Scoliosis

Snapshot

• A 12-year-old girl presents to her pediatrician’s office for an annual visit. She reports that she feels like her body is not symmetric, but has attributed this to a growth spurt and growing pains. On physical exam, there is subtle curvature of her spine. When she bends forward, there is some bony prominences from her ribs and curvature of the spine. Inclinometer shows > 7° of curvature. She is sent for radiography, which confirms the diagnosis.

Introduction

• Clinical definition
  • lateral curvature of the spine
    • most common type is adolescent idiopathic scoliosis
• Epidemiology
  • incidence
    • 2% of the population
  • demographics
    • female > male
    • onset in adolescence but can be earlier (infantile or juvenile)
    • most common spinal deformity
  • risk factors
    • female
    • family history
• Pathogenesis
  • exact pathogenesis is unknown but the curvature worsens as the spine grows
• Associated conditions
  • connective tissue disorders (e.g., Marfan syndrome)
  • neurofibromatosis
  • Down syndrome
• Prognosis
• scoliosis is not progressive after skeletal maturity

Presentation

• Symptoms
  • asymmetry in the back, shoulders, waists, or breasts
  • typically not very painful but may have nonspecific aching
    • if there is severe pain, may indicate an underlying condition such as spinal tumor or infection
  • may have rib prominence
• Physical exam
  • asymmetry in shoulder or waist
  • curvature of the spine when standing or sitting
  • provocative tests
    • Adam forward bend test with inclinometer
      • patient’s back is assessed for scoliosis as they bend forward
      • if inclinometer is > 6°, the test is suggestive for scoliosis
• normal neurologic exam

Imaging

• Radiographs 
  • indications
    • for all patients suspected of having scoliosis
    • confirms diagnosis
  • recommend view
    • coronal posteroanterior spinal radiographs
  • finding
• Cobb angle (lateral curvature of spine) ≥ 10°

Studies

• Making the diagnosis
• based on clinical presentation and imaging studies

Differential

• Spinal curvature due to unequal leg length
  • distinguishing factor
    • curvature resolves when the patient is seated
• Tethered cord syndrome
  • distinguishing factor
• abnormal neurologic exam, including weakness or spasticity and abnormal reflexes

Treatment

• Management approach
  • treatment depends on the Cobb angle
• Conservative
  • monitoring with frequent radiography
    • indication
      • Cobb angle < 25°
• Non-operative
  • bracing
    • indication
      • Cobb angle 25-45°
• Operative
  • surgical fusion of the spine
    • indication
      • Cobb angle > 45°
• prevent curve progression

Complications

• Restrictive lung disease 
• Chronic back pain