OHSU Scoliosis

OHSU Musculoskeletal Update

Scoliosis

Matthew F. Halsey, M.D.

Doernbecher Children’s Hospital

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6 Sep 2019

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Scoliosis

Definition:

An abnormal curvature

of the spine in all

three planes resulting

in deformity, pain and

functional impairment

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Definition

• Coronal plane

– Evaluated on P/A

radiographs

– Measured by Cobb

angle

– Must measure >10°

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Definition

• Sagittal plane

– Evaluated on lateral

radiograph

– Usually characterized by

flattening of thoracic

kyphosis and

accentuation of lumbar

lordosis

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Definition

• Transverse plane

– Evaluated on physical exam

– Adam’s forward bending

test

– Characterized by rib and/or

lumbar prominences

• Measured with a scoliometer

– Posterior prominence is

located on the convex side of

the curve

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Incidence

• Idiopathic

– 4.5%

– Gender ratio is 1.25:1::female:male

– For curves >20° ratio is 5.4:1

– Treatment required 2.75/1000

– 1/20 progress to possible bracing

– 1/25 progress to possible surgery– Rogala EJ, et al. JBJS 60A:173, 1978

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Etiology

• Idiopathic

– Adolescent is most common

– Incomplete understanding of

etiology

– Genetic factors –

multifactorial with variable

penetrance, unclear

environmental impacts

– Tissue deficiencies

– Vertebral growth abnormality

– CNS abnormality

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Not clinically indicated!!!OHSU


Etiology

• Other etiologies include

– Neuromuscular

– Neural axis

– Congenital

– Syndromic

– Metabolic

– Traumatic

– Adult-onset

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Natural History

• Natural History

– Lonstein & Carlson, 1984

• Smaller curves tend to stay small

• Larger curves tend to progress

• Progression is associated with

growth, especially at puberty

– Sanders confirmed, 2008

• Based on hand film rather than

pelvis

• More easily applied to boys, as well

as girlsOHSU Musculoskeletal Update6 Sep 2019

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Natural History

• In childhood dependent

on several factors

including:

– Etiology

– Age (growth remaining)

– Gender

– Curve type

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Natural History of AIS curves in

Adulthood• Curves <30º

– No differences compared to age-matched controls

• Curves >50°– Curve progression (2-3°/year)

– Pain – increased frequency, similar duration/severity

– Dyspnea

– Cor pulmonale rarely

– Mental health unaffected


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Evaluation - History

• What prompted referral?

• Pain profile

• Neurologic symptoms

• Family history

• Medical history

• Goal is to identify overall level of skeletal

maturity and possible red flags6 Sep 2019

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Red Flags in the History

• Night pain, especially if easily relieved by

NSAIDs

– Osteoid osteoma, osteoblastoma, aneurysmal

bone cyst, giant cell tumor

• Neurologic deficit

– Spinal cord tumor, tethered cord

• Either of these findings should prompt

MRI evaluation


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Physical Examination

• Height, Weight, Proportions

• Skin exam

• Normal neuromuscular exam

– Strength

– Sensation

– Deep tendon reflexes

– Clonus

– Babinski

– Abdominal reflex

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• Back

– Shoulders

– Flanks

– Pelvis - limb length

discrepancy

– Sagittal

– Forward bend test

– Flexibility – posture

• Use a robe and paper

shorts for this exam

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• Standing position

• Forward bending

position

• Scoliometer

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Red Flags in Physical

Examination• Neurologic deficits or asymmetries

– Suggests neural axis disorder (MRI)

• Café au lait spots

– Suggests neurofibromatosis (MRI)

• Leg length discrepancy

– Perhaps not a structural (true) scoliosis (leg

length x-ray)


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Radiologic Examination

• Scoliosis Screen

– Standing PA entire spine

– Standing lateral entire spine

– Cobb method

– Risser sign

– Left-hand film

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• EOS imaging

– Lower radiation dose

– May allow concurrent

hand imaging


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• MRI

– Suspicion of neural axis abnormality• Left thoracic curve

• Babinski/clonus

• Asymmetric abdominal reflex

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Goals of Treatment

• Potential Goals

– Maintain straight spine and normal figure

– Avoid pain

– Avoid activity limitations

– Avoid surgery

– Avoid pulmonary limitations

– Have a normal life; not be disabled

– Not waste time or treasure

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Goals of Treatment

• Whose goals do we address?

– Patients

– Families

– Primary care providers

– Therapists

– Surgeons

– Hospital administrators

– Insurance payors

– Government policy makers


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Choices

• Typical treatments

– Surgery

– Observation

– Bracing

– Physiotherapeutic

scoliosis specific

exercises (PSSE), e.g.

the Schroth method

• Atypical treatments

– Typical physical

therapy

– Muscle stimulation

– Chiropractic

– Acupuncture


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Surgery

• Option of last resort

• Powerful tool with significant risks

• Main goals

– Prevent progression of curve

– Correction of deformity

– Secondary prevention of problems associated with

worsening of curve (pain, restrictive lung disease)

• Typical indication: Cobb > 50º


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Surgery


srs.org

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Surgery

• Challenges– Surgical risks including:

• Neurologic injury

• Infection

• Mal-positioned hardware

– Long-term problems

• Curve progression

• Pain

• Degenerative disk disease

– 10% reoperation rate for all reasons


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Observation

• Benefits of observation– Low cost in terms of time and treasure

– No risks associated with treatment

– Less anxiety (usually)

• Challenges– Predicting natural history is imperfect

– Curve size and maturity level (age) are inadequate to

predict outcome

– Identify other curve parameters (EOS 3D analysis)


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Bracing

• Alternative to casting

• Well-established “industry”

– Orthotists in most communities

– Standardized techniques and

approaches


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Bracing

• Demonstrated efficacy in high-level

prospective multi-center study (BrAIST)

– Weinstein & Dolan, 2013, New England

Journal of Medicine

– Bracing works!!!

– So many more questions are raised though!


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Bracing

• Challenges– Patient compliance – monitoring?

– How many hours each day?

– Plethora of choices

• Day v night; soft v hard; Boston v Rigo-Cheneau

– Quality control – correction in brace

• Stiff curve v inadequate brace mold; does it matter?

– When to start?

– When to stop?

– How to reduce number needed to treat (NNT=3)


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Physiotherapeutic Scoliosis Specific

Exercises

• Initial development in

1920s

• Alternative to casting

and fusion surgeries

• Promoted in European

centers for decades

• Over the last decade has

gained a foothold in

North America


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Exercises

• Potential benefits

– Prevent progression

– Improve deformity (curve

correction)!?

– Maintain figure and overall

appearance


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Exercises

• Challenges

– Data are more limited

• Are results generalizable?

• Are results persistent and/or sustainable?

– Infrastructure

• Limited number of trained therapists

• What patient and therapist commitment is

required?

– Insurance does not always cover this therapy


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Standard Physical Therapy

• Potential

– Common method

• Well-promulgated

• Easily taught and communicated

• Easy maintenance

– Very helpful to limit pain that may be

associated with AIS (Zapata et al, 2015)


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Standard Physical Therapy

• Challenges

– Little impact on natural history

– Pain not always completely relieved


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Lateral Electrical Surface Stimulation

• Developed by Axelgaard in

1976

– Nighttime application of

electrodes on lateral

convexity of spine

– Potential replacement of

bracing

– Supportive articles through

the 1980s


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Lateral Electrical Surface Stimulation

• Challenges

– A subsequent study found results equal to

natural history (Nachemson, 1995). SRS-

funded, prospective study

• Bracing success 74% (95% CI=52-84%)

• LESS success 33% (12-60%)

• Natural history success 34% (16-49%)

• Abandoned treatment modality


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Chiropractic Manipulation

• Potential

– Limit progression of scoliosis without

surgery

– Decrease pain associated with

scoliosis

• Challenges

– Lack of data (Romano & Negrini,

2008)

– Emphasis on early diagnosis and

treatment (? NNT elevated)

– Lack of anatomic basis of treatment


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Acupuncture

• Few studies available to analyze

– Weiss et al, 2008

• Brief exploratory study

• No follow-up data to this point


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Synopsis

• Scientific understanding of scoliosis

remains elusive

• Natural history is not without consequence

and remains difficult to predict

• Treatments are imperfect and flawed

• Goals for patients/parents, providers, and

payors are frequently disparate and

incongruent


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Challenges

• Identify the etiology

• Improve our prediction models

• Evaluate rigorously our treatment methods

• Increase value


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Thanks!

6 Sep 2019

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