is recommended at the initial 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.

31.  ORTHOTIC TREATMENT
The goal of brace treatment is to limit further
progression of the scoliotic curve and avoid surgery.
Correction may occur while in the brace, but the curve
will generally settle to its pretreatment degree of
curvature once the brace is discontinued. Brace
correction of spinal curves is thought to occur through
molding of the spine, trunk, and rib cage during
growth, specifically through transverse loading of the
spine through the use of corrective pads.

32.  A brace for a flexible curve of 20 to 30 degrees in a
growing child with documented progression of 5
degrees or more. Curves in the 30- to 40-degree range
in growing children are treated at initial evaluation.
Although surgery usually is indicated for curves in the
40- to 50-degree range in growing children, orthotic
treatment may be considered for some curves, such as
a cosmetically acceptable double major curve of 40 to
45 degrees. Orthotic treatment is not used in patients
with curves of more than 50 degrees.

33. Wearing Schedule
 The correction achieved by a brace is thought to be
caused by the constant corrective molding of the trunk
and spine during growth.
 Full-time (23 hours per day) brace wear was first
advised by Blount and continues to be recommended
by many who prescribe scoliosis braces.
 Certain centers began to treat patients for only 16
hours per day, allowing the child to go to school
without the brace

34. Brace Efficacy
 The effectiveness of bracing for idiopathic scoliosis has
been presumed for many years, yet controlled
treatment trials with and without bracing have not
been completed until recently .
 An initial curve between 20 and 29 degrees and at high
risk for progression, the brace was found to be effective
compared to natural history data pertaining to the
untreated state

35. Boston Brace

36. Milwaukee brace

37. Charleston
sleeping brace

38. OPERATIVE TREATMENT
 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. To
accomplish these goals in patients with idiopathic
scoliosis, surgical techniques may include anterior,
posterior, or combined anterior and posterior
procedures.

39. Harrington distraction rod
is seen on the left,
combined with a smaller
threaded compression rod
on the right. B: Distraction
into the lumbar spine
associated with this system
unfortunately often leads
to a reduction in lumbar
lordosis, creating a flat-
back deformity.

40. COMPLICATIONS
 The complications of scoliosis surgery can be serious,
although over the last 20 years these procedures have
become much safer due to advances in anesthesia,
blood loss management, instrumentation systems, and
neurologic monitoring.
 Neurologic Injury
A result of direct trauma (contusion) to the cord;
excessive traction to the neural elements caused by
corrective instrumentation; and vascular insufficiency
to the cord.

41. Spinal Cord Monitoring
 Continuous electrical spinal cord monitoring has
become almost standard in surgical correction of spine
deformity. Monitoring of both sensory and motor
pathways is possible; however, from a technical
standpoint, sensory monitoring is simpler and more
widely accepted. Somatosensory evoked potentials
(SSEPs) are obtained by stimulating distally (legs) and
measuring the response proximally (brain), and have
been very reliable in detecting changes in spinal cord
function, giving the surgeon relatively rapid feedback
about any effect that the deformity correction
procedure may be having on neurologic function.

42. Blood Loss
 Scoliosis surgery may be associated with blood loss
requiring transfusion.
 Preoperative autologous donation may be the most
reliable way to avoid exposure to allogenic blood
products, although this is not possible in all patients

43. Implant Related Complications
 Complications related to the implants may present
early or late in the postoperative period. Despite
greatly improved implant systems, there is still a
potential for early failure of the bone and hardware
interface by either implant dislodgment or bony
fracture.

44. Thank You…!!!