ADOLESCENT IDIOPATHIC SCOLIOSIS
Section snippets
PREVALENCE AND CAUSE
The Scoliosis Research Society (SRS) definition of scoliosis is a lateral curvature of the spine greater than 10° as measured by the Cobb method on a standing radiograph.19 Scoliosis is rather common, with approximately 2% to 4% of children between 10 and 16 years of age having measurable but small curves.37 In patients with curves around 10°, the ratio of girls to boys is equal, but the ratio of girls to boys increases to more than 5 : 1 in populations with curves greater than 20°.37, 40 The
CLINICAL EXAMINATION
Scoliosis is a lateral bending of the spine, but as the spine curves, it also rotates and produces the characteristic paravertebral rib hump. This truncal rotation and posterior prominence of the apical ribs and paravertebral muscles on the convexity causes most of the visible deformity seen in scoliosis and is used as a method to detect the deformity.
The diagnosis of scoliosis is most commonly made in adolescence during a screening examination, either in school or in a routine physical
ROUTINE RADIOGRAPHIC EVALUATION
To improve the accuracy of measurement, routine standing anteroposterior and lateral radiographs should be taken using 3-foot cassettes with the patient standing 6 feet from the gantry. Even with careful radiologic techniques, fine-tipped pencils, and a detailed protractor, the measurement error between different observers and between observations at different times by the same observer is between 5° and 10°.5 Because of this measurement error, when two radiographs taken at two different times
NATURAL HISTORY
Most patients with AIS live normal lives without functional limitations or pain. In certain instances, progression of the curve in AIS has been associated with both pulmonary problems and back pain. Thoracic curves greater than 100° have been shown to decrease forced vital capacity to below 70% to 80% of the predicted value.43 The decrease in pulmonary function is secondary to restrictive lung disease, and if the pulmonary compromise is of a severe magnitude, the patient is at theoretical risk
INDICATIONS FOR TREATMENT
The current treatment recommendation for an immature patient with a scoliosis curve between 25° and 40° is to wear a brace. An immature girl generally is defined as premenarcheal and Risser 0 or 1. Because boys can have significant spinal growth even when they have reached Risser 2 or 3, they should be treated further into maturity. Many spinal surgeons still recommend treatment for a boy with a 30° curve who is Risser 3 and then would treat until the patient is Risser 5. Patients with small
BRACE TREATMENT
If a brace is prescribed, the patient should be assessed immediately after fitting to determine pad placement and curve correction. Radiographs in the brace should be made in the standing position for the Boston brace and in the supine position for the Charleston and Providence braces. Successful outcomes from brace treatment correlate with an in-brace radiograph that demonstrates more than 50% reduction in curve magnitude. Patients requiring brace treatment are encouraged to increase their
SURGICAL TREATMENT
Girls who are premenarcheal and Risser 0 to 1 and boys who are Risser 2 or 3 have considerable spinal growth remaining and thus are at a high degree of risk for further progression. This type of patient with a curve greater than 40° should undergo a spine fusion. Young patients have even more growth remaining, and if they have only a posterior spinal fusion, the subsequent anterior growth produces more deformity.12 This further deformity is called the crankshaft phenomenon and is of a
SUMMARY
Because of the relatively recent understanding of the untreated natural history of idiopathic scoliosis, many patients do not require treatment and are simply observed. Immature patients whose curves are between 25° and 40° are at high risk for further progression and should be treated with a brace. Seventy percent to 80% of the time, the patient can expect that the brace will prevent further progression. Curves in growing children greater than 40° require a spinal fusion. Modern scoliosis
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Address reprint requests to James W. Roach, MD, Department of Orthopedic Surgery, Cook Children's Medical Center, 801 7th Avenue, Fort Worth, TX 76102
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Department of Pediatric Orthopaedics and Spine Surgery, Cook Children's Medical Center, Fort Worth; and Department of Orthopaedic Surgery, University of Texas Southwestern Medical School, Dallas, Texas