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Scoliosis

Scoliosis is a deformity which is something you can see when youíre looking at the patient from the front or back, where as kyphosis is an increase in usually the thoracic prominence. Here is a diagram of essentially a normal spine, you can see from the front, the spine is supposed to line up just like poker chips one on top of the other. From the side, you are supposed to have lordosis in the lumbar spine and kyphosis in the thoracic spine that are supposed to be sort of slow and gentle, if we measure this, it would be about 35 to 40 degrees in the thoracic spine.

This is what it would look like on x-ray, this is a scoliosis, this is the typical idiopathic scoliosis looking from the back. The curve tends to go to the right in the thoracic spine to the left in the lumbar spine. This is kyphosis. This is a patient who doesnít have any scoliosis but he kind of sticks out a little bit too sharp here in the middle of his back and typically this presents as pain in the midportion of the back and is referred to as Shoremanís kyphosis. The Dowagerís hump that you see in older woman is an increased kyphosis rather than scoliosis. The hunch back of Notre Dame was actually a severe scoliosis, where the right side of the spine and ribs stuck out a lot, rather than a kyphosis. There are different types of scoliosis, the first one we want to talk about is congenital scoliosis, and this refers to any scoliosis thatís associated with abnormalities in the way the spine was formed prenatally, so these abnormalities have all occurred in the first two months intrauterine.

There are a couple of different common types, a hemivertebrae refers to a vertebrae that formed up on one side and didnít develop on the other side, so you have a wedge shaped vertebrae if itís a hemivertebrae. A failure of segmentation refers to a situation where, you remember all the way back to your embryology, your spinal segments actually form, there is a block here and then they sort of separate, the bottom of this one connects to the top of the one below it, then you get the vertebral body. If these donít separate, then you can have what are called blocked vertebrae or in this case, one side is still connected.

So these all have slightly different prognosis and different manifestations. If you have this and itís in the middle of your spine, itís not a big deal because the other levels can compensate for it. If you have it at the very base of your spine, then you donít have enough room to compensate, and either your pelvis is going to be tilted or youíre going to be tilting over sideways.

This is an example of a patient with multiple congenital spinal anomalies. Her mother had diabetes and she has a couple of hemivertebrae here and here, and she has a failure to segment here and up here. You see her spine is sort of a zig zag. This is a very sort of complicated situation to deal with. This is a child we are treating right now, actually that presented with bilateral club feet and has a little dimple down here on the bottom of his spine. Sometimes the hairy patches and the abnormalities in the back of the spine are really obvious, and sometimes they are pretty subtle. This is sort of subtle and Iím not sure if itís going to turn out to be real or not, but the patient had club feet when he was born, we stretch casted, they got better really fast. That concerns me that maybe he doesnít have a club foot, maybe he has a spinal cord abnormality that we have straightened out now, but itís likely to come back if in fact itís a spinal cord problem. So you want to look down here at the base of the spine for hairy patches.

There is more of it out there than we expect. This is a patient who is 25 years old and not from the Chicago area. She had the same story where she had bilateral club feet as a child, stretch casted, treated successfully at 11 years of age. She had recurrence of her club feet and she had surgery to straighten out her Achilles tendons and at age 21, she had recurrence again along with weakness of her right knee and the start of bladder problems. 

These are very treatable if they are identified and itís hard to understand how she didnít get picked up earlier. There are still adults running around that have these problems. The prognosis and congenital scoliosis, 25% donít progress at all, 75% do progress but only 50% of those need treatment, so just having a congenital anomaly.

The next category we want to talk about is neuromuscular type scoliosis, and this refers to any scoliosis thatís associated with some other disease, neurologic condition or condition such as neurofibromatosis or a few other things. In cerebral palsy, this is usually associated with nonambulators. In people who are hemiplegics that can walk, they may look like they have some scoliosis but their trunk control is good enough to where they donít get fixed scoliosis that requires bracing or fusion. The people that do get this are the ones that are confined to wheelchairs that donít have enough control of their trunks to keep upright, and essentially they get a collapsing type scoliosis that then becomes fixed. We can use orthotics to delay surgery in a lot of k ids, in some we just treat their whole lives in braces, the problem is they donít stop getting worse later on.

Paralytic scoliosis, we donít see a lot of polio, but this is a child from Vietnam who had this tremendous curve as a result of his weakness. He could walk with crutches but his trunk control obviously is off. Spinal cord injuries will also lead to scoliosis.

Now we are going to talk about idiopathic scoliosis, which should be the thing that you see most often in the office unless you have an unusual practice. The onset is usually after nine years of age, it is said to be equal incidence in males than females, but it progresses nine times more commonly in females. Certainly the ones that we end up seeing in the office are much more commonly females than males. Tall girls seem to be more at risk, we donít know the etiology of this, so itís not clear what is actually causing it, but tall girls seem to have more problems with it. The theories all have to do with things like abnormal vibration, reflexes or sort of hard to measure obscure type reflexes, but it occurs in this age range.

The treatment of idiopathic scoliosis is based on a study from Northern Europe that found that people that had curves under 40 degrees when the finished growing at skeletal maturity, stopped progressing and didnít get worse as adults. People that have curves that were 50 degrees or greater continued to progress at a degree a year after that. So if you had a 50 degree curve when you were 17 years old, when you were 37 years old you should have a 70 degree curve. Between 40 and 50 is considered a gray zone and is unpredictable. What we usually do in that range is just follow people longer and see if it stays in the same place or whether it progresses. If the curves are above 20 degrees, then we treat with an orthotic.

We use something called a Rosenberger, there are a bunch of these that are much more cosmetically acceptable, and since itís always teenage girls that need these, we need compliance of the patient, we need to make their lives not miserable, so these work pretty well. Fifteen years ago electrical stimulation was very popular, it was found subsequently not to do anything, and I donít think anybody is really using it at this point. The last paper I saw on this was implantable electrodes about 10 years ago. This is the Milwaukee brace, if you saw the movie Sixteen Candles, a girl was trying to drink out of a drinking fountain using one of these, and she kept hitting the drinking fountain, but very few people are in these, these days.