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Musculoskeletal Medicine for Medical Students

 

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Description

Scoliosis is a sideways curvature of the spine.

Mayoclinic website

Pathology (organ, cell, system)

Scoliosis is a descriptive term and not a diagnosis. For some reason, the vertebral bodies of a person with scoliosis do no line up appropriately and result in a curvature of the spine. This appears grossly on exam as a spine with an "S" or a "C" shape rather than a straight line.  Some of the bones in a scoliotic spine also may have rotated slightly, making the person's waist or shoulders appear uneven.

Scoliosis research society website

Pathophysiology

Everyone's spine has natural curves. These curves round our shoulders and make our lower back curve slightly inward. During growth and development these curves should be maintained, but no side to side curve should be present. In more than 80% of cases, a specific cause is not found and is termed idiopathic. This can be s ub-classified as infantile, juvenile, adolescent, or adult according to when onset occurred. This is particularly true among the type of scoliosis seen in adolescent girls. Conditions known to cause spinal deformity are congenital spinal column abnormalities, neurological disorders, genetic conditions and a multitude of other causes.

Scoliosis research society website

Differential Diagnosis

Scoliosis is a descriptive term of the appearance of the spine and not a diagnosis. Even though most cases are idiopathic, it is important to look for an underlying cause such as congenital vertebral anomalies, a tethered cord, spina bifida, or associated genetic conditions.

Scoliosis research society website

Epidemiology

Congenital scoliosis is a fixed spinal curvature that is present at birth and usually is due to a deformity in the bony structure of 1 or more vertebrae. According to Scoliosis Research Society, congenital scoliosis affects girls more often than boys (60% to 40%) and affects approximately 1 in 10 000 Americans. According to the National Scoliosis Foundation, in the United States alone, an estimated 6 million people have scoliosis. Estimates are that idiopathic scoliosis affects 2% to 4% of all adolescents. Adolescent idiopathic scoliosis (AIS) accounts for an estimated 80% of idiopathic scoliosis cases and is detected most commonly in children between the ages of 10 and 16 years. Neuromuscular and traumatic scoliosis account for only a small fraction of cases.

Anderson SM . Spinal curves and scoliosis . R a diol Technol. 2007 Sep-Oct; 79(1):44-65.

 

Etiology

Theories on AIS s etiology have included mechanical, hormonal, metabolic, neuromuscular, growth, and genetic abnormalities. Given the strong epidemiological data demonstrating familial clustering, AIS is thought to be a complex genetic disorder, with one or more genes interacting with the environment to result in spinal deformity. The relationship of growth to curve progression makes growth hormone an obvious candidate. Several studies have found an increase in the level of growth hormone or somatomedins in adolescent girls. In addition, sporadic cases of a rapid increase in scoliotic curvature have been reported in patients undergoing growth-hormone therapy. Some research suggests that primary neurological pathologies might cause a functional asymmetry in balance and consequently result in scoliosis. Syringomyelia associated with a Chiari type I malformation at the foramen magnum has a substantially increased prevalence in patients with AIS. Collagen and elastic fibres are principal elements in the supporting structures of the spinal column and have been the focus of many studies dealing with the pathophysiology of AIS. Although changes have been identified within the musculature, extracellular matrix of spinal ligaments, and the intervertebral disc, it is not possible to differentiate whether these are primary, i.e., causing scoliosis, or secondary, i.e., resulting from the spinal deformity. Growth asymmetry has been put forward as an etiology of AIS, although has not been supported definitively by research studies.

Cheung KM , Wang T , Qiu GX , Luk KD . Recent advances in the aetiology of adolescent idiopathic scoliosis.

Int Orthop. 2008 Dec; 32(6):729-34.

 

Clinical manifestations

Signs of scoliosis are usually picked up on routine screening at school or at yearly well-child visits. Physical exam could reveal overt curvature of the spine, shoulder blade asymmetry, waistline asymmetry, and any trunk shift. The Adam’s Forward Bend Test looks for the rotational aspect of the scoliosis in the upper part of the back (rib prominence) or in the lower part of your back (flank or waist prominence). Physical exam is a useful test for detecting scoliosis, but it must be confirmed by X-ray to assess the severity of the curvature. Mild cases usually do not cause physical restrictions or complaints from patients. Progression of the curvature can result in more severe symptoms. Mild and moderate cases are often more problematic from a social standpoint in appearance conscious adolescents.

Scoliosis research society website

Late presentation, complications

Severe cases of scoliosis can lead to diminishing lung capacity, putting pressure on the heart, and restricting physical activities. These more serious symptoms are only seen with severe curvature, which results in compression of the thoracic cavity. It is more common in progressive, untreated scoliosis, but can be seen in treatment-resistant cases.

Scoliosis research society website

Nutritional factors

Not applicable

 

Radiographic evidence

The preferred initial images for assessing a suspected case of scoliosis are the PA erect and lateral erect which include the entire length of the spine. The curve of the spine is then measured in degrees to determine the severity of the curvature. The standard method for assessing the curvature quantitatively is measurement of the Cobb angle. The Cobb angle is the angle between two lines, drawn perpendicular to the upper endplate of the uppermost vertebrae involved and the lower endplate of the lowest vertebrae involved. Although the Cobb angle does have some inter-rater variability it is a reliable indicator of curve severity.

Anderson SM . Spinal curves and scoliosis . Radiol Technol. 2007 Sep-Oct; 79(1):44-65.

 

Laboratory evidence

There is no laboratory test to diagnose scoliosis, however, various tests may be used to diagnose associated genetic and metabolic conditions. Radiologic imaging is the gold-standard in diagnosing scoliosis.

 

Psychosocial impact of disease

Even mild cases of scoliosis may have a negative psychosocial impact due to the disfiguring nature of the disease. This is especially relevant since the majority of cases develop in adolescent girls. Obvious spinal curvature and uneven shoulders and hips can be very uncomfortable for self-conscious adolescents at a time when physical appearance is extremely important. 

 

Risk factors

Genetic predisposition is thought to be the biggest risk factor, although the exact genes involved have not been determined. The three main risk factors of curve progression are female gender, future growth potential, and the curve magnitude at the time of diagnosis. In all cases, females have a risk of curve progression 10 times higher than males. The greater the growth potential and the larger the curve, the greater the likelihood of curve progression.

Reamy BV , Slakey JB . Adolescent idiopathic scoliosis: Review and current concepts . Am Fam Physician. 2001 Jul 1;64(1):111-6.

 

Prevention

Due to the elusive nature of the cause of most cases of scoliosis, preventative measures have not been established.

 

Treatment options

Observation for curves that have a small degree measurement when the patient is still growing (adolescent scoliosis), or for moderate size curves (< 40-45 degrees) when done growing.

Bracing for curves between 25 and 45 degrees in growing children. The goal of bracing is to prevent further progression since the brace cannot correct curves, however this is not evidenced based.

Surgical treatment is reserved for curves that are generally greater than 50 degrees for adolescent patients and adults. The goals of surgical treatment are to obtain curve correction and to prevent curve progression. This is generally achieved by placing metal implants onto the spine, which are then attached to rods which correct the spine curvature and hold it in the corrected position.

Scoliosis research society website

Outcomes  of treatment

No definite evidence has shown that physical therapy or bracing reduces the risk of curve progression, corrects the existing deformity, or decreases the need for surgery. Surgery has been shown to decrease deformity and prevent progression. Long term outcomes of recently developed surgical techniques, however, still need to be examined.

Weinstein SL , Dolan LA , Cheng JC , Danielsson A , Morcuende JA . Adolescent idiopathic scoliosis . Lancet. 2008 May 3;371(9623):1527-37.

Potential
Complications of treatment

The main complication of bracing is psychological stress. Surgical complications include blood loss and anesthesia reactions during surgery. Immediate postoperative complications commonly involve pneumothorax, pleural effusion, pneumonia, post-operative ileus, and infection. In later follow-up, major problems remain pseudarthrosis, instrumentation failure, loss of correction, extension of a curve beyond the corrected area, and neurologic complications.

I did not have access to many of the journals that included articles related to this question and therefore was unable to find any article that explicitly stated the odds of potential complications.

Oestreich AE , Young LW , Poussaint TY . Scoliosis circa 2000: radiologic imaging perspective. II. Treatment and follow-up. Skeletal Radiol. 1998 Dec;27(12):651-6.

 

Misc

I did not find any interesting factoids about scoliosis.

 

 

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