A JOURNAL REVIEW ON SCOLIOSIS

• Scoliosis (from Greek: skoliōsis meaning from skolios, "crooked")[1] is a medical condition in which a person's spine is curved from side to side

• Lateral curvature of the spine >10º accompanied by vertebral rotation.

 [1]. Online Etymology Dictionary. Douglas Harper, Historian. Accessed 27 December 2008. Dictionary.com

Scoliosis is defined as a lateral curvature of the spine with torsion of the spine and chest as well as a disturbance of the sagittal profile [2].

Classification and Terminology. In Moe's Textbook of Scoliosis and Other Spinal Deformities 3rd edition. Philadelphia Saunders; Winter RB 2002:39-43.

Types:STRUCTURAL SCOLIOSIS

Idiopathic

Infantile0-3years

Juvenile3-10years

Adolescent> 10years

Neuromuscular

Neuropathic

Myopathic

Congenital Degenerative

UMN

LMNDysautonomia

ArthrogryposisMuscular dystrophyCongenital hypotoniaMyotonia dystrophica

Failure of formation

Wedge vertebra

Hemivertebra

Failure of segmentation

Traumatic

Fractures

Surgical

PostlaminectomyPostthoracoplasty

OthersNeurofibromatosis

Extraspinal contracturesFollowing empyema

Following burns

Infections of bone

Metabolic disordersRickets

Osteogenesis imperfecta

Mesenchymal disorders

Marfan’s Syndrome

Ehlers-Danlos Syndrome

NON-STRUCTURAL SCOLIOSIS

Postural scoliosis

Hysterical scoliosis

Inflammatory

Leg length discrepancy

Contractures around the Hip

Classification by anatomic area:• Cervical curve: apex between C1 and C6• Cervico-thoracic curve: apex at C7 to T1• Thoracic curve: apex between T2 to T11• Thoraco-lumbar curve: apex between T12 and L1• Lumbar curve: apex between L2 and L4• Lumbosacral curve: apex between L5 to S1

Terminology Committee. Scoliosis Research Society: A glossary of scoliosis terms. Spine 1:57- 58, 1976

Etiology:• GENETIC FACTORS: Harrington studied women with a scoliotic 

curve that exceeded 15° and found a 27 percent prevalence of scoliosis among their daughters.[1]

• EFFECTS OF CONNECTIVE TISSUE: Changes in the distribution of collagen in patients with IS differ from those of seen in subjects without IS, but these changes are not consistent among those with IS.[2] Elastic fiber abnormalities in the spinal ligaments have also been reported in a substantial number of patients with IS compared with those of individuals without IS.[3]

[1]. Harrington PR. The etiology of IS. Clin Orthop 1977;126:17-25.

[2]. Echenne B, Barneon G, Pages M, et al. Skin elastic fiber pathology and IS. J Pediatr Orthop 1988;8:522-528.

[3]. Hadley-Miller N, Mims B, Milewicz DM. The potential role of the elastic fiber system in adolescent IS. J Bone Joint Surg [Am] 1994;76:1193-1206.

Sahgal V, Shah A, Flanagan, N, et al. Morphologic and morphometric studies of muscle in IS. Acta orthopaedica Scandinavica, 1983;54:242-251.

•The differences between type I (slow-twitch) and type II (fast-twitch) muscle fibers in those with IS have been studied.• •Decreased type II fibers in the paraspinous and gluteus medius muscles have been reported.

SKELETAL MUSCLE ABNORMALITIES:

Spencer GS, Eccles MJ. Spinal muscle in scoliosis. Part 2. The proportion and size of type 1 and type 2 skeletal muscle fibres measured using a computer-controlled microscope. Journal of Neurological Science 1976;30:143-154.

Bylund P, Jansson E, Dahlberg E, et al.

Muscle fiber types in thoracic erector spinae muscles. Fiber types in idiopathic and other forms of scoliosis.

Clinical Orthopaedics 1987;214:222-228.

Another article reported a normal distribution of Type I and type II fibers on the convexity of the curve, but a lower frequency of Type I fibers on the concavity.

Another article showed a decrease in the number and size of type II fibers, with no preference for the convex or concave side.Slager UT, Hsu JD. Morphometry and pathology of the paraspinous muscles in IS. Developmental Medicine & Child Neurology. 1986;28:749-756.

Another study found similar results of decrease in the number and size of type II fibers from distant muscle sites (deltoid, trapezius, gluteus, and quadriceps)

Yarom R, Robin GC, Gorodetsky R. X-ray fluorescence analysis of muscles in scoliosis. Spine 1978;3:142-145.

CONCLUSION: A myopathic process may play a significant role in the etiology of IS.

An imbalance of growth that appears to exist between the anterior and posterior structures of the spine has been hypothesized as a contributing factor to the etiology of IS.

It is suggested the anterior structures grow more rapidly than the posterior ones, in effect forcing the spine to rotate to the side upon forward bending.

THE ROLE OF GROWTH AND DEVELOPMENT

• 70 patients with thoracic curves taken•  Average Cobb angle was 39° with an average kyphosis of 20°, 

as measured by a simple standing lateral radiographs.• However, a"true" lateral of the apical vertebrae of the 

thoracic curve could be viewed, by taking into account the vertebral rotation associated with the curve, average lordosis of 3° was noted.

• the apical one or two vertebrae were distinctly wedged, anterior height greater than the posterior height

• Thus, Dickson et al. argued the coronal plane curvature as seen in IS is entirely secondary to the sagittal plane imbalance of growth.

Dickson RA, Lawton JO, Archer IA, et al.The pathogenesis of IS. Biplanar spinal asymmetry.

Journal of Bone & Joint Surgery, 1984;66:8-15.

Diagnosis:• Diagnosis is made by physical examination• Extent is often underestimated until 

radiographs are visualized.• Degree of spinal deformity is the most 

important risk factor for respiratory failure, and the effects of kyphosis and scoliosis are additive.

Scoliosis Screening

Scoliosis Screening Recommendations

• American Academy of Orthopedic Surgeons - Screen girls at ages 11 and 13- Screen boys once at age 13 or 14

• American Academy of Pediatrics- Screen at 10, 12, 14 and 16 years

Cobb Angle:• The Cobb angle, named after the American orthopedic 

surgeon John Robert Cobb (1903-1967)• Originally used to measure coronal plane deformity on 

antero-posterior plain radiographs in the classification of scoliosis. 

• Cobb angle is defined as the angle formed between a line drawn parallel to the superior endplate of one vertebra above the fracture and a line drawn parallel to the inferior endplate of the vertebra one level below the fracture.

• The Cobb angle is the preferred method of measuring scoliosis and post-traumatic kyphosis in a recent meta-analysis of traumatic spine fracture classifications.

Keynan O, Fisher CG, Vaccaro A, Fehlings MG, Oner FC, Dietz J, Kwon B, Rampersaud R, Bono C, France J, Dvorak M.Radiographic measurement parameters in thoracolumbar fractures: a systematic review and consensus statement of the spine trauma study group.Spine. 2006 Mar 1;31(5):E156-65.

‘All of the Cobb angle prognostic assumptions are based off a single study by Lonstein and Carlson in 1984, which has never been repeated or re-produced to this very day’, according to Stitzel.

Dr Stitzel Lititz, Pennsylvania, United StatesIs Cobb angle an obstacle to the future progress in scoliosis treatment?

Source: www.fixscoliosis.com, Non surgical scoliosis treatment program.

Adam’s Forward Bend Test

• The child bends forward dangling the arms, with the feet together and knees straight.

• Examiner may observe an imbalanced rib cage, with one side being higher than the other, or other deformities.

The Tanner Stages

• Tanner has proposed a scale, now uniformly accepted, to describe the onset and progression of pubertal changes

• rated on a 5 point scale

Pubic hair development in females

Stage I (Preadolescent) - Vellos hair develops over the pubes in a manner not greater than that over the anterior wall. There is no sexual hair.

Stage II - Sparse, long, pigmented, downy hair, which is straight or only slightly curled, appears. These hairs are seen mainly along the labia. This stage is difficult to quantitate on black and white photographs, particularly when pictures are of fair-haired subjects.

Stage III - Considerably darker, coarser, and curlier sexual hair appears. The hair has now spread sparsely over the junction of the pubes.

Stage IV - The hair distribution is adult in type but decreased in total quantity. There is no spread to the medial surface of the thighs.

Stage V - Hair is adult in quantity and type and appears to have an inverse triangle of the classically feminine type. There is spread to the medial surface of the thighs but not above the base of the inverse triangle.

Male pubic hair developmentStage I (Preadolescent) - Vellos hair appears over the pubes with a degree of 

development similar to that over the abdominal wall. There is no androgen-sensitive pubic hair.

Stage II - There is sparse development of long pigmented downy hair, which is only slightly curled or straight. The hair is seen chiefly at the base of penis. This stage may be difficult to evaluate on a photograph, especially if the subject has fair hair.

Stage III - The pubic hair is considerably darker, coarser, and curlier. The distribution is now spread over the junction of the pubes, and at this point that hair may be recognized easily on black and white photographs.

Stage IV - The hair distribution is now adult in type but still is considerably less that seen in adults. There is no spread to the medial surface of the thighs.

Stage V - Hair distribution is adult in quantity and type and is described in the inverse triangle. There can be spread to the medial surface of the thighs.

Tanner stages for breast developmentStage I (Preadolescent) - Only the papilla is elevated above the level 

of the chest wall.Stage II - (Breast Budding) - Elevation of the breasts and papillae may 

occur as small mounds along with some increased diameter of the areolae.

Stage III - The breasts and areolae continue to enlarge, although they show no separation of contour.

Stage IV - The areolae and papillae elevate above the level of the breasts and form secondary mounds with further development of the overall breast tissue.

Stage V - Mature female breasts have developed. The papillae may extend slightly above the contour of the breasts as the result of the recession of the aerolae.

Male genitalia developmentStage I (Preadolescent)- The testes, scrotal sac, and penis have a size and 

proportion similar to those seen in early childhood.Stage II - There is enlargement of the scrotum and testes and a change in the 

texture of the scrotal skin. The scrotal skin may also be reddened, a finding not obvious when viewed on a black and white photograph.

Stage III - Further growth of the penis has occurred, initially in length, although with some increase in circumference. There also is increased growth of the testes and scrotum.

Stage IV - The penis is significantly enlarged in length and circumference, with further development of the glans penis. The testes and scrotum continue to enlarge, and there is distinct darkening of the scrotal skin. This is difficult to evaluate on a black-and-white photograph.

Stage V - The genitalia are adult with regard to size and shape.

Walter Reed Visual Assessment Scale

Sonia Pineda, Juan Bago, Carmen Gilperez and Jose M Climent.Validity of the Walter Reed Visual Assessment Scale to measure subjective perception of spine deformity in patients with idiopathic scoliosis.BioMed Central Published: 08 November 2006Scoliosis 2006, 1:18 doi:10.1186/1748-7161-1-18

Modified SRS Outcome Scale:

The SRS Outcomes Instrument is simple and internally consistent.

Much sophisticated than SF-36

Asher, Marc A. MD; Min Lai, Sue PhD; Burton, Douglas C. MDFurther Development and Validation of the Scoliosis Research Society (SRS) Outcomes InstrumentSpine: 15 September 2000 - Volume 25 - Issue 18 - pp 2381-2386

• The SRS-22 is a disease-specific instrument• capacity to demonstrate change in health status more

effectively than the SF-12 and in more domains than the Oswestry

• Test/retest reliability was excellent.

Bridwell, Keith H. MD; Cats-Baril, William PhD; Harrast, John; Berven, Sigurd MD; Glassman, Steven MD; Farcy, Jean-Pierre MD; Horton, William C. MD; Lenke, Lawrence G. MD; Baldus, Christine RN; Radake, Terri RN

The Validity of the SRS-22 Instrument in an Adult Spinal Deformity Population Compared With the Oswestry and SF-12: A Study of Response Distribution, Concurrent Validity, Internal Consistency, and Reliability

Spine: 15 February 2005 - Volume 30 - Issue 4 - pp 455-461

Trunk Appearance Perception Scale (TAPS)

• valid instrument for evaluating the perception patients have of their trunk deformity

• shows excellent distribution of scores, internal consistency, and test-retest reliability, and has good capacity to differentiate the severity of the disease.

Juan Bago, Judith Sanchez-Raya, Francisco Javier Sanchez Perez- Grueso, Jose Maria ClimentThe Trunk Appearance Perception Scale (TAPS): a new tool to evaluate subjective impression of trunk deformity in patients with idiopathic scoliosis.Scoliosis 2010, 5:6

Prognosis:• Mild disease has a good prognosis and requires

supportive care only.• Adolescents- both surgery and brace treatment

improve lung function. • Adults- surgery is of questionable benefit and

carries a significant complication rate.• Medical therapy can include pulmonary

rehabilitation, supplemental oxygen as needed, and managing ventilatory failure.

TREATMENT :

Idiopathic Scoliosis:

• Infantile scoliosis: – Curve may disappear by itself with increasing age– Well-applied body cast, under  anesthesia, 

regularly reapplied until maximum correction– Milwaukee brace full time (23hrs a day) preferable 

to TLSO-  circumferential nature, can reduce pulmonary functions by creating a tubular thorax

– Surgical correction• Instrumentation without fusion• Fusion of curve

Juvenile idiopathic scoliosis:• Milwaukee brace- worn full time for 18-24 

months• With reduction in curve, time of wearing the 

brace reduced from 20 hours to 6 hours everyday.

• Surgery:– Instrumentation without fusion– Definite fusion(anterior and posterior approaches)

Adolescent idiopathic scoliosis:

• School screening

• Curves under 45 degrees: exercises, bracing, electrical stimulation, manipulations, biofeedback.

• Curves over 45-50 degrees: surgical intervention.

Moe’s Textbook of Scoliosis and other Spinal Deformities, 3rd Edn, Pub: WB Saunders Company

Curves under 45 degrees:

Orthosis:• Most common- Boston brace

(TLSO)74% success rate at halting curve progression (while worn)Circumferential natureCan reduce pulmonary functions by creating a tubular thorax

• Milwaukee brace

SpineCor Brace• Is the first and only truly dynamic brace, which 

provides a progressive correction of Idiopathic Scoliosis from 15º Cobb angle and above. 

• Preserves normal body movement and growth and allows normal activities of daily living.

The current study showed that the compliance of patients in a dynamic SpineCor is as limited as in a conventional brace.

Carol C. Hasler, Stephanie Wietlisbach, Philippe Buchler. Objective compliance of adolescent girls with idiopathic scoliosis in a dynamic SpineCor brace.Journal of Child Orthopaedics (2010) 4:211–218

• First section – the pelvic base (1), – the crotch bands (2) – and the thigh bands (3).

Second section   the bolero (4) and  the corrective elastic bands (5). 

Chêneau Brace• The objectives of the Chêneau brace are to obtain a 

three-dimensional correction of the scoliotic deformity, with emphasis not only on the coronal and transverse planes, but also on the sagittal plane.

THORACIC SECTION LUMBAR SECTION

PELVIC SECTION TRANSVERSAL DEFORMITIES

Katarzyna Zaborowska-Sapeta, Ireneusz M Kowalski, Tomasz Kotwicki, Halina Protasiewicz-Fałdowska, Wojciech Kiebzk4Effectiveness of Chêneau brace treatment for idiopathic scoliosis: prospective study in 79 patients followed to skeletal maturityScoliosis 2011, 6:2

•79 patients (58 girls and 21 boys) with progressive idiopathic scoliosis, with initial Cobb angle between 20 and 45 degrees.

•Treated with Chêneau brace and physiotherapy •Conservative treatment with Chêneau orthosis and physiotherapy was effective in halting scoliosis progression in 48.1% of patients.

Curves beyond 40-50 degreesSurgical Approaches:

Basic Exposure: posterior approach

• Facet Joint Arthrodesis

• Instrumentation:– HARRINGTON instrumentation- with fusion or without 

fusion– HARRINGTON instrumentation with Luque wiring– WISCONSIN procedure– LUQUE system

• Two great advantages in using Harrington’s instruments. Firstly, a powerful corrective force can be applied without pressure on the skin ; and secondly, the time that the patient has to remain in hospital is considerably reduced.

C. R. BERKIN, HULL, ENGLANDHARRINGTON’S INSTRUMENTATION AS A SALVAGE PROCEDURE FOR PSEUDARTHROSES IN SPINE FUSIONS FOR SCOLIOSISJournal of Bone and Joint Surgery VOL. 50 B, NO. 3, AUGUST 1968

• Patients with segmentation failures should be treated surgically as early as possible, according to the rate of deformity formation and certainly before pubertal growth spurt to try to avoid cor pulmonale.

Angelos Kaspiris, Theodoros B Grivas, Hans-Rudolf Weiss and Deborah TurnbullSurgical and conservative treatment of patients with congenital scoliosis: a search for long-term results.Scoliosis 2011, 6:12

• 92.9% of the patients are active in professional life or household

• 82.1% are actively engaged in sports activities• the cosmetic appearance was rated in 87.7%• the average correction of the scoliotic deformity in the frontal 

plain was 50.6%.

CONCLUSION:The operative technique according to Harrington provides satisfactory results in idiopathic scoliosis after 20–30 year follow–up.

D. Grob, M.D.,M. Rasmus, M.D., Thomas Egloff, M.D. Idiopathic Scoliosis Treated with Harrington Instrumentation - A Long-Term Follow-Up.

• Wisconsin segmental spinal instrumentation safely achieves the objectives of partial correction, arthrodesis, and early return to function.

• Complications of the procedure included two wound infections (one superficial, one deep), one rod displacement, and two wire breakages. No pseudarthroses or neurologic complications were identified in this series. 

Jeng CL, Sponseller PD, Tolo VTOutcome of Wisconsin instrumentation in idiopathic scoliosis. Minimum 5-year follow-up.Spine (Phila Pa 1976). 1993 Sep 15;18(12):1584-90

• In all groups, the use of derotational instrumentation increased correction (37% Wisconsin vs. 24.5% Harrington-Luque) and decreased loss of correction (5% Harrington-Luque vs. 28% Wisconsin). 

• Rates of neurological complications were similar in all groups; no persistent deficits were note

• Anterior release with halo traction and posterior fusion is the optimal treatment of severe scoliosis.

Potaczek T, Jasiewicz B, Tesiorowski M, Zarzycki D, Szcześniak ATreatment of idiopathic scoliosis exceeding 100 degrees - comparison of different surgical techniques.Orthopedic & Traumatology Rehabilitation. 2009 Nov-Dec;11(6):485-94.

Exercises:

Pelvic tilts:

Spine extension in prone-lying

Exercises to be done while wearing the brace

Sit-ups

Hamstrings stretch

Push-ups

Exercises to be done out of the brace:

Back stretchBack strengthening

Side stretch

Bicycle

Abs strengthening

Yi-Ta Tsai, MD; Chau-Peng Leong, MD; Yu-Chi Huang, MD; Shih-Hua Kuo, MD; Ho-Cheng Wang1, MD; Hsiang-Chun Yeh, BS; Yiu-Chung Lau, MDThe Electromyographic Responses of Paraspinal Muscles during Isokinetic Exercise in Adolescents with Idiopathic Scoliosis with A Cobb’s Angle Less than 50 DegreesChang Gung Medical Journal 2010;33:540-50

• Bilateral paraspinals do not act symmetrically during isokinetic exercises, the muscles of the convexity having stronger contraction.

• Isokinetic exercises better than isometric exercises in treating scoliosis, because Isokinetic exercise may trigger more motor units to act together than isometric exercise.

• EMG activities of the thoracic muscle were significantly higher on the nondominant(concave) side than on the dominant (convex) side. This phenomenon suggests that compensated muscle activity may be needed for larger curve scoliosis when doing resistance exercise.

• Recommendation: more midback protection for large curves scoliosis  when they are doing resistance exercises.

• The subject improved in most measures, especially with pain, combined thoracic and lumbar rotation and posture.

• Pain levels improved significantly, as did qualityof-life measures (SRS-22) and pulmonary function(UCSD SOB)(UCSD SOB): San Diego Shortness of Breath questionnaire(SRS-22) : The Scoliosis Research Society-22 questionnaire

• The subject completed three pre-tests and post-tests before and after completing 6 weeks of MFR treatment consisting of two sessions each week for 60 min.

• Conclusion: significant improvement of the self-reported questionnaires.

Aaron LeBauer, Robert Brtalik, Katherine Stowe.The effect of myofascial release (MFR) on an adult with idiopathic scoliosis.Journal of Bodywork and Movement Therapies (2008) 12, 356–363

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