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Dr. Eman Baraka
Lecteurer of Rheumatology, Physical
Medicine& Rehabilitation
Normal Spinal Curves
Each section of the spine
has a natural curve.
Viewed from the side:
1.The cervical and lumbar
spines have lordotic, or
slight concave curves.
2.The thoracic spine has a
kyphotic, or gentle convex
The normal thoracolumbar spine
is relatively straight in the
sagittal plane and has a double
curve in the coronal plane. As
shown below, the thoracic spine
in convex posteriorly (kyphosis)
and the lumbar spine is convex
anteriorly (lordosis). Normally
there should be no lateral
curvature of the spine
Scoliosis – lateral •
(side-to-side) curve •
of the spine. •
Scoliosis is a complicated deformity
that involved lateral curvature of the spine
greater than 10o accompanied by vertebral
rotation, excluding mobile scoliosis.
1-Lateral deviation of the .1
2. Longitudinal rotation of the vertebrae
(torsion: procesus spinosus rotates toward
the concavity, while the body of the
vertebrae rotates toward the convexity).
The body of the vertebrae are wedged on the
side of the concavity.
The spine changes its shape and way of
3. When the vertebrae rotates, the ribs also
rotates, therefore we find a rib hump.
4. The intercostal space is reduced on the
concav side (ribs are getting closer).
5. The intervertebral space is narrower on
the concav side, and wider on the convex
6. The vertebral canal is narrower on
the convex side.
7. Constriction of the vertebrae (the
wedge of the vertebrae is situated on the
concav side; the bigger wedge is located in
the apex of the deformation).
• The apical vertebra – in a curve, the
vertebra most deviated laterally from
the vertical axis that passes through
the patient's sacrum, i.e. from the
central sacral line
• Structural - usually combined
with a rotation of the vertebrae.
• Non structural – scoliotic poor
• Classification of scoliosis
• Nonstructural scoliosis
 postural scoliosis resolves when the child is recumbent
 compensatory scoliosis caused by leg-length discrepancy;
there is no fixed rotation of the vertebrae
• Transient non structural scoliosis
 sciatic scoliosis
 hysterical scoliosis
 inflammatory scoliosis
• Structural scoliosis
 idiopathic (70 - 80 % of all cases)
 congenital
 neuromuscular
1. IDIOPATHIC – the cause is unknown.
2. NEUROMUSCULAR – is due to loss of control of the
nerves or muscles that support the spine. The most
common causes of this type of scoliosis are cerebral palsy
and muscular dystrophy.
3. DEGENERATIVE – may be caused by breaking down of the
discs that separate the vertebrae or by arthritis in the
joints that link them.
4. CONGENITAL – due to abnormal formation of the bones of
the spine and is often associated with other organ defects.
Idiopathic scoliosis accounts for about 80 % of all
cases of the disorder, and has a strong female
predilection (7:1).
It can be subclassified into
INFANTILE – Curvature appears before age .1
2-JUVENILE – Curvature appears between ages
three and ten.
3-ADOLESCENT– Curvature usually appears
between ages of ten and 13, near the beginning
of puberty.
4-ADULT - Curvature begins after physical
maturation is completed.
Infantile Idiopathic
Scoliosis of 20
month-old boy
Young boy with juvenile
• Adolescent Idiopathic Scoliosis (AIS)
• Definition:(10x10(
Adolescent Idiopathic Scoliosis (AIS) is a
deformity that involved lateral curvature of the
spine greater than 10o accompanied by
vertebral rotation and occurs in children aged
10 years to maturity.
• AIS may start at puberty or during an
adolescent growth spurt. 5 % of adolescents
will be found to have some form of scoliosis.
• The incidence of AIS of females to males is
about 9:1 3% of these girls usually develop
more severely progressive curves than males
Assessment of the
scoliotic child
The following is a list of questions that may
ask to cover causes and important risk
1. The of age
2. The family history
3. History suggesting any underlying medical
conditions to exclude individuals who have 2ry
This will help us to determine the
number of years that remain before the child
reaches skeletal maturity. The curve mainly
continue to progress throughout adulthood.
(A) Symptoms of scoliosis
1.Deformity is the first symptoms:
Many patients are asymptomatic while others
complain of muscle aches in the lower back after
sitting or standing a long time‫ا‬
a. The pain is mechanical in nature mainly at night
and is probably caused by disc and/or facet joint
The pain becomes worse the longer they are
ambulatory and the symptoms are rapidly relieved
upon lying down
b. In sometimes, the pain is radicular in nature;
due to nerve root compression.
(B) Neurological complain
(II) The clinical examination of AIS
This clinical assessment provides the physician with a
“baseline” from which future curve progression can
be measured & determines the strategies of ttt.
•Complete general & neurological examinations:
During the physical and neurological examinations the
physician has to evaluate the patient’s health and
general fitness.
•. Cardiopulmonary assessment:
Checking for medical complications and testing of
functions of the heart and lungs
•Neurological examination:
To exclude other neurological causes of scoliosis
.Physical assessment for the back:
Physical assessment for the back in 3
positions: standing, lying & suspending.
Back exam : Inspection, palpation & ROM
2. Physical assessment for the extremities:
3. Physical assessment for the chest
4. Assessment for the gait
5. Special diagnostic tests.
• Plumb line
• Adam’s forward bending test
• Scoliometer
Lowered shoulder
Lowered shoulder blade
Curvature of the spine
Inequality of the Lorent`s triangle
Lowered pelvis
Standing posture shows an elevated Rt
shoulder and scapular asymmetry
Forward bend demonstrates the large right rib hump. Forward
bend test brings out the rib prominence and is a vital part of
the clinical examination. The rib hump that is often noticeable
in scoliosis is due to rotation of the rib cage.
AIS leads to lateral curvature of the spine, a twisting (rotation)
of the spinal column and rib hump.
The scoliosis is determined according
to the convex side.
Scoliosis may develop:
• In the whole spine (total scoliosis)
• Only in one part of the spine (partial
Scoliosis may be:
 Simplex
 Duplex
 Triplex
– with the primary and
compensatory curves
• Cervical
• Cervicotoracal
• Toracal
• Toracolumbar
• Lumbar
• Lumbosacral
It is quite accurate in identifying the degree of trunk
rotation done by a physician, school nurse & Parents.
Children with reading of 5 or more have a curve
measuring less than 20.
Imaging evaluation
1.The radiological assessment
• The radiographic assessment of the
scoliosis patient begins with erect
anteroposterior and lateral views of the
entire spine (occiput to sacrum).
• In addition, the examination should
include a lateral view of the lumbar
spine to look for the presence of
spondylolysis or spondylolisthesis
(prevalence in the general population is
about 5 %). The scoliotic curve is then
measured from the AP view
Components of the curve
•Apical vertebra: It is the
vertebra at the summit of the
•End vertebrae: Are the last
vertebrae of the curve.
•Neural vertebra: It is the
vertebra at the junction of two
primary curves and it is part of
both curves; it is both the lowest
vertebra in the upper curve and
the highest in the lower curve .
The shape of the spinal curves
are usually S or C-shaped.
The scoliotic curve is named according
1.To side of the convex side. (Right or left
2- to the location of the apex of the curve, as
shown below.
1.Cobb’s method
To use the Cobb metho
d, one must first decide
which vertebrae are the end-vertebrae of
the curve. These endvertebrae are the vertebrae at the upper
and lower limits of the curve which tilt
most severely toward
the concavity of the curve. Once these
vertebrae have been selected, one then
draws a line along the upper endplate of
the upper body and along the lower
endplate of the lower body as shown
X-ray 53° Rt thoracic curve
1.Determination of the severity of
• Mild scoliosis: curves between 0-69
• Severe scoliosis: curves between 70-99
• Very severe scoliosis: curves 100 or
• 2. Assessment of functional state of
the back
• If the spine is compensated or
• An uncompensated spine as in Paralytic,
congenital scoliosis & AIS
(1) The primary curve (structural,
It is identified by persistence of lateral
curvature with fixed rotation on forward
bending. This curving may be progress until
epiphysial closure is completed & the end of
skeletal maturity.
(2) The secondary curves =Compensatory
2nd curves develop to counter balance 1ry
They may be early mobile, by progression of
the condition, they may become fixed.
The aim of the presence of the 2nd curves:
To maintain & develop a balance of the body by
keeping the head of the patient in vertical
level with the horizontal level of ocular vision
i.e. to maintain the alignment of the body with
the center of gravity.
lateral bending films are often taken to
assess the rigidity or flexibility of the curves
2. The Harrington factor
This method is used to measure the severity
of spine curvature & to follow progression.
The angle of the curvature is divided by the
number of the vertebrae forming the curve and the
resultant is the Harrington factor. A value 5 or
more is a significant of severe deformity.
3. The method of Nash and Moe
This technique is used to measure vertebral
rotation related to rotation of the vertebral pedicle
& by dividing the vertebral body into 4 segments.
Grades 1 and 2: The convex pedicle is visible on AP
Grades 3 and 4: The convex pedicle has twisted out
of view.
2-Estimate the degree of rotation of the
vertebra at the apex of the curve by
looking at the relation of the pedicles to
3-The presence of any vertebral or rib
anomalies should be reported
X-ray 53° Rt thoracic curve
2. MRI
MRI scan of the spine can be requested to rule out an
intracanal spinal lesion that can result in scoliosis.
If there are any neurological deficits that would
indicate impingement of the spinal cord (e.g.
hyperactive reflexes)
Laboratory investigations
Laboratory tests are normal in-patients with AIS
Prognosis of AIS
1. The curve pattern.
2. Age of recognition
3. Skeletal age
4. Status of ossification pattern of the iliac apophysis and
the vertebral ring
5. Stage development of the physical characteristics of
Coronal images
Scoliotic deformity
Risser Sign
The Risser Sign looks at the iliac crest growth
plate, a fan-shaped part of the pelvis that fuses with
the pelvis at maturity. When the ossification of the
iliac apophysis is complete also the vertebral ring
apophysis is closed---- skeletal maturation.
Vertebral growth usually ceases at bone age
of 16 years in girls and 18 years in boys.
At skeletal maturity,
Progression may stop in a curve is less than 45
Progression continue in a curve is greater than 50
So, the treatment objective is to try to get the child
into adulthood with less than 50 curvature.
The girls skeletal maturity rarely continues
more than 18 months after the menarche.
Risser's sign
Risser grade: Each grade from 1-4 •
corresponds with a 25% increment of iliac
crest ossification. A low grade indicates
that the skeleton still has considerable
growth. A Risser grade 5 corresponds to
skeletal maturity. The lower the Risser
grade at the time of curve detection, the
greater the risk of progression
determination of vertebral maturity
One can also look for evidence of maturation in the
vertebral bodies themselves at the endplates, as shown
below When the plates blend in with the vertebral bodies
to form a solid union, maturation is complete.
Back braces
Physical training:
Therapeutic exercises for
scoliosis & complications
Surgical interventions
Patient & family education
-Principles of anatomy of the spine,
body mechanics & posture.
Nature of the disease
Applications of orthosis
Modified life style
Management of scoliosis
Three treatment options for AIS:
• Follow up (observation) &Alternative treatment
• Orthosis & Physical programs
• Scoliosis surgery.
Main aims of treatment
.Maintaining balanced spine and
preventing more deformity until skeletal
• Prevent more complications.
• Change the child's life style.
• Observation
Observation is generally for patients whose curves
are less than 25-30º who are still growing, or for curves
less than 45º in patients who have completed their
growth. Scoliosis surgeons often wish to observe the
scoliosis every few years after patients complete their
growth to make sure it does not progress into adulthood.
Alternative Treatment
Alternative treatments to prevent curve progression or
prevent further curve progression such as chiropractic
medicine, physical therapy, yoga, etc. have not
demonstrated any scientific value in the treatment of
scoliosis. However, these and other methods can be
utilized if they provide some physical benefit to the
patient such as core strengthening, symptom relief, etc.
These should not, however, be utilized to formally treat
Most curves can be treated nonoperatively if they
are detected before they become too severe.
However, 60 % of curvatures in rapidly growing
prepubertal children will progress. Therefore,
scoliosis screening should be done. This screening
is probably not necessary until the fifth grade.
Beyond that point, boys and girls should be
examined every 6 - 9 months. Generally,
curvatures less than 30 degrees will not progress
after the child is skeletally mature. Once this has
been established, scoliosis screening and monitoring
can usually be stopped. However, with greater
curvatures, the curvature may progress at about 1
degree per year in adults. In this population,
monitoring should be continued.
The indications of back Orthosis:
1.All preadolescent children when the curve
measures 25-40 degrees in a skeletally
immature patient.
Since the majority of curve progression happens
during a child's growth phase, bracing treatment
is continued until the end of growth to keep the
correct the spinal alignment.
2. To relief the pain by reduction of axial
Contraindication of back orthosis:
1. Growing children + the curve is 45-50
2. Child with already skeletally mature + the
curve 50 or more.
Back Orthosis
Biomechanics of orthosis :
Orthosis does not reduce the amount of
angulation already present but it is designed to
stop the progression of the spinal curve.
Orthosis can successfully prevent curve
progression in the majority of patients(80%).
Orthosis applies three-point pressure
to the curvature to prevent its progression: end
point control, transverse loading & curve correction.
So, the back orthosis is a kinetic, not a static
brace in treatment of AIS.
Types of back Orthosis
(I) High profile orthosis
Cervico – thoracolumbo - sacral orthosis (CTLSO):
Milwaukee orthosis: It is the ideal brace for AIS.
(II) Low profile orthosis
Thoracolumbo -sacral orthosis (TLSO):
Boston orthosis.
Charleston bending orthosis.
(III) Recently computer aided design (CAD) using
the (Insignia technique)
It is 3 dimensional image of body parts
transmitted to the computer for more accuracy of
the measurements.
Milwakee Brace
Boston Brace
Boston Brace (low profile brace)
Boston Brace
What is the protocol for wearing the orthosis?
1. Full time protocol: 23 hours a day. It can be
taken off to swim or to play sports as Boston &
Milwaukee. Most patients start wearing the
orthosis at nighttime and then gradually extend the
time into the day.
2. Part time protocol: It is worn only at night while
the child is asleep as Charleston
3. After 4 -5 weeks: the patient will return to the
scoliotic clinic for an x-ray in the orthosis and a
follow-up examination to ensure that the brace is
correcting the curve effectively.
4. The child is skeletally mature and finished
Boston Brace in X-ray
Response of curves to bracing
1. Most curves substantially improved:
Most curves will appear substantially improved
(80%) while the brace is worn; however, the great
majority will return to the original pre-treatment
magnitude shortly after brace discontinuance.
2.Some spinal curves will continue to progress.
Unfortunately, even with appropriate bracing, some
spinal curves will continue to progress.
Many times it is very difficult to predict which
curves will continue to progress and need surgery
later, especially if the child is young and skeletally
Disadvantages of back bracing
Braces can be uncomfortable, unattractive, hot, and
can make a child self-conscious even though well
disguised under clothing.
It is recommended that a cotton T-shirt be worn
underneath the brace so that the brace does not
have direct contact with the skin.
Also it is important during removing of the orthosis
to check the skin for any signs of breakdown
Children may loose weight from the brace, due to
increased pressure on the abdominal area.
Surgical Management
Surgical treatment is recommended for
patients whose curves are greater than 45o
while still growing, or are continuing to
progress greater than 45o when growth
The goal of surgical treatment is two-fold:
first, to prevent curve progression and
secondly to obtain some curve correction
Surgical management of scoliosis is generally
intended to prevent future consequences of
progressive deformity.
Although most adolescents have little impairment or
symptoms related to their deformity, future
consequences include the possible:
• development of progressive pain
• pulmonary or cardiac compromise
• progressive deformity and
unacceptable appearance
• neurological deterioration
• Surgical treatment today utilizes metal
implants that are attached to the spine, and
then connected to a single rod or two rods.
Implants are used to correct the spine and
hold the spine in the corrected position until
the instrumented segments fuse as one bone.
• The surgery can be performed from the
back of the spine (posterior approach)
through a straight incision along the midline
of the back or through the front of the
spine (anterior approach)
Although there are advantages and
disadvantages to both approaches, the posterior
approach is utilized most often in the treatment of
AIS and can be utilized for all curve types.
The anterior approach is an option when a single
thoracic curve or a single lumbar curve is being
Following surgical treatment, no external
bracing or casts are used. The hospital stay is
generally between 3 and 6 days. The patient can
perform regular daily activities and generally returns
to school in 3-4 weeks. Depending on the activities of
the patient, full participation is allowed between 3
and 6 months after surgery. Most children will not
need pain medications 10-14 days after surgery.
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