Structural Scoliosis

Scoliosis is a lateral deviation of a series of vertebral bodies from the normal spinal axis. If scoliosis is progressive, structural deformities occur in the vertebral bodies and the rib cage. Scoliosis is a physical sign and is not itself a diagnosis. Eighty percent of structural scoliosis is idiopathic: it is not related to a paralytic or neurologic etiology, and there are no causative congenital vertebral anomalies.

There are three peak periods of onset of idiopathic structural scoliosis: infantile (0 to 3 years), juvenile (4 years to puberty), and adolescent (onset of puberty to physeal closure). Prevalence data have been obtained in two ways historically: school screening and chest radiographs obtained for screening of tuberculosis. The prevalence of curves of less than 10° is 2 to 3 percent in North America, while the prevalence of more severe curves decreases as the severity of the curve increases. While the prevalence of minor (<10°) curves is equal among boys and girls, there is a distinct female gender predilection for curves exceeding 15° to 20°. This presumably is related to the observation that curve progression is more common in girls.

Large-scale screening programs remain somewhat controversial. Overreferral to orthopedists is common and is to be expected. Use of a scoliometer can dramatically reduce overreferral. The potential for excessive exposure to ionizing radiation is minimized by ensuring that an experienced orthopedic surgeon reexamines all referred patients prior to the ordering of the diagnostic scoliosis radiogram (single, standing AP radiogram of the entire spine with the iliac crests as high as possible). Another difficulty with screening programs is parental noncompliance. Finally, the cost effectiveness of large-scale screening programs is yet to be firmly established.

Despite the difficulties and controversies of large-scale screening programs, primary care physicians and emergency physicians are in a strong position to rapidly and easily identify scoliosis in children presenting to the emergency department for unrelated problems. Children with scoliosis do not usually complain of backache or fatigue. Their complaints, if they have any, relate to concerns of high shoulder; prominent scapula or breast; prominent hip; asymmetry of rib cage, trunk, or flank creases; or poor posture; or they have noticed the curve itself.

When the diagnosis is being considered, the examination of the child and the spine should be orderly. The child is observed standing, first clothed, then unclothed (but with appropriate draping for modesty), for body habitus, posture, and alignment. Lateral deformity of the spine is usually best visualized from behind the standing child. Look for balance of the head, neck, and shoulders over the pelvis. A plumb line held over the spinous process of the seventh cervical vertebra normally should pass right over the intergluteal cleft. Lateral deviation from the midline should be noted and can be measured in centimeters.

The Adams forward bending test optimally demonstrates the degree and direction of any associated rotation of the vertebrae. The patient's knees should be straight and the feet placed together. The child bends forward at the hips with the arms dependent and the palms held in opposition. The child is inspected head on for cervical and thoracic rotation and from the rear for thoracolumbar and lumbar rotation. The right and left posterior rib cage and the paravertebral lumbosacral muscles are inspected and compared for asymmetry. Rotational abnormalities of the vertebral bodies, associated with the lateral curvature of scoliosis, will result in one side (rib cage and paravertebral lumbar muscles) being higher than the other. In structural scoliosis, the vertebral body rotation is toward the convex side of the curve of the scoliosis and toward the elevated side of the rib cage or paravertebral lumbar muscles. This asymmetry can be quantified by use of a scoliometer, a gravity level device that measures in degrees of rotation. Scoliosis manifesting greater than 10° of vertebral rotation warrants referral to an orthopedic surgeon.

Conservative management of scoliosis is employed for structural scoliosis manifesting less than 50° of vertebral rotation or 50° of curve when measured radiographically. Various orthotic braces are utilized with varying success. Nonoperative candidates with more severe curves (35° to 50°) usually obtain better results using orthotic devices worn nearly continuously (23 h daily), compared to nighttime-only braces. All of these devices are fitted to a particular child's torso. They require substantial discipline on the part of the child and the parents, however. Careful follow-up care is provided by the orthopedic surgeon, who must be particularly vigilant for progression of the scoliosis, defined as an increase in the curvature of more than 5° on two or more successive visits. Such curve progression is ominous in that it is associated with the development of more severe curvatures ultimately requiring surgical stabilization.

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