Idiopathic Scoliosis

Presented By Siti Nur Rifhan

 OVERVIEW
Definition: A spinal deformity characterized by lateral
bending and fixed rotation of the spine in the absence
of any cause.

This groups constitutes about 80% of all cases of

scoliosis
In general, the younger the age at onset, the more
likely the deformity will progress and require
treatment
The deformity is often familial
Age of onset :
- Early Onset : Before puberty
- Late Onset : After puberty
 ETIOLOGY

Remains unknown
Several studies have suggested :
- Genetic cause
- Tissue deficiencies
- Vertebral growth abnormalities
- Central nervous system theories.
 CLASSIFICATION
Based on Curve Location :
Cervical Apex : C2-C6
Cervicothoraxic Apex : C7-
T1
Thoraxic Apex: T2-T12
Thoracolumbar Apex : T12-
L1
Lumbar Apex : L2-L4
Based on Age at Onset
Age of Onset :
Infantile : Age birth to 3
years
Juvenile : Age 4 to 10
years
Adolescent : Age 11- 17
years
(the most common)
CLINICAL FEATURES
Pain : Not a common complaint
Discomfort can be a common feature
but not severe pain
Mild back discomfort and fatigue in
23% of cases.
If severe pain : Must question etiology
of the idiopathic curve.
Adolescent IDIOPATHIC SCOLIOSIS
Commonest type. Mostly in girls
Primary thoraxic curves are usually convex to
the right , lumbar curves to the left.
Most curves < 20% : either resolve
spontaneously or remain unchanged
Once a curve start progress, it usually goes
on doing throughout growth period.
Progression predictors:
- Very young age
- Marked curvature
- An incomplete Risser sign at presentation
 TREATMENT For Adolescent
Idiopathic Scoliosis
Aim:
To prevent progression
To correct deformity
Based on :
Skeletal maturity : Risser stage
Curve magnitude : Cobbs angle
Curve progression : Observation
Treatment Options :
The Three Os
Observation
Osthoses
Operation
 TheRisser signis an indirect measure of skeletal maturity,
whereby the ossification stage of the Iliac apophysisis used to judge
the ossification of the spinal vertebrae
The earlier the Risser Grade, the greater the likelihood of a scoliosis
1.OBSERVATION
The aim of observation for
Adolescent idiopathic scoliosis is
to identify and document the
curve progression
Curves less than 20 are
observed.
2. ORTHOTIC TREATMENT
Spinal orthotic is used to prevent curve
progression and generally, does not
lead to permanent curve improvement.
Although bracing is still being used, it is
now recognized that it does not actually
improve curve at best, it just stops it
from getting worse.
Preference now : Wait for the curve to
progress to the stage where corrective
surgery would be justified.
 Contraindication for Brace
treatment
Skeletally mature patients

Curves greater than 40

Thoracic lordosis ( Bracing potentiates

cardiopulmonary restriction)
Patient unable to cope emotionally
with treatment
 Type of Brace
CTLSO ( Milwaukee Brace) : Consist of a pelvic corset
connected by adjustable steel supports to a cervical ring
carrying occipital & chin pads.
Used less commonly due to its cosmetic appearance.
Aim: Reduce lumbar lordosis & encourage stretching &
straightening of thoracic spine.
TLSO (i.e. Boston brace): Snug-fitting underarm
brace.
Provide lumbar or lower thoracolumbar support.
Are better accepted by Pts. Indicated for curves with an
apex T8 or below.
Bending brace (i.e. Charleston brace). It is worn
only during sleep. This type holds the Pt in an acutely
bent position in a direction opposite to the curve apex.
Flexible brace (i.e. SpinCor brace)
Milwaukee
Brace

Boston
Brace

Charleston
SpineCor Brace
3. OPERATION
Objectives :
To halt progression of the deformity
To straighten the curve
To anthrodese the primary curve by bone
grafting.
Indications:
Curves greater than 30 that are
cosmetically unacceptable esp. in
prepubertal children
Milder deformity that is deteriorating
rapidly
 Operative/Surgery
Options
The Harrington System
- The old, original system.
- A rod was applied
posteriorly along the
concave side of curve-
attached to the rod were
movable hooks that were
engaged in the uppermost
& lowermost vertebrae to
distract the curve.
- Major Disadvantage: It does
not correct the rotational
deformity- rib prominence
remains unchanged.
 Rod and Sublaminar
Wiring (Luque)
- Modified Harrington
System
- Wires are passed under
vertebral laminae at
multiple levels and fixed
to the rod at concave
side of curve. provides
more controlled, secure
fixation
- Disadvantage:
Because the wires are
dangerously close to the
dura -> increase risk of
neurological damage
The Cotrel-Dubousset
System
- This method combines a
pedicle screw box foundation
at the caudal end of deformity
- With multiple hooks placed at
various levels to produce either
distraction or compression.
- Using double rods can distract
on the concave and compress on
the convex side of the curve.
- Claimed that this method can
correct rotational deformity
as well.
- It is sufficiently rigid to make
postoperative bracing
unnecessary.
Anterior
instrumentation
This method approaches
the spine from the front.
It removes the discs
throughout the curve &
then applying a
compression device
along convex side of
curve.
Bone grafts added to
achieve fusion.
Advantages- It provides
strong fixation with less
vertebral segment to be
 COMPLICATIONS OF

SURGERY
Neurological compromise
- With modern techniques, the incidence of
permanent paralysis has been reduced to less <1%
Spinal Decompression
- Over correction may produce an unbalanced spine.
- This should be avoided by careful preoperative
planning.
Implant Failure
- Hooks may cut out and rods may break. If this is
assoc.
a symptomatic pseudarthrosis, revision surgery will
be
needed.
 EARLY ONSET IDIOPATHIC SCOLIOSIS
(INFANTILE) (< 3 YEARS)

Rare Most babies nowadays are

allowed to sleep prone
Male predominance
Left thoracic curve pattern is most
common
90% of infantile scoliosis resolves
spontaneously
Association with plagiocephaly,
developmental delay, CHD
and DDH.
 Treatment for Infantile Id. Scoliosis
Due to the favorable natural history in 70% to 90% of patients with
infantile idiopathic scoliosis, active treatment often is not required.
Resolving curves
- Most correct by 3 years age.
observed with serial physical examinations and radiographic
monitoring. (may recur in adolescence)
Sleeping in the prone position is recommended

Progressive curves are treated with serial casting followed by

orthotic treatment with a Milwaukee brace
The interval between cast changes is determined by the rate of the
childs growth, but a cast change usually is required every 2 to 3
months

Surgery : posterior spinal instrumentation without fusion or

the vertically expandable prosthetic titanium rib (VEPTR).
A: Position on table with traction applied to halter
and pelvis.
B: Example of correction maneuver for de-rotation of
left thoracic curve.
EARLY ONSET IDIOPATHIC
SCOLIOSIS
(JUVENILE) (AGED 4-9
Less common than adolescent
YEARS)
type.
Increasing female
predominance
Most common curve patterns
are right thoracic.
Prognosis is worse : 70% of
curves progress and require
treatment (surgery or bracing)
If the child is very young, a
brace may hold temporarily
until Age 10, when fusion is
likely to succeed.
 Treatment of Juvenile Id.
Scoliosis
Juvenile idiopathic scoliosis is treated according to
guidelines similar to those for adolescent
idiopathic scoliosis.
Curve < 20: Observation with examination and
standing posteroanterior radiographs every 4-6
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.
Curve 25 to 50 range : Orthotic treatment
Curve > 50 : Surgery
 REFERENCES
Apley and Solomons Concise System
of Orthopedics and Trauma 4th
Edition. CRC Press