Overview
Definition:
Scoliosis is a three-dimensional deformity of the spine characterized by lateral curvature and rotation of the vertebral bodies
It can be congenital, neuromuscular, or idiopathic, with idiopathic scoliosis being the most common type, particularly adolescent idiopathic scoliosis (AIS).
Epidemiology:
Idiopathic scoliosis affects approximately 2-3% of adolescents, with a higher prevalence in girls, especially for curves greater than 10 degrees
Adolescent idiopathic scoliosis typically manifests between the ages of 10 and 18 years
Congenital scoliosis accounts for about 10% of cases and results from vertebral malformations.
Clinical Significance:
Early detection of scoliosis is crucial for timely intervention, potentially preventing the progression of spinal deformity
Untreated significant scoliosis can lead to chronic back pain, pulmonary compromise, and psychological distress, impacting a child's quality of life and long-term health.
Clinical Presentation
Symptoms:
Often asymptomatic in early stages
Visible asymmetry in shoulder height
One shoulder blade appearing higher than the other
Unevenness in waistline or hip height
Head not centered directly above the pelvis
Persistent back pain, though less common in AIS.
Signs:
Asymmetric shoulder levels
Asymmetric scapular height
Prominent rib hump on one side when bending forward
Asymmetric iliac crest height
Waist asymmetry
Uneven leg lengths (functional or true)
Adam's forward bend test positive for asymmetry.
Diagnostic Criteria:
A Cobb angle of 10 degrees or greater on a standing AP radiograph of the entire spine is diagnostic of scoliosis
For screening purposes, visible asymmetry or a positive Adam's test prompts further investigation.
Diagnostic Approach
History Taking:
Age of onset
Family history of scoliosis
History of back pain
Presence of neurological symptoms such as weakness, numbness, or gait disturbance
Previous spinal trauma or surgery
History of other congenital anomalies
Red flags include infantile onset, rapid progression, neurological deficits, and associated systemic conditions.
Physical Examination:
Observation of posture from anterior, posterior, and lateral views
Assess shoulder height and position
Scapular symmetry
Waist asymmetry
Assess for any skin dimples, hair patches, or birthmarks suggestive of spinal dysraphism
Perform the Adam's forward bend test: Ask the patient to bend forward at the waist with feet together and arms hanging down
observe for asymmetry of the rib cage or flank.
Investigations:
Standing posterior-anterior (PA) and lateral radiographs of the entire spine are essential to measure the Cobb angle, assess vertebral rotation, and identify the curve apex
A minimum of a standing PA film of the spine is needed for initial assessment
For curves >30 degrees, or in cases with significant risk factors, a full spinal X-ray from occiput to sacrum may be necessary
MRI of the spine may be indicated in cases with suspected congenital or neuromuscular scoliosis, neurological deficits, or specific red flags to rule out intraspinal pathology like diastematomyelia or tumors.
Differential Diagnosis:
Functional scoliosis (due to leg length discrepancy, muscle spasm, or poor posture)
Congenital scoliosis (vertebral anomalies)
Neuromuscular scoliosis (cerebral palsy, muscular dystrophy, spinal muscular atrophy)
Syndromic scoliosis (Marfan syndrome, neurofibromatosis)
Degenerative scoliosis (rare in children).
Screening And Referral
Screening Recommendations:
Routine screening for scoliosis is recommended for all children aged 10-12 years, especially girls, as this is a period of rapid growth
School screening programs and pediatric well-child visits should incorporate visual inspection and the Adam's forward bend test
Girls at age 10 or 11
Boys at age 13 or 14
Patients with known conditions associated with scoliosis (e.g., neuromuscular disorders) should be screened more frequently.
When To Refer To Specialist:
Referral to a pediatric orthopedic surgeon is indicated for any child with a suspected scoliosis curve of 10 degrees or more on X-ray
Significant asymmetry noted on physical examination, even with a small Cobb angle
Any curve progressing rapidly (e.g., >5 degrees per year)
Presence of neurological deficits
Children with curves that are likely to progress significantly based on skeletal maturity and curve magnitude
Curves in pre-pubertal children are at higher risk of progression
Curves >25-30 degrees at skeletal immaturity generally require bracing.
Management
Observation:
For curves less than 20-25 degrees in growing adolescents, observation with serial radiographic follow-up every 4-6 months is usually sufficient
Skeletal maturity assessment (e.g., Risser sign) is important
Skeletal maturity is crucial for prognosis and management decisions.
Bracing:
Bracing is typically indicated for curves between 25-45 degrees in skeletally immature patients with significant growth potential
The goal of bracing is to halt or slow curve progression, not to correct the deformity completely
Common bracing systems include the Thoracolumbosacral Orthosis (TLSO).
Surgical Intervention:
Surgery is considered for curves greater than 45-50 degrees in skeletally immature patients or curves that continue to progress despite bracing
Surgical goals include preventing further progression and improving spinal alignment
Spinal fusion with instrumentation is the standard surgical approach
The timing of surgery depends on curve magnitude, skeletal maturity, and progression rate.
Supportive Care:
Physical therapy focused on core strengthening and flexibility may be recommended as an adjunct to bracing or observation
Psychological support can be beneficial for adolescents undergoing treatment for scoliosis, addressing body image concerns and the impact of treatment on their lives.
Prognosis
Factors Affecting Prognosis:
Curve magnitude at diagnosis
Skeletal maturity (Risser sign, age at menarche)
Sex (females have higher risk of progression)
Curve pattern
Presence of congenital or neuromuscular causes
Rate of curve progression.
Outcomes:
With appropriate management, most children with idiopathic scoliosis achieve satisfactory outcomes, with minimal or no long-term functional impairment
Early detection and intervention are key to preventing severe deformities
Untreated large curves can lead to chronic pain, restricted pulmonary function, and cosmetic concerns.
Follow Up:
Regular follow-up with serial X-rays is essential until skeletal maturity is achieved
The frequency of follow-up depends on the severity of the curve, treatment modality, and patient age
Post-surgical patients require long-term follow-up to monitor for hardware complications or pseudarthrosis.
Key Points
Exam Focus:
Recognize the typical age of onset for AIS
Understand the components of the Adam's forward bend test
Know the Cobb angle thresholds for observation, bracing, and surgery
Differentiate idiopathic, congenital, and neuromuscular scoliosis
Red flags requiring immediate referral.
Clinical Pearls:
Always perform a full spinal assessment and check for associated anomalies when a spinal deformity is suspected
Consider sex and skeletal maturity when assessing the risk of progression
Educate parents about the natural history and treatment options
Emphasize that bracing aims to prevent progression, not cure scoliosis
Consider scoliosis in any child with unexplained back pain or asymmetry.
Common Mistakes:
Underestimating the risk of progression in young, skeletally immature patients
Delaying referral for a suspicious finding
Relying solely on visual assessment without radiographic confirmation
Not considering underlying causes in atypical scoliosis presentations
Inadequate follow-up leading to missed progression.