Background

  • Scoliosis is a common spinal deformity characterized by a lateral curvature of the spine 10°or greater on a posterior-anterior radiograph while standing.
  • Adolescent idiopathic scoliosis is the onset of scoliosis of unknown cause at age 10 to18 years.
    • Most common type in children, with a reported prevalence of about 2% in the general population
    • More common in girls than boys
  •  Risk factors for curve progression include lateral spine curvature (Cobb angle) greater than 30° skeletal immaturity, and female gender
  • Adolescents with spine curvature greater than 50°at skeletal maturity are likely to have continued curve progression in adulthood

Presentation Concerns

  • Typically presents as chest wall or back asymmetry, or affecting shoulders or waist
  • Patients may report breast asymmetry
  • Severe pain not a major characteristic of scoliosis in adolescents; if severe pain present, may indicate alternative diagnosis

Medical and Family History

  • History of heart disease may suggest syndromic cause of scoliosis, as in Marfan syndrome
  • Ask about family history of scoliosis

Continue Reading

Physical

  • Assess for:
    • Lateral curvature while standing
    • Left-right asymmetry of:
      • Shoulders
      • Waist
      • Pelvis
      • Scapula
      • Flank
      • Space between loosely hanging arm and body
    • Head not centered over pelvis
  • Use Adam’s forward bend test to assess curve rotation
    • Inspect patient from behind while flexed forward, with head and arms relaxed
    • Assess for rib prominence in thoracic spine area, and/or paraspinal muscle prominence in lumbar region 
  • Examine extremities
    • If tall with high arm span to height ratio, consider Marfan syndrome
    • Arachnodactyly/joint laxity may indicate connective tissue disorder such as Ehlers-Danlos syndrome

Differential Diagnosis

  • Other types of scoliosis
    • Congenital
      • Caused by spinal malformations present at birth, but may not be apparent until later in childhood
      • Can be associated with cardiac and genitourinary malformations
    • Neuromuscular
      • Caused by disorders resulting in lack of muscular support to spinal column
    • Miscellaneous/syndromic scoliosis due to other causes, including:
      • Neurofibromatosis
      • Connective tissue disorders
      • Osteochondrodystrophies
      • Metabolic conditions
      • Tumors
  • Unequal leg length
  • Hemihypertrophy

Evaluation

  • Suspect diagnosis in children aged 10 to 18 years with new-onset chest wall, back, pelvis, shoulder, and/or waist asymmetry
  • Use Adam’s forward bend test and inclinometer to assess curve rotation
    • Findings suggestive of scoliosis include:
      • Rib prominence in thoracic spine area and/or paraspinal muscle prominence in lumbar region.≥ 7° of axial rotation on inclinometer
    • If axial rotation < 7°but other findings suggest scoliosis, reassess in 6 to 12 months
  • In adolescents with ≥ 7° of axial rotation, obtain a posteroanterior spinal radiograph.
    • Lateral curvature of the spine ≥ 10° in the coronal plane while standing confirms scoliosis.
    • Lack of an identifiable cause confirms adolescent idiopathic scoliosis.
  • Evaluate skeletal maturity with Risser grade (lower score indicates less mature skeleton)
    • Measures ossification of iliac apophysis
    • United States classification (total score range 0-5)
      • Grade 0 – 0% ossification
      • Grade 1 – 25% 
      • Grade 2 – 50% 
      • Grade 3 – 75% 
      • Grade 4 – 100% 
      • Grade 5 – fusion of ossified epiphysis to the iliac wing

Management

  • Management is based on
    • Curve severity (Cobb angle)
    • Minimizing curve progression and reaching skeletal maturity with spine curvature < 50° (curves < 50° are more likely to remain stable, while curves ≥ 50° are likely to worsen)
  • For curves ≤ 25°
  • For curves 25° to 45° in skeletally immature adolescents (Risser grade ≤ 2)
    • Consider bracing
      • Goal is to prevent progression to surgical threshold (bracing unlikely to improve cosmetic deformity)
      • Bracing efficacy increases with increased use (should be worn ≥ 12 hours/day)
  • Scoliosis-specific exercises may be considered as adjuvant treatment to other conservative treatments, but evidence for efficacy is inconsistent
  • Surgical options
    • For curves > 45° in skeletally immature adolescents and in skeletally mature adolescents (Risser grade ≥ 3) with curves > 50°, consider spinal fusion 
      • Fusion of spine via instrumentation and bone graftingIntended to stop curve progression and improve spinal balance/alignment
      • Complications may include:
        • Infection
        • Spinal cord injury
        • Decreased spinal motion
        • “Flat back” syndrome (loss of lumbar lordosis)
        • Superior mesenteric artery syndrome
  • For curves  30° to 65° in skeletally immature patients
    • Consider spinal tether device in patients with failed/intolerant to bracing 
    • Device includes anchors/vertebral body screws that are placed into same side of each vertebra  
    • Tension applied to tether to compress one side of spine and partially correct curve

Follow-up

  • Follow-up depends on growth potential and Cobb angle
  • For prepubertal girls and boys 10 years and older with Cobb angle
    • 10-14° – repeat assessment in 1 year
    • 15-19° – repeat assessment in 3-6 months/refer to orthopedist if angle increased ≥ 5°
    • 20-24° – refer to orthopedist, or repeat assessment in 3 months/refer to orthopedist if angle increased ≥ 5°
    • ≥ 25° – refer to orthopedist/see patient in 1 month
  • For pubertal premenarchal girls and pubertal boys aged 12-14 years with Cobb angle
    • 10-14° – repeat assessment in 1 year
    • 15-19° – repeat assessment in 3-6 months/refer to orthopedist if angle increased ≥ 5°
    • 20-24° – repeat assessment in 3 months/refer to orthopedist if angle increased ≥ 5°
    • ≥ 25° – refer to orthopedist/see patient in 1 month
  • For postmenarchal girls and boys aged 14-16 years with Cobb angle
    • 10-14° – repeat assessment in 1 year
    • 15-29° – repeat assessment in 6 months/refer to orthopedist if angle increased ≥ 5°
    • 30-45° – refer to orthopedist
    • ≥ 45° – refer to orthopedist/see patient in 1 month
  • For girls ≥ 2 years after menarche or boys aged 16-18 years with Cobb angle
    • 10-19° – no treatment necessary
    • 20-29° – repeat radiographic assessment in 5 years and refer to orthopedist if angle increased ≥ 5°
    • 30-45° – refer to orthopedist
    • ≥ 45° – refer to orthopedist/see patient in 1 month
  • Atypical features such as clinically significant pain, left thoracic curvature, neurologic abnormalities, foot deformity, or excessive lordosis or kyphosis require earlier follow-up

Complications

  • Primary complication is disfigurement of torso with shoulder or waist asymmetry, rib rotation, or trunk imbalance
  • Pulmonary insufficiency syndromes
    • Thoracic deformity can impede attainment of adult chest volume and restrict pulmonary development
    • Thoracic scoliosis
      • > 50° increases risk for shortness of breath later in life
      • ≥ 70° is associated with reduced lung volume
      • > 100° associated with symptomatic restrictive pulmonary disease

Prognosis

  • Reoperation within 10 years reported in 3% to 10% of surgically-treated idiopathic scoliosis
  • Scoliosis progression
    • Factors associated with increased risk for curve progression
      • Cobb angle > 25 to 30°
      • Skeletal immaturity
      • Female gender
    • Curve progression after skeletal maturity
      • Progression rare if Cobb angle ≤ 30° and patient has reached skeletal maturity (bone age 15 years in girls or 17 years in boys)
      • If Cobb angle > 50° at skeletal maturity, curve usually worsens throughout adulthood
  • Adolescent idiopathic scoliosis associated with increased risk for chronic back pain in adulthood

Kendra Church MS, PA-C, is a physician assistant at Dana-Farber Cancer Institute/Brigham & Women’s Hospital, and is also a senior clinical editor for DynaMed, an evidence-based, point-of-care database.

References

  1. El-Hawary R, Chukwunyerenwa C. Update on evaluation and treatment of scoliosis. Pediatr Clin North Am. 2014;61(6):1223-1241. doi:10.1016/j.pcl.2014.08.007
  2. Hresko MT. Clinical practice. Idiopathic scoliosis in adolescents. N Engl J Med. 2013;368(9):834-841. doi:10.1056/NEJMcp1209063
  3. Negrini S, De Mauroy JC, Grivas TB, et al. Actual evidence in the medical approach to adolescents with idiopathic scoliosis. Eur J Phys Rehabil Med. 2014;50(1):87-92.
  4. Hacquebord JH, Leopold SS. In brief: the Risser classification: a classic tool for the clinician treating adolescent idiopathic scoliosis. Clin Orthop Relat Res. 2012;470(8):2335-2338. doi:10.1007/s11999-012-2371-y

Topics:

Orthopedics Pediatrics