SCOLIOSIS IDIOPATHIC SCOLIOSIS IN ADOLESCENTS NEJM FEB 28

SCOLIOSIS IDIOPATHIC SCOLIOSIS IN ADOLESCENTS NEJM FEB 28, 2013: 368: 9 BROWN BAG #1

SCOLIOSIS • Definition: 10 degrees or greater lateral curvature of the spine (Cobb Angle, XR) • Etiology • Congenital (vertebral anomaly) • Neuromuscular (Brain – spastic quadriplegia; Cord – syringomelia, Periph– SMA, MD, NF • Connective Tissue Disorder (Marfan, Ehlers Danlos) • Idiopathic – any age possible, FH (10% in 1 st degree relative - no specific gene)

PREVALENCE OF IDIOPATHIC SCOLIOSIS • Of 2000 adolescents screened with shoulder, hip, forward bend testing • Asymmetry is exceedingly common, > 98% had asymmetric posture • Diagnosis requiring treatment is not • ~4% screened positive for scoliosis (n = 80) • ~2% had idiopathic scoliosis (> 10 degree curvature on XR) (n = 40) • 0. 4% required treatment (n = 8)

THE DANGEROUS CURVE - CONSEQUENCES • Disfigurement #1 concern • Rarely pain in adolescents or adults – Proceed with separate evaluation for BACK PAIN • Only affects lung volumes if > 70 degrees

SCOLIOSIS TREATMENT • Most do not need treatment • Goal to prevent progression • Limited data on PT other modalities • Cast for children < 3 years old if significant curve • Bracing for children > 3 yo with curves 25 -45º • Observational data supports bracing • Ongoing RCT Br. AIST: bracing vs. watchful waiting • Spinal fusion if > 45º with immature skeleton or progression after maturity

SCREENING GUIDELINES • USPTF – no screening as screening has not demonstrated improved outcomes • AAP/ AAOS / SRS / POSNA – visual inspection at set ages • Girls 5 th grade (age 10 -11) & 7 th grade (13 -14) • Boys in 8 th grade (13 -14)

SCOLIOSIS EVALUATION • Physical exam • Asymmetry Assessment • shoulder and scapula, • rib prominence on forward bend (Adams Test)- usually left lumbar, right thoracic • waist and trunk • Scoliometer Measurement • <7º is associated with a 95% probability of curve < 30 degrees on XR • RULE OUT OTHER POTENTIAL ETIOLOGIES • Skin: café au lait spots, axillary freckles, subcutaneous fibromas • Neurologic exam and midline spinal deformities • Musculoskeletal – joint laxity, spider digits, leg length discrepancy

SCOLIOSIS IMAGING • X-RAY • SCOLIOSIS FILMS with Cobb Angle: C 7 to iliac crest PA standing and lateral • Bone age if serial heights not available (to predict skeletal maturity) • MRI • <10 years of age • True kyphosis • Clinically significant pain • Abnormal neurologic exam or midline neurocutaneous defects • *Left thoracic curve is less common, but not sufficient condition for MRI

SUMMARY OF PROPOSED ALGORITHM FOR IDOPATHIC SCOLIOSIS • Physical exam / screen at set ages* • XR if scoliometer > 7º • Then use XRAY results to determine f/u and referral needs • Other considerations • MRI if neurologic concerns or < 10 yo / Neurosurgery consult • Cardiology and Genetics consults if c/f Connective Tissues Problem • Separate back pain evaluation if child has significant back pain

SUMMARY OF PROPOSED ALGORITHM • Refer immediately • • > 30 degrees at any age 25 -29 degrees and early puberty 20 -24 degrees before puberty Increase in 5 degrees on XR at any interval • Follow-up 3 months • 15 -24 degrees and early puberty • Follow-up 6 months • 15 -29 degrees and late puberty • Follow-up in 1 year • < 14 degrees but not yet done with puberty • Follow-up in 5 years • Post puberty and Cobb angle 20 -29 degrees • Do not monitor • Normal exam, scoliometer < 7 • Scoliosis < 19 degrees and done with puberty

THE “DANGEROUS CURVE” BY NUMBERS • 7º on scoliometer = GET INITIAL X-RAY • 10º Cobb Angle on XR = DIAGNOSIS • < 14º on XR = F/U IN 1 YEAR if still growing, otherwise stop • 15 -29º = F/U and REFERRAL GUIDELINES BASED ON PUBERTY STAGE & CHANGE • 30º at end of puberty = UNLIKELY TO PROGRESS, get f/u film in 5 years • >50º at end of puberty may progress 1º/year • >70º affects lung volumes • >100º symptomatic restrictive lung disease