OHSU Musculoskeletal Update
Scoliosis
Matthew F. Halsey, M.D.
Doernbecher Children’s Hospital
OHSU
6 Sep 2019
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OHSU Musculoskeletal Update
Scoliosis
Definition:
An abnormal curvature
of the spine in all
three planes resulting
in deformity, pain and
functional impairment
6 Sep 2019
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OHSU Musculoskeletal Update
Definition
• Coronal plane
– Evaluated on P/A
radiographs
– Measured by Cobb
angle
– Must measure >10°
6 Sep 2019
verywellhealth.com
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Definition
• Sagittal plane
– Evaluated on lateral
radiograph
– Usually characterized by
flattening of thoracic
kyphosis and
accentuation of lumbar
lordosis
6 Sep 2019
jcvjs.com
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OHSU Musculoskeletal Update
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
6 Sep 2019 OHSU Musculoskeletal Update
Not clinically indicated!!!OHSU
OHSU Musculoskeletal Update
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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OHSU Musculoskeletal Update
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
6 Sep 2019 OHSU Musculoskeletal Update
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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
6 Sep 2019 OHSU Musculoskeletal Update
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OHSU Musculoskeletal Update
Physical Examination
• Height, Weight, Proportions
• Skin exam
• Normal neuromuscular exam
– Strength
– Sensation
– Deep tendon reflexes
– Clonus
– Babinski
– Abdominal reflex
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Physical Examination
• 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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OHSU Musculoskeletal Update
Physical Examination
• 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)
6 Sep 2019 OHSU Musculoskeletal Update
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OHSU Musculoskeletal Update
Radiologic Examination
• Scoliosis Screen
– Standing PA entire spine
– Standing lateral entire spine
– Cobb method
– Risser sign
– Left-hand film
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Radiologic Examination
• EOS imaging
– Lower radiation dose
– May allow concurrent
hand imaging
6 Sep 2019 OHSU Musculoskeletal Update
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OHSU Musculoskeletal Update
Radiologic Examination
• MRI
– Suspicion of neural axis abnormality• Left thoracic curve
• Babinski/clonus
• Asymmetric abdominal reflex
6 Sep 2019
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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
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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)
OHSU Musculoskeletal Update6 Sep 2019
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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
OHSU Musculoskeletal Update6 Sep 2019
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Physiotherapeutic Scoliosis Specific
Exercises
• Potential benefits
– Prevent progression
– Improve deformity (curve
correction)!?
– Maintain figure and overall
appearance
OHSU Musculoskeletal Update6 Sep 2019
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Physiotherapeutic Scoliosis Specific
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
OHSU Musculoskeletal Update6 Sep 2019
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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
OHSU Musculoskeletal Update6 Sep 2019
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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
OHSU Musculoskeletal Update6 Sep 2019
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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
OHSU Musculoskeletal Update6 Sep 2019
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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
OHSU Musculoskeletal Update6 Sep 2019
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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
OHSU Musculoskeletal Update6 Sep 2019
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Challenges
• Identify the etiology
• Improve our prediction models
• Evaluate rigorously our treatment methods
• Increase value
OHSU Musculoskeletal Update6 Sep 2019
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OHSU Musculoskeletal Update
Thanks!
6 Sep 2019
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